{ "hospital_name": "SBH-Green Bay, LLC", "last_updated_on": "2026-05-20", "version": "3.0.0", "location_name": [ "Willow Creek Behavioral Health" ], "hospital_address": [ "1351 Ontario Road, Green Bay, WI 54311" ], "license_information": { "state": "WI", "license_number": "137" }, "type_2_npi": [ "1922556778" ], "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": "Alison Denil" }, "standard_charge_information": [ { "description": "Bridge Services", "code_information": [ { "code": "H0032", "type": "HCPCS" }, { "code": "1090", "type": "LOCAL" } ], "standard_charges": [ { "setting": "inpatient", "payers_information": [ { "payer_name": "Security Health Commercial", "plan_name": "Security Health Commercial", "standard_charge_dollar": 90.0, "methodology": "fee schedule" }, { "payer_name": "Security Health Medicare", "plan_name": "Security Health Medicare", "standard_charge_dollar": 90.0, "methodology": "fee schedule" }, { "payer_name": "Security Health Plan", "plan_name": "Security Health Plan", "standard_charge_dollar": 90.0, "methodology": "fee schedule" }, { "payer_name": "Security Health Plan Managed Medicaid", "plan_name": "Security Health Plan Managed Medicaid", "standard_charge_dollar": 90.0, "methodology": "fee schedule" } ], "minimum": 90.0, "maximum": 90.0 } ] }, { "description": "LOA Adult CD (Detox)", "code_information": [ { "code": "101004", "type": "RC" }, { "code": "101004", "type": "LOCAL" } ], "standard_charges": [ { "setting": "inpatient", "payers_information": [ { "payer_name": "Manitowoc County DHS", "plan_name": "Manitowoc County DHS", "standard_charge_dollar": 1074.0, "methodology": "fee schedule" } ], "minimum": 1074.0, "maximum": 1074.0 } ] }, { "description": "Acute Adol R&B", "code_information": [ { "code": "124", "type": "RC" }, { "code": "1003", "type": "LOCAL" } ], "standard_charges": [ { "setting": "inpatient", "payers_information": [ { "payer_name": "AARP Supplement Plan", "plan_name": "AARP Supplement Plan", "standard_charge_dollar": 925.0, "methodology": "fee schedule" }, { "payer_name": "Advocate Aurora Health Inc UMR", "plan_name": "Advocate Aurora Health Inc UMR", "standard_charge_dollar": 1300.0, "methodology": "fee schedule" }, { "payer_name": "Aetna Life Insurance Company", "plan_name": "Aetna Life Insurance Company", "standard_charge_dollar": 1029.29, "methodology": "fee schedule" }, { "payer_name": "Aetna Medicare", "plan_name": "Aetna Medicare", "standard_charge_dollar": 820.0, "methodology": "fee schedule" }, { "payer_name": "Aetna-SCA", "plan_name": "Aetna-SCA", "standard_charge_dollar": 1000.0, "methodology": "fee schedule" }, { "payer_name": "Aither Health", "plan_name": "Aither Health", "standard_charge_dollar": 1115.0, "methodology": "fee schedule" }, { "payer_name": "All Savers", "plan_name": "All Savers", "standard_charge_dollar": 1300.0, "methodology": "fee schedule" }, { "payer_name": "ALLIED BENEFITS", "plan_name": "ALLIED BENEFITS", "standard_charge_dollar": 800.0, "methodology": "fee schedule" }, { "payer_name": "Allied Trades - Local 25", "plan_name": "Allied Trades - Local 25", "standard_charge_dollar": 1000.0, "methodology": "fee schedule" }, { "payer_name": "American Health Resources", "plan_name": "American Health Resources", "standard_charge_dollar": 1000.0, "methodology": "fee schedule" }, { "payer_name": "Amerigroup", "plan_name": "Amerigroup", "standard_charge_dollar": 951.07, "methodology": "fee schedule" }, { "payer_name": "Amerihealth By Multiplan", "plan_name": "Amerihealth By Multiplan", "standard_charge_dollar": 1550.0, "methodology": "fee schedule" }, { "payer_name": "Amfirst", "plan_name": "Amfirst", "standard_charge_dollar": 1200.0, "methodology": "fee schedule" }, { "payer_name": "ANTHEM BLUE PREFERRED PLUS", "plan_name": "ANTHEM BLUE PREFERRED PLUS", "standard_charge_dollar": 1200.0, "methodology": "fee schedule" }, { "payer_name": "Anthem Commercial", "plan_name": "Anthem Commercial", "standard_charge_dollar": 1200.0, "methodology": "fee schedule" }, { "payer_name": "Anthem Federal Employee", "plan_name": "Anthem Federal Employee", "standard_charge_dollar": 1200.0, "methodology": "fee schedule" }, { "payer_name": "Anthem Medicaid", "plan_name": "Anthem Medicaid", "standard_charge_dollar": 951.07, "methodology": "fee schedule" }, { "payer_name": "Anthem Medicare", "plan_name": "Anthem Medicare", "standard_charge_dollar": 820.0, "methodology": "fee schedule" }, { "payer_name": "Aspirus Health Plan", "plan_name": "Aspirus Health Plan", "standard_charge_dollar": 2100.0, "methodology": "fee schedule" }, { "payer_name": "ASPIRUS WPS- DON'T USE ANYMORE", "plan_name": "ASPIRUS WPS- DON'T USE ANYMORE", "standard_charge_dollar": 650.0, "methodology": "fee schedule" }, { "payer_name": "ASR Health Benefits", "plan_name": "ASR Health Benefits", "standard_charge_dollar": 1150.0, "methodology": "fee schedule" }, { "payer_name": "Auxiant", "plan_name": "Auxiant", "standard_charge_dollar": 1200.66, "methodology": "fee schedule" }, { "payer_name": "Bayfield County", "plan_name": "Bayfield County", "standard_charge_dollar": 1485.26, "methodology": "fee schedule" }, { "payer_name": "BCBS OF MICHIGAN", "plan_name": "BCBS OF MICHIGAN", "standard_charge_dollar": 1200.0, "methodology": "fee schedule" }, { "payer_name": "BEACON HEALTH", "plan_name": "BEACON HEALTH", "standard_charge_dollar": 1111.0, "methodology": "fee schedule" }, { "payer_name": "Behavioral Health Systems", "plan_name": "Behavioral Health Systems", "standard_charge_dollar": 950.0, "methodology": "fee schedule" }, { "payer_name": "Benefit Administrative Services", "plan_name": "Benefit Administrative Services", "standard_charge_dollar": 650.0, "methodology": "fee schedule" }, { "payer_name": "Benefit Plan Admininstrators", "plan_name": "Benefit Plan Admininstrators", "standard_charge_dollar": 1100.0, "methodology": "fee schedule" }, { "payer_name": "Bind Benefits", "plan_name": "Bind Benefits", "standard_charge_dollar": 1379.0, "methodology": "fee schedule" }, { "payer_name": "Boon Administrative Services", "plan_name": "Boon Administrative Services", "standard_charge_dollar": 700.0, "methodology": "fee schedule" }, { "payer_name": "Buckeye Health Plan - OH Medicaid", "plan_name": "Buckeye Health Plan - OH Medicaid", "standard_charge_dollar": 568.8, "methodology": "fee schedule" }, { "payer_name": "Calumet Cty Mental Health", "plan_name": "Calumet Cty Mental Health", "standard_charge_dollar": 1286.52, "methodology": "fee schedule" }, { "payer_name": "Centivo Insurance", "plan_name": "Centivo Insurance", "standard_charge_dollar": 1100.0, "methodology": "fee schedule" }, { "payer_name": "Children Come First Rise Wisconsin Inc", "plan_name": "Children Come First Rise Wisconsin Inc", "standard_charge_dollar": 951.07, "methodology": "fee schedule" }, { "payer_name": "Chorus - Childrens Community Health Plan", "plan_name": "Chorus - Childrens Community Health Plan", "standard_charge_dollar": 951.07, "methodology": "fee schedule" }, { "payer_name": "Cigna Behavioral Health", "plan_name": "Cigna Behavioral Health", "standard_charge_dollar": 1250.0, "methodology": "fee schedule" }, { "payer_name": "Cigna BH Beacon Health Options", "plan_name": "Cigna BH Beacon Health Options", "standard_charge_dollar": 1150.0, "methodology": "fee schedule" }, { "payer_name": "Cigna Healthcare", "plan_name": "Cigna Healthcare", "standard_charge_dollar": 1250.0, "methodology": "fee schedule" }, { "payer_name": "Cigna Healthgram Inc", "plan_name": "Cigna Healthgram Inc", "standard_charge_dollar": 1250.0, "methodology": "fee schedule" }, { "payer_name": "Common Ground Commercial", "plan_name": "Common Ground Commercial", "standard_charge_dollar": 1552.0, "methodology": "fee schedule" }, { "payer_name": "Community Care Inc Medicaid", "plan_name": "Community Care Inc Medicaid", "standard_charge_dollar": 951.07, "methodology": "fee schedule" }, { "payer_name": "CompCare Medicaid", "plan_name": "CompCare Medicaid", "standard_charge_dollar": 951.07, "methodology": "fee schedule" }, { "payer_name": "CON-ForwardHealth", "plan_name": "CON-ForwardHealth", "standard_charge_dollar": 951.07, "methodology": "fee schedule" }, { "payer_name": "Continental Benefits", "plan_name": "Continental Benefits", "standard_charge_dollar": 897.12, "methodology": "fee schedule" }, { "payer_name": "Cypress Benefits", "plan_name": "Cypress Benefits", "standard_charge_dollar": 1170.0, "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": 951.07, "methodology": "fee schedule" }, { "payer_name": "Dodge County Human Services", "plan_name": "Dodge County Human 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": 800.0, "methodology": "fee schedule" }, { "payer_name": "Federated Mutal Insurance Co", "plan_name": "Federated Mutal Insurance Co", "standard_charge_dollar": 1200.0, "methodology": "fee schedule" }, { "payer_name": "Forest Cty Potawatomi Community", "plan_name": "Forest Cty Potawatomi Community", "standard_charge_dollar": 1250.0, "methodology": "fee schedule" }, { "payer_name": "Golden Rule", "plan_name": "Golden Rule", "standard_charge_dollar": 1560.0, "methodology": "fee schedule" }, { "payer_name": "GPA Group & Pension Administrators", "plan_name": "GPA Group & Pension Administrators", "standard_charge_dollar": 1550.0, "methodology": "fee schedule" }, { "payer_name": "Green County", "plan_name": "Green County", "standard_charge_dollar": 1200.0, "methodology": "fee schedule" }, { "payer_name": "Green Lake County", "plan_name": "Green Lake County", "standard_charge_dollar": 1200.0, "methodology": "fee schedule" }, { "payer_name": "Group Administrators", "plan_name": "Group Administrators", "standard_charge_dollar": 1550.0, "methodology": "fee schedule" }, { "payer_name": "Group Health Commercial", "plan_name": "Group Health Commercial", "standard_charge_dollar": 1300.0, "methodology": "fee schedule" }, { "payer_name": "Group Health Coop South Central WI", "plan_name": "Group Health Coop South Central WI", "standard_charge_dollar": 951.07, "methodology": "fee schedule" }, { "payer_name": "Group Health Cooperative Of South Centra", "plan_name": "Group Health Cooperative Of South Centra", "standard_charge_dollar": 1507.07, "methodology": "fee schedule" }, { "payer_name": "Group Health Medicaid", "plan_name": "Group Health Medicaid", "standard_charge_dollar": 951.07, "methodology": "fee schedule" }, { "payer_name": "Health EOS By MultiPlan", "plan_name": "Health EOS By MultiPlan", "standard_charge_dollar": 1550.0, "methodology": "fee schedule" }, { "payer_name": "Health EZ", "plan_name": "Health EZ", "standard_charge_dollar": 1457.0, "methodology": "fee schedule" }, { "payer_name": "HEALTH PAYMENT SYST", "plan_name": "HEALTH PAYMENT SYST", "standard_charge_dollar": 1111.0, "methodology": "fee schedule" }, { "payer_name": "Health Tradition - Commerical", "plan_name": "Health Tradition - Commerical", "standard_charge_dollar": 800.0, "methodology": "fee schedule" }, { "payer_name": "Health Traditions Medicaid", "plan_name": "Health Traditions Medicaid", "standard_charge_dollar": 951.07, "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": 1238.78, "methodology": "fee schedule" }, { "payer_name": "Humana Medicare", "plan_name": "Humana Medicare", "standard_charge_dollar": 1100.0, "methodology": "fee schedule" }, { "payer_name": "ICare Medicaid", "plan_name": "ICare Medicaid", "standard_charge_dollar": 951.07, "methodology": "fee schedule" }, { "payer_name": "ICare Medicare", "plan_name": "ICare Medicare", "standard_charge_dollar": 925.0, "methodology": "fee schedule" }, { "payer_name": "Kaiser Permanente", "plan_name": "Kaiser Permanente", "standard_charge_dollar": 1200.0, "methodology": "fee schedule" }, { "payer_name": "KBIC Health System", "plan_name": "KBIC Health System", "standard_charge_dollar": 1000.0, "methodology": "fee schedule" }, { "payer_name": "Lakeland Care Inc. MA Managed Care/WPS", "plan_name": "Lakeland Care Inc. MA Managed Care/WPS", "standard_charge_dollar": 951.07, "methodology": "fee schedule" }, { "payer_name": "Macomb County Community Mental Health", "plan_name": "Macomb County Community Mental Health", "standard_charge_dollar": 1000.0, "methodology": "fee schedule" }, { "payer_name": "Maestro Health", "plan_name": "Maestro Health", "standard_charge_dollar": 897.12, "methodology": "fee schedule" }, { "payer_name": "Magellan Behavioral Health Systems", "plan_name": "Magellan Behavioral Health Systems", "standard_charge_dollar": 1255.0, "methodology": "fee schedule" }, { "payer_name": "Managed Health Services-Managed MA", "plan_name": "Managed Health Services-Managed MA", "standard_charge_dollar": 951.07, "methodology": "fee schedule" }, { "payer_name": "Manitowoc County DHS", "plan_name": "Manitowoc County DHS", "standard_charge_dollar": 1286.52, "methodology": "fee schedule" }, { "payer_name": "Marathon County", "plan_name": "Marathon County", "standard_charge_dollar": 1255.24, "methodology": "fee schedule" }, { "payer_name": "Mayo Clinic Health Solutions", "plan_name": "Mayo Clinic Health Solutions", "standard_charge_dollar": 1074.0, "methodology": "fee schedule" }, { "payer_name": "MDHHS: Gogebic Community Mental Health", "plan_name": "MDHHS: Gogebic Community Mental Health", "standard_charge_dollar": 1293.0, "methodology": "fee schedule" }, { "payer_name": "MDHHS: North Pointe HHS", "plan_name": "MDHHS: North Pointe HHS", "standard_charge_dollar": 1293.0, "methodology": "fee schedule" }, { "payer_name": "MDHHS: Pathways", "plan_name": "MDHHS: Pathways", "standard_charge_dollar": 1293.0, "methodology": "fee schedule" }, { "payer_name": "MDHHS: UPHP MI Medicaid C/o Northcare", "plan_name": "MDHHS: UPHP MI Medicaid C/o Northcare", "standard_charge_dollar": 1331.0, "methodology": "fee schedule" }, { "payer_name": "MEDICA", "plan_name": "MEDICA", "standard_charge_dollar": 1379.0, "methodology": "fee schedule" }, { "payer_name": "Medica Behavior Health", "plan_name": "Medica Behavior Health", "standard_charge_dollar": 1000.0, "methodology": "fee schedule" }, { "payer_name": "Medica Medicare Advantage Prime Solution", "plan_name": "Medica Medicare Advantage Prime Solution", "standard_charge_dollar": 1000.0, "methodology": "fee schedule" }, { "payer_name": "Medical Associates", "plan_name": "Medical Associates", "standard_charge_dollar": 925.0, "methodology": "fee schedule" }, { "payer_name": "Member Of National Individual Insurance", "plan_name": "Member Of National Individual Insurance", "standard_charge_dollar": 1000.0, "methodology": "fee schedule" }, { "payer_name": "Menominee Tribal", "plan_name": "Menominee Tribal", "standard_charge_dollar": 977.61, "methodology": "fee schedule" }, { "payer_name": "Mercy Care Wi Medicaid MCO", "plan_name": "Mercy Care Wi Medicaid MCO", "standard_charge_dollar": 951.07, "methodology": "fee schedule" }, { "payer_name": "MercyCare Commerical", "plan_name": "MercyCare Commerical", "standard_charge_dollar": 1284.0, "methodology": "fee schedule" }, { "payer_name": "Meritain Health", "plan_name": "Meritain Health", "standard_charge_dollar": 1550.0, "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": 951.07, "methodology": "fee schedule" }, { "payer_name": "Molina Healthcare Medicare", "plan_name": "Molina Healthcare Medicare", "standard_charge_dollar": 925.0, "methodology": "fee schedule" }, { "payer_name": "Monroe County Human Services", "plan_name": "Monroe County Human Services", "standard_charge_dollar": 1300.0, "methodology": "fee schedule" }, { "payer_name": "My Choice-Care WI Medicaid", "plan_name": "My Choice-Care WI Medicaid", "standard_charge_dollar": 951.07, "methodology": "fee schedule" }, { "payer_name": "My Choice-Trilogy Medicaid", "plan_name": "My Choice-Trilogy Medicaid", "standard_charge_dollar": 951.07, "methodology": "fee schedule" }, { "payer_name": "My Health Link Plan", "plan_name": "My Health Link Plan", "standard_charge_dollar": 1331.0, "methodology": "fee schedule" }, { "payer_name": "Network 180", "plan_name": "Network 180", "standard_charge_dollar": 650.0, "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": 951.07, "methodology": "fee schedule" }, { "payer_name": "Network Health Medicare", "plan_name": "Network Health Medicare", "standard_charge_dollar": 820.0, "methodology": "fee schedule" }, { "payer_name": "Network Health Plan PPO", "plan_name": "Network Health Plan PPO", "standard_charge_dollar": 2100.0, "methodology": "fee schedule" }, { "payer_name": "Oneida Nation/Purchase & Referrals", "plan_name": "Oneida Nation/Purchase & Referrals", "standard_charge_dollar": 1250.0, "methodology": "fee schedule" }, { "payer_name": "Oxford - United Healthcare", "plan_name": "Oxford - United Healthcare", "standard_charge_dollar": 1000.0, "methodology": "fee schedule" }, { "payer_name": "Pan American Life Insurane Co", "plan_name": "Pan American Life Insurane Co", "standard_charge_dollar": 1100.0, "methodology": "fee schedule" }, { "payer_name": "Passport Health Plan", "plan_name": "Passport Health Plan", "standard_charge_dollar": 951.07, "methodology": "fee schedule" }, { "payer_name": "Pierce County DHS", "plan_name": "Pierce County DHS", "standard_charge_dollar": 1362.6, "methodology": "fee schedule" }, { "payer_name": "Planned Administrators Inc", "plan_name": "Planned Administrators Inc", "standard_charge_dollar": 661.79, "methodology": "fee schedule" }, { "payer_name": "Polk County Health And Human Services", "plan_name": "Polk County Health And Human Services", "standard_charge_dollar": 1344.99, "methodology": "fee schedule" }, { "payer_name": "Portage County Health And Human Services", "plan_name": "Portage County Health And Human Services", "standard_charge_dollar": 1305.82, "methodology": "fee schedule" }, { "payer_name": "Prairie States Enterprises INC", "plan_name": "Prairie States Enterprises INC", "standard_charge_dollar": 1170.0, "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": 1379.55, "methodology": "fee schedule" }, { "payer_name": "Prevea 360 DeanCare ASO", "plan_name": "Prevea 360 DeanCare ASO", "standard_charge_dollar": 1407.14, "methodology": "fee schedule" }, { "payer_name": "Quartz", "plan_name": "Quartz", "standard_charge_dollar": 1250.0, "methodology": "fee schedule" }, { "payer_name": "Quartz Medicaid", "plan_name": "Quartz Medicaid", "standard_charge_dollar": 951.07, "methodology": "fee schedule" }, { "payer_name": "Saginaw CMH", "plan_name": "Saginaw CMH", "standard_charge_dollar": 1293.0, "methodology": "fee schedule" }, { "payer_name": "Sawyer County", "plan_name": "Sawyer County", "standard_charge_dollar": 1300.0, "methodology": "fee schedule" }, { "payer_name": "Security Administrative Services", "plan_name": "Security Administrative Services", "standard_charge_dollar": 1212.0, "methodology": "fee schedule" }, { "payer_name": "Security Health Commercial", "plan_name": "Security Health Commercial", "standard_charge_dollar": 1287.5, "methodology": "fee schedule" }, { "payer_name": "Security Health Medicare", "plan_name": "Security Health Medicare", "standard_charge_dollar": 820.0, "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": 951.07, "methodology": "fee schedule" }, { "payer_name": "Simplan Administrators", "plan_name": "Simplan Administrators", "standard_charge_dollar": 1550.0, "methodology": "fee schedule" }, { "payer_name": "Stockbridge-Munsee Health And Wellness", "plan_name": "Stockbridge-Munsee Health And Wellness", "standard_charge_dollar": 1250.0, "methodology": "fee schedule" }, { "payer_name": "Superior", "plan_name": "Superior", "standard_charge_dollar": 780.67, "methodology": "fee schedule" }, { "payer_name": "Surest", "plan_name": "Surest", "standard_charge_dollar": 1379.0, "methodology": "fee schedule" }, { "payer_name": "The Alliance Auxiant", "plan_name": "The Alliance Auxiant", "standard_charge_dollar": 1300.0, "methodology": "fee schedule" }, { "payer_name": "The Benefit Group", "plan_name": "The Benefit Group", "standard_charge_dollar": 1000.0, "methodology": "fee schedule" }, { "payer_name": "Together With CCHP", "plan_name": "Together With CCHP", "standard_charge_dollar": 951.07, "methodology": "fee schedule" }, { "payer_name": "TRICARE EAST-WPS", "plan_name": "TRICARE EAST-WPS", "standard_charge_dollar": 900.6, "methodology": "fee schedule" }, { "payer_name": "Tricare West", "plan_name": "Tricare West", "standard_charge_dollar": 930.05, "methodology": "fee schedule" }, { "payer_name": "Trilogy Commercial", "plan_name": "Trilogy Commercial", "standard_charge_dollar": 1300.0, "methodology": "fee schedule" }, { "payer_name": "Ucare MN Medicaid", "plan_name": "Ucare MN Medicaid", "standard_charge_dollar": 951.07, "methodology": "fee schedule" }, { "payer_name": "UHC/OPTUM", "plan_name": "UHC/OPTUM", "standard_charge_dollar": 1379.0, "methodology": "fee schedule" }, { "payer_name": "UMR", "plan_name": "UMR", "standard_charge_dollar": 1379.0, "methodology": "fee schedule" }, { "payer_name": "UMR Commercial", "plan_name": "UMR Commercial", "standard_charge_dollar": 1379.0, "methodology": "fee schedule" }, { "payer_name": "Unicare", "plan_name": "Unicare", "standard_charge_dollar": 1100.0, "methodology": "fee schedule" }, { "payer_name": "United Behavioral Health", "plan_name": "United Behavioral Health", "standard_charge_dollar": 1379.0, "methodology": "fee schedule" }, { "payer_name": "United Behavorial Health", "plan_name": "United Behavorial Health", "standard_charge_dollar": 1379.0, "methodology": "fee schedule" }, { "payer_name": "United Healthcare", "plan_name": "United Healthcare", "standard_charge_dollar": 1379.0, "methodology": "fee schedule" }, { "payer_name": "United Healthcare Dual Complete LP1", "plan_name": "United Healthcare Dual Complete LP1", "standard_charge_dollar": 1000.0, "methodology": "fee schedule" }, { "payer_name": "United Healthcare Healthscope", "plan_name": "United Healthcare Healthscope", "standard_charge_dollar": 1030.0, "methodology": "fee schedule" }, { "payer_name": "United Healthcare Managed Medicare", "plan_name": "United Healthcare Managed Medicare", "standard_charge_dollar": 820.0, "methodology": "fee schedule" }, { "payer_name": "United Healthcare Medicaid Community Pla", "plan_name": "United Healthcare Medicaid Community Pla", "standard_charge_dollar": 951.07, "methodology": "fee schedule" }, { "payer_name": "United Healthcare Shared Services", "plan_name": "United Healthcare Shared Services", "standard_charge_dollar": 1379.0, "methodology": "fee schedule" }, { "payer_name": "Unity Health Plan Medicaid", "plan_name": "Unity Health Plan Medicaid", "standard_charge_dollar": 951.07, "methodology": "fee schedule" }, { "payer_name": "UPHP Medicare Advantage", "plan_name": "UPHP Medicare Advantage", "standard_charge_dollar": 1293.0, "methodology": "fee schedule" }, { "payer_name": "VA Office Of Integrated Care", "plan_name": "VA Office Of Integrated Care", 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"payer_name": "Eau Claire Human Services", "plan_name": "Eau Claire Human Services", "standard_charge_dollar": 1300.0, "methodology": "fee schedule" }, { "payer_name": "Everpointe", "plan_name": "Everpointe", "standard_charge_dollar": 1150.0, "methodology": "fee schedule" }, { "payer_name": "Exceedent", "plan_name": "Exceedent", "standard_charge_dollar": 800.0, "methodology": "fee schedule" }, { "payer_name": "Federated Mutal Insurance Co", "plan_name": "Federated Mutal Insurance Co", "standard_charge_dollar": 1200.0, "methodology": "fee schedule" }, { "payer_name": "Forest Cty Potawatomi Community", "plan_name": "Forest Cty Potawatomi Community", "standard_charge_dollar": 1250.0, "methodology": "fee schedule" }, { "payer_name": "GPA Group & Pension Administrators", "plan_name": "GPA Group & Pension Administrators", "standard_charge_dollar": 1550.0, "methodology": "fee schedule" }, { "payer_name": "Green Lake County", "plan_name": "Green Lake County", "standard_charge_dollar": 1200.0, 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MA Managed Care/WPS", "plan_name": "Lakeland Care Inc. 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"Minnesota Health Care Program", "plan_name": "Minnesota Health Care Program", "standard_charge_dollar": 897.12, "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": 951.07, "methodology": "fee schedule" }, { "payer_name": "Molina Healthcare Medicare", "plan_name": "Molina Healthcare Medicare", "standard_charge_dollar": 925.0, "methodology": "fee schedule" }, { "payer_name": "Monroe County Human Services", "plan_name": "Monroe County Human Services", "standard_charge_dollar": 1300.0, "methodology": "fee schedule" }, { "payer_name": "My Choice-Care WI Medicaid", "plan_name": "My Choice-Care WI Medicaid", "standard_charge_dollar": 951.07, "methodology": "fee schedule" }, { "payer_name": "My Choice-Trilogy Medicaid", "plan_name": "My Choice-Trilogy Medicaid", "standard_charge_dollar": 951.07, "methodology": "fee schedule" }, { "payer_name": "My Health Link Plan", "plan_name": "My Health Link Plan", "standard_charge_dollar": 1331.0, "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": 951.07, "methodology": "fee schedule" }, { "payer_name": "Network Health Medicare", "plan_name": "Network Health Medicare", "standard_charge_dollar": 820.0, "methodology": "fee schedule" }, { "payer_name": "Network Health Plan PPO", "plan_name": "Network Health Plan PPO", "standard_charge_dollar": 2100.0, "methodology": "fee schedule" }, { "payer_name": "Oneida Nation/Purchase & Referrals", "plan_name": "Oneida Nation/Purchase & Referrals", "standard_charge_dollar": 1250.0, "methodology": "fee schedule" }, { "payer_name": "Oxford - United Healthcare", "plan_name": "Oxford - United Healthcare", "standard_charge_dollar": 1000.0, "methodology": "fee schedule" }, { "payer_name": "Pan American Life Insurane Co", "plan_name": "Pan American Life Insurane Co", "standard_charge_dollar": 1100.0, "methodology": "fee schedule" }, { "payer_name": "Passport Health Plan", "plan_name": "Passport Health Plan", "standard_charge_dollar": 951.07, "methodology": "fee schedule" }, { "payer_name": "Peter Christianson Health Center", "plan_name": "Peter Christianson Health Center", "standard_charge_dollar": 800.0, "methodology": "fee schedule" }, { "payer_name": "Pierce County DHS", "plan_name": "Pierce County DHS", "standard_charge_dollar": 1362.6, "methodology": "fee schedule" }, { "payer_name": "Planned Administrators Inc", "plan_name": "Planned Administrators Inc", "standard_charge_dollar": 661.79, "methodology": "fee schedule" }, { "payer_name": "Polk County Health And Human Services", "plan_name": "Polk County Health And Human Services", "standard_charge_dollar": 1344.99, "methodology": "fee schedule" }, { "payer_name": "Portage County Health And Human Services", "plan_name": "Portage County Health And Human Services", "standard_charge_dollar": 1305.82, "methodology": "fee schedule" }, { "payer_name": "Prairie States Enterprises INC", "plan_name": "Prairie States Enterprises INC", "standard_charge_dollar": 1170.0, "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": 1379.55, "methodology": "fee schedule" }, { "payer_name": "Prevea 360 DeanCare ASO", "plan_name": "Prevea 360 DeanCare ASO", "standard_charge_dollar": 1407.14, "methodology": "fee schedule" }, { "payer_name": "Quartz", "plan_name": "Quartz", "standard_charge_dollar": 1250.0, "methodology": "fee schedule" }, { "payer_name": "Quartz Medicaid", "plan_name": "Quartz Medicaid", "standard_charge_dollar": 951.07, "methodology": "fee schedule" }, { "payer_name": "Saginaw CMH", "plan_name": "Saginaw CMH", "standard_charge_dollar": 1293.0, "methodology": "fee schedule" }, { "payer_name": "Sawyer County", "plan_name": "Sawyer County", "standard_charge_dollar": 1300.0, "methodology": "fee schedule" }, { "payer_name": "Security Administrative Services", "plan_name": "Security Administrative Services", "standard_charge_dollar": 1212.0, "methodology": "fee schedule" }, { "payer_name": "Security Health Commercial", "plan_name": "Security Health Commercial", "standard_charge_dollar": 1287.5, "methodology": "fee schedule" }, { "payer_name": "Security Health Medicare", "plan_name": "Security Health Medicare", "standard_charge_dollar": 820.0, "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": 951.07, "methodology": "fee schedule" }, { "payer_name": "Simplan Administrators", "plan_name": "Simplan Administrators", "standard_charge_dollar": 1550.0, "methodology": "fee schedule" }, { "payer_name": "South Country Health Alliance", "plan_name": "South Country Health Alliance", "standard_charge_dollar": 951.07, "methodology": "fee schedule" }, { "payer_name": "Stockbridge-Munsee Health And Wellness", "plan_name": "Stockbridge-Munsee Health And Wellness", "standard_charge_dollar": 1250.0, "methodology": "fee schedule" }, { "payer_name": "Surest", "plan_name": "Surest", "standard_charge_dollar": 1379.0, "methodology": "fee schedule" }, { "payer_name": "Taylor County DHS", "plan_name": "Taylor County DHS", "standard_charge_dollar": 1344.99, "methodology": "fee schedule" }, { "payer_name": "The Alliance Auxiant", "plan_name": "The Alliance Auxiant", "standard_charge_dollar": 1300.0, "methodology": "fee schedule" }, { "payer_name": "The Benefit Group", "plan_name": "The Benefit Group", "standard_charge_dollar": 1000.0, "methodology": "fee schedule" }, { "payer_name": "Together With CCHP", "plan_name": "Together With CCHP", "standard_charge_dollar": 951.07, "methodology": "fee schedule" }, { "payer_name": "Total Plan Concepts - Elap Network", "plan_name": "Total Plan Concepts - Elap Network", "standard_charge_dollar": 850.0, "methodology": "fee schedule" }, { "payer_name": "TRICARE EAST-WPS", "plan_name": "TRICARE EAST-WPS", "standard_charge_dollar": 900.6, "methodology": "fee schedule" }, { "payer_name": "Tricare West", "plan_name": "Tricare West", "standard_charge_dollar": 930.05, "methodology": "fee schedule" }, { "payer_name": "Trilogy Commercial", "plan_name": "Trilogy Commercial", "standard_charge_dollar": 1300.0, "methodology": "fee schedule" }, { "payer_name": "Ucare MN Medicaid", "plan_name": "Ucare MN Medicaid", "standard_charge_dollar": 951.07, "methodology": "fee schedule" }, { "payer_name": "UHC/OPTUM", "plan_name": "UHC/OPTUM", "standard_charge_dollar": 1379.0, "methodology": "fee schedule" }, { "payer_name": "UMR", "plan_name": "UMR", "standard_charge_dollar": 1379.0, "methodology": "fee schedule" }, { "payer_name": "UMR Commercial", "plan_name": "UMR Commercial", "standard_charge_dollar": 1379.0, "methodology": "fee schedule" }, { "payer_name": "Unicare", "plan_name": "Unicare", "standard_charge_dollar": 1100.0, "methodology": "fee schedule" }, { "payer_name": "United Behavioral Health", "plan_name": "United Behavioral Health", "standard_charge_dollar": 1379.0, "methodology": "fee schedule" }, { "payer_name": "United Behavorial Health", "plan_name": "United Behavorial Health", "standard_charge_dollar": 1379.0, "methodology": "fee schedule" }, { "payer_name": "United Healthcare", "plan_name": "United Healthcare", 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1208.5, "methodology": "fee schedule" }, { "payer_name": "WPS Health Plan - SCA", "plan_name": "WPS Health Plan - SCA", "standard_charge_dollar": 1200.0, "methodology": "fee schedule" } ], "gross_charge": 3000.0, "discounted_cash": 1000.0, "minimum": 568.8, "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": "AARP Supplement Plan", "plan_name": "AARP Supplement Plan", "standard_charge_dollar": 925.0, "methodology": "fee schedule" }, { "payer_name": "Advocate Aurora Health Inc UMR", "plan_name": "Advocate Aurora Health Inc UMR", "standard_charge_dollar": 1300.0, "methodology": "fee schedule" }, { "payer_name": "Aetna Life Insurance Company", "plan_name": "Aetna Life Insurance Company", "standard_charge_dollar": 1029.29, "methodology": "fee schedule" }, { "payer_name": "Aetna Medicare", "plan_name": 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"standard_charge_dollar": 800.0, "methodology": "fee schedule" }, { "payer_name": "Federated Mutal Insurance Co", "plan_name": "Federated Mutal Insurance Co", "standard_charge_dollar": 1200.0, "methodology": "fee schedule" }, { "payer_name": "Forest Cty Potawatomi Community", "plan_name": "Forest Cty Potawatomi Community", "standard_charge_dollar": 1250.0, "methodology": "fee schedule" }, { "payer_name": "GPA Group & Pension Administrators", "plan_name": "GPA Group & Pension Administrators", "standard_charge_dollar": 1550.0, "methodology": "fee schedule" }, { "payer_name": "Green Lake County", "plan_name": "Green Lake County", "standard_charge_dollar": 1200.0, "methodology": "fee schedule" }, { "payer_name": "Group Health Commercial", "plan_name": "Group Health Commercial", "standard_charge_dollar": 1300.0, "methodology": "fee schedule" }, { "payer_name": "Group Health Coop South Central WI", "plan_name": "Group Health Coop South Central WI", "standard_charge_dollar": 951.07, 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Chunk Nation", "standard_charge_dollar": 1300.0, "methodology": "fee schedule" }, { "payer_name": "Humana Commercial", "plan_name": "Humana Commercial", "standard_charge_dollar": 1238.78, "methodology": "fee schedule" }, { "payer_name": "Humana Medicare", "plan_name": "Humana Medicare", "standard_charge_dollar": 1100.0, "methodology": "fee schedule" }, { "payer_name": "ICare Medicaid", "plan_name": "ICare Medicaid", "standard_charge_dollar": 951.07, "methodology": "fee schedule" }, { "payer_name": "ICare Medicare", "plan_name": "ICare Medicare", "standard_charge_dollar": 925.0, "methodology": "fee schedule" }, { "payer_name": "Kaiser Permanente", "plan_name": "Kaiser Permanente", "standard_charge_dollar": 1200.0, "methodology": "fee schedule" }, { "payer_name": "KBIC Health System", "plan_name": "KBIC Health System", "standard_charge_dollar": 1000.0, "methodology": "fee schedule" }, { "payer_name": "Lakeland Care Inc. MA Managed Care/WPS", "plan_name": "Lakeland Care Inc. 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schedule" }, { "payer_name": "MDHHS: Gogebic Community Mental Health", "plan_name": "MDHHS: Gogebic Community Mental Health", "standard_charge_dollar": 1293.0, "methodology": "fee schedule" }, { "payer_name": "MDHHS: North Pointe HHS", "plan_name": "MDHHS: North Pointe HHS", "standard_charge_dollar": 1293.0, "methodology": "fee schedule" }, { "payer_name": "MDHHS: UPHP MI Medicaid C/o Northcare", "plan_name": "MDHHS: UPHP MI Medicaid C/o Northcare", "standard_charge_dollar": 1331.0, "methodology": "fee schedule" }, { "payer_name": "MEDICA", "plan_name": "MEDICA", "standard_charge_dollar": 1379.0, "methodology": "fee schedule" }, { "payer_name": "Medica Behavior Health", "plan_name": "Medica Behavior Health", "standard_charge_dollar": 1000.0, "methodology": "fee schedule" }, { "payer_name": "Medica Medicare Advantage Prime Solution", "plan_name": "Medica Medicare Advantage Prime Solution", "standard_charge_dollar": 1000.0, "methodology": "fee schedule" }, { "payer_name": "Mercy Care Wi Medicaid MCO", "plan_name": "Mercy Care Wi Medicaid MCO", "standard_charge_dollar": 951.07, "methodology": "fee schedule" }, { "payer_name": "MercyCare Commerical", "plan_name": "MercyCare Commerical", "standard_charge_dollar": 1284.0, "methodology": "fee schedule" }, { "payer_name": "Meritain Health", "plan_name": "Meritain Health", "standard_charge_dollar": 1550.0, "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": 951.07, "methodology": "fee schedule" }, { "payer_name": "Molina Healthcare Medicare", "plan_name": "Molina Healthcare Medicare", "standard_charge_dollar": 925.0, "methodology": "fee schedule" }, { "payer_name": "Monroe County Human Services", "plan_name": "Monroe County Human Services", "standard_charge_dollar": 1300.0, "methodology": "fee schedule" }, { "payer_name": "My Choice-Trilogy Medicaid", "plan_name": "My Choice-Trilogy Medicaid", "standard_charge_dollar": 951.07, "methodology": "fee schedule" }, { "payer_name": "My Health Link Plan", "plan_name": "My Health Link Plan", "standard_charge_dollar": 1331.0, "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": 951.07, "methodology": "fee schedule" }, { "payer_name": "Network Health Medicare", "plan_name": "Network Health Medicare", "standard_charge_dollar": 820.0, "methodology": "fee schedule" }, { "payer_name": "Network Health Plan PPO", "plan_name": "Network Health Plan PPO", "standard_charge_dollar": 2100.0, "methodology": "fee schedule" }, { "payer_name": "Oxford - United Healthcare", "plan_name": 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"standard_charge_dollar": 1305.82, "methodology": "fee schedule" }, { "payer_name": "Prairie States Enterprises INC", "plan_name": "Prairie States Enterprises INC", "standard_charge_dollar": 1170.0, "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": 1379.55, "methodology": "fee schedule" }, { "payer_name": "Prevea 360 DeanCare ASO", "plan_name": "Prevea 360 DeanCare ASO", "standard_charge_dollar": 1407.14, "methodology": "fee schedule" }, { "payer_name": "Quartz", "plan_name": "Quartz", "standard_charge_dollar": 1250.0, "methodology": "fee schedule" }, { "payer_name": "Quartz Medicaid", "plan_name": "Quartz Medicaid", "standard_charge_dollar": 951.07, "methodology": "fee schedule" }, { "payer_name": "Saginaw CMH", "plan_name": "Saginaw CMH", "standard_charge_dollar": 1293.0, "methodology": "fee schedule" }, { "payer_name": "Sawyer County", "plan_name": "Sawyer County", "standard_charge_dollar": 1300.0, "methodology": "fee schedule" }, { "payer_name": "Security Administrative Services", "plan_name": "Security Administrative Services", "standard_charge_dollar": 1212.0, "methodology": "fee schedule" }, { "payer_name": "Security Health Commercial", "plan_name": "Security Health Commercial", "standard_charge_dollar": 1287.5, "methodology": "fee schedule" }, { "payer_name": "Security Health Medicare", "plan_name": "Security Health Medicare", "standard_charge_dollar": 820.0, "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": 951.07, "methodology": "fee schedule" }, { "payer_name": "Simplan Administrators", "plan_name": "Simplan Administrators", "standard_charge_dollar": 1550.0, "methodology": "fee schedule" }, { "payer_name": "Stockbridge-Munsee Health And Wellness", "plan_name": "Stockbridge-Munsee Health And Wellness", "standard_charge_dollar": 1250.0, "methodology": "fee schedule" }, { "payer_name": "Superior", "plan_name": "Superior", "standard_charge_dollar": 780.67, "methodology": "fee schedule" }, { "payer_name": "Surest", "plan_name": "Surest", "standard_charge_dollar": 1379.0, "methodology": "fee schedule" }, { "payer_name": "The Alliance Auxiant", "plan_name": "The Alliance Auxiant", "standard_charge_dollar": 1300.0, "methodology": "fee schedule" }, { "payer_name": "The Benefit Group", "plan_name": "The Benefit Group", "standard_charge_dollar": 1000.0, "methodology": "fee schedule" }, { "payer_name": "Together With CCHP", "plan_name": "Together With CCHP", "standard_charge_dollar": 951.07, "methodology": "fee schedule" }, { "payer_name": "TRICARE EAST-WPS", "plan_name": "TRICARE EAST-WPS", "standard_charge_dollar": 900.6, "methodology": "fee schedule" }, { "payer_name": "Tricare West", "plan_name": "Tricare West", "standard_charge_dollar": 930.05, "methodology": "fee schedule" }, { "payer_name": "Trilogy Commercial", "plan_name": "Trilogy Commercial", "standard_charge_dollar": 1300.0, "methodology": "fee schedule" }, { "payer_name": "Ucare MN Medicaid", "plan_name": "Ucare MN Medicaid", "standard_charge_dollar": 951.07, "methodology": "fee schedule" }, { "payer_name": "UHC/OPTUM", "plan_name": "UHC/OPTUM", "standard_charge_dollar": 1379.0, "methodology": "fee schedule" }, { "payer_name": "UMR", "plan_name": "UMR", "standard_charge_dollar": 1379.0, "methodology": "fee schedule" }, { "payer_name": "UMR Commercial", "plan_name": "UMR Commercial", "standard_charge_dollar": 1379.0, "methodology": "fee schedule" }, { "payer_name": "Unicare", "plan_name": "Unicare", "standard_charge_dollar": 1100.0, "methodology": "fee schedule" }, { "payer_name": "United Behavioral Health", "plan_name": "United Behavioral Health", "standard_charge_dollar": 1379.0, "methodology": "fee schedule" }, { "payer_name": "United Behavorial Health", "plan_name": "United Behavorial Health", "standard_charge_dollar": 1379.0, "methodology": "fee schedule" }, { "payer_name": "United Healthcare", "plan_name": "United Healthcare", "standard_charge_dollar": 1379.0, "methodology": "fee schedule" }, { "payer_name": "United Healthcare Dual Complete LP1", "plan_name": "United Healthcare Dual Complete LP1", "standard_charge_dollar": 1000.0, "methodology": "fee schedule" }, { "payer_name": "United Healthcare Healthscope", "plan_name": "United Healthcare Healthscope", "standard_charge_dollar": 1030.0, "methodology": "fee schedule" }, { "payer_name": "United Healthcare Managed Medicare", "plan_name": "United Healthcare Managed Medicare", "standard_charge_dollar": 820.0, "methodology": "fee schedule" }, { "payer_name": "United Healthcare Medicaid Community Pla", "plan_name": "United Healthcare Medicaid Community Pla", "standard_charge_dollar": 780.67, "methodology": "fee schedule" }, { "payer_name": "United Healthcare Shared Services", "plan_name": "United Healthcare Shared Services", "standard_charge_dollar": 1379.0, "methodology": "fee schedule" }, { "payer_name": "Unity Health Plan Medicaid", "plan_name": "Unity Health Plan Medicaid", "standard_charge_dollar": 951.07, "methodology": "fee schedule" }, { "payer_name": "UPHP Medicare Advantage", "plan_name": "UPHP Medicare Advantage", "standard_charge_dollar": 1293.0, "methodology": "fee schedule" }, { "payer_name": "VA Office Of Integrated Care", "plan_name": "VA Office Of Integrated Care", "standard_charge_dollar": 1000.0, "methodology": "fee schedule" }, { "payer_name": "WEA Trust Commercial", "plan_name": "WEA Trust Commercial", "standard_charge_dollar": 1250.0, "methodology": "fee schedule" }, { "payer_name": "Western Region Recovery & Wellness Conso", "plan_name": "Western Region Recovery & Wellness Conso", "standard_charge_dollar": 1305.82, "methodology": "fee schedule" }, { "payer_name": "WISCONSIN ANTHEM MEDI BLUE DUAL ADV", "plan_name": "WISCONSIN ANTHEM MEDI BLUE DUAL ADV", "standard_charge_dollar": 1115.0, "methodology": "fee schedule" }, { "payer_name": "WPS Health Insurance", "plan_name": "WPS Health Insurance", "standard_charge_dollar": 1208.5, "methodology": "fee schedule" }, { "payer_name": "WPS Health Plan - SCA", "plan_name": "WPS Health Plan - SCA", "standard_charge_dollar": 1200.0, "methodology": "fee schedule" } ], "gross_charge": 3000.0, "discounted_cash": 1000.0, "minimum": 568.8, "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": "AARP Supplement Plan", "plan_name": "AARP Supplement Plan", "standard_charge_dollar": 925.0, "methodology": "fee schedule" }, { "payer_name": "Advocate Aurora Health Inc UMR", "plan_name": "Advocate Aurora Health Inc UMR", "standard_charge_dollar": 1300.0, "methodology": "fee schedule" }, { "payer_name": "Aetna Life Insurance Company", "plan_name": "Aetna Life Insurance Company", "standard_charge_dollar": 1550.0, "methodology": "fee schedule" }, { "payer_name": "Aetna Medicare", "plan_name": "Aetna Medicare", "standard_charge_dollar": 820.0, "methodology": "fee schedule" }, { "payer_name": "Aither Health", "plan_name": "Aither Health", "standard_charge_dollar": 1115.0, "methodology": "fee schedule" }, { "payer_name": "All Savers", "plan_name": "All Savers", "standard_charge_dollar": 1300.0, "methodology": "fee schedule" }, { "payer_name": "ALLIED BENEFITS", "plan_name": "ALLIED BENEFITS", "standard_charge_dollar": 800.0, "methodology": "fee schedule" }, { "payer_name": "Allied Trades - Local 25", "plan_name": "Allied Trades - Local 25", "standard_charge_dollar": 1000.0, 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"payer_name": "Aspirus Health Plan", "plan_name": "Aspirus Health Plan", "standard_charge_dollar": 2100.0, "methodology": "fee schedule" }, { "payer_name": "Auxiant", "plan_name": "Auxiant", "standard_charge_dollar": 1200.66, "methodology": "fee schedule" }, { "payer_name": "Bayfield County", "plan_name": "Bayfield County", "standard_charge_dollar": 1485.26, "methodology": "fee schedule" }, { "payer_name": "BCBS OF MICHIGAN", "plan_name": "BCBS OF MICHIGAN", "standard_charge_dollar": 1200.0, "methodology": "fee schedule" }, { "payer_name": "BEACON HEALTH", "plan_name": "BEACON HEALTH", "standard_charge_dollar": 1111.0, "methodology": "fee schedule" }, { "payer_name": "Behavioral Health Systems", "plan_name": "Behavioral Health Systems", "standard_charge_dollar": 950.0, "methodology": "fee schedule" }, { "payer_name": "Benefit Administrative Services", "plan_name": "Benefit Administrative Services", "standard_charge_dollar": 650.0, "methodology": "fee schedule" }, { "payer_name": 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"plan_name": "Group Health Coop South Central WI", "standard_charge_dollar": 951.07, "methodology": "fee schedule" }, { "payer_name": "Group Health Cooperative Of South Centra", "plan_name": "Group Health Cooperative Of South Centra", "standard_charge_dollar": 1507.07, "methodology": "fee schedule" }, { "payer_name": "Group Health Medicaid", "plan_name": "Group Health Medicaid", "standard_charge_dollar": 951.07, "methodology": "fee schedule" }, { "payer_name": "Health EOS By MultiPlan", "plan_name": "Health EOS By MultiPlan", "standard_charge_dollar": 1550.0, "methodology": "fee schedule" }, { "payer_name": "HEALTH PAYMENT SYST", "plan_name": "HEALTH PAYMENT SYST", "standard_charge_dollar": 1111.0, "methodology": "fee schedule" }, { "payer_name": "Health Traditions Medicaid", "plan_name": "Health Traditions Medicaid", "standard_charge_dollar": 951.07, "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": 1238.78, "methodology": "fee schedule" }, { "payer_name": "Humana Medicare", "plan_name": "Humana Medicare", "standard_charge_dollar": 1100.0, "methodology": "fee schedule" }, { "payer_name": "ICare Medicaid", "plan_name": "ICare Medicaid", "standard_charge_dollar": 951.07, "methodology": "fee schedule" }, { "payer_name": "ICare Medicare", "plan_name": "ICare Medicare", "standard_charge_dollar": 925.0, "methodology": "fee schedule" }, { "payer_name": "Kaiser Permanente", "plan_name": "Kaiser Permanente", "standard_charge_dollar": 1200.0, "methodology": "fee schedule" }, { "payer_name": "KBIC Health System", "plan_name": "KBIC Health System", "standard_charge_dollar": 1000.0, "methodology": "fee schedule" }, { "payer_name": 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MA Managed Care/WPS", "plan_name": "Lakeland Care Inc. 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"payer_name": "MDHHS: Gogebic Community Mental Health", "plan_name": "MDHHS: Gogebic Community Mental Health", "standard_charge_dollar": 1293.0, "methodology": "fee schedule" }, { "payer_name": "MDHHS: North Pointe HHS", "plan_name": "MDHHS: North Pointe HHS", "standard_charge_dollar": 1293.0, "methodology": "fee schedule" }, { "payer_name": "MDHHS: UPHP MI Medicaid C/o Northcare", "plan_name": "MDHHS: UPHP MI Medicaid C/o Northcare", "standard_charge_dollar": 1331.0, "methodology": "fee schedule" }, { "payer_name": "MEDICA", "plan_name": "MEDICA", "standard_charge_dollar": 1379.0, "methodology": "fee schedule" }, { "payer_name": "Medica Behavior Health", "plan_name": "Medica Behavior Health", "standard_charge_dollar": 1000.0, "methodology": "fee schedule" }, { "payer_name": "Medica Medicare Advantage Prime Solution", "plan_name": "Medica Medicare Advantage Prime Solution", "standard_charge_dollar": 1000.0, "methodology": "fee schedule" }, { "payer_name": "Mercy Care Wi Medicaid MCO", "plan_name": "Mercy Care Wi Medicaid MCO", "standard_charge_dollar": 951.07, "methodology": "fee schedule" }, { "payer_name": "MercyCare Commerical", "plan_name": "MercyCare Commerical", "standard_charge_dollar": 1284.0, "methodology": "fee schedule" }, { "payer_name": "Meritain Health", "plan_name": "Meritain Health", "standard_charge_dollar": 1550.0, "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": 951.07, "methodology": "fee schedule" }, { "payer_name": "Molina Healthcare Medicare", "plan_name": "Molina Healthcare Medicare", "standard_charge_dollar": 925.0, "methodology": "fee schedule" }, { "payer_name": "Monroe County Human Services", "plan_name": "Monroe County Human Services", "standard_charge_dollar": 1300.0, "methodology": 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Plan PPO", "standard_charge_dollar": 2100.0, "methodology": "fee schedule" }, { "payer_name": "Oneida Nation/Purchase & Referrals", "plan_name": "Oneida Nation/Purchase & Referrals", "standard_charge_dollar": 1250.0, "methodology": "fee schedule" }, { "payer_name": "Oxford - United Healthcare", "plan_name": "Oxford - United Healthcare", "standard_charge_dollar": 1000.0, "methodology": "fee schedule" }, { "payer_name": "Pan American Life Insurane Co", "plan_name": "Pan American Life Insurane Co", "standard_charge_dollar": 1100.0, "methodology": "fee schedule" }, { "payer_name": "Passport Health Plan", "plan_name": "Passport Health Plan", "standard_charge_dollar": 951.07, "methodology": "fee schedule" }, { "payer_name": "Pierce County DHS", "plan_name": "Pierce County DHS", "standard_charge_dollar": 1362.6, "methodology": "fee schedule" }, { "payer_name": "Planned Administrators Inc", "plan_name": "Planned Administrators Inc", "standard_charge_dollar": 661.79, "methodology": "fee schedule" }, { "payer_name": "Polk County Health And Human Services", "plan_name": "Polk County Health And Human Services", "standard_charge_dollar": 1344.99, "methodology": "fee schedule" }, { "payer_name": "Prairie States Enterprises INC", "plan_name": "Prairie States Enterprises INC", "standard_charge_dollar": 1170.0, "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": 1379.55, "methodology": "fee schedule" }, { "payer_name": "Prevea 360 DeanCare ASO", "plan_name": "Prevea 360 DeanCare ASO", "standard_charge_dollar": 1407.14, "methodology": "fee schedule" }, { "payer_name": "Quartz", "plan_name": "Quartz", "standard_charge_dollar": 1250.0, "methodology": "fee schedule" }, { "payer_name": "Quartz Medicaid", "plan_name": "Quartz Medicaid", "standard_charge_dollar": 951.07, "methodology": "fee schedule" }, { "payer_name": "Sawyer County", "plan_name": "Sawyer County", "standard_charge_dollar": 1300.0, "methodology": "fee schedule" }, { "payer_name": "Security Administrative Services", "plan_name": "Security Administrative Services", "standard_charge_dollar": 1212.0, "methodology": "fee schedule" }, { "payer_name": "Security Health Commercial", "plan_name": "Security Health Commercial", "standard_charge_dollar": 1287.5, "methodology": "fee schedule" }, { "payer_name": "Security Health Medicare", "plan_name": "Security Health Medicare", "standard_charge_dollar": 820.0, "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": 951.07, "methodology": "fee schedule" }, { "payer_name": "Sentury Insurance", "plan_name": "Sentury Insurance", "standard_charge_dollar": 897.12, "methodology": "fee schedule" }, { "payer_name": "Simplan Administrators", "plan_name": "Simplan Administrators", "standard_charge_dollar": 1550.0, "methodology": "fee schedule" }, { "payer_name": "Stockbridge-Munsee Health And Wellness", "plan_name": "Stockbridge-Munsee Health And Wellness", "standard_charge_dollar": 1250.0, "methodology": "fee schedule" }, { "payer_name": "Superior", "plan_name": "Superior", "standard_charge_dollar": 780.67, "methodology": "fee schedule" }, { "payer_name": "Surest", "plan_name": "Surest", "standard_charge_dollar": 1379.0, "methodology": "fee schedule" }, { "payer_name": "The Alliance Auxiant", "plan_name": "The Alliance Auxiant", "standard_charge_dollar": 1300.0, "methodology": "fee schedule" }, { "payer_name": "Together With CCHP", "plan_name": "Together With CCHP", "standard_charge_dollar": 951.07, "methodology": "fee schedule" }, { "payer_name": "TRICARE EAST-WPS", "plan_name": "TRICARE EAST-WPS", "standard_charge_dollar": 900.6, "methodology": "fee schedule" }, { "payer_name": "Tricare West", "plan_name": "Tricare West", "standard_charge_dollar": 930.05, "methodology": "fee schedule" }, { "payer_name": "Trilogy Commercial", "plan_name": "Trilogy Commercial", "standard_charge_dollar": 1300.0, "methodology": "fee schedule" }, { "payer_name": "Ucare MN Medicaid", "plan_name": "Ucare MN Medicaid", "standard_charge_dollar": 951.07, "methodology": "fee schedule" }, { "payer_name": "UHC/OPTUM", "plan_name": "UHC/OPTUM", "standard_charge_dollar": 1379.0, "methodology": "fee schedule" }, { "payer_name": "UMR", "plan_name": "UMR", "standard_charge_dollar": 1379.0, "methodology": "fee schedule" }, { "payer_name": "UMR Commercial", "plan_name": "UMR Commercial", "standard_charge_dollar": 1379.0, "methodology": "fee schedule" }, { "payer_name": "Unicare", "plan_name": "Unicare", "standard_charge_dollar": 1100.0, "methodology": "fee schedule" }, { "payer_name": "United Behavioral Health", "plan_name": "United Behavioral Health", "standard_charge_dollar": 1379.0, "methodology": "fee schedule" }, { "payer_name": "United Behavorial Health", "plan_name": "United Behavorial Health", "standard_charge_dollar": 1379.0, "methodology": "fee schedule" }, { "payer_name": "United Healthcare", "plan_name": "United Healthcare", "standard_charge_dollar": 1379.0, "methodology": "fee schedule" }, { "payer_name": "United Healthcare Dual Complete LP1", "plan_name": "United Healthcare Dual Complete LP1", "standard_charge_dollar": 1000.0, "methodology": "fee schedule" }, { "payer_name": "United Healthcare Healthscope", "plan_name": "United Healthcare Healthscope", "standard_charge_dollar": 1030.0, "methodology": "fee schedule" }, { "payer_name": "United Healthcare Managed Medicare", "plan_name": "United Healthcare Managed Medicare", "standard_charge_dollar": 820.0, "methodology": "fee schedule" }, { "payer_name": "United Healthcare Medicaid Community Pla", "plan_name": "United Healthcare Medicaid Community Pla", "standard_charge_dollar": 951.07, "methodology": "fee schedule" }, { "payer_name": "United Healthcare Shared Services", "plan_name": "United Healthcare Shared Services", "standard_charge_dollar": 1379.0, "methodology": "fee schedule" }, { "payer_name": "Unity Health Plan Medicaid", "plan_name": "Unity Health Plan Medicaid", "standard_charge_dollar": 951.07, "methodology": "fee schedule" }, { "payer_name": "UPHP Medicare Advantage", "plan_name": "UPHP Medicare Advantage", "standard_charge_dollar": 1293.0, "methodology": "fee schedule" }, { "payer_name": "VA Office Of Integrated Care", "plan_name": "VA Office Of Integrated Care", "standard_charge_dollar": 1000.0, "methodology": "fee schedule" }, { "payer_name": "WEA Trust Commercial", "plan_name": "WEA Trust Commercial", "standard_charge_dollar": 1250.0, "methodology": "fee schedule" }, { "payer_name": "Western Region Recovery & Wellness Conso", "plan_name": "Western Region Recovery & Wellness Conso", "standard_charge_dollar": 1305.82, "methodology": "fee schedule" }, { "payer_name": "WISCONSIN ANTHEM MEDI BLUE DUAL ADV", "plan_name": "WISCONSIN ANTHEM MEDI BLUE DUAL ADV", "standard_charge_dollar": 1115.0, "methodology": "fee schedule" }, { "payer_name": "WPS Health Insurance", "plan_name": "WPS Health Insurance", "standard_charge_dollar": 1208.5, "methodology": "fee schedule" }, { "payer_name": "WPS Health Plan - SCA", "plan_name": "WPS Health Plan - SCA", "standard_charge_dollar": 1200.0, "methodology": "fee schedule" } ], "gross_charge": 3000.0, "minimum": 568.8, "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": "Transamerica", "plan_name": "Transamerica", "standard_charge_dollar": 897.12, "methodology": "fee schedule" } ], "gross_charge": 3000.0, "minimum": 897.12, "maximum": 897.12 } ] }, { "description": "Acute Psych Adult R&B", "code_information": [ { "code": "124", "type": "RC" }, { "code": "901", "type": "LOCAL" } ], "standard_charges": [ { "setting": "inpatient", "payers_information": [ { "payer_name": "Member Of National Individual Insurance", "plan_name": "Member Of National Individual Insurance", "standard_charge_dollar": 1000.0, "methodology": "fee schedule" }, { "payer_name": "Transamerica", "plan_name": "Transamerica", "standard_charge_dollar": 897.12, "methodology": "fee schedule" } ], "gross_charge": 3000.0, "minimum": 897.12, "maximum": 1000.0 } ] }, { "description": "Acute Psych Child R&B", "code_information": [ { "code": "124", "type": "RC" }, { "code": "903", "type": "LOCAL" } ], "standard_charges": [ { "setting": "inpatient", "payers_information": [ { "payer_name": "Transamerica", "plan_name": "Transamerica", "standard_charge_dollar": 897.12, "methodology": "fee schedule" } ], "gross_charge": 2600.0, "minimum": 897.12, "maximum": 897.12 } ] }, { "description": "Acute Psych Gero R&B", "code_information": [ { "code": "124", "type": "RC" }, { "code": "900", "type": "LOCAL" } ], "standard_charges": [ { "setting": "inpatient", "payers_information": [ { "payer_name": "Transamerica", "plan_name": "Transamerica", "standard_charge_dollar": 897.12, "methodology": "fee schedule" } ], "gross_charge": 3000.0, "minimum": 897.12, "maximum": 897.12 } ] }, { "description": "Acute Adult CD R&B", "code_information": [ { "code": "126", "type": "RC" }, { "code": "1004", "type": "LOCAL" } ], "standard_charges": [ { "setting": "inpatient", "payers_information": [ { "payer_name": "AARP Supplement Plan", "plan_name": "AARP Supplement Plan", "standard_charge_dollar": 925.0, "methodology": "fee schedule" }, { "payer_name": "Advocate Aurora Health Inc UMR", "plan_name": "Advocate Aurora Health Inc UMR", "standard_charge_dollar": 1300.0, "methodology": "fee schedule" }, { "payer_name": 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"standard_charge_dollar": 951.07, "methodology": "fee schedule" }, { "payer_name": "ANTHEM BLUE PREFERRED PLUS", "plan_name": "ANTHEM BLUE PREFERRED PLUS", "standard_charge_dollar": 1200.0, "methodology": "fee schedule" }, { "payer_name": "Anthem Commercial", "plan_name": "Anthem Commercial", "standard_charge_dollar": 1200.0, "methodology": "fee schedule" }, { "payer_name": "Anthem Federal Employee", "plan_name": "Anthem Federal Employee", "standard_charge_dollar": 1200.0, "methodology": "fee schedule" }, { "payer_name": "Anthem Medicaid", "plan_name": "Anthem Medicaid", "standard_charge_dollar": 951.07, "methodology": "fee schedule" }, { "payer_name": "Anthem Medicare", "plan_name": "Anthem Medicare", "standard_charge_dollar": 820.0, "methodology": "fee schedule" }, { "payer_name": "Aspirus Health Plan", "plan_name": "Aspirus Health Plan", "standard_charge_dollar": 2100.0, "methodology": "fee schedule" }, { "payer_name": "ASPIRUS WPS- DON'T USE ANYMORE", "plan_name": "ASPIRUS WPS- DON'T USE ANYMORE", "standard_charge_dollar": 650.0, "methodology": "fee schedule" }, { "payer_name": "Auxiant", "plan_name": "Auxiant", "standard_charge_dollar": 1200.66, "methodology": "fee schedule" }, { "payer_name": "BCBS OF MICHIGAN", "plan_name": "BCBS OF MICHIGAN", "standard_charge_dollar": 1200.0, "methodology": "fee schedule" }, { "payer_name": "BEACON HEALTH", "plan_name": "BEACON HEALTH", "standard_charge_dollar": 1111.0, "methodology": "fee schedule" }, { "payer_name": "Behavioral Health Systems", "plan_name": "Behavioral Health Systems", "standard_charge_dollar": 950.0, "methodology": "fee schedule" }, { "payer_name": "Benefit Administrative Services", "plan_name": "Benefit Administrative Services", "standard_charge_dollar": 650.0, "methodology": "fee schedule" }, { "payer_name": "Benefit Plan Admininstrators", "plan_name": "Benefit Plan Admininstrators", "standard_charge_dollar": 1100.0, "methodology": "fee schedule" }, { "payer_name": "Bind Benefits", "plan_name": "Bind Benefits", "standard_charge_dollar": 1379.0, "methodology": "fee schedule" }, { "payer_name": "Buckeye Health Plan - OH Medicaid", "plan_name": "Buckeye Health Plan - OH Medicaid", "standard_charge_dollar": 568.8, "methodology": "fee schedule" }, { "payer_name": "Calumet Cty Mental Health", "plan_name": "Calumet Cty Mental Health", "standard_charge_dollar": 1286.52, "methodology": "fee schedule" }, { "payer_name": "Centivo Insurance", "plan_name": "Centivo Insurance", "standard_charge_dollar": 1100.0, "methodology": "fee schedule" }, { "payer_name": "Children Come First Rise Wisconsin Inc", "plan_name": "Children Come First Rise Wisconsin Inc", "standard_charge_dollar": 951.07, "methodology": "fee schedule" }, { "payer_name": "Chorus - Childrens Community Health Plan", "plan_name": "Chorus - Childrens Community Health Plan", "standard_charge_dollar": 951.07, "methodology": "fee schedule" }, { "payer_name": "Cigna BH Beacon Health Options", "plan_name": "Cigna BH Beacon Health Options", 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Mutal Insurance Co", "standard_charge_dollar": 1200.0, "methodology": "fee schedule" }, { "payer_name": "Forest Cty Potawatomi Community", "plan_name": "Forest Cty Potawatomi Community", "standard_charge_dollar": 1250.0, "methodology": "fee schedule" }, { "payer_name": "GPA Group & Pension Administrators", "plan_name": "GPA Group & Pension Administrators", "standard_charge_dollar": 1550.0, "methodology": "fee schedule" }, { "payer_name": "Green Lake County", "plan_name": "Green Lake County", "standard_charge_dollar": 1200.0, "methodology": "fee schedule" }, { "payer_name": "Group Health Commercial", "plan_name": "Group Health Commercial", "standard_charge_dollar": 1300.0, "methodology": "fee schedule" }, { "payer_name": "Group Health Coop South Central WI", "plan_name": "Group Health Coop South Central WI", "standard_charge_dollar": 951.07, "methodology": "fee schedule" }, { "payer_name": "Group Health Cooperative Of South Centra", "plan_name": "Group Health Cooperative Of South Centra", "standard_charge_dollar": 1507.07, "methodology": "fee schedule" }, { "payer_name": "Group Health Medicaid", "plan_name": "Group Health Medicaid", "standard_charge_dollar": 951.07, "methodology": "fee schedule" }, { "payer_name": "Health EOS By MultiPlan", "plan_name": "Health EOS By MultiPlan", "standard_charge_dollar": 1550.0, "methodology": "fee schedule" }, { "payer_name": "HEALTH PAYMENT SYST", "plan_name": "HEALTH PAYMENT SYST", "standard_charge_dollar": 1111.0, "methodology": "fee schedule" }, { "payer_name": "Health Traditions Medicaid", "plan_name": "Health Traditions Medicaid", "standard_charge_dollar": 951.07, "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": 1351.39, "methodology": "fee schedule" }, { "payer_name": "Humana Medicare", "plan_name": "Humana Medicare", "standard_charge_dollar": 1100.0, "methodology": "fee schedule" }, { "payer_name": "ICare Medicaid", "plan_name": "ICare Medicaid", "standard_charge_dollar": 951.07, "methodology": "fee schedule" }, { "payer_name": "ICare Medicare", "plan_name": "ICare Medicare", "standard_charge_dollar": 925.0, "methodology": "fee schedule" }, { "payer_name": "Kaiser Permanente", "plan_name": "Kaiser Permanente", "standard_charge_dollar": 1200.0, "methodology": "fee schedule" }, { "payer_name": "KBIC Health System", "plan_name": "KBIC Health System", "standard_charge_dollar": 1000.0, "methodology": "fee schedule" }, { "payer_name": "Lakeland Care Inc. MA Managed Care/WPS", "plan_name": "Lakeland Care Inc. MA Managed Care/WPS", "standard_charge_dollar": 951.07, "methodology": "fee schedule" }, { "payer_name": "Lucent Health", "plan_name": "Lucent Health", "standard_charge_dollar": 1030.0, "methodology": "fee schedule" }, { "payer_name": "Maestro Health", "plan_name": "Maestro Health", "standard_charge_dollar": 897.12, "methodology": "fee schedule" }, { "payer_name": "Magellan Behavioral Health Systems", "plan_name": "Magellan Behavioral Health Systems", "standard_charge_dollar": 1255.0, "methodology": "fee schedule" }, { "payer_name": "Managed Health Services-Managed MA", "plan_name": "Managed Health Services-Managed MA", "standard_charge_dollar": 951.07, "methodology": "fee schedule" }, { "payer_name": "Manitowoc County DHS", "plan_name": "Manitowoc County DHS", "standard_charge_dollar": 1286.52, "methodology": "fee schedule" }, { "payer_name": "Marathon County", "plan_name": "Marathon County", "standard_charge_dollar": 1255.24, "methodology": "fee schedule" }, { "payer_name": "Mayo Clinic Health Solutions", "plan_name": "Mayo Clinic Health Solutions", "standard_charge_dollar": 1074.0, "methodology": "fee schedule" }, { "payer_name": "MDHHS: Gogebic Community Mental Health", "plan_name": "MDHHS: Gogebic Community Mental Health", "standard_charge_dollar": 1293.0, "methodology": "fee schedule" }, { "payer_name": "MDHHS: North Pointe HHS", "plan_name": "MDHHS: North Pointe HHS", "standard_charge_dollar": 1293.0, "methodology": "fee schedule" }, { "payer_name": "MDHHS: UPHP MI Medicaid C/o Northcare", "plan_name": "MDHHS: UPHP MI Medicaid C/o Northcare", "standard_charge_dollar": 1331.0, "methodology": "fee schedule" }, { "payer_name": "MEDICA", "plan_name": "MEDICA", "standard_charge_dollar": 1379.0, "methodology": "fee schedule" }, { "payer_name": "Medica Behavior Health", "plan_name": "Medica Behavior Health", "standard_charge_dollar": 1000.0, "methodology": "fee schedule" }, { "payer_name": "Medica Medicare Advantage Prime Solution", "plan_name": "Medica Medicare Advantage Prime Solution", "standard_charge_dollar": 1000.0, "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": 951.07, "methodology": "fee schedule" }, { "payer_name": "Molina Healthcare Medicare", "plan_name": "Molina Healthcare Medicare", "standard_charge_dollar": 925.0, "methodology": "fee schedule" }, { "payer_name": "Monroe County Human Services", "plan_name": "Monroe County Human Services", "standard_charge_dollar": 1300.0, "methodology": "fee schedule" }, { "payer_name": "My Choice-Care WI Medicaid", "plan_name": "My Choice-Care WI Medicaid", "standard_charge_dollar": 951.07, "methodology": "fee schedule" }, { "payer_name": "My Choice-Trilogy Medicaid", "plan_name": "My Choice-Trilogy Medicaid", "standard_charge_dollar": 951.07, "methodology": "fee schedule" }, { "payer_name": "My Health Link Plan", "plan_name": "My Health Link Plan", "standard_charge_dollar": 1331.0, "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": 951.07, "methodology": "fee schedule" }, { "payer_name": "Network Health Medicare", "plan_name": "Network Health Medicare", "standard_charge_dollar": 820.0, "methodology": "fee schedule" }, { "payer_name": "Network Health Plan PPO", "plan_name": "Network Health Plan PPO", "standard_charge_dollar": 2100.0, "methodology": "fee schedule" }, { "payer_name": "Oneida Nation/Purchase & Referrals", "plan_name": "Oneida Nation/Purchase & Referrals", "standard_charge_dollar": 1250.0, "methodology": "fee schedule" }, { "payer_name": "Oxford - United Healthcare", "plan_name": "Oxford - United Healthcare", "standard_charge_dollar": 1000.0, "methodology": "fee schedule" }, { "payer_name": "Pan American Life Insurane Co", "plan_name": "Pan American Life Insurane Co", "standard_charge_dollar": 1100.0, "methodology": "fee schedule" }, { "payer_name": "Passport Health Plan", "plan_name": "Passport Health Plan", "standard_charge_dollar": 951.07, "methodology": "fee schedule" }, { "payer_name": "Pierce County DHS", "plan_name": "Pierce County DHS", "standard_charge_dollar": 1362.6, "methodology": "fee schedule" }, { "payer_name": "Planned Administrators Inc", "plan_name": "Planned Administrators Inc", "standard_charge_dollar": 661.79, "methodology": "fee schedule" }, { "payer_name": "Polk County Health And Human Services", "plan_name": "Polk County Health And Human Services", "standard_charge_dollar": 1344.99, "methodology": "fee schedule" }, { "payer_name": "Prairie States Enterprises INC", "plan_name": "Prairie States Enterprises INC", "standard_charge_dollar": 1170.0, "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": 1379.55, "methodology": "fee schedule" }, { "payer_name": "Prevea 360 DeanCare ASO", "plan_name": "Prevea 360 DeanCare ASO", "standard_charge_dollar": 1527.75, "methodology": "fee schedule" }, { "payer_name": "Quartz", "plan_name": "Quartz", "standard_charge_dollar": 1250.0, "methodology": "fee schedule" }, { "payer_name": "Quartz Medicaid", "plan_name": "Quartz Medicaid", "standard_charge_dollar": 951.07, "methodology": "fee schedule" }, { "payer_name": "Saginaw CMH", "plan_name": "Saginaw CMH", "standard_charge_dollar": 1293.0, "methodology": "fee schedule" }, { "payer_name": "Security Health Commercial", "plan_name": "Security Health Commercial", "standard_charge_dollar": 1287.5, "methodology": "fee schedule" }, { "payer_name": "Security Health Medicare", "plan_name": "Security Health Medicare", "standard_charge_dollar": 820.0, "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": 951.07, "methodology": "fee schedule" }, { "payer_name": "Simplan Administrators", "plan_name": "Simplan Administrators", "standard_charge_dollar": 1550.0, "methodology": "fee schedule" }, { "payer_name": "Stockbridge-Munsee Health And Wellness", "plan_name": "Stockbridge-Munsee Health And Wellness", "standard_charge_dollar": 1250.0, "methodology": "fee schedule" }, { "payer_name": "Superior", "plan_name": "Superior", "standard_charge_dollar": 780.67, "methodology": "fee schedule" }, { "payer_name": "Surest", "plan_name": "Surest", "standard_charge_dollar": 1379.0, "methodology": "fee schedule" }, { "payer_name": "The Alliance Auxiant", "plan_name": "The Alliance Auxiant", "standard_charge_dollar": 1300.0, "methodology": "fee schedule" }, { "payer_name": "The Benefit Group", "plan_name": "The Benefit Group", "standard_charge_dollar": 1000.0, "methodology": "fee schedule" }, { "payer_name": "Tricare West", "plan_name": "Tricare West", "standard_charge_dollar": 930.05, "methodology": "fee schedule" }, { "payer_name": "Trilogy Commercial", "plan_name": "Trilogy Commercial", "standard_charge_dollar": 975.0, "methodology": "fee schedule" }, { "payer_name": "Ucare MN Medicaid", "plan_name": "Ucare MN Medicaid", "standard_charge_dollar": 951.07, "methodology": "fee schedule" }, { "payer_name": "UHC/OPTUM", "plan_name": "UHC/OPTUM", "standard_charge_dollar": 1379.0, "methodology": "fee schedule" }, { "payer_name": "UMR", "plan_name": "UMR", "standard_charge_dollar": 1379.0, "methodology": "fee schedule" }, { "payer_name": "UMR Commercial", "plan_name": "UMR Commercial", "standard_charge_dollar": 1379.0, "methodology": "fee schedule" }, { "payer_name": "Unicare", "plan_name": "Unicare", "standard_charge_dollar": 1100.0, "methodology": "fee schedule" }, { "payer_name": "United Behavioral Health", "plan_name": "United Behavioral Health", "standard_charge_dollar": 1379.0, "methodology": "fee schedule" }, { "payer_name": "United Behavorial Health", "plan_name": "United Behavorial Health", "standard_charge_dollar": 1379.0, "methodology": "fee schedule" }, { "payer_name": "United Healthcare", "plan_name": "United Healthcare", "standard_charge_dollar": 1379.0, "methodology": "fee schedule" }, { "payer_name": "United Healthcare Dual Complete LP1", "plan_name": "United Healthcare Dual Complete LP1", "standard_charge_dollar": 1000.0, "methodology": "fee schedule" }, { "payer_name": "United Healthcare Healthscope", "plan_name": "United Healthcare Healthscope", "standard_charge_dollar": 1030.0, "methodology": "fee schedule" }, { "payer_name": "United Healthcare Managed Medicare", "plan_name": "United Healthcare Managed Medicare", "standard_charge_dollar": 820.0, "methodology": "fee schedule" }, { "payer_name": "United Healthcare Medicaid Community Pla", "plan_name": "United Healthcare Medicaid Community Pla", "standard_charge_dollar": 951.07, "methodology": "fee schedule" }, { "payer_name": "United Healthcare Shared Services", "plan_name": "United Healthcare Shared Services", "standard_charge_dollar": 1379.0, "methodology": "fee schedule" }, { "payer_name": "Unity Health Plan Medicaid", "plan_name": "Unity Health Plan Medicaid", "standard_charge_dollar": 951.07, "methodology": "fee schedule" }, { "payer_name": "UPHP Medicare Advantage", "plan_name": "UPHP Medicare Advantage", "standard_charge_dollar": 1293.0, "methodology": "fee schedule" }, { "payer_name": "VA Office Of Integrated Care", "plan_name": "VA Office Of Integrated Care", "standard_charge_dollar": 1000.0, "methodology": "fee schedule" }, { "payer_name": "WEA Trust Commercial", "plan_name": "WEA Trust Commercial", "standard_charge_dollar": 1350.0, "methodology": "fee schedule" }, { "payer_name": "Western Region Recovery & Wellness Conso", "plan_name": "Western Region Recovery & Wellness Conso", "standard_charge_dollar": 1305.82, "methodology": "fee schedule" }, { "payer_name": "WISCONSIN ANTHEM MEDI BLUE DUAL ADV", "plan_name": "WISCONSIN ANTHEM MEDI BLUE DUAL ADV", "standard_charge_dollar": 1225.0, "methodology": "fee schedule" }, { "payer_name": "WPS Health Insurance", "plan_name": "WPS Health Insurance", "standard_charge_dollar": 1208.5, "methodology": "fee schedule" }, { "payer_name": "WPS Health Plan - SCA", "plan_name": "WPS Health Plan - SCA", "standard_charge_dollar": 1200.0, "methodology": "fee schedule" } ], "gross_charge": 3000.0, "discounted_cash": 1000.0, "minimum": 568.8, "maximum": 2100.0 } ] }, { "description": "Acute CD Adol R&B", "code_information": [ { "code": "126", "type": "RC" }, { "code": "906", "type": "LOCAL" } ], "standard_charges": [ { "setting": "inpatient", "payers_information": [ { "payer_name": "Transamerica", "plan_name": "Transamerica", "standard_charge_dollar": 897.12, "methodology": "fee schedule" } ], "gross_charge": 2600.0, "minimum": 897.12, "maximum": 897.12 } ] }, { "description": "Acute CD Adult R&B", "code_information": [ { "code": "126", "type": "RC" }, { "code": "905", "type": "LOCAL" } ], "standard_charges": [ { "setting": "inpatient", "payers_information": [ { "payer_name": "Transamerica", "plan_name": "Transamerica", "standard_charge_dollar": 897.12, "methodology": "fee schedule" } ], "gross_charge": 3000.0, "minimum": 897.12, "maximum": 897.12 } ] }, { "description": "Acute CD Gero R&B", "code_information": [ { "code": "126", "type": "RC" }, { "code": "904", "type": "LOCAL" } ], "standard_charges": [ { "setting": "inpatient", "payers_information": [ { "payer_name": "Transamerica", "plan_name": "Transamerica", "standard_charge_dollar": 897.12, "methodology": "fee schedule" } ], "gross_charge": 3000.0, "minimum": 897.12, "maximum": 897.12 } ] }, { "description": "Acute Adult Rehab R&B", "code_information": [ { "code": "128", "type": "RC" }, { "code": "1005", "type": "LOCAL" } ], "standard_charges": [ { "setting": "inpatient", "payers_information": [ { "payer_name": "AARP Supplement Plan", "plan_name": "AARP Supplement Plan", "standard_charge_dollar": 925.0, "methodology": "fee schedule" }, { "payer_name": "Advocate Aurora Health Inc UMR", "plan_name": "Advocate Aurora Health Inc UMR", "standard_charge_dollar": 1300.0, "methodology": "fee schedule" }, { "payer_name": "Aetna Life Insurance Company", "plan_name": "Aetna Life Insurance Company", "standard_charge_dollar": 1550.0, "methodology": "fee 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"standard_charge_dollar": 1300.0, "methodology": "fee schedule" }, { "payer_name": "Humana Commercial", "plan_name": "Humana Commercial", "standard_charge_dollar": 1351.39, "methodology": "fee schedule" }, { "payer_name": "Humana Medicare", "plan_name": "Humana Medicare", "standard_charge_dollar": 1100.0, "methodology": "fee schedule" }, { "payer_name": "ICare Medicaid", "plan_name": "ICare Medicaid", "standard_charge_dollar": 951.07, "methodology": "fee schedule" }, { "payer_name": "ICare Medicare", "plan_name": "ICare Medicare", "standard_charge_dollar": 925.0, "methodology": "fee schedule" }, { "payer_name": "Kaiser Permanente", "plan_name": "Kaiser Permanente", "standard_charge_dollar": 1200.0, "methodology": "fee schedule" }, { "payer_name": "KBIC Health System", "plan_name": "KBIC Health System", "standard_charge_dollar": 1000.0, "methodology": "fee schedule" }, { "payer_name": "Lakeland Care Inc. 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schedule" }, { "payer_name": "MDHHS: Gogebic Community Mental Health", "plan_name": "MDHHS: Gogebic Community Mental Health", "standard_charge_dollar": 1293.0, "methodology": "fee schedule" }, { "payer_name": "MDHHS: North Pointe HHS", "plan_name": "MDHHS: North Pointe HHS", "standard_charge_dollar": 1293.0, "methodology": "fee schedule" }, { "payer_name": "MDHHS: UPHP MI Medicaid C/o Northcare", "plan_name": "MDHHS: UPHP MI Medicaid C/o Northcare", "standard_charge_dollar": 1331.0, "methodology": "fee schedule" }, { "payer_name": "MEDICA", "plan_name": "MEDICA", "standard_charge_dollar": 1379.0, "methodology": "fee schedule" }, { "payer_name": "Medica Behavior Health", "plan_name": "Medica Behavior Health", "standard_charge_dollar": 1000.0, "methodology": "fee schedule" }, { "payer_name": "Medica Medicare Advantage Prime Solution", "plan_name": "Medica Medicare Advantage Prime Solution", "standard_charge_dollar": 1000.0, "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": 951.07, "methodology": "fee schedule" }, { "payer_name": "Molina Healthcare Medicare", "plan_name": "Molina Healthcare Medicare", "standard_charge_dollar": 925.0, "methodology": "fee schedule" }, { "payer_name": "Monroe County Human Services", "plan_name": "Monroe County Human Services", "standard_charge_dollar": 1300.0, "methodology": "fee schedule" }, { "payer_name": "My Choice-Care WI Medicaid", "plan_name": "My Choice-Care WI Medicaid", "standard_charge_dollar": 951.07, "methodology": "fee schedule" }, { "payer_name": "My Choice-Trilogy Medicaid", "plan_name": "My Choice-Trilogy Medicaid", "standard_charge_dollar": 951.07, "methodology": "fee schedule" }, { "payer_name": "My Health Link Plan", "plan_name": "My Health Link Plan", "standard_charge_dollar": 1331.0, "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": 951.07, "methodology": "fee schedule" }, { "payer_name": "Network Health Medicare", "plan_name": "Network Health Medicare", "standard_charge_dollar": 820.0, "methodology": "fee schedule" }, { "payer_name": "Network Health Plan PPO", "plan_name": "Network Health Plan PPO", "standard_charge_dollar": 2100.0, "methodology": "fee schedule" }, { "payer_name": "Oneida Nation/Purchase & Referrals", "plan_name": "Oneida Nation/Purchase & Referrals", "standard_charge_dollar": 1250.0, "methodology": "fee schedule" }, { "payer_name": "Oxford - United Healthcare", "plan_name": "Oxford - United Healthcare", "standard_charge_dollar": 1000.0, "methodology": "fee schedule" }, { "payer_name": "Pan American Life Insurane Co", "plan_name": "Pan American Life Insurane Co", "standard_charge_dollar": 1100.0, "methodology": "fee schedule" }, { "payer_name": "Passport Health Plan", "plan_name": "Passport Health Plan", "standard_charge_dollar": 951.07, "methodology": "fee schedule" }, { "payer_name": "Pierce County DHS", "plan_name": "Pierce County DHS", "standard_charge_dollar": 1362.6, "methodology": "fee schedule" }, { "payer_name": "Planned Administrators Inc", "plan_name": "Planned Administrators Inc", "standard_charge_dollar": 661.79, "methodology": "fee schedule" }, { "payer_name": "Polk County Health And Human Services", "plan_name": "Polk County Health And Human Services", "standard_charge_dollar": 1344.99, "methodology": "fee schedule" }, { "payer_name": "Prairie States Enterprises INC", "plan_name": "Prairie States Enterprises INC", "standard_charge_dollar": 1170.0, "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", "plan_name": "Quartz", "standard_charge_dollar": 1250.0, "methodology": "fee schedule" }, { "payer_name": "Quartz Medicaid", "plan_name": "Quartz Medicaid", "standard_charge_dollar": 951.07, "methodology": "fee schedule" }, { "payer_name": "Saginaw CMH", "plan_name": "Saginaw CMH", "standard_charge_dollar": 1293.0, "methodology": "fee schedule" }, { "payer_name": "Security Health Commercial", "plan_name": "Security Health Commercial", "standard_charge_dollar": 1287.5, "methodology": "fee schedule" }, { "payer_name": "Security Health Medicare", "plan_name": "Security Health Medicare", "standard_charge_dollar": 820.0, "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": 951.07, "methodology": "fee schedule" }, { "payer_name": "Simplan Administrators", "plan_name": "Simplan Administrators", "standard_charge_dollar": 1550.0, "methodology": "fee schedule" }, { "payer_name": "Stockbridge-Munsee Health And Wellness", "plan_name": "Stockbridge-Munsee Health And Wellness", "standard_charge_dollar": 1250.0, "methodology": "fee schedule" }, { "payer_name": "Superior", "plan_name": "Superior", "standard_charge_dollar": 780.67, "methodology": "fee schedule" }, { "payer_name": "Surest", "plan_name": "Surest", "standard_charge_dollar": 1379.0, "methodology": "fee schedule" }, { "payer_name": "The Alliance Auxiant", "plan_name": "The Alliance Auxiant", "standard_charge_dollar": 1300.0, "methodology": "fee schedule" }, { "payer_name": "The Benefit Group", "plan_name": "The Benefit Group", "standard_charge_dollar": 1000.0, "methodology": "fee schedule" }, { "payer_name": "Trilogy Commercial", "plan_name": "Trilogy Commercial", "standard_charge_dollar": 975.0, "methodology": "fee schedule" }, { "payer_name": "UHC/OPTUM", "plan_name": "UHC/OPTUM", "standard_charge_dollar": 1379.0, "methodology": "fee schedule" }, { "payer_name": "UMR", "plan_name": "UMR", "standard_charge_dollar": 1379.0, "methodology": "fee schedule" }, { "payer_name": "UMR Commercial", "plan_name": "UMR Commercial", "standard_charge_dollar": 1379.0, "methodology": "fee schedule" }, { "payer_name": "Unicare", "plan_name": "Unicare", "standard_charge_dollar": 1100.0, "methodology": "fee schedule" }, { "payer_name": "United Behavioral Health", "plan_name": "United Behavioral Health", "standard_charge_dollar": 1379.0, "methodology": "fee schedule" }, { "payer_name": "United Behavorial Health", "plan_name": "United Behavorial Health", "standard_charge_dollar": 1379.0, "methodology": "fee schedule" }, { "payer_name": "United Healthcare", "plan_name": "United Healthcare", "standard_charge_dollar": 1379.0, "methodology": "fee schedule" }, { "payer_name": "United Healthcare Dual Complete LP1", "plan_name": "United Healthcare Dual Complete LP1", "standard_charge_dollar": 1000.0, "methodology": "fee schedule" }, { "payer_name": "United Healthcare Managed Medicare", "plan_name": "United Healthcare Managed Medicare", "standard_charge_dollar": 820.0, "methodology": "fee schedule" }, { "payer_name": "United Healthcare Medicaid Community Pla", "plan_name": "United Healthcare Medicaid Community Pla", "standard_charge_dollar": 951.07, "methodology": "fee schedule" }, { "payer_name": "United Healthcare Shared Services", "plan_name": "United Healthcare Shared Services", "standard_charge_dollar": 1379.0, "methodology": "fee schedule" }, { "payer_name": "Unity Health Plan Medicaid", "plan_name": "Unity Health Plan Medicaid", "standard_charge_dollar": 951.07, "methodology": "fee schedule" }, { "payer_name": "UPHP Medicare Advantage", "plan_name": "UPHP Medicare Advantage", "standard_charge_dollar": 1293.0, "methodology": "fee schedule" }, { "payer_name": "VA Office Of Integrated Care", "plan_name": "VA Office Of Integrated Care", "standard_charge_dollar": 1000.0, "methodology": "fee schedule" }, { "payer_name": "WEA Trust Commercial", "plan_name": "WEA Trust Commercial", "standard_charge_dollar": 1350.0, "methodology": "fee schedule" }, { "payer_name": "Western Region Recovery & Wellness Conso", "plan_name": "Western Region Recovery & Wellness Conso", "standard_charge_dollar": 1305.82, "methodology": "fee schedule" }, { "payer_name": "WISCONSIN ANTHEM MEDI BLUE DUAL ADV", "plan_name": "WISCONSIN ANTHEM MEDI BLUE DUAL ADV", "standard_charge_dollar": 1225.0, "methodology": "fee schedule" }, { "payer_name": "WPS Health Insurance", "plan_name": "WPS Health Insurance", "standard_charge_dollar": 1208.5, "methodology": "fee schedule" }, { "payer_name": "WPS Health Plan - SCA", "plan_name": "WPS Health Plan - SCA", "standard_charge_dollar": 1200.0, "methodology": "fee schedule" } ], "gross_charge": 3000.0, "discounted_cash": 1000.0, "minimum": 568.8, "maximum": 2100.0 } ] }, { "description": "ECT", "code_information": [ { "code": "90870", "type": "CPT" }, { "code": "1092", "type": "LOCAL" } ], "standard_charges": [ { "setting": "inpatient", "payers_information": [ { "payer_name": "Cigna BH Beacon Health Options", "plan_name": "Cigna BH Beacon Health Options", "standard_charge_dollar": 625.0, "methodology": "fee schedule" }, { "payer_name": "Cigna Healthcare", "plan_name": "Cigna Healthcare", "standard_charge_dollar": 625.0, "methodology": "fee schedule" }, { "payer_name": "Cigna Healthgram Inc", "plan_name": "Cigna Healthgram Inc", "standard_charge_dollar": 625.0, "methodology": "fee schedule" }, { "payer_name": "Security Health Commercial", "plan_name": "Security Health Commercial", "standard_charge_dollar": 900.0, "methodology": "fee schedule" }, { "payer_name": "Security Health Medicare", "plan_name": "Security Health Medicare", "standard_charge_dollar": 900.0, "methodology": "fee schedule" }, { "payer_name": "Security Health Plan", "plan_name": "Security Health Plan", "standard_charge_dollar": 900.0, "methodology": "fee schedule" }, { "payer_name": "Security Health Plan Managed Medicaid", "plan_name": "Security Health Plan Managed Medicaid", "standard_charge_dollar": 900.0, "methodology": "fee schedule" } ], "gross_charge": 1700.0, "minimum": 625.0, "maximum": 900.0 } ] }, { "description": "Adol Psych IOP 3 hrs", "code_information": [ { "code": "H0015", "type": "HCPCS" }, { "code": "1060", "type": "LOCAL" } ], "standard_charges": [ { "setting": "outpatient", "payers_information": [ { "payer_name": "AARP Medicare Complete", "plan_name": "AARP Medicare Complete", "standard_charge_dollar": 200.0, "methodology": "fee schedule" }, { "payer_name": "AARP Supplement Plan", "plan_name": "AARP Supplement Plan", "standard_charge_dollar": 212.0, "methodology": "fee schedule" }, { "payer_name": "Advocate Aurora Health Inc UMR", "plan_name": "Advocate Aurora Health Inc UMR", "standard_charge_dollar": 250.0, "methodology": "fee schedule" }, { "payer_name": "Aetna Life Insurance Company", "plan_name": "Aetna Life Insurance Company", "standard_charge_dollar": 350.0, "methodology": "fee schedule" }, { "payer_name": "Aetna Medicare", "plan_name": "Aetna Medicare", "standard_charge_dollar": 185.0, "methodology": "fee schedule" }, { "payer_name": "Aetna-SCA", "plan_name": "Aetna-SCA", "standard_charge_dollar": 350.0, "methodology": "fee schedule" }, { "payer_name": "Aither Health", "plan_name": "Aither Health", "standard_charge_dollar": 210.0, "methodology": "fee schedule" }, { "payer_name": "All Savers", "plan_name": "All Savers", "standard_charge_dollar": 275.0, "methodology": "fee schedule" }, { "payer_name": "Amerigroup", "plan_name": "Amerigroup", "standard_charge_dollar": 473.71, "methodology": "fee schedule" }, { "payer_name": "ANTHEM BLUE PREFERRED PLUS", "plan_name": "ANTHEM BLUE PREFERRED PLUS", "standard_charge_dollar": 210.0, "methodology": "fee schedule" }, { "payer_name": "Anthem Commercial", "plan_name": "Anthem Commercial", "standard_charge_dollar": 210.0, "methodology": "fee schedule" }, { "payer_name": "Anthem Federal Employee", "plan_name": "Anthem Federal Employee", "standard_charge_dollar": 210.0, "methodology": "fee schedule" }, { "payer_name": "Anthem Medicaid", "plan_name": "Anthem Medicaid", "standard_charge_dollar": 473.71, "methodology": "fee schedule" }, { "payer_name": "Anthem Medicare", "plan_name": "Anthem Medicare", "standard_charge_dollar": 212.0, "methodology": "fee schedule" }, { "payer_name": "ASPIRUS WPS- DON'T USE ANYMORE", "plan_name": "ASPIRUS WPS- DON'T USE ANYMORE", "standard_charge_dollar": 175.0, "methodology": "fee schedule" }, { "payer_name": "Auxiant", "plan_name": "Auxiant", "standard_charge_dollar": 350.0, "methodology": "fee schedule" }, { "payer_name": "BCBS OF MICHIGAN", "plan_name": "BCBS OF MICHIGAN", "standard_charge_dollar": 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"methodology": "fee schedule" }, { "payer_name": "KBIC Health System", "plan_name": "KBIC Health System", "standard_charge_dollar": 175.0, "methodology": "fee schedule" }, { "payer_name": "Maestro Health", "plan_name": "Maestro Health", "standard_charge_dollar": 175.0, "methodology": "fee schedule" }, { "payer_name": "Magellan Behavioral Health Systems", "plan_name": "Magellan Behavioral Health Systems", "standard_charge_dollar": 275.0, "methodology": "fee schedule" }, { "payer_name": "Managed Health Services-Managed MA", "plan_name": "Managed Health Services-Managed MA", "standard_charge_dollar": 473.71, "methodology": "fee schedule" }, { "payer_name": "Manitowoc County DHS", "plan_name": "Manitowoc County DHS", "standard_charge_dollar": 212.0, "methodology": "fee schedule" }, { "payer_name": "Marathon County", "plan_name": "Marathon County", "standard_charge_dollar": 212.0, "methodology": "fee schedule" }, { "payer_name": "Mayo Clinic Health Solutions", "plan_name": "Mayo Clinic Health Solutions", "standard_charge_dollar": 212.0, "methodology": "fee schedule" }, { "payer_name": "MDHHS: Gogebic Community Mental Health", "plan_name": "MDHHS: Gogebic Community Mental Health", "standard_charge_dollar": 212.0, "methodology": "fee schedule" }, { "payer_name": "MDHHS: North Pointe HHS", "plan_name": "MDHHS: North Pointe HHS", "standard_charge_dollar": 212.0, "methodology": "fee schedule" }, { "payer_name": "MDHHS: UPHP MI Medicaid C/o Northcare", "plan_name": "MDHHS: UPHP MI Medicaid C/o Northcare", "standard_charge_dollar": 212.0, "methodology": "fee schedule" }, { "payer_name": "MEDICA", "plan_name": "MEDICA", "standard_charge_dollar": 291.0, "methodology": "fee schedule" }, { "payer_name": "Medica Behavior Health", "plan_name": "Medica Behavior Health", "standard_charge_dollar": 175.0, "methodology": "fee schedule" }, { "payer_name": "Medica Medicare Advantage Prime Solution", "plan_name": "Medica Medicare Advantage Prime Solution", "standard_charge_dollar": 175.0, "methodology": "fee schedule" }, { "payer_name": "Mercy Care Wi Medicaid MCO", "plan_name": "Mercy Care Wi Medicaid MCO", "standard_charge_dollar": 473.71, "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": 473.71, "methodology": "fee schedule" }, { "payer_name": "Molina Healthcare Medicare", "plan_name": "Molina Healthcare Medicare", "standard_charge_dollar": 212.0, "methodology": "fee schedule" }, { "payer_name": "My Choice-Care WI Medicaid", "plan_name": "My Choice-Care WI Medicaid", "standard_charge_dollar": 473.71, "methodology": "fee schedule" }, { "payer_name": "My Choice-Trilogy Medicaid", "plan_name": "My Choice-Trilogy Medicaid", "standard_charge_dollar": 473.71, "methodology": "fee schedule" }, { "payer_name": "My Health Link Plan", "plan_name": "My Health Link Plan", "standard_charge_dollar": 212.0, "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": 473.71, "methodology": "fee schedule" }, { "payer_name": "Network Health Medicare", "plan_name": "Network Health Medicare", "standard_charge_dollar": 200.0, "methodology": "fee schedule" }, { "payer_name": "Network Health Plan PPO", "plan_name": "Network Health Plan PPO", "standard_charge_dollar": 1190.0, "methodology": "fee schedule" }, { "payer_name": "Oneida Nation/Purchase & Referrals", "plan_name": "Oneida Nation/Purchase & Referrals", "standard_charge_dollar": 212.0, "methodology": "fee schedule" }, { "payer_name": "Oxford - United Healthcare", "plan_name": "Oxford - United Healthcare", "standard_charge_dollar": 175.0, "methodology": "fee schedule" }, { "payer_name": "Pan American Life Insurane Co", "plan_name": "Pan American Life Insurane Co", "standard_charge_dollar": 212.0, "methodology": "fee schedule" }, { "payer_name": "Passport Health Plan", "plan_name": "Passport Health Plan", "standard_charge_dollar": 473.71, "methodology": "fee schedule" }, { "payer_name": "Portage County Health And Human Services", "plan_name": "Portage County Health And Human Services", "standard_charge_dollar": 252.5, "methodology": "fee schedule" }, { "payer_name": "Prairie States Enterprises INC", "plan_name": "Prairie States Enterprises INC", "standard_charge_dollar": 212.0, "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": "Prevea 360 Commercial", "plan_name": "Prevea 360 Commercial", "standard_charge_dollar": 256.2, "methodology": "fee schedule" }, { "payer_name": "Prevea 360 DeanCare ASO", "plan_name": "Prevea 360 DeanCare ASO", "standard_charge_dollar": 261.33, "methodology": "fee schedule" }, { "payer_name": "Quartz", "plan_name": "Quartz", "standard_charge_dollar": 350.0, "methodology": "fee schedule" }, { "payer_name": "Quartz Medicaid", "plan_name": "Quartz Medicaid", "standard_charge_dollar": 473.71, "methodology": "fee schedule" }, { "payer_name": "Saginaw CMH", "plan_name": "Saginaw CMH", "standard_charge_dollar": 212.0, "methodology": "fee schedule" }, { "payer_name": "Security Health Commercial", "plan_name": "Security Health Commercial", "standard_charge_dollar": 283.25, "methodology": "fee schedule" }, { "payer_name": "Security Health Medicare", "plan_name": "Security Health Medicare", "standard_charge_dollar": 70.11, "methodology": "fee schedule" }, { "payer_name": "Security Health Plan", "plan_name": "Security Health Plan", "standard_charge_dollar": 283.25, "methodology": "fee schedule" }, { "payer_name": "Security Health Plan Managed Medicaid", "plan_name": "Security Health Plan Managed Medicaid", "standard_charge_dollar": 473.71, "methodology": "fee schedule" }, { "payer_name": "Simplan Administrators", "plan_name": "Simplan Administrators", "standard_charge_dollar": 350.0, "methodology": "fee schedule" }, { "payer_name": "Stockbridge-Munsee Health And Wellness", "plan_name": "Stockbridge-Munsee Health And Wellness", "standard_charge_dollar": 212.0, "methodology": "fee schedule" }, { "payer_name": "Superior", "plan_name": "Superior", "standard_charge_dollar": 212.0, "methodology": "fee schedule" }, { "payer_name": "Surest", "plan_name": "Surest", "standard_charge_dollar": 291.0, "methodology": "fee schedule" }, { "payer_name": "The Alliance Auxiant", "plan_name": "The Alliance Auxiant", "standard_charge_dollar": 250.0, "methodology": "fee schedule" }, { "payer_name": "The Benefit Group", "plan_name": "The Benefit Group", "standard_charge_dollar": 350.0, "methodology": "fee schedule" }, { "payer_name": "Trilogy Commercial", "plan_name": "Trilogy Commercial", "standard_charge_dollar": 345.0, "methodology": "fee schedule" }, { "payer_name": "UHC/OPTUM", "plan_name": "UHC/OPTUM", "standard_charge_dollar": 291.0, "methodology": "fee schedule" }, { "payer_name": "UMR", "plan_name": "UMR", "standard_charge_dollar": 291.0, "methodology": "fee schedule" }, { "payer_name": "UMR Commercial", "plan_name": "UMR Commercial", "standard_charge_dollar": 291.0, "methodology": "fee schedule" }, { "payer_name": "Unicare", "plan_name": "Unicare", "standard_charge_dollar": 212.0, "methodology": "fee schedule" }, { "payer_name": "United Behavioral Health", "plan_name": "United Behavioral Health", "standard_charge_dollar": 291.0, "methodology": "fee schedule" }, { "payer_name": "United Behavorial Health", "plan_name": "United Behavorial Health", "standard_charge_dollar": 291.0, "methodology": "fee schedule" }, { "payer_name": "United Healthcare", "plan_name": "United Healthcare", "standard_charge_dollar": 291.0, "methodology": "fee schedule" }, { "payer_name": "United Healthcare Dual Complete LP1", "plan_name": "United Healthcare Dual Complete LP1", "standard_charge_dollar": 125.0, "methodology": "fee schedule" }, { "payer_name": "United Healthcare Managed Medicare", "plan_name": "United Healthcare Managed Medicare", "standard_charge_dollar": 125.0, "methodology": "fee schedule" }, { "payer_name": "United Healthcare Medicaid Community Pla", "plan_name": "United Healthcare Medicaid Community Pla", "standard_charge_dollar": 338.94, "methodology": "fee schedule" }, { "payer_name": "United Healthcare Shared Services", "plan_name": "United Healthcare Shared Services", "standard_charge_dollar": 150.0, "methodology": "fee schedule" }, { "payer_name": "Unity Health Plan Medicaid", "plan_name": "Unity Health Plan Medicaid", "standard_charge_dollar": 473.71, "methodology": "fee schedule" }, { "payer_name": "UPHP Medicare Advantage", "plan_name": "UPHP Medicare Advantage", "standard_charge_dollar": 212.0, "methodology": "fee schedule" }, { "payer_name": "VA Office Of Integrated Care", "plan_name": "VA Office Of Integrated Care", "standard_charge_dollar": 175.0, "methodology": "fee schedule" }, { "payer_name": "WEA Trust Commercial", "plan_name": "WEA Trust Commercial", "standard_charge_dollar": 225.0, "methodology": "fee schedule" }, { "payer_name": "WISCONSIN ANTHEM MEDI BLUE DUAL ADV", "plan_name": "WISCONSIN ANTHEM MEDI BLUE DUAL ADV", "standard_charge_dollar": 210.0, "methodology": "fee schedule" }, { "payer_name": "WPS Health Insurance", "plan_name": "WPS Health Insurance", "standard_charge_dollar": 275.0, "methodology": "fee schedule" }, { "payer_name": "WPS Health Plan - SCA", "plan_name": "WPS Health Plan - SCA", "standard_charge_dollar": 212.0, "methodology": "fee schedule" } ], "gross_charge": 1700.0, "discounted_cash": 300.0, "minimum": 70.11, "maximum": 1190.0 } ] }, { "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": 200.0, "methodology": "fee schedule" }, { "payer_name": "AARP Supplement Plan", "plan_name": "AARP Supplement Plan", "standard_charge_dollar": 212.0, "methodology": "fee schedule" }, { "payer_name": "Administrative Concepts", "plan_name": "Administrative Concepts", "standard_charge_dollar": 175.0, "methodology": "fee schedule" }, { "payer_name": "Advocate Aurora Health Inc UMR", "plan_name": "Advocate Aurora Health Inc UMR", "standard_charge_dollar": 250.0, "methodology": "fee schedule" }, { "payer_name": "Aetna Life Insurance Company", "plan_name": "Aetna Life Insurance Company", "standard_charge_dollar": 350.0, "methodology": "fee schedule" }, { "payer_name": "Aetna Medicare", "plan_name": "Aetna Medicare", 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}, { "payer_name": "Anthem Medicaid", "plan_name": "Anthem Medicaid", "standard_charge_dollar": 473.71, "methodology": "fee schedule" }, { "payer_name": "Anthem Medicare", "plan_name": "Anthem Medicare", "standard_charge_dollar": 212.0, "methodology": "fee schedule" }, { "payer_name": "Aspirus Health Plan", "plan_name": "Aspirus Health Plan", "standard_charge_dollar": 1190.0, "methodology": "fee schedule" }, { "payer_name": "ASPIRUS WPS- DON'T USE ANYMORE", "plan_name": "ASPIRUS WPS- DON'T USE ANYMORE", "standard_charge_dollar": 175.0, "methodology": "fee schedule" }, { "payer_name": "Auxiant", "plan_name": "Auxiant", "standard_charge_dollar": 350.0, "methodology": "fee schedule" }, { "payer_name": "BCBS OF MICHIGAN", "plan_name": "BCBS OF MICHIGAN", "standard_charge_dollar": 210.0, "methodology": "fee schedule" }, { "payer_name": "BEACON HEALTH", "plan_name": "BEACON HEALTH", "standard_charge_dollar": 250.0, "methodology": "fee schedule" }, { "payer_name": "Benefit Plan 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schedule" }, { "payer_name": "Manitowoc County DHS", "plan_name": "Manitowoc County DHS", "standard_charge_dollar": 212.0, "methodology": "fee schedule" }, { "payer_name": "Marathon County", "plan_name": "Marathon County", "standard_charge_dollar": 212.0, "methodology": "fee schedule" }, { "payer_name": "Mayo Clinic Health Solutions", "plan_name": "Mayo Clinic Health Solutions", "standard_charge_dollar": 212.0, "methodology": "fee schedule" }, { "payer_name": "MDHHS: Gogebic Community Mental Health", "plan_name": "MDHHS: Gogebic Community Mental Health", "standard_charge_dollar": 212.0, "methodology": "fee schedule" }, { "payer_name": "MDHHS: North Pointe HHS", "plan_name": "MDHHS: North Pointe HHS", "standard_charge_dollar": 212.0, "methodology": "fee schedule" }, { "payer_name": "MDHHS: UPHP MI Medicaid C/o Northcare", "plan_name": "MDHHS: UPHP MI Medicaid C/o Northcare", "standard_charge_dollar": 212.0, "methodology": "fee schedule" }, { "payer_name": "MEDICA", "plan_name": "MEDICA", "standard_charge_dollar": 291.0, "methodology": "fee schedule" }, { "payer_name": "Medica Behavior Health", "plan_name": "Medica Behavior Health", "standard_charge_dollar": 175.0, "methodology": "fee schedule" }, { "payer_name": "Medica Medicare Advantage Prime Solution", "plan_name": "Medica Medicare Advantage Prime Solution", "standard_charge_dollar": 175.0, "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": 473.71, "methodology": "fee schedule" }, { "payer_name": "Molina Healthcare Medicare", "plan_name": "Molina Healthcare Medicare", "standard_charge_dollar": 212.0, "methodology": "fee schedule" }, { "payer_name": "My Choice-Care WI Medicaid", "plan_name": "My Choice-Care WI Medicaid", "standard_charge_dollar": 473.71, "methodology": "fee schedule" }, { "payer_name": "My Choice-Trilogy Medicaid", "plan_name": "My Choice-Trilogy Medicaid", "standard_charge_dollar": 473.71, "methodology": "fee schedule" }, { "payer_name": "My Health Link Plan", "plan_name": "My Health Link Plan", "standard_charge_dollar": 212.0, "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": 473.71, "methodology": "fee schedule" }, { "payer_name": "Network Health Medicare", "plan_name": "Network Health Medicare", "standard_charge_dollar": 200.0, "methodology": "fee schedule" }, { "payer_name": "Network Health Plan PPO", "plan_name": "Network Health Plan PPO", "standard_charge_dollar": 1190.0, "methodology": "fee schedule" }, { "payer_name": "Oneida Nation/Purchase & Referrals", "plan_name": "Oneida Nation/Purchase & Referrals", "standard_charge_dollar": 212.0, "methodology": "fee schedule" }, { "payer_name": "Oxford - United Healthcare", "plan_name": "Oxford - United Healthcare", "standard_charge_dollar": 175.0, "methodology": "fee schedule" }, { "payer_name": "Pan American Life Insurane Co", "plan_name": "Pan American Life Insurane Co", "standard_charge_dollar": 212.0, "methodology": "fee schedule" }, { "payer_name": "Passport Health Plan", "plan_name": "Passport Health Plan", "standard_charge_dollar": 473.71, "methodology": "fee schedule" }, { "payer_name": "Portage County Health And Human Services", "plan_name": "Portage County Health And Human Services", "standard_charge_dollar": 252.5, "methodology": "fee schedule" }, { "payer_name": "Prairie States Enterprises INC", "plan_name": "Prairie States Enterprises INC", "standard_charge_dollar": 212.0, "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": "Prevea 360 Commercial", "plan_name": "Prevea 360 Commercial", "standard_charge_dollar": 256.2, "methodology": "fee schedule" }, { "payer_name": "Prevea 360 DeanCare ASO", "plan_name": "Prevea 360 DeanCare ASO", "standard_charge_dollar": 261.33, "methodology": "fee schedule" }, { "payer_name": "Quartz", "plan_name": "Quartz", "standard_charge_dollar": 350.0, "methodology": "fee schedule" }, { "payer_name": "Quartz Medicaid", "plan_name": "Quartz Medicaid", "standard_charge_dollar": 473.71, "methodology": "fee schedule" }, { "payer_name": "Saginaw CMH", "plan_name": "Saginaw CMH", "standard_charge_dollar": 212.0, "methodology": "fee schedule" }, { "payer_name": "Security Health Commercial", "plan_name": "Security Health Commercial", "standard_charge_dollar": 283.25, "methodology": "fee schedule" }, { "payer_name": "Security Health Medicare", "plan_name": "Security Health Medicare", "standard_charge_dollar": 70.11, "methodology": "fee schedule" }, { "payer_name": "Security Health Plan", "plan_name": "Security Health Plan", "standard_charge_dollar": 283.25, "methodology": "fee schedule" }, { "payer_name": "Security Health Plan Managed Medicaid", "plan_name": "Security Health Plan Managed Medicaid", "standard_charge_dollar": 473.71, "methodology": "fee schedule" }, { "payer_name": "Simplan Administrators", "plan_name": "Simplan Administrators", "standard_charge_dollar": 350.0, "methodology": "fee schedule" }, { "payer_name": "Stockbridge-Munsee Health And Wellness", "plan_name": "Stockbridge-Munsee Health And Wellness", "standard_charge_dollar": 212.0, "methodology": "fee schedule" }, { "payer_name": "Superior", "plan_name": "Superior", "standard_charge_dollar": 212.0, "methodology": "fee schedule" }, { "payer_name": "Surest", "plan_name": "Surest", "standard_charge_dollar": 291.0, "methodology": "fee schedule" }, { "payer_name": "The Alliance Auxiant", "plan_name": "The Alliance Auxiant", "standard_charge_dollar": 250.0, "methodology": "fee schedule" }, { "payer_name": "The Benefit Group", "plan_name": "The Benefit Group", "standard_charge_dollar": 350.0, "methodology": "fee schedule" }, { "payer_name": "Together With CCHP", "plan_name": "Together With CCHP", "standard_charge_dollar": 473.71, "methodology": "fee schedule" }, { "payer_name": "TRICARE EAST-WPS", "plan_name": "TRICARE EAST-WPS", "standard_charge_dollar": 70.0, "methodology": "fee schedule" }, { "payer_name": "Tricare West", "plan_name": "Tricare West", "standard_charge_dollar": 321.1, "methodology": "fee schedule" }, { "payer_name": "Trilogy Commercial", "plan_name": "Trilogy Commercial", "standard_charge_dollar": 345.0, "methodology": "fee schedule" }, { "payer_name": "UHC/OPTUM", "plan_name": "UHC/OPTUM", "standard_charge_dollar": 291.0, "methodology": "fee schedule" }, { "payer_name": "UMR", "plan_name": "UMR", "standard_charge_dollar": 291.0, "methodology": "fee schedule" }, { "payer_name": "UMR Commercial", "plan_name": "UMR Commercial", "standard_charge_dollar": 291.0, "methodology": "fee schedule" }, { "payer_name": "Unicare", "plan_name": "Unicare", "standard_charge_dollar": 212.0, "methodology": "fee schedule" }, { "payer_name": "United Behavioral Health", "plan_name": "United Behavioral Health", "standard_charge_dollar": 291.0, "methodology": "fee schedule" }, { "payer_name": "United Behavorial Health", "plan_name": "United Behavorial Health", "standard_charge_dollar": 291.0, "methodology": "fee schedule" }, { "payer_name": "United Healthcare", "plan_name": "United Healthcare", "standard_charge_dollar": 291.0, "methodology": "fee schedule" }, { "payer_name": "United Healthcare Dual Complete LP1", "plan_name": "United Healthcare Dual Complete LP1", "standard_charge_dollar": 125.0, "methodology": "fee schedule" }, { "payer_name": "United Healthcare Healthscope", "plan_name": "United Healthcare Healthscope", "standard_charge_dollar": 175.0, "methodology": "fee schedule" }, { "payer_name": "United Healthcare Managed Medicare", "plan_name": "United Healthcare Managed Medicare", "standard_charge_dollar": 125.0, "methodology": "fee schedule" }, { "payer_name": "United Healthcare Medicaid Community Pla", "plan_name": "United Healthcare Medicaid Community Pla", "standard_charge_dollar": 473.71, "methodology": "fee schedule" }, { "payer_name": "United Healthcare Shared Services", "plan_name": "United Healthcare Shared Services", "standard_charge_dollar": 150.0, "methodology": "fee schedule" }, { "payer_name": "Unity Health Plan Medicaid", "plan_name": "Unity Health Plan Medicaid", "standard_charge_dollar": 473.71, "methodology": "fee schedule" }, { "payer_name": "UPHP Medicare Advantage", "plan_name": "UPHP Medicare Advantage", "standard_charge_dollar": 212.0, "methodology": "fee schedule" }, { "payer_name": "VA Office Of Integrated Care", "plan_name": "VA Office Of Integrated Care", "standard_charge_dollar": 175.0, "methodology": "fee schedule" }, { "payer_name": "WEA Trust Commercial", "plan_name": "WEA Trust Commercial", "standard_charge_dollar": 225.0, "methodology": "fee schedule" }, { "payer_name": "WISCONSIN ANTHEM MEDI BLUE DUAL ADV", "plan_name": "WISCONSIN ANTHEM MEDI BLUE DUAL ADV", "standard_charge_dollar": 210.0, "methodology": "fee schedule" }, { "payer_name": "WPS Health Insurance", "plan_name": "WPS Health Insurance", "standard_charge_dollar": 275.0, "methodology": "fee schedule" }, { "payer_name": "WPS Health Plan - SCA", "plan_name": "WPS Health Plan - SCA", "standard_charge_dollar": 212.0, "methodology": "fee schedule" } ], "gross_charge": 1700.0, "discounted_cash": 300.0, "minimum": 67.8, "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": "AARP Medicare Complete", "plan_name": "AARP Medicare Complete", "standard_charge_dollar": 200.0, "methodology": "fee schedule" }, { "payer_name": "AARP Supplement Plan", "plan_name": "AARP Supplement Plan", "standard_charge_dollar": 212.0, "methodology": "fee schedule" }, { "payer_name": "Advocate Aurora Health Inc UMR", "plan_name": "Advocate Aurora Health Inc UMR", "standard_charge_dollar": 250.0, "methodology": "fee schedule" }, { "payer_name": "Aetna Life Insurance Company", "plan_name": "Aetna Life Insurance Company", "standard_charge_dollar": 350.0, "methodology": "fee schedule" }, { "payer_name": "Aetna Medicare", "plan_name": "Aetna Medicare", "standard_charge_dollar": 185.0, "methodology": "fee schedule" }, { "payer_name": "Aetna-SCA", "plan_name": "Aetna-SCA", "standard_charge_dollar": 350.0, "methodology": "fee schedule" }, { "payer_name": "Aither Health", "plan_name": "Aither Health", "standard_charge_dollar": 210.0, "methodology": "fee schedule" }, { "payer_name": "All Savers", "plan_name": "All Savers", "standard_charge_dollar": 174.97, "methodology": "fee schedule" }, { "payer_name": "Amerigroup", "plan_name": "Amerigroup", "standard_charge_dollar": 473.71, "methodology": "fee schedule" }, { "payer_name": "ANTHEM BLUE PREFERRED PLUS", "plan_name": "ANTHEM BLUE PREFERRED PLUS", "standard_charge_dollar": 210.0, "methodology": "fee schedule" }, { "payer_name": "Anthem Commercial", "plan_name": "Anthem Commercial", "standard_charge_dollar": 210.0, "methodology": "fee schedule" }, { "payer_name": "Anthem Federal Employee", "plan_name": "Anthem Federal Employee", "standard_charge_dollar": 210.0, "methodology": "fee schedule" }, { "payer_name": "Anthem Medicaid", "plan_name": "Anthem Medicaid", "standard_charge_dollar": 473.71, "methodology": "fee schedule" }, { "payer_name": "Anthem Medicare", "plan_name": "Anthem Medicare", "standard_charge_dollar": 212.0, "methodology": "fee schedule" }, { "payer_name": "ASPIRUS WPS- DON'T USE ANYMORE", "plan_name": "ASPIRUS WPS- DON'T USE ANYMORE", "standard_charge_dollar": 175.0, "methodology": "fee schedule" }, { "payer_name": "Auxiant", "plan_name": "Auxiant", "standard_charge_dollar": 350.0, "methodology": "fee schedule" }, { "payer_name": "BCBS OF MICHIGAN", "plan_name": "BCBS OF MICHIGAN", "standard_charge_dollar": 210.0, "methodology": "fee schedule" }, { "payer_name": "BEACON HEALTH", "plan_name": "BEACON HEALTH", "standard_charge_dollar": 250.0, "methodology": "fee schedule" }, { "payer_name": "Benefit Administrative Services", "plan_name": "Benefit Administrative Services", "standard_charge_dollar": 175.0, "methodology": "fee schedule" }, { "payer_name": "Benefit Plan Admininstrators", "plan_name": "Benefit Plan Admininstrators", "standard_charge_dollar": 212.0, "methodology": "fee schedule" }, { "payer_name": "Children Come First Rise Wisconsin Inc", "plan_name": "Children Come First Rise Wisconsin Inc", "standard_charge_dollar": 473.71, "methodology": "fee schedule" }, { "payer_name": "Chorus - Childrens Community Health Plan", "plan_name": "Chorus - Childrens Community Health Plan", "standard_charge_dollar": 473.71, "methodology": "fee schedule" }, { "payer_name": "Cigna Behavioral Health", "plan_name": "Cigna Behavioral Health", "standard_charge_dollar": 250.0, "methodology": "fee schedule" }, { "payer_name": "Cigna BH Beacon Health Options", "plan_name": "Cigna BH Beacon Health Options", "standard_charge_dollar": 215.0, "methodology": "fee schedule" }, { "payer_name": "Cigna Healthcare", "plan_name": "Cigna Healthcare", "standard_charge_dollar": 250.0, "methodology": "fee schedule" }, { "payer_name": "Cigna Healthgram Inc", "plan_name": "Cigna Healthgram Inc", "standard_charge_dollar": 250.0, "methodology": "fee schedule" }, { "payer_name": "Common Ground Commercial", "plan_name": "Common Ground Commercial", "standard_charge_dollar": 358.0, "methodology": "fee schedule" }, { "payer_name": "Community Care Inc Medicaid", "plan_name": "Community Care Inc Medicaid", "standard_charge_dollar": 473.71, "methodology": "fee schedule" }, { "payer_name": "CompCare Medicaid", "plan_name": "CompCare Medicaid", "standard_charge_dollar": 473.71, "methodology": "fee schedule" }, { "payer_name": "CON-ForwardHealth", "plan_name": "CON-ForwardHealth", "standard_charge_dollar": 473.71, "methodology": "fee schedule" }, { "payer_name": "Cypress Benefits", "plan_name": "Cypress Benefits", "standard_charge_dollar": 212.0, "methodology": "fee schedule" }, { "payer_name": "Dean Health Plan", "plan_name": "Dean Health Plan", "standard_charge_dollar": 261.33, "methodology": "fee schedule" }, { "payer_name": "Dean Health-Medicaid", "plan_name": "Dean Health-Medicaid", "standard_charge_dollar": 473.71, "methodology": "fee schedule" }, { "payer_name": "Eau Claire Human Services", "plan_name": "Eau Claire Human Services", "standard_charge_dollar": 212.0, "methodology": "fee schedule" }, { "payer_name": "Elderplan Extra Help", "plan_name": "Elderplan Extra Help", "standard_charge_dollar": 67.8, "methodology": "fee schedule" }, { "payer_name": "Federated Mutal Insurance Co", "plan_name": "Federated Mutal Insurance Co", "standard_charge_dollar": 212.0, "methodology": "fee schedule" }, { "payer_name": "Forest Cty Potawatomi Community", "plan_name": "Forest Cty Potawatomi Community", "standard_charge_dollar": 212.0, "methodology": "fee schedule" }, { "payer_name": "GPA Group & Pension Administrators", "plan_name": "GPA Group & Pension Administrators", "standard_charge_dollar": 144.28, "methodology": "fee schedule" }, { "payer_name": "Group Health Coop South Central WI", "plan_name": "Group Health Coop South Central WI", "standard_charge_dollar": 473.71, "methodology": "fee schedule" }, { "payer_name": "Group Health Cooperative Of South Centra", "plan_name": "Group Health Cooperative Of South Centra", "standard_charge_dollar": 347.78, "methodology": "fee schedule" }, { "payer_name": "Group Health Medicaid", "plan_name": "Group Health Medicaid", "standard_charge_dollar": 473.71, "methodology": "fee schedule" }, { "payer_name": "Health EOS By MultiPlan", "plan_name": "Health EOS By MultiPlan", "standard_charge_dollar": 350.0, "methodology": "fee schedule" }, { "payer_name": "HEALTH PAYMENT SYST", "plan_name": "HEALTH PAYMENT SYST", "standard_charge_dollar": 212.0, "methodology": "fee schedule" }, { "payer_name": "Health Traditions Medicaid", "plan_name": "Health Traditions Medicaid", "standard_charge_dollar": 473.71, "methodology": "fee schedule" }, { "payer_name": "HealthPartners", "plan_name": "HealthPartners", "standard_charge_dollar": 325.0, "methodology": "fee schedule" }, { "payer_name": "Humana Commercial", "plan_name": "Humana Commercial", "standard_charge_dollar": 259.02, "methodology": "fee schedule" }, { "payer_name": "Humana Medicare", "plan_name": "Humana Medicare", "standard_charge_dollar": 74.04, "methodology": "fee schedule" }, { "payer_name": "ICare Medicaid", "plan_name": "ICare Medicaid", "standard_charge_dollar": 473.71, "methodology": "fee schedule" }, { "payer_name": "ICare Medicare", "plan_name": "ICare Medicare", "standard_charge_dollar": 217.53, "methodology": "fee schedule" }, { "payer_name": "Kaiser Permanente", "plan_name": "Kaiser Permanente", "standard_charge_dollar": 212.0, "methodology": "fee schedule" }, { "payer_name": "KBIC Health System", "plan_name": "KBIC Health System", "standard_charge_dollar": 175.0, "methodology": "fee schedule" }, { "payer_name": "Magellan Behavioral Health Systems", "plan_name": "Magellan Behavioral Health Systems", "standard_charge_dollar": 275.0, "methodology": "fee schedule" }, { "payer_name": "Managed Health Services-Managed MA", "plan_name": "Managed Health Services-Managed MA", "standard_charge_dollar": 473.71, "methodology": "fee schedule" }, { "payer_name": "Manitowoc County DHS", "plan_name": "Manitowoc County DHS", "standard_charge_dollar": 212.0, "methodology": "fee schedule" }, { "payer_name": "Marathon County", "plan_name": "Marathon County", "standard_charge_dollar": 212.0, "methodology": "fee schedule" }, { "payer_name": "Mayo Clinic Health Solutions", "plan_name": "Mayo Clinic Health Solutions", "standard_charge_dollar": 212.0, "methodology": "fee schedule" }, { "payer_name": "MDHHS: Gogebic Community Mental Health", "plan_name": "MDHHS: Gogebic Community Mental Health", "standard_charge_dollar": 212.0, "methodology": "fee schedule" }, { "payer_name": "MDHHS: North Pointe HHS", "plan_name": "MDHHS: North Pointe HHS", "standard_charge_dollar": 212.0, "methodology": "fee schedule" }, { "payer_name": "MDHHS: UPHP MI Medicaid C/o Northcare", "plan_name": "MDHHS: UPHP MI Medicaid C/o Northcare", "standard_charge_dollar": 212.0, "methodology": "fee schedule" }, { "payer_name": "MEDICA", "plan_name": "MEDICA", "standard_charge_dollar": 291.0, "methodology": "fee schedule" }, { "payer_name": "Medica Behavior Health", "plan_name": "Medica Behavior Health", "standard_charge_dollar": 175.0, "methodology": "fee schedule" }, { "payer_name": "Medica Medicare Advantage Prime Solution", "plan_name": "Medica Medicare Advantage Prime Solution", "standard_charge_dollar": 175.0, "methodology": "fee schedule" }, { "payer_name": "Mercy Care Wi Medicaid MCO", "plan_name": "Mercy Care Wi Medicaid MCO", "standard_charge_dollar": 473.71, "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": 473.71, "methodology": "fee schedule" }, { "payer_name": "Molina Healthcare Medicare", "plan_name": "Molina Healthcare Medicare", "standard_charge_dollar": 212.0, "methodology": "fee schedule" }, { "payer_name": "My Choice-Care WI Medicaid", "plan_name": "My Choice-Care WI Medicaid", "standard_charge_dollar": 473.71, "methodology": "fee schedule" }, { "payer_name": "My Choice-Trilogy Medicaid", "plan_name": "My Choice-Trilogy Medicaid", "standard_charge_dollar": 473.71, "methodology": "fee schedule" }, { "payer_name": "My Health Link Plan", "plan_name": "My Health Link Plan", "standard_charge_dollar": 212.0, "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": 473.71, "methodology": "fee schedule" }, { "payer_name": "Network Health Medicare", "plan_name": "Network Health Medicare", "standard_charge_dollar": 200.0, "methodology": "fee schedule" }, { "payer_name": "Network Health Plan PPO", "plan_name": "Network Health Plan PPO", "standard_charge_dollar": 1190.0, "methodology": "fee schedule" }, { "payer_name": "Oneida Nation/Purchase & Referrals", "plan_name": "Oneida Nation/Purchase & Referrals", "standard_charge_dollar": 212.0, "methodology": "fee schedule" }, { "payer_name": "Oxford - United Healthcare", "plan_name": "Oxford - United Healthcare", "standard_charge_dollar": 175.0, "methodology": "fee schedule" }, { "payer_name": "Pan American Life Insurane Co", "plan_name": "Pan American Life Insurane Co", "standard_charge_dollar": 212.0, "methodology": "fee schedule" }, { "payer_name": "Passport Health Plan", "plan_name": "Passport Health Plan", "standard_charge_dollar": 951.07, "methodology": "fee schedule" }, { "payer_name": "Portage County Health And Human Services", "plan_name": "Portage County Health And Human Services", "standard_charge_dollar": 252.5, "methodology": "fee schedule" }, { "payer_name": "Prairie States Enterprises INC", "plan_name": "Prairie States Enterprises INC", "standard_charge_dollar": 212.0, "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": "Prevea 360 Commercial", "plan_name": "Prevea 360 Commercial", "standard_charge_dollar": 256.2, "methodology": "fee schedule" }, { "payer_name": "Prevea 360 DeanCare ASO", "plan_name": "Prevea 360 DeanCare ASO", "standard_charge_dollar": 261.33, "methodology": "fee schedule" }, { "payer_name": "Quartz", "plan_name": "Quartz", "standard_charge_dollar": 350.0, "methodology": "fee schedule" }, { "payer_name": "Quartz Medicaid", "plan_name": "Quartz Medicaid", "standard_charge_dollar": 473.71, "methodology": "fee schedule" }, { "payer_name": "Saginaw CMH", "plan_name": "Saginaw CMH", "standard_charge_dollar": 212.0, "methodology": "fee schedule" }, { "payer_name": "Security Health Commercial", "plan_name": "Security Health Commercial", "standard_charge_dollar": 283.25, "methodology": "fee schedule" }, { "payer_name": "Security Health Medicare", "plan_name": "Security Health Medicare", "standard_charge_dollar": 70.11, "methodology": "fee schedule" }, { "payer_name": "Security Health Plan", "plan_name": "Security Health Plan", "standard_charge_dollar": 283.25, "methodology": "fee schedule" }, { "payer_name": "Security Health Plan Managed Medicaid", "plan_name": "Security Health Plan Managed Medicaid", "standard_charge_dollar": 473.71, "methodology": "fee schedule" }, { "payer_name": "Simplan Administrators", "plan_name": "Simplan Administrators", "standard_charge_dollar": 350.0, "methodology": "fee schedule" }, { "payer_name": "Stockbridge-Munsee Health And Wellness", "plan_name": "Stockbridge-Munsee Health And Wellness", "standard_charge_dollar": 212.0, "methodology": "fee schedule" }, { "payer_name": "Superior", "plan_name": "Superior", "standard_charge_dollar": 212.0, "methodology": "fee schedule" }, { "payer_name": "The Alliance Auxiant", "plan_name": "The Alliance Auxiant", "standard_charge_dollar": 250.0, "methodology": "fee schedule" }, { "payer_name": "The Benefit Group", "plan_name": "The Benefit Group", "standard_charge_dollar": 350.0, "methodology": "fee schedule" }, { "payer_name": "Tricare West", "plan_name": "Tricare West", "standard_charge_dollar": 321.1, "methodology": "fee schedule" }, { "payer_name": "Trilogy Commercial", "plan_name": "Trilogy Commercial", "standard_charge_dollar": 345.0, "methodology": "fee schedule" }, { "payer_name": "UMR", "plan_name": "UMR", "standard_charge_dollar": 291.0, "methodology": "fee schedule" }, { "payer_name": "UMR Commercial", "plan_name": "UMR Commercial", "standard_charge_dollar": 291.0, "methodology": "fee schedule" }, { "payer_name": "Unicare", "plan_name": "Unicare", "standard_charge_dollar": 212.0, "methodology": "fee schedule" }, { "payer_name": "United Behavioral Health", "plan_name": "United Behavioral Health", "standard_charge_dollar": 291.0, "methodology": "fee schedule" }, { "payer_name": "United Behavorial Health", "plan_name": "United Behavorial Health", "standard_charge_dollar": 291.0, "methodology": "fee schedule" }, { "payer_name": "United Healthcare", "plan_name": "United Healthcare", "standard_charge_dollar": 291.0, "methodology": "fee schedule" }, { "payer_name": "United Healthcare Dual Complete LP1", "plan_name": "United Healthcare Dual Complete LP1", "standard_charge_dollar": 125.0, "methodology": "fee schedule" }, { "payer_name": "United Healthcare Healthscope", "plan_name": "United Healthcare Healthscope", "standard_charge_dollar": 325.0, "methodology": "fee schedule" }, { "payer_name": "United Healthcare Managed Medicare", "plan_name": "United Healthcare Managed Medicare", "standard_charge_dollar": 125.0, "methodology": "fee schedule" }, { "payer_name": "United Healthcare Medicaid Community Pla", "plan_name": "United Healthcare Medicaid Community Pla", "standard_charge_dollar": 473.71, "methodology": "fee schedule" }, { "payer_name": "United Healthcare Shared Services", "plan_name": "United Healthcare Shared Services", "standard_charge_dollar": 150.0, "methodology": "fee schedule" }, { "payer_name": "Unity Health Plan Medicaid", "plan_name": "Unity Health Plan Medicaid", "standard_charge_dollar": 473.71, "methodology": "fee schedule" }, { "payer_name": "UPHP Medicare Advantage", "plan_name": "UPHP Medicare Advantage", "standard_charge_dollar": 212.0, "methodology": "fee schedule" }, { "payer_name": "VA Office Of Integrated Care", "plan_name": "VA Office Of Integrated Care", "standard_charge_dollar": 175.0, "methodology": "fee schedule" }, { "payer_name": "WEA Trust Commercial", "plan_name": "WEA Trust Commercial", "standard_charge_dollar": 225.0, "methodology": "fee schedule" }, { "payer_name": "WISCONSIN ANTHEM MEDI BLUE DUAL ADV", "plan_name": "WISCONSIN ANTHEM MEDI BLUE DUAL ADV", "standard_charge_dollar": 210.0, "methodology": "fee schedule" }, { "payer_name": "WPS Health Insurance", "plan_name": "WPS Health Insurance", "standard_charge_dollar": 275.0, "methodology": "fee schedule" }, { "payer_name": "WPS Health Plan - SCA", "plan_name": "WPS Health Plan - SCA", "standard_charge_dollar": 212.0, "methodology": "fee schedule" } ], "gross_charge": 1700.0, "discounted_cash": 300.0, "minimum": 67.8, "maximum": 1190.0 } ] }, { "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": "Advocate Aurora Health Inc UMR", "plan_name": "Advocate Aurora Health Inc UMR", "standard_charge_dollar": 250.0, "methodology": "fee schedule" }, { "payer_name": "Aetna Life Insurance Company", "plan_name": "Aetna Life Insurance Company", "standard_charge_dollar": 350.0, "methodology": "fee schedule" }, { "payer_name": "Anthem Commercial", "plan_name": "Anthem Commercial", "standard_charge_dollar": 210.0, "methodology": "fee schedule" }, { "payer_name": "Anthem Medicaid", "plan_name": "Anthem Medicaid", "standard_charge_dollar": 473.71, "methodology": "fee schedule" }, { "payer_name": "Aspirus Health Plan", "plan_name": "Aspirus Health Plan", "standard_charge_dollar": 1190.0, "methodology": "fee schedule" }, { "payer_name": "Auxiant", "plan_name": "Auxiant", "standard_charge_dollar": 350.0, "methodology": "fee schedule" }, { "payer_name": "Chorus - Childrens Community Health Plan", "plan_name": "Chorus - Childrens Community Health Plan", "standard_charge_dollar": 473.71, "methodology": "fee schedule" }, { "payer_name": "Common Ground Commercial", "plan_name": "Common Ground Commercial", "standard_charge_dollar": 358.0, "methodology": "fee schedule" }, { "payer_name": "HealthPartners", "plan_name": "HealthPartners", "standard_charge_dollar": 325.0, "methodology": "fee schedule" }, { "payer_name": "ICare Medicaid", "plan_name": "ICare Medicaid", "standard_charge_dollar": 473.71, "methodology": "fee schedule" }, { "payer_name": "Managed Health Services-Managed MA", "plan_name": "Managed Health Services-Managed MA", "standard_charge_dollar": 473.71, "methodology": "fee schedule" }, { "payer_name": "Molina Healthcare Medicaid", "plan_name": "Molina Healthcare Medicaid", "standard_charge_dollar": 473.71, "methodology": "fee schedule" }, { "payer_name": "Prevea 360 Commercial", "plan_name": "Prevea 360 Commercial", "standard_charge_dollar": 256.2, "methodology": "fee schedule" }, { "payer_name": "Prevea 360 DeanCare ASO", "plan_name": "Prevea 360 DeanCare ASO", "standard_charge_dollar": 261.33, "methodology": "fee schedule" }, { "payer_name": "Security Health Plan", "plan_name": "Security Health Plan", "standard_charge_dollar": 283.25, "methodology": "fee schedule" }, { "payer_name": "Security Health Plan Managed Medicaid", "plan_name": "Security Health Plan Managed Medicaid", "standard_charge_dollar": 473.71, "methodology": "fee schedule" }, { "payer_name": "Tricare West", "plan_name": "Tricare West", "standard_charge_dollar": 321.1, "methodology": "fee schedule" }, { "payer_name": "UMR Commercial", "plan_name": "UMR Commercial", "standard_charge_dollar": 291.0, "methodology": "fee schedule" }, { "payer_name": "United Healthcare", "plan_name": "United Healthcare", "standard_charge_dollar": 291.0, "methodology": "fee schedule" }, { "payer_name": "United Healthcare Managed Medicare", "plan_name": "United Healthcare Managed Medicare", "standard_charge_dollar": 125.0, "methodology": "fee schedule" }, { "payer_name": "United Healthcare Medicaid Community Pla", "plan_name": "United Healthcare Medicaid Community Pla", "standard_charge_dollar": 473.71, "methodology": "fee schedule" } ], "gross_charge": 1700.0, "discounted_cash": 300.0, "minimum": 125.0, "maximum": 1190.0 } ] }, { "description": "Tri/Medi Gero IOP-1 unit", "code_information": [ { "code": "90853", "type": "CPT" }, { "code": "1051", "type": "LOCAL" } ], "standard_charges": [ { "setting": "outpatient", "payers_information": [ { "payer_name": "Elderplan Extra Help", "plan_name": "Elderplan Extra Help", "standard_charge_dollar": 67.8, "methodology": "fee schedule" } ], "gross_charge": 1700.0, "discounted_cash": 300.0, "minimum": 67.8, "maximum": 67.8 } ] }, { "description": "Tri/Medi Gero IOP-2 unit", "code_information": [ { "code": "90853", "type": "CPT" }, { "code": "1052", "type": "LOCAL" } ], "standard_charges": [ { "setting": "outpatient", "payers_information": [ { "payer_name": "Elderplan Extra Help", "plan_name": "Elderplan Extra Help", "standard_charge_dollar": 67.8, "methodology": "fee schedule" } ], "gross_charge": 1700.0, "discounted_cash": 300.0, "minimum": 67.8, "maximum": 67.8 } ] }, { "description": "Tri/Medi Gero IOP-3 unit", "code_information": [ { "code": "90853", "type": "CPT" }, { "code": "1053", "type": "LOCAL" } ], "standard_charges": [ { "setting": "outpatient", "payers_information": [ { "payer_name": "Elderplan Extra Help", "plan_name": "Elderplan Extra Help", "standard_charge_dollar": 67.8, "methodology": "fee schedule" } ], "gross_charge": 1700.0, "discounted_cash": 300.0, "minimum": 67.8, "maximum": 67.8 } ] }, { "description": "Adol CD IOP 3 hrs", "code_information": [ { "code": "H0015", "type": "HCPCS" }, { "code": "1040", "type": "LOCAL" } ], "standard_charges": [ { "setting": "outpatient", "payers_information": [ { "payer_name": "All Savers", "plan_name": "All Savers", "standard_charge_dollar": 174.97, "methodology": "fee schedule" }, { "payer_name": "Amerigroup", "plan_name": "Amerigroup", "standard_charge_dollar": 473.71, "methodology": "fee schedule" }, { "payer_name": "Anthem Medicaid", "plan_name": "Anthem Medicaid", "standard_charge_dollar": 473.71, "methodology": "fee schedule" }, { "payer_name": "ASPIRUS WPS- DON'T USE ANYMORE", "plan_name": "ASPIRUS WPS- DON'T USE ANYMORE", "standard_charge_dollar": 175.0, "methodology": "fee schedule" }, { "payer_name": "Auxiant", "plan_name": "Auxiant", "standard_charge_dollar": 345.0, "methodology": "fee schedule" }, { "payer_name": "Benefit Administrative Services", "plan_name": "Benefit Administrative Services", "standard_charge_dollar": 175.0, "methodology": "fee schedule" }, { "payer_name": "Chorus - Childrens Community Health Plan", "plan_name": "Chorus - Childrens Community Health Plan", "standard_charge_dollar": 473.71, "methodology": "fee schedule" }, { "payer_name": "Community Care Inc Medicaid", "plan_name": "Community Care Inc Medicaid", "standard_charge_dollar": 473.71, "methodology": "fee schedule" }, { "payer_name": "CON-ForwardHealth", "plan_name": "CON-ForwardHealth", "standard_charge_dollar": 473.71, "methodology": "fee schedule" }, { "payer_name": "Group Health Coop South Central WI", "plan_name": "Group Health Coop South Central WI", "standard_charge_dollar": 473.71, "methodology": "fee schedule" }, { "payer_name": "Group Health Medicaid", "plan_name": "Group Health Medicaid", "standard_charge_dollar": 473.71, "methodology": "fee schedule" }, { "payer_name": "Health Traditions Medicaid", "plan_name": "Health Traditions Medicaid", "standard_charge_dollar": 473.71, "methodology": "fee schedule" }, { "payer_name": "Humana Commercial", "plan_name": "Humana Commercial", "standard_charge_dollar": 259.02, "methodology": "fee schedule" }, { "payer_name": "ICare Medicaid", "plan_name": "ICare Medicaid", "standard_charge_dollar": 473.71, "methodology": "fee schedule" }, { "payer_name": "KBIC Health System", "plan_name": "KBIC Health System", "standard_charge_dollar": 175.0, "methodology": "fee schedule" }, { "payer_name": "Magellan Behavioral Health Systems", "plan_name": "Magellan Behavioral Health Systems", "standard_charge_dollar": 275.0, "methodology": "fee schedule" }, { "payer_name": "Managed Health Services-Managed MA", "plan_name": "Managed Health Services-Managed MA", "standard_charge_dollar": 473.71, "methodology": "fee schedule" }, { "payer_name": "Medica Behavior Health", "plan_name": "Medica Behavior Health", "standard_charge_dollar": 175.0, "methodology": "fee schedule" }, { "payer_name": "Medica Medicare Advantage Prime Solution", "plan_name": "Medica Medicare Advantage Prime Solution", "standard_charge_dollar": 175.0, "methodology": "fee schedule" }, { "payer_name": "Mercy Care Wi Medicaid MCO", "plan_name": "Mercy Care Wi Medicaid MCO", "standard_charge_dollar": 473.71, "methodology": "fee schedule" }, { "payer_name": "Molina Healthcare Medicaid", "plan_name": "Molina Healthcare Medicaid", "standard_charge_dollar": 473.71, "methodology": "fee schedule" }, { "payer_name": "My Choice-Care WI Medicaid", "plan_name": "My Choice-Care WI Medicaid", "standard_charge_dollar": 473.71, "methodology": "fee schedule" }, { "payer_name": "Network Health Medicaid Managed", "plan_name": "Network Health Medicaid Managed", "standard_charge_dollar": 473.71, "methodology": "fee schedule" }, { "payer_name": "Oxford - United Healthcare", "plan_name": "Oxford - United Healthcare", "standard_charge_dollar": 175.0, "methodology": "fee schedule" }, { "payer_name": "Portage County Health And Human Services", "plan_name": "Portage County Health And Human Services", "standard_charge_dollar": 252.5, "methodology": "fee schedule" }, { "payer_name": "Prevea 360 Commercial", "plan_name": "Prevea 360 Commercial", "standard_charge_dollar": 236.6, "methodology": "fee schedule" }, { "payer_name": "Quartz Medicaid", "plan_name": "Quartz Medicaid", "standard_charge_dollar": 473.71, "methodology": "fee schedule" }, { "payer_name": "Security Health Plan Managed Medicaid", "plan_name": "Security Health Plan Managed Medicaid", "standard_charge_dollar": 88.03, "methodology": "fee schedule" }, { "payer_name": "The Alliance Auxiant", "plan_name": "The Alliance Auxiant", "standard_charge_dollar": 345.0, "methodology": "fee schedule" }, { "payer_name": "UMR", "plan_name": "UMR", "standard_charge_dollar": 291.0, "methodology": "fee schedule" }, { "payer_name": "UMR Commercial", "plan_name": "UMR Commercial", "standard_charge_dollar": 291.0, "methodology": "fee schedule" }, { "payer_name": "United Behavioral Health", "plan_name": "United Behavioral Health", "standard_charge_dollar": 291.0, "methodology": "fee schedule" }, { "payer_name": "United Behavorial Health", "plan_name": "United Behavorial Health", "standard_charge_dollar": 291.0, "methodology": "fee schedule" }, { "payer_name": "United Healthcare", "plan_name": "United Healthcare", "standard_charge_dollar": 291.0, "methodology": "fee schedule" }, { "payer_name": "United Healthcare Dual Complete LP1", "plan_name": "United Healthcare Dual Complete LP1", "standard_charge_dollar": 125.0, "methodology": "fee schedule" }, { "payer_name": "United Healthcare Healthscope", "plan_name": "United Healthcare Healthscope", "standard_charge_dollar": 325.0, "methodology": "fee schedule" }, { "payer_name": "United Healthcare Managed Medicare", "plan_name": "United Healthcare Managed Medicare", "standard_charge_dollar": 125.0, "methodology": "fee schedule" }, { "payer_name": "United Healthcare Medicaid Community Pla", "plan_name": "United Healthcare Medicaid Community Pla", "standard_charge_dollar": 107.15, "methodology": "fee schedule" }, { "payer_name": "United Healthcare Shared Services", "plan_name": "United Healthcare Shared Services", "standard_charge_dollar": 150.0, "methodology": "fee schedule" }, { "payer_name": "VA Office Of Integrated Care", "plan_name": "VA Office Of Integrated Care", "standard_charge_dollar": 175.0, "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": 300.0, "minimum": 88.03, "maximum": 473.71 } ] }, { "description": "Adult CD IOP 3 hrs", "code_information": [ { "code": "90853", "type": "CPT" }, { "code": "1070", "type": "LOCAL" } ], "standard_charges": [ { "setting": "outpatient", "payers_information": [ { "payer_name": "AARP Medicare Complete", "plan_name": "AARP Medicare Complete", "standard_charge_dollar": 200.0, "methodology": "fee schedule" }, { "payer_name": "AARP Supplement Plan", "plan_name": "AARP Supplement Plan", "standard_charge_dollar": 212.0, "methodology": "fee schedule" }, { "payer_name": "Advocate Aurora Health Inc UMR", "plan_name": "Advocate Aurora Health Inc UMR", "standard_charge_dollar": 250.0, "methodology": "fee schedule" }, { "payer_name": "Aetna Medicare", "plan_name": "Aetna Medicare", "standard_charge_dollar": 185.0, "methodology": "fee schedule" }, { "payer_name": "Aetna-SCA", "plan_name": "Aetna-SCA", "standard_charge_dollar": 350.0, "methodology": "fee schedule" }, { "payer_name": "Aither Health", "plan_name": "Aither Health", "standard_charge_dollar": 210.0, "methodology": "fee schedule" }, { "payer_name": "All Savers", "plan_name": "All Savers", "standard_charge_dollar": 275.0, "methodology": "fee schedule" }, { "payer_name": "Amerigroup", "plan_name": "Amerigroup", "standard_charge_dollar": 473.71, "methodology": "fee schedule" }, { "payer_name": "ANTHEM BLUE PREFERRED PLUS", "plan_name": "ANTHEM BLUE PREFERRED PLUS", "standard_charge_dollar": 210.0, "methodology": "fee schedule" }, { "payer_name": "Anthem Commercial", "plan_name": "Anthem Commercial", "standard_charge_dollar": 210.0, "methodology": "fee schedule" }, { "payer_name": "Anthem Federal Employee", "plan_name": "Anthem Federal Employee", "standard_charge_dollar": 210.0, "methodology": "fee schedule" }, { "payer_name": "Anthem Medicaid", "plan_name": "Anthem Medicaid", "standard_charge_dollar": 473.71, "methodology": "fee schedule" }, { "payer_name": "Anthem Medicare", "plan_name": "Anthem Medicare", "standard_charge_dollar": 212.0, "methodology": "fee schedule" }, { "payer_name": "ASPIRUS WPS- DON'T USE ANYMORE", "plan_name": "ASPIRUS WPS- DON'T USE ANYMORE", "standard_charge_dollar": 175.0, "methodology": "fee schedule" }, { "payer_name": "Auxiant", "plan_name": "Auxiant", "standard_charge_dollar": 350.0, "methodology": "fee schedule" }, { "payer_name": "BCBS OF MICHIGAN", "plan_name": "BCBS OF MICHIGAN", "standard_charge_dollar": 210.0, "methodology": "fee schedule" }, { "payer_name": "BEACON HEALTH", "plan_name": "BEACON HEALTH", "standard_charge_dollar": 250.0, "methodology": "fee schedule" }, { "payer_name": "Benefit Plan Admininstrators", "plan_name": "Benefit Plan Admininstrators", "standard_charge_dollar": 212.0, "methodology": "fee schedule" }, { "payer_name": "Bind Benefits", "plan_name": "Bind Benefits", "standard_charge_dollar": 291.0, "methodology": "fee schedule" }, { "payer_name": "Children Come First Rise Wisconsin Inc", "plan_name": "Children Come First Rise Wisconsin Inc", "standard_charge_dollar": 473.71, "methodology": "fee schedule" }, { "payer_name": "Chorus - Childrens Community Health Plan", "plan_name": "Chorus - Childrens Community Health Plan", "standard_charge_dollar": 473.71, "methodology": "fee schedule" }, { "payer_name": "Cigna BH Beacon Health Options", "plan_name": "Cigna BH Beacon Health Options", "standard_charge_dollar": 215.0, "methodology": "fee schedule" }, { "payer_name": "Cigna Healthcare", "plan_name": "Cigna Healthcare", "standard_charge_dollar": 250.0, "methodology": "fee schedule" }, { "payer_name": "Cigna Healthgram Inc", "plan_name": "Cigna Healthgram Inc", "standard_charge_dollar": 250.0, "methodology": "fee schedule" }, { "payer_name": "Common Ground Commercial", "plan_name": "Common Ground Commercial", "standard_charge_dollar": 358.0, "methodology": "fee schedule" }, { "payer_name": "Community Care Inc Medicaid", "plan_name": "Community Care Inc Medicaid", "standard_charge_dollar": 473.71, "methodology": "fee schedule" }, { "payer_name": "CompCare Medicaid", "plan_name": "CompCare Medicaid", "standard_charge_dollar": 473.71, "methodology": "fee schedule" }, { "payer_name": "Cypress Benefits", "plan_name": "Cypress Benefits", "standard_charge_dollar": 212.0, "methodology": "fee schedule" }, { "payer_name": "Dean Health Plan", "plan_name": "Dean Health Plan", "standard_charge_dollar": 261.33, "methodology": "fee schedule" }, { "payer_name": "Dean Health-Medicaid", "plan_name": "Dean Health-Medicaid", "standard_charge_dollar": 473.71, "methodology": "fee schedule" }, { "payer_name": "Eau Claire Human Services", "plan_name": "Eau Claire Human Services", "standard_charge_dollar": 212.0, "methodology": "fee schedule" }, { "payer_name": "Federated Mutal Insurance Co", "plan_name": "Federated Mutal Insurance Co", "standard_charge_dollar": 212.0, "methodology": "fee schedule" }, { "payer_name": "Forest Cty Potawatomi Community", "plan_name": "Forest Cty Potawatomi Community", "standard_charge_dollar": 212.0, "methodology": "fee schedule" }, { "payer_name": "GPA Group & Pension Administrators", "plan_name": "GPA Group & Pension Administrators", "standard_charge_dollar": 144.28, "methodology": "fee schedule" }, { "payer_name": "Group Health Coop South Central WI", "plan_name": "Group Health Coop South Central WI", "standard_charge_dollar": 473.71, "methodology": "fee schedule" }, { "payer_name": "Group Health Cooperative Of South Centra", "plan_name": "Group Health Cooperative Of South Centra", "standard_charge_dollar": 347.78, "methodology": "fee schedule" }, { "payer_name": "Group Health Medicaid", "plan_name": "Group Health Medicaid", "standard_charge_dollar": 473.71, "methodology": "fee schedule" }, { "payer_name": "Health EOS By MultiPlan", "plan_name": "Health EOS By MultiPlan", "standard_charge_dollar": 400.0, "methodology": "fee schedule" }, { "payer_name": "HEALTH PAYMENT SYST", "plan_name": "HEALTH PAYMENT SYST", "standard_charge_dollar": 212.0, "methodology": "fee schedule" }, { "payer_name": "Health Traditions Medicaid", "plan_name": "Health Traditions Medicaid", "standard_charge_dollar": 473.71, "methodology": "fee schedule" }, { "payer_name": "HealthPartners", "plan_name": "HealthPartners", "standard_charge_dollar": 325.0, "methodology": "fee schedule" }, { "payer_name": "Humana Commercial", "plan_name": "Humana Commercial", "standard_charge_dollar": 259.02, "methodology": "fee schedule" }, { "payer_name": "Humana Medicare", "plan_name": "Humana Medicare", "standard_charge_dollar": 74.04, "methodology": "fee schedule" }, { "payer_name": "ICare Medicaid", "plan_name": "ICare Medicaid", "standard_charge_dollar": 473.71, "methodology": "fee schedule" }, { "payer_name": "ICare Medicare", "plan_name": "ICare Medicare", "standard_charge_dollar": 217.53, "methodology": "fee schedule" }, { "payer_name": "Kaiser Permanente", "plan_name": "Kaiser Permanente", "standard_charge_dollar": 212.0, "methodology": "fee schedule" }, { "payer_name": "KBIC Health System", "plan_name": "KBIC Health System", "standard_charge_dollar": 175.0, "methodology": "fee schedule" }, { "payer_name": "Magellan Behavioral Health Systems", "plan_name": "Magellan Behavioral Health Systems", "standard_charge_dollar": 275.0, "methodology": "fee schedule" }, { "payer_name": "Managed Health Services-Managed MA", "plan_name": "Managed Health Services-Managed MA", "standard_charge_dollar": 473.71, "methodology": "fee schedule" }, { "payer_name": "Manitowoc County DHS", "plan_name": "Manitowoc County DHS", "standard_charge_dollar": 212.0, "methodology": "fee schedule" }, { "payer_name": "Marathon County", "plan_name": "Marathon County", "standard_charge_dollar": 212.0, "methodology": "fee schedule" }, { "payer_name": "Mayo Clinic Health Solutions", "plan_name": "Mayo Clinic Health Solutions", "standard_charge_dollar": 212.0, "methodology": "fee schedule" }, { "payer_name": "MDHHS: Gogebic Community Mental Health", "plan_name": "MDHHS: Gogebic Community Mental Health", "standard_charge_dollar": 212.0, "methodology": "fee schedule" }, { "payer_name": "MDHHS: North Pointe HHS", "plan_name": "MDHHS: North Pointe HHS", "standard_charge_dollar": 212.0, "methodology": "fee schedule" }, { "payer_name": "MDHHS: UPHP MI Medicaid C/o Northcare", "plan_name": "MDHHS: UPHP MI Medicaid C/o Northcare", "standard_charge_dollar": 212.0, "methodology": "fee schedule" }, { "payer_name": "MEDICA", "plan_name": "MEDICA", "standard_charge_dollar": 291.0, "methodology": "fee schedule" }, { "payer_name": "Medica Behavior Health", "plan_name": "Medica Behavior Health", "standard_charge_dollar": 175.0, "methodology": "fee schedule" }, { "payer_name": "Medica Medicare Advantage Prime Solution", "plan_name": "Medica Medicare Advantage Prime Solution", "standard_charge_dollar": 175.0, "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": 473.71, "methodology": "fee schedule" }, { "payer_name": "Molina Healthcare Medicare", "plan_name": "Molina Healthcare Medicare", "standard_charge_dollar": 212.0, "methodology": "fee schedule" }, { "payer_name": "My Choice-Care WI Medicaid", "plan_name": "My Choice-Care WI Medicaid", "standard_charge_dollar": 473.71, "methodology": "fee schedule" }, { "payer_name": "My Choice-Trilogy Medicaid", "plan_name": "My Choice-Trilogy Medicaid", "standard_charge_dollar": 473.71, "methodology": "fee schedule" }, { "payer_name": "My Health Link Plan", "plan_name": "My Health Link Plan", "standard_charge_dollar": 212.0, "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": 473.71, "methodology": "fee schedule" }, { "payer_name": "Network Health Medicare", "plan_name": "Network Health Medicare", "standard_charge_dollar": 200.0, "methodology": "fee schedule" }, { "payer_name": "Network Health Plan PPO", "plan_name": "Network Health Plan PPO", "standard_charge_dollar": 1190.0, "methodology": "fee schedule" }, { "payer_name": "Oneida Nation/Purchase & Referrals", "plan_name": "Oneida Nation/Purchase & Referrals", "standard_charge_dollar": 212.0, "methodology": "fee schedule" }, { "payer_name": "Oxford - United Healthcare", "plan_name": "Oxford - United Healthcare", "standard_charge_dollar": 150.0, "methodology": "fee schedule" }, { "payer_name": "Pan American Life Insurane Co", "plan_name": "Pan American Life Insurane Co", "standard_charge_dollar": 212.0, "methodology": "fee schedule" }, { "payer_name": "Passport Health Plan", "plan_name": "Passport Health Plan", "standard_charge_dollar": 473.71, "methodology": "fee schedule" }, { "payer_name": "Portage County Health And Human Services", "plan_name": "Portage County Health And Human Services", "standard_charge_dollar": 252.5, "methodology": "fee schedule" }, { "payer_name": "Prairie States Enterprises INC", "plan_name": "Prairie States Enterprises INC", "standard_charge_dollar": 212.0, "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": "Prevea 360 Commercial", "plan_name": "Prevea 360 Commercial", "standard_charge_dollar": 256.2, "methodology": "fee schedule" }, { "payer_name": "Prevea 360 DeanCare ASO", "plan_name": "Prevea 360 DeanCare ASO", "standard_charge_dollar": 261.33, "methodology": "fee schedule" }, { "payer_name": "Quartz", "plan_name": "Quartz", "standard_charge_dollar": 350.0, "methodology": "fee schedule" }, { "payer_name": "Quartz Medicaid", "plan_name": "Quartz Medicaid", "standard_charge_dollar": 473.71, "methodology": "fee schedule" }, { "payer_name": "Saginaw CMH", "plan_name": "Saginaw CMH", "standard_charge_dollar": 212.0, "methodology": "fee schedule" }, { "payer_name": "Security Health Commercial", "plan_name": "Security Health Commercial", "standard_charge_dollar": 283.25, "methodology": "fee schedule" }, { "payer_name": "Security Health Medicare", "plan_name": "Security Health Medicare", "standard_charge_dollar": 70.11, "methodology": "fee schedule" }, { "payer_name": "Security Health Plan", "plan_name": "Security Health Plan", "standard_charge_dollar": 283.25, "methodology": "fee schedule" }, { "payer_name": "Security Health Plan Managed Medicaid", "plan_name": "Security Health Plan Managed Medicaid", "standard_charge_dollar": 473.71, "methodology": "fee schedule" }, { "payer_name": "Simplan Administrators", "plan_name": "Simplan Administrators", "standard_charge_dollar": 350.0, "methodology": "fee schedule" }, { "payer_name": "Stockbridge-Munsee Health And Wellness", "plan_name": "Stockbridge-Munsee Health And Wellness", "standard_charge_dollar": 212.0, "methodology": "fee schedule" }, { "payer_name": "Superior", "plan_name": "Superior", "standard_charge_dollar": 212.0, "methodology": "fee schedule" }, { "payer_name": "Surest", "plan_name": "Surest", "standard_charge_dollar": 291.0, "methodology": "fee schedule" }, { "payer_name": "The Alliance Auxiant", "plan_name": "The Alliance Auxiant", "standard_charge_dollar": 250.0, "methodology": "fee schedule" }, { "payer_name": "The Benefit Group", "plan_name": "The Benefit Group", "standard_charge_dollar": 350.0, "methodology": "fee schedule" }, { "payer_name": "Trilogy Commercial", "plan_name": "Trilogy Commercial", "standard_charge_dollar": 345.0, "methodology": "fee schedule" }, { "payer_name": "UHC/OPTUM", "plan_name": "UHC/OPTUM", "standard_charge_dollar": 291.0, "methodology": "fee schedule" }, { "payer_name": "UMR", "plan_name": "UMR", "standard_charge_dollar": 291.0, "methodology": "fee schedule" }, { "payer_name": "UMR Commercial", "plan_name": "UMR Commercial", "standard_charge_dollar": 291.0, "methodology": "fee schedule" }, { "payer_name": "Unicare", "plan_name": "Unicare", "standard_charge_dollar": 212.0, "methodology": "fee schedule" }, { "payer_name": "United Behavioral Health", "plan_name": "United Behavioral Health", "standard_charge_dollar": 291.0, "methodology": "fee schedule" }, { "payer_name": "United Behavorial Health", "plan_name": "United Behavorial Health", "standard_charge_dollar": 291.0, "methodology": "fee schedule" }, { "payer_name": "United Healthcare", "plan_name": "United Healthcare", "standard_charge_dollar": 291.0, "methodology": "fee schedule" }, { "payer_name": "United Healthcare Dual Complete LP1", "plan_name": "United Healthcare Dual Complete LP1", "standard_charge_dollar": 100.0, "methodology": "fee schedule" }, { "payer_name": "United Healthcare Managed Medicare", "plan_name": "United Healthcare Managed Medicare", "standard_charge_dollar": 100.0, "methodology": "fee schedule" }, { "payer_name": "United Healthcare Medicaid Community Pla", "plan_name": "United Healthcare Medicaid Community Pla", "standard_charge_dollar": 473.71, "methodology": "fee schedule" }, { "payer_name": "United Healthcare Shared Services", "plan_name": "United Healthcare Shared Services", "standard_charge_dollar": 150.0, "methodology": "fee schedule" }, { "payer_name": "Unity Health Plan Medicaid", "plan_name": "Unity Health Plan Medicaid", "standard_charge_dollar": 473.71, "methodology": "fee schedule" }, { "payer_name": "UPHP Medicare Advantage", "plan_name": "UPHP Medicare Advantage", "standard_charge_dollar": 212.0, "methodology": "fee schedule" }, { "payer_name": "VA Office Of Integrated Care", "plan_name": "VA Office Of Integrated Care", "standard_charge_dollar": 175.0, "methodology": "fee schedule" }, { "payer_name": "WEA Trust Commercial", "plan_name": "WEA Trust Commercial", "standard_charge_dollar": 225.0, "methodology": "fee schedule" }, { "payer_name": "WISCONSIN ANTHEM MEDI BLUE DUAL ADV", "plan_name": "WISCONSIN ANTHEM MEDI BLUE DUAL ADV", "standard_charge_dollar": 210.0, "methodology": "fee schedule" }, { "payer_name": "WPS Health Insurance", "plan_name": "WPS Health Insurance", "standard_charge_dollar": 275.0, "methodology": "fee schedule" }, { "payer_name": "WPS Health Plan - SCA", "plan_name": "WPS Health Plan - SCA", "standard_charge_dollar": 212.0, "methodology": "fee schedule" } ], "gross_charge": 1700.0, "discounted_cash": 300.0, "minimum": 70.11, "maximum": 1190.0 } ] }, { "description": "Rehab Gero R&B", "code_information": [ { "code": "907", "type": "RC" }, { "code": "907", "type": "LOCAL" } ], "standard_charges": [ { "setting": "inpatient", "payers_information": [ { "payer_name": "Transamerica", "plan_name": "Transamerica", "standard_charge_dollar": 897.12, "methodology": "fee schedule" } ], "minimum": 897.12, "maximum": 897.12 } ] }, { "description": "PHP Daily Adult", "code_information": [ { "code": "H0035", "type": "HCPCS" }, { "code": "5200", "type": "LOCAL" } ], "standard_charges": [ { "setting": "outpatient", "payers_information": [ { "payer_name": "AARP Medicare Complete", "plan_name": "AARP Medicare Complete", "standard_charge_dollar": 300.0, "methodology": "fee schedule" }, { "payer_name": "AARP Supplement Plan", "plan_name": "AARP Supplement Plan", "standard_charge_dollar": 315.0, "methodology": "fee schedule" }, { "payer_name": "Advocate Aurora Health Inc UMR", "plan_name": "Advocate Aurora Health Inc UMR", "standard_charge_dollar": 395.0, "methodology": "fee schedule" }, { "payer_name": "Aetna Life Insurance Company", "plan_name": "Aetna Life Insurance Company", "standard_charge_dollar": 600.0, "methodology": "fee schedule" }, { "payer_name": "Aetna Medicare", "plan_name": "Aetna Medicare", "standard_charge_dollar": 335.0, "methodology": "fee schedule" }, { "payer_name": "Aetna-SCA", "plan_name": "Aetna-SCA", "standard_charge_dollar": 600.0, "methodology": "fee schedule" }, { "payer_name": "Aither Health", "plan_name": "Aither Health", "standard_charge_dollar": 315.0, "methodology": "fee schedule" }, { "payer_name": "All Savers", "plan_name": "All Savers", "standard_charge_dollar": 400.0, "methodology": "fee schedule" }, { "payer_name": "Amerigroup", "plan_name": "Amerigroup", "standard_charge_dollar": 473.71, "methodology": "fee schedule" }, { "payer_name": "ANTHEM BLUE PREFERRED PLUS", "plan_name": "ANTHEM BLUE PREFERRED PLUS", "standard_charge_dollar": 315.0, "methodology": "fee schedule" }, { "payer_name": "Anthem Commercial", "plan_name": "Anthem Commercial", "standard_charge_dollar": 315.0, "methodology": "fee schedule" }, { "payer_name": "Anthem Federal Employee", "plan_name": "Anthem Federal Employee", "standard_charge_dollar": 315.0, "methodology": "fee schedule" }, { "payer_name": "Anthem Medicaid", "plan_name": "Anthem Medicaid", "standard_charge_dollar": 473.71, "methodology": "fee schedule" }, { "payer_name": "Anthem Medicare", "plan_name": "Anthem Medicare", "standard_charge_dollar": 315.0, "methodology": "fee schedule" }, { "payer_name": "Aspirus Health Plan", "plan_name": "Aspirus Health Plan", "standard_charge_dollar": 1750.0, "methodology": "fee schedule" }, { "payer_name": "ASPIRUS WPS- DON'T USE ANYMORE", "plan_name": "ASPIRUS WPS- DON'T USE ANYMORE", "standard_charge_dollar": 325.0, "methodology": "fee schedule" }, { "payer_name": "Auxiant", "plan_name": "Auxiant", "standard_charge_dollar": 600.0, "methodology": "fee schedule" }, { "payer_name": "BCBS OF MICHIGAN", "plan_name": "BCBS OF MICHIGAN", "standard_charge_dollar": 315.0, "methodology": "fee schedule" }, { "payer_name": "BEACON HEALTH", "plan_name": "BEACON HEALTH", "standard_charge_dollar": 395.0, "methodology": "fee schedule" }, { "payer_name": "Benefit Administrative Services", "plan_name": "Benefit Administrative Services", "standard_charge_dollar": 325.0, "methodology": "fee schedule" }, { "payer_name": "Benefit Plan Admininstrators", "plan_name": "Benefit Plan Admininstrators", "standard_charge_dollar": 315.0, "methodology": "fee schedule" }, { "payer_name": "Bind Benefits", "plan_name": "Bind Benefits", "standard_charge_dollar": 424.0, "methodology": "fee schedule" }, { "payer_name": "Children Come First Rise Wisconsin Inc", "plan_name": "Children Come First Rise Wisconsin Inc", "standard_charge_dollar": 473.71, "methodology": "fee schedule" }, { "payer_name": "Chorus - Childrens Community Health Plan", "plan_name": "Chorus - Childrens Community Health Plan", "standard_charge_dollar": 473.71, "methodology": "fee schedule" }, { "payer_name": "Cigna Behavioral Health", "plan_name": "Cigna Behavioral Health", "standard_charge_dollar": 475.0, "methodology": "fee schedule" }, { "payer_name": "Cigna BH Beacon Health Options", "plan_name": "Cigna BH Beacon Health Options", "standard_charge_dollar": 425.0, "methodology": "fee schedule" }, { "payer_name": "Cigna Healthcare", "plan_name": "Cigna Healthcare", "standard_charge_dollar": 475.0, "methodology": "fee schedule" }, { "payer_name": "Cigna Healthgram Inc", "plan_name": "Cigna Healthgram Inc", "standard_charge_dollar": 475.0, "methodology": "fee schedule" }, { "payer_name": "Common Ground Commercial", "plan_name": "Common Ground Commercial", "standard_charge_dollar": 597.0, "methodology": "fee schedule" }, { "payer_name": "Community Care Inc Medicaid", "plan_name": "Community Care Inc Medicaid", "standard_charge_dollar": 473.71, "methodology": "fee schedule" }, { "payer_name": "CompCare Medicaid", "plan_name": "CompCare Medicaid", "standard_charge_dollar": 473.71, "methodology": "fee schedule" }, { "payer_name": "CON-ForwardHealth", "plan_name": "CON-ForwardHealth", "standard_charge_dollar": 473.71, "methodology": "fee schedule" }, { "payer_name": "Cypress Benefits", "plan_name": "Cypress Benefits", "standard_charge_dollar": 315.0, "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": 473.71, "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": "Eau Claire Human Services", "plan_name": "Eau Claire Human Services", "standard_charge_dollar": 315.0, "methodology": "fee schedule" }, { "payer_name": "Federated Mutal Insurance Co", "plan_name": "Federated Mutal Insurance Co", "standard_charge_dollar": 315.0, "methodology": "fee schedule" }, { "payer_name": "Forest Cty Potawatomi Community", "plan_name": "Forest Cty Potawatomi Community", "standard_charge_dollar": 600.0, "methodology": "fee schedule" }, { "payer_name": "Golden Rule", "plan_name": "Golden Rule", "standard_charge_dollar": 325.0, "methodology": "fee schedule" }, { "payer_name": "GPA Group & Pension Administrators", "plan_name": "GPA Group & Pension Administrators", "standard_charge_dollar": 600.0, "methodology": "fee schedule" }, { "payer_name": "Group Health Commercial", "plan_name": "Group Health Commercial", "standard_charge_dollar": 500.0, "methodology": "fee schedule" }, { "payer_name": "Group Health Coop South Central WI", "plan_name": "Group Health Coop South Central WI", "standard_charge_dollar": 473.71, "methodology": "fee schedule" }, { "payer_name": "Group Health Medicaid", "plan_name": "Group Health Medicaid", "standard_charge_dollar": 473.71, "methodology": "fee schedule" }, { "payer_name": "Health EOS By MultiPlan", "plan_name": "Health EOS By MultiPlan", "standard_charge_dollar": 600.0, "methodology": "fee schedule" }, { "payer_name": "HEALTH PAYMENT SYST", "plan_name": "HEALTH PAYMENT SYST", "standard_charge_dollar": 510.0, "methodology": "fee schedule" }, { "payer_name": "Health Traditions Medicaid", "plan_name": "Health Traditions Medicaid", "standard_charge_dollar": 473.71, "methodology": "fee schedule" }, { "payer_name": "HealthPartners", "plan_name": "HealthPartners", "standard_charge_dollar": 500.0, "methodology": "fee schedule" }, { "payer_name": "Humana Commercial", "plan_name": "Humana Commercial", "standard_charge_dollar": 422.31, "methodology": "fee schedule" }, { "payer_name": "Humana Medicare", "plan_name": "Humana Medicare", "standard_charge_dollar": 210.46, "methodology": "fee schedule" }, { "payer_name": "ICare Medicaid", "plan_name": "ICare Medicaid", "standard_charge_dollar": 473.71, "methodology": "fee schedule" }, { "payer_name": "ICare Medicare", "plan_name": "ICare Medicare", "standard_charge_dollar": 315.0, "methodology": "fee schedule" }, { "payer_name": "Kaiser Permanente", "plan_name": "Kaiser Permanente", "standard_charge_dollar": 315.0, "methodology": "fee schedule" }, { "payer_name": "KBIC Health System", "plan_name": "KBIC Health System", "standard_charge_dollar": 300.0, "methodology": "fee schedule" }, { "payer_name": "Lucent Health", "plan_name": "Lucent Health", "standard_charge_dollar": 325.0, "methodology": "fee schedule" }, { "payer_name": "Maestro Health", "plan_name": "Maestro Health", "standard_charge_dollar": 350.0, "methodology": "fee schedule" }, { "payer_name": "Magellan Behavioral Health Systems", "plan_name": "Magellan Behavioral Health Systems", "standard_charge_dollar": 450.0, "methodology": "fee schedule" }, { "payer_name": "Managed Health Services-Managed MA", "plan_name": "Managed Health Services-Managed MA", "standard_charge_dollar": 473.71, "methodology": "fee schedule" }, { "payer_name": "Manitowoc County DHS", "plan_name": "Manitowoc County DHS", "standard_charge_dollar": 315.0, "methodology": "fee schedule" }, { "payer_name": "Marathon County", "plan_name": "Marathon County", "standard_charge_dollar": 315.0, "methodology": "fee schedule" }, { "payer_name": "Mayo Clinic Health Solutions", "plan_name": "Mayo Clinic Health Solutions", "standard_charge_dollar": 315.0, "methodology": "fee schedule" }, { "payer_name": "MDHHS: Gogebic Community Mental Health", "plan_name": "MDHHS: Gogebic Community Mental Health", "standard_charge_dollar": 315.0, "methodology": "fee schedule" }, { "payer_name": "MDHHS: North Pointe HHS", "plan_name": "MDHHS: North Pointe HHS", "standard_charge_dollar": 315.0, "methodology": "fee schedule" }, { "payer_name": "MDHHS: UPHP MI Medicaid C/o Northcare", "plan_name": "MDHHS: UPHP MI Medicaid C/o Northcare", "standard_charge_dollar": 600.0, "methodology": "fee schedule" }, { "payer_name": "MEDICA", "plan_name": "MEDICA", "standard_charge_dollar": 424.0, "methodology": "fee schedule" }, { "payer_name": "Medica Behavior Health", "plan_name": "Medica Behavior Health", "standard_charge_dollar": 300.0, "methodology": "fee schedule" }, { "payer_name": "Medica Medicare Advantage Prime Solution", "plan_name": "Medica Medicare Advantage Prime Solution", "standard_charge_dollar": 300.0, "methodology": "fee schedule" }, { "payer_name": "Mercy Care Wi Medicaid MCO", "plan_name": "Mercy Care Wi Medicaid MCO", "standard_charge_dollar": 473.71, "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": 473.71, "methodology": "fee schedule" }, { "payer_name": "Molina Healthcare Medicare", "plan_name": "Molina Healthcare Medicare", "standard_charge_dollar": 315.0, "methodology": "fee schedule" }, { "payer_name": "My Choice-Care WI Medicaid", "plan_name": "My Choice-Care WI Medicaid", "standard_charge_dollar": 473.71, "methodology": "fee schedule" }, { "payer_name": "My Choice-Trilogy Medicaid", "plan_name": "My Choice-Trilogy Medicaid", "standard_charge_dollar": 473.71, "methodology": "fee schedule" }, { "payer_name": "My Health Link Plan", "plan_name": "My Health Link Plan", "standard_charge_dollar": 600.0, "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": 473.71, "methodology": "fee schedule" }, { "payer_name": "Network Health Medicare", "plan_name": "Network Health Medicare", "standard_charge_dollar": 300.0, "methodology": "fee schedule" }, { "payer_name": "Network Health Plan PPO", "plan_name": "Network Health Plan PPO", "standard_charge_dollar": 1750.0, "methodology": "fee schedule" }, { "payer_name": "Oneida Nation/Purchase & Referrals", "plan_name": "Oneida Nation/Purchase & Referrals", "standard_charge_dollar": 315.0, "methodology": "fee schedule" }, { "payer_name": "Oxford - United Healthcare", "plan_name": "Oxford - United Healthcare", "standard_charge_dollar": 300.0, "methodology": "fee schedule" }, { "payer_name": "Pan American Life Insurane Co", "plan_name": "Pan American Life Insurane Co", "standard_charge_dollar": 315.0, "methodology": "fee schedule" }, { "payer_name": "Portage County Health And Human Services", "plan_name": "Portage County Health And Human Services", "standard_charge_dollar": 454.5, "methodology": "fee schedule" }, { "payer_name": "Prairie States Enterprises INC", "plan_name": "Prairie States Enterprises INC", "standard_charge_dollar": 485.0, "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": "Prevea 360 Commercial", "plan_name": "Prevea 360 Commercial", "standard_charge_dollar": 433.57, "methodology": "fee schedule" }, { "payer_name": "Prevea 360 DeanCare ASO", "plan_name": "Prevea 360 DeanCare ASO", "standard_charge_dollar": 442.24, "methodology": "fee schedule" }, { "payer_name": "Quartz", "plan_name": "Quartz", "standard_charge_dollar": 550.0, "methodology": "fee schedule" }, { "payer_name": "Saginaw CMH", "plan_name": "Saginaw CMH", "standard_charge_dollar": 315.0, "methodology": "fee schedule" }, { "payer_name": "Security Health Commercial", "plan_name": "Security Health Commercial", "standard_charge_dollar": 463.5, "methodology": "fee schedule" }, { "payer_name": "Security Health Medicare", "plan_name": "Security Health Medicare", "standard_charge_dollar": 212.0, "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": 473.71, "methodology": "fee schedule" }, { "payer_name": "Simplan Administrators", "plan_name": "Simplan Administrators", "standard_charge_dollar": 600.0, "methodology": "fee schedule" }, { "payer_name": "Stockbridge-Munsee Health And Wellness", "plan_name": "Stockbridge-Munsee Health And Wellness", "standard_charge_dollar": 315.0, "methodology": "fee schedule" }, { "payer_name": "Superior", "plan_name": "Superior", "standard_charge_dollar": 315.0, "methodology": "fee schedule" }, { "payer_name": "Surest", "plan_name": "Surest", "standard_charge_dollar": 424.0, "methodology": "fee schedule" }, { "payer_name": "The Alliance Auxiant", "plan_name": "The Alliance Auxiant", "standard_charge_dollar": 450.0, "methodology": "fee schedule" }, { "payer_name": "The Benefit Group", "plan_name": "The Benefit Group", "standard_charge_dollar": 600.0, "methodology": "fee schedule" }, { "payer_name": "Together With CCHP", "plan_name": "Together With CCHP", "standard_charge_dollar": 473.71, "methodology": "fee schedule" }, { "payer_name": "Tricare West", "plan_name": "Tricare West", "standard_charge_dollar": 427.5, "methodology": "fee schedule" }, { "payer_name": "Trilogy Commercial", "plan_name": "Trilogy Commercial", "standard_charge_dollar": 485.0, "methodology": "fee schedule" }, { "payer_name": "UHC/OPTUM", "plan_name": "UHC/OPTUM", "standard_charge_dollar": 424.0, "methodology": "fee schedule" }, { "payer_name": "UMR", "plan_name": "UMR", "standard_charge_dollar": 424.0, "methodology": "fee schedule" }, { "payer_name": "UMR Commercial", "plan_name": "UMR Commercial", "standard_charge_dollar": 424.0, "methodology": "fee schedule" }, { "payer_name": "Unicare", "plan_name": "Unicare", "standard_charge_dollar": 315.0, "methodology": "fee schedule" }, { "payer_name": "United Behavioral Health", "plan_name": "United Behavioral Health", "standard_charge_dollar": 424.0, "methodology": "fee schedule" }, { "payer_name": "United Behavorial Health", "plan_name": "United Behavorial Health", "standard_charge_dollar": 424.0, "methodology": "fee schedule" }, { "payer_name": "United Healthcare", "plan_name": "United Healthcare", "standard_charge_dollar": 424.0, "methodology": "fee schedule" }, { "payer_name": "United Healthcare Dual Complete LP1", "plan_name": "United Healthcare Dual Complete LP1", "standard_charge_dollar": 252.28, "methodology": "fee schedule" }, { "payer_name": "United Healthcare Healthscope", "plan_name": "United Healthcare Healthscope", "standard_charge_dollar": 325.0, "methodology": "fee schedule" }, { "payer_name": "United Healthcare Managed Medicare", "plan_name": "United Healthcare Managed Medicare", "standard_charge_dollar": 250.0, "methodology": "fee schedule" }, { "payer_name": "United Healthcare Medicaid Community Pla", "plan_name": "United Healthcare Medicaid Community Pla", "standard_charge_dollar": 473.71, "methodology": "fee schedule" }, { "payer_name": "United Healthcare Shared Services", "plan_name": "United Healthcare Shared Services", "standard_charge_dollar": 300.0, "methodology": "fee schedule" }, { "payer_name": "Unity Health Plan Medicaid", "plan_name": "Unity Health Plan Medicaid", "standard_charge_dollar": 473.71, "methodology": "fee schedule" }, { "payer_name": "UPHP Medicare Advantage", "plan_name": "UPHP Medicare Advantage", "standard_charge_dollar": 315.0, "methodology": "fee schedule" }, { "payer_name": "VA Office Of Integrated Care", "plan_name": "VA Office Of Integrated Care", "standard_charge_dollar": 300.0, "methodology": "fee schedule" }, { "payer_name": "WEA Trust Commercial", "plan_name": "WEA Trust Commercial", "standard_charge_dollar": 425.0, "methodology": "fee schedule" }, { "payer_name": "WISCONSIN ANTHEM MEDI BLUE DUAL ADV", "plan_name": "WISCONSIN ANTHEM MEDI BLUE DUAL ADV", "standard_charge_dollar": 315.0, "methodology": "fee schedule" }, { "payer_name": "WPS Health Insurance", "plan_name": "WPS Health Insurance", "standard_charge_dollar": 400.0, "methodology": "fee schedule" }, { "payer_name": "WPS Health Plan - SCA", "plan_name": "WPS Health Plan - SCA", "standard_charge_dollar": 315.0, "methodology": "fee schedule" } ], "gross_charge": 2500.0, "discounted_cash": 400.0, "minimum": 210.46, "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": "AARP Medicare Complete", "plan_name": "AARP Medicare Complete", "standard_charge_dollar": 300.0, "methodology": "fee schedule" }, { "payer_name": "AARP Supplement Plan", "plan_name": "AARP Supplement Plan", "standard_charge_dollar": 315.0, "methodology": "fee schedule" }, { "payer_name": "Advocate Aurora Health Inc UMR", "plan_name": "Advocate Aurora Health Inc UMR", "standard_charge_dollar": 395.0, "methodology": "fee schedule" }, { "payer_name": "Aetna Life Insurance Company", "plan_name": "Aetna Life Insurance Company", "standard_charge_dollar": 600.0, "methodology": "fee schedule" }, { "payer_name": "Aetna Medicare", "plan_name": "Aetna Medicare", "standard_charge_dollar": 335.0, "methodology": "fee schedule" }, { "payer_name": "Aetna-SCA", "plan_name": "Aetna-SCA", "standard_charge_dollar": 600.0, "methodology": "fee schedule" }, { "payer_name": "Aither Health", "plan_name": "Aither Health", "standard_charge_dollar": 315.0, "methodology": "fee schedule" }, { "payer_name": "All Savers", "plan_name": "All Savers", "standard_charge_dollar": 400.0, "methodology": "fee schedule" }, { "payer_name": "Amerigroup", "plan_name": "Amerigroup", "standard_charge_dollar": 473.71, "methodology": "fee schedule" }, { "payer_name": "ANTHEM BLUE PREFERRED PLUS", "plan_name": "ANTHEM BLUE PREFERRED PLUS", "standard_charge_dollar": 315.0, "methodology": "fee schedule" }, { "payer_name": "Anthem Commercial", "plan_name": "Anthem Commercial", "standard_charge_dollar": 315.0, "methodology": "fee schedule" }, { "payer_name": "Anthem Federal Employee", "plan_name": "Anthem Federal Employee", "standard_charge_dollar": 315.0, "methodology": "fee schedule" }, { "payer_name": "Anthem Medicaid", "plan_name": "Anthem Medicaid", "standard_charge_dollar": 473.71, "methodology": "fee schedule" }, { "payer_name": "Anthem Medicare", "plan_name": "Anthem Medicare", "standard_charge_dollar": 315.0, "methodology": "fee schedule" }, { "payer_name": "ASPIRUS WPS- DON'T USE ANYMORE", "plan_name": "ASPIRUS WPS- DON'T USE ANYMORE", "standard_charge_dollar": 325.0, "methodology": "fee schedule" }, { "payer_name": "Auxiant", "plan_name": "Auxiant", "standard_charge_dollar": 600.0, "methodology": "fee schedule" }, { "payer_name": "BCBS OF MICHIGAN", "plan_name": "BCBS OF MICHIGAN", "standard_charge_dollar": 315.0, "methodology": "fee schedule" }, { "payer_name": "Benefit Administrative Services", "plan_name": "Benefit Administrative Services", "standard_charge_dollar": 325.0, "methodology": "fee schedule" }, { "payer_name": "Benefit Plan Admininstrators", "plan_name": "Benefit Plan Admininstrators", "standard_charge_dollar": 315.0, "methodology": "fee schedule" }, { "payer_name": "Bind Benefits", "plan_name": "Bind Benefits", "standard_charge_dollar": 424.0, "methodology": "fee schedule" }, { "payer_name": "Children Come First Rise Wisconsin Inc", "plan_name": "Children Come First Rise Wisconsin Inc", "standard_charge_dollar": 473.71, "methodology": "fee schedule" }, { "payer_name": "Chorus - Childrens Community Health Plan", "plan_name": "Chorus - Childrens Community Health Plan", "standard_charge_dollar": 473.71, "methodology": "fee schedule" }, { "payer_name": "Cigna Behavioral Health", "plan_name": "Cigna Behavioral Health", "standard_charge_dollar": 475.0, "methodology": "fee schedule" }, { "payer_name": "Cigna BH Beacon Health Options", "plan_name": "Cigna BH Beacon Health Options", "standard_charge_dollar": 425.0, "methodology": "fee schedule" }, { "payer_name": "Cigna Healthcare", "plan_name": "Cigna Healthcare", "standard_charge_dollar": 475.0, "methodology": "fee schedule" }, { "payer_name": "Cigna Healthgram Inc", "plan_name": "Cigna Healthgram Inc", "standard_charge_dollar": 475.0, "methodology": "fee schedule" }, { "payer_name": "Common Ground Commercial", "plan_name": "Common Ground Commercial", "standard_charge_dollar": 597.0, "methodology": "fee schedule" }, { "payer_name": "Community Care Inc Medicaid", "plan_name": "Community Care Inc Medicaid", "standard_charge_dollar": 473.71, "methodology": "fee schedule" }, { "payer_name": "CompCare Medicaid", "plan_name": "CompCare Medicaid", "standard_charge_dollar": 473.71, "methodology": "fee schedule" }, { "payer_name": "CON-ForwardHealth", "plan_name": "CON-ForwardHealth", "standard_charge_dollar": 473.71, "methodology": "fee schedule" }, { "payer_name": "Cypress Benefits", "plan_name": "Cypress Benefits", "standard_charge_dollar": 315.0, "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": 473.71, "methodology": "fee schedule" }, { "payer_name": "Eau Claire Human Services", "plan_name": "Eau Claire Human Services", "standard_charge_dollar": 315.0, "methodology": "fee schedule" }, { "payer_name": "Federated Mutal Insurance Co", "plan_name": "Federated Mutal Insurance Co", "standard_charge_dollar": 315.0, "methodology": "fee schedule" }, { "payer_name": "Forest Cty Potawatomi Community", "plan_name": "Forest Cty Potawatomi Community", "standard_charge_dollar": 600.0, "methodology": "fee schedule" }, { "payer_name": "GPA Group & Pension Administrators", "plan_name": "GPA Group & Pension Administrators", "standard_charge_dollar": 600.0, "methodology": "fee schedule" }, { "payer_name": "Group Health Coop South Central WI", "plan_name": "Group Health Coop South Central WI", "standard_charge_dollar": 473.71, "methodology": "fee schedule" }, { "payer_name": "Group Health Medicaid", "plan_name": "Group Health Medicaid", "standard_charge_dollar": 473.71, "methodology": "fee schedule" }, { "payer_name": "Health EOS By MultiPlan", "plan_name": "Health EOS By MultiPlan", "standard_charge_dollar": 600.0, "methodology": "fee schedule" }, { "payer_name": "HEALTH PAYMENT SYST", "plan_name": "HEALTH PAYMENT SYST", "standard_charge_dollar": 510.0, "methodology": "fee schedule" }, { "payer_name": "Health Traditions Medicaid", "plan_name": "Health Traditions Medicaid", "standard_charge_dollar": 473.71, "methodology": "fee schedule" }, { "payer_name": "HealthPartners", "plan_name": "HealthPartners", "standard_charge_dollar": 500.0, "methodology": "fee schedule" }, { "payer_name": "Humana Commercial", "plan_name": "Humana Commercial", "standard_charge_dollar": 422.31, "methodology": "fee schedule" }, { "payer_name": "Humana Medicare", "plan_name": "Humana Medicare", "standard_charge_dollar": 210.46, "methodology": "fee schedule" }, { "payer_name": "ICare Medicaid", "plan_name": "ICare Medicaid", "standard_charge_dollar": 473.71, "methodology": "fee schedule" }, { "payer_name": "ICare Medicare", "plan_name": "ICare Medicare", "standard_charge_dollar": 315.0, "methodology": "fee schedule" }, { "payer_name": "Kaiser Permanente", "plan_name": "Kaiser Permanente", "standard_charge_dollar": 315.0, "methodology": "fee schedule" }, { "payer_name": "KBIC Health System", "plan_name": "KBIC Health System", "standard_charge_dollar": 300.0, "methodology": "fee schedule" }, { "payer_name": "Lucent Health", "plan_name": "Lucent Health", "standard_charge_dollar": 325.0, "methodology": "fee schedule" }, { "payer_name": "Magellan Behavioral Health Systems", "plan_name": "Magellan Behavioral Health Systems", "standard_charge_dollar": 450.0, "methodology": "fee schedule" }, { "payer_name": "Managed Health Services-Managed MA", "plan_name": "Managed Health Services-Managed MA", "standard_charge_dollar": 473.71, "methodology": "fee schedule" }, { "payer_name": "Manitowoc County DHS", "plan_name": "Manitowoc County DHS", "standard_charge_dollar": 315.0, "methodology": "fee schedule" }, { "payer_name": "Marathon County", "plan_name": "Marathon County", "standard_charge_dollar": 315.0, "methodology": "fee schedule" }, { "payer_name": "Mayo Clinic Health Solutions", "plan_name": "Mayo Clinic Health Solutions", "standard_charge_dollar": 315.0, "methodology": "fee schedule" }, { "payer_name": "MDHHS: Gogebic Community Mental Health", "plan_name": "MDHHS: Gogebic Community Mental Health", "standard_charge_dollar": 315.0, "methodology": "fee schedule" }, { "payer_name": "MDHHS: North Pointe HHS", "plan_name": "MDHHS: North Pointe HHS", "standard_charge_dollar": 315.0, "methodology": "fee schedule" }, { "payer_name": "MEDICA", "plan_name": "MEDICA", "standard_charge_dollar": 424.0, "methodology": "fee schedule" }, { "payer_name": "Medica Behavior Health", "plan_name": "Medica Behavior Health", "standard_charge_dollar": 300.0, "methodology": "fee schedule" }, { "payer_name": "Medica Medicare Advantage Prime Solution", "plan_name": "Medica Medicare Advantage Prime Solution", "standard_charge_dollar": 300.0, "methodology": "fee schedule" }, { "payer_name": "Mercy Care Wi Medicaid MCO", "plan_name": "Mercy Care Wi Medicaid MCO", "standard_charge_dollar": 473.71, "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": 473.71, "methodology": "fee schedule" }, { "payer_name": "Molina Healthcare Medicare", "plan_name": "Molina Healthcare Medicare", "standard_charge_dollar": 315.0, "methodology": "fee schedule" }, { "payer_name": "My Choice-Care WI Medicaid", "plan_name": "My Choice-Care WI Medicaid", "standard_charge_dollar": 473.71, "methodology": "fee schedule" }, { "payer_name": "My Choice-Trilogy Medicaid", "plan_name": "My Choice-Trilogy Medicaid", "standard_charge_dollar": 473.71, "methodology": "fee schedule" }, { "payer_name": "My Health Link Plan", "plan_name": "My Health Link Plan", "standard_charge_dollar": 600.0, "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": 473.71, "methodology": "fee schedule" }, { "payer_name": "Network Health Medicare", "plan_name": "Network Health Medicare", "standard_charge_dollar": 300.0, "methodology": "fee schedule" }, { "payer_name": "Network Health Plan PPO", "plan_name": "Network Health Plan PPO", "standard_charge_dollar": 1750.0, "methodology": "fee schedule" }, { "payer_name": "Oneida Nation/Purchase & Referrals", "plan_name": "Oneida Nation/Purchase & Referrals", "standard_charge_dollar": 315.0, "methodology": "fee schedule" }, { "payer_name": "Oxford - United Healthcare", "plan_name": "Oxford - United Healthcare", "standard_charge_dollar": 300.0, "methodology": "fee schedule" }, { "payer_name": "Pan American Life Insurane Co", "plan_name": "Pan American Life Insurane Co", "standard_charge_dollar": 315.0, "methodology": "fee schedule" }, { "payer_name": "Portage County Health And Human Services", "plan_name": "Portage County Health And Human Services", "standard_charge_dollar": 454.5, "methodology": "fee schedule" }, { "payer_name": "Prairie States Enterprises INC", "plan_name": "Prairie States Enterprises INC", "standard_charge_dollar": 485.0, "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": "Prevea 360 Commercial", "plan_name": "Prevea 360 Commercial", "standard_charge_dollar": 433.57, "methodology": "fee schedule" }, { "payer_name": "Prevea 360 DeanCare ASO", "plan_name": "Prevea 360 DeanCare ASO", "standard_charge_dollar": 442.24, "methodology": "fee schedule" }, { "payer_name": "Quartz", "plan_name": "Quartz", "standard_charge_dollar": 550.0, "methodology": "fee schedule" }, { "payer_name": "Quartz Medicaid", "plan_name": "Quartz Medicaid", "standard_charge_dollar": 473.71, "methodology": "fee schedule" }, { "payer_name": "Saginaw CMH", "plan_name": "Saginaw CMH", "standard_charge_dollar": 315.0, "methodology": "fee schedule" }, { "payer_name": "Security Health Commercial", "plan_name": "Security Health Commercial", "standard_charge_dollar": 463.5, "methodology": "fee schedule" }, { "payer_name": "Security Health Medicare", "plan_name": "Security Health Medicare", "standard_charge_dollar": 212.0, "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": 473.71, "methodology": "fee schedule" }, { "payer_name": "Simplan Administrators", "plan_name": "Simplan Administrators", "standard_charge_dollar": 600.0, "methodology": "fee schedule" }, { "payer_name": "Stockbridge-Munsee Health And Wellness", "plan_name": "Stockbridge-Munsee Health And Wellness", "standard_charge_dollar": 315.0, "methodology": "fee schedule" }, { "payer_name": "Superior", "plan_name": "Superior", "standard_charge_dollar": 315.0, "methodology": "fee schedule" }, { "payer_name": "Surest", "plan_name": "Surest", "standard_charge_dollar": 424.0, "methodology": "fee schedule" }, { "payer_name": "The Alliance Auxiant", "plan_name": "The Alliance Auxiant", "standard_charge_dollar": 450.0, "methodology": "fee schedule" }, { "payer_name": "The Benefit Group", "plan_name": "The Benefit Group", "standard_charge_dollar": 600.0, "methodology": "fee schedule" }, { "payer_name": "TRICARE EAST-WPS", "plan_name": "TRICARE EAST-WPS", "standard_charge_dollar": 414.2, "methodology": "fee schedule" }, { "payer_name": "Trilogy Commercial", "plan_name": "Trilogy Commercial", "standard_charge_dollar": 485.0, "methodology": "fee schedule" }, { "payer_name": "UHC/OPTUM", "plan_name": "UHC/OPTUM", "standard_charge_dollar": 424.0, "methodology": "fee schedule" }, { "payer_name": "UMR", "plan_name": "UMR", "standard_charge_dollar": 424.0, "methodology": "fee schedule" }, { "payer_name": "UMR Commercial", "plan_name": "UMR Commercial", "standard_charge_dollar": 424.0, "methodology": "fee schedule" }, { "payer_name": "Unicare", "plan_name": "Unicare", "standard_charge_dollar": 315.0, "methodology": "fee schedule" }, { "payer_name": "United Behavioral Health", "plan_name": "United Behavioral Health", "standard_charge_dollar": 424.0, "methodology": "fee schedule" }, { "payer_name": "United Behavorial Health", "plan_name": "United Behavorial Health", "standard_charge_dollar": 424.0, "methodology": "fee schedule" }, { "payer_name": "United Healthcare", "plan_name": "United Healthcare", "standard_charge_dollar": 424.0, "methodology": "fee schedule" }, { "payer_name": "United Healthcare Dual Complete LP1", "plan_name": "United Healthcare Dual Complete LP1", "standard_charge_dollar": 252.28, "methodology": "fee schedule" }, { "payer_name": "United Healthcare Healthscope", "plan_name": "United Healthcare Healthscope", "standard_charge_dollar": 325.0, "methodology": "fee schedule" }, { "payer_name": "United Healthcare Managed Medicare", "plan_name": "United Healthcare Managed Medicare", "standard_charge_dollar": 250.0, "methodology": "fee schedule" }, { "payer_name": "United Healthcare Medicaid Community Pla", "plan_name": "United Healthcare Medicaid Community Pla", "standard_charge_dollar": 107.15, "methodology": "fee schedule" }, { "payer_name": "United Healthcare Shared Services", "plan_name": "United Healthcare Shared Services", "standard_charge_dollar": 300.0, "methodology": "fee schedule" }, { "payer_name": "Unity Health Plan Medicaid", "plan_name": "Unity Health Plan Medicaid", "standard_charge_dollar": 473.71, "methodology": "fee schedule" }, { "payer_name": "UPHP Medicare Advantage", "plan_name": "UPHP Medicare Advantage", "standard_charge_dollar": 315.0, "methodology": "fee schedule" }, { "payer_name": "VA Office Of Integrated Care", "plan_name": "VA Office Of Integrated Care", "standard_charge_dollar": 300.0, "methodology": "fee schedule" }, { "payer_name": "WEA Trust Commercial", "plan_name": "WEA Trust Commercial", "standard_charge_dollar": 425.0, "methodology": "fee schedule" }, { "payer_name": "WISCONSIN ANTHEM MEDI BLUE DUAL ADV", "plan_name": "WISCONSIN ANTHEM MEDI BLUE DUAL ADV", "standard_charge_dollar": 315.0, "methodology": "fee schedule" }, { "payer_name": "WPS Health Insurance", "plan_name": "WPS Health Insurance", "standard_charge_dollar": 400.0, "methodology": "fee schedule" }, { "payer_name": "WPS Health Plan - SCA", "plan_name": "WPS Health Plan - SCA", "standard_charge_dollar": 315.0, "methodology": "fee schedule" } ], "gross_charge": 2500.0, "discounted_cash": 400.0, "minimum": 107.15, "maximum": 1750.0 } ] }, { "description": "PHP Daily Gero", "code_information": [ { "code": "H0035", "type": "HCPCS" }, { "code": "1030", "type": "LOCAL" } ], "standard_charges": [ { "setting": "outpatient", "payers_information": [ { "payer_name": "AARP Medicare Complete", "plan_name": "AARP Medicare Complete", "standard_charge_dollar": 300.0, "methodology": "fee schedule" }, { "payer_name": "AARP Supplement Plan", "plan_name": "AARP Supplement Plan", "standard_charge_dollar": 315.0, "methodology": "fee schedule" }, { "payer_name": "Advocate Aurora Health Inc UMR", "plan_name": "Advocate Aurora Health Inc UMR", "standard_charge_dollar": 395.0, "methodology": "fee schedule" }, { "payer_name": "Aetna Life Insurance Company", "plan_name": "Aetna Life Insurance Company", "standard_charge_dollar": 600.0, "methodology": "fee schedule" }, { "payer_name": "Aetna Medicare", "plan_name": "Aetna Medicare", "standard_charge_dollar": 335.0, "methodology": "fee schedule" }, { "payer_name": "Aetna-SCA", "plan_name": "Aetna-SCA", "standard_charge_dollar": 600.0, "methodology": "fee schedule" }, { "payer_name": "Aither Health", "plan_name": "Aither Health", "standard_charge_dollar": 315.0, "methodology": "fee schedule" }, { "payer_name": "All Savers", "plan_name": "All Savers", "standard_charge_dollar": 400.0, "methodology": "fee schedule" }, { "payer_name": "Amerigroup", "plan_name": "Amerigroup", "standard_charge_dollar": 473.71, "methodology": "fee schedule" }, { "payer_name": "ANTHEM BLUE PREFERRED PLUS", "plan_name": "ANTHEM BLUE PREFERRED PLUS", "standard_charge_dollar": 315.0, "methodology": "fee schedule" }, { "payer_name": "Anthem Commercial", "plan_name": "Anthem Commercial", "standard_charge_dollar": 315.0, "methodology": "fee schedule" }, { "payer_name": "Anthem Federal Employee", "plan_name": "Anthem Federal Employee", "standard_charge_dollar": 315.0, "methodology": "fee schedule" }, { "payer_name": "Anthem Medicaid", "plan_name": "Anthem Medicaid", "standard_charge_dollar": 473.71, "methodology": "fee schedule" }, { "payer_name": "Anthem Medicare", "plan_name": "Anthem Medicare", "standard_charge_dollar": 315.0, "methodology": "fee schedule" }, { "payer_name": "ASPIRUS WPS- DON'T USE ANYMORE", "plan_name": "ASPIRUS WPS- DON'T USE ANYMORE", "standard_charge_dollar": 325.0, "methodology": "fee schedule" }, { "payer_name": "Auxiant", "plan_name": "Auxiant", "standard_charge_dollar": 600.0, "methodology": "fee schedule" }, { "payer_name": "BCBS OF MICHIGAN", "plan_name": "BCBS OF MICHIGAN", "standard_charge_dollar": 315.0, "methodology": "fee schedule" }, { "payer_name": "Benefit Administrative Services", "plan_name": "Benefit Administrative Services", "standard_charge_dollar": 325.0, "methodology": "fee schedule" }, { "payer_name": "Benefit Plan Admininstrators", "plan_name": "Benefit Plan Admininstrators", "standard_charge_dollar": 315.0, "methodology": "fee schedule" }, { "payer_name": "Bind Benefits", "plan_name": "Bind Benefits", "standard_charge_dollar": 424.0, "methodology": "fee schedule" }, { "payer_name": "Children Come First Rise Wisconsin Inc", "plan_name": "Children Come First Rise Wisconsin Inc", "standard_charge_dollar": 473.71, "methodology": "fee schedule" }, { "payer_name": "Cigna Behavioral Health", "plan_name": "Cigna Behavioral Health", "standard_charge_dollar": 475.0, "methodology": "fee schedule" }, { "payer_name": "Cigna BH Beacon Health Options", "plan_name": "Cigna BH Beacon Health Options", "standard_charge_dollar": 425.0, "methodology": "fee schedule" }, { "payer_name": "Cigna Healthcare", "plan_name": "Cigna Healthcare", "standard_charge_dollar": 475.0, "methodology": "fee schedule" }, { "payer_name": "Cigna Healthgram Inc", "plan_name": "Cigna Healthgram Inc", "standard_charge_dollar": 475.0, "methodology": "fee schedule" }, { "payer_name": "Common Ground Commercial", "plan_name": "Common Ground Commercial", "standard_charge_dollar": 597.0, "methodology": "fee schedule" }, { "payer_name": "Community Care Inc Medicaid", "plan_name": "Community Care Inc Medicaid", "standard_charge_dollar": 473.71, "methodology": "fee schedule" }, { "payer_name": "CompCare Medicaid", "plan_name": "CompCare Medicaid", "standard_charge_dollar": 473.71, "methodology": "fee schedule" }, { "payer_name": "CON-ForwardHealth", "plan_name": "CON-ForwardHealth", "standard_charge_dollar": 473.71, "methodology": "fee schedule" }, { "payer_name": "Cypress Benefits", "plan_name": "Cypress Benefits", "standard_charge_dollar": 315.0, "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": 473.71, "methodology": "fee schedule" }, { "payer_name": "Eau Claire Human Services", "plan_name": "Eau Claire Human Services", "standard_charge_dollar": 315.0, "methodology": "fee schedule" }, { "payer_name": "Federated Mutal Insurance Co", "plan_name": "Federated Mutal Insurance Co", "standard_charge_dollar": 315.0, "methodology": "fee schedule" }, { "payer_name": "Forest Cty Potawatomi Community", "plan_name": "Forest Cty Potawatomi Community", "standard_charge_dollar": 600.0, "methodology": "fee schedule" }, { "payer_name": "GPA Group & Pension Administrators", "plan_name": "GPA Group & Pension Administrators", "standard_charge_dollar": 600.0, "methodology": "fee schedule" }, { "payer_name": "Group Health Coop South Central WI", "plan_name": "Group Health Coop South Central WI", "standard_charge_dollar": 473.71, "methodology": "fee schedule" }, { "payer_name": "Group Health Medicaid", "plan_name": "Group Health Medicaid", "standard_charge_dollar": 473.71, "methodology": "fee schedule" }, { "payer_name": "Health EOS By MultiPlan", "plan_name": "Health EOS By MultiPlan", "standard_charge_dollar": 600.0, "methodology": "fee schedule" }, { "payer_name": "HEALTH PAYMENT SYST", "plan_name": "HEALTH PAYMENT SYST", "standard_charge_dollar": 510.0, "methodology": "fee schedule" }, { "payer_name": "Health Traditions Medicaid", "plan_name": "Health Traditions Medicaid", "standard_charge_dollar": 473.71, "methodology": "fee schedule" }, { "payer_name": "HealthPartners", "plan_name": "HealthPartners", "standard_charge_dollar": 500.0, "methodology": "fee schedule" }, { "payer_name": "Humana Commercial", "plan_name": "Humana Commercial", "standard_charge_dollar": 422.31, "methodology": "fee schedule" }, { "payer_name": "Humana Medicare", "plan_name": "Humana Medicare", "standard_charge_dollar": 210.46, "methodology": "fee schedule" }, { "payer_name": "ICare Medicaid", "plan_name": "ICare Medicaid", "standard_charge_dollar": 473.71, "methodology": "fee schedule" }, { "payer_name": "ICare Medicare", "plan_name": "ICare Medicare", "standard_charge_dollar": 315.0, "methodology": "fee schedule" }, { "payer_name": "Kaiser Permanente", "plan_name": "Kaiser Permanente", "standard_charge_dollar": 315.0, "methodology": "fee schedule" }, { "payer_name": "KBIC Health System", "plan_name": "KBIC Health System", "standard_charge_dollar": 300.0, "methodology": "fee schedule" }, { "payer_name": "Lucent Health", "plan_name": "Lucent Health", "standard_charge_dollar": 325.0, "methodology": "fee schedule" }, { "payer_name": "Magellan Behavioral Health Systems", "plan_name": "Magellan Behavioral Health Systems", "standard_charge_dollar": 450.0, "methodology": "fee schedule" }, { "payer_name": "Managed Health Services-Managed MA", "plan_name": "Managed Health Services-Managed MA", "standard_charge_dollar": 473.71, "methodology": "fee schedule" }, { "payer_name": "Manitowoc County DHS", "plan_name": "Manitowoc County DHS", "standard_charge_dollar": 315.0, "methodology": "fee schedule" }, { "payer_name": "Marathon County", "plan_name": "Marathon County", "standard_charge_dollar": 315.0, "methodology": "fee schedule" }, { "payer_name": "Mayo Clinic Health Solutions", "plan_name": "Mayo Clinic Health Solutions", "standard_charge_dollar": 315.0, "methodology": "fee schedule" }, { "payer_name": "MDHHS: Gogebic Community Mental Health", "plan_name": "MDHHS: Gogebic Community Mental Health", "standard_charge_dollar": 315.0, "methodology": "fee schedule" }, { "payer_name": "MDHHS: North Pointe HHS", "plan_name": "MDHHS: North Pointe HHS", "standard_charge_dollar": 315.0, "methodology": "fee schedule" }, { "payer_name": "MEDICA", "plan_name": "MEDICA", "standard_charge_dollar": 424.0, "methodology": "fee schedule" }, { "payer_name": "Medica Behavior Health", "plan_name": "Medica Behavior Health", "standard_charge_dollar": 300.0, "methodology": "fee schedule" }, { "payer_name": "Medica Medicare Advantage Prime Solution", "plan_name": "Medica Medicare Advantage Prime Solution", "standard_charge_dollar": 300.0, "methodology": "fee schedule" }, { "payer_name": "Mercy Care Wi Medicaid MCO", "plan_name": "Mercy Care Wi Medicaid MCO", "standard_charge_dollar": 473.71, "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": 473.71, "methodology": "fee schedule" }, { "payer_name": "Molina Healthcare Medicare", "plan_name": "Molina Healthcare Medicare", "standard_charge_dollar": 315.0, "methodology": "fee schedule" }, { "payer_name": "My Choice-Care WI Medicaid", "plan_name": "My Choice-Care WI Medicaid", "standard_charge_dollar": 473.71, "methodology": "fee schedule" }, { "payer_name": "My Choice-Trilogy Medicaid", "plan_name": "My Choice-Trilogy Medicaid", "standard_charge_dollar": 473.71, "methodology": "fee schedule" }, { "payer_name": "My Health Link Plan", "plan_name": "My Health Link Plan", "standard_charge_dollar": 600.0, "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": 473.71, "methodology": "fee schedule" }, { "payer_name": "Network Health Medicare", "plan_name": "Network Health Medicare", "standard_charge_dollar": 300.0, "methodology": "fee schedule" }, { "payer_name": "Network Health Plan PPO", "plan_name": "Network Health Plan PPO", "standard_charge_dollar": 1750.0, "methodology": "fee schedule" }, { "payer_name": "Oneida Nation/Purchase & Referrals", "plan_name": "Oneida Nation/Purchase & Referrals", "standard_charge_dollar": 315.0, "methodology": "fee schedule" }, { "payer_name": "Oxford - United Healthcare", "plan_name": "Oxford - United Healthcare", "standard_charge_dollar": 300.0, "methodology": "fee schedule" }, { "payer_name": "Pan American Life Insurane Co", "plan_name": "Pan American Life Insurane Co", "standard_charge_dollar": 315.0, "methodology": "fee schedule" }, { "payer_name": "Portage County Health And Human Services", "plan_name": "Portage County Health And Human Services", "standard_charge_dollar": 454.5, "methodology": "fee schedule" }, { "payer_name": "Prairie States Enterprises INC", "plan_name": "Prairie States Enterprises INC", "standard_charge_dollar": 485.0, "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": "Prevea 360 Commercial", "plan_name": "Prevea 360 Commercial", "standard_charge_dollar": 433.57, "methodology": "fee schedule" }, { "payer_name": "Prevea 360 DeanCare ASO", "plan_name": "Prevea 360 DeanCare ASO", "standard_charge_dollar": 442.24, "methodology": "fee schedule" }, { "payer_name": "Quartz", "plan_name": "Quartz", "standard_charge_dollar": 550.0, "methodology": "fee schedule" }, { "payer_name": "Quartz Medicaid", "plan_name": "Quartz Medicaid", "standard_charge_dollar": 473.71, "methodology": "fee schedule" }, { "payer_name": "Saginaw CMH", "plan_name": "Saginaw CMH", "standard_charge_dollar": 315.0, "methodology": "fee schedule" }, { "payer_name": "Security Health Commercial", "plan_name": "Security Health Commercial", "standard_charge_dollar": 463.5, "methodology": "fee schedule" }, { "payer_name": "Security Health Medicare", "plan_name": "Security Health Medicare", "standard_charge_dollar": 212.0, "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": 473.71, "methodology": "fee schedule" }, { "payer_name": "Simplan Administrators", "plan_name": "Simplan Administrators", "standard_charge_dollar": 600.0, "methodology": "fee schedule" }, { "payer_name": "Stockbridge-Munsee Health And Wellness", "plan_name": "Stockbridge-Munsee Health And Wellness", "standard_charge_dollar": 315.0, "methodology": "fee schedule" }, { "payer_name": "Superior", "plan_name": "Superior", "standard_charge_dollar": 315.0, "methodology": "fee schedule" }, { "payer_name": "Surest", "plan_name": "Surest", "standard_charge_dollar": 424.0, "methodology": "fee schedule" }, { "payer_name": "The Alliance Auxiant", "plan_name": "The Alliance Auxiant", "standard_charge_dollar": 450.0, "methodology": "fee schedule" }, { "payer_name": "The Benefit Group", "plan_name": "The Benefit Group", "standard_charge_dollar": 600.0, "methodology": "fee schedule" }, { "payer_name": "Trilogy Commercial", "plan_name": "Trilogy Commercial", "standard_charge_dollar": 485.0, "methodology": "fee schedule" }, { "payer_name": "UHC/OPTUM", "plan_name": "UHC/OPTUM", "standard_charge_dollar": 424.0, "methodology": "fee schedule" }, { "payer_name": "UMR", "plan_name": "UMR", "standard_charge_dollar": 424.0, "methodology": "fee schedule" }, { "payer_name": "UMR Commercial", "plan_name": "UMR Commercial", "standard_charge_dollar": 424.0, "methodology": "fee schedule" }, { "payer_name": "Unicare", "plan_name": "Unicare", "standard_charge_dollar": 315.0, "methodology": "fee schedule" }, { "payer_name": "United Behavioral Health", "plan_name": "United Behavioral Health", "standard_charge_dollar": 424.0, "methodology": "fee schedule" }, { "payer_name": "United Behavorial Health", "plan_name": "United Behavorial Health", "standard_charge_dollar": 424.0, "methodology": "fee schedule" }, { "payer_name": "United Healthcare", "plan_name": "United Healthcare", "standard_charge_dollar": 424.0, "methodology": "fee schedule" }, { "payer_name": "United Healthcare Dual Complete LP1", "plan_name": "United Healthcare Dual Complete LP1", "standard_charge_dollar": 252.28, "methodology": "fee schedule" }, { "payer_name": "United Healthcare Healthscope", "plan_name": "United Healthcare Healthscope", "standard_charge_dollar": 325.0, "methodology": "fee schedule" }, { "payer_name": "United Healthcare Managed Medicare", "plan_name": "United Healthcare Managed Medicare", "standard_charge_dollar": 250.0, "methodology": "fee schedule" }, { "payer_name": "United Healthcare Medicaid Community Pla", "plan_name": "United Healthcare Medicaid Community Pla", "standard_charge_dollar": 473.71, "methodology": "fee schedule" }, { "payer_name": "United Healthcare Shared Services", "plan_name": "United Healthcare Shared Services", "standard_charge_dollar": 300.0, "methodology": "fee schedule" }, { "payer_name": "Unity Health Plan Medicaid", "plan_name": "Unity Health Plan Medicaid", "standard_charge_dollar": 473.71, "methodology": "fee schedule" }, { "payer_name": "UPHP Medicare Advantage", "plan_name": "UPHP Medicare Advantage", "standard_charge_dollar": 315.0, "methodology": "fee schedule" }, { "payer_name": "VA Office Of Integrated Care", "plan_name": "VA Office Of Integrated Care", "standard_charge_dollar": 300.0, "methodology": "fee schedule" }, { "payer_name": "WEA Trust Commercial", "plan_name": "WEA Trust Commercial", "standard_charge_dollar": 425.0, "methodology": "fee schedule" }, { "payer_name": "WISCONSIN ANTHEM MEDI BLUE DUAL ADV", "plan_name": "WISCONSIN ANTHEM MEDI BLUE DUAL ADV", "standard_charge_dollar": 315.0, "methodology": "fee schedule" }, { "payer_name": "WPS Health Insurance", "plan_name": "WPS Health Insurance", "standard_charge_dollar": 400.0, "methodology": "fee schedule" }, { "payer_name": "WPS Health Plan - SCA", "plan_name": "WPS Health Plan - SCA", "standard_charge_dollar": 315.0, "methodology": "fee schedule" } ], "gross_charge": 2500.0, "discounted_cash": 400.0, "minimum": 210.46, "maximum": 1750.0 } ] }, { "description": "Telehealth PHP Psych Adult Daily", "code_information": [ { "code": "H0035", "type": "HCPCS" }, { "code": "846", "type": "LOCAL" } ], "standard_charges": [ { "setting": "outpatient", "payers_information": [ { "payer_name": "Prevea 360 DeanCare ASO", "plan_name": "Prevea 360 DeanCare ASO", "standard_charge_dollar": 442.24, "methodology": "fee schedule" } ], "gross_charge": 2500.0, "discounted_cash": 400.0, "minimum": 442.24, "maximum": 442.24 } ] }, { "description": "Tri/Medi Adult IOP-2 unit", "code_information": [ { "code": "90853", "type": "CPT" }, { "code": "1082", "type": "LOCAL" } ], "standard_charges": [ { "setting": "outpatient", "payers_information": [ { "payer_name": "Elderplan Extra Help", "plan_name": "Elderplan Extra Help", "standard_charge_dollar": 97.62, "methodology": "fee schedule" } ], "gross_charge": 850.0, "discounted_cash": 300.0, "minimum": 97.62, "maximum": 97.62 } ] }, { "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": "Anthem Medicaid", "plan_name": "Anthem Medicaid", "standard_charge_dollar": 473.71, "methodology": "fee schedule" }, { "payer_name": "Elderplan Extra Help", "plan_name": "Elderplan Extra Help", "standard_charge_dollar": 65.08, "methodology": "fee schedule" }, { "payer_name": "TRICARE EAST-WPS", "plan_name": "TRICARE EAST-WPS", "standard_charge_dollar": 70.0, "methodology": "fee schedule" } ], "gross_charge": 566.67, "discounted_cash": 300.0, "minimum": 65.08, "maximum": 473.71 } ] }, { "description": "Tri/Medi Adult PHP - 1 unit", "code_information": [ { "code": "G0411", "type": "HCPCS" }, { "code": "1011", "type": "LOCAL" } ], "standard_charges": [ { "setting": "outpatient", "payers_information": [ { "payer_name": "Humana Commercial", "plan_name": "Humana Commercial", "standard_charge_dollar": 422.31, "methodology": "fee schedule" }, { "payer_name": "Managed Health Services-Managed MA", "plan_name": "Managed Health Services-Managed MA", "standard_charge_dollar": 18.3, "methodology": "fee schedule" } ], "gross_charge": 2500.0, "minimum": 18.3, "maximum": 422.31 } ] }, { "description": "Tri/Medi Adult PHP - 2 unit", "code_information": [ { "code": "G0411", "type": "HCPCS" }, { "code": "1012", "type": "LOCAL" } ], "standard_charges": [ { "setting": "outpatient", "payers_information": [ { "payer_name": "Humana Commercial", "plan_name": "Humana Commercial", "standard_charge_dollar": 422.31, "methodology": "fee schedule" }, { "payer_name": "Managed Health Services-Managed MA", "plan_name": "Managed Health Services-Managed MA", "standard_charge_dollar": 36.6, "methodology": "fee schedule" } ], "gross_charge": 1250.0, "minimum": 36.6, "maximum": 422.31 } ] }, { "description": "Tri/Medi Adult PHP - 3 unit", "code_information": [ { "code": "G0411", "type": "HCPCS" }, { "code": "1013", "type": "LOCAL" } ], "standard_charges": [ { "setting": "outpatient", "payers_information": [ { "payer_name": "Elderplan Extra Help", "plan_name": "Elderplan Extra Help", "standard_charge_dollar": 196.24, "methodology": "fee schedule" }, { "payer_name": "Humana Commercial", "plan_name": "Humana Commercial", "standard_charge_dollar": 422.31, "methodology": "fee schedule" }, { "payer_name": "Managed Health Services-Managed MA", "plan_name": "Managed Health Services-Managed MA", "standard_charge_dollar": 54.9, "methodology": "fee schedule" }, { "payer_name": "TRICARE EAST-WPS", "plan_name": "TRICARE EAST-WPS", "standard_charge_dollar": 293.33, "methodology": "fee schedule" } ], "gross_charge": 833.33, "minimum": 54.9, "maximum": 422.31 } ] }, { "description": "Tri/Medi Adult PHP - 4 unit", "code_information": [ { "code": "G0411", "type": "HCPCS" }, { "code": "1014", "type": "LOCAL" } ], "standard_charges": [ { "setting": "outpatient", "payers_information": [ { "payer_name": "Elderplan Extra Help", "plan_name": "Elderplan Extra Help", "standard_charge_dollar": 196.24, "methodology": "fee schedule" }, { "payer_name": "Humana Commercial", "plan_name": "Humana Commercial", "standard_charge_dollar": 422.31, "methodology": "fee schedule" }, { "payer_name": "Managed Health Services-Managed MA", "plan_name": "Managed Health Services-Managed MA", "standard_charge_dollar": 73.2, "methodology": "fee schedule" }, { "payer_name": "TRICARE EAST-WPS", "plan_name": "TRICARE EAST-WPS", "standard_charge_dollar": 220.0, "methodology": "fee schedule" } ], "gross_charge": 625.0, "minimum": 73.2, "maximum": 422.31 } ] }, { "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": "Chorus - Childrens Community Health Plan", "plan_name": "Chorus - Childrens Community Health Plan", "standard_charge_dollar": 63.78, "methodology": "fee schedule" }, { "payer_name": "Elderplan Extra Help", "plan_name": "Elderplan Extra Help", "standard_charge_dollar": 196.24, "methodology": "fee schedule" }, { "payer_name": "Humana Commercial", "plan_name": "Humana Commercial", "standard_charge_dollar": 422.31, "methodology": "fee schedule" }, { "payer_name": "ICare Medicaid", "plan_name": "ICare Medicaid", "standard_charge_dollar": 473.71, "methodology": "fee schedule" }, { "payer_name": "Managed Health Services-Managed MA", "plan_name": "Managed Health Services-Managed MA", "standard_charge_dollar": 91.5, "methodology": "fee schedule" }, { "payer_name": "TRICARE EAST-WPS", "plan_name": "TRICARE EAST-WPS", "standard_charge_dollar": 70.0, "methodology": "fee schedule" }, { "payer_name": "United Healthcare Dual Complete LP1", "plan_name": "United Healthcare Dual Complete LP1", "standard_charge_dollar": 252.28, "methodology": "fee schedule" } ], "gross_charge": 500.0, "minimum": 63.78, "maximum": 473.71 } ] }, { "description": "Tri/Medi Child/Adol PHP-1 unit", "code_information": [ { "code": "G0411", "type": "HCPCS" }, { "code": "1021", "type": "LOCAL" } ], "standard_charges": [ { "setting": "outpatient", "payers_information": [ { "payer_name": "TRICARE EAST-WPS", "plan_name": "TRICARE EAST-WPS", "standard_charge_dollar": 70.0, "methodology": "fee schedule" } ], "gross_charge": 2500.0, "minimum": 70.0, "maximum": 70.0 } ] }, { "description": "Tri/Medi Child/Adol PHP-2 unit", "code_information": [ { "code": "G0411", "type": "HCPCS" }, { "code": "1022", "type": "LOCAL" } ], "standard_charges": [ { "setting": "outpatient", "payers_information": [ { "payer_name": "TRICARE EAST-WPS", "plan_name": "TRICARE EAST-WPS", "standard_charge_dollar": 70.0, "methodology": "fee schedule" } ], "gross_charge": 2500.0, "minimum": 70.0, "maximum": 70.0 } ] }, { "description": "Tri/Medi Child/Adol PHP-3 unit", "code_information": [ { "code": "G0411", "type": "HCPCS" }, { "code": "1023", "type": "LOCAL" } ], "standard_charges": [ { "setting": "outpatient", "payers_information": [ { "payer_name": "TRICARE EAST-WPS", "plan_name": "TRICARE EAST-WPS", "standard_charge_dollar": 70.0, "methodology": "fee schedule" } ], "gross_charge": 2500.0, "minimum": 70.0, "maximum": 70.0 } ] }, { "description": "Tri/Medi Child/Adol PHP-4 unit", "code_information": [ { "code": "G0411", "type": "HCPCS" }, { "code": "1024", "type": "LOCAL" } ], "standard_charges": [ { "setting": "outpatient", "payers_information": [ { "payer_name": "TRICARE EAST-WPS", "plan_name": "TRICARE EAST-WPS", "standard_charge_dollar": 70.0, "methodology": "fee schedule" } ], "gross_charge": 2500.0, "minimum": 70.0, "maximum": 70.0 } ] }, { "description": "Tri/Medi Child/Adol PHP-5 unit", "code_information": [ { "code": "G0411", "type": "HCPCS" }, { "code": "1025", "type": "LOCAL" } ], "standard_charges": [ { "setting": "outpatient", "payers_information": [ { "payer_name": "TRICARE EAST-WPS", "plan_name": "TRICARE EAST-WPS", "standard_charge_dollar": 70.0, "methodology": "fee schedule" } ], "gross_charge": 500.0, "minimum": 70.0, "maximum": 70.0 } ] }, { "description": "Tri/Medi Gero PHP - 5 unit", "code_information": [ { "code": "G0411", "type": "HCPCS" }, { "code": "1035", "type": "LOCAL" } ], "standard_charges": [ { "setting": "outpatient", "payers_information": [ { "payer_name": "Elderplan Extra Help", "plan_name": "Elderplan Extra Help", "standard_charge_dollar": 196.24, "methodology": "fee schedule" } ], "gross_charge": 500.0, "minimum": 196.24, "maximum": 196.24 } ] }, { "description": "Tri/Medi Gero PHP-4 unit", "code_information": [ { "code": "G0411", "type": "HCPCS" }, { "code": "1034", "type": "LOCAL" } ], "standard_charges": [ { "setting": "outpatient", "payers_information": [ { "payer_name": "Elderplan Extra Help", "plan_name": "Elderplan Extra Help", "standard_charge_dollar": 196.24, "methodology": "fee schedule" } ], "gross_charge": 2500.0, "minimum": 196.24, "maximum": 196.24 } ] }, { "description": "Tri/Medi Psych Gero PHP-2 unit", "code_information": [ { "code": "G0411", "type": "HCPCS" }, { "code": "912", "type": "LOCAL" } ], "standard_charges": [ { "setting": "outpatient", "payers_information": [ { "payer_name": "United Healthcare", "plan_name": "United Healthcare", "standard_charge_dollar": 400.0, "methodology": "fee schedule" } ], "gross_charge": 2500.0, "minimum": 400.0, "maximum": 400.0 } ] }, { "description": "SUBSEQ HOSP (15 MIN)", "code_information": [ { "code": "99231", "type": "CPT" }, { "code": "99231", "type": "LOCAL" } ], "standard_charges": [ { "setting": "inpatient", "payers_information": [ { "payer_name": "Eau Claire Human Services", "plan_name": "Eau Claire Human Services", "standard_charge_dollar": 20.62, "methodology": "fee schedule" } ], "gross_charge": 140.0, "minimum": 20.62, "maximum": 20.62 } ] } ] }