{ "hospital_name": "SBH-Madison, LLC", "last_updated_on": "2026-05-20", "version": "3.0.0", "location_name": [ "Miramont Behavioral Health" ], "hospital_address": [ "3169 Deming Way, Middleton, WI 53562" ], "license_information": { "state": "WI", "license_number": "3535" }, "type_2_npi": [ "1003413816" ], "attestation": { "attestation": "To the best of its knowledge and belief, this hospital has included all applicable standard charge information in accordance with the requirements of 45 CFR 180.50, and the information encoded is true, accurate, and complete as of the date in the file. This hospital has included all payer-specific negotiated charges in dollars that can be expressed as a dollar amount. For payer-specific negotiated charges that cannot be expressed as a dollar amount in the machine-readable file or not knowable in advance, the hospital attests that the payer-specific negotiated charge is based on a contractual algorithm, percentage or formula that precludes the provision of a dollar amount and has provided all necessary information available to the hospital for the public to be able to derive the dollar amount, including, but not limited to, the specific fee schedule or components referenced in such percentage, algorithm or formula.", "confirm_attestation": true, "attester_name": "Ricky Ament" }, "standard_charge_information": [ { "description": "Acute Adol R&B", "code_information": [ { "code": "124", "type": "RC" }, { "code": "1003", "type": "LOCAL" } ], "standard_charges": [ { "setting": "inpatient", "payers_information": [ { "payer_name": "Administrative Concepts Inc", "plan_name": "Administrative Concepts Inc", "standard_charge_dollar": 800.0, "methodology": "fee schedule" }, { "payer_name": "Aetna", "plan_name": "Aetna", "standard_charge_dollar": 928.0, "methodology": "fee schedule" }, { "payer_name": "Aetna Medicare", "plan_name": "Aetna Medicare", "standard_charge_dollar": 1645.0, "methodology": "fee schedule" }, { "payer_name": "All Savers - UHC", "plan_name": "All Savers - UHC", "standard_charge_dollar": 800.0, "methodology": "fee schedule" }, { "payer_name": "Allegiance Benefit Plan Management", "plan_name": "Allegiance Benefit Plan Management", "standard_charge_dollar": 1250.0, "methodology": "fee schedule" }, { "payer_name": "Anthem Commercial- HMO/PPO", "plan_name": "Anthem Commercial- HMO/PPO", "standard_charge_dollar": 1200.0, "methodology": "fee schedule" }, { "payer_name": "Anthem Commerical- Blue Priority", "plan_name": "Anthem Commerical- Blue Priority", "standard_charge_dollar": 1200.0, "methodology": "fee schedule" }, { "payer_name": "Anthem Medicaid", "plan_name": "Anthem Medicaid", "standard_charge_dollar": 1379.52, "methodology": "fee schedule" }, { "payer_name": "Aspirus Health Plan", "plan_name": "Aspirus Health Plan", "standard_charge_dollar": 1820.0, "methodology": "fee schedule" }, { "payer_name": "Barron County Dept Of Health & Human Ser", "plan_name": "Barron County Dept Of Health & Human Ser", "standard_charge_dollar": 1200.0, "methodology": "fee schedule" }, { "payer_name": "Bayfield County", "plan_name": "Bayfield County", "standard_charge_dollar": 1485.26, "methodology": "fee schedule" }, { "payer_name": "Carelon Behavioral Health", "plan_name": "Carelon Behavioral Health", "standard_charge_dollar": 1000.0, "methodology": "fee schedule" }, { "payer_name": "Centivo - Multiplan", "plan_name": "Centivo - Multiplan", "standard_charge_dollar": 1300.0, "methodology": "fee schedule" }, { "payer_name": "Children Come First - Rise", "plan_name": "Children Come First - Rise", "standard_charge_dollar": 1162.0, "methodology": "fee schedule" }, { "payer_name": "Chorus Childrens Community Health Plan", "plan_name": "Chorus Childrens Community Health Plan", "standard_charge_dollar": 1379.52, "methodology": "fee schedule" }, { "payer_name": "Cigna Healthcare", "plan_name": "Cigna Healthcare", "standard_charge_dollar": 1250.0, "methodology": "fee schedule" }, { "payer_name": "Columbia County DHS", "plan_name": "Columbia County DHS", "standard_charge_dollar": 1200.0, "methodology": "fee schedule" }, { "payer_name": "Crawford County Human Services", "plan_name": "Crawford County Human Services", "standard_charge_dollar": 1335.75, "methodology": "fee schedule" }, { "payer_name": "Dane County", "plan_name": "Dane County", "standard_charge_dollar": 1402.51, "methodology": "fee schedule" }, { "payer_name": "Dean Health ASO", "plan_name": "Dean Health ASO", "standard_charge_dollar": 681.5, "methodology": "fee schedule" }, { "payer_name": "Dean Health Plan", "plan_name": "Dean Health Plan", "standard_charge_dollar": 1407.14, "methodology": "fee schedule" }, { "payer_name": "Dean Health-Medicaid", "plan_name": "Dean Health-Medicaid", "standard_charge_dollar": 1379.52, "methodology": "fee schedule" }, { "payer_name": "Dodge County Humana Services", "plan_name": "Dodge County Humana Services", "standard_charge_dollar": 1267.79, "methodology": "fee schedule" }, { "payer_name": "Eau Claire Human Services", "plan_name": "Eau Claire Human Services", "standard_charge_dollar": 1300.0, "methodology": "fee schedule" }, { "payer_name": "Exceedent", "plan_name": "Exceedent", "standard_charge_dollar": 925.0, "methodology": "fee schedule" }, { "payer_name": "Group Health Coop Eau Claire - Commercia", "plan_name": "Group Health Coop Eau Claire - Commercia", "standard_charge_dollar": 1300.0, "methodology": "fee schedule" }, { "payer_name": "Group Health EauClaire Medicaid", "plan_name": "Group Health EauClaire Medicaid", "standard_charge_dollar": 1379.52, "methodology": "fee schedule" }, { "payer_name": "Group Health South Commerical", "plan_name": "Group Health South Commerical", "standard_charge_dollar": 1410.0, "methodology": "fee schedule" }, { "payer_name": "Group Health South Medicaid", "plan_name": "Group Health South Medicaid", "standard_charge_dollar": 1379.52, "methodology": "fee schedule" }, { "payer_name": "Health EOS - Multiplan", "plan_name": "Health EOS - Multiplan", "standard_charge_dollar": 1300.0, "methodology": "fee schedule" }, { "payer_name": "HealthComp", "plan_name": "HealthComp", "standard_charge_dollar": 1250.0, "methodology": "fee schedule" }, { "payer_name": "HealthPartners", "plan_name": "HealthPartners", "standard_charge_dollar": 1450.0, "methodology": "fee schedule" }, { "payer_name": "Humana Commercial", "plan_name": "Humana Commercial", "standard_charge_dollar": 800.0, "methodology": "fee schedule" }, { "payer_name": "ICare Medicaid", "plan_name": "ICare Medicaid", "standard_charge_dollar": 1379.52, "methodology": "fee schedule" }, { "payer_name": "ICare Medicare", "plan_name": "ICare Medicare", "standard_charge_dollar": 800.0, "methodology": "fee schedule" }, { "payer_name": "Illinois Medicaid - Molina", "plan_name": "Illinois Medicaid - Molina", "standard_charge_dollar": 500.0, "methodology": "fee schedule" }, { "payer_name": "Iowa Medicaid - Amerigroup", "plan_name": "Iowa Medicaid - Amerigroup", "standard_charge_dollar": 500.0, "methodology": "fee schedule" }, { "payer_name": "Magellan Behavioral Health", "plan_name": "Magellan Behavioral Health", "standard_charge_dollar": 1255.0, "methodology": "fee schedule" }, { "payer_name": "Managed Health Services-Medicaid", "plan_name": "Managed Health Services-Medicaid", "standard_charge_dollar": 1379.52, "methodology": "fee schedule" }, { "payer_name": "McLaren Medicaid/Michigan", "plan_name": "McLaren Medicaid/Michigan", "standard_charge_dollar": 500.0, "methodology": "fee schedule" }, { "payer_name": "MDHHS: UPHP MI Medicaid C/o Northcare", "plan_name": "MDHHS: UPHP MI Medicaid C/o Northcare", "standard_charge_dollar": 500.0, "methodology": "fee schedule" }, { "payer_name": "MEDICA - SSM HEALTH DEAN EHP", "plan_name": "MEDICA - SSM HEALTH DEAN EHP", "standard_charge_dollar": 1300.0, "methodology": "fee schedule" }, { "payer_name": "Medica Government Programs", "plan_name": "Medica Government Programs", "standard_charge_dollar": 1250.0, "methodology": "fee schedule" }, { "payer_name": "Medical Associates", "plan_name": "Medical Associates", "standard_charge_dollar": 800.0, "methodology": "fee schedule" }, { "payer_name": "Mercy Care Wi Medicaid MCO", "plan_name": "Mercy Care Wi Medicaid MCO", "standard_charge_dollar": 1379.52, "methodology": "fee schedule" }, { "payer_name": "MercyCare Commerical", "plan_name": "MercyCare Commerical", "standard_charge_dollar": 1284.0, "methodology": "fee schedule" }, { "payer_name": "Minnesota Medicaid - Blue Plus", "plan_name": "Minnesota Medicaid - Blue Plus", "standard_charge_dollar": 500.0, "methodology": "fee schedule" }, { "payer_name": "Molina Healthcare Commercial", "plan_name": "Molina Healthcare Commercial", "standard_charge_dollar": 1400.0, "methodology": "fee schedule" }, { "payer_name": "Molina Healthcare Medicaid", "plan_name": "Molina Healthcare Medicaid", "standard_charge_dollar": 1379.52, "methodology": "fee schedule" }, { "payer_name": "My Choice-Care WI Medicaid", "plan_name": "My Choice-Care WI Medicaid", "standard_charge_dollar": 1379.52, "methodology": "fee schedule" }, { "payer_name": "My Choice-Trilogy Medicaid", "plan_name": "My Choice-Trilogy Medicaid", "standard_charge_dollar": 1379.52, "methodology": "fee schedule" }, { "payer_name": "Network Health HMO", "plan_name": "Network Health HMO", "standard_charge_dollar": 1300.0, "methodology": "fee schedule" }, { "payer_name": "Network Health Medicaid Managed", "plan_name": "Network Health Medicaid Managed", "standard_charge_dollar": 1379.52, "methodology": "fee schedule" }, { "payer_name": "Network Health PPO", "plan_name": "Network Health PPO", "standard_charge_dollar": 2100.0, "methodology": "fee schedule" }, { "payer_name": "Physicians Mutual", "plan_name": "Physicians Mutual", "standard_charge_dollar": 1250.0, "methodology": "fee schedule" }, { "payer_name": "Prairie States Enterprises INC", "plan_name": "Prairie States Enterprises INC", "standard_charge_dollar": 1059.0, "methodology": "fee schedule" }, { "payer_name": "Preferred One Admin Services", "plan_name": "Preferred One Admin Services", "standard_charge_dollar": 1100.0, "methodology": "fee schedule" }, { "payer_name": "Quartz Align - Brighton Health Plan", "plan_name": "Quartz Align - Brighton Health Plan", "standard_charge_dollar": 800.0, "methodology": "fee schedule" }, { "payer_name": "Quartz Commercial Plan", "plan_name": "Quartz Commercial Plan", "standard_charge_dollar": 1250.0, "methodology": "fee schedule" }, { "payer_name": "Quartz Medicaid", "plan_name": "Quartz Medicaid", "standard_charge_dollar": 1379.52, "methodology": "fee schedule" }, { "payer_name": "RAS Workers Comp", "plan_name": "RAS Workers Comp", "standard_charge_dollar": 700.0, "methodology": "fee schedule" }, { "payer_name": "Richland County Health & Human Services", "plan_name": "Richland County Health & Human Services", "standard_charge_dollar": 1296.84, "methodology": "fee schedule" }, { "payer_name": "Rock County Human Services", "plan_name": "Rock County Human Services", "standard_charge_dollar": 1296.84, "methodology": "fee schedule" }, { "payer_name": "Sauk County Human Services", "plan_name": "Sauk County Human Services", "standard_charge_dollar": 1362.6, "methodology": "fee schedule" }, { "payer_name": "Security Health Plan", "plan_name": "Security Health Plan", "standard_charge_dollar": 1287.5, "methodology": "fee schedule" }, { "payer_name": "Security Health Plan Managed Medicaid", "plan_name": "Security Health Plan Managed Medicaid", "standard_charge_dollar": 1379.52, "methodology": "fee schedule" }, { "payer_name": "Sharp Health Plan HMO", "plan_name": "Sharp Health Plan HMO", "standard_charge_dollar": 800.0, "methodology": "fee schedule" }, { "payer_name": "Surest", "plan_name": "Surest", "standard_charge_dollar": 1300.0, "methodology": "fee schedule" }, { "payer_name": "The Alliance Auxiant", "plan_name": "The Alliance Auxiant", "standard_charge_dollar": 1300.0, "methodology": "fee schedule" }, { "payer_name": "The American Worker - First Health Netwo", "plan_name": "The American Worker - First Health Netwo", "standard_charge_dollar": 1200.0, "methodology": "fee schedule" }, { "payer_name": "TRICARE EAST-WPS", "plan_name": "TRICARE EAST-WPS", "standard_charge_dollar": 776.76, "methodology": "fee schedule" }, { "payer_name": "Tricare West", "plan_name": "Tricare West", "standard_charge_dollar": 930.05, "methodology": "fee schedule" }, { "payer_name": "UHC Shared Services", "plan_name": "UHC Shared Services", "standard_charge_dollar": 1300.0, "methodology": "fee schedule" }, { "payer_name": "UHC/OPTUM", "plan_name": "UHC/OPTUM", "standard_charge_dollar": 1300.0, "methodology": "fee schedule" }, { "payer_name": "UMR Commercial", "plan_name": "UMR Commercial", "standard_charge_dollar": 1300.0, "methodology": "fee schedule" }, { "payer_name": "Unified Community Services", "plan_name": "Unified Community Services", "standard_charge_dollar": 1250.0, "methodology": "fee schedule" }, { "payer_name": "United Healthcare", "plan_name": "United Healthcare", "standard_charge_dollar": 1300.0, "methodology": "fee schedule" }, { "payer_name": "United Healthcare Medicaid Community Pla", "plan_name": "United Healthcare Medicaid Community Pla", "standard_charge_dollar": 1379.52, "methodology": "fee schedule" }, { "payer_name": "VA Medicaid United Healthcare", "plan_name": "VA Medicaid United Healthcare", "standard_charge_dollar": 500.0, "methodology": "fee schedule" }, { "payer_name": "Vernon County Human Services", "plan_name": "Vernon County Human Services", "standard_charge_dollar": 1400.0, "methodology": "fee schedule" }, { "payer_name": "Walworth County DHS", "plan_name": "Walworth County DHS", "standard_charge_dollar": 1389.57, "methodology": "fee schedule" }, { "payer_name": "Washington County", "plan_name": "Washington County", "standard_charge_dollar": 1362.6, "methodology": "fee schedule" }, { "payer_name": "Waukesha County", "plan_name": "Waukesha County", "standard_charge_dollar": 1442.0, "methodology": "fee schedule" }, { "payer_name": "WEA Trust Commercial", "plan_name": "WEA Trust Commercial", "standard_charge_dollar": 1250.0, "methodology": "fee schedule" }, { "payer_name": "Wellcare By Allwell", "plan_name": "Wellcare By Allwell", "standard_charge_dollar": 1300.0, "methodology": "fee schedule" }, { "payer_name": "Western Region Recovery & Wellness Conso", "plan_name": "Western Region Recovery & Wellness Conso", "standard_charge_dollar": 1212.0, "methodology": "fee schedule" }, { "payer_name": "Winnebago County Human Services", "plan_name": "Winnebago County Human Services", "standard_charge_dollar": 1344.99, "methodology": "fee schedule" }, { "payer_name": "Wood County Human Services Dept", "plan_name": "Wood County Human Services Dept", "standard_charge_dollar": 1344.99, "methodology": "fee schedule" }, { "payer_name": "WPS Health Insurance", "plan_name": "WPS Health Insurance", "standard_charge_dollar": 1475.18, "methodology": "fee schedule" } ], "gross_charge": 3000.0, "discounted_cash": 992.87, "minimum": 500.0, "maximum": 2100.0 } ] }, { "description": "Acute Adult R&B", "code_information": [ { "code": "124", "type": "RC" }, { "code": "1001", "type": "LOCAL" } ], "standard_charges": [ { "setting": "inpatient", "payers_information": [ { "payer_name": "Administrative Concepts Inc", "plan_name": "Administrative Concepts Inc", "standard_charge_dollar": 800.0, "methodology": "fee schedule" }, { "payer_name": "Aetna", "plan_name": "Aetna", "standard_charge_dollar": 928.0, "methodology": "fee schedule" }, { "payer_name": "Aetna Medicare", "plan_name": "Aetna Medicare", "standard_charge_dollar": 1645.0, "methodology": "fee schedule" }, { "payer_name": "All Savers - UHC", "plan_name": "All Savers - UHC", "standard_charge_dollar": 800.0, "methodology": "fee schedule" }, { "payer_name": "Allegiance Benefit Plan Management", "plan_name": "Allegiance Benefit Plan Management", "standard_charge_dollar": 1250.0, "methodology": "fee schedule" }, { "payer_name": "Allied Benefits", "plan_name": "Allied Benefits", "standard_charge_dollar": 1000.0, "methodology": "fee schedule" }, { "payer_name": "Ambetter From Sunshine Health", "plan_name": "Ambetter From Sunshine Health", "standard_charge_dollar": 925.0, "methodology": "fee schedule" }, { "payer_name": "Anthem Commercial- HMO/PPO", "plan_name": "Anthem Commercial- HMO/PPO", "standard_charge_dollar": 1200.0, "methodology": "fee schedule" }, { "payer_name": "Anthem Commerical- Blue Priority", "plan_name": "Anthem Commerical- Blue Priority", "standard_charge_dollar": 1200.0, "methodology": "fee schedule" }, { "payer_name": "Anthem Medicaid", "plan_name": "Anthem Medicaid", "standard_charge_dollar": 1379.52, "methodology": "fee schedule" }, { "payer_name": "Aspirus Health Plan", "plan_name": "Aspirus Health Plan", "standard_charge_dollar": 1820.0, "methodology": "fee schedule" }, { "payer_name": "Barron County Dept Of Health & Human Ser", "plan_name": "Barron County Dept Of Health & Human Ser", "standard_charge_dollar": 1200.0, "methodology": "fee schedule" }, { "payer_name": "Bayfield County", "plan_name": "Bayfield County", "standard_charge_dollar": 1485.26, "methodology": "fee schedule" }, { "payer_name": "Carelon Behavioral Health", "plan_name": "Carelon Behavioral Health", "standard_charge_dollar": 1000.0, "methodology": "fee schedule" }, { "payer_name": "Chorus Childrens Community Health Plan", "plan_name": "Chorus Childrens Community Health Plan", "standard_charge_dollar": 1379.52, "methodology": "fee schedule" }, { "payer_name": "Cigna Healthcare", "plan_name": "Cigna Healthcare", "standard_charge_dollar": 1250.0, "methodology": "fee schedule" }, { "payer_name": "Columbia County DHS", "plan_name": "Columbia County DHS", "standard_charge_dollar": 1200.0, "methodology": "fee schedule" }, { "payer_name": "Common Ground Commercial", "plan_name": "Common Ground Commercial", "standard_charge_dollar": 1000.0, "methodology": "fee schedule" }, { "payer_name": "Crawford County Human Services", "plan_name": "Crawford County Human Services", "standard_charge_dollar": 1335.75, "methodology": "fee schedule" }, { "payer_name": "Dane County", "plan_name": "Dane County", "standard_charge_dollar": 1402.51, "methodology": "fee schedule" }, { "payer_name": "Dean Health Plan", "plan_name": "Dean Health Plan", "standard_charge_dollar": 1407.14, "methodology": "fee schedule" }, { "payer_name": "Dean Health-Medicaid", "plan_name": "Dean Health-Medicaid", "standard_charge_dollar": 1379.52, "methodology": "fee schedule" }, { "payer_name": "Dodge County Humana Services", "plan_name": "Dodge County Humana Services", "standard_charge_dollar": 1267.79, "methodology": "fee schedule" }, { "payer_name": "Eau Claire Human Services", "plan_name": "Eau Claire Human Services", "standard_charge_dollar": 1300.0, "methodology": "fee schedule" }, { "payer_name": "FL Medicaid - Simply Healthcare", "plan_name": "FL Medicaid - Simply Healthcare", "standard_charge_dollar": 500.0, "methodology": "fee schedule" }, { "payer_name": "Green County Human Services", "plan_name": "Green County Human Services", "standard_charge_dollar": 1375.82, "methodology": "fee schedule" }, { "payer_name": "Group Health Coop Eau Claire - Commercia", "plan_name": "Group Health Coop Eau Claire - Commercia", "standard_charge_dollar": 1300.0, "methodology": "fee schedule" }, { "payer_name": "Group Health EauClaire Medicaid", "plan_name": "Group Health EauClaire Medicaid", "standard_charge_dollar": 1379.52, "methodology": "fee schedule" }, { "payer_name": "Group Health South Commerical", "plan_name": "Group Health South Commerical", "standard_charge_dollar": 1410.0, "methodology": "fee schedule" }, { "payer_name": "Group Health South Medicaid", "plan_name": "Group Health South Medicaid", "standard_charge_dollar": 1379.52, "methodology": "fee schedule" }, { "payer_name": "Health EOS - Multiplan", "plan_name": "Health EOS - Multiplan", "standard_charge_dollar": 1300.0, "methodology": "fee schedule" }, { "payer_name": "HealthComp", "plan_name": "HealthComp", "standard_charge_dollar": 1250.0, "methodology": "fee schedule" }, { "payer_name": "HealthPartners", "plan_name": "HealthPartners", "standard_charge_dollar": 1450.0, "methodology": "fee schedule" }, { "payer_name": "Ho Chunk Nation", "plan_name": "Ho Chunk Nation", "standard_charge_dollar": 1300.0, "methodology": "fee schedule" }, { "payer_name": "Humana Commercial", "plan_name": "Humana Commercial", "standard_charge_dollar": 800.0, "methodology": "fee schedule" }, { "payer_name": "ICare Medicaid", "plan_name": "ICare Medicaid", "standard_charge_dollar": 1379.52, "methodology": "fee schedule" }, { "payer_name": "ICare Medicare", "plan_name": "ICare Medicare", "standard_charge_dollar": 800.0, "methodology": "fee schedule" }, { "payer_name": "Illinois Medicaid - Molina", "plan_name": "Illinois Medicaid - Molina", "standard_charge_dollar": 500.0, "methodology": "fee schedule" }, { "payer_name": "Illnois Medicaid - BCBS Community Plan", "plan_name": "Illnois Medicaid - BCBS Community Plan", "standard_charge_dollar": 2063.95, "methodology": "fee schedule" }, { "payer_name": "Iowa County Health And Human Services", "plan_name": "Iowa County Health And Human Services", "standard_charge_dollar": 1200.0, "methodology": "fee schedule" }, { "payer_name": "Iowa Medicaid - Amerigroup", "plan_name": "Iowa Medicaid - Amerigroup", "standard_charge_dollar": 500.0, "methodology": "fee schedule" }, { "payer_name": "Iowa Medicaid - Total Care", "plan_name": "Iowa Medicaid - Total Care", "standard_charge_dollar": 700.0, "methodology": "fee schedule" }, { "payer_name": "Jackson County Health & Human Services", "plan_name": "Jackson County Health & Human Services", "standard_charge_dollar": 1200.0, "methodology": "fee schedule" }, { "payer_name": "Lafayette County Human Services", "plan_name": "Lafayette County Human Services", "standard_charge_dollar": 1200.0, "methodology": "fee schedule" }, { "payer_name": "Lucent Health", "plan_name": "Lucent Health", "standard_charge_dollar": 925.0, "methodology": "fee schedule" }, { "payer_name": "Magellan Behavioral Health", "plan_name": "Magellan Behavioral Health", "standard_charge_dollar": 1255.0, "methodology": "fee schedule" }, { "payer_name": "Managed Health Services-Medicaid", "plan_name": "Managed Health Services-Medicaid", "standard_charge_dollar": 1379.52, "methodology": "fee schedule" }, { "payer_name": "McLaren Medicaid/Michigan", "plan_name": "McLaren Medicaid/Michigan", "standard_charge_dollar": 500.0, "methodology": "fee schedule" }, { "payer_name": "MDHHS: UPHP MI Medicaid C/o Northcare", "plan_name": "MDHHS: UPHP MI Medicaid C/o Northcare", "standard_charge_dollar": 500.0, "methodology": "fee schedule" }, { "payer_name": "MEDICA - DEAN COMMERCIAL", "plan_name": "MEDICA - DEAN COMMERCIAL", "standard_charge_dollar": 1200.0, "methodology": "fee schedule" }, { "payer_name": "MEDICA - SSM HEALTH DEAN EHP", "plan_name": "MEDICA - SSM HEALTH DEAN EHP", "standard_charge_dollar": 1300.0, "methodology": "fee schedule" }, { "payer_name": "Medica Government Programs", "plan_name": "Medica Government Programs", "standard_charge_dollar": 1250.0, "methodology": "fee schedule" }, { "payer_name": "Medical Associates", "plan_name": "Medical Associates", "standard_charge_dollar": 800.0, "methodology": "fee schedule" }, { "payer_name": "Mercy Care Wi Medicaid MCO", "plan_name": "Mercy Care Wi Medicaid MCO", "standard_charge_dollar": 1379.52, "methodology": "fee schedule" }, { "payer_name": "MercyCare Commerical", "plan_name": "MercyCare Commerical", "standard_charge_dollar": 1284.0, "methodology": "fee schedule" }, { "payer_name": "Minnesota Medicaid - Blue Plus", "plan_name": "Minnesota Medicaid - Blue Plus", "standard_charge_dollar": 500.0, "methodology": "fee schedule" }, { "payer_name": "Molina Healthcare Commercial", "plan_name": "Molina Healthcare Commercial", "standard_charge_dollar": 1400.0, "methodology": "fee schedule" }, { "payer_name": "Molina Healthcare Medicaid", "plan_name": "Molina Healthcare Medicaid", "standard_charge_dollar": 1379.52, "methodology": "fee schedule" }, { "payer_name": "Monroe County Human Services", "plan_name": "Monroe County Human Services", "standard_charge_dollar": 1335.75, "methodology": "fee schedule" }, { "payer_name": "My Choice-Care WI Medicaid", "plan_name": "My Choice-Care WI Medicaid", "standard_charge_dollar": 1379.52, "methodology": "fee schedule" }, { "payer_name": "My Choice-Trilogy Medicaid", "plan_name": "My Choice-Trilogy Medicaid", "standard_charge_dollar": 1379.52, "methodology": "fee schedule" }, { "payer_name": "Network Health HMO", "plan_name": "Network Health HMO", "standard_charge_dollar": 1300.0, "methodology": "fee schedule" }, { "payer_name": "Network Health Medicaid Managed", "plan_name": "Network Health Medicaid Managed", "standard_charge_dollar": 1379.52, "methodology": "fee schedule" }, { "payer_name": "Network Health PPO", "plan_name": "Network Health PPO", "standard_charge_dollar": 2100.0, "methodology": "fee schedule" }, { "payer_name": "Ozaukee County Health And Human Services", "plan_name": "Ozaukee County Health And Human Services", "standard_charge_dollar": 1403.48, "methodology": "fee schedule" }, { "payer_name": "Physicians Mutual", "plan_name": "Physicians Mutual", "standard_charge_dollar": 1250.0, "methodology": "fee schedule" }, { "payer_name": "Pierce County DHS", "plan_name": "Pierce County DHS", "standard_charge_dollar": 1403.48, "methodology": "fee schedule" }, { "payer_name": "Prairie States Enterprises INC", "plan_name": "Prairie States Enterprises INC", "standard_charge_dollar": 1059.0, "methodology": "fee schedule" }, { "payer_name": "Preferred One Admin Services", "plan_name": "Preferred One Admin Services", "standard_charge_dollar": 1100.0, "methodology": "fee schedule" }, { "payer_name": "Quartz Align - Brighton Health Plan", "plan_name": "Quartz Align - Brighton Health Plan", "standard_charge_dollar": 800.0, "methodology": "fee schedule" }, { "payer_name": "Quartz Commercial Plan", "plan_name": "Quartz Commercial Plan", "standard_charge_dollar": 1250.0, "methodology": "fee schedule" }, { "payer_name": "Quartz Medicaid", "plan_name": "Quartz Medicaid", "standard_charge_dollar": 1379.52, "methodology": "fee schedule" }, { "payer_name": "RAS Workers Comp", "plan_name": "RAS Workers Comp", "standard_charge_dollar": 700.0, "methodology": "fee schedule" }, { "payer_name": "Richland County Health & Human Services", "plan_name": "Richland County Health & Human Services", "standard_charge_dollar": 1296.84, "methodology": "fee schedule" }, { "payer_name": "Rock County Human Services", "plan_name": "Rock County Human Services", "standard_charge_dollar": 1296.84, "methodology": "fee schedule" }, { "payer_name": "Sauk County Human Services", "plan_name": "Sauk County Human Services", "standard_charge_dollar": 1362.6, "methodology": "fee schedule" }, { "payer_name": "Security Health Plan", "plan_name": "Security Health Plan", "standard_charge_dollar": 1287.5, "methodology": "fee schedule" }, { "payer_name": "Security Health Plan Managed Medicaid", "plan_name": "Security Health Plan Managed Medicaid", "standard_charge_dollar": 1379.52, "methodology": "fee schedule" }, { "payer_name": "Sharp Health Plan HMO", "plan_name": "Sharp Health Plan HMO", "standard_charge_dollar": 800.0, "methodology": "fee schedule" }, { "payer_name": "Surest", "plan_name": "Surest", "standard_charge_dollar": 1300.0, "methodology": "fee schedule" }, { "payer_name": "The Alliance Auxiant", "plan_name": "The Alliance Auxiant", "standard_charge_dollar": 1300.0, "methodology": "fee schedule" }, { "payer_name": "TRICARE EAST-WPS", "plan_name": "TRICARE EAST-WPS", "standard_charge_dollar": 776.76, "methodology": "fee schedule" }, { "payer_name": "UHC Shared Services", "plan_name": "UHC Shared Services", "standard_charge_dollar": 1300.0, "methodology": "fee schedule" }, { "payer_name": "UHC/OPTUM", "plan_name": "UHC/OPTUM", "standard_charge_dollar": 1300.0, "methodology": "fee schedule" }, { "payer_name": "UMR Commercial", "plan_name": "UMR Commercial", "standard_charge_dollar": 1300.0, "methodology": "fee schedule" }, { "payer_name": "Unified Community Services", "plan_name": "Unified Community Services", "standard_charge_dollar": 1250.0, "methodology": "fee schedule" }, { "payer_name": "United Healthcare", "plan_name": "United Healthcare", "standard_charge_dollar": 1300.0, "methodology": "fee schedule" }, { "payer_name": "United Healthcare Medicaid Community Pla", "plan_name": "United Healthcare Medicaid Community Pla", "standard_charge_dollar": 1379.52, "methodology": "fee schedule" }, { "payer_name": "VA Medicaid United Healthcare", "plan_name": "VA Medicaid United Healthcare", "standard_charge_dollar": 500.0, "methodology": "fee schedule" }, { "payer_name": "Vernon County Human Services", "plan_name": "Vernon County Human Services", "standard_charge_dollar": 1400.0, "methodology": "fee schedule" }, { "payer_name": "Walworth County DHS", "plan_name": "Walworth County DHS", "standard_charge_dollar": 1389.57, "methodology": "fee schedule" }, { "payer_name": "Waukesha County", "plan_name": "Waukesha County", "standard_charge_dollar": 1442.0, "methodology": "fee schedule" }, { "payer_name": "WEA Trust Commercial", "plan_name": "WEA Trust Commercial", "standard_charge_dollar": 1250.0, "methodology": "fee schedule" }, { "payer_name": "Wellcare By Allwell", "plan_name": "Wellcare By Allwell", "standard_charge_dollar": 1300.0, "methodology": "fee schedule" }, { "payer_name": "Western Region Recovery & Wellness Conso", "plan_name": "Western Region Recovery & Wellness Conso", "standard_charge_dollar": 1212.0, "methodology": "fee schedule" }, { "payer_name": "Winnebago County Human Services", "plan_name": "Winnebago County Human Services", "standard_charge_dollar": 1344.99, "methodology": "fee schedule" }, { "payer_name": "Wood County Human Services Dept", "plan_name": "Wood County Human Services Dept", "standard_charge_dollar": 1344.99, "methodology": "fee schedule" }, { "payer_name": "WPS Health Insurance", "plan_name": "WPS Health Insurance", "standard_charge_dollar": 1475.18, "methodology": "fee schedule" } ], "gross_charge": 3000.0, "discounted_cash": 992.87, "minimum": 500.0, "maximum": 2100.0 } ] }, { "description": "Acute Child R&B", "code_information": [ { "code": "124", "type": "RC" }, { "code": "1002", "type": "LOCAL" } ], "standard_charges": [ { "setting": "inpatient", "payers_information": [ { "payer_name": "Administrative Concepts Inc", "plan_name": "Administrative Concepts Inc", "standard_charge_dollar": 800.0, "methodology": "fee schedule" }, { "payer_name": "Aetna", "plan_name": "Aetna", "standard_charge_dollar": 928.0, "methodology": "fee schedule" }, { "payer_name": "Aetna Medicare", "plan_name": "Aetna Medicare", "standard_charge_dollar": 1645.0, "methodology": "fee schedule" }, { "payer_name": "All Savers - UHC", "plan_name": "All Savers - UHC", "standard_charge_dollar": 800.0, "methodology": "fee schedule" }, { "payer_name": "Anthem Commercial- HMO/PPO", "plan_name": "Anthem Commercial- HMO/PPO", "standard_charge_dollar": 1200.0, "methodology": "fee schedule" }, { "payer_name": "Anthem Commerical- Blue Priority", "plan_name": "Anthem Commerical- Blue Priority", "standard_charge_dollar": 1200.0, "methodology": "fee schedule" }, { "payer_name": "Anthem Medicaid", "plan_name": "Anthem Medicaid", "standard_charge_dollar": 1379.52, "methodology": "fee schedule" }, { "payer_name": "Aspirus Health Plan", "plan_name": "Aspirus Health Plan", "standard_charge_dollar": 1820.0, "methodology": "fee schedule" }, { "payer_name": "Barron County Dept Of Health & Human Ser", "plan_name": "Barron County Dept Of Health & Human Ser", "standard_charge_dollar": 1200.0, "methodology": "fee schedule" }, { "payer_name": "Bayfield County", "plan_name": "Bayfield County", "standard_charge_dollar": 1485.26, "methodology": "fee schedule" }, { "payer_name": "Carelon Behavioral Health", "plan_name": "Carelon Behavioral Health", "standard_charge_dollar": 1000.0, "methodology": "fee schedule" }, { "payer_name": "Crawford County Human Services", "plan_name": "Crawford County Human Services", "standard_charge_dollar": 1335.75, "methodology": "fee schedule" }, { "payer_name": "Dane County", "plan_name": "Dane County", "standard_charge_dollar": 1402.51, "methodology": "fee schedule" }, { "payer_name": "Dean Health Plan", "plan_name": "Dean Health Plan", "standard_charge_dollar": 1407.14, "methodology": "fee schedule" }, { "payer_name": "Dean Health-Medicaid", "plan_name": "Dean Health-Medicaid", "standard_charge_dollar": 1379.52, "methodology": "fee schedule" }, { "payer_name": "Dodge County Humana Services", "plan_name": "Dodge County Humana Services", "standard_charge_dollar": 1267.79, "methodology": "fee schedule" }, { "payer_name": "Group Health EauClaire Medicaid", "plan_name": "Group Health EauClaire Medicaid", "standard_charge_dollar": 1379.52, "methodology": "fee schedule" }, { "payer_name": "Group Health South Commerical", "plan_name": "Group Health South Commerical", "standard_charge_dollar": 1410.0, "methodology": "fee schedule" }, { "payer_name": "Group Health South Medicaid", "plan_name": "Group Health South Medicaid", "standard_charge_dollar": 1379.52, "methodology": "fee schedule" }, { "payer_name": "Health EOS - Multiplan", "plan_name": "Health EOS - Multiplan", "standard_charge_dollar": 1300.0, "methodology": "fee schedule" }, { "payer_name": "Humana Commercial", "plan_name": "Humana Commercial", "standard_charge_dollar": 800.0, "methodology": "fee schedule" }, { "payer_name": "ICare Medicaid", "plan_name": "ICare Medicaid", "standard_charge_dollar": 1379.52, "methodology": "fee schedule" }, { "payer_name": "ICare Medicare", "plan_name": "ICare Medicare", "standard_charge_dollar": 800.0, "methodology": "fee schedule" }, { "payer_name": "Illinois Medicaid - Molina", "plan_name": "Illinois Medicaid - Molina", "standard_charge_dollar": 500.0, "methodology": "fee schedule" }, { "payer_name": "Iowa Medicaid - Amerigroup", "plan_name": "Iowa Medicaid - Amerigroup", "standard_charge_dollar": 500.0, "methodology": "fee schedule" }, { "payer_name": "Magellan Behavioral Health", "plan_name": "Magellan Behavioral Health", "standard_charge_dollar": 1255.0, "methodology": "fee schedule" }, { "payer_name": "Managed Health Services-Medicaid", "plan_name": "Managed Health Services-Medicaid", "standard_charge_dollar": 1379.52, "methodology": "fee schedule" }, { "payer_name": "McLaren Medicaid/Michigan", "plan_name": "McLaren Medicaid/Michigan", "standard_charge_dollar": 500.0, "methodology": "fee schedule" }, { "payer_name": "MDHHS: UPHP MI Medicaid C/o Northcare", "plan_name": "MDHHS: UPHP MI Medicaid C/o Northcare", "standard_charge_dollar": 500.0, "methodology": "fee schedule" }, { "payer_name": "MEDICA - SSM HEALTH DEAN EHP", "plan_name": "MEDICA - SSM HEALTH DEAN EHP", "standard_charge_dollar": 1300.0, "methodology": "fee schedule" }, { "payer_name": "Medical Associates", "plan_name": "Medical Associates", "standard_charge_dollar": 800.0, "methodology": "fee schedule" }, { "payer_name": "Mercy Care Wi Medicaid MCO", "plan_name": "Mercy Care Wi Medicaid MCO", "standard_charge_dollar": 1379.52, "methodology": "fee schedule" }, { "payer_name": "MercyCare Commerical", "plan_name": "MercyCare Commerical", "standard_charge_dollar": 1284.0, "methodology": "fee schedule" }, { "payer_name": "Minnesota Medicaid - Blue Plus", "plan_name": "Minnesota Medicaid - Blue Plus", "standard_charge_dollar": 500.0, "methodology": "fee schedule" }, { "payer_name": "Molina Healthcare Commercial", "plan_name": "Molina Healthcare Commercial", "standard_charge_dollar": 1400.0, "methodology": "fee schedule" }, { "payer_name": "Molina Healthcare Medicaid", "plan_name": "Molina Healthcare Medicaid", "standard_charge_dollar": 1379.52, "methodology": "fee schedule" }, { "payer_name": "My Choice-Care WI Medicaid", "plan_name": "My Choice-Care WI Medicaid", "standard_charge_dollar": 1379.52, "methodology": "fee schedule" }, { "payer_name": "My Choice-Trilogy Medicaid", "plan_name": "My Choice-Trilogy Medicaid", "standard_charge_dollar": 1379.52, "methodology": "fee schedule" }, { "payer_name": "Network Health HMO", "plan_name": "Network Health HMO", "standard_charge_dollar": 1300.0, "methodology": "fee schedule" }, { "payer_name": "Network Health Medicaid Managed", "plan_name": "Network Health Medicaid Managed", "standard_charge_dollar": 1379.52, "methodology": "fee schedule" }, { "payer_name": "Network Health PPO", "plan_name": "Network Health PPO", "standard_charge_dollar": 2100.0, "methodology": "fee schedule" }, { "payer_name": "Prairie States Enterprises INC", "plan_name": "Prairie States Enterprises INC", "standard_charge_dollar": 1059.0, "methodology": "fee schedule" }, { "payer_name": "Preferred One Admin Services", "plan_name": "Preferred One Admin Services", "standard_charge_dollar": 1100.0, "methodology": "fee schedule" }, { "payer_name": "Quartz Align - Brighton Health Plan", "plan_name": "Quartz Align - Brighton Health Plan", "standard_charge_dollar": 1250.0, "methodology": "fee schedule" }, { "payer_name": "Quartz Commercial Plan", "plan_name": "Quartz Commercial Plan", "standard_charge_dollar": 1250.0, "methodology": "fee schedule" }, { "payer_name": "Quartz Medicaid", "plan_name": "Quartz Medicaid", "standard_charge_dollar": 1379.52, "methodology": "fee schedule" }, { "payer_name": "RAS Workers Comp", "plan_name": "RAS Workers Comp", "standard_charge_dollar": 700.0, "methodology": "fee schedule" }, { "payer_name": "Richland County Health & Human Services", "plan_name": "Richland County Health & Human Services", "standard_charge_dollar": 1296.84, "methodology": "fee schedule" }, { "payer_name": "Rock County Human Services", "plan_name": "Rock County Human Services", "standard_charge_dollar": 1296.84, "methodology": "fee schedule" }, { "payer_name": "Sauk County Human Services", "plan_name": "Sauk County Human Services", "standard_charge_dollar": 1362.6, "methodology": "fee schedule" }, { "payer_name": "Security Health Plan", "plan_name": "Security Health Plan", "standard_charge_dollar": 1287.5, "methodology": "fee schedule" }, { "payer_name": "Security Health Plan Managed Medicaid", "plan_name": "Security Health Plan Managed Medicaid", "standard_charge_dollar": 1379.52, "methodology": "fee schedule" }, { "payer_name": "Sharp Health Plan HMO", "plan_name": "Sharp Health Plan HMO", "standard_charge_dollar": 800.0, "methodology": "fee schedule" }, { "payer_name": "Surest", "plan_name": "Surest", "standard_charge_dollar": 1300.0, "methodology": "fee schedule" }, { "payer_name": "The Alliance Auxiant", "plan_name": "The Alliance Auxiant", "standard_charge_dollar": 1300.0, "methodology": "fee schedule" }, { "payer_name": "TRICARE EAST-WPS", "plan_name": "TRICARE EAST-WPS", "standard_charge_dollar": 776.76, "methodology": "fee schedule" }, { "payer_name": "UHC Shared Services", "plan_name": "UHC Shared Services", "standard_charge_dollar": 1300.0, "methodology": "fee schedule" }, { "payer_name": "UHC/OPTUM", "plan_name": "UHC/OPTUM", "standard_charge_dollar": 1300.0, "methodology": "fee schedule" }, { "payer_name": "UMR Commercial", "plan_name": "UMR Commercial", "standard_charge_dollar": 1300.0, "methodology": "fee schedule" }, { "payer_name": "United Healthcare", "plan_name": "United Healthcare", "standard_charge_dollar": 1300.0, "methodology": "fee schedule" }, { "payer_name": "United Healthcare Medicaid Community Pla", "plan_name": "United Healthcare Medicaid Community Pla", "standard_charge_dollar": 1379.52, "methodology": "fee schedule" }, { "payer_name": "VA Medicaid United Healthcare", "plan_name": "VA Medicaid United Healthcare", "standard_charge_dollar": 500.0, "methodology": "fee schedule" }, { "payer_name": "Vernon County Human Services", "plan_name": "Vernon County Human Services", "standard_charge_dollar": 1400.0, "methodology": "fee schedule" }, { "payer_name": "Walworth County DHS", "plan_name": "Walworth County DHS", "standard_charge_dollar": 1389.57, "methodology": "fee schedule" }, { "payer_name": "WEA Trust Commercial", "plan_name": "WEA Trust Commercial", "standard_charge_dollar": 1250.0, "methodology": "fee schedule" }, { "payer_name": "Wellcare By Allwell", "plan_name": "Wellcare By Allwell", "standard_charge_dollar": 1300.0, "methodology": "fee schedule" }, { "payer_name": "Western Region Recovery & Wellness Conso", "plan_name": "Western Region Recovery & Wellness Conso", "standard_charge_dollar": 1212.0, "methodology": "fee schedule" }, { "payer_name": "Wood County Human Services Dept", "plan_name": "Wood County Human Services Dept", "standard_charge_dollar": 1344.99, "methodology": "fee schedule" } ], "gross_charge": 3000.0, "discounted_cash": 992.87, "minimum": 500.0, "maximum": 2100.0 } ] }, { "description": "Acute Gero R&B", "code_information": [ { "code": "124", "type": "RC" }, { "code": "1000", "type": "LOCAL" } ], "standard_charges": [ { "setting": "inpatient", "payers_information": [ { "payer_name": "Aetna Medicare", "plan_name": "Aetna Medicare", "standard_charge_dollar": 1645.0, "methodology": "fee schedule" }, { "payer_name": "All Savers - UHC", "plan_name": "All Savers - UHC", "standard_charge_dollar": 800.0, "methodology": "fee schedule" }, { "payer_name": "Anthem Commercial- HMO/PPO", "plan_name": "Anthem Commercial- HMO/PPO", "standard_charge_dollar": 1200.0, "methodology": "fee schedule" }, { "payer_name": "Anthem Medicaid", "plan_name": "Anthem Medicaid", "standard_charge_dollar": 1379.52, "methodology": "fee schedule" }, { "payer_name": "Aspirus Health Plan", "plan_name": "Aspirus Health Plan", "standard_charge_dollar": 1820.0, "methodology": "fee schedule" }, { "payer_name": "Barron County Dept Of Health & Human Ser", "plan_name": "Barron County Dept Of Health & Human Ser", "standard_charge_dollar": 1200.0, "methodology": "fee schedule" }, { "payer_name": "Bayfield County", "plan_name": "Bayfield County", "standard_charge_dollar": 1485.26, "methodology": "fee schedule" }, { "payer_name": "Chorus Childrens Community Health Plan", "plan_name": "Chorus Childrens Community Health Plan", "standard_charge_dollar": 1379.52, "methodology": "fee schedule" }, { "payer_name": "Dane County", "plan_name": "Dane County", "standard_charge_dollar": 1402.51, "methodology": "fee schedule" }, { "payer_name": "Dean Health Plan", "plan_name": "Dean Health Plan", "standard_charge_dollar": 1407.14, "methodology": "fee schedule" }, { "payer_name": "Dean Health-Medicaid", "plan_name": "Dean Health-Medicaid", "standard_charge_dollar": 1379.52, "methodology": "fee schedule" }, { "payer_name": "Dodge County Humana Services", "plan_name": "Dodge County Humana Services", "standard_charge_dollar": 1267.79, "methodology": "fee schedule" }, { "payer_name": "Group Health EauClaire Medicaid", "plan_name": "Group Health EauClaire Medicaid", "standard_charge_dollar": 1379.52, "methodology": "fee schedule" }, { "payer_name": "Group Health South Commerical", "plan_name": "Group Health South Commerical", "standard_charge_dollar": 1410.0, "methodology": "fee schedule" }, { "payer_name": "Group Health South Medicaid", "plan_name": "Group Health South Medicaid", "standard_charge_dollar": 1379.52, "methodology": "fee schedule" }, { "payer_name": "Health EOS - Multiplan", "plan_name": "Health EOS - Multiplan", "standard_charge_dollar": 1300.0, "methodology": "fee schedule" }, { "payer_name": "Humana Commercial", "plan_name": "Humana Commercial", "standard_charge_dollar": 800.0, "methodology": "fee schedule" }, { "payer_name": "ICare Medicaid", "plan_name": "ICare Medicaid", "standard_charge_dollar": 1379.52, "methodology": "fee schedule" }, { "payer_name": "ICare Medicare", "plan_name": "ICare Medicare", "standard_charge_dollar": 800.0, "methodology": "fee schedule" }, { "payer_name": "Illinois Medicaid - Molina", "plan_name": "Illinois Medicaid - Molina", "standard_charge_dollar": 500.0, "methodology": "fee schedule" }, { "payer_name": "Iowa Medicaid - Amerigroup", "plan_name": "Iowa Medicaid - Amerigroup", "standard_charge_dollar": 500.0, "methodology": "fee schedule" }, { "payer_name": "Magellan Behavioral Health", "plan_name": "Magellan Behavioral Health", "standard_charge_dollar": 1255.0, "methodology": "fee schedule" }, { "payer_name": "Managed Health Services-Medicaid", "plan_name": "Managed Health Services-Medicaid", "standard_charge_dollar": 1379.52, "methodology": "fee schedule" }, { "payer_name": "McLaren Medicaid/Michigan", "plan_name": "McLaren Medicaid/Michigan", "standard_charge_dollar": 500.0, "methodology": "fee schedule" }, { "payer_name": "MDHHS: UPHP MI Medicaid C/o Northcare", "plan_name": "MDHHS: UPHP MI Medicaid C/o Northcare", "standard_charge_dollar": 500.0, "methodology": "fee schedule" }, { "payer_name": "Mercy Care Wi Medicaid MCO", "plan_name": "Mercy Care Wi Medicaid MCO", "standard_charge_dollar": 1379.52, "methodology": "fee schedule" }, { "payer_name": "MercyCare Commerical", "plan_name": "MercyCare Commerical", "standard_charge_dollar": 1284.0, "methodology": "fee schedule" }, { "payer_name": "Minnesota Medicaid - Blue Plus", "plan_name": "Minnesota Medicaid - Blue Plus", "standard_charge_dollar": 500.0, "methodology": "fee schedule" }, { "payer_name": "Molina Healthcare Commercial", "plan_name": "Molina Healthcare Commercial", "standard_charge_dollar": 1400.0, "methodology": "fee schedule" }, { "payer_name": "Molina Healthcare Medicaid", "plan_name": "Molina Healthcare Medicaid", "standard_charge_dollar": 1379.52, "methodology": "fee schedule" }, { "payer_name": "My Choice-Care WI Medicaid", "plan_name": "My Choice-Care WI Medicaid", "standard_charge_dollar": 1379.52, "methodology": "fee schedule" }, { "payer_name": "My Choice-Trilogy Medicaid", "plan_name": "My Choice-Trilogy Medicaid", "standard_charge_dollar": 1379.52, "methodology": "fee schedule" }, { "payer_name": "Network Health HMO", "plan_name": "Network Health HMO", "standard_charge_dollar": 1300.0, "methodology": "fee schedule" }, { "payer_name": "Network Health Medicaid Managed", "plan_name": "Network Health Medicaid Managed", "standard_charge_dollar": 1379.52, "methodology": "fee schedule" }, { "payer_name": "Network Health PPO", "plan_name": "Network Health PPO", "standard_charge_dollar": 2100.0, "methodology": "fee schedule" }, { "payer_name": "Prairie States Enterprises INC", "plan_name": "Prairie States Enterprises INC", "standard_charge_dollar": 1059.0, "methodology": "fee schedule" }, { "payer_name": "Preferred One Admin Services", "plan_name": "Preferred One Admin Services", "standard_charge_dollar": 1100.0, "methodology": "fee schedule" }, { "payer_name": "Quartz Align - Brighton Health Plan", "plan_name": "Quartz Align - Brighton Health Plan", "standard_charge_dollar": 1250.0, "methodology": "fee schedule" }, { "payer_name": "Quartz Commercial Plan", "plan_name": "Quartz Commercial Plan", "standard_charge_dollar": 1250.0, "methodology": "fee schedule" }, { "payer_name": "Quartz Medicaid", "plan_name": "Quartz Medicaid", "standard_charge_dollar": 1379.52, "methodology": "fee schedule" }, { "payer_name": "RAS Workers Comp", "plan_name": "RAS Workers Comp", "standard_charge_dollar": 700.0, "methodology": "fee schedule" }, { "payer_name": "Richland County Health & Human Services", "plan_name": "Richland County Health & Human Services", "standard_charge_dollar": 1296.84, "methodology": "fee schedule" }, { "payer_name": "Rock County Human Services", "plan_name": "Rock County Human Services", "standard_charge_dollar": 1296.84, "methodology": "fee schedule" }, { "payer_name": "Sauk County Human Services", "plan_name": "Sauk County Human Services", "standard_charge_dollar": 1362.6, "methodology": "fee schedule" }, { "payer_name": "Security Health Plan", "plan_name": "Security Health Plan", "standard_charge_dollar": 1287.5, "methodology": "fee schedule" }, { "payer_name": "Security Health Plan Managed Medicaid", "plan_name": "Security Health Plan Managed Medicaid", "standard_charge_dollar": 1379.52, "methodology": "fee schedule" }, { "payer_name": "The Alliance Auxiant", "plan_name": "The Alliance Auxiant", "standard_charge_dollar": 1300.0, "methodology": "fee schedule" }, { "payer_name": "TRICARE EAST-WPS", "plan_name": "TRICARE EAST-WPS", "standard_charge_dollar": 776.76, "methodology": "fee schedule" }, { "payer_name": "UMR Commercial", "plan_name": "UMR Commercial", "standard_charge_dollar": 1300.0, "methodology": "fee schedule" }, { "payer_name": "United Healthcare", "plan_name": "United Healthcare", "standard_charge_dollar": 1300.0, "methodology": "fee schedule" }, { "payer_name": "United Healthcare Medicaid Community Pla", "plan_name": "United Healthcare Medicaid Community Pla", "standard_charge_dollar": 1379.52, "methodology": "fee schedule" }, { "payer_name": "VA Medicaid United Healthcare", "plan_name": "VA Medicaid United Healthcare", "standard_charge_dollar": 500.0, "methodology": "fee schedule" }, { "payer_name": "Vernon County Human Services", "plan_name": "Vernon County Human Services", "standard_charge_dollar": 1400.0, "methodology": "fee schedule" }, { "payer_name": "Walworth County DHS", "plan_name": "Walworth County DHS", "standard_charge_dollar": 1389.57, "methodology": "fee schedule" }, { "payer_name": "WEA Trust Commercial", "plan_name": "WEA Trust Commercial", "standard_charge_dollar": 1250.0, "methodology": "fee schedule" }, { "payer_name": "Wood County Human Services Dept", "plan_name": "Wood County Human Services Dept", "standard_charge_dollar": 1344.99, "methodology": "fee schedule" } ], "gross_charge": 3000.0, "minimum": 500.0, "maximum": 2100.0 } ] }, { "description": "Acute Psych Adol R&B", "code_information": [ { "code": "124", "type": "RC" }, { "code": "902", "type": "LOCAL" } ], "standard_charges": [ { "setting": "inpatient", "payers_information": [ { "payer_name": "Group Health Coop Eau Claire - Commercia", "plan_name": "Group Health Coop Eau Claire - Commercia", "standard_charge_dollar": 1300.0, "methodology": "fee schedule" } ], "gross_charge": 3000.0, "minimum": 1300.0, "maximum": 1300.0 } ] }, { "description": "Acute Psych Adult R&B", "code_information": [ { "code": "124", "type": "RC" }, { "code": "901", "type": "LOCAL" } ], "standard_charges": [ { "setting": "inpatient", "payers_information": [ { "payer_name": "Allied Benefits", "plan_name": "Allied Benefits", "standard_charge_dollar": 1000.0, "methodology": "fee schedule" }, { "payer_name": "Centivo - Multiplan", "plan_name": "Centivo - Multiplan", "standard_charge_dollar": 1300.0, "methodology": "fee schedule" }, { "payer_name": "Group Health Coop Eau Claire - Commercia", "plan_name": "Group Health Coop Eau Claire - Commercia", "standard_charge_dollar": 1300.0, "methodology": "fee schedule" }, { "payer_name": "UHC Shared Services", "plan_name": "UHC Shared Services", "standard_charge_dollar": 1300.0, "methodology": "fee schedule" } ], "gross_charge": 3000.0, "minimum": 1000.0, "maximum": 1300.0 } ] }, { "description": "Acute Adult CD R&B", "code_information": [ { "code": "126", "type": "RC" }, { "code": "1004", "type": "LOCAL" } ], "standard_charges": [ { "setting": "inpatient", "payers_information": [ { "payer_name": "Administrative Concepts Inc", "plan_name": "Administrative Concepts Inc", "standard_charge_dollar": 800.0, "methodology": "fee schedule" }, { "payer_name": "Aetna", "plan_name": "Aetna", "standard_charge_dollar": 928.0, "methodology": "fee schedule" }, { "payer_name": "Aetna Medicare", "plan_name": "Aetna Medicare", "standard_charge_dollar": 1645.0, "methodology": "fee schedule" }, { "payer_name": "All Savers - UHC", "plan_name": "All Savers - UHC", "standard_charge_dollar": 800.0, "methodology": "fee schedule" }, { "payer_name": "Allegiance Benefit Plan Management", "plan_name": "Allegiance Benefit Plan Management", "standard_charge_dollar": 1250.0, "methodology": "fee schedule" }, { "payer_name": "Anthem Commercial- HMO/PPO", "plan_name": "Anthem Commercial- HMO/PPO", "standard_charge_dollar": 1200.0, "methodology": "fee schedule" }, { "payer_name": "Anthem Commerical- Blue Priority", "plan_name": "Anthem Commerical- Blue Priority", "standard_charge_dollar": 1200.0, "methodology": "fee schedule" }, { "payer_name": "Anthem Medicaid", "plan_name": "Anthem Medicaid", "standard_charge_dollar": 1379.52, "methodology": "fee schedule" }, { "payer_name": "Aspirus Health Plan", "plan_name": "Aspirus Health Plan", "standard_charge_dollar": 1820.0, "methodology": "fee schedule" }, { "payer_name": "Carelon Behavioral Health", "plan_name": "Carelon Behavioral Health", "standard_charge_dollar": 1000.0, "methodology": "fee schedule" }, { "payer_name": "Chorus Childrens Community Health Plan", "plan_name": "Chorus Childrens Community Health Plan", "standard_charge_dollar": 1379.52, "methodology": "fee schedule" }, { "payer_name": "Cigna Healthcare", "plan_name": "Cigna Healthcare", "standard_charge_dollar": 1250.0, "methodology": "fee schedule" }, { "payer_name": "Crawford County Human Services", "plan_name": "Crawford County Human Services", "standard_charge_dollar": 1335.75, "methodology": "fee schedule" }, { "payer_name": "Dean Health Plan", "plan_name": "Dean Health Plan", "standard_charge_dollar": 1407.14, "methodology": "fee schedule" }, { "payer_name": "Dean Health-Medicaid", "plan_name": "Dean Health-Medicaid", "standard_charge_dollar": 1379.52, "methodology": "fee schedule" }, { "payer_name": "Group Health Coop Eau Claire - Commercia", "plan_name": "Group Health Coop Eau Claire - Commercia", "standard_charge_dollar": 1300.0, "methodology": "fee schedule" }, { "payer_name": "Group Health EauClaire Medicaid", "plan_name": "Group Health EauClaire Medicaid", "standard_charge_dollar": 1379.52, "methodology": "fee schedule" }, { "payer_name": "Group Health South Commerical", "plan_name": "Group Health South Commerical", "standard_charge_dollar": 1410.0, "methodology": "fee schedule" }, { "payer_name": "Group Health South Medicaid", "plan_name": "Group Health South Medicaid", "standard_charge_dollar": 1379.52, "methodology": "fee schedule" }, { "payer_name": "Health EOS - Multiplan", "plan_name": "Health EOS - Multiplan", "standard_charge_dollar": 1300.0, "methodology": "fee schedule" }, { "payer_name": "HealthComp", "plan_name": "HealthComp", "standard_charge_dollar": 1250.0, "methodology": "fee schedule" }, { "payer_name": "HealthPartners", "plan_name": "HealthPartners", "standard_charge_dollar": 1450.0, "methodology": "fee schedule" }, { "payer_name": "Humana Commercial", "plan_name": "Humana Commercial", "standard_charge_dollar": 800.0, "methodology": "fee schedule" }, { "payer_name": "ICare Medicaid", "plan_name": "ICare Medicaid", "standard_charge_dollar": 1379.52, "methodology": "fee schedule" }, { "payer_name": "Iowa Medicaid - Amerigroup", "plan_name": "Iowa Medicaid - Amerigroup", "standard_charge_dollar": 500.0, "methodology": "fee schedule" }, { "payer_name": "Magellan Behavioral Health", "plan_name": "Magellan Behavioral Health", "standard_charge_dollar": 1255.0, "methodology": "fee schedule" }, { "payer_name": "Managed Health Services-Medicaid", "plan_name": "Managed Health Services-Medicaid", "standard_charge_dollar": 1379.52, "methodology": "fee schedule" }, { "payer_name": "McLaren Medicaid/Michigan", "plan_name": "McLaren Medicaid/Michigan", "standard_charge_dollar": 500.0, "methodology": "fee schedule" }, { "payer_name": "MDHHS: UPHP MI Medicaid C/o Northcare", "plan_name": "MDHHS: UPHP MI Medicaid C/o Northcare", "standard_charge_dollar": 500.0, "methodology": "fee schedule" }, { "payer_name": "MEDICA - DEAN COMMERCIAL", "plan_name": "MEDICA - DEAN COMMERCIAL", "standard_charge_dollar": 1200.0, "methodology": "fee schedule" }, { "payer_name": "MEDICA - SSM HEALTH DEAN EHP", "plan_name": "MEDICA - SSM HEALTH DEAN EHP", "standard_charge_dollar": 1300.0, "methodology": "fee schedule" }, { "payer_name": "Medica Government Programs", "plan_name": "Medica Government Programs", "standard_charge_dollar": 1250.0, "methodology": "fee schedule" }, { "payer_name": "Medical Associates", "plan_name": "Medical Associates", "standard_charge_dollar": 800.0, "methodology": "fee schedule" }, { "payer_name": "Mercy Care Wi Medicaid MCO", "plan_name": "Mercy Care Wi Medicaid MCO", "standard_charge_dollar": 1379.52, "methodology": "fee schedule" }, { "payer_name": "MercyCare Commerical", "plan_name": "MercyCare Commerical", "standard_charge_dollar": 1284.0, "methodology": "fee schedule" }, { "payer_name": "Molina Healthcare Commercial", "plan_name": "Molina Healthcare Commercial", "standard_charge_dollar": 1400.0, "methodology": "fee schedule" }, { "payer_name": "Molina Healthcare Medicaid", "plan_name": "Molina Healthcare Medicaid", "standard_charge_dollar": 1379.52, "methodology": "fee schedule" }, { "payer_name": "My Choice-Care WI Medicaid", "plan_name": "My Choice-Care WI Medicaid", "standard_charge_dollar": 1379.52, "methodology": "fee schedule" }, { "payer_name": "Network Health HMO", "plan_name": "Network Health HMO", "standard_charge_dollar": 1300.0, "methodology": "fee schedule" }, { "payer_name": "Network Health Medicaid Managed", "plan_name": "Network Health Medicaid Managed", "standard_charge_dollar": 1379.52, "methodology": "fee schedule" }, { "payer_name": "Network Health PPO", "plan_name": "Network Health PPO", "standard_charge_dollar": 2100.0, "methodology": "fee schedule" }, { "payer_name": "Physicians Mutual", "plan_name": "Physicians Mutual", "standard_charge_dollar": 1250.0, "methodology": "fee schedule" }, { "payer_name": "Prairie States Enterprises INC", "plan_name": "Prairie States Enterprises INC", "standard_charge_dollar": 1059.0, "methodology": "fee schedule" }, { "payer_name": "Preferred One Admin Services", "plan_name": "Preferred One Admin Services", "standard_charge_dollar": 1100.0, "methodology": "fee schedule" }, { "payer_name": "Prevea 360 Commercial", "plan_name": "Prevea 360 Commercial", "standard_charge_dollar": 1000.0, "methodology": "fee schedule" }, { "payer_name": "Quartz Align - Brighton Health Plan", "plan_name": "Quartz Align - Brighton Health Plan", "standard_charge_dollar": 1250.0, "methodology": "fee schedule" }, { "payer_name": "Quartz Commercial Plan", "plan_name": "Quartz Commercial Plan", "standard_charge_dollar": 1250.0, "methodology": "fee schedule" }, { "payer_name": "Quartz Medicaid", "plan_name": "Quartz Medicaid", "standard_charge_dollar": 1379.52, "methodology": "fee schedule" }, { "payer_name": "RAS Workers Comp", "plan_name": "RAS Workers Comp", "standard_charge_dollar": 700.0, "methodology": "fee schedule" }, { "payer_name": "Richland County Health & Human Services", "plan_name": "Richland County Health & Human Services", "standard_charge_dollar": 1296.84, "methodology": "fee schedule" }, { "payer_name": "Sauk County Human Services", "plan_name": "Sauk County Human Services", "standard_charge_dollar": 1362.6, "methodology": "fee schedule" }, { "payer_name": "Security Health Plan", "plan_name": "Security Health Plan", "standard_charge_dollar": 1287.5, "methodology": "fee schedule" }, { "payer_name": "Security Health Plan Managed Medicaid", "plan_name": "Security Health Plan Managed Medicaid", "standard_charge_dollar": 1379.52, "methodology": "fee schedule" }, { "payer_name": "Sharp Health Plan HMO", "plan_name": "Sharp Health Plan HMO", "standard_charge_dollar": 800.0, "methodology": "fee schedule" }, { "payer_name": "Surest", "plan_name": "Surest", "standard_charge_dollar": 1300.0, "methodology": "fee schedule" }, { "payer_name": "The Alliance Auxiant", "plan_name": "The Alliance Auxiant", "standard_charge_dollar": 1300.0, "methodology": "fee schedule" }, { "payer_name": "UHC Shared Services", "plan_name": "UHC Shared Services", "standard_charge_dollar": 1300.0, "methodology": "fee schedule" }, { "payer_name": "UHC/OPTUM", "plan_name": "UHC/OPTUM", "standard_charge_dollar": 1300.0, "methodology": "fee schedule" }, { "payer_name": "UMR Commercial", "plan_name": "UMR Commercial", "standard_charge_dollar": 1300.0, "methodology": "fee schedule" }, { "payer_name": "Unified Community Services", "plan_name": "Unified Community Services", "standard_charge_dollar": 1250.0, "methodology": "fee schedule" }, { "payer_name": "United Healthcare", "plan_name": "United Healthcare", "standard_charge_dollar": 1300.0, "methodology": "fee schedule" }, { "payer_name": "United Healthcare Medicaid Community Pla", "plan_name": "United Healthcare Medicaid Community Pla", "standard_charge_dollar": 1379.52, "methodology": "fee schedule" }, { "payer_name": "WEA Trust Commercial", "plan_name": "WEA Trust Commercial", "standard_charge_dollar": 1250.0, "methodology": "fee schedule" }, { "payer_name": "Wellcare By Allwell", "plan_name": "Wellcare By Allwell", "standard_charge_dollar": 1300.0, "methodology": "fee schedule" }, { "payer_name": "Western Region Recovery & Wellness Conso", "plan_name": "Western Region Recovery & Wellness Conso", "standard_charge_dollar": 1212.0, "methodology": "fee schedule" }, { "payer_name": "Wood County Human Services Dept", "plan_name": "Wood County Human Services Dept", "standard_charge_dollar": 1344.99, "methodology": "fee schedule" } ], "gross_charge": 3000.0, "discounted_cash": 992.87, "minimum": 500.0, "maximum": 2100.0 } ] }, { "description": "Adol Psych IOP 3 hrs", "code_information": [ { "code": "H0015", "type": "HCPCS" }, { "code": "1060", "type": "LOCAL" } ], "standard_charges": [ { "setting": "outpatient", "payers_information": [ { "payer_name": "Aetna Medicare", "plan_name": "Aetna Medicare", "standard_charge_dollar": 980.0, "methodology": "fee schedule" }, { "payer_name": "Aspirus Health Plan", "plan_name": "Aspirus Health Plan", "standard_charge_dollar": 980.0, "methodology": "fee schedule" }, { "payer_name": "Chorus Childrens Community Health Plan", "plan_name": "Chorus Childrens Community Health Plan", "standard_charge_dollar": 847.57, "methodology": "fee schedule" }, { "payer_name": "Health EOS - Multiplan", "plan_name": "Health EOS - Multiplan", "standard_charge_dollar": 300.0, "methodology": "fee schedule" }, { "payer_name": "MercyCare Commerical", "plan_name": "MercyCare Commerical", "standard_charge_dollar": 240.75, "methodology": "fee schedule" }, { "payer_name": "WEA Trust Commercial", "plan_name": "WEA Trust Commercial", "standard_charge_dollar": 225.0, "methodology": "fee schedule" } ], "gross_charge": 1700.0, "minimum": 225.0, "maximum": 980.0 } ] }, { "description": "Adult Psych IOP 3 Hrs", "code_information": [ { "code": "90853", "type": "CPT" }, { "code": "956", "type": "LOCAL" } ], "standard_charges": [ { "setting": "outpatient", "payers_information": [ { "payer_name": "AARP Medicare Complete", "plan_name": "AARP Medicare Complete", "standard_charge_dollar": 250.0, "methodology": "fee schedule" }, { "payer_name": "Administrative Concepts Inc", "plan_name": "Administrative Concepts Inc", "standard_charge_dollar": 200.0, "methodology": "fee schedule" }, { "payer_name": "Aetna", "plan_name": "Aetna", "standard_charge_dollar": 200.0, "methodology": "fee schedule" }, { "payer_name": "Aetna Medicare", "plan_name": "Aetna Medicare", "standard_charge_dollar": 980.0, "methodology": "fee schedule" }, { "payer_name": "Allegiance Benefit Plan Management", "plan_name": "Allegiance Benefit Plan Management", "standard_charge_dollar": 250.0, "methodology": "fee schedule" }, { "payer_name": "Anthem Commercial- HMO/PPO", "plan_name": "Anthem Commercial- HMO/PPO", "standard_charge_dollar": 210.0, "methodology": "fee schedule" }, { "payer_name": "Anthem Commerical- Blue Priority", "plan_name": "Anthem Commerical- Blue Priority", "standard_charge_dollar": 210.0, "methodology": "fee schedule" }, { "payer_name": "Anthem Medicaid", "plan_name": "Anthem Medicaid", "standard_charge_dollar": 847.57, "methodology": "fee schedule" }, { "payer_name": "Anthem Medicare", "plan_name": "Anthem Medicare", "standard_charge_dollar": 200.0, "methodology": "fee schedule" }, { "payer_name": "Aspirus Health Plan", "plan_name": "Aspirus Health Plan", "standard_charge_dollar": 980.0, "methodology": "fee schedule" }, { "payer_name": "Aspirus Medicare", "plan_name": "Aspirus Medicare", "standard_charge_dollar": 200.0, "methodology": "fee schedule" }, { "payer_name": "Carelon Behavioral Health", "plan_name": "Carelon Behavioral Health", "standard_charge_dollar": 225.0, "methodology": "fee schedule" }, { "payer_name": "Cigna Healthcare", "plan_name": "Cigna Healthcare", "standard_charge_dollar": 250.0, "methodology": "fee schedule" }, { "payer_name": "Dean Health Plan", "plan_name": "Dean Health Plan", "standard_charge_dollar": 261.32, "methodology": "fee schedule" }, { "payer_name": "Dean Health-Medicaid", "plan_name": "Dean Health-Medicaid", "standard_charge_dollar": 847.57, "methodology": "fee schedule" }, { "payer_name": "Dean Medicare Advantage Plan", "plan_name": "Dean Medicare Advantage Plan", "standard_charge_dollar": 200.0, "methodology": "fee schedule" }, { "payer_name": "Group Health South Commerical", "plan_name": "Group Health South Commerical", "standard_charge_dollar": 225.0, "methodology": "fee schedule" }, { "payer_name": "Group Health South Medicaid", "plan_name": "Group Health South Medicaid", "standard_charge_dollar": 847.57, "methodology": "fee schedule" }, { "payer_name": "Health EOS - Multiplan", "plan_name": "Health EOS - Multiplan", "standard_charge_dollar": 300.0, "methodology": "fee schedule" }, { "payer_name": "HealthPartners", "plan_name": "HealthPartners", "standard_charge_dollar": 325.0, "methodology": "fee schedule" }, { "payer_name": "Humana Medicare", "plan_name": "Humana Medicare", "standard_charge_dollar": 250.0, "methodology": "fee schedule" }, { "payer_name": "ICare Medicaid", "plan_name": "ICare Medicaid", "standard_charge_dollar": 847.57, "methodology": "fee schedule" }, { "payer_name": "ICare Medicare", "plan_name": "ICare Medicare", "standard_charge_dollar": 175.0, "methodology": "fee schedule" }, { "payer_name": "Lutheran Social Services Of WI And UP", "plan_name": "Lutheran Social Services Of WI And UP", "standard_charge_dollar": 200.0, "methodology": "fee schedule" }, { "payer_name": "Magellan Behavioral Health", "plan_name": "Magellan Behavioral Health", "standard_charge_dollar": 275.0, "methodology": "fee schedule" }, { "payer_name": "Managed Health Services Medicare Advanta", "plan_name": "Managed Health Services Medicare Advanta", "standard_charge_dollar": 250.0, "methodology": "fee schedule" }, { "payer_name": "Managed Health Services-Medicaid", "plan_name": "Managed Health Services-Medicaid", "standard_charge_dollar": 847.57, "methodology": "fee schedule" }, { "payer_name": "MEDICA - SSM HEALTH DEAN EHP", "plan_name": "MEDICA - SSM HEALTH DEAN EHP", "standard_charge_dollar": 275.0, "methodology": "fee schedule" }, { "payer_name": "Mercy Care Wi Medicaid MCO", "plan_name": "Mercy Care Wi Medicaid MCO", "standard_charge_dollar": 847.57, "methodology": "fee schedule" }, { "payer_name": "MercyCare Commerical", "plan_name": "MercyCare Commerical", "standard_charge_dollar": 240.75, "methodology": "fee schedule" }, { "payer_name": "Molina Healthcare Commercial", "plan_name": "Molina Healthcare Commercial", "standard_charge_dollar": 170.0, "methodology": "fee schedule" }, { "payer_name": "Molina Healthcare Medicaid", "plan_name": "Molina Healthcare Medicaid", "standard_charge_dollar": 847.57, "methodology": "fee schedule" }, { "payer_name": "My Choice -Medicare Advantage Plan", "plan_name": "My Choice -Medicare Advantage Plan", "standard_charge_dollar": 55.22, "methodology": "fee schedule" }, { "payer_name": "My Choice-Care WI Medicaid", "plan_name": "My Choice-Care WI Medicaid", "standard_charge_dollar": 847.57, "methodology": "fee schedule" }, { "payer_name": "Network Health HMO", "plan_name": "Network Health HMO", "standard_charge_dollar": 225.23, "methodology": "fee schedule" }, { "payer_name": "Network Health Medicaid Managed", "plan_name": "Network Health Medicaid Managed", "standard_charge_dollar": 847.57, "methodology": "fee schedule" }, { "payer_name": "Network Health PPO", "plan_name": "Network Health PPO", "standard_charge_dollar": 1190.0, "methodology": "fee schedule" }, { "payer_name": "Preferred One Admin Services", "plan_name": "Preferred One Admin Services", "standard_charge_dollar": 212.0, "methodology": "fee schedule" }, { "payer_name": "Quartz Align - Brighton Health Plan", "plan_name": "Quartz Align - Brighton Health Plan", "standard_charge_dollar": 350.0, "methodology": "fee schedule" }, { "payer_name": "Quartz Commercial Plan", "plan_name": "Quartz Commercial Plan", "standard_charge_dollar": 350.0, "methodology": "fee schedule" }, { "payer_name": "Quartz Medicaid", "plan_name": "Quartz Medicaid", "standard_charge_dollar": 847.57, "methodology": "fee schedule" }, { "payer_name": "Quartz Medicare Advantage Plan", "plan_name": "Quartz Medicare Advantage Plan", "standard_charge_dollar": 200.0, "methodology": "fee schedule" }, { "payer_name": "Security Health Medicare Advantage", "plan_name": "Security Health Medicare Advantage", "standard_charge_dollar": 200.0, "methodology": "fee schedule" }, { "payer_name": "Security Health Plan", "plan_name": "Security Health Plan", "standard_charge_dollar": 283.25, "methodology": "fee schedule" }, { "payer_name": "Sharp Health Plan HMO", "plan_name": "Sharp Health Plan HMO", "standard_charge_dollar": 200.0, "methodology": "fee schedule" }, { "payer_name": "Surest", "plan_name": "Surest", "standard_charge_dollar": 275.0, "methodology": "fee schedule" }, { "payer_name": "The Alliance Auxiant", "plan_name": "The Alliance Auxiant", "standard_charge_dollar": 250.0, "methodology": "fee schedule" }, { "payer_name": "Tricare West", "plan_name": "Tricare West", "standard_charge_dollar": 321.1, "methodology": "fee schedule" }, { "payer_name": "UHC Medicare Advantage Plan", "plan_name": "UHC Medicare Advantage Plan", "standard_charge_dollar": 200.0, "methodology": "fee schedule" }, { "payer_name": "UHC Shared Services", "plan_name": "UHC Shared Services", "standard_charge_dollar": 275.0, "methodology": "fee schedule" }, { "payer_name": "UHC/OPTUM", "plan_name": "UHC/OPTUM", "standard_charge_dollar": 275.0, "methodology": "fee schedule" }, { "payer_name": "UMR Commercial", "plan_name": "UMR Commercial", "standard_charge_dollar": 275.0, "methodology": "fee schedule" }, { "payer_name": "United Healthcare", "plan_name": "United Healthcare", "standard_charge_dollar": 275.0, "methodology": "fee schedule" }, { "payer_name": "United Healthcare Medicaid Community Pla", "plan_name": "United Healthcare Medicaid Community Pla", "standard_charge_dollar": 847.57, "methodology": "fee schedule" }, { "payer_name": "WEA Trust Commercial", "plan_name": "WEA Trust Commercial", "standard_charge_dollar": 225.0, "methodology": "fee schedule" }, { "payer_name": "Wellcare By Allwell", "plan_name": "Wellcare By Allwell", "standard_charge_dollar": 275.0, "methodology": "fee schedule" } ], "gross_charge": 1700.0, "discounted_cash": 200.0, "minimum": 55.22, "maximum": 1190.0 } ] }, { "description": "Gero IOP 3 hrs", "code_information": [ { "code": "90853", "type": "CPT" }, { "code": "1050", "type": "LOCAL" } ], "standard_charges": [ { "setting": "outpatient", "payers_information": [ { "payer_name": "Aetna Medicare", "plan_name": "Aetna Medicare", "standard_charge_dollar": 980.0, "methodology": "fee schedule" }, { "payer_name": "Aspirus Health Plan", "plan_name": "Aspirus Health Plan", "standard_charge_dollar": 980.0, "methodology": "fee schedule" }, { "payer_name": "Chorus Childrens Community Health Plan", "plan_name": "Chorus Childrens Community Health Plan", "standard_charge_dollar": 847.57, "methodology": "fee schedule" }, { "payer_name": "Cigna Healthcare", "plan_name": "Cigna Healthcare", "standard_charge_dollar": 250.0, "methodology": "fee schedule" }, { "payer_name": "Health EOS - Multiplan", "plan_name": "Health EOS - Multiplan", "standard_charge_dollar": 300.0, "methodology": "fee schedule" }, { "payer_name": "MercyCare Commerical", "plan_name": "MercyCare Commerical", "standard_charge_dollar": 240.75, "methodology": "fee schedule" }, { "payer_name": "WEA Trust Commercial", "plan_name": "WEA Trust Commercial", "standard_charge_dollar": 225.0, "methodology": "fee schedule" } ], "gross_charge": 1700.0, "discounted_cash": 200.0, "minimum": 225.0, "maximum": 980.0 } ] }, { "description": "Telehealth Adult Psych IOP 3 hrs", "code_information": [ { "code": "90853", "type": "CPT" }, { "code": "825", "type": "LOCAL" } ], "standard_charges": [ { "setting": "outpatient", "payers_information": [ { "payer_name": "Anthem Commercial- HMO/PPO", "plan_name": "Anthem Commercial- HMO/PPO", "standard_charge_dollar": 210.0, "methodology": "fee schedule" }, { "payer_name": "Anthem Commerical- Blue Priority", "plan_name": "Anthem Commerical- Blue Priority", "standard_charge_dollar": 210.0, "methodology": "fee schedule" }, { "payer_name": "Anthem Medicaid", "plan_name": "Anthem Medicaid", "standard_charge_dollar": 847.57, "methodology": "fee schedule" }, { "payer_name": "Anthem Medicare", "plan_name": "Anthem Medicare", "standard_charge_dollar": 200.0, "methodology": "fee schedule" }, { "payer_name": "Chorus Childrens Community Health Plan", "plan_name": "Chorus Childrens Community Health Plan", "standard_charge_dollar": 847.57, "methodology": "fee schedule" }, { "payer_name": "Cigna Healthcare", "plan_name": "Cigna Healthcare", "standard_charge_dollar": 250.0, "methodology": "fee schedule" }, { "payer_name": "Dean Health Plan", "plan_name": "Dean Health Plan", "standard_charge_dollar": 261.32, "methodology": "fee schedule" }, { "payer_name": "Dean Health-Medicaid", "plan_name": "Dean Health-Medicaid", "standard_charge_dollar": 847.57, "methodology": "fee schedule" }, { "payer_name": "Group Health EauClaire Medicaid", "plan_name": "Group Health EauClaire Medicaid", "standard_charge_dollar": 847.57, "methodology": "fee schedule" }, { "payer_name": "HealthPartners", "plan_name": "HealthPartners", "standard_charge_dollar": 325.0, "methodology": "fee schedule" }, { "payer_name": "Humana Medicare", "plan_name": "Humana Medicare", "standard_charge_dollar": 250.0, "methodology": "fee schedule" }, { "payer_name": "ICare Medicaid", "plan_name": "ICare Medicaid", "standard_charge_dollar": 847.57, "methodology": "fee schedule" }, { "payer_name": "ICare Medicare", "plan_name": "ICare Medicare", "standard_charge_dollar": 175.0, "methodology": "fee schedule" }, { "payer_name": "Managed Health Services-Medicaid", "plan_name": "Managed Health Services-Medicaid", "standard_charge_dollar": 847.57, "methodology": "fee schedule" }, { "payer_name": "Molina Healthcare Medicaid", "plan_name": "Molina Healthcare Medicaid", "standard_charge_dollar": 847.57, "methodology": "fee schedule" }, { "payer_name": "My Choice-Care WI Medicaid", "plan_name": "My Choice-Care WI Medicaid", "standard_charge_dollar": 847.57, "methodology": "fee schedule" }, { "payer_name": "Network Health HMO", "plan_name": "Network Health HMO", "standard_charge_dollar": 225.23, "methodology": "fee schedule" }, { "payer_name": "Network Health PPO", "plan_name": "Network Health PPO", "standard_charge_dollar": 1190.0, "methodology": "fee schedule" }, { "payer_name": "Quartz Align - Brighton Health Plan", "plan_name": "Quartz Align - Brighton Health Plan", "standard_charge_dollar": 350.0, "methodology": "fee schedule" }, { "payer_name": "Quartz Commercial Plan", "plan_name": "Quartz Commercial Plan", "standard_charge_dollar": 350.0, "methodology": "fee schedule" }, { "payer_name": "Quartz Medicaid", "plan_name": "Quartz Medicaid", "standard_charge_dollar": 847.57, "methodology": "fee schedule" }, { "payer_name": "Security Health Plan Managed Medicaid", "plan_name": "Security Health Plan Managed Medicaid", "standard_charge_dollar": 847.57, "methodology": "fee schedule" }, { "payer_name": "Surest", "plan_name": "Surest", "standard_charge_dollar": 275.0, "methodology": "fee schedule" }, { "payer_name": "TRICARE EAST-WPS", "plan_name": "TRICARE EAST-WPS", "standard_charge_dollar": 249.1, "methodology": "fee schedule" }, { "payer_name": "UHC Medicare Advantage Plan", "plan_name": "UHC Medicare Advantage Plan", "standard_charge_dollar": 200.0, "methodology": "fee schedule" }, { "payer_name": "UHC Medicare Dual Complete", "plan_name": "UHC Medicare Dual Complete", "standard_charge_dollar": 150.0, "methodology": "fee schedule" }, { "payer_name": "UHC Shared Services", "plan_name": "UHC Shared Services", "standard_charge_dollar": 275.0, "methodology": "fee schedule" }, { "payer_name": "UMR Commercial", "plan_name": "UMR Commercial", "standard_charge_dollar": 275.0, "methodology": "fee schedule" }, { "payer_name": "United Healthcare", "plan_name": "United Healthcare", "standard_charge_dollar": 275.0, "methodology": "fee schedule" }, { "payer_name": "United Healthcare Medicaid Community Pla", "plan_name": "United Healthcare Medicaid Community Pla", "standard_charge_dollar": 847.57, "methodology": "fee schedule" }, { "payer_name": "Wellcare By Allwell", "plan_name": "Wellcare By Allwell", "standard_charge_dollar": 275.0, "methodology": "fee schedule" } ], "gross_charge": 1700.0, "discounted_cash": 200.0, "minimum": 150.0, "maximum": 1190.0 } ] }, { "description": "Adol CD IOP 3 hrs", "code_information": [ { "code": "H0015", "type": "HCPCS" }, { "code": "1040", "type": "LOCAL" } ], "standard_charges": [ { "setting": "outpatient", "payers_information": [ { "payer_name": "Chorus Childrens Community Health Plan", "plan_name": "Chorus Childrens Community Health Plan", "standard_charge_dollar": 847.57, "methodology": "fee schedule" }, { "payer_name": "MercyCare Commerical", "plan_name": "MercyCare Commerical", "standard_charge_dollar": 240.75, "methodology": "fee schedule" } ], "gross_charge": 1700.0, "minimum": 240.75, "maximum": 847.57 } ] }, { "description": "Adult Psych PHP 6 hrs", "code_information": [ { "code": "H0035", "type": "HCPCS" }, { "code": "215", "type": "LOCAL" } ], "standard_charges": [ { "setting": "outpatient", "payers_information": [ { "payer_name": "HealthPartners", "plan_name": "HealthPartners", "standard_charge_dollar": 500.0, "methodology": "fee schedule" } ], "gross_charge": 2500.0, "discounted_cash": 350.0, "minimum": 500.0, "maximum": 500.0 } ] }, { "description": "PHP Daily Adult", "code_information": [ { "code": "H0035", "type": "HCPCS" }, { "code": "5200", "type": "LOCAL" } ], "standard_charges": [ { "setting": "outpatient", "payers_information": [ { "payer_name": "Administrative Concepts Inc", "plan_name": "Administrative Concepts Inc", "standard_charge_dollar": 500.0, "methodology": "fee schedule" }, { "payer_name": "Aetna", "plan_name": "Aetna", "standard_charge_dollar": 500.0, "methodology": "fee schedule" }, { "payer_name": "Aetna Medicare", "plan_name": "Aetna Medicare", "standard_charge_dollar": 1435.0, "methodology": "fee schedule" }, { "payer_name": "Anthem Commercial- HMO/PPO", "plan_name": "Anthem Commercial- HMO/PPO", "standard_charge_dollar": 315.0, "methodology": "fee schedule" }, { "payer_name": "Anthem Commerical- Blue Priority", "plan_name": "Anthem Commerical- Blue Priority", "standard_charge_dollar": 299.0, "methodology": "fee schedule" }, { "payer_name": "Anthem Medicaid", "plan_name": "Anthem Medicaid", "standard_charge_dollar": 847.57, "methodology": "fee schedule" }, { "payer_name": "Anthem Medicare", "plan_name": "Anthem Medicare", "standard_charge_dollar": 350.0, "methodology": "fee schedule" }, { "payer_name": "Aspirus Health Plan", "plan_name": "Aspirus Health Plan", "standard_charge_dollar": 1435.0, "methodology": "fee schedule" }, { "payer_name": "Carelon Behavioral Health", "plan_name": "Carelon Behavioral Health", "standard_charge_dollar": 430.0, "methodology": "fee schedule" }, { "payer_name": "Chorus Childrens Community Health Plan", "plan_name": "Chorus Childrens Community Health Plan", "standard_charge_dollar": 847.57, "methodology": "fee schedule" }, { "payer_name": "Cigna Healthcare", "plan_name": "Cigna Healthcare", "standard_charge_dollar": 475.0, "methodology": "fee schedule" }, { "payer_name": "Dean Health Plan", "plan_name": "Dean Health Plan", "standard_charge_dollar": 442.24, "methodology": "fee schedule" }, { "payer_name": "Dean Health-Medicaid", "plan_name": "Dean Health-Medicaid", "standard_charge_dollar": 847.57, "methodology": "fee schedule" }, { "payer_name": "Dean Medicare Advantage Plan", "plan_name": "Dean Medicare Advantage Plan", "standard_charge_dollar": 300.0, "methodology": "fee schedule" }, { "payer_name": "Group Health South Commerical", "plan_name": "Group Health South Commerical", "standard_charge_dollar": 525.0, "methodology": "fee schedule" }, { "payer_name": "Group Health South Medicaid", "plan_name": "Group Health South Medicaid", "standard_charge_dollar": 847.57, "methodology": "fee schedule" }, { "payer_name": "Health EOS - Multiplan", "plan_name": "Health EOS - Multiplan", "standard_charge_dollar": 500.0, "methodology": "fee schedule" }, { "payer_name": "HealthPartners", "plan_name": "HealthPartners", "standard_charge_dollar": 500.0, "methodology": "fee schedule" }, { "payer_name": "Humana Medicare", "plan_name": "Humana Medicare", "standard_charge_dollar": 915.0, "methodology": "fee schedule" }, { "payer_name": "ICare Medicaid", "plan_name": "ICare Medicaid", "standard_charge_dollar": 847.57, "methodology": "fee schedule" }, { "payer_name": "ICare Medicare", "plan_name": "ICare Medicare", "standard_charge_dollar": 268.79, "methodology": "fee schedule" }, { "payer_name": "Iowa Medicaid - Amerigroup", "plan_name": "Iowa Medicaid - Amerigroup", "standard_charge_dollar": 395.0, "methodology": "fee schedule" }, { "payer_name": "Magellan Behavioral Health", "plan_name": "Magellan Behavioral Health", "standard_charge_dollar": 450.0, "methodology": "fee schedule" }, { "payer_name": "Managed Health Services Medicare Advanta", "plan_name": "Managed Health Services Medicare Advanta", "standard_charge_dollar": 300.0, "methodology": "fee schedule" }, { "payer_name": "Managed Health Services-Medicaid", "plan_name": "Managed Health Services-Medicaid", "standard_charge_dollar": 847.57, "methodology": "fee schedule" }, { "payer_name": "MEDICA - SSM HEALTH DEAN EHP", "plan_name": "MEDICA - SSM HEALTH DEAN EHP", "standard_charge_dollar": 400.0, "methodology": "fee schedule" }, { "payer_name": "Mercy Care Wi Medicaid MCO", "plan_name": "Mercy Care Wi Medicaid MCO", "standard_charge_dollar": 847.57, "methodology": "fee schedule" }, { "payer_name": "MercyCare Commerical", "plan_name": "MercyCare Commerical", "standard_charge_dollar": 454.75, "methodology": "fee schedule" }, { "payer_name": "Molina Healthcare Commercial", "plan_name": "Molina Healthcare Commercial", "standard_charge_dollar": 325.0, "methodology": "fee schedule" }, { "payer_name": "Molina Healthcare Medicaid", "plan_name": "Molina Healthcare Medicaid", "standard_charge_dollar": 847.57, "methodology": "fee schedule" }, { "payer_name": "My Choice -Medicare Advantage Plan", "plan_name": "My Choice -Medicare Advantage Plan", "standard_charge_dollar": 90.1, "methodology": "fee schedule" }, { "payer_name": "My Choice-Care WI Medicaid", "plan_name": "My Choice-Care WI Medicaid", "standard_charge_dollar": 847.57, "methodology": "fee schedule" }, { "payer_name": "My Choice-Trilogy Medicaid", "plan_name": "My Choice-Trilogy Medicaid", "standard_charge_dollar": 91.5, "methodology": "fee schedule" }, { "payer_name": "Network Health HMO", "plan_name": "Network Health HMO", "standard_charge_dollar": 337.85, "methodology": "fee schedule" }, { "payer_name": "Network Health Medicaid Managed", "plan_name": "Network Health Medicaid Managed", "standard_charge_dollar": 847.57, "methodology": "fee schedule" }, { "payer_name": "Network Health PPO", "plan_name": "Network Health PPO", "standard_charge_dollar": 1750.0, "methodology": "fee schedule" }, { "payer_name": "Physicians Mutual", "plan_name": "Physicians Mutual", "standard_charge_dollar": 500.0, "methodology": "fee schedule" }, { "payer_name": "Prairie States Enterprises INC", "plan_name": "Prairie States Enterprises INC", "standard_charge_dollar": 299.0, "methodology": "fee schedule" }, { "payer_name": "Preferred One Admin Services", "plan_name": "Preferred One Admin Services", "standard_charge_dollar": 315.0, "methodology": "fee schedule" }, { "payer_name": "Quartz Align - Brighton Health Plan", "plan_name": "Quartz Align - Brighton Health Plan", "standard_charge_dollar": 550.0, "methodology": "fee schedule" }, { "payer_name": "Quartz Commercial Plan", "plan_name": "Quartz Commercial Plan", "standard_charge_dollar": 550.0, "methodology": "fee schedule" }, { "payer_name": "Quartz Medicaid", "plan_name": "Quartz Medicaid", "standard_charge_dollar": 847.57, "methodology": "fee schedule" }, { "payer_name": "Quartz Medicare Advantage Plan", "plan_name": "Quartz Medicare Advantage Plan", "standard_charge_dollar": 350.0, "methodology": "fee schedule" }, { "payer_name": "RAS Workers Comp", "plan_name": "RAS Workers Comp", "standard_charge_dollar": 43.75, "methodology": "fee schedule" }, { "payer_name": "Security Health Medicare Advantage", "plan_name": "Security Health Medicare Advantage", "standard_charge_dollar": 300.0, "methodology": "fee schedule" }, { "payer_name": "Security Health Plan", "plan_name": "Security Health Plan", "standard_charge_dollar": 463.5, "methodology": "fee schedule" }, { "payer_name": "Security Health Plan Managed Medicaid", "plan_name": "Security Health Plan Managed Medicaid", "standard_charge_dollar": 847.57, "methodology": "fee schedule" }, { "payer_name": "Sharp Health Plan HMO", "plan_name": "Sharp Health Plan HMO", "standard_charge_dollar": 500.0, "methodology": "fee schedule" }, { "payer_name": "Surest", "plan_name": "Surest", "standard_charge_dollar": 400.0, "methodology": "fee schedule" }, { "payer_name": "The Alliance Auxiant", "plan_name": "The Alliance Auxiant", "standard_charge_dollar": 450.0, "methodology": "fee schedule" }, { "payer_name": "TRICARE EAST-WPS", "plan_name": "TRICARE EAST-WPS", "standard_charge_dollar": 268.79, "methodology": "fee schedule" }, { "payer_name": "UHC Medicare Advantage Plan", "plan_name": "UHC Medicare Advantage Plan", "standard_charge_dollar": 500.0, "methodology": "fee schedule" }, { "payer_name": "UHC Medicare Dual Complete", "plan_name": "UHC Medicare Dual Complete", "standard_charge_dollar": 300.0, "methodology": "fee schedule" }, { "payer_name": "UHC Shared Services", "plan_name": "UHC Shared Services", "standard_charge_dollar": 300.0, "methodology": "fee schedule" }, { "payer_name": "UHC/OPTUM", "plan_name": "UHC/OPTUM", "standard_charge_dollar": 400.0, "methodology": "fee schedule" }, { "payer_name": "UMR Commercial", "plan_name": "UMR Commercial", "standard_charge_dollar": 400.0, "methodology": "fee schedule" }, { "payer_name": "United Healthcare", "plan_name": "United Healthcare", "standard_charge_dollar": 400.0, "methodology": "fee schedule" }, { "payer_name": "United Healthcare Medicaid Community Pla", "plan_name": "United Healthcare Medicaid Community Pla", "standard_charge_dollar": 847.57, "methodology": "fee schedule" }, { "payer_name": "WEA Trust Commercial", "plan_name": "WEA Trust Commercial", "standard_charge_dollar": 425.0, "methodology": "fee schedule" }, { "payer_name": "Wellcare By Allwell", "plan_name": "Wellcare By Allwell", "standard_charge_dollar": 400.0, "methodology": "fee schedule" } ], "gross_charge": 2500.0, "discounted_cash": 350.0, "minimum": 43.75, "maximum": 1750.0 } ] }, { "description": "PHP Daily Child/Adol", "code_information": [ { "code": "H0035", "type": "HCPCS" }, { "code": "1020", "type": "LOCAL" } ], "standard_charges": [ { "setting": "outpatient", "payers_information": [ { "payer_name": "Aetna Medicare", "plan_name": "Aetna Medicare", "standard_charge_dollar": 1435.0, "methodology": "fee schedule" }, { "payer_name": "Aspirus Health Plan", "plan_name": "Aspirus Health Plan", "standard_charge_dollar": 1435.0, "methodology": "fee schedule" }, { "payer_name": "Chorus Childrens Community Health Plan", "plan_name": "Chorus Childrens Community Health Plan", "standard_charge_dollar": 847.57, "methodology": "fee schedule" }, { "payer_name": "Cigna Healthcare", "plan_name": "Cigna Healthcare", "standard_charge_dollar": 475.0, "methodology": "fee schedule" }, { "payer_name": "Health EOS - Multiplan", "plan_name": "Health EOS - Multiplan", "standard_charge_dollar": 500.0, "methodology": "fee schedule" }, { "payer_name": "Managed Health Services-Medicaid", "plan_name": "Managed Health Services-Medicaid", "standard_charge_dollar": 847.57, "methodology": "fee schedule" }, { "payer_name": "Quartz Align - Brighton Health Plan", "plan_name": "Quartz Align - Brighton Health Plan", "standard_charge_dollar": 550.0, "methodology": "fee schedule" }, { "payer_name": "Quartz Commercial Plan", "plan_name": "Quartz Commercial Plan", "standard_charge_dollar": 550.0, "methodology": "fee schedule" }, { "payer_name": "WEA Trust Commercial", "plan_name": "WEA Trust Commercial", "standard_charge_dollar": 425.0, "methodology": "fee schedule" } ], "gross_charge": 2500.0, "discounted_cash": 350.0, "minimum": 425.0, "maximum": 1435.0 } ] }, { "description": "PHP Daily Gero", "code_information": [ { "code": "H0035", "type": "HCPCS" }, { "code": "1030", "type": "LOCAL" } ], "standard_charges": [ { "setting": "outpatient", "payers_information": [ { "payer_name": "Aetna Medicare", "plan_name": "Aetna Medicare", "standard_charge_dollar": 1435.0, "methodology": "fee schedule" }, { "payer_name": "Aspirus Health Plan", "plan_name": "Aspirus Health Plan", "standard_charge_dollar": 1435.0, "methodology": "fee schedule" }, { "payer_name": "Chorus Childrens Community Health Plan", "plan_name": "Chorus Childrens Community Health Plan", "standard_charge_dollar": 847.57, "methodology": "fee schedule" }, { "payer_name": "Cigna Healthcare", "plan_name": "Cigna Healthcare", "standard_charge_dollar": 475.0, "methodology": "fee schedule" }, { "payer_name": "Dean Health Plan", "plan_name": "Dean Health Plan", "standard_charge_dollar": 442.24, "methodology": "fee schedule" }, { "payer_name": "Health EOS - Multiplan", "plan_name": "Health EOS - Multiplan", "standard_charge_dollar": 500.0, "methodology": "fee schedule" }, { "payer_name": "Managed Health Services-Medicaid", "plan_name": "Managed Health Services-Medicaid", "standard_charge_dollar": 847.57, "methodology": "fee schedule" }, { "payer_name": "MercyCare Commerical", "plan_name": "MercyCare Commerical", "standard_charge_dollar": 454.75, "methodology": "fee schedule" }, { "payer_name": "Network Health HMO", "plan_name": "Network Health HMO", "standard_charge_dollar": 337.85, "methodology": "fee schedule" }, { "payer_name": "Network Health PPO", "plan_name": "Network Health PPO", "standard_charge_dollar": 1750.0, "methodology": "fee schedule" }, { "payer_name": "Quartz Align - Brighton Health Plan", "plan_name": "Quartz Align - Brighton Health Plan", "standard_charge_dollar": 550.0, "methodology": "fee schedule" }, { "payer_name": "Quartz Commercial Plan", "plan_name": "Quartz Commercial Plan", "standard_charge_dollar": 550.0, "methodology": "fee schedule" }, { "payer_name": "WEA Trust Commercial", "plan_name": "WEA Trust Commercial", "standard_charge_dollar": 425.0, "methodology": "fee schedule" } ], "gross_charge": 2500.0, "discounted_cash": 350.0, "minimum": 337.85, "maximum": 1750.0 } ] }, { "description": "Telehealth PHP CD Adult Daily", "code_information": [ { "code": "H0035", "type": "HCPCS" }, { "code": "858", "type": "LOCAL" } ], "standard_charges": [ { "setting": "outpatient", "payers_information": [ { "payer_name": "Quartz Align - Brighton Health Plan", "plan_name": "Quartz Align - Brighton Health Plan", "standard_charge_dollar": 550.0, "methodology": "fee schedule" }, { "payer_name": "Quartz Commercial Plan", "plan_name": "Quartz Commercial Plan", "standard_charge_dollar": 550.0, "methodology": "fee schedule" } ], "gross_charge": 2500.0, "discounted_cash": 350.0, "minimum": 550.0, "maximum": 550.0 } ] }, { "description": "Telehealth PHP CD Child/Adol Daily", "code_information": [ { "code": "H0035", "type": "HCPCS" }, { "code": "864", "type": "LOCAL" } ], "standard_charges": [ { "setting": "outpatient", "payers_information": [ { "payer_name": "Quartz Align - Brighton Health Plan", "plan_name": "Quartz Align - Brighton Health Plan", "standard_charge_dollar": 550.0, "methodology": "fee schedule" }, { "payer_name": "Quartz Commercial Plan", "plan_name": "Quartz Commercial Plan", "standard_charge_dollar": 550.0, "methodology": "fee schedule" } ], "gross_charge": 2500.0, "discounted_cash": 350.0, "minimum": 550.0, "maximum": 550.0 } ] }, { "description": "Telehealth PHP CD Gero Daily", "code_information": [ { "code": "H0035", "type": "HCPCS" }, { "code": "870", "type": "LOCAL" } ], "standard_charges": [ { "setting": "outpatient", "payers_information": [ { "payer_name": "Quartz Align - Brighton Health Plan", "plan_name": "Quartz Align - Brighton Health Plan", "standard_charge_dollar": 550.0, "methodology": "fee schedule" }, { "payer_name": "Quartz Commercial Plan", "plan_name": "Quartz Commercial Plan", "standard_charge_dollar": 550.0, "methodology": "fee schedule" } ], "gross_charge": 2500.0, "discounted_cash": 350.0, "minimum": 550.0, "maximum": 550.0 } ] }, { "description": "Telehealth PHP Psych Adult Daily", "code_information": [ { "code": "H0035", "type": "HCPCS" }, { "code": "846", "type": "LOCAL" } ], "standard_charges": [ { "setting": "outpatient", "payers_information": [ { "payer_name": "Quartz Align - Brighton Health Plan", "plan_name": "Quartz Align - Brighton Health Plan", "standard_charge_dollar": 550.0, "methodology": "fee schedule" }, { "payer_name": "Quartz Commercial Plan", "plan_name": "Quartz Commercial Plan", "standard_charge_dollar": 550.0, "methodology": "fee schedule" } ], "gross_charge": 2500.0, "discounted_cash": 350.0, "minimum": 550.0, "maximum": 550.0 } ] }, { "description": "Telehealth PHP Psych Child/Adol Daily", "code_information": [ { "code": "H0035", "type": "HCPCS" }, { "code": "852", "type": "LOCAL" } ], "standard_charges": [ { "setting": "outpatient", "payers_information": [ { "payer_name": "Quartz Align - Brighton Health Plan", "plan_name": "Quartz Align - Brighton Health Plan", "standard_charge_dollar": 550.0, "methodology": "fee schedule" }, { "payer_name": "Quartz Commercial Plan", "plan_name": "Quartz Commercial Plan", "standard_charge_dollar": 550.0, "methodology": "fee schedule" } ], "gross_charge": 2500.0, "discounted_cash": 350.0, "minimum": 550.0, "maximum": 550.0 } ] }, { "description": "Telehealth PHP Psych Gero Daily", "code_information": [ { "code": "H0035", "type": "HCPCS" }, { "code": "840", "type": "LOCAL" } ], "standard_charges": [ { "setting": "outpatient", "payers_information": [ { "payer_name": "Quartz Align - Brighton Health Plan", "plan_name": "Quartz Align - Brighton Health Plan", "standard_charge_dollar": 550.0, "methodology": "fee schedule" }, { "payer_name": "Quartz Commercial Plan", "plan_name": "Quartz Commercial Plan", "standard_charge_dollar": 550.0, "methodology": "fee schedule" } ], "gross_charge": 2500.0, "discounted_cash": 350.0, "minimum": 550.0, "maximum": 550.0 } ] }, { "description": "Tri/Medi Adult IOP-3 unit", "code_information": [ { "code": "90853", "type": "CPT" }, { "code": "1083", "type": "LOCAL" } ], "standard_charges": [ { "setting": "outpatient", "payers_information": [ { "payer_name": "Dean Health-Medicaid", "plan_name": "Dean Health-Medicaid", "standard_charge_dollar": 112.98, "methodology": "fee schedule" }, { "payer_name": "ICare Medicare", "plan_name": "ICare Medicare", "standard_charge_dollar": 175.0, "methodology": "fee schedule" }, { "payer_name": "Quartz Medicaid", "plan_name": "Quartz Medicaid", "standard_charge_dollar": 847.57, "methodology": "fee schedule" }, { "payer_name": "TRICARE EAST-WPS", "plan_name": "TRICARE EAST-WPS", "standard_charge_dollar": 249.1, "methodology": "fee schedule" }, { "payer_name": "Tricare West", "plan_name": "Tricare West", "standard_charge_dollar": 321.1, "methodology": "fee schedule" } ], "gross_charge": 566.67, "discounted_cash": 200.0, "minimum": 112.98, "maximum": 847.57 } ] }, { "description": "Tri/Medi Adult PHP - 5 unit", "code_information": [ { "code": "G0411", "type": "HCPCS" }, { "code": "1015", "type": "LOCAL" } ], "standard_charges": [ { "setting": "outpatient", "payers_information": [ { "payer_name": "Anthem Medicare", "plan_name": "Anthem Medicare", "standard_charge_dollar": 350.0, "methodology": "fee schedule" } ], "gross_charge": 500.0, "minimum": 350.0, "maximum": 350.0 } ] } ] }