{ "hospital_name": "LUCILE SALTER PACKARD CHILDREN'S HOSPITAL AT STANFORD", "last_updated_on": "2026-03-31", "version": "3.0.0", "location_name": [ "PALO ALTO, CA" ], "hospital_address": [ "725 WELCH RD, PALO ALTO, CA 94304" ], "license_information": { "state": "CA", "license_number": "70000659" }, "type_2_npi": [ "1467442749" ], "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": "KRISTIEN KARMARKAR" }, "standard_charge_information": [ { "description": "HC IP Convent Hemodialysis <2yrs", "code_information": [ { "code": "PX-1300000001", "type": "CDM" }, { "code": "90935", "type": "CPT" }, { "code": "0801", "type": "RC" } ], "standard_charges": [ { "setting": "outpatient", "gross_charge": 5707.0, "discounted_cash": 2853.5, "minimum": 2408.35, "maximum": 2967.64, "additional_generic_notes": "Zero final payments for the item or service in the 15 months prior to posting the file.", "payers_information": [ { "payer_name": "AETNA", "plan_name": "AETNA ALL OTHER PLANS", "methodology": "percent of total billed charges", "standard_charge_dollar": 2967.64, "standard_charge_percentage": 52.0, "median_amount": 2835.04, "10th_percentile": 2835.04, "90th_percentile": 2835.04, "count": "13" }, { "payer_name": "AETNA", "plan_name": "AETNA ALL OTHER PLANS", "methodology": "percent of total billed charges", "standard_charge_dollar": 2967.64, "standard_charge_percentage": 52.0, "count": "0", "additional_payer_notes": "Zero final payments for the item or service in the 15 months prior to posting the file." }, { "payer_name": "MERITAIN HEALTH", "plan_name": "AETNA ALL OTHER PLANS", "methodology": "percent of total billed charges", "standard_charge_dollar": 2967.64, "standard_charge_percentage": 52.0, "count": "0", "additional_payer_notes": "Zero final payments for the item or service in the 15 months prior to posting the file." }, { "payer_name": "BLUE SHIELD OUT OF STATE", "plan_name": "STANFORD HEALTHCARE ALLIANCE PLAN", "methodology": "percent of total billed charges", "standard_charge_dollar": 2773.03, "standard_charge_percentage": 48.59, "count": "0", "additional_payer_notes": "Zero final payments for the item or service in the 15 months prior to posting the file." }, { "payer_name": "BLUE SHIELD", "plan_name": "STANFORD HEALTHCARE ALLIANCE PLAN", "methodology": "percent of total billed charges", "standard_charge_dollar": 2773.03, "standard_charge_percentage": 48.59, "median_amount": 2736.48, "10th_percentile": 2736.48, "90th_percentile": 2736.48, "count": "99" }, { "payer_name": "BLUE SHIELD", "plan_name": "STANFORD HEALTHCARE ALLIANCE PLAN", "methodology": "percent of total billed charges", "standard_charge_dollar": 2773.03, "standard_charge_percentage": 48.59, "count": "0", "additional_payer_notes": "Zero final payments for the item or service in the 15 months prior to posting the file." }, { "payer_name": "BLUE SHIELD", "plan_name": "STANFORD HEALTHCARE ALLIANCE PLAN", "methodology": "percent of total billed charges", "standard_charge_dollar": 2773.03, "standard_charge_percentage": 48.59, "count": "0", "additional_payer_notes": "Zero final payments for the item or service in the 15 months prior to posting the file." }, { "payer_name": "CIGNA", "plan_name": "CIGNA COM ALT HMO PLAN", "methodology": "percent of total billed charges", "standard_charge_dollar": 2408.35, "standard_charge_percentage": 42.2, "count": "0", "additional_payer_notes": "Zero final payments for the item or service in the 15 months prior to posting the file." }, { "payer_name": "CIGNA", "plan_name": "CIGNA COM ALT HMO PLAN", "methodology": "percent of total billed charges", "standard_charge_dollar": 2408.35, "standard_charge_percentage": 42.2, "count": "0", "additional_payer_notes": "Zero final payments for the item or service in the 15 months prior to posting the file." }, { "payer_name": "HEALTH NET", "plan_name": "HEALTHNET HMO, PPO, POS, EPO, CANOPY HEALTHNET HMO, OTHER-IN-NETWORK PLANS", "methodology": "per diem", "standard_charge_dollar": 8000.0, "standard_charge_algorithm": "Expected reimbursement is the lesser of Per diem ($8,000) for the length of stay and 70% of billed.", "count": "0", "additional_payer_notes": "Zero final payments for the item or service in the 15 months prior to posting the file." }, { "payer_name": "HEALTH NET", "plan_name": "HEALTHNET HMO, PPO, POS, EPO, CANOPY HEALTHNET HMO, OTHER-IN-NETWORK PLANS", "methodology": "per diem", "standard_charge_dollar": 8000.0, "standard_charge_algorithm": "Expected reimbursement is the lesser of Per diem ($8,000) for the length of stay and 70% of billed.", "count": "0", "additional_payer_notes": "Zero final payments for the item or service in the 15 months prior to posting the file." }, { "payer_name": "UNITED HEALTHCARE", "plan_name": "SUTTER SELECT & SUTTER HEALTH PLAN HMO PLANS", "methodology": "per diem", "standard_charge_dollar": 28538.0, "standard_charge_algorithm": "Per diem ($28,538).", "count": "0", "additional_payer_notes": "Zero final payments for the item or service in the 15 months prior to posting the file." }, { "payer_name": "UNITED HEALTHCARE", "plan_name": "SUTTER SELECT & SUTTER HEALTH PLAN HMO PLANS", "methodology": "per diem", "standard_charge_dollar": 28538.0, "standard_charge_algorithm": "Per diem ($28,538).", "count": "0", "additional_payer_notes": "Zero final payments for the item or service in the 15 months prior to posting the file." }, { "payer_name": "SUTTER", "plan_name": "SUTTER SELECT & SUTTER HEALTH PLAN HMO PLANS", "methodology": "per diem", "standard_charge_dollar": 28538.0, "standard_charge_algorithm": "Per diem ($28,538).", "count": "0", "additional_payer_notes": "Zero final payments for the item or service in the 15 months prior to posting the file." }, { "payer_name": "UNITED HEALTHCARE", "plan_name": "SUTTER SELECT & SUTTER HEALTH PLAN HMO PLANS", "methodology": "per diem", "standard_charge_dollar": 28538.0, "standard_charge_algorithm": "Per diem ($28,538).", "count": "0", "additional_payer_notes": "Zero final payments for the item or service in the 15 months prior to posting the file." }, { "payer_name": "UMR", "plan_name": "SUTTER SELECT & SUTTER HEALTH PLAN HMO PLANS", "methodology": "per diem", "standard_charge_dollar": 28538.0, "standard_charge_algorithm": "Per diem ($28,538).", "count": "0", "additional_payer_notes": "Zero final payments for the item or service in the 15 months prior to posting the file." }, { "payer_name": "UNITED HEALTHCARE", "plan_name": "SUTTER SELECT & SUTTER HEALTH PLAN HMO PLANS", "methodology": "per diem", "standard_charge_dollar": 28538.0, "standard_charge_algorithm": "Per diem ($28,538).", "count": "0", "additional_payer_notes": "Zero final payments for the item or service in the 15 months prior to posting the file." } ] } ] }, { "description": "HC IP Convent Hemodialysis >2 Yrs", "code_information": [ { "code": "PX-1300000002", "type": "CDM" }, { "code": "90935", "type": "CPT" }, { "code": "0801", "type": "RC" } ], "standard_charges": [ { "setting": "outpatient", "gross_charge": 5707.0, "discounted_cash": 2853.5, "minimum": 2408.35, "maximum": 2967.64, "additional_generic_notes": "Zero final payments for the item or service in the 15 months prior to posting the file.", "payers_information": [ { "payer_name": "AETNA", "plan_name": "AETNA ALL OTHER PLANS", "methodology": "percent of total billed charges", "standard_charge_dollar": 2967.64, "standard_charge_percentage": 52.0, "median_amount": 2835.04, "10th_percentile": 2835.04, "90th_percentile": 2835.04, "count": "13" }, { "payer_name": "AETNA", "plan_name": "AETNA ALL OTHER PLANS", "methodology": "percent of total billed charges", "standard_charge_dollar": 2967.64, "standard_charge_percentage": 52.0, "count": "0", "additional_payer_notes": "Zero final payments for the item or service in the 15 months prior to posting the file." }, { "payer_name": "MERITAIN HEALTH", "plan_name": "AETNA ALL OTHER PLANS", "methodology": "percent of total billed charges", "standard_charge_dollar": 2967.64, "standard_charge_percentage": 52.0, "count": "0", "additional_payer_notes": "Zero final payments for the item or service in the 15 months prior to posting the file." }, { "payer_name": "BLUE SHIELD OUT OF STATE", "plan_name": "STANFORD HEALTHCARE ALLIANCE PLAN", "methodology": "percent of total billed charges", "standard_charge_dollar": 2773.03, "standard_charge_percentage": 48.59, "count": "0", "additional_payer_notes": "Zero final payments for the item or service in the 15 months prior to posting the file." }, { "payer_name": "BLUE SHIELD", "plan_name": "STANFORD HEALTHCARE ALLIANCE PLAN", "methodology": "percent of total billed charges", "standard_charge_dollar": 2773.03, "standard_charge_percentage": 48.59, "median_amount": 2736.48, "10th_percentile": 2736.48, "90th_percentile": 2736.48, "count": "99" }, { "payer_name": "BLUE SHIELD", "plan_name": "STANFORD HEALTHCARE ALLIANCE PLAN", "methodology": "percent of total billed charges", "standard_charge_dollar": 2773.03, "standard_charge_percentage": 48.59, "count": "0", "additional_payer_notes": "Zero final payments for the item or service in the 15 months prior to posting the file." }, { "payer_name": "BLUE SHIELD", "plan_name": "STANFORD HEALTHCARE ALLIANCE PLAN", "methodology": "percent of total billed charges", "standard_charge_dollar": 2773.03, "standard_charge_percentage": 48.59, "count": "0", "additional_payer_notes": "Zero final payments for the item or service in the 15 months prior to posting the file." }, { "payer_name": "CIGNA", "plan_name": "CIGNA COM ALT HMO PLAN", "methodology": "percent of total billed charges", "standard_charge_dollar": 2408.35, "standard_charge_percentage": 42.2, "count": "0", "additional_payer_notes": "Zero final payments for the item or service in the 15 months prior to posting the file." }, { "payer_name": "CIGNA", "plan_name": "CIGNA COM ALT HMO PLAN", "methodology": "percent of total billed charges", "standard_charge_dollar": 2408.35, "standard_charge_percentage": 42.2, "count": "0", "additional_payer_notes": "Zero final payments for the item or service in the 15 months prior to posting the file." }, { "payer_name": "HEALTH NET", "plan_name": "HEALTHNET HMO, PPO, POS, EPO, CANOPY HEALTHNET HMO, OTHER-IN-NETWORK PLANS", "methodology": "per diem", "standard_charge_dollar": 8000.0, "standard_charge_algorithm": "Expected reimbursement is the lesser of Per diem ($8,000) for the length of stay and 70% of billed.", "count": "0", "additional_payer_notes": "Zero final payments for the item or service in the 15 months prior to posting the file." }, { "payer_name": "HEALTH NET", "plan_name": "HEALTHNET HMO, PPO, POS, EPO, CANOPY HEALTHNET HMO, OTHER-IN-NETWORK PLANS", "methodology": "per diem", "standard_charge_dollar": 8000.0, "standard_charge_algorithm": "Expected reimbursement is the lesser of Per diem ($8,000) for the length of stay and 70% of billed.", "count": "0", "additional_payer_notes": "Zero final payments for the item or service in the 15 months prior to posting the file." }, { "payer_name": "UNITED HEALTHCARE", "plan_name": "SUTTER SELECT & SUTTER HEALTH PLAN HMO PLANS", "methodology": "per diem", "standard_charge_dollar": 28538.0, "standard_charge_algorithm": "Per diem ($28,538).", "count": "0", "additional_payer_notes": "Zero final payments for the item or service in the 15 months prior to posting the file." }, { "payer_name": "UNITED HEALTHCARE", "plan_name": "SUTTER SELECT & SUTTER HEALTH PLAN HMO PLANS", "methodology": "per diem", "standard_charge_dollar": 28538.0, "standard_charge_algorithm": "Per diem ($28,538).", "count": "0", "additional_payer_notes": "Zero final payments for the item or service in the 15 months prior to posting the file." }, { "payer_name": "SUTTER", "plan_name": "SUTTER SELECT & SUTTER HEALTH PLAN HMO PLANS", "methodology": "per diem", "standard_charge_dollar": 28538.0, "standard_charge_algorithm": "Per diem ($28,538).", "count": "0", "additional_payer_notes": "Zero final payments for the item or service in the 15 months prior to posting the file." }, { "payer_name": "UNITED HEALTHCARE", "plan_name": "SUTTER SELECT & SUTTER HEALTH PLAN HMO PLANS", "methodology": "per diem", "standard_charge_dollar": 28538.0, "standard_charge_algorithm": "Per diem ($28,538).", "count": "0", "additional_payer_notes": "Zero final payments for the item or service in the 15 months prior to posting the file." }, { "payer_name": "UMR", "plan_name": "SUTTER SELECT & SUTTER HEALTH PLAN HMO PLANS", "methodology": "per diem", "standard_charge_dollar": 28538.0, "standard_charge_algorithm": "Per diem ($28,538).", "count": "0", "additional_payer_notes": "Zero final payments for the item or service in the 15 months prior to posting the file." }, { "payer_name": "UNITED HEALTHCARE", "plan_name": "SUTTER SELECT & SUTTER HEALTH PLAN HMO PLANS", "methodology": "per diem", "standard_charge_dollar": 28538.0, "standard_charge_algorithm": "Per diem ($28,538).", "count": "0", "additional_payer_notes": "Zero final payments for the item or service in the 15 months prior to posting the file." } ] } ] }, { "description": "HC IP High Flux Hemodialysis>2yrs", "code_information": [ { "code": "PX-1300000003", "type": "CDM" }, { "code": "90935", "type": "CPT" }, { "code": "0801", "type": "RC" } ], "standard_charges": [ { "setting": "outpatient", "gross_charge": 5707.0, "discounted_cash": 2853.5, "minimum": 2408.35, "maximum": 2967.64, "additional_generic_notes": "Zero final payments for the item or service in the 15 months prior to posting the file.", "payers_information": [ { "payer_name": "AETNA", "plan_name": "AETNA ALL OTHER PLANS", "methodology": "percent of total billed charges", "standard_charge_dollar": 2967.64, "standard_charge_percentage": 52.0, "median_amount": 2835.04, "10th_percentile": 2835.04, "90th_percentile": 2835.04, "count": "13" }, { "payer_name": "AETNA", "plan_name": "AETNA ALL OTHER PLANS", "methodology": "percent of total billed charges", "standard_charge_dollar": 2967.64, "standard_charge_percentage": 52.0, "count": "0", "additional_payer_notes": "Zero final payments for the item or service in the 15 months prior to posting the file." }, { "payer_name": "MERITAIN HEALTH", "plan_name": "AETNA ALL OTHER PLANS", "methodology": "percent of total billed charges", "standard_charge_dollar": 2967.64, "standard_charge_percentage": 52.0, "count": "0", "additional_payer_notes": "Zero final payments for the item or service in the 15 months prior to posting the file." }, { "payer_name": "BLUE SHIELD OUT OF STATE", "plan_name": "STANFORD HEALTHCARE ALLIANCE PLAN", "methodology": "percent of total billed charges", "standard_charge_dollar": 2773.03, "standard_charge_percentage": 48.59, "count": "0", "additional_payer_notes": "Zero final payments for the item or service in the 15 months prior to posting the file." }, { "payer_name": "BLUE SHIELD", "plan_name": "STANFORD HEALTHCARE ALLIANCE PLAN", "methodology": "percent of total billed charges", "standard_charge_dollar": 2773.03, "standard_charge_percentage": 48.59, "median_amount": 2736.48, "10th_percentile": 2736.48, "90th_percentile": 2736.48, "count": "99" }, { "payer_name": "BLUE SHIELD", "plan_name": "STANFORD HEALTHCARE ALLIANCE PLAN", "methodology": "percent of total billed charges", "standard_charge_dollar": 2773.03, "standard_charge_percentage": 48.59, "count": "0", "additional_payer_notes": "Zero final payments for the item or service in the 15 months prior to posting the file." }, { "payer_name": "BLUE SHIELD", "plan_name": "STANFORD HEALTHCARE ALLIANCE PLAN", "methodology": "percent of total billed charges", "standard_charge_dollar": 2773.03, "standard_charge_percentage": 48.59, "count": "0", "additional_payer_notes": "Zero final payments for the item or service in the 15 months prior to posting the file." }, { "payer_name": "CIGNA", "plan_name": "CIGNA COM ALT HMO PLAN", "methodology": "percent of total billed charges", "standard_charge_dollar": 2408.35, "standard_charge_percentage": 42.2, "count": "0", "additional_payer_notes": "Zero final payments for the item or service in the 15 months prior to posting the file." }, { "payer_name": "CIGNA", "plan_name": "CIGNA COM ALT HMO PLAN", "methodology": "percent of total billed charges", "standard_charge_dollar": 2408.35, "standard_charge_percentage": 42.2, "count": "0", "additional_payer_notes": "Zero final payments for the item or service in the 15 months prior to posting the file." }, { "payer_name": "HEALTH NET", "plan_name": "HEALTHNET HMO, PPO, POS, EPO, CANOPY HEALTHNET HMO, OTHER-IN-NETWORK PLANS", "methodology": "per diem", "standard_charge_dollar": 8000.0, "standard_charge_algorithm": "Expected reimbursement is the lesser of Per diem ($8,000) for the length of stay and 70% of billed.", "count": "0", "additional_payer_notes": "Zero final payments for the item or service in the 15 months prior to posting the file." }, { "payer_name": "HEALTH NET", "plan_name": "HEALTHNET HMO, PPO, POS, EPO, CANOPY HEALTHNET HMO, OTHER-IN-NETWORK PLANS", "methodology": "per diem", "standard_charge_dollar": 8000.0, "standard_charge_algorithm": "Expected reimbursement is the lesser of Per diem ($8,000) for the length of stay and 70% of billed.", "count": "0", "additional_payer_notes": "Zero final payments for the item or service in the 15 months prior to posting the file." }, { "payer_name": "UNITED HEALTHCARE", "plan_name": "SUTTER SELECT & SUTTER HEALTH PLAN HMO PLANS", "methodology": "per diem", "standard_charge_dollar": 28538.0, "standard_charge_algorithm": "Per diem ($28,538).", "count": "0", "additional_payer_notes": "Zero final payments for the item or service in the 15 months prior to posting the file." }, { "payer_name": "UNITED HEALTHCARE", "plan_name": "SUTTER SELECT & SUTTER HEALTH PLAN HMO PLANS", "methodology": "per diem", "standard_charge_dollar": 28538.0, "standard_charge_algorithm": "Per diem ($28,538).", "count": "0", "additional_payer_notes": "Zero final payments for the item or service in the 15 months prior to posting the file." }, { "payer_name": "SUTTER", "plan_name": "SUTTER SELECT & SUTTER HEALTH PLAN HMO PLANS", "methodology": "per diem", "standard_charge_dollar": 28538.0, "standard_charge_algorithm": "Per diem ($28,538).", "count": "0", "additional_payer_notes": "Zero final payments for the item or service in the 15 months prior to posting the file." }, { "payer_name": "UNITED HEALTHCARE", "plan_name": "SUTTER SELECT & SUTTER HEALTH PLAN HMO PLANS", "methodology": "per diem", "standard_charge_dollar": 28538.0, "standard_charge_algorithm": "Per diem ($28,538).", "count": "0", "additional_payer_notes": "Zero final payments for the item or service in the 15 months prior to posting the file." }, { "payer_name": "UMR", "plan_name": "SUTTER SELECT & SUTTER HEALTH PLAN HMO PLANS", "methodology": "per diem", "standard_charge_dollar": 28538.0, "standard_charge_algorithm": "Per diem ($28,538).", "count": "0", "additional_payer_notes": "Zero final payments for the item or service in the 15 months prior to posting the file." }, { "payer_name": "UNITED HEALTHCARE", "plan_name": "SUTTER SELECT & SUTTER HEALTH PLAN HMO PLANS", "methodology": "per diem", "standard_charge_dollar": 28538.0, "standard_charge_algorithm": "Per diem ($28,538).", "count": "0", "additional_payer_notes": "Zero final payments for the item or service in the 15 months prior to posting the file." } ] } ] }, { "description": "HC OP Convent Hemodialysis <2 Yrs", "code_information": [ { "code": "PX-1300000004", "type": "CDM" }, { "code": "90935", "type": "CPT" }, { "code": "0821", "type": "RC" } ], "standard_charges": [ { "setting": "outpatient", "gross_charge": 5707.0, "discounted_cash": 2853.5, "minimum": 2408.35, "maximum": 2967.64, "additional_generic_notes": "Zero final payments for the item or service in the 15 months prior to posting the file.", "payers_information": [ { "payer_name": "AETNA", "plan_name": "AETNA ALL OTHER PLANS", "methodology": "percent of total billed charges", "standard_charge_dollar": 2967.64, "standard_charge_percentage": 52.0, "median_amount": 2835.04, "10th_percentile": 2835.04, "90th_percentile": 2835.04, "count": "13" }, { "payer_name": "AETNA", "plan_name": "AETNA ALL OTHER PLANS", "methodology": "percent of total billed charges", "standard_charge_dollar": 2967.64, "standard_charge_percentage": 52.0, "count": "0", "additional_payer_notes": "Zero final payments for the item or service in the 15 months prior to posting the file." }, { "payer_name": "MERITAIN HEALTH", "plan_name": "AETNA ALL OTHER PLANS", "methodology": "percent of total billed charges", "standard_charge_dollar": 2967.64, "standard_charge_percentage": 52.0, "count": "0", "additional_payer_notes": "Zero final payments for the item or service in the 15 months prior to posting the file." }, { "payer_name": "BLUE SHIELD OUT OF STATE", "plan_name": "STANFORD HEALTHCARE ALLIANCE PLAN", "methodology": "percent of total billed charges", "standard_charge_dollar": 2773.03, "standard_charge_percentage": 48.59, "count": "0", "additional_payer_notes": "Zero final payments for the item or service in the 15 months prior to posting the file." }, { "payer_name": "BLUE SHIELD", "plan_name": "STANFORD HEALTHCARE ALLIANCE PLAN", "methodology": "percent of total billed charges", "standard_charge_dollar": 2773.03, "standard_charge_percentage": 48.59, "median_amount": 2736.48, "10th_percentile": 2736.48, "90th_percentile": 2736.48, "count": "99" }, { "payer_name": "BLUE SHIELD", "plan_name": "STANFORD HEALTHCARE ALLIANCE PLAN", "methodology": "percent of total billed charges", "standard_charge_dollar": 2773.03, "standard_charge_percentage": 48.59, "count": "0", "additional_payer_notes": "Zero final payments for the item or service in the 15 months prior to posting the file." }, { "payer_name": "BLUE SHIELD", "plan_name": "STANFORD HEALTHCARE ALLIANCE PLAN", "methodology": "percent of total billed charges", "standard_charge_dollar": 2773.03, "standard_charge_percentage": 48.59, "count": "0", "additional_payer_notes": "Zero final payments for the item or service in the 15 months prior to posting the file." }, { "payer_name": "CIGNA", "plan_name": "CIGNA COM ALT HMO PLAN", "methodology": "percent of total billed charges", "standard_charge_dollar": 2408.35, "standard_charge_percentage": 42.2, "count": "0", "additional_payer_notes": "Zero final payments for the item or service in the 15 months prior to posting the file." }, { "payer_name": "CIGNA", "plan_name": "CIGNA COM ALT HMO PLAN", "methodology": "percent of total billed charges", "standard_charge_dollar": 2408.35, "standard_charge_percentage": 42.2, "count": "0", "additional_payer_notes": "Zero final payments for the item or service in the 15 months prior to posting the file." }, { "payer_name": "HEALTH NET", "plan_name": "HEALTHNET HMO, PPO, POS, EPO, CANOPY HEALTHNET HMO, OTHER-IN-NETWORK PLANS", "methodology": "per diem", "standard_charge_dollar": 8000.0, "standard_charge_algorithm": "Expected reimbursement is the lesser of Per diem ($8,000) for the length of stay and 70% of billed.", "count": "0", "additional_payer_notes": "Zero final payments for the item or service in the 15 months prior to posting the file." }, { "payer_name": "HEALTH NET", "plan_name": "HEALTHNET HMO, PPO, POS, EPO, CANOPY HEALTHNET HMO, OTHER-IN-NETWORK PLANS", "methodology": "per diem", "standard_charge_dollar": 8000.0, "standard_charge_algorithm": "Expected reimbursement is the lesser of Per diem ($8,000) for the length of stay and 70% of billed.", "count": "0", "additional_payer_notes": "Zero final payments for the item or service in the 15 months prior to posting the file." }, { "payer_name": "UNITED HEALTHCARE", "plan_name": "SUTTER SELECT & SUTTER HEALTH PLAN HMO PLANS", "methodology": "per diem", "standard_charge_dollar": 28538.0, "standard_charge_algorithm": "Per diem ($28,538).", "count": "0", "additional_payer_notes": "Zero final payments for the item or service in the 15 months prior to posting the file." }, { "payer_name": "UNITED HEALTHCARE", "plan_name": "SUTTER SELECT & SUTTER HEALTH PLAN HMO PLANS", "methodology": "per diem", "standard_charge_dollar": 28538.0, "standard_charge_algorithm": "Per diem ($28,538).", "count": "0", "additional_payer_notes": "Zero final payments for the item or service in the 15 months prior to posting the file." }, { "payer_name": "SUTTER", "plan_name": "SUTTER SELECT & SUTTER HEALTH PLAN HMO PLANS", "methodology": "per diem", "standard_charge_dollar": 28538.0, "standard_charge_algorithm": "Per diem ($28,538).", "count": "0", "additional_payer_notes": "Zero final payments for the item or service in the 15 months prior to posting the file." }, { "payer_name": "UNITED HEALTHCARE", "plan_name": "SUTTER SELECT & SUTTER HEALTH PLAN HMO PLANS", "methodology": "per diem", "standard_charge_dollar": 28538.0, "standard_charge_algorithm": "Per diem ($28,538).", "count": "0", "additional_payer_notes": "Zero final payments for the item or service in the 15 months prior to posting the file." }, { "payer_name": "UMR", "plan_name": "SUTTER SELECT & SUTTER HEALTH PLAN HMO PLANS", "methodology": "per diem", "standard_charge_dollar": 28538.0, "standard_charge_algorithm": "Per diem ($28,538).", "count": "0", "additional_payer_notes": "Zero final payments for the item or service in the 15 months prior to posting the file." }, { "payer_name": "UNITED HEALTHCARE", "plan_name": "SUTTER SELECT & SUTTER HEALTH PLAN HMO PLANS", "methodology": "per diem", "standard_charge_dollar": 28538.0, "standard_charge_algorithm": "Per diem ($28,538).", "count": "0", "additional_payer_notes": "Zero final payments for the item or service in the 15 months prior to posting the file." } ] } ] }, { "description": "HC OP Convent Hemodialysis >2 Yrs", "code_information": [ { "code": "PX-1300000005", "type": "CDM" }, { "code": "90935", "type": "CPT" }, { "code": "0821", "type": "RC" } ], "standard_charges": [ { "setting": "outpatient", "gross_charge": 5707.0, "discounted_cash": 2853.5, "minimum": 2408.35, "maximum": 2967.64, "additional_generic_notes": "Zero final payments for the item or service in the 15 months prior to posting the file.", "payers_information": [ { "payer_name": "AETNA", "plan_name": "AETNA ALL OTHER PLANS", "methodology": "percent of total billed charges", "standard_charge_dollar": 2967.64, "standard_charge_percentage": 52.0, "median_amount": 2835.04, "10th_percentile": 2835.04, "90th_percentile": 2835.04, "count": "13" }, { "payer_name": "AETNA", "plan_name": "AETNA ALL OTHER PLANS", "methodology": "percent of total billed charges", "standard_charge_dollar": 2967.64, "standard_charge_percentage": 52.0, "count": "0", "additional_payer_notes": "Zero final payments for the item or service in the 15 months prior to posting the file." }, { "payer_name": "MERITAIN HEALTH", "plan_name": "AETNA ALL OTHER PLANS", "methodology": "percent of total billed charges", "standard_charge_dollar": 2967.64, "standard_charge_percentage": 52.0, "count": "0", "additional_payer_notes": "Zero final payments for the item or service in the 15 months prior to posting the file." }, { "payer_name": "BLUE SHIELD OUT OF STATE", "plan_name": "STANFORD HEALTHCARE ALLIANCE PLAN", "methodology": "percent of total billed charges", "standard_charge_dollar": 2773.03, "standard_charge_percentage": 48.59, "count": "0", "additional_payer_notes": "Zero final payments for the item or service in the 15 months prior to posting the file." }, { "payer_name": "BLUE SHIELD", "plan_name": "STANFORD HEALTHCARE ALLIANCE PLAN", "methodology": "percent of total billed charges", "standard_charge_dollar": 2773.03, "standard_charge_percentage": 48.59, "median_amount": 2736.48, "10th_percentile": 2736.48, "90th_percentile": 2736.48, "count": "99" }, { "payer_name": "BLUE SHIELD", "plan_name": "STANFORD HEALTHCARE ALLIANCE PLAN", "methodology": "percent of total billed charges", "standard_charge_dollar": 2773.03, "standard_charge_percentage": 48.59, "count": "0", "additional_payer_notes": "Zero final payments for the item or service in the 15 months prior to posting the file." }, { "payer_name": "BLUE SHIELD", "plan_name": "STANFORD HEALTHCARE ALLIANCE PLAN", "methodology": "percent of total billed charges", "standard_charge_dollar": 2773.03, "standard_charge_percentage": 48.59, "count": "0", "additional_payer_notes": "Zero final payments for the item or service in the 15 months prior to posting the file." }, { "payer_name": "CIGNA", "plan_name": "CIGNA COM ALT HMO PLAN", "methodology": "percent of total billed charges", "standard_charge_dollar": 2408.35, "standard_charge_percentage": 42.2, "count": "0", "additional_payer_notes": "Zero final payments for the item or service in the 15 months prior to posting the file." }, { "payer_name": "CIGNA", "plan_name": "CIGNA COM ALT HMO PLAN", "methodology": "percent of total billed charges", "standard_charge_dollar": 2408.35, "standard_charge_percentage": 42.2, "count": "0", "additional_payer_notes": "Zero final payments for the item or service in the 15 months prior to posting the file." }, { "payer_name": "HEALTH NET", "plan_name": "HEALTHNET HMO, PPO, POS, EPO, CANOPY HEALTHNET HMO, OTHER-IN-NETWORK PLANS", "methodology": "per diem", "standard_charge_dollar": 8000.0, "standard_charge_algorithm": "Expected reimbursement is the lesser of Per diem ($8,000) for the length of stay and 70% of billed.", "count": "0", "additional_payer_notes": "Zero final payments for the item or service in the 15 months prior to posting the file." }, { "payer_name": "HEALTH NET", "plan_name": "HEALTHNET HMO, PPO, POS, EPO, CANOPY HEALTHNET HMO, OTHER-IN-NETWORK PLANS", "methodology": "per diem", "standard_charge_dollar": 8000.0, "standard_charge_algorithm": "Expected reimbursement is the lesser of Per diem ($8,000) for the length of stay and 70% of billed.", "count": "0", "additional_payer_notes": "Zero final payments for the item or service in the 15 months prior to posting the file." }, { "payer_name": "UNITED HEALTHCARE", "plan_name": "SUTTER SELECT & SUTTER HEALTH PLAN HMO PLANS", "methodology": "per diem", "standard_charge_dollar": 28538.0, "standard_charge_algorithm": "Per diem ($28,538).", "count": "0", "additional_payer_notes": "Zero final payments for the item or service in the 15 months prior to posting the file." }, { "payer_name": "UNITED HEALTHCARE", "plan_name": "SUTTER SELECT & SUTTER HEALTH PLAN HMO PLANS", "methodology": "per diem", "standard_charge_dollar": 28538.0, "standard_charge_algorithm": "Per diem ($28,538).", "count": "0", "additional_payer_notes": "Zero final payments for the item or service in the 15 months prior to posting the file." }, { "payer_name": "SUTTER", "plan_name": "SUTTER SELECT & SUTTER HEALTH PLAN HMO PLANS", "methodology": "per diem", "standard_charge_dollar": 28538.0, "standard_charge_algorithm": "Per diem ($28,538).", "count": "0", "additional_payer_notes": "Zero final payments for the item or service in the 15 months prior to posting the file." }, { "payer_name": "UNITED HEALTHCARE", "plan_name": "SUTTER SELECT & SUTTER HEALTH PLAN HMO PLANS", "methodology": "per diem", "standard_charge_dollar": 28538.0, "standard_charge_algorithm": "Per diem ($28,538).", "count": "0", "additional_payer_notes": "Zero final payments for the item or service in the 15 months prior to posting the file." }, { "payer_name": "UMR", "plan_name": "SUTTER SELECT & SUTTER HEALTH PLAN HMO PLANS", "methodology": "per diem", "standard_charge_dollar": 28538.0, "standard_charge_algorithm": "Per diem ($28,538).", "count": "0", "additional_payer_notes": "Zero final payments for the item or service in the 15 months prior to posting the file." }, { "payer_name": "UNITED HEALTHCARE", "plan_name": "SUTTER SELECT & SUTTER HEALTH PLAN HMO PLANS", "methodology": "per diem", "standard_charge_dollar": 28538.0, "standard_charge_algorithm": "Per diem ($28,538).", "count": "0", "additional_payer_notes": "Zero final payments for the item or service in the 15 months prior to posting the file." } ] } ] }, { "description": "HC OP High Flux Hemodialysis>2yrs", "code_information": [ { "code": "PX-1300000006", "type": "CDM" }, { "code": "90935", "type": "CPT" }, { "code": "0821", "type": "RC" } ], "standard_charges": [ { "setting": "outpatient", "gross_charge": 5707.0, "discounted_cash": 2853.5, "minimum": 2408.35, "maximum": 2967.64, "additional_generic_notes": "Zero final payments for the item or service in the 15 months prior to posting the file.", "payers_information": [ { "payer_name": "AETNA", "plan_name": "AETNA ALL OTHER PLANS", "methodology": "percent of total billed charges", "standard_charge_dollar": 2967.64, "standard_charge_percentage": 52.0, "median_amount": 2835.04, "10th_percentile": 2835.04, "90th_percentile": 2835.04, "count": "13" }, { "payer_name": "AETNA", "plan_name": "AETNA ALL OTHER PLANS", "methodology": "percent of total billed charges", "standard_charge_dollar": 2967.64, "standard_charge_percentage": 52.0, "count": "0", "additional_payer_notes": "Zero final payments for the item or service in the 15 months prior to posting the file." }, { "payer_name": "MERITAIN HEALTH", "plan_name": "AETNA ALL OTHER PLANS", "methodology": "percent of total billed charges", "standard_charge_dollar": 2967.64, "standard_charge_percentage": 52.0, "count": "0", "additional_payer_notes": "Zero final payments for the item or service in the 15 months prior to posting the file." }, { "payer_name": "BLUE SHIELD OUT OF STATE", "plan_name": "STANFORD HEALTHCARE ALLIANCE PLAN", "methodology": "percent of total billed charges", "standard_charge_dollar": 2773.03, "standard_charge_percentage": 48.59, "count": "0", "additional_payer_notes": "Zero final payments for the item or service in the 15 months prior to posting the file." }, { "payer_name": "BLUE SHIELD", "plan_name": "STANFORD HEALTHCARE ALLIANCE PLAN", "methodology": "percent of total billed charges", "standard_charge_dollar": 2773.03, "standard_charge_percentage": 48.59, "median_amount": 2736.48, "10th_percentile": 2736.48, "90th_percentile": 2736.48, "count": "99" }, { "payer_name": "BLUE SHIELD", "plan_name": "STANFORD HEALTHCARE ALLIANCE PLAN", "methodology": "percent of total billed charges", "standard_charge_dollar": 2773.03, "standard_charge_percentage": 48.59, "count": "0", "additional_payer_notes": "Zero final payments for the item or service in the 15 months prior to posting the file." }, { "payer_name": "BLUE SHIELD", "plan_name": "STANFORD HEALTHCARE ALLIANCE PLAN", "methodology": "percent of total billed charges", "standard_charge_dollar": 2773.03, "standard_charge_percentage": 48.59, "count": "0", "additional_payer_notes": "Zero final payments for the item or service in the 15 months prior to posting the file." }, { "payer_name": "CIGNA", "plan_name": "CIGNA COM ALT HMO PLAN", "methodology": "percent of total billed charges", "standard_charge_dollar": 2408.35, "standard_charge_percentage": 42.2, "count": "0", "additional_payer_notes": "Zero final payments for the item or service in the 15 months prior to posting the file." }, { "payer_name": "CIGNA", "plan_name": "CIGNA COM ALT HMO PLAN", "methodology": "percent of total billed charges", "standard_charge_dollar": 2408.35, "standard_charge_percentage": 42.2, "count": "0", "additional_payer_notes": "Zero final payments for the item or service in the 15 months prior to posting the file." }, { "payer_name": "HEALTH NET", "plan_name": "HEALTHNET HMO, PPO, POS, EPO, CANOPY HEALTHNET HMO, OTHER-IN-NETWORK PLANS", "methodology": "per diem", "standard_charge_dollar": 8000.0, "standard_charge_algorithm": "Expected reimbursement is the lesser of Per diem ($8,000) for the length of stay and 70% of billed.", "count": "0", "additional_payer_notes": "Zero final payments for the item or service in the 15 months prior to posting the file." }, { "payer_name": "HEALTH NET", "plan_name": "HEALTHNET HMO, PPO, POS, EPO, CANOPY HEALTHNET HMO, OTHER-IN-NETWORK PLANS", "methodology": "per diem", "standard_charge_dollar": 8000.0, "standard_charge_algorithm": "Expected reimbursement is the lesser of Per diem ($8,000) for the length of stay and 70% of billed.", "count": "0", "additional_payer_notes": "Zero final payments for the item or service in the 15 months prior to posting the file." }, { "payer_name": "UNITED HEALTHCARE", "plan_name": "SUTTER SELECT & SUTTER HEALTH PLAN HMO PLANS", "methodology": "per diem", "standard_charge_dollar": 28538.0, "standard_charge_algorithm": "Per diem ($28,538).", "count": "0", "additional_payer_notes": "Zero final payments for the item or service in the 15 months prior to posting the file." }, { "payer_name": "UNITED HEALTHCARE", "plan_name": "SUTTER SELECT & SUTTER HEALTH PLAN HMO PLANS", "methodology": "per diem", "standard_charge_dollar": 28538.0, "standard_charge_algorithm": "Per diem ($28,538).", "count": "0", "additional_payer_notes": "Zero final payments for the item or service in the 15 months prior to posting the file." }, { "payer_name": "SUTTER", "plan_name": "SUTTER SELECT & SUTTER HEALTH PLAN HMO PLANS", "methodology": "per diem", "standard_charge_dollar": 28538.0, "standard_charge_algorithm": "Per diem ($28,538).", "count": "0", "additional_payer_notes": "Zero final payments for the item or service in the 15 months prior to posting the file." }, { "payer_name": "UNITED HEALTHCARE", "plan_name": "SUTTER SELECT & SUTTER HEALTH PLAN HMO PLANS", "methodology": "per diem", "standard_charge_dollar": 28538.0, "standard_charge_algorithm": "Per diem ($28,538).", "count": "0", "additional_payer_notes": "Zero final payments for the item or service in the 15 months prior to posting the file." }, { "payer_name": "UMR", "plan_name": "SUTTER SELECT & SUTTER HEALTH PLAN HMO PLANS", "methodology": "per diem", "standard_charge_dollar": 28538.0, "standard_charge_algorithm": "Per diem ($28,538).", "count": "0", "additional_payer_notes": "Zero final payments for the item or service in the 15 months prior to posting the file." }, { "payer_name": "UNITED HEALTHCARE", "plan_name": "SUTTER SELECT & SUTTER HEALTH PLAN HMO PLANS", "methodology": "per diem", "standard_charge_dollar": 28538.0, "standard_charge_algorithm": "Per diem ($28,538).", "count": "0", "additional_payer_notes": "Zero final payments for the item or service in the 15 months prior to posting the file." } ] } ] }, { "description": "HC Hemodialysis Access Flow Study", "code_information": [ { "code": "PX-1300000007", "type": "CDM" }, { "code": "90940", "type": "CPT" }, { "code": "0820", "type": "RC" } ], "standard_charges": [ { "setting": "outpatient", "gross_charge": 953.0, "discounted_cash": 476.5, "minimum": 402.17, "maximum": 495.56, "additional_generic_notes": "Zero final payments for the item or service in the 15 months prior to posting the file.", "payers_information": [ { "payer_name": "AETNA", "plan_name": "AETNA ALL OTHER PLANS", "methodology": "percent of total billed charges", "standard_charge_dollar": 495.56, "standard_charge_percentage": 52.0, "count": "0", "additional_payer_notes": "Zero final payments for the item or service in the 15 months prior to posting the file." }, { "payer_name": "AETNA", "plan_name": "AETNA ALL OTHER PLANS", "methodology": "percent of total billed charges", "standard_charge_dollar": 495.56, "standard_charge_percentage": 52.0, "count": "0", "additional_payer_notes": "Zero final payments for the item or service in the 15 months prior to posting the file." }, { "payer_name": "MERITAIN HEALTH", "plan_name": "AETNA ALL OTHER PLANS", "methodology": "percent of total billed charges", "standard_charge_dollar": 495.56, "standard_charge_percentage": 52.0, "count": "0", "additional_payer_notes": "Zero final payments for the item or service in the 15 months prior to posting the file." }, { "payer_name": "BLUE SHIELD OUT OF STATE", "plan_name": "STANFORD HEALTHCARE ALLIANCE PLAN", "methodology": "percent of total billed charges", "standard_charge_dollar": 463.06, "standard_charge_percentage": 48.59, "count": "0", "additional_payer_notes": "Zero final payments for the item or service in the 15 months prior to posting the file." }, { "payer_name": "BLUE SHIELD", "plan_name": "STANFORD HEALTHCARE ALLIANCE PLAN", "methodology": "percent of total billed charges", "standard_charge_dollar": 463.06, "standard_charge_percentage": 48.59, "median_amount": 456.75, "10th_percentile": 456.75, "90th_percentile": 456.75, "count": "1 through 10" }, { "payer_name": "BLUE SHIELD", "plan_name": "STANFORD HEALTHCARE ALLIANCE PLAN", "methodology": "percent of total billed charges", "standard_charge_dollar": 463.06, "standard_charge_percentage": 48.59, "count": "0", "additional_payer_notes": "Zero final payments for the item or service in the 15 months prior to posting the file." }, { "payer_name": "BLUE SHIELD", "plan_name": "STANFORD HEALTHCARE ALLIANCE PLAN", "methodology": "percent of total billed charges", "standard_charge_dollar": 463.06, "standard_charge_percentage": 48.59, "count": "0", "additional_payer_notes": "Zero final payments for the item or service in the 15 months prior to posting the file." }, { "payer_name": "CIGNA", "plan_name": "CIGNA COM ALT HMO PLAN", "methodology": "percent of total billed charges", "standard_charge_dollar": 402.17, "standard_charge_percentage": 42.2, "count": "0", "additional_payer_notes": "Zero final payments for the item or service in the 15 months prior to posting the file." }, { "payer_name": "CIGNA", "plan_name": "CIGNA COM ALT HMO PLAN", "methodology": "percent of total billed charges", "standard_charge_dollar": 402.17, "standard_charge_percentage": 42.2, "count": "0", "additional_payer_notes": "Zero final payments for the item or service in the 15 months prior to posting the file." }, { "payer_name": "HEALTH NET", "plan_name": "HEALTHNET HMO, PPO, POS, EPO, CANOPY HEALTHNET HMO, OTHER-IN-NETWORK PLANS", "methodology": "per diem", "standard_charge_dollar": 8000.0, "standard_charge_algorithm": "Expected reimbursement is the lesser of Per diem ($8,000) for the length of stay and 70% of billed.", "count": "0", "additional_payer_notes": "Zero final payments for the item or service in the 15 months prior to posting the file." }, { "payer_name": "HEALTH NET", "plan_name": "HEALTHNET HMO, PPO, POS, EPO, CANOPY HEALTHNET HMO, OTHER-IN-NETWORK PLANS", "methodology": "per diem", "standard_charge_dollar": 8000.0, "standard_charge_algorithm": "Expected reimbursement is the lesser of Per diem ($8,000) for the length of stay and 70% of billed.", "count": "0", "additional_payer_notes": "Zero final payments for the item or service in the 15 months prior to posting the file." }, { "payer_name": "UNITED HEALTHCARE", "plan_name": "SUTTER SELECT & SUTTER HEALTH PLAN HMO PLANS", "methodology": "per diem", "standard_charge_dollar": 28538.0, "standard_charge_algorithm": "Per diem ($28,538).", "count": "0", "additional_payer_notes": "Zero final payments for the item or service in the 15 months prior to posting the file." }, { "payer_name": "UNITED HEALTHCARE", "plan_name": "SUTTER SELECT & SUTTER HEALTH PLAN HMO PLANS", "methodology": "per diem", "standard_charge_dollar": 28538.0, "standard_charge_algorithm": "Per diem ($28,538).", "count": "0", "additional_payer_notes": "Zero final payments for the item or service in the 15 months prior to posting the file." }, { "payer_name": "SUTTER", "plan_name": "SUTTER SELECT & SUTTER HEALTH PLAN HMO PLANS", "methodology": "per diem", "standard_charge_dollar": 28538.0, "standard_charge_algorithm": "Per diem ($28,538).", "count": "0", "additional_payer_notes": "Zero final payments for the item or service in the 15 months prior to posting the file." }, { "payer_name": "UNITED HEALTHCARE", "plan_name": "SUTTER SELECT & SUTTER HEALTH PLAN HMO PLANS", "methodology": "per diem", "standard_charge_dollar": 28538.0, "standard_charge_algorithm": "Per diem ($28,538).", "count": "0", "additional_payer_notes": "Zero final payments for the item or service in the 15 months prior to posting the file." }, { "payer_name": "UMR", "plan_name": "SUTTER SELECT & SUTTER HEALTH PLAN HMO PLANS", "methodology": "per diem", "standard_charge_dollar": 28538.0, "standard_charge_algorithm": "Per diem ($28,538).", "count": "0", "additional_payer_notes": "Zero final payments for the item or service in the 15 months prior to posting the file." }, { "payer_name": "UNITED HEALTHCARE", "plan_name": "SUTTER SELECT & SUTTER HEALTH PLAN HMO PLANS", "methodology": "per diem", "standard_charge_dollar": 28538.0, "standard_charge_algorithm": "Per diem ($28,538).", "count": "0", "additional_payer_notes": "Zero final payments for the item or service in the 15 months prior to posting the file." } ] } ] }, { "description": "HC Crrt Inpt Acute", "code_information": [ { "code": "PX-1300000008", "type": "CDM" }, { "code": "90945", "type": "CPT" }, { "code": "0803", "type": "RC" } ], "standard_charges": [ { "setting": "outpatient", "gross_charge": 8651.0, "discounted_cash": 4325.5, "minimum": 3650.72, "maximum": 4498.52, "additional_generic_notes": "Zero final payments for the item or service in the 15 months prior to posting the file.", "payers_information": [ { "payer_name": "AETNA", "plan_name": "AETNA ALL OTHER PLANS", "methodology": "percent of total billed charges", "standard_charge_dollar": 4498.52, "standard_charge_percentage": 52.0, "count": "0", "additional_payer_notes": "Zero final payments for the item or service in the 15 months prior to posting the file." }, { "payer_name": "AETNA", "plan_name": "AETNA ALL OTHER PLANS", "methodology": "percent of total billed charges", "standard_charge_dollar": 4498.52, "standard_charge_percentage": 52.0, "count": "0", "additional_payer_notes": "Zero final payments for the item or service in the 15 months prior to posting the file." }, { "payer_name": "MERITAIN HEALTH", "plan_name": "AETNA ALL OTHER PLANS", "methodology": "percent of total billed charges", "standard_charge_dollar": 4498.52, "standard_charge_percentage": 52.0, "count": "0", "additional_payer_notes": "Zero final payments for the item or service in the 15 months prior to posting the file." }, { "payer_name": "BLUE SHIELD OUT OF STATE", "plan_name": "STANFORD HEALTHCARE ALLIANCE PLAN", "methodology": "percent of total billed charges", "standard_charge_dollar": 4203.52, "standard_charge_percentage": 48.59, "count": "0", "additional_payer_notes": "Zero final payments for the item or service in the 15 months prior to posting the file." }, { "payer_name": "BLUE SHIELD", "plan_name": "STANFORD HEALTHCARE ALLIANCE PLAN", "methodology": "percent of total billed charges", "standard_charge_dollar": 4203.52, "standard_charge_percentage": 48.59, "count": "0", "additional_payer_notes": "Zero final payments for the item or service in the 15 months prior to posting the file." }, { "payer_name": "BLUE SHIELD", "plan_name": "STANFORD HEALTHCARE ALLIANCE PLAN", "methodology": "percent of total billed charges", "standard_charge_dollar": 4203.52, "standard_charge_percentage": 48.59, "count": "0", "additional_payer_notes": "Zero final payments for the item or service in the 15 months prior to posting the file." }, { "payer_name": "BLUE SHIELD", "plan_name": "STANFORD HEALTHCARE ALLIANCE PLAN", "methodology": "percent of total billed charges", "standard_charge_dollar": 4203.52, "standard_charge_percentage": 48.59, "count": "0", "additional_payer_notes": "Zero final payments for the item or service in the 15 months prior to posting the file." }, { "payer_name": "CIGNA", "plan_name": "CIGNA COM ALT HMO PLAN", "methodology": "percent of total billed charges", "standard_charge_dollar": 3650.72, "standard_charge_percentage": 42.2, "count": "0", "additional_payer_notes": "Zero final payments for the item or service in the 15 months prior to posting the file." }, { "payer_name": "CIGNA", "plan_name": "CIGNA COM ALT HMO PLAN", "methodology": "percent of total billed charges", "standard_charge_dollar": 3650.72, "standard_charge_percentage": 42.2, "count": "0", "additional_payer_notes": "Zero final payments for the item or service in the 15 months prior to posting the file." }, { "payer_name": "HEALTH NET", "plan_name": "HEALTHNET HMO, PPO, POS, EPO, CANOPY HEALTHNET HMO, OTHER-IN-NETWORK PLANS", "methodology": "per diem", "standard_charge_dollar": 8000.0, "standard_charge_algorithm": "Expected reimbursement is the lesser of Per diem ($8,000) for the length of stay and 70% of billed.", "count": "0", "additional_payer_notes": "Zero final payments for the item or service in the 15 months prior to posting the file." }, { "payer_name": "HEALTH NET", "plan_name": "HEALTHNET HMO, PPO, POS, EPO, CANOPY HEALTHNET HMO, OTHER-IN-NETWORK PLANS", "methodology": "per diem", "standard_charge_dollar": 8000.0, "standard_charge_algorithm": "Expected reimbursement is the lesser of Per diem ($8,000) for the length of stay and 70% of billed.", "count": "0", "additional_payer_notes": "Zero final payments for the item or service in the 15 months prior to posting the file." }, { "payer_name": "UNITED HEALTHCARE", "plan_name": "SUTTER SELECT & SUTTER HEALTH PLAN HMO PLANS", "methodology": "per diem", "standard_charge_dollar": 28538.0, "standard_charge_algorithm": "Per diem ($28,538).", "count": "0", "additional_payer_notes": "Zero final payments for the item or service in the 15 months prior to posting the file." }, { "payer_name": "UNITED HEALTHCARE", "plan_name": "SUTTER SELECT & SUTTER HEALTH PLAN HMO PLANS", "methodology": "per diem", "standard_charge_dollar": 28538.0, "standard_charge_algorithm": "Per diem ($28,538).", "count": "0", "additional_payer_notes": "Zero final payments for the item or service in the 15 months prior to posting the file." }, { "payer_name": "SUTTER", "plan_name": "SUTTER SELECT & SUTTER HEALTH PLAN HMO PLANS", "methodology": "per diem", "standard_charge_dollar": 28538.0, "standard_charge_algorithm": "Per diem ($28,538).", "count": "0", "additional_payer_notes": "Zero final payments for the item or service in the 15 months prior to posting the file." }, { "payer_name": "UNITED HEALTHCARE", "plan_name": "SUTTER SELECT & SUTTER HEALTH PLAN HMO PLANS", "methodology": "per diem", "standard_charge_dollar": 28538.0, "standard_charge_algorithm": "Per diem ($28,538).", "count": "0", "additional_payer_notes": "Zero final payments for the item or service in the 15 months prior to posting the file." }, { "payer_name": "UMR", "plan_name": "SUTTER SELECT & SUTTER HEALTH PLAN HMO PLANS", "methodology": "per diem", "standard_charge_dollar": 28538.0, "standard_charge_algorithm": "Per diem ($28,538).", "count": "0", "additional_payer_notes": "Zero final payments for the item or service in the 15 months prior to posting the file." }, { "payer_name": "UNITED HEALTHCARE", "plan_name": "SUTTER SELECT & SUTTER HEALTH PLAN HMO PLANS", "methodology": "per diem", "standard_charge_dollar": 28538.0, "standard_charge_algorithm": "Per diem ($28,538).", "count": "0", "additional_payer_notes": "Zero final payments for the item or service in the 15 months prior to posting the file." } ] } ] }, { "description": "HC Capd Chronic Outpatient", "code_information": [ { "code": "PX-1300000009", "type": "CDM" }, { "code": "90945", "type": "CPT" }, { "code": "0830", "type": "RC" } ], "standard_charges": [ { "setting": "outpatient", "gross_charge": 8433.0, "discounted_cash": 4216.5, "minimum": 3558.73, "maximum": 4385.16, "additional_generic_notes": "Zero final payments for the item or service in the 15 months prior to posting the file.", "payers_information": [ { "payer_name": "AETNA", "plan_name": "AETNA ALL OTHER PLANS", "methodology": "percent of total billed charges", "standard_charge_dollar": 4385.16, "standard_charge_percentage": 52.0, "count": "0", "additional_payer_notes": "Zero final payments for the item or service in the 15 months prior to posting the file." }, { "payer_name": "AETNA", "plan_name": "AETNA ALL OTHER PLANS", "methodology": "percent of total billed charges", "standard_charge_dollar": 4385.16, "standard_charge_percentage": 52.0, "count": "0", "additional_payer_notes": "Zero final payments for the item or service in the 15 months prior to posting the file." }, { "payer_name": "MERITAIN HEALTH", "plan_name": "AETNA ALL OTHER PLANS", "methodology": "percent of total billed charges", "standard_charge_dollar": 4385.16, "standard_charge_percentage": 52.0, "count": "0", "additional_payer_notes": "Zero final payments for the item or service in the 15 months prior to posting the file." }, { "payer_name": "BLUE SHIELD OUT OF STATE", "plan_name": "STANFORD HEALTHCARE ALLIANCE PLAN", "methodology": "percent of total billed charges", "standard_charge_dollar": 4097.59, "standard_charge_percentage": 48.59, "count": "0", "additional_payer_notes": "Zero final payments for the item or service in the 15 months prior to posting the file." }, { "payer_name": "BLUE SHIELD", "plan_name": "STANFORD HEALTHCARE ALLIANCE PLAN", "methodology": "percent of total billed charges", "standard_charge_dollar": 4097.59, "standard_charge_percentage": 48.59, "count": "0", "additional_payer_notes": "Zero final payments for the item or service in the 15 months prior to posting the file." }, { "payer_name": "BLUE SHIELD", "plan_name": "STANFORD HEALTHCARE ALLIANCE PLAN", "methodology": "percent of total billed charges", "standard_charge_dollar": 4097.59, "standard_charge_percentage": 48.59, "count": "0", "additional_payer_notes": "Zero final payments for the item or service in the 15 months prior to posting the file." }, { "payer_name": "BLUE SHIELD", "plan_name": "STANFORD HEALTHCARE ALLIANCE PLAN", "methodology": "percent of total billed charges", "standard_charge_dollar": 4097.59, "standard_charge_percentage": 48.59, "count": "0", "additional_payer_notes": "Zero final payments for the item or service in the 15 months prior to posting the file." }, { "payer_name": "CIGNA", "plan_name": "CIGNA COM ALT HMO PLAN", "methodology": "percent of total billed charges", "standard_charge_dollar": 3558.73, "standard_charge_percentage": 42.2, "count": "0", "additional_payer_notes": "Zero final payments for the item or service in the 15 months prior to posting the file." }, { "payer_name": "CIGNA", "plan_name": "CIGNA COM ALT HMO PLAN", "methodology": "percent of total billed charges", "standard_charge_dollar": 3558.73, "standard_charge_percentage": 42.2, "count": "0", "additional_payer_notes": "Zero final payments for the item or service in the 15 months prior to posting the file." }, { "payer_name": "HEALTH NET", "plan_name": "HEALTHNET HMO, PPO, POS, EPO, CANOPY HEALTHNET HMO, OTHER-IN-NETWORK PLANS", "methodology": "per diem", "standard_charge_dollar": 8000.0, "standard_charge_algorithm": "Expected reimbursement is the lesser of Per diem ($8,000) for the length of stay and 70% of billed.", "count": "0", "additional_payer_notes": "Zero final payments for the item or service in the 15 months prior to posting the file." }, { "payer_name": "HEALTH NET", "plan_name": "HEALTHNET HMO, PPO, POS, EPO, CANOPY HEALTHNET HMO, OTHER-IN-NETWORK PLANS", "methodology": "per diem", "standard_charge_dollar": 8000.0, "standard_charge_algorithm": "Expected reimbursement is the lesser of Per diem ($8,000) for the length of stay and 70% of billed.", "count": "0", "additional_payer_notes": "Zero final payments for the item or service in the 15 months prior to posting the file." }, { "payer_name": "UNITED HEALTHCARE", "plan_name": "SUTTER SELECT & SUTTER HEALTH PLAN HMO PLANS", "methodology": "per diem", "standard_charge_dollar": 28538.0, "standard_charge_algorithm": "Per diem ($28,538).", "count": "0", "additional_payer_notes": "Zero final payments for the item or service in the 15 months prior to posting the file." }, { "payer_name": "UNITED HEALTHCARE", "plan_name": "SUTTER SELECT & SUTTER HEALTH PLAN HMO PLANS", "methodology": "per diem", "standard_charge_dollar": 28538.0, "standard_charge_algorithm": "Per diem ($28,538).", "count": "0", "additional_payer_notes": "Zero final payments for the item or service in the 15 months prior to posting the file." }, { "payer_name": "SUTTER", "plan_name": "SUTTER SELECT & SUTTER HEALTH PLAN HMO PLANS", "methodology": "per diem", "standard_charge_dollar": 28538.0, "standard_charge_algorithm": "Per diem ($28,538).", "count": "0", "additional_payer_notes": "Zero final payments for the item or service in the 15 months prior to posting the file." }, { "payer_name": "UNITED HEALTHCARE", "plan_name": "SUTTER SELECT & SUTTER HEALTH PLAN HMO PLANS", "methodology": "per diem", "standard_charge_dollar": 28538.0, "standard_charge_algorithm": "Per diem ($28,538).", "count": "0", "additional_payer_notes": "Zero final payments for the item or service in the 15 months prior to posting the file." }, { "payer_name": "UMR", "plan_name": "SUTTER SELECT & SUTTER HEALTH PLAN HMO PLANS", "methodology": "per diem", "standard_charge_dollar": 28538.0, "standard_charge_algorithm": "Per diem ($28,538).", "count": "0", "additional_payer_notes": "Zero final payments for the item or service in the 15 months prior to posting the file." }, { "payer_name": "UNITED HEALTHCARE", "plan_name": "SUTTER SELECT & SUTTER HEALTH PLAN HMO PLANS", "methodology": "per diem", "standard_charge_dollar": 28538.0, "standard_charge_algorithm": "Per diem ($28,538).", "count": "0", "additional_payer_notes": "Zero final payments for the item or service in the 15 months prior to posting the file." } ] } ] }, { "description": "HC Ccpd Chronic Outpatient", "code_information": [ { "code": "PX-1300000010", "type": "CDM" }, { "code": "90945", "type": "CPT" }, { "code": "0830", "type": "RC" } ], "standard_charges": [ { "setting": "outpatient", "gross_charge": 9443.0, "discounted_cash": 4721.5, "minimum": 3984.95, "maximum": 4910.36, "additional_generic_notes": "Zero final payments for the item or service in the 15 months prior to posting the file.", "payers_information": [ { "payer_name": "AETNA", "plan_name": "AETNA ALL OTHER PLANS", "methodology": "percent of total billed charges", "standard_charge_dollar": 4910.36, "standard_charge_percentage": 52.0, "count": "0", "additional_payer_notes": "Zero final payments for the item or service in the 15 months prior to posting the file." }, { "payer_name": "AETNA", "plan_name": "AETNA ALL OTHER PLANS", "methodology": "percent of total billed charges", "standard_charge_dollar": 4910.36, "standard_charge_percentage": 52.0, "count": "0", "additional_payer_notes": "Zero final payments for the item or service in the 15 months prior to posting the file." }, { "payer_name": "MERITAIN HEALTH", "plan_name": "AETNA ALL OTHER PLANS", "methodology": "percent of total billed charges", "standard_charge_dollar": 4910.36, "standard_charge_percentage": 52.0, "count": "0", "additional_payer_notes": "Zero final payments for the item or service in the 15 months prior to posting the file." }, { "payer_name": "BLUE SHIELD OUT OF STATE", "plan_name": "STANFORD HEALTHCARE ALLIANCE PLAN", "methodology": "percent of total billed charges", "standard_charge_dollar": 4588.35, "standard_charge_percentage": 48.59, "count": "0", "additional_payer_notes": "Zero final payments for the item or service in the 15 months prior to posting the file." }, { "payer_name": "BLUE SHIELD", "plan_name": "STANFORD HEALTHCARE ALLIANCE PLAN", "methodology": "percent of total billed charges", "standard_charge_dollar": 4588.35, "standard_charge_percentage": 48.59, "count": "0", "additional_payer_notes": "Zero final payments for the item or service in the 15 months prior to posting the file." }, { "payer_name": "BLUE SHIELD", "plan_name": "STANFORD HEALTHCARE ALLIANCE PLAN", "methodology": "percent of total billed charges", "standard_charge_dollar": 4588.35, "standard_charge_percentage": 48.59, "count": "0", "additional_payer_notes": "Zero final payments for the item or service in the 15 months prior to posting the file." }, { "payer_name": "BLUE SHIELD", "plan_name": "STANFORD HEALTHCARE ALLIANCE PLAN", "methodology": "percent of total billed charges", "standard_charge_dollar": 4588.35, "standard_charge_percentage": 48.59, "count": "0", "additional_payer_notes": "Zero final payments for the item or service in the 15 months prior to posting the file." }, { "payer_name": "CIGNA", "plan_name": "CIGNA COM ALT HMO PLAN", "methodology": "percent of total billed charges", "standard_charge_dollar": 3984.95, "standard_charge_percentage": 42.2, "count": "0", "additional_payer_notes": "Zero final payments for the item or service in the 15 months prior to posting the file." }, { "payer_name": "CIGNA", "plan_name": "CIGNA COM ALT HMO PLAN", "methodology": "percent of total billed charges", "standard_charge_dollar": 3984.95, "standard_charge_percentage": 42.2, "count": "0", "additional_payer_notes": "Zero final payments for the item or service in the 15 months prior to posting the file." }, { "payer_name": "HEALTH NET", "plan_name": "HEALTHNET HMO, PPO, POS, EPO, CANOPY HEALTHNET HMO, OTHER-IN-NETWORK PLANS", "methodology": "per diem", "standard_charge_dollar": 8000.0, "standard_charge_algorithm": "Expected reimbursement is the lesser of Per diem ($8,000) for the length of stay and 70% of billed.", "count": "0", "additional_payer_notes": "Zero final payments for the item or service in the 15 months prior to posting the file." }, { "payer_name": "HEALTH NET", "plan_name": "HEALTHNET HMO, PPO, POS, EPO, CANOPY HEALTHNET HMO, OTHER-IN-NETWORK PLANS", "methodology": "per diem", "standard_charge_dollar": 8000.0, "standard_charge_algorithm": "Expected reimbursement is the lesser of Per diem ($8,000) for the length of stay and 70% of billed.", "count": "0", "additional_payer_notes": "Zero final payments for the item or service in the 15 months prior to posting the file." }, { "payer_name": "UNITED HEALTHCARE", "plan_name": "SUTTER SELECT & SUTTER HEALTH PLAN HMO PLANS", "methodology": "per diem", "standard_charge_dollar": 28538.0, "standard_charge_algorithm": "Per diem ($28,538).", "count": "0", "additional_payer_notes": "Zero final payments for the item or service in the 15 months prior to posting the file." }, { "payer_name": "UNITED HEALTHCARE", "plan_name": "SUTTER SELECT & SUTTER HEALTH PLAN HMO PLANS", "methodology": "per diem", "standard_charge_dollar": 28538.0, "standard_charge_algorithm": "Per diem ($28,538).", "count": "0", "additional_payer_notes": "Zero final payments for the item or service in the 15 months prior to posting the file." }, { "payer_name": "SUTTER", "plan_name": "SUTTER SELECT & SUTTER HEALTH PLAN HMO PLANS", "methodology": "per diem", "standard_charge_dollar": 28538.0, "standard_charge_algorithm": "Per diem ($28,538).", "count": "0", "additional_payer_notes": "Zero final payments for the item or service in the 15 months prior to posting the file." }, { "payer_name": "UNITED HEALTHCARE", "plan_name": "SUTTER SELECT & SUTTER HEALTH PLAN HMO PLANS", "methodology": "per diem", "standard_charge_dollar": 28538.0, "standard_charge_algorithm": "Per diem ($28,538).", "count": "0", "additional_payer_notes": "Zero final payments for the item or service in the 15 months prior to posting the file." }, { "payer_name": "UMR", "plan_name": "SUTTER SELECT & SUTTER HEALTH PLAN HMO PLANS", "methodology": "per diem", "standard_charge_dollar": 28538.0, "standard_charge_algorithm": "Per diem ($28,538).", "count": "0", "additional_payer_notes": "Zero final payments for the item or service in the 15 months prior to posting the file." }, { "payer_name": "UNITED HEALTHCARE", "plan_name": "SUTTER SELECT & SUTTER HEALTH PLAN HMO PLANS", "methodology": "per diem", "standard_charge_dollar": 28538.0, "standard_charge_algorithm": "Per diem ($28,538).", "count": "0", "additional_payer_notes": "Zero final payments for the item or service in the 15 months prior to posting the file." } ] } ] }, { "description": "HC Capd Acute Inpt", "code_information": [ { "code": "PX-1300000011", "type": "CDM" }, { "code": "90947", "type": "CPT" }, { "code": "0803", "type": "RC" } ], "standard_charges": [ { "setting": "outpatient", "gross_charge": 15241.0, "discounted_cash": 7620.5, "minimum": 6431.7, "maximum": 7925.32, "additional_generic_notes": "Zero final payments for the item or service in the 15 months prior to posting the file.", "payers_information": [ { "payer_name": "AETNA", "plan_name": "AETNA ALL OTHER PLANS", "methodology": "percent of total billed charges", "standard_charge_dollar": 7925.32, "standard_charge_percentage": 52.0, "count": "0", "additional_payer_notes": "Zero final payments for the item or service in the 15 months prior to posting the file." }, { "payer_name": "AETNA", "plan_name": "AETNA ALL OTHER PLANS", "methodology": "percent of total billed charges", "standard_charge_dollar": 7925.32, "standard_charge_percentage": 52.0, "count": "0", "additional_payer_notes": "Zero final payments for the item or service in the 15 months prior to posting the file." }, { "payer_name": "MERITAIN HEALTH", "plan_name": "AETNA ALL OTHER PLANS", "methodology": "percent of total billed charges", "standard_charge_dollar": 7925.32, "standard_charge_percentage": 52.0, "count": "0", "additional_payer_notes": "Zero final payments for the item or service in the 15 months prior to posting the file." }, { "payer_name": "BLUE SHIELD OUT OF STATE", "plan_name": "STANFORD HEALTHCARE ALLIANCE PLAN", "methodology": "percent of total billed charges", "standard_charge_dollar": 7405.6, "standard_charge_percentage": 48.59, "count": "0", "additional_payer_notes": "Zero final payments for the item or service in the 15 months prior to posting the file." }, { "payer_name": "BLUE SHIELD", "plan_name": "STANFORD HEALTHCARE ALLIANCE PLAN", "methodology": "percent of total billed charges", "standard_charge_dollar": 7405.6, "standard_charge_percentage": 48.59, "count": "0", "additional_payer_notes": "Zero final payments for the item or service in the 15 months prior to posting the file." }, { "payer_name": "BLUE SHIELD", "plan_name": "STANFORD HEALTHCARE ALLIANCE PLAN", "methodology": "percent of total billed charges", "standard_charge_dollar": 7405.6, "standard_charge_percentage": 48.59, "count": "0", "additional_payer_notes": "Zero final payments for the item or service in the 15 months prior to posting the file." }, { "payer_name": "BLUE SHIELD", "plan_name": "STANFORD HEALTHCARE ALLIANCE PLAN", "methodology": "percent of total billed charges", "standard_charge_dollar": 7405.6, "standard_charge_percentage": 48.59, "count": "0", "additional_payer_notes": "Zero final payments for the item or service in the 15 months prior to posting the file." }, { "payer_name": "CIGNA", "plan_name": "CIGNA COM ALT HMO PLAN", "methodology": "percent of total billed charges", "standard_charge_dollar": 6431.7, "standard_charge_percentage": 42.2, "count": "0", "additional_payer_notes": "Zero final payments for the item or service in the 15 months prior to posting the file." }, { "payer_name": "CIGNA", "plan_name": "CIGNA COM ALT HMO PLAN", "methodology": "percent of total billed charges", "standard_charge_dollar": 6431.7, "standard_charge_percentage": 42.2, "count": "0", "additional_payer_notes": "Zero final payments for the item or service in the 15 months prior to posting the file." }, { "payer_name": "HEALTH NET", "plan_name": "HEALTHNET HMO, PPO, POS, EPO, CANOPY HEALTHNET HMO, OTHER-IN-NETWORK PLANS", "methodology": "per diem", "standard_charge_dollar": 8000.0, "standard_charge_algorithm": "Expected reimbursement is the lesser of Per diem ($8,000) for the length of stay and 70% of billed.", "count": "0", "additional_payer_notes": "Zero final payments for the item or service in the 15 months prior to posting the file." }, { "payer_name": "HEALTH NET", "plan_name": "HEALTHNET HMO, PPO, POS, EPO, CANOPY HEALTHNET HMO, OTHER-IN-NETWORK PLANS", "methodology": "per diem", "standard_charge_dollar": 8000.0, "standard_charge_algorithm": "Expected reimbursement is the lesser of Per diem ($8,000) for the length of stay and 70% of billed.", "count": "0", "additional_payer_notes": "Zero final payments for the item or service in the 15 months prior to posting the file." }, { "payer_name": "UNITED HEALTHCARE", "plan_name": "SUTTER SELECT & SUTTER HEALTH PLAN HMO PLANS", "methodology": "per diem", "standard_charge_dollar": 28538.0, "standard_charge_algorithm": "Per diem ($28,538).", "count": "0", "additional_payer_notes": "Zero final payments for the item or service in the 15 months prior to posting the file." }, { "payer_name": "UNITED HEALTHCARE", "plan_name": "SUTTER SELECT & SUTTER HEALTH PLAN HMO PLANS", "methodology": "per diem", "standard_charge_dollar": 28538.0, "standard_charge_algorithm": "Per diem ($28,538).", "count": "0", "additional_payer_notes": "Zero final payments for the item or service in the 15 months prior to posting the file." }, { "payer_name": "SUTTER", "plan_name": "SUTTER SELECT & SUTTER HEALTH PLAN HMO PLANS", "methodology": "per diem", "standard_charge_dollar": 28538.0, "standard_charge_algorithm": "Per diem ($28,538).", "count": "0", "additional_payer_notes": "Zero final payments for the item or service in the 15 months prior to posting the file." }, { "payer_name": "UNITED HEALTHCARE", "plan_name": "SUTTER SELECT & SUTTER HEALTH PLAN HMO PLANS", "methodology": "per diem", "standard_charge_dollar": 28538.0, "standard_charge_algorithm": "Per diem ($28,538).", "count": "0", "additional_payer_notes": "Zero final payments for the item or service in the 15 months prior to posting the file." }, { "payer_name": "UMR", "plan_name": "SUTTER SELECT & SUTTER HEALTH PLAN HMO PLANS", "methodology": "per diem", "standard_charge_dollar": 28538.0, "standard_charge_algorithm": "Per diem ($28,538).", "count": "0", "additional_payer_notes": "Zero final payments for the item or service in the 15 months prior to posting the file." }, { "payer_name": "UNITED HEALTHCARE", "plan_name": "SUTTER SELECT & SUTTER HEALTH PLAN HMO PLANS", "methodology": "per diem", "standard_charge_dollar": 28538.0, "standard_charge_algorithm": "Per diem ($28,538).", "count": "0", "additional_payer_notes": "Zero final payments for the item or service in the 15 months prior to posting the file." } ] } ] }, { "description": "HC Capd Chronic Inpt", "code_information": [ { "code": "PX-1300000012", "type": "CDM" }, { "code": "90947", "type": "CPT" }, { "code": "0803", "type": "RC" } ], "standard_charges": [ { "setting": "outpatient", "gross_charge": 8433.0, "discounted_cash": 4216.5, "minimum": 3558.73, "maximum": 4385.16, "additional_generic_notes": "Zero final payments for the item or service in the 15 months prior to posting the file.", "payers_information": [ { "payer_name": "AETNA", "plan_name": "AETNA ALL OTHER PLANS", "methodology": "percent of total billed charges", "standard_charge_dollar": 4385.16, "standard_charge_percentage": 52.0, "count": "0", "additional_payer_notes": "Zero final payments for the item or service in the 15 months prior to posting the file." }, { "payer_name": "AETNA", "plan_name": "AETNA ALL OTHER PLANS", "methodology": "percent of total billed charges", "standard_charge_dollar": 4385.16, "standard_charge_percentage": 52.0, "count": "0", "additional_payer_notes": "Zero final payments for the item or service in the 15 months prior to posting the file." }, { "payer_name": "MERITAIN HEALTH", "plan_name": "AETNA ALL OTHER PLANS", "methodology": "percent of total billed charges", "standard_charge_dollar": 4385.16, "standard_charge_percentage": 52.0, "count": "0", "additional_payer_notes": "Zero final payments for the item or service in the 15 months prior to posting the file." }, { "payer_name": "BLUE SHIELD OUT OF STATE", "plan_name": "STANFORD HEALTHCARE ALLIANCE PLAN", "methodology": "percent of total billed charges", "standard_charge_dollar": 4097.59, "standard_charge_percentage": 48.59, "count": "0", "additional_payer_notes": "Zero final payments for the item or service in the 15 months prior to posting the file." }, { "payer_name": "BLUE SHIELD", "plan_name": "STANFORD HEALTHCARE ALLIANCE PLAN", "methodology": "percent of total billed charges", "standard_charge_dollar": 4097.59, "standard_charge_percentage": 48.59, "count": "0", "additional_payer_notes": "Zero final payments for the item or service in the 15 months prior to posting the file." }, { "payer_name": "BLUE SHIELD", "plan_name": "STANFORD HEALTHCARE ALLIANCE PLAN", "methodology": "percent of total billed charges", "standard_charge_dollar": 4097.59, "standard_charge_percentage": 48.59, "count": "0", "additional_payer_notes": "Zero final payments for the item or service in the 15 months prior to posting the file." }, { "payer_name": "BLUE SHIELD", "plan_name": "STANFORD HEALTHCARE ALLIANCE PLAN", "methodology": "percent of total billed charges", "standard_charge_dollar": 4097.59, "standard_charge_percentage": 48.59, "count": "0", "additional_payer_notes": "Zero final payments for the item or service in the 15 months prior to posting the file." }, { "payer_name": "CIGNA", "plan_name": "CIGNA COM ALT HMO PLAN", "methodology": "percent of total billed charges", "standard_charge_dollar": 3558.73, "standard_charge_percentage": 42.2, "count": "0", "additional_payer_notes": "Zero final payments for the item or service in the 15 months prior to posting the file." }, { "payer_name": "CIGNA", "plan_name": "CIGNA COM ALT HMO PLAN", "methodology": "percent of total billed charges", "standard_charge_dollar": 3558.73, "standard_charge_percentage": 42.2, "count": "0", "additional_payer_notes": "Zero final payments for the item or service in the 15 months prior to posting the file." }, { "payer_name": "HEALTH NET", "plan_name": "HEALTHNET HMO, PPO, POS, EPO, CANOPY HEALTHNET HMO, OTHER-IN-NETWORK PLANS", "methodology": "per diem", "standard_charge_dollar": 8000.0, "standard_charge_algorithm": "Expected reimbursement is the lesser of Per diem ($8,000) for the length of stay and 70% of billed.", "count": "0", "additional_payer_notes": "Zero final payments for the item or service in the 15 months prior to posting the file." }, { "payer_name": "HEALTH NET", "plan_name": "HEALTHNET HMO, PPO, POS, EPO, CANOPY HEALTHNET HMO, OTHER-IN-NETWORK PLANS", "methodology": "per diem", "standard_charge_dollar": 8000.0, "standard_charge_algorithm": "Expected reimbursement is the lesser of Per diem ($8,000) for the length of stay and 70% of billed.", "count": "0", "additional_payer_notes": "Zero final payments for the item or service in the 15 months prior to posting the file." }, { "payer_name": "UNITED HEALTHCARE", "plan_name": "SUTTER SELECT & SUTTER HEALTH PLAN HMO PLANS", "methodology": "per diem", "standard_charge_dollar": 28538.0, "standard_charge_algorithm": "Per diem ($28,538).", "count": "0", "additional_payer_notes": "Zero final payments for the item or service in the 15 months prior to posting the file." }, { "payer_name": "UNITED HEALTHCARE", "plan_name": "SUTTER SELECT & SUTTER HEALTH PLAN HMO PLANS", "methodology": "per diem", "standard_charge_dollar": 28538.0, "standard_charge_algorithm": "Per diem ($28,538).", "count": "0", "additional_payer_notes": "Zero final payments for the item or service in the 15 months prior to posting the file." }, { "payer_name": "SUTTER", "plan_name": "SUTTER SELECT & SUTTER HEALTH PLAN HMO PLANS", "methodology": "per diem", "standard_charge_dollar": 28538.0, "standard_charge_algorithm": "Per diem ($28,538).", "count": "0", "additional_payer_notes": "Zero final payments for the item or service in the 15 months prior to posting the file." }, { "payer_name": "UNITED HEALTHCARE", "plan_name": "SUTTER SELECT & SUTTER HEALTH PLAN HMO PLANS", "methodology": "per diem", "standard_charge_dollar": 28538.0, "standard_charge_algorithm": "Per diem ($28,538).", "count": "0", "additional_payer_notes": "Zero final payments for the item or service in the 15 months prior to posting the file." }, { "payer_name": "UMR", "plan_name": "SUTTER SELECT & SUTTER HEALTH PLAN HMO PLANS", "methodology": "per diem", "standard_charge_dollar": 28538.0, "standard_charge_algorithm": "Per diem ($28,538).", "count": "0", "additional_payer_notes": "Zero final payments for the item or service in the 15 months prior to posting the file." }, { "payer_name": "UNITED HEALTHCARE", "plan_name": "SUTTER SELECT & SUTTER HEALTH PLAN HMO PLANS", "methodology": "per diem", "standard_charge_dollar": 28538.0, "standard_charge_algorithm": "Per diem ($28,538).", "count": "0", "additional_payer_notes": "Zero final payments for the item or service in the 15 months prior to posting the file." } ] } ] }, { "description": "HC Ccpd Acute Inpt", "code_information": [ { "code": "PX-1300000013", "type": "CDM" }, { "code": "90947", "type": "CPT" }, { "code": "0804", "type": "RC" } ], "standard_charges": [ { "setting": "outpatient", "gross_charge": 17070.0, "discounted_cash": 8535.0, "minimum": 7203.54, "maximum": 8876.4, "additional_generic_notes": "Zero final payments for the item or service in the 15 months prior to posting the file.", "payers_information": [ { "payer_name": "AETNA", "plan_name": "AETNA ALL OTHER PLANS", "methodology": "percent of total billed charges", "standard_charge_dollar": 8876.4, "standard_charge_percentage": 52.0, "count": "0", "additional_payer_notes": "Zero final payments for the item or service in the 15 months prior to posting the file." }, { "payer_name": "AETNA", "plan_name": "AETNA ALL OTHER PLANS", "methodology": "percent of total billed charges", "standard_charge_dollar": 8876.4, "standard_charge_percentage": 52.0, "count": "0", "additional_payer_notes": "Zero final payments for the item or service in the 15 months prior to posting the file." }, { "payer_name": "MERITAIN HEALTH", "plan_name": "AETNA ALL OTHER PLANS", "methodology": "percent of total billed charges", "standard_charge_dollar": 8876.4, "standard_charge_percentage": 52.0, "count": "0", "additional_payer_notes": "Zero final payments for the item or service in the 15 months prior to posting the file." }, { "payer_name": "BLUE SHIELD OUT OF STATE", "plan_name": "STANFORD HEALTHCARE ALLIANCE PLAN", "methodology": "percent of total billed charges", "standard_charge_dollar": 8294.31, "standard_charge_percentage": 48.59, "count": "0", "additional_payer_notes": "Zero final payments for the item or service in the 15 months prior to posting the file." }, { "payer_name": "BLUE SHIELD", "plan_name": "STANFORD HEALTHCARE ALLIANCE PLAN", "methodology": "percent of total billed charges", "standard_charge_dollar": 8294.31, "standard_charge_percentage": 48.59, "count": "0", "additional_payer_notes": "Zero final payments for the item or service in the 15 months prior to posting the file." }, { "payer_name": "BLUE SHIELD", "plan_name": "STANFORD HEALTHCARE ALLIANCE PLAN", "methodology": "percent of total billed charges", "standard_charge_dollar": 8294.31, "standard_charge_percentage": 48.59, "count": "0", "additional_payer_notes": "Zero final payments for the item or service in the 15 months prior to posting the file." }, { "payer_name": "BLUE SHIELD", "plan_name": "STANFORD HEALTHCARE ALLIANCE PLAN", "methodology": "percent of total billed charges", "standard_charge_dollar": 8294.31, "standard_charge_percentage": 48.59, "count": "0", "additional_payer_notes": "Zero final payments for the item or service in the 15 months prior to posting the file." }, { "payer_name": "CIGNA", "plan_name": "CIGNA COM ALT HMO PLAN", "methodology": "percent of total billed charges", "standard_charge_dollar": 7203.54, "standard_charge_percentage": 42.2, "count": "0", "additional_payer_notes": "Zero final payments for the item or service in the 15 months prior to posting the file." }, { "payer_name": "CIGNA", "plan_name": "CIGNA COM ALT HMO PLAN", "methodology": "percent of total billed charges", "standard_charge_dollar": 7203.54, "standard_charge_percentage": 42.2, "count": "0", "additional_payer_notes": "Zero final payments for the item or service in the 15 months prior to posting the file." }, { "payer_name": "HEALTH NET", "plan_name": "HEALTHNET HMO, PPO, POS, EPO, CANOPY HEALTHNET HMO, OTHER-IN-NETWORK PLANS", "methodology": "per diem", "standard_charge_dollar": 8000.0, "standard_charge_algorithm": "Expected reimbursement is the lesser of Per diem ($8,000) for the length of stay and 70% of billed.", "count": "0", "additional_payer_notes": "Zero final payments for the item or service in the 15 months prior to posting the file." }, { "payer_name": "HEALTH NET", "plan_name": "HEALTHNET HMO, PPO, POS, EPO, CANOPY HEALTHNET HMO, OTHER-IN-NETWORK PLANS", "methodology": "per diem", "standard_charge_dollar": 8000.0, "standard_charge_algorithm": "Expected reimbursement is the lesser of Per diem ($8,000) for the length of stay and 70% of billed.", "count": "0", "additional_payer_notes": "Zero final payments for the item or service in the 15 months prior to posting the file." }, { "payer_name": "UNITED HEALTHCARE", "plan_name": "SUTTER SELECT & SUTTER HEALTH PLAN HMO PLANS", "methodology": "per diem", "standard_charge_dollar": 28538.0, "standard_charge_algorithm": "Per diem ($28,538).", "count": "0", "additional_payer_notes": "Zero final payments for the item or service in the 15 months prior to posting the file." }, { "payer_name": "UNITED HEALTHCARE", "plan_name": "SUTTER SELECT & SUTTER HEALTH PLAN HMO PLANS", "methodology": "per diem", "standard_charge_dollar": 28538.0, "standard_charge_algorithm": "Per diem ($28,538).", "count": "0", "additional_payer_notes": "Zero final payments for the item or service in the 15 months prior to posting the file." }, { "payer_name": "SUTTER", "plan_name": "SUTTER SELECT & SUTTER HEALTH PLAN HMO PLANS", "methodology": "per diem", "standard_charge_dollar": 28538.0, "standard_charge_algorithm": "Per diem ($28,538).", "count": "0", "additional_payer_notes": "Zero final payments for the item or service in the 15 months prior to posting the file." }, { "payer_name": "UNITED HEALTHCARE", "plan_name": "SUTTER SELECT & SUTTER HEALTH PLAN HMO PLANS", "methodology": "per diem", "standard_charge_dollar": 28538.0, "standard_charge_algorithm": "Per diem ($28,538).", "count": "0", "additional_payer_notes": "Zero final payments for the item or service in the 15 months prior to posting the file." }, { "payer_name": "UMR", "plan_name": "SUTTER SELECT & SUTTER HEALTH PLAN HMO PLANS", "methodology": "per diem", "standard_charge_dollar": 28538.0, "standard_charge_algorithm": "Per diem ($28,538).", "count": "0", "additional_payer_notes": "Zero final payments for the item or service in the 15 months prior to posting the file." }, { "payer_name": "UNITED HEALTHCARE", "plan_name": "SUTTER SELECT & SUTTER HEALTH PLAN HMO PLANS", "methodology": "per diem", "standard_charge_dollar": 28538.0, "standard_charge_algorithm": "Per diem ($28,538).", "count": "0", "additional_payer_notes": "Zero final payments for the item or service in the 15 months prior to posting the file." } ] } ] }, { "description": "HC Ccpd Chronic Inpt", "code_information": [ { "code": "PX-1300000014", "type": "CDM" }, { "code": "90947", "type": "CPT" }, { "code": "0804", "type": "RC" } ], "standard_charges": [ { "setting": "outpatient", "gross_charge": 9443.0, "discounted_cash": 4721.5, "minimum": 3984.95, "maximum": 4910.36, "additional_generic_notes": "Zero final payments for the item or service in the 15 months prior to posting the file.", "payers_information": [ { "payer_name": "AETNA", "plan_name": "AETNA ALL OTHER PLANS", "methodology": "percent of total billed charges", "standard_charge_dollar": 4910.36, "standard_charge_percentage": 52.0, "count": "0", "additional_payer_notes": "Zero final payments for the item or service in the 15 months prior to posting the file." }, { "payer_name": "AETNA", "plan_name": "AETNA ALL OTHER PLANS", "methodology": "percent of total billed charges", "standard_charge_dollar": 4910.36, "standard_charge_percentage": 52.0, "count": "0", "additional_payer_notes": "Zero final payments for the item or service in the 15 months prior to posting the file." }, { "payer_name": "MERITAIN HEALTH", "plan_name": "AETNA ALL OTHER PLANS", "methodology": "percent of total billed charges", "standard_charge_dollar": 4910.36, "standard_charge_percentage": 52.0, "count": "0", "additional_payer_notes": "Zero final payments for the item or service in the 15 months prior to posting the file." }, { "payer_name": "BLUE SHIELD OUT OF STATE", "plan_name": "STANFORD HEALTHCARE ALLIANCE PLAN", "methodology": "percent of total billed charges", "standard_charge_dollar": 4588.35, "standard_charge_percentage": 48.59, "count": "0", "additional_payer_notes": "Zero final payments for the item or service in the 15 months prior to posting the file." }, { "payer_name": "BLUE SHIELD", "plan_name": "STANFORD HEALTHCARE ALLIANCE PLAN", "methodology": "percent of total billed charges", "standard_charge_dollar": 4588.35, "standard_charge_percentage": 48.59, "count": "0", "additional_payer_notes": "Zero final payments for the item or service in the 15 months prior to posting the file." }, { "payer_name": "BLUE SHIELD", "plan_name": "STANFORD HEALTHCARE ALLIANCE PLAN", "methodology": "percent of total billed charges", "standard_charge_dollar": 4588.35, "standard_charge_percentage": 48.59, "count": "0", "additional_payer_notes": "Zero final payments for the item or service in the 15 months prior to posting the file." }, { "payer_name": "BLUE SHIELD", "plan_name": "STANFORD HEALTHCARE ALLIANCE PLAN", "methodology": "percent of total billed charges", "standard_charge_dollar": 4588.35, "standard_charge_percentage": 48.59, "count": "0", "additional_payer_notes": "Zero final payments for the item or service in the 15 months prior to posting the file." }, { "payer_name": "CIGNA", "plan_name": "CIGNA COM ALT HMO PLAN", "methodology": "percent of total billed charges", "standard_charge_dollar": 3984.95, "standard_charge_percentage": 42.2, "count": "0", "additional_payer_notes": "Zero final payments for the item or service in the 15 months prior to posting the file." }, { "payer_name": "CIGNA", "plan_name": "CIGNA COM ALT HMO PLAN", "methodology": "percent of total billed charges", "standard_charge_dollar": 3984.95, "standard_charge_percentage": 42.2, "count": "0", "additional_payer_notes": "Zero final payments for the item or service in the 15 months prior to posting the file." }, { "payer_name": "HEALTH NET", "plan_name": "HEALTHNET HMO, PPO, POS, EPO, CANOPY HEALTHNET HMO, OTHER-IN-NETWORK PLANS", "methodology": "per diem", "standard_charge_dollar": 8000.0, "standard_charge_algorithm": "Expected reimbursement is the lesser of Per diem ($8,000) for the length of stay and 70% of billed.", "count": "0", "additional_payer_notes": "Zero final payments for the item or service in the 15 months prior to posting the file." }, { "payer_name": "HEALTH NET", "plan_name": "HEALTHNET HMO, PPO, POS, EPO, CANOPY HEALTHNET HMO, OTHER-IN-NETWORK PLANS", "methodology": "per diem", "standard_charge_dollar": 8000.0, "standard_charge_algorithm": "Expected reimbursement is the lesser of Per diem ($8,000) for the length of stay and 70% of billed.", "count": "0", "additional_payer_notes": "Zero final payments for the item or service in the 15 months prior to posting the file." }, { "payer_name": "UNITED HEALTHCARE", "plan_name": "SUTTER SELECT & SUTTER HEALTH PLAN HMO PLANS", "methodology": "per diem", "standard_charge_dollar": 28538.0, "standard_charge_algorithm": "Per diem ($28,538).", "count": "0", "additional_payer_notes": "Zero final payments for the item or service in the 15 months prior to posting the file." }, { "payer_name": "UNITED HEALTHCARE", "plan_name": "SUTTER SELECT & SUTTER HEALTH PLAN HMO PLANS", "methodology": "per diem", "standard_charge_dollar": 28538.0, "standard_charge_algorithm": "Per diem ($28,538).", "count": "0", "additional_payer_notes": "Zero final payments for the item or service in the 15 months prior to posting the file." }, { "payer_name": "SUTTER", "plan_name": "SUTTER SELECT & SUTTER HEALTH PLAN HMO PLANS", "methodology": "per diem", "standard_charge_dollar": 28538.0, "standard_charge_algorithm": "Per diem ($28,538).", "count": "0", "additional_payer_notes": "Zero final payments for the item or service in the 15 months prior to posting the file." }, { "payer_name": "UNITED HEALTHCARE", "plan_name": "SUTTER SELECT & SUTTER HEALTH PLAN HMO PLANS", "methodology": "per diem", "standard_charge_dollar": 28538.0, "standard_charge_algorithm": "Per diem ($28,538).", "count": "0", "additional_payer_notes": "Zero final payments for the item or service in the 15 months prior to posting the file." }, { "payer_name": "UMR", "plan_name": "SUTTER SELECT & SUTTER HEALTH PLAN HMO PLANS", "methodology": "per diem", "standard_charge_dollar": 28538.0, "standard_charge_algorithm": "Per diem ($28,538).", "count": "0", "additional_payer_notes": "Zero final payments for the item or service in the 15 months prior to posting the file." }, { "payer_name": "UNITED HEALTHCARE", "plan_name": "SUTTER SELECT & SUTTER HEALTH PLAN HMO PLANS", "methodology": "per diem", "standard_charge_dollar": 28538.0, "standard_charge_algorithm": "Per diem ($28,538).", "count": "0", "additional_payer_notes": "Zero final payments for the item or service in the 15 months prior to posting the file." } ] } ] }, { "description": "HC Icu Manual Pd per Day", "code_information": [ { "code": "PX-1300000015", "type": "CDM" }, { "code": "90947", "type": "CPT" }, { "code": "0802", "type": "RC" } ], "standard_charges": [ { "setting": "outpatient", "gross_charge": 9443.0, "discounted_cash": 4721.5, "minimum": 3984.95, "maximum": 4910.36, "additional_generic_notes": "Zero final payments for the item or service in the 15 months prior to posting the file.", "payers_information": [ { "payer_name": "AETNA", "plan_name": "AETNA ALL OTHER PLANS", "methodology": "percent of total billed charges", "standard_charge_dollar": 4910.36, "standard_charge_percentage": 52.0, "count": "0", "additional_payer_notes": "Zero final payments for the item or service in the 15 months prior to posting the file." }, { "payer_name": "AETNA", "plan_name": "AETNA ALL OTHER PLANS", "methodology": "percent of total billed charges", "standard_charge_dollar": 4910.36, "standard_charge_percentage": 52.0, "count": "0", "additional_payer_notes": "Zero final payments for the item or service in the 15 months prior to posting the file." }, { "payer_name": "MERITAIN HEALTH", "plan_name": "AETNA ALL OTHER PLANS", "methodology": "percent of total billed charges", "standard_charge_dollar": 4910.36, "standard_charge_percentage": 52.0, "count": "0", "additional_payer_notes": "Zero final payments for the item or service in the 15 months prior to posting the file." }, { "payer_name": "BLUE SHIELD OUT OF STATE", "plan_name": "STANFORD HEALTHCARE ALLIANCE PLAN", "methodology": "percent of total billed charges", "standard_charge_dollar": 4588.35, "standard_charge_percentage": 48.59, "count": "0", "additional_payer_notes": "Zero final payments for the item or service in the 15 months prior to posting the file." }, { "payer_name": "BLUE SHIELD", "plan_name": "STANFORD HEALTHCARE ALLIANCE PLAN", "methodology": "percent of total billed charges", "standard_charge_dollar": 4588.35, "standard_charge_percentage": 48.59, "count": "0", "additional_payer_notes": "Zero final payments for the item or service in the 15 months prior to posting the file." }, { "payer_name": "BLUE SHIELD", "plan_name": "STANFORD HEALTHCARE ALLIANCE PLAN", "methodology": "percent of total billed charges", "standard_charge_dollar": 4588.35, "standard_charge_percentage": 48.59, "count": "0", "additional_payer_notes": "Zero final payments for the item or service in the 15 months prior to posting the file." }, { "payer_name": "BLUE SHIELD", "plan_name": "STANFORD HEALTHCARE ALLIANCE PLAN", "methodology": "percent of total billed charges", "standard_charge_dollar": 4588.35, "standard_charge_percentage": 48.59, "count": "0", "additional_payer_notes": "Zero final payments for the item or service in the 15 months prior to posting the file." }, { "payer_name": "CIGNA", "plan_name": "CIGNA COM ALT HMO PLAN", "methodology": "percent of total billed charges", "standard_charge_dollar": 3984.95, "standard_charge_percentage": 42.2, "count": "0", "additional_payer_notes": "Zero final payments for the item or service in the 15 months prior to posting the file." }, { "payer_name": "CIGNA", "plan_name": "CIGNA COM ALT HMO PLAN", "methodology": "percent of total billed charges", "standard_charge_dollar": 3984.95, "standard_charge_percentage": 42.2, "count": "0", "additional_payer_notes": "Zero final payments for the item or service in the 15 months prior to posting the file." }, { "payer_name": "HEALTH NET", "plan_name": "HEALTHNET HMO, PPO, POS, EPO, CANOPY HEALTHNET HMO, OTHER-IN-NETWORK PLANS", "methodology": "per diem", "standard_charge_dollar": 8000.0, "standard_charge_algorithm": "Expected reimbursement is the lesser of Per diem ($8,000) for the length of stay and 70% of billed.", "count": "0", "additional_payer_notes": "Zero final payments for the item or service in the 15 months prior to posting the file." }, { "payer_name": "HEALTH NET", "plan_name": "HEALTHNET HMO, PPO, POS, EPO, CANOPY HEALTHNET HMO, OTHER-IN-NETWORK PLANS", "methodology": "per diem", "standard_charge_dollar": 8000.0, "standard_charge_algorithm": "Expected reimbursement is the lesser of Per diem ($8,000) for the length of stay and 70% of billed.", "count": "0", "additional_payer_notes": "Zero final payments for the item or service in the 15 months prior to posting the file." }, { "payer_name": "UNITED HEALTHCARE", "plan_name": "SUTTER SELECT & SUTTER HEALTH PLAN HMO PLANS", "methodology": "per diem", "standard_charge_dollar": 28538.0, "standard_charge_algorithm": "Per diem ($28,538).", "count": "0", "additional_payer_notes": "Zero final payments for the item or service in the 15 months prior to posting the file." }, { "payer_name": "UNITED HEALTHCARE", "plan_name": "SUTTER SELECT & SUTTER HEALTH PLAN HMO PLANS", "methodology": "per diem", "standard_charge_dollar": 28538.0, "standard_charge_algorithm": "Per diem ($28,538).", "count": "0", "additional_payer_notes": "Zero final payments for the item or service in the 15 months prior to posting the file." }, { "payer_name": "SUTTER", "plan_name": "SUTTER SELECT & SUTTER HEALTH PLAN HMO PLANS", "methodology": "per diem", "standard_charge_dollar": 28538.0, "standard_charge_algorithm": "Per diem ($28,538).", "count": "0", "additional_payer_notes": "Zero final payments for the item or service in the 15 months prior to posting the file." }, { "payer_name": "UNITED HEALTHCARE", "plan_name": "SUTTER SELECT & SUTTER HEALTH PLAN HMO PLANS", "methodology": "per diem", "standard_charge_dollar": 28538.0, "standard_charge_algorithm": "Per diem ($28,538).", "count": "0", "additional_payer_notes": "Zero final payments for the item or service in the 15 months prior to posting the file." }, { "payer_name": "UMR", "plan_name": "SUTTER SELECT & SUTTER HEALTH PLAN HMO PLANS", "methodology": "per diem", "standard_charge_dollar": 28538.0, "standard_charge_algorithm": "Per diem ($28,538).", "count": "0", "additional_payer_notes": "Zero final payments for the item or service in the 15 months prior to posting the file." }, { "payer_name": "UNITED HEALTHCARE", "plan_name": "SUTTER SELECT & SUTTER HEALTH PLAN HMO PLANS", "methodology": "per diem", "standard_charge_dollar": 28538.0, "standard_charge_algorithm": "Per diem ($28,538).", "count": "0", "additional_payer_notes": "Zero final payments for the item or service in the 15 months prior to posting the file." } ] } ] }, { "description": "HC IP Only Hemoperfusion 1 4 Hrs", "code_information": [ { "code": "PX-1300000016", "type": "CDM" }, { "code": "90997", "type": "CPT" }, { "code": "0801", "type": "RC" } ], "standard_charges": [ { "setting": "outpatient", "gross_charge": 9936.0, "discounted_cash": 4968.0, "minimum": 4192.99, "maximum": 5166.72, "additional_generic_notes": "Zero final payments for the item or service in the 15 months prior to posting the file.", "payers_information": [ { "payer_name": "AETNA", "plan_name": "AETNA ALL OTHER PLANS", "methodology": "percent of total billed charges", "standard_charge_dollar": 5166.72, "standard_charge_percentage": 52.0, "count": "0", "additional_payer_notes": "Zero final payments for the item or service in the 15 months prior to posting the file." }, { "payer_name": "AETNA", "plan_name": "AETNA ALL OTHER PLANS", "methodology": "percent of total billed charges", "standard_charge_dollar": 5166.72, "standard_charge_percentage": 52.0, "count": "0", "additional_payer_notes": "Zero final payments for the item or service in the 15 months prior to posting the file." }, { "payer_name": "MERITAIN HEALTH", "plan_name": "AETNA ALL OTHER PLANS", "methodology": "percent of total billed charges", "standard_charge_dollar": 5166.72, "standard_charge_percentage": 52.0, "count": "0", "additional_payer_notes": "Zero final payments for the item or service in the 15 months prior to posting the file." }, { "payer_name": "BLUE SHIELD OUT OF STATE", "plan_name": "STANFORD HEALTHCARE ALLIANCE PLAN", "methodology": "percent of total billed charges", "standard_charge_dollar": 4827.9, "standard_charge_percentage": 48.59, "count": "0", "additional_payer_notes": "Zero final payments for the item or service in the 15 months prior to posting the file." }, { "payer_name": "BLUE SHIELD", "plan_name": "STANFORD HEALTHCARE ALLIANCE PLAN", "methodology": "percent of total billed charges", "standard_charge_dollar": 4827.9, "standard_charge_percentage": 48.59, "count": "0", "additional_payer_notes": "Zero final payments for the item or service in the 15 months prior to posting the file." }, { "payer_name": "BLUE SHIELD", "plan_name": "STANFORD HEALTHCARE ALLIANCE PLAN", "methodology": "percent of total billed charges", "standard_charge_dollar": 4827.9, "standard_charge_percentage": 48.59, "count": "0", "additional_payer_notes": "Zero final payments for the item or service in the 15 months prior to posting the file." }, { "payer_name": "BLUE SHIELD", "plan_name": "STANFORD HEALTHCARE ALLIANCE PLAN", "methodology": "percent of total billed charges", "standard_charge_dollar": 4827.9, "standard_charge_percentage": 48.59, "count": "0", "additional_payer_notes": "Zero final payments for the item or service in the 15 months prior to posting the file." }, { "payer_name": "CIGNA", "plan_name": "CIGNA COM ALT HMO PLAN", "methodology": "percent of total billed charges", "standard_charge_dollar": 4192.99, "standard_charge_percentage": 42.2, "count": "0", "additional_payer_notes": "Zero final payments for the item or service in the 15 months prior to posting the file." }, { "payer_name": "CIGNA", "plan_name": "CIGNA COM ALT HMO PLAN", "methodology": "percent of total billed charges", "standard_charge_dollar": 4192.99, "standard_charge_percentage": 42.2, "count": "0", "additional_payer_notes": "Zero final payments for the item or service in the 15 months prior to posting the file." }, { "payer_name": "HEALTH NET", "plan_name": "HEALTHNET HMO, PPO, POS, EPO, CANOPY HEALTHNET HMO, OTHER-IN-NETWORK PLANS", "methodology": "per diem", "standard_charge_dollar": 8000.0, "standard_charge_algorithm": "Expected reimbursement is the lesser of Per diem ($8,000) for the length of stay and 70% of billed.", "count": "0", "additional_payer_notes": "Zero final payments for the item or service in the 15 months prior to posting the file." }, { "payer_name": "HEALTH NET", "plan_name": "HEALTHNET HMO, PPO, POS, EPO, CANOPY HEALTHNET HMO, OTHER-IN-NETWORK PLANS", "methodology": "per diem", "standard_charge_dollar": 8000.0, "standard_charge_algorithm": "Expected reimbursement is the lesser of Per diem ($8,000) for the length of stay and 70% of billed.", "count": "0", "additional_payer_notes": "Zero final payments for the item or service in the 15 months prior to posting the file." }, { "payer_name": "UNITED HEALTHCARE", "plan_name": "SUTTER SELECT & SUTTER HEALTH PLAN HMO PLANS", "methodology": "per diem", "standard_charge_dollar": 28538.0, "standard_charge_algorithm": "Per diem ($28,538).", "count": "0", "additional_payer_notes": "Zero final payments for the item or service in the 15 months prior to posting the file." }, { "payer_name": "UNITED HEALTHCARE", "plan_name": "SUTTER SELECT & SUTTER HEALTH PLAN HMO PLANS", "methodology": "per diem", "standard_charge_dollar": 28538.0, "standard_charge_algorithm": "Per diem ($28,538).", "count": "0", "additional_payer_notes": "Zero final payments for the item or service in the 15 months prior to posting the file." }, { "payer_name": "SUTTER", "plan_name": "SUTTER SELECT & SUTTER HEALTH PLAN HMO PLANS", "methodology": "per diem", "standard_charge_dollar": 28538.0, "standard_charge_algorithm": "Per diem ($28,538).", "count": "0", "additional_payer_notes": "Zero final payments for the item or service in the 15 months prior to posting the file." }, { "payer_name": "UNITED HEALTHCARE", "plan_name": "SUTTER SELECT & SUTTER HEALTH PLAN HMO PLANS", "methodology": "per diem", "standard_charge_dollar": 28538.0, "standard_charge_algorithm": "Per diem ($28,538).", "count": "0", "additional_payer_notes": "Zero final payments for the item or service in the 15 months prior to posting the file." }, { "payer_name": "UMR", "plan_name": "SUTTER SELECT & SUTTER HEALTH PLAN HMO PLANS", "methodology": "per diem", "standard_charge_dollar": 28538.0, "standard_charge_algorithm": "Per diem ($28,538).", "count": "0", "additional_payer_notes": "Zero final payments for the item or service in the 15 months prior to posting the file." }, { "payer_name": "UNITED HEALTHCARE", "plan_name": "SUTTER SELECT & SUTTER HEALTH PLAN HMO PLANS", "methodology": "per diem", "standard_charge_dollar": 28538.0, "standard_charge_algorithm": "Per diem ($28,538).", "count": "0", "additional_payer_notes": "Zero final payments for the item or service in the 15 months prior to posting the file." } ] } ] }, { "description": "HC IP Ccpd Training per Session", "code_information": [ { "code": "PX-1300000017", "type": "CDM" }, { "code": "99999", "type": "CPT" }, { "code": "0804", "type": "RC" } ], "standard_charges": [ { "setting": "outpatient", "gross_charge": 1697.0, "discounted_cash": 848.5, "minimum": 716.13, "maximum": 882.44, "additional_generic_notes": "Zero final payments for the item or service in the 15 months prior to posting the file.", "payers_information": [ { "payer_name": "AETNA", "plan_name": "AETNA ALL OTHER PLANS", "methodology": "percent of total billed charges", "standard_charge_dollar": 882.44, "standard_charge_percentage": 52.0, "count": "0", "additional_payer_notes": "Zero final payments for the item or service in the 15 months prior to posting the file." }, { "payer_name": "AETNA", "plan_name": "AETNA ALL OTHER PLANS", "methodology": "percent of total billed charges", "standard_charge_dollar": 882.44, "standard_charge_percentage": 52.0, "count": "0", "additional_payer_notes": "Zero final payments for the item or service in the 15 months prior to posting the file." }, { "payer_name": "MERITAIN HEALTH", "plan_name": "AETNA ALL OTHER PLANS", "methodology": "percent of total billed charges", "standard_charge_dollar": 882.44, "standard_charge_percentage": 52.0, "count": "0", "additional_payer_notes": "Zero final payments for the item or service in the 15 months prior to posting the file." }, { "payer_name": "BLUE SHIELD OUT OF STATE", "plan_name": "STANFORD HEALTHCARE ALLIANCE PLAN", "methodology": "percent of total billed charges", "standard_charge_dollar": 824.57, "standard_charge_percentage": 48.59, "count": "0", "additional_payer_notes": "Zero final payments for the item or service in the 15 months prior to posting the file." }, { "payer_name": "BLUE SHIELD", "plan_name": "STANFORD HEALTHCARE ALLIANCE PLAN", "methodology": "percent of total billed charges", "standard_charge_dollar": 824.57, "standard_charge_percentage": 48.59, "median_amount": 68.24, "10th_percentile": 13.6, "90th_percentile": 1043.06, "count": "30" }, { "payer_name": "BLUE SHIELD", "plan_name": "STANFORD HEALTHCARE ALLIANCE PLAN", "methodology": "percent of total billed charges", "standard_charge_dollar": 824.57, "standard_charge_percentage": 48.59, "count": "0", "additional_payer_notes": "Zero final payments for the item or service in the 15 months prior to posting the file." }, { "payer_name": "BLUE SHIELD", "plan_name": "STANFORD HEALTHCARE ALLIANCE PLAN", "methodology": "percent of total billed charges", "standard_charge_dollar": 824.57, "standard_charge_percentage": 48.59, "count": "0", "additional_payer_notes": "Zero final payments for the item or service in the 15 months prior to posting the file." }, { "payer_name": "CIGNA", "plan_name": "CIGNA COM ALT HMO PLAN", "methodology": "percent of total billed charges", "standard_charge_dollar": 716.13, "standard_charge_percentage": 42.2, "count": "0", "additional_payer_notes": "Zero final payments for the item or service in the 15 months prior to posting the file." }, { "payer_name": "CIGNA", "plan_name": "CIGNA COM ALT HMO PLAN", "methodology": "percent of total billed charges", "standard_charge_dollar": 716.13, "standard_charge_percentage": 42.2, "count": "0", "additional_payer_notes": "Zero final payments for the item or service in the 15 months prior to posting the file." }, { "payer_name": "HEALTH NET", "plan_name": "HEALTHNET HMO, PPO, POS, EPO, CANOPY HEALTHNET HMO, OTHER-IN-NETWORK PLANS", "methodology": "per diem", "standard_charge_dollar": 8000.0, "standard_charge_algorithm": "Expected reimbursement is the lesser of Per diem ($8,000) for the length of stay and 70% of billed.", "count": "0", "additional_payer_notes": "Zero final payments for the item or service in the 15 months prior to posting the file." }, { "payer_name": "HEALTH NET", "plan_name": "HEALTHNET HMO, PPO, POS, EPO, CANOPY HEALTHNET HMO, OTHER-IN-NETWORK PLANS", "methodology": "per diem", "standard_charge_dollar": 8000.0, "standard_charge_algorithm": "Expected reimbursement is the lesser of Per diem ($8,000) for the length of stay and 70% of billed.", "count": "0", "additional_payer_notes": "Zero final payments for the item or service in the 15 months prior to posting the file." }, { "payer_name": "UNITED HEALTHCARE", "plan_name": "SUTTER SELECT & SUTTER HEALTH PLAN HMO PLANS", "methodology": "per diem", "standard_charge_dollar": 28538.0, "standard_charge_algorithm": "Per diem ($28,538).", "count": "0", "additional_payer_notes": "Zero final payments for the item or service in the 15 months prior to posting the file." }, { "payer_name": "UNITED HEALTHCARE", "plan_name": "SUTTER SELECT & SUTTER HEALTH PLAN HMO PLANS", "methodology": "per diem", "standard_charge_dollar": 28538.0, "standard_charge_algorithm": "Per diem ($28,538).", "count": "0", "additional_payer_notes": "Zero final payments for the item or service in the 15 months prior to posting the file." }, { "payer_name": "SUTTER", "plan_name": "SUTTER SELECT & SUTTER HEALTH PLAN HMO PLANS", "methodology": "per diem", "standard_charge_dollar": 28538.0, "standard_charge_algorithm": "Per diem ($28,538).", "count": "0", "additional_payer_notes": "Zero final payments for the item or service in the 15 months prior to posting the file." }, { "payer_name": "UNITED HEALTHCARE", "plan_name": "SUTTER SELECT & SUTTER HEALTH PLAN HMO PLANS", "methodology": "per diem", "standard_charge_dollar": 28538.0, "standard_charge_algorithm": "Per diem ($28,538).", "count": "0", "additional_payer_notes": "Zero final payments for the item or service in the 15 months prior to posting the file." }, { "payer_name": "UMR", "plan_name": "SUTTER SELECT & SUTTER HEALTH PLAN HMO PLANS", "methodology": "per diem", "standard_charge_dollar": 28538.0, "standard_charge_algorithm": "Per diem ($28,538).", "count": "0", "additional_payer_notes": "Zero final payments for the item or service in the 15 months prior to posting the file." } ] } ] }, { "description": "HC Capd Home", "code_information": [ { "code": "PX-1300000018", "type": "CDM" }, { "code": "99999", "type": "CPT" }, { "code": "0841", "type": "RC" } ], "standard_charges": [ { "setting": "outpatient", "gross_charge": 817.0, "discounted_cash": 408.5, "minimum": 344.77, "maximum": 424.84, "additional_generic_notes": "Zero final payments for the item or service in the 15 months prior to posting the file.", "payers_information": [ { "payer_name": "AETNA", "plan_name": "AETNA ALL OTHER PLANS", "methodology": "percent of total billed charges", "standard_charge_dollar": 424.84, "standard_charge_percentage": 52.0, "count": "0", "additional_payer_notes": "Zero final payments for the item or service in the 15 months prior to posting the file." }, { "payer_name": "AETNA", "plan_name": "AETNA ALL OTHER PLANS", "methodology": "percent of total billed charges", "standard_charge_dollar": 424.84, "standard_charge_percentage": 52.0, "count": "0", "additional_payer_notes": "Zero final payments for the item or service in the 15 months prior to posting the file." }, { "payer_name": "MERITAIN HEALTH", "plan_name": "AETNA ALL OTHER PLANS", "methodology": "percent of total billed charges", "standard_charge_dollar": 424.84, "standard_charge_percentage": 52.0, "count": "0", "additional_payer_notes": "Zero final payments for the item or service in the 15 months prior to posting the file." }, { "payer_name": "BLUE SHIELD OUT OF STATE", "plan_name": "STANFORD HEALTHCARE ALLIANCE PLAN", "methodology": "percent of total billed charges", "standard_charge_dollar": 396.98, "standard_charge_percentage": 48.59, "count": "0", "additional_payer_notes": "Zero final payments for the item or service in the 15 months prior to posting the file." }, { "payer_name": "BLUE SHIELD", "plan_name": "STANFORD HEALTHCARE ALLIANCE PLAN", "methodology": "percent of total billed charges", "standard_charge_dollar": 396.98, "standard_charge_percentage": 48.59, "count": "0", "additional_payer_notes": "Zero final payments for the item or service in the 15 months prior to posting the file." }, { "payer_name": "BLUE SHIELD", "plan_name": "STANFORD HEALTHCARE ALLIANCE PLAN", "methodology": "percent of total billed charges", "standard_charge_dollar": 396.98, "standard_charge_percentage": 48.59, "count": "0", "additional_payer_notes": "Zero final payments for the item or service in the 15 months prior to posting the file." }, { "payer_name": "CIGNA", "plan_name": "CIGNA COM ALT HMO PLAN", "methodology": "percent of total billed charges", "standard_charge_dollar": 344.77, "standard_charge_percentage": 42.2, "count": "0", "additional_payer_notes": "Zero final payments for the item or service in the 15 months prior to posting the file." }, { "payer_name": "CIGNA", "plan_name": "CIGNA COM ALT HMO PLAN", "methodology": "percent of total billed charges", "standard_charge_dollar": 344.77, "standard_charge_percentage": 42.2, "count": "0", "additional_payer_notes": "Zero final payments for the item or service in the 15 months prior to posting the file." }, { "payer_name": "HEALTH NET", "plan_name": "HEALTHNET HMO, PPO, POS, EPO, CANOPY HEALTHNET HMO, OTHER-IN-NETWORK PLANS", "methodology": "per diem", "standard_charge_dollar": 8000.0, "standard_charge_algorithm": "Expected reimbursement is the lesser of Per diem ($8,000) for the length of stay and 70% of billed.", "count": "0", "additional_payer_notes": "Zero final payments for the item or service in the 15 months prior to posting the file." }, { "payer_name": "HEALTH NET", "plan_name": "HEALTHNET HMO, PPO, POS, EPO, CANOPY HEALTHNET HMO, OTHER-IN-NETWORK PLANS", "methodology": "per diem", "standard_charge_dollar": 8000.0, "standard_charge_algorithm": "Expected reimbursement is the lesser of Per diem ($8,000) for the length of stay and 70% of billed.", "count": "0", "additional_payer_notes": "Zero final payments for the item or service in the 15 months prior to posting the file." }, { "payer_name": "UNITED HEALTHCARE", "plan_name": "SUTTER SELECT & SUTTER HEALTH PLAN HMO PLANS", "methodology": "per diem", "standard_charge_dollar": 28538.0, "standard_charge_algorithm": "Per diem ($28,538).", "count": "0", "additional_payer_notes": "Zero final payments for the item or service in the 15 months prior to posting the file." }, { "payer_name": "UNITED HEALTHCARE", "plan_name": "SUTTER SELECT & SUTTER HEALTH PLAN HMO PLANS", "methodology": "per diem", "standard_charge_dollar": 28538.0, "standard_charge_algorithm": "Per diem ($28,538).", "count": "0", "additional_payer_notes": "Zero final payments for the item or service in the 15 months prior to posting the file." }, { "payer_name": "SUTTER", "plan_name": "SUTTER SELECT & SUTTER HEALTH PLAN HMO PLANS", "methodology": "per diem", "standard_charge_dollar": 28538.0, "standard_charge_algorithm": "Per diem ($28,538).", "count": "0", "additional_payer_notes": "Zero final payments for the item or service in the 15 months prior to posting the file." }, { "payer_name": "UNITED HEALTHCARE", "plan_name": "SUTTER SELECT & SUTTER HEALTH PLAN HMO PLANS", "methodology": "per diem", "standard_charge_dollar": 28538.0, "standard_charge_algorithm": "Per diem ($28,538).", "count": "0", "additional_payer_notes": "Zero final payments for the item or service in the 15 months prior to posting the file." }, { "payer_name": "UMR", "plan_name": "SUTTER SELECT & SUTTER HEALTH PLAN HMO PLANS", "methodology": "per diem", "standard_charge_dollar": 28538.0, "standard_charge_algorithm": "Per diem ($28,538).", "count": "0", "additional_payer_notes": "Zero final payments for the item or service in the 15 months prior to posting the file." } ] } ] }, { "description": "HC OP Ccpd Home", "code_information": [ { "code": "PX-1300000019", "type": "CDM" }, { "code": "99999", "type": "CPT" }, { "code": "0851", "type": "RC" } ], "standard_charges": [ { "setting": "outpatient", "gross_charge": 920.0, "discounted_cash": 460.0, "minimum": 388.24, "maximum": 478.4, "additional_generic_notes": "Zero final payments for the item or service in the 15 months prior to posting the file.", "payers_information": [ { "payer_name": "AETNA", "plan_name": "AETNA ALL OTHER PLANS", "methodology": "percent of total billed charges", "standard_charge_dollar": 478.4, "standard_charge_percentage": 52.0, "count": "0", "additional_payer_notes": "Zero final payments for the item or service in the 15 months prior to posting the file." }, { "payer_name": "AETNA", "plan_name": "AETNA ALL OTHER PLANS", "methodology": "percent of total billed charges", "standard_charge_dollar": 478.4, "standard_charge_percentage": 52.0, "count": "0", "additional_payer_notes": "Zero final payments for the item or service in the 15 months prior to posting the file." }, { "payer_name": "MERITAIN HEALTH", "plan_name": "AETNA ALL OTHER PLANS", "methodology": "percent of total billed charges", "standard_charge_dollar": 478.4, "standard_charge_percentage": 52.0, "count": "0", "additional_payer_notes": "Zero final payments for the item or service in the 15 months prior to posting the file." }, { "payer_name": "BLUE SHIELD OUT OF STATE", "plan_name": "STANFORD HEALTHCARE ALLIANCE PLAN", "methodology": "percent of total billed charges", "standard_charge_dollar": 447.03, "standard_charge_percentage": 48.59, "count": "0", "additional_payer_notes": "Zero final payments for the item or service in the 15 months prior to posting the file." }, { "payer_name": "BLUE SHIELD", "plan_name": "STANFORD HEALTHCARE ALLIANCE PLAN", "methodology": "percent of total billed charges", "standard_charge_dollar": 447.03, "standard_charge_percentage": 48.59, "count": "0", "additional_payer_notes": "Zero final payments for the item or service in the 15 months prior to posting the file." }, { "payer_name": "BLUE SHIELD", "plan_name": "STANFORD HEALTHCARE ALLIANCE PLAN", "methodology": "percent of total billed charges", "standard_charge_dollar": 447.03, "standard_charge_percentage": 48.59, "count": "0", "additional_payer_notes": "Zero final payments for the item or service in the 15 months prior to posting the file." }, { "payer_name": "CIGNA", "plan_name": "CIGNA COM ALT HMO PLAN", "methodology": "percent of total billed charges", "standard_charge_dollar": 388.24, "standard_charge_percentage": 42.2, "count": "0", "additional_payer_notes": "Zero final payments for the item or service in the 15 months prior to posting the file." }, { "payer_name": "CIGNA", "plan_name": "CIGNA COM ALT HMO PLAN", "methodology": "percent of total billed charges", "standard_charge_dollar": 388.24, "standard_charge_percentage": 42.2, "count": "0", "additional_payer_notes": "Zero final payments for the item or service in the 15 months prior to posting the file." }, { "payer_name": "HEALTH NET", "plan_name": "HEALTHNET HMO, PPO, POS, EPO, CANOPY HEALTHNET HMO, OTHER-IN-NETWORK PLANS", "methodology": "per diem", "standard_charge_dollar": 8000.0, "standard_charge_algorithm": "Expected reimbursement is the lesser of Per diem ($8,000) for the length of stay and 70% of billed.", "count": "0", "additional_payer_notes": "Zero final payments for the item or service in the 15 months prior to posting the file." }, { "payer_name": "HEALTH NET", "plan_name": "HEALTHNET HMO, PPO, POS, EPO, CANOPY HEALTHNET HMO, OTHER-IN-NETWORK PLANS", "methodology": "per diem", "standard_charge_dollar": 8000.0, "standard_charge_algorithm": "Expected reimbursement is the lesser of Per diem ($8,000) for the length of stay and 70% of billed.", "count": "0", "additional_payer_notes": "Zero final payments for the item or service in the 15 months prior to posting the file." }, { "payer_name": "UNITED HEALTHCARE", "plan_name": "SUTTER SELECT & SUTTER HEALTH PLAN HMO PLANS", "methodology": "per diem", "standard_charge_dollar": 28538.0, "standard_charge_algorithm": "Per diem ($28,538).", "count": "0", "additional_payer_notes": "Zero final payments for the item or service in the 15 months prior to posting the file." }, { "payer_name": "UNITED HEALTHCARE", "plan_name": "SUTTER SELECT & SUTTER HEALTH PLAN HMO PLANS", "methodology": "per diem", "standard_charge_dollar": 28538.0, "standard_charge_algorithm": "Per diem ($28,538).", "count": "0", "additional_payer_notes": "Zero final payments for the item or service in the 15 months prior to posting the file." }, { "payer_name": "SUTTER", "plan_name": "SUTTER SELECT & SUTTER HEALTH PLAN HMO PLANS", "methodology": "per diem", "standard_charge_dollar": 28538.0, "standard_charge_algorithm": "Per diem ($28,538).", "count": "0", "additional_payer_notes": "Zero final payments for the item or service in the 15 months prior to posting the file." }, { "payer_name": "UNITED HEALTHCARE", "plan_name": "SUTTER SELECT & SUTTER HEALTH PLAN HMO PLANS", "methodology": "per diem", "standard_charge_dollar": 28538.0, "standard_charge_algorithm": "Per diem ($28,538).", "count": "0", "additional_payer_notes": "Zero final payments for the item or service in the 15 months prior to posting the file." }, { "payer_name": "UMR", "plan_name": "SUTTER SELECT & SUTTER HEALTH PLAN HMO PLANS", "methodology": "per diem", "standard_charge_dollar": 28538.0, "standard_charge_algorithm": "Per diem ($28,538).", "count": "0", "additional_payer_notes": "Zero final payments for the item or service in the 15 months prior to posting the file." } ] } ] }, { "description": "HC OP Ccpd Training per Session", "code_information": [ { "code": "PX-1300000020", "type": "CDM" }, { "code": "99999", "type": "CPT" }, { "code": "0830", "type": "RC" } ], "standard_charges": [ { "setting": "outpatient", "gross_charge": 1697.0, "discounted_cash": 848.5, "minimum": 716.13, "maximum": 882.44, "additional_generic_notes": "Zero final payments for the item or service in the 15 months prior to posting the file.", "payers_information": [ { "payer_name": "AETNA", "plan_name": "AETNA ALL OTHER PLANS", "methodology": "percent of total billed charges", "standard_charge_dollar": 882.44, "standard_charge_percentage": 52.0, "count": "0", "additional_payer_notes": "Zero final payments for the item or service in the 15 months prior to posting the file." }, { "payer_name": "AETNA", "plan_name": "AETNA ALL OTHER PLANS", "methodology": "percent of total billed charges", "standard_charge_dollar": 882.44, "standard_charge_percentage": 52.0, "count": "0", "additional_payer_notes": "Zero final payments for the item or service in the 15 months prior to posting the file." }, { "payer_name": "MERITAIN HEALTH", "plan_name": "AETNA ALL OTHER PLANS", "methodology": "percent of total billed charges", "standard_charge_dollar": 882.44, "standard_charge_percentage": 52.0, "count": "0", "additional_payer_notes": "Zero final payments for the item or service in the 15 months prior to posting the file." }, { "payer_name": "BLUE SHIELD OUT OF STATE", "plan_name": "STANFORD HEALTHCARE ALLIANCE PLAN", "methodology": "percent of total billed charges", "standard_charge_dollar": 824.57, "standard_charge_percentage": 48.59, "count": "0", "additional_payer_notes": "Zero final payments for the item or service in the 15 months prior to posting the file." }, { "payer_name": "BLUE SHIELD", "plan_name": "STANFORD HEALTHCARE ALLIANCE PLAN", "methodology": "percent of total billed charges", "standard_charge_dollar": 824.57, "standard_charge_percentage": 48.59, "median_amount": 68.24, "10th_percentile": 13.6, "90th_percentile": 1043.06, "count": "30" }, { "payer_name": "BLUE SHIELD", "plan_name": "STANFORD HEALTHCARE ALLIANCE PLAN", "methodology": "percent of total billed charges", "standard_charge_dollar": 824.57, "standard_charge_percentage": 48.59, "count": "0", "additional_payer_notes": "Zero final payments for the item or service in the 15 months prior to posting the file." }, { "payer_name": "BLUE SHIELD", "plan_name": "STANFORD HEALTHCARE ALLIANCE PLAN", "methodology": "percent of total billed charges", "standard_charge_dollar": 824.57, "standard_charge_percentage": 48.59, "count": "0", "additional_payer_notes": "Zero final payments for the item or service in the 15 months prior to posting the file." }, { "payer_name": "CIGNA", "plan_name": "CIGNA COM ALT HMO PLAN", "methodology": "percent of total billed charges", "standard_charge_dollar": 716.13, "standard_charge_percentage": 42.2, "count": "0", "additional_payer_notes": "Zero final payments for the item or service in the 15 months prior to posting the file." }, { "payer_name": "CIGNA", "plan_name": "CIGNA COM ALT HMO PLAN", "methodology": "percent of total billed charges", "standard_charge_dollar": 716.13, "standard_charge_percentage": 42.2, "count": "0", "additional_payer_notes": "Zero final payments for the item or service in the 15 months prior to posting the file." }, { "payer_name": "HEALTH NET", "plan_name": "HEALTHNET HMO, PPO, POS, EPO, CANOPY HEALTHNET HMO, OTHER-IN-NETWORK PLANS", "methodology": "per diem", "standard_charge_dollar": 8000.0, "standard_charge_algorithm": "Expected reimbursement is the lesser of Per diem ($8,000) for the length of stay and 70% of billed.", "count": "0", "additional_payer_notes": "Zero final payments for the item or service in the 15 months prior to posting the file." }, { "payer_name": "HEALTH NET", "plan_name": "HEALTHNET HMO, PPO, POS, EPO, CANOPY HEALTHNET HMO, OTHER-IN-NETWORK PLANS", "methodology": "per diem", "standard_charge_dollar": 8000.0, "standard_charge_algorithm": "Expected reimbursement is the lesser of Per diem ($8,000) for the length of stay and 70% of billed.", "count": "0", "additional_payer_notes": "Zero final payments for the item or service in the 15 months prior to posting the file." }, { "payer_name": "UNITED HEALTHCARE", "plan_name": "SUTTER SELECT & SUTTER HEALTH PLAN HMO PLANS", "methodology": "per diem", "standard_charge_dollar": 28538.0, "standard_charge_algorithm": "Per diem ($28,538).", "count": "0", "additional_payer_notes": "Zero final payments for the item or service in the 15 months prior to posting the file." }, { "payer_name": "UNITED HEALTHCARE", "plan_name": "SUTTER SELECT & SUTTER HEALTH PLAN HMO PLANS", "methodology": "per diem", "standard_charge_dollar": 28538.0, "standard_charge_algorithm": "Per diem ($28,538).", "count": "0", "additional_payer_notes": "Zero final payments for the item or service in the 15 months prior to posting the file." }, { "payer_name": "SUTTER", "plan_name": "SUTTER SELECT & SUTTER HEALTH PLAN HMO PLANS", "methodology": "per diem", "standard_charge_dollar": 28538.0, "standard_charge_algorithm": "Per diem ($28,538).", "count": "0", "additional_payer_notes": "Zero final payments for the item or service in the 15 months prior to posting the file." }, { "payer_name": "UNITED HEALTHCARE", "plan_name": "SUTTER SELECT & SUTTER HEALTH PLAN HMO PLANS", "methodology": "per diem", "standard_charge_dollar": 28538.0, "standard_charge_algorithm": "Per diem ($28,538).", "count": "0", "additional_payer_notes": "Zero final payments for the item or service in the 15 months prior to posting the file." }, { "payer_name": "UMR", "plan_name": "SUTTER SELECT & SUTTER HEALTH PLAN HMO PLANS", "methodology": "per diem", "standard_charge_dollar": 28538.0, "standard_charge_algorithm": "Per diem ($28,538).", "count": "0", "additional_payer_notes": "Zero final payments for the item or service in the 15 months prior to posting the file." } ] } ] }, { "description": "HC Hemodialysis Access Flow Study IP", "code_information": [ { "code": "PX-1300000021", "type": "CDM" }, { "code": "90940", "type": "CPT" }, { "code": "0801", "type": "RC" } ], "standard_charges": [ { "setting": "outpatient", "gross_charge": 953.0, "discounted_cash": 476.5, "minimum": 402.17, "maximum": 495.56, "additional_generic_notes": "Zero final payments for the item or service in the 15 months prior to posting the file.", "payers_information": [ { "payer_name": "AETNA", "plan_name": "AETNA ALL OTHER PLANS", "methodology": "percent of total billed charges", "standard_charge_dollar": 495.56, "standard_charge_percentage": 52.0, "count": "0", "additional_payer_notes": "Zero final payments for the item or service in the 15 months prior to posting the file." }, { "payer_name": "AETNA", "plan_name": "AETNA ALL OTHER PLANS", "methodology": "percent of total billed charges", "standard_charge_dollar": 495.56, "standard_charge_percentage": 52.0, "count": "0", "additional_payer_notes": "Zero final payments for the item or service in the 15 months prior to posting the file." }, { "payer_name": "MERITAIN HEALTH", "plan_name": "AETNA ALL OTHER PLANS", "methodology": "percent of total billed charges", "standard_charge_dollar": 495.56, "standard_charge_percentage": 52.0, "count": "0", "additional_payer_notes": "Zero final payments for the item or service in the 15 months prior to posting the file." }, { "payer_name": "BLUE SHIELD OUT OF STATE", "plan_name": "STANFORD HEALTHCARE ALLIANCE PLAN", "methodology": "percent of total billed charges", "standard_charge_dollar": 463.06, "standard_charge_percentage": 48.59, "count": "0", "additional_payer_notes": "Zero final payments for the item or service in the 15 months prior to posting the file." }, { "payer_name": "BLUE SHIELD", "plan_name": "STANFORD HEALTHCARE ALLIANCE PLAN", "methodology": "percent of total billed charges", "standard_charge_dollar": 463.06, "standard_charge_percentage": 48.59, "median_amount": 456.75, "10th_percentile": 456.75, "90th_percentile": 456.75, "count": "1 through 10" }, { "payer_name": "BLUE SHIELD", "plan_name": "STANFORD HEALTHCARE ALLIANCE PLAN", "methodology": "percent of total billed charges", "standard_charge_dollar": 463.06, "standard_charge_percentage": 48.59, "count": "0", "additional_payer_notes": "Zero final payments for the item or service in the 15 months prior to posting the file." }, { "payer_name": "BLUE SHIELD", "plan_name": "STANFORD HEALTHCARE ALLIANCE PLAN", "methodology": "percent of total billed charges", "standard_charge_dollar": 463.06, "standard_charge_percentage": 48.59, "count": "0", "additional_payer_notes": "Zero final payments for the item or service in the 15 months prior to posting the file." }, { "payer_name": "CIGNA", "plan_name": "CIGNA COM ALT HMO PLAN", "methodology": "percent of total billed charges", "standard_charge_dollar": 402.17, "standard_charge_percentage": 42.2, "count": "0", "additional_payer_notes": "Zero final payments for the item or service in the 15 months prior to posting the file." }, { "payer_name": "CIGNA", "plan_name": "CIGNA COM ALT HMO PLAN", "methodology": "percent of total billed charges", "standard_charge_dollar": 402.17, "standard_charge_percentage": 42.2, "count": "0", "additional_payer_notes": "Zero final payments for the item or service in the 15 months prior to posting the file." }, { "payer_name": "HEALTH NET", "plan_name": "HEALTHNET HMO, PPO, POS, EPO, CANOPY HEALTHNET HMO, OTHER-IN-NETWORK PLANS", "methodology": "per diem", "standard_charge_dollar": 8000.0, "standard_charge_algorithm": "Expected reimbursement is the lesser of Per diem ($8,000) for the length of stay and 70% of billed.", "count": "0", "additional_payer_notes": "Zero final payments for the item or service in the 15 months prior to posting the file." }, { "payer_name": "HEALTH NET", "plan_name": "HEALTHNET HMO, PPO, POS, EPO, CANOPY HEALTHNET HMO, OTHER-IN-NETWORK PLANS", "methodology": "per diem", "standard_charge_dollar": 8000.0, "standard_charge_algorithm": "Expected reimbursement is the lesser of Per diem ($8,000) for the length of stay and 70% of billed.", "count": "0", "additional_payer_notes": "Zero final payments for the item or service in the 15 months prior to posting the file." }, { "payer_name": "UNITED HEALTHCARE", "plan_name": "SUTTER SELECT & SUTTER HEALTH PLAN HMO PLANS", "methodology": "per diem", "standard_charge_dollar": 28538.0, "standard_charge_algorithm": "Per diem ($28,538).", "count": "0", "additional_payer_notes": "Zero final payments for the item or service in the 15 months prior to posting the file." }, { "payer_name": "UNITED HEALTHCARE", "plan_name": "SUTTER SELECT & SUTTER HEALTH PLAN HMO PLANS", "methodology": "per diem", "standard_charge_dollar": 28538.0, "standard_charge_algorithm": "Per diem ($28,538).", "count": "0", "additional_payer_notes": "Zero final payments for the item or service in the 15 months prior to posting the file." }, { "payer_name": "SUTTER", "plan_name": "SUTTER SELECT & SUTTER HEALTH PLAN HMO PLANS", "methodology": "per diem", "standard_charge_dollar": 28538.0, "standard_charge_algorithm": "Per diem ($28,538).", "count": "0", "additional_payer_notes": "Zero final payments for the item or service in the 15 months prior to posting the file." }, { "payer_name": "UNITED HEALTHCARE", "plan_name": "SUTTER SELECT & SUTTER HEALTH PLAN HMO PLANS", "methodology": "per diem", "standard_charge_dollar": 28538.0, "standard_charge_algorithm": "Per diem ($28,538).", "count": "0", "additional_payer_notes": "Zero final payments for the item or service in the 15 months prior to posting the file." }, { "payer_name": "UMR", "plan_name": "SUTTER SELECT & SUTTER HEALTH PLAN HMO PLANS", "methodology": "per diem", "standard_charge_dollar": 28538.0, "standard_charge_algorithm": "Per diem ($28,538).", "count": "0", "additional_payer_notes": "Zero final payments for the item or service in the 15 months prior to posting the file." }, { "payer_name": "UNITED HEALTHCARE", "plan_name": "SUTTER SELECT & SUTTER HEALTH PLAN HMO PLANS", "methodology": "per diem", "standard_charge_dollar": 28538.0, "standard_charge_algorithm": "Per diem ($28,538).", "count": "0", "additional_payer_notes": "Zero final payments for the item or service in the 15 months prior to posting the file." } ] } ] }, { "description": "HC Ech Psych Day Care/30 Min", "code_information": [ { "code": "PX-1400000001", "type": "CDM" }, { "code": "99999", "type": "CPT" }, { "code": "0900", "type": "RC" } ], "standard_charges": [ { "setting": "outpatient", "gross_charge": 242.0, "discounted_cash": 121.0, "minimum": 102.12, "maximum": 125.84, "additional_generic_notes": "Zero final payments for the item or service in the 15 months prior to posting the file.", "payers_information": [ { "payer_name": "AETNA", "plan_name": "AETNA ALL OTHER PLANS", "methodology": "percent of total billed charges", "standard_charge_dollar": 125.84, "standard_charge_percentage": 52.0, "count": "0", "additional_payer_notes": "Zero final payments for the item or service in the 15 months prior to posting the file." }, { "payer_name": "AETNA", "plan_name": "AETNA ALL OTHER PLANS", "methodology": "percent of total billed charges", "standard_charge_dollar": 125.84, "standard_charge_percentage": 52.0, "count": "0", "additional_payer_notes": "Zero final payments for the item or service in the 15 months prior to posting the file." }, { "payer_name": "MERITAIN HEALTH", "plan_name": "AETNA ALL OTHER PLANS", "methodology": "percent of total billed charges", "standard_charge_dollar": 125.84, "standard_charge_percentage": 52.0, "count": "0", "additional_payer_notes": "Zero final payments for the item or service in the 15 months prior to posting the file." }, { "payer_name": "BLUE SHIELD OUT OF STATE", "plan_name": "STANFORD HEALTHCARE ALLIANCE PLAN", "methodology": "percent of total billed charges", "standard_charge_dollar": 117.59, "standard_charge_percentage": 48.59, "count": "0", "additional_payer_notes": "Zero final payments for the item or service in the 15 months prior to posting the file." }, { "payer_name": "BLUE SHIELD", "plan_name": "STANFORD HEALTHCARE ALLIANCE PLAN", "methodology": "percent of total billed charges", "standard_charge_dollar": 117.59, "standard_charge_percentage": 48.59, "count": "0", "additional_payer_notes": "Zero final payments for the item or service in the 15 months prior to posting the file." }, { "payer_name": "BLUE SHIELD", "plan_name": "STANFORD HEALTHCARE ALLIANCE PLAN", "methodology": "percent of total billed charges", "standard_charge_dollar": 117.59, "standard_charge_percentage": 48.59, "count": "0", "additional_payer_notes": "Zero final payments for the item or service in the 15 months prior to posting the file." }, { "payer_name": "CIGNA", "plan_name": "CIGNA COM ALT HMO PLAN", "methodology": "percent of total billed charges", "standard_charge_dollar": 102.12, "standard_charge_percentage": 42.2, "count": "0", "additional_payer_notes": "Zero final payments for the item or service in the 15 months prior to posting the file." }, { "payer_name": "CIGNA", "plan_name": "CIGNA COM ALT HMO PLAN", "methodology": "percent of total billed charges", "standard_charge_dollar": 102.12, "standard_charge_percentage": 42.2, "count": "0", "additional_payer_notes": "Zero final payments for the item or service in the 15 months prior to posting the file." }, { "payer_name": "HEALTH NET", "plan_name": "HEALTHNET HMO, PPO, POS, EPO, CANOPY HEALTHNET HMO, OTHER-IN-NETWORK PLANS", "methodology": "per diem", "standard_charge_dollar": 8000.0, "standard_charge_algorithm": "Expected reimbursement is the lesser of Per diem ($8,000) for the length of stay and 70% of billed.", "count": "0", "additional_payer_notes": "Zero final payments for the item or service in the 15 months prior to posting the file." }, { "payer_name": "HEALTH NET", "plan_name": "HEALTHNET HMO, PPO, POS, EPO, CANOPY HEALTHNET HMO, OTHER-IN-NETWORK PLANS", "methodology": "per diem", "standard_charge_dollar": 8000.0, "standard_charge_algorithm": "Expected reimbursement is the lesser of Per diem ($8,000) for the length of stay and 70% of billed.", "count": "0", "additional_payer_notes": "Zero final payments for the item or service in the 15 months prior to posting the file." }, { "payer_name": "UNITED HEALTHCARE", "plan_name": "SUTTER SELECT & SUTTER HEALTH PLAN HMO PLANS", "methodology": "per diem", "standard_charge_dollar": 28538.0, "standard_charge_algorithm": "Per diem ($28,538).", "count": "0", "additional_payer_notes": "Zero final payments for the item or service in the 15 months prior to posting the file." }, { "payer_name": "UNITED HEALTHCARE", "plan_name": "SUTTER SELECT & SUTTER HEALTH PLAN HMO PLANS", "methodology": "per diem", "standard_charge_dollar": 28538.0, "standard_charge_algorithm": "Per diem ($28,538).", "count": "0", "additional_payer_notes": "Zero final payments for the item or service in the 15 months prior to posting the file." }, { "payer_name": "SUTTER", "plan_name": "SUTTER SELECT & SUTTER HEALTH PLAN HMO PLANS", "methodology": "per diem", "standard_charge_dollar": 28538.0, "standard_charge_algorithm": "Per diem ($28,538).", "count": "0", "additional_payer_notes": "Zero final payments for the item or service in the 15 months prior to posting the file." }, { "payer_name": "UNITED HEALTHCARE", "plan_name": "SUTTER SELECT & SUTTER HEALTH PLAN HMO PLANS", "methodology": "per diem", "standard_charge_dollar": 28538.0, "standard_charge_algorithm": "Per diem ($28,538).", "count": "0", "additional_payer_notes": "Zero final payments for the item or service in the 15 months prior to posting the file." }, { "payer_name": "UMR", "plan_name": "SUTTER SELECT & SUTTER HEALTH PLAN HMO PLANS", "methodology": "per diem", "standard_charge_dollar": 28538.0, "standard_charge_algorithm": "Per diem ($28,538).", "count": "0", "additional_payer_notes": "Zero final payments for the item or service in the 15 months prior to posting the file." } ] } ] }, { "description": "HC Ech Psychosomatic Day Care", "code_information": [ { "code": "PX-1400000002", "type": "CDM" }, { "code": "99999", "type": "CPT" }, { "code": "0900", "type": "RC" } ], "standard_charges": [ { "setting": "outpatient", "gross_charge": 3190.0, "discounted_cash": 1595.0, "minimum": 1346.18, "maximum": 1658.8, "additional_generic_notes": "Zero final payments for the item or service in the 15 months prior to posting the file.", "payers_information": [ { "payer_name": "AETNA", "plan_name": "AETNA ALL OTHER PLANS", "methodology": "percent of total billed charges", "standard_charge_dollar": 1658.8, "standard_charge_percentage": 52.0, "count": "0", "additional_payer_notes": "Zero final payments for the item or service in the 15 months prior to posting the file." }, { "payer_name": "AETNA", "plan_name": "AETNA ALL OTHER PLANS", "methodology": "percent of total billed charges", "standard_charge_dollar": 1658.8, "standard_charge_percentage": 52.0, "count": "0", "additional_payer_notes": "Zero final payments for the item or service in the 15 months prior to posting the file." }, { "payer_name": "MERITAIN HEALTH", "plan_name": "AETNA ALL OTHER PLANS", "methodology": "percent of total billed charges", "standard_charge_dollar": 1658.8, "standard_charge_percentage": 52.0, "count": "0", "additional_payer_notes": "Zero final payments for the item or service in the 15 months prior to posting the file." }, { "payer_name": "BLUE SHIELD OUT OF STATE", "plan_name": "STANFORD HEALTHCARE ALLIANCE PLAN", "methodology": "percent of total billed charges", "standard_charge_dollar": 1550.02, "standard_charge_percentage": 48.59, "count": "0", "additional_payer_notes": "Zero final payments for the item or service in the 15 months prior to posting the file." }, { "payer_name": "BLUE SHIELD", "plan_name": "STANFORD HEALTHCARE ALLIANCE PLAN", "methodology": "percent of total billed charges", "standard_charge_dollar": 1550.02, "standard_charge_percentage": 48.59, "median_amount": 68.24, "10th_percentile": 13.6, "90th_percentile": 1043.06, "count": "30" }, { "payer_name": "BLUE SHIELD", "plan_name": "STANFORD HEALTHCARE ALLIANCE PLAN", "methodology": "percent of total billed charges", "standard_charge_dollar": 1550.02, "standard_charge_percentage": 48.59, "count": "0", "additional_payer_notes": "Zero final payments for the item or service in the 15 months prior to posting the file." }, { "payer_name": "BLUE SHIELD", "plan_name": "STANFORD HEALTHCARE ALLIANCE PLAN", "methodology": "percent of total billed charges", "standard_charge_dollar": 1550.02, "standard_charge_percentage": 48.59, "count": "0", "additional_payer_notes": "Zero final payments for the item or service in the 15 months prior to posting the file." }, { "payer_name": "CIGNA", "plan_name": "CIGNA COM ALT HMO PLAN", "methodology": "percent of total billed charges", "standard_charge_dollar": 1346.18, "standard_charge_percentage": 42.2, "count": "0", "additional_payer_notes": "Zero final payments for the item or service in the 15 months prior to posting the file." }, { "payer_name": "CIGNA", "plan_name": "CIGNA COM ALT HMO PLAN", "methodology": "percent of total billed charges", "standard_charge_dollar": 1346.18, "standard_charge_percentage": 42.2, "count": "0", "additional_payer_notes": "Zero final payments for the item or service in the 15 months prior to posting the file." }, { "payer_name": "HEALTH NET", "plan_name": "HEALTHNET HMO, PPO, POS, EPO, CANOPY HEALTHNET HMO, OTHER-IN-NETWORK PLANS", "methodology": "per diem", "standard_charge_dollar": 8000.0, "standard_charge_algorithm": "Expected reimbursement is the lesser of Per diem ($8,000) for the length of stay and 70% of billed.", "count": "0", "additional_payer_notes": "Zero final payments for the item or service in the 15 months prior to posting the file." }, { "payer_name": "HEALTH NET", "plan_name": "HEALTHNET HMO, PPO, POS, EPO, CANOPY HEALTHNET HMO, OTHER-IN-NETWORK PLANS", "methodology": "per diem", "standard_charge_dollar": 8000.0, "standard_charge_algorithm": "Expected reimbursement is the lesser of Per diem ($8,000) for the length of stay and 70% of billed.", "count": "0", "additional_payer_notes": "Zero final payments for the item or service in the 15 months prior to posting the file." }, { "payer_name": "UNITED HEALTHCARE", "plan_name": "SUTTER SELECT & SUTTER HEALTH PLAN HMO PLANS", "methodology": "per diem", "standard_charge_dollar": 28538.0, "standard_charge_algorithm": "Per diem ($28,538).", "count": "0", "additional_payer_notes": "Zero final payments for the item or service in the 15 months prior to posting the file." }, { "payer_name": "UNITED HEALTHCARE", "plan_name": "SUTTER SELECT & SUTTER HEALTH PLAN HMO PLANS", "methodology": "per diem", "standard_charge_dollar": 28538.0, "standard_charge_algorithm": "Per diem ($28,538).", "count": "0", "additional_payer_notes": "Zero final payments for the item or service in the 15 months prior to posting the file." }, { "payer_name": "SUTTER", "plan_name": "SUTTER SELECT & SUTTER HEALTH PLAN HMO PLANS", "methodology": "per diem", "standard_charge_dollar": 28538.0, "standard_charge_algorithm": "Per diem ($28,538).", "count": "0", "additional_payer_notes": "Zero final payments for the item or service in the 15 months prior to posting the file." }, { "payer_name": "UNITED HEALTHCARE", "plan_name": "SUTTER SELECT & SUTTER HEALTH PLAN HMO PLANS", "methodology": "per diem", "standard_charge_dollar": 28538.0, "standard_charge_algorithm": "Per diem ($28,538).", "count": "0", "additional_payer_notes": "Zero final payments for the item or service in the 15 months prior to posting the file." }, { "payer_name": "UMR", "plan_name": "SUTTER SELECT & SUTTER HEALTH PLAN HMO PLANS", "methodology": "per diem", "standard_charge_dollar": 28538.0, "standard_charge_algorithm": "Per diem ($28,538).", "count": "0", "additional_payer_notes": "Zero final payments for the item or service in the 15 months prior to posting the file." } ] } ] }, { "description": "HC Ech Patient Education 15 Min", "code_information": [ { "code": "PX-1400000003", "type": "CDM" }, { "code": "99999", "type": "CPT" }, { "code": "0233", "type": "RC" } ], "standard_charges": [ { "setting": "outpatient", "gross_charge": 99.0, "discounted_cash": 49.5, "minimum": 41.78, "maximum": 51.48, "additional_generic_notes": "Zero final payments for the item or service in the 15 months prior to posting the file.", "payers_information": [ { "payer_name": "AETNA", "plan_name": "AETNA ALL OTHER PLANS", "methodology": "percent of total billed charges", "standard_charge_dollar": 51.48, "standard_charge_percentage": 52.0, "count": "0", "additional_payer_notes": "Zero final payments for the item or service in the 15 months prior to posting the file." }, { "payer_name": "AETNA", "plan_name": "AETNA ALL OTHER PLANS", "methodology": "percent of total billed charges", "standard_charge_dollar": 51.48, "standard_charge_percentage": 52.0, "count": "0", "additional_payer_notes": "Zero final payments for the item or service in the 15 months prior to posting the file." }, { "payer_name": "MERITAIN HEALTH", "plan_name": "AETNA ALL OTHER PLANS", "methodology": "percent of total billed charges", "standard_charge_dollar": 51.48, "standard_charge_percentage": 52.0, "count": "0", "additional_payer_notes": "Zero final payments for the item or service in the 15 months prior to posting the file." }, { "payer_name": "BLUE SHIELD OUT OF STATE", "plan_name": "STANFORD HEALTHCARE ALLIANCE PLAN", "methodology": "percent of total billed charges", "standard_charge_dollar": 48.1, "standard_charge_percentage": 48.59, "count": "0", "additional_payer_notes": "Zero final payments for the item or service in the 15 months prior to posting the file." }, { "payer_name": "BLUE SHIELD", "plan_name": "STANFORD HEALTHCARE ALLIANCE PLAN", "methodology": "percent of total billed charges", "standard_charge_dollar": 48.1, "standard_charge_percentage": 48.59, "count": "0", "additional_payer_notes": "Zero final payments for the item or service in the 15 months prior to posting the file." }, { "payer_name": "BLUE SHIELD", "plan_name": "STANFORD HEALTHCARE ALLIANCE PLAN", "methodology": "percent of total billed charges", "standard_charge_dollar": 48.1, "standard_charge_percentage": 48.59, "count": "0", "additional_payer_notes": "Zero final payments for the item or service in the 15 months prior to posting the file." }, { "payer_name": "CIGNA", "plan_name": "CIGNA COM ALT HMO PLAN", "methodology": "percent of total billed charges", "standard_charge_dollar": 41.78, "standard_charge_percentage": 42.2, "count": "0", "additional_payer_notes": "Zero final payments for the item or service in the 15 months prior to posting the file." }, { "payer_name": "CIGNA", "plan_name": "CIGNA COM ALT HMO PLAN", "methodology": "percent of total billed charges", "standard_charge_dollar": 41.78, "standard_charge_percentage": 42.2, "count": "0", "additional_payer_notes": "Zero final payments for the item or service in the 15 months prior to posting the file." }, { "payer_name": "HEALTH NET", "plan_name": "HEALTHNET HMO, PPO, POS, EPO, CANOPY HEALTHNET HMO, OTHER-IN-NETWORK PLANS", "methodology": "per diem", "standard_charge_dollar": 8000.0, "standard_charge_algorithm": "Expected reimbursement is the lesser of Per diem ($8,000) for the length of stay and 70% of billed.", "count": "0", "additional_payer_notes": "Zero final payments for the item or service in the 15 months prior to posting the file." }, { "payer_name": "HEALTH NET", "plan_name": "HEALTHNET HMO, PPO, POS, EPO, CANOPY HEALTHNET HMO, OTHER-IN-NETWORK PLANS", "methodology": "per diem", "standard_charge_dollar": 8000.0, "standard_charge_algorithm": "Expected reimbursement is the lesser of Per diem ($8,000) for the length of stay and 70% of billed.", "count": "0", "additional_payer_notes": "Zero final payments for the item or service in the 15 months prior to posting the file." }, { "payer_name": "UNITED HEALTHCARE", "plan_name": "SUTTER SELECT & SUTTER HEALTH PLAN HMO PLANS", "methodology": "per diem", "standard_charge_dollar": 28538.0, "standard_charge_algorithm": "Per diem ($28,538).", "count": "0", "additional_payer_notes": "Zero final payments for the item or service in the 15 months prior to posting the file." }, { "payer_name": "UNITED HEALTHCARE", "plan_name": "SUTTER SELECT & SUTTER HEALTH PLAN HMO PLANS", "methodology": "per diem", "standard_charge_dollar": 28538.0, "standard_charge_algorithm": "Per diem ($28,538).", "count": "0", "additional_payer_notes": "Zero final payments for the item or service in the 15 months prior to posting the file." }, { "payer_name": "SUTTER", "plan_name": "SUTTER SELECT & SUTTER HEALTH PLAN HMO PLANS", "methodology": "per diem", "standard_charge_dollar": 28538.0, "standard_charge_algorithm": "Per diem ($28,538).", "count": "0", "additional_payer_notes": "Zero final payments for the item or service in the 15 months prior to posting the file." }, { "payer_name": "UNITED HEALTHCARE", "plan_name": "SUTTER SELECT & SUTTER HEALTH PLAN HMO PLANS", "methodology": "per diem", "standard_charge_dollar": 28538.0, "standard_charge_algorithm": "Per diem ($28,538).", "count": "0", "additional_payer_notes": "Zero final payments for the item or service in the 15 months prior to posting the file." }, { "payer_name": "UMR", "plan_name": "SUTTER SELECT & SUTTER HEALTH PLAN HMO PLANS", "methodology": "per diem", "standard_charge_dollar": 28538.0, "standard_charge_algorithm": "Per diem ($28,538).", "count": "0", "additional_payer_notes": "Zero final payments for the item or service in the 15 months prior to posting the file." } ] } ] }, { "description": "HC Tube Exchange Gp020", "code_information": [ { "code": "PX-2020243020", "type": "CDM" }, { "code": "99999", "type": "CPT" }, { "code": "0272", "type": "RC" } ], "standard_charges": [ { "setting": "outpatient", "gross_charge": 2550.0, "discounted_cash": 1275.0, "minimum": 1076.1, "maximum": 1326.0, "additional_generic_notes": "Zero final payments for the item or service in the 15 months prior to posting the file.", "payers_information": [ { "payer_name": "AETNA", "plan_name": "AETNA ALL OTHER PLANS", "methodology": "percent of total billed charges", "standard_charge_dollar": 1326.0, "standard_charge_percentage": 52.0, "count": "0", "additional_payer_notes": "Zero final payments for the item or service in the 15 months prior to posting the file." }, { "payer_name": "AETNA", "plan_name": "AETNA ALL OTHER PLANS", "methodology": "percent of total billed charges", "standard_charge_dollar": 1326.0, "standard_charge_percentage": 52.0, "count": "0", "additional_payer_notes": "Zero final payments for the item or service in the 15 months prior to posting the file." }, { "payer_name": "MERITAIN HEALTH", "plan_name": "AETNA ALL OTHER PLANS", "methodology": "percent of total billed charges", "standard_charge_dollar": 1326.0, "standard_charge_percentage": 52.0, "count": "0", "additional_payer_notes": "Zero final payments for the item or service in the 15 months prior to posting the file." }, { "payer_name": "BLUE SHIELD OUT OF STATE", "plan_name": "STANFORD HEALTHCARE ALLIANCE PLAN", "methodology": "percent of total billed charges", "standard_charge_dollar": 1239.05, "standard_charge_percentage": 48.59, "count": "0", "additional_payer_notes": "Zero final payments for the item or service in the 15 months prior to posting the file." }, { "payer_name": "BLUE SHIELD", "plan_name": "STANFORD HEALTHCARE ALLIANCE PLAN", "methodology": "percent of total billed charges", "standard_charge_dollar": 1239.05, "standard_charge_percentage": 48.59, "median_amount": 68.24, "10th_percentile": 13.6, "90th_percentile": 1043.06, "count": "30" }, { "payer_name": "BLUE SHIELD", "plan_name": "STANFORD HEALTHCARE ALLIANCE PLAN", "methodology": "percent of total billed charges", "standard_charge_dollar": 1239.05, "standard_charge_percentage": 48.59, "count": "0", "additional_payer_notes": "Zero final payments for the item or service in the 15 months prior to posting the file." }, { "payer_name": "BLUE SHIELD", "plan_name": "STANFORD HEALTHCARE ALLIANCE PLAN", "methodology": "percent of total billed charges", "standard_charge_dollar": 1239.05, "standard_charge_percentage": 48.59, "count": "0", "additional_payer_notes": "Zero final payments for the item or service in the 15 months prior to posting the file." }, { "payer_name": "CIGNA", "plan_name": "CIGNA COM ALT HMO PLAN", "methodology": "percent of total billed charges", "standard_charge_dollar": 1076.1, "standard_charge_percentage": 42.2, "count": "0", "additional_payer_notes": "Zero final payments for the item or service in the 15 months prior to posting the file." }, { "payer_name": "CIGNA", "plan_name": "CIGNA COM ALT HMO PLAN", "methodology": "percent of total billed charges", "standard_charge_dollar": 1076.1, "standard_charge_percentage": 42.2, "count": "0", "additional_payer_notes": "Zero final payments for the item or service in the 15 months prior to posting the file." }, { "payer_name": "HEALTH NET", "plan_name": "HEALTHNET HMO, PPO, POS, EPO, CANOPY HEALTHNET HMO, OTHER-IN-NETWORK PLANS", "methodology": "per diem", "standard_charge_dollar": 8000.0, "standard_charge_algorithm": "Expected reimbursement is the lesser of Per diem ($8,000) for the length of stay and 70% of billed.", "count": "0", "additional_payer_notes": "Zero final payments for the item or service in the 15 months prior to posting the file." }, { "payer_name": "HEALTH NET", "plan_name": "HEALTHNET HMO, PPO, POS, EPO, CANOPY HEALTHNET HMO, OTHER-IN-NETWORK PLANS", "methodology": "per diem", "standard_charge_dollar": 8000.0, "standard_charge_algorithm": "Expected reimbursement is the lesser of Per diem ($8,000) for the length of stay and 70% of billed.", "count": "0", "additional_payer_notes": "Zero final payments for the item or service in the 15 months prior to posting the file." }, { "payer_name": "UNITED HEALTHCARE", "plan_name": "SUTTER SELECT & SUTTER HEALTH PLAN HMO PLANS", "methodology": "per diem", "standard_charge_dollar": 28538.0, "standard_charge_algorithm": "Per diem ($28,538).", "count": "0", "additional_payer_notes": "Zero final payments for the item or service in the 15 months prior to posting the file." }, { "payer_name": "UNITED HEALTHCARE", "plan_name": "SUTTER SELECT & SUTTER HEALTH PLAN HMO PLANS", "methodology": "per diem", "standard_charge_dollar": 28538.0, "standard_charge_algorithm": "Per diem ($28,538).", "count": "0", "additional_payer_notes": "Zero final payments for the item or service in the 15 months prior to posting the file." }, { "payer_name": "SUTTER", "plan_name": "SUTTER SELECT & SUTTER HEALTH PLAN HMO PLANS", "methodology": "per diem", "standard_charge_dollar": 28538.0, "standard_charge_algorithm": "Per diem ($28,538).", "count": "0", "additional_payer_notes": "Zero final payments for the item or service in the 15 months prior to posting the file." }, { "payer_name": "UNITED HEALTHCARE", "plan_name": "SUTTER SELECT & SUTTER HEALTH PLAN HMO PLANS", "methodology": "per diem", "standard_charge_dollar": 28538.0, "standard_charge_algorithm": "Per diem ($28,538).", "count": "0", "additional_payer_notes": "Zero final payments for the item or service in the 15 months prior to posting the file." }, { "payer_name": "UMR", "plan_name": "SUTTER SELECT & SUTTER HEALTH PLAN HMO PLANS", "methodology": "per diem", "standard_charge_dollar": 28538.0, "standard_charge_algorithm": "Per diem ($28,538).", "count": "0", "additional_payer_notes": "Zero final payments for the item or service in the 15 months prior to posting the file." } ] } ] }, { "description": "HC Vad Pump Revolution Lev 19", "code_information": [ { "code": "PX-2100006019", "type": "CDM" }, { "code": "99999", "type": "CPT" }, { "code": "0272", "type": "RC" } ], "standard_charges": [ { "setting": "outpatient", "gross_charge": 2125.0, "discounted_cash": 1062.5, "minimum": 896.75, "maximum": 1105.0, "additional_generic_notes": "Zero final payments for the item or service in the 15 months prior to posting the file.", "payers_information": [ { "payer_name": "AETNA", "plan_name": "AETNA ALL OTHER PLANS", "methodology": "percent of total billed charges", "standard_charge_dollar": 1105.0, "standard_charge_percentage": 52.0, "count": "0", "additional_payer_notes": "Zero final payments for the item or service in the 15 months prior to posting the file." }, { "payer_name": "AETNA", "plan_name": "AETNA ALL OTHER PLANS", "methodology": "percent of total billed charges", "standard_charge_dollar": 1105.0, "standard_charge_percentage": 52.0, "count": "0", "additional_payer_notes": "Zero final payments for the item or service in the 15 months prior to posting the file." }, { "payer_name": "MERITAIN HEALTH", "plan_name": "AETNA ALL OTHER PLANS", "methodology": "percent of total billed charges", "standard_charge_dollar": 1105.0, "standard_charge_percentage": 52.0, "count": "0", "additional_payer_notes": "Zero final payments for the item or service in the 15 months prior to posting the file." }, { "payer_name": "BLUE SHIELD OUT OF STATE", "plan_name": "STANFORD HEALTHCARE ALLIANCE PLAN", "methodology": "percent of total billed charges", "standard_charge_dollar": 1032.54, "standard_charge_percentage": 48.59, "count": "0", "additional_payer_notes": "Zero final payments for the item or service in the 15 months prior to posting the file." }, { "payer_name": "BLUE SHIELD", "plan_name": "STANFORD HEALTHCARE ALLIANCE PLAN", "methodology": "percent of total billed charges", "standard_charge_dollar": 1032.54, "standard_charge_percentage": 48.59, "median_amount": 68.24, "10th_percentile": 13.6, "90th_percentile": 1043.06, "count": "30" }, { "payer_name": "BLUE SHIELD", "plan_name": "STANFORD HEALTHCARE ALLIANCE PLAN", "methodology": "percent of total billed charges", "standard_charge_dollar": 1032.54, "standard_charge_percentage": 48.59, "count": "0", "additional_payer_notes": "Zero final payments for the item or service in the 15 months prior to posting the file." }, { "payer_name": "BLUE SHIELD", "plan_name": "STANFORD HEALTHCARE ALLIANCE PLAN", "methodology": "percent of total billed charges", "standard_charge_dollar": 1032.54, "standard_charge_percentage": 48.59, "count": "0", "additional_payer_notes": "Zero final payments for the item or service in the 15 months prior to posting the file." }, { "payer_name": "CIGNA", "plan_name": "CIGNA COM ALT HMO PLAN", "methodology": "percent of total billed charges", "standard_charge_dollar": 896.75, "standard_charge_percentage": 42.2, "count": "0", "additional_payer_notes": "Zero final payments for the item or service in the 15 months prior to posting the file." }, { "payer_name": "CIGNA", "plan_name": "CIGNA COM ALT HMO PLAN", "methodology": "percent of total billed charges", "standard_charge_dollar": 896.75, "standard_charge_percentage": 42.2, "count": "0", "additional_payer_notes": "Zero final payments for the item or service in the 15 months prior to posting the file." }, { "payer_name": "HEALTH NET", "plan_name": "HEALTHNET HMO, PPO, POS, EPO, CANOPY HEALTHNET HMO, OTHER-IN-NETWORK PLANS", "methodology": "per diem", "standard_charge_dollar": 8000.0, "standard_charge_algorithm": "Expected reimbursement is the lesser of Per diem ($8,000) for the length of stay and 70% of billed.", "count": "0", "additional_payer_notes": "Zero final payments for the item or service in the 15 months prior to posting the file." }, { "payer_name": "HEALTH NET", "plan_name": "HEALTHNET HMO, PPO, POS, EPO, CANOPY HEALTHNET HMO, OTHER-IN-NETWORK PLANS", "methodology": "per diem", "standard_charge_dollar": 8000.0, "standard_charge_algorithm": "Expected reimbursement is the lesser of Per diem ($8,000) for the length of stay and 70% of billed.", "count": "0", "additional_payer_notes": "Zero final payments for the item or service in the 15 months prior to posting the file." }, { "payer_name": "UNITED HEALTHCARE", "plan_name": "SUTTER SELECT & SUTTER HEALTH PLAN HMO PLANS", "methodology": "per diem", "standard_charge_dollar": 28538.0, "standard_charge_algorithm": "Per diem ($28,538).", "count": "0", "additional_payer_notes": "Zero final payments for the item or service in the 15 months prior to posting the file." }, { "payer_name": "UNITED HEALTHCARE", "plan_name": "SUTTER SELECT & SUTTER HEALTH PLAN HMO PLANS", "methodology": "per diem", "standard_charge_dollar": 28538.0, "standard_charge_algorithm": "Per diem ($28,538).", "count": "0", "additional_payer_notes": "Zero final payments for the item or service in the 15 months prior to posting the file." }, { "payer_name": "SUTTER", "plan_name": "SUTTER SELECT & SUTTER HEALTH PLAN HMO PLANS", "methodology": "per diem", "standard_charge_dollar": 28538.0, "standard_charge_algorithm": "Per diem ($28,538).", "count": "0", "additional_payer_notes": "Zero final payments for the item or service in the 15 months prior to posting the file." }, { "payer_name": "UNITED HEALTHCARE", "plan_name": "SUTTER SELECT & SUTTER HEALTH PLAN HMO PLANS", "methodology": "per diem", "standard_charge_dollar": 28538.0, "standard_charge_algorithm": "Per diem ($28,538).", "count": "0", "additional_payer_notes": "Zero final payments for the item or service in the 15 months prior to posting the file." }, { "payer_name": "UMR", "plan_name": "SUTTER SELECT & SUTTER HEALTH PLAN HMO PLANS", "methodology": "per diem", "standard_charge_dollar": 28538.0, "standard_charge_algorithm": "Per diem ($28,538).", "count": "0", "additional_payer_notes": "Zero final payments for the item or service in the 15 months prior to posting the file." } ] } ] }, { "description": "HC Impl Placeholder", "code_information": [ { "code": "PX-2100009998", "type": "CDM" }, { "code": "99999", "type": "CPT" }, { "code": "0272", "type": "RC" } ], "standard_charges": [ { "setting": "outpatient", "gross_charge": 0.01, "minimum": 0.01, "maximum": 0.01, "additional_generic_notes": "Zero final payments for the item or service in the 15 months prior to posting the file.", "payers_information": [ { "payer_name": "AETNA", "plan_name": "AETNA ALL OTHER PLANS", "methodology": "percent of total billed charges", "standard_charge_dollar": 0.01, "standard_charge_percentage": 52.0, "count": "0", "additional_payer_notes": "Zero final payments for the item or service in the 15 months prior to posting the file." }, { "payer_name": "AETNA", "plan_name": "AETNA ALL OTHER PLANS", "methodology": "percent of total billed charges", "standard_charge_dollar": 0.01, "standard_charge_percentage": 52.0, "count": "0", "additional_payer_notes": "Zero final payments for the item or service in the 15 months prior to posting the file." }, { "payer_name": "MERITAIN HEALTH", "plan_name": "AETNA ALL OTHER PLANS", "methodology": "percent of total billed charges", "standard_charge_dollar": 0.01, "standard_charge_percentage": 52.0, "count": "0", "additional_payer_notes": "Zero final payments for the item or service in the 15 months prior to posting the file." }, { "payer_name": "BLUE SHIELD OUT OF STATE", "plan_name": "STANFORD HEALTHCARE ALLIANCE PLAN", "methodology": "percent of total billed charges", "standard_charge_percentage": 48.59, "count": "0", "additional_payer_notes": "Zero final payments for the item or service in the 15 months prior to posting the file. standard_charge|negotiated_dollar calculated as 0;" }, { "payer_name": "BLUE SHIELD", "plan_name": "STANFORD HEALTHCARE ALLIANCE PLAN", "methodology": "percent of total billed charges", "standard_charge_percentage": 48.59, "count": "0", "additional_payer_notes": "Zero final payments for the item or service in the 15 months prior to posting the file. standard_charge|negotiated_dollar calculated as 0;" }, { "payer_name": "BLUE SHIELD", "plan_name": "STANFORD HEALTHCARE ALLIANCE PLAN", "methodology": "percent of total billed charges", "standard_charge_percentage": 48.59, "count": "0", "additional_payer_notes": "Zero final payments for the item or service in the 15 months prior to posting the file. standard_charge|negotiated_dollar calculated as 0;" }, { "payer_name": "CIGNA", "plan_name": "CIGNA COM ALT HMO PLAN", "methodology": "percent of total billed charges", "standard_charge_percentage": 42.2, "count": "0", "additional_payer_notes": "Zero final payments for the item or service in the 15 months prior to posting the file. standard_charge|negotiated_dollar calculated as 0;" }, { "payer_name": "CIGNA", "plan_name": "CIGNA COM ALT HMO PLAN", "methodology": "percent of total billed charges", "standard_charge_percentage": 42.2, "count": "0", "additional_payer_notes": "Zero final payments for the item or service in the 15 months prior to posting the file. standard_charge|negotiated_dollar calculated as 0;" }, { "payer_name": "HEALTH NET", "plan_name": "HEALTHNET HMO, PPO, POS, EPO, CANOPY HEALTHNET HMO, OTHER-IN-NETWORK PLANS", "methodology": "per diem", "standard_charge_dollar": 8000.0, "standard_charge_algorithm": "Expected reimbursement is the lesser of Per diem ($8,000) for the length of stay and 70% of billed.", "count": "0", "additional_payer_notes": "Zero final payments for the item or service in the 15 months prior to posting the file." }, { "payer_name": "HEALTH NET", "plan_name": "HEALTHNET HMO, PPO, POS, EPO, CANOPY HEALTHNET HMO, OTHER-IN-NETWORK PLANS", "methodology": "per diem", "standard_charge_dollar": 8000.0, "standard_charge_algorithm": "Expected reimbursement is the lesser of Per diem ($8,000) for the length of stay and 70% of billed.", "count": "0", "additional_payer_notes": "Zero final payments for the item or service in the 15 months prior to posting the file." }, { "payer_name": "UNITED HEALTHCARE", "plan_name": "SUTTER SELECT & SUTTER HEALTH PLAN HMO PLANS", "methodology": "per diem", "standard_charge_dollar": 28538.0, "standard_charge_algorithm": "Per diem ($28,538).", "count": "0", "additional_payer_notes": "Zero final payments for the item or service in the 15 months prior to posting the file." }, { "payer_name": "UNITED HEALTHCARE", "plan_name": "SUTTER SELECT & SUTTER HEALTH PLAN HMO PLANS", "methodology": "per diem", "standard_charge_dollar": 28538.0, "standard_charge_algorithm": "Per diem ($28,538).", "count": "0", "additional_payer_notes": "Zero final payments for the item or service in the 15 months prior to posting the file." }, { "payer_name": "SUTTER", "plan_name": "SUTTER SELECT & SUTTER HEALTH PLAN HMO PLANS", "methodology": "per diem", "standard_charge_dollar": 28538.0, "standard_charge_algorithm": "Per diem ($28,538).", "count": "0", "additional_payer_notes": "Zero final payments for the item or service in the 15 months prior to posting the file." }, { "payer_name": "UNITED HEALTHCARE", "plan_name": "SUTTER SELECT & SUTTER HEALTH PLAN HMO PLANS", "methodology": "per diem", "standard_charge_dollar": 28538.0, "standard_charge_algorithm": "Per diem ($28,538).", "count": "0", "additional_payer_notes": "Zero final payments for the item or service in the 15 months prior to posting the file." }, { "payer_name": "UMR", "plan_name": "SUTTER SELECT & SUTTER HEALTH PLAN HMO PLANS", "methodology": "per diem", "standard_charge_dollar": 28538.0, "standard_charge_algorithm": "Per diem ($28,538).", "count": "0", "additional_payer_notes": "Zero final payments for the item or service in the 15 months prior to posting the file." } ] } ] }, { "description": "HC Supply Placeholder", "code_information": [ { "code": "PX-2100009999", "type": "CDM" }, { "code": "99999", "type": "CPT" }, { "code": "0999", "type": "RC" } ], "standard_charges": [ { "setting": "outpatient", "gross_charge": 0.01, "minimum": 0.01, "maximum": 0.01, "additional_generic_notes": "Zero final payments for the item or service in the 15 months prior to posting the file.", "payers_information": [ { "payer_name": "AETNA", "plan_name": "AETNA ALL OTHER PLANS", "methodology": "percent of total billed charges", "standard_charge_dollar": 0.01, "standard_charge_percentage": 52.0, "count": "0", "additional_payer_notes": "Zero final payments for the item or service in the 15 months prior to posting the file." }, { "payer_name": "AETNA", "plan_name": "AETNA ALL OTHER PLANS", "methodology": "percent of total billed charges", "standard_charge_dollar": 0.01, "standard_charge_percentage": 52.0, "count": "0", "additional_payer_notes": "Zero final payments for the item or service in the 15 months prior to posting the file." }, { "payer_name": "MERITAIN HEALTH", "plan_name": "AETNA ALL OTHER PLANS", "methodology": "percent of total billed charges", "standard_charge_dollar": 0.01, "standard_charge_percentage": 52.0, "count": "0", "additional_payer_notes": "Zero final payments for the item or service in the 15 months prior to posting the file." }, { "payer_name": "BLUE SHIELD OUT OF STATE", "plan_name": "STANFORD HEALTHCARE ALLIANCE PLAN", "methodology": "percent of total billed charges", "standard_charge_percentage": 48.59, "count": "0", "additional_payer_notes": "Zero final payments for the item or service in the 15 months prior to posting the file. standard_charge|negotiated_dollar calculated as 0;" }, { "payer_name": "BLUE SHIELD", "plan_name": "STANFORD HEALTHCARE ALLIANCE PLAN", "methodology": "percent of total billed charges", "standard_charge_percentage": 48.59, "count": "0", "additional_payer_notes": "Zero final payments for the item or service in the 15 months prior to posting the file. standard_charge|negotiated_dollar calculated as 0;" }, { "payer_name": "BLUE SHIELD", "plan_name": "STANFORD HEALTHCARE ALLIANCE PLAN", "methodology": "percent of total billed charges", "standard_charge_percentage": 48.59, "count": "0", "additional_payer_notes": "Zero final payments for the item or service in the 15 months prior to posting the file. standard_charge|negotiated_dollar calculated as 0;" }, { "payer_name": "CIGNA", "plan_name": "CIGNA COM ALT HMO PLAN", "methodology": "percent of total billed charges", "standard_charge_percentage": 42.2, "count": "0", "additional_payer_notes": "Zero final payments for the item or service in the 15 months prior to posting the file. standard_charge|negotiated_dollar calculated as 0;" }, { "payer_name": "CIGNA", "plan_name": "CIGNA COM ALT HMO PLAN", "methodology": "percent of total billed charges", "standard_charge_percentage": 42.2, "count": "0", "additional_payer_notes": "Zero final payments for the item or service in the 15 months prior to posting the file. standard_charge|negotiated_dollar calculated as 0;" }, { "payer_name": "HEALTH NET", "plan_name": "HEALTHNET HMO, PPO, POS, EPO, CANOPY HEALTHNET HMO, OTHER-IN-NETWORK PLANS", "methodology": "per diem", "standard_charge_dollar": 8000.0, "standard_charge_algorithm": "Expected reimbursement is the lesser of Per diem ($8,000) for the length of stay and 70% of billed.", "count": "0", "additional_payer_notes": "Zero final payments for the item or service in the 15 months prior to posting the file." }, { "payer_name": "HEALTH NET", "plan_name": "HEALTHNET HMO, PPO, POS, EPO, CANOPY HEALTHNET HMO, OTHER-IN-NETWORK PLANS", "methodology": "per diem", "standard_charge_dollar": 8000.0, "standard_charge_algorithm": "Expected reimbursement is the lesser of Per diem ($8,000) for the length of stay and 70% of billed.", "count": "0", "additional_payer_notes": "Zero final payments for the item or service in the 15 months prior to posting the file." }, { "payer_name": "UNITED HEALTHCARE", "plan_name": "SUTTER SELECT & SUTTER HEALTH PLAN HMO PLANS", "methodology": "per diem", "standard_charge_dollar": 28538.0, "standard_charge_algorithm": "Per diem ($28,538).", "count": "0", "additional_payer_notes": "Zero final payments for the item or service in the 15 months prior to posting the file." }, { "payer_name": "UNITED HEALTHCARE", "plan_name": "SUTTER SELECT & SUTTER HEALTH PLAN HMO PLANS", "methodology": "per diem", "standard_charge_dollar": 28538.0, "standard_charge_algorithm": "Per diem ($28,538).", "count": "0", "additional_payer_notes": "Zero final payments for the item or service in the 15 months prior to posting the file." }, { "payer_name": "SUTTER", "plan_name": "SUTTER SELECT & SUTTER HEALTH PLAN HMO PLANS", "methodology": "per diem", "standard_charge_dollar": 28538.0, "standard_charge_algorithm": "Per diem ($28,538).", "count": "0", "additional_payer_notes": "Zero final payments for the item or service in the 15 months prior to posting the file." }, { "payer_name": "UNITED HEALTHCARE", "plan_name": "SUTTER SELECT & SUTTER HEALTH PLAN HMO PLANS", "methodology": "per diem", "standard_charge_dollar": 28538.0, "standard_charge_algorithm": "Per diem ($28,538).", "count": "0", "additional_payer_notes": "Zero final payments for the item or service in the 15 months prior to posting the file." }, { "payer_name": "UMR", "plan_name": "SUTTER SELECT & SUTTER HEALTH PLAN HMO PLANS", "methodology": "per diem", "standard_charge_dollar": 28538.0, "standard_charge_algorithm": "Per diem ($28,538).", "count": "0", "additional_payer_notes": "Zero final payments for the item or service in the 15 months prior to posting the file." } ] } ] }, { "description": "HC Soln Lactated Ringers 3l", "code_information": [ { "code": "PX-2110000004", "type": "CDM" }, { "code": "99999", "type": "CPT" }, { "code": "0258", "type": "RC" } ], "standard_charges": [ { "setting": "outpatient", "gross_charge": 50.0, "discounted_cash": 25.0, "minimum": 21.1, "maximum": 26.0, "additional_generic_notes": "Zero final payments for the item or service in the 15 months prior to posting the file.", "payers_information": [ { "payer_name": "AETNA", "plan_name": "AETNA ALL OTHER PLANS", "methodology": "percent of total billed charges", "standard_charge_dollar": 26.0, "standard_charge_percentage": 52.0, "count": "0", "additional_payer_notes": "Zero final payments for the item or service in the 15 months prior to posting the file." }, { "payer_name": "AETNA", "plan_name": "AETNA ALL OTHER PLANS", "methodology": "percent of total billed charges", "standard_charge_dollar": 26.0, "standard_charge_percentage": 52.0, "count": "0", "additional_payer_notes": "Zero final payments for the item or service in the 15 months prior to posting the file." }, { "payer_name": "MERITAIN HEALTH", "plan_name": "AETNA ALL OTHER PLANS", "methodology": "percent of total billed charges", "standard_charge_dollar": 26.0, "standard_charge_percentage": 52.0, "count": "0", "additional_payer_notes": "Zero final payments for the item or service in the 15 months prior to posting the file." }, { "payer_name": "BLUE SHIELD OUT OF STATE", "plan_name": "STANFORD HEALTHCARE ALLIANCE PLAN", "methodology": "percent of total billed charges", "standard_charge_dollar": 24.3, "standard_charge_percentage": 48.59, "count": "0", "additional_payer_notes": "Zero final payments for the item or service in the 15 months prior to posting the file." }, { "payer_name": "BLUE SHIELD", "plan_name": "STANFORD HEALTHCARE ALLIANCE PLAN", "methodology": "percent of total billed charges", "standard_charge_dollar": 24.3, "standard_charge_percentage": 48.59, "count": "0", "additional_payer_notes": "Zero final payments for the item or service in the 15 months prior to posting the file." }, { "payer_name": "BLUE SHIELD", "plan_name": "STANFORD HEALTHCARE ALLIANCE PLAN", "methodology": "percent of total billed charges", "standard_charge_dollar": 24.3, "standard_charge_percentage": 48.59, "count": "0", "additional_payer_notes": "Zero final payments for the item or service in the 15 months prior to posting the file." }, { "payer_name": "CIGNA", "plan_name": "CIGNA COM ALT HMO PLAN", "methodology": "percent of total billed charges", "standard_charge_dollar": 21.1, "standard_charge_percentage": 42.2, "count": "0", "additional_payer_notes": "Zero final payments for the item or service in the 15 months prior to posting the file." }, { "payer_name": "CIGNA", "plan_name": "CIGNA COM ALT HMO PLAN", "methodology": "percent of total billed charges", "standard_charge_dollar": 21.1, "standard_charge_percentage": 42.2, "count": "0", "additional_payer_notes": "Zero final payments for the item or service in the 15 months prior to posting the file." }, { "payer_name": "HEALTH NET", "plan_name": "HEALTHNET HMO, PPO, POS, EPO, CANOPY HEALTHNET HMO, OTHER-IN-NETWORK PLANS", "methodology": "per diem", "standard_charge_dollar": 8000.0, "standard_charge_algorithm": "Expected reimbursement is the lesser of Per diem ($8,000) for the length of stay and 70% of billed.", "count": "0", "additional_payer_notes": "Zero final payments for the item or service in the 15 months prior to posting the file." }, { "payer_name": "HEALTH NET", "plan_name": "HEALTHNET HMO, PPO, POS, EPO, CANOPY HEALTHNET HMO, OTHER-IN-NETWORK PLANS", "methodology": "per diem", "standard_charge_dollar": 8000.0, "standard_charge_algorithm": "Expected reimbursement is the lesser of Per diem ($8,000) for the length of stay and 70% of billed.", "count": "0", "additional_payer_notes": "Zero final payments for the item or service in the 15 months prior to posting the file." }, { "payer_name": "UNITED HEALTHCARE", "plan_name": "SUTTER SELECT & SUTTER HEALTH PLAN HMO PLANS", "methodology": "per diem", "standard_charge_dollar": 28538.0, "standard_charge_algorithm": "Per diem ($28,538).", "count": "0", "additional_payer_notes": "Zero final payments for the item or service in the 15 months prior to posting the file." }, { "payer_name": "UNITED HEALTHCARE", "plan_name": "SUTTER SELECT & SUTTER HEALTH PLAN HMO PLANS", "methodology": "per diem", "standard_charge_dollar": 28538.0, "standard_charge_algorithm": "Per diem ($28,538).", "count": "0", "additional_payer_notes": "Zero final payments for the item or service in the 15 months prior to posting the file." }, { "payer_name": "SUTTER", "plan_name": "SUTTER SELECT & SUTTER HEALTH PLAN HMO PLANS", "methodology": "per diem", "standard_charge_dollar": 28538.0, "standard_charge_algorithm": "Per diem ($28,538).", "count": "0", "additional_payer_notes": "Zero final payments for the item or service in the 15 months prior to posting the file." }, { "payer_name": "UNITED HEALTHCARE", "plan_name": "SUTTER SELECT & SUTTER HEALTH PLAN HMO PLANS", "methodology": "per diem", "standard_charge_dollar": 28538.0, "standard_charge_algorithm": "Per diem ($28,538).", "count": "0", "additional_payer_notes": "Zero final payments for the item or service in the 15 months prior to posting the file." }, { "payer_name": "UMR", "plan_name": "SUTTER SELECT & SUTTER HEALTH PLAN HMO PLANS", "methodology": "per diem", "standard_charge_dollar": 28538.0, "standard_charge_algorithm": "Per diem ($28,538).", "count": "0", "additional_payer_notes": "Zero final payments for the item or service in the 15 months prior to posting the file." } ] } ] }, { "description": "HC Tobradex Ointment 3.5g", "code_information": [ { "code": "PX-2110000005", "type": "CDM" }, { "code": "99999", "type": "CPT" }, { "code": "0270", "type": "RC" } ], "standard_charges": [ { "setting": "outpatient", "gross_charge": 123.3, "discounted_cash": 61.65, "minimum": 52.03, "maximum": 64.12, "additional_generic_notes": "Zero final payments for the item or service in the 15 months prior to posting the file.", "payers_information": [ { "payer_name": "AETNA", "plan_name": "AETNA ALL OTHER PLANS", "methodology": "percent of total billed charges", "standard_charge_dollar": 64.12, "standard_charge_percentage": 52.0, "count": "0", "additional_payer_notes": "Zero final payments for the item or service in the 15 months prior to posting the file." }, { "payer_name": "AETNA", "plan_name": "AETNA ALL OTHER PLANS", "methodology": "percent of total billed charges", "standard_charge_dollar": 64.12, "standard_charge_percentage": 52.0, "count": "0", "additional_payer_notes": "Zero final payments for the item or service in the 15 months prior to posting the file." }, { "payer_name": "MERITAIN HEALTH", "plan_name": "AETNA ALL OTHER PLANS", "methodology": "percent of total billed charges", "standard_charge_dollar": 64.12, "standard_charge_percentage": 52.0, "count": "0", "additional_payer_notes": "Zero final payments for the item or service in the 15 months prior to posting the file." }, { "payer_name": "BLUE SHIELD OUT OF STATE", "plan_name": "STANFORD HEALTHCARE ALLIANCE PLAN", "methodology": "percent of total billed charges", "standard_charge_dollar": 59.91, "standard_charge_percentage": 48.59, "count": "0", "additional_payer_notes": "Zero final payments for the item or service in the 15 months prior to posting the file." }, { "payer_name": "BLUE SHIELD", "plan_name": "STANFORD HEALTHCARE ALLIANCE PLAN", "methodology": "percent of total billed charges", "standard_charge_dollar": 59.91, "standard_charge_percentage": 48.59, "count": "0", "additional_payer_notes": "Zero final payments for the item or service in the 15 months prior to posting the file." }, { "payer_name": "BLUE SHIELD", "plan_name": "STANFORD HEALTHCARE ALLIANCE PLAN", "methodology": "percent of total billed charges", "standard_charge_dollar": 59.91, "standard_charge_percentage": 48.59, "count": "0", "additional_payer_notes": "Zero final payments for the item or service in the 15 months prior to posting the file." }, { "payer_name": "CIGNA", "plan_name": "CIGNA COM ALT HMO PLAN", "methodology": "percent of total billed charges", "standard_charge_dollar": 52.03, "standard_charge_percentage": 42.2, "count": "0", "additional_payer_notes": "Zero final payments for the item or service in the 15 months prior to posting the file." }, { "payer_name": "CIGNA", "plan_name": "CIGNA COM ALT HMO PLAN", "methodology": "percent of total billed charges", "standard_charge_dollar": 52.03, "standard_charge_percentage": 42.2, "count": "0", "additional_payer_notes": "Zero final payments for the item or service in the 15 months prior to posting the file." }, { "payer_name": "HEALTH NET", "plan_name": "HEALTHNET HMO, PPO, POS, EPO, CANOPY HEALTHNET HMO, OTHER-IN-NETWORK PLANS", "methodology": "per diem", "standard_charge_dollar": 8000.0, "standard_charge_algorithm": "Expected reimbursement is the lesser of Per diem ($8,000) for the length of stay and 70% of billed.", "count": "0", "additional_payer_notes": "Zero final payments for the item or service in the 15 months prior to posting the file." }, { "payer_name": "HEALTH NET", "plan_name": "HEALTHNET HMO, PPO, POS, EPO, CANOPY HEALTHNET HMO, OTHER-IN-NETWORK PLANS", "methodology": "per diem", "standard_charge_dollar": 8000.0, "standard_charge_algorithm": "Expected reimbursement is the lesser of Per diem ($8,000) for the length of stay and 70% of billed.", "count": "0", "additional_payer_notes": "Zero final payments for the item or service in the 15 months prior to posting the file." }, { "payer_name": "UNITED HEALTHCARE", "plan_name": "SUTTER SELECT & SUTTER HEALTH PLAN HMO PLANS", "methodology": "per diem", "standard_charge_dollar": 28538.0, "standard_charge_algorithm": "Per diem ($28,538).", "count": "0", "additional_payer_notes": "Zero final payments for the item or service in the 15 months prior to posting the file." }, { "payer_name": "UNITED HEALTHCARE", "plan_name": "SUTTER SELECT & SUTTER HEALTH PLAN HMO PLANS", "methodology": "per diem", "standard_charge_dollar": 28538.0, "standard_charge_algorithm": "Per diem ($28,538).", "count": "0", "additional_payer_notes": "Zero final payments for the item or service in the 15 months prior to posting the file." }, { "payer_name": "SUTTER", "plan_name": "SUTTER SELECT & SUTTER HEALTH PLAN HMO PLANS", "methodology": "per diem", "standard_charge_dollar": 28538.0, "standard_charge_algorithm": "Per diem ($28,538).", "count": "0", "additional_payer_notes": "Zero final payments for the item or service in the 15 months prior to posting the file." }, { "payer_name": "UNITED HEALTHCARE", "plan_name": "SUTTER SELECT & SUTTER HEALTH PLAN HMO PLANS", "methodology": "per diem", "standard_charge_dollar": 28538.0, "standard_charge_algorithm": "Per diem ($28,538).", "count": "0", "additional_payer_notes": "Zero final payments for the item or service in the 15 months prior to posting the file." }, { "payer_name": "UMR", "plan_name": "SUTTER SELECT & SUTTER HEALTH PLAN HMO PLANS", "methodology": "per diem", "standard_charge_dollar": 28538.0, "standard_charge_algorithm": "Per diem ($28,538).", "count": "0", "additional_payer_notes": "Zero final payments for the item or service in the 15 months prior to posting the file." } ] } ] }, { "description": "HC Glutaraldehyde 16oz 0.625perct", "code_information": [ { "code": "PX-2110000006", "type": "CDM" }, { "code": "99999", "type": "CPT" }, { "code": "0270", "type": "RC" } ], "standard_charges": [ { "setting": "outpatient", "gross_charge": 1080.0, "discounted_cash": 540.0, "minimum": 455.76, "maximum": 561.6, "additional_generic_notes": "Zero final payments for the item or service in the 15 months prior to posting the file.", "payers_information": [ { "payer_name": "AETNA", "plan_name": "AETNA ALL OTHER PLANS", "methodology": "percent of total billed charges", "standard_charge_dollar": 561.6, "standard_charge_percentage": 52.0, "count": "0", "additional_payer_notes": "Zero final payments for the item or service in the 15 months prior to posting the file." }, { "payer_name": "AETNA", "plan_name": "AETNA ALL OTHER PLANS", "methodology": "percent of total billed charges", "standard_charge_dollar": 561.6, "standard_charge_percentage": 52.0, "count": "0", "additional_payer_notes": "Zero final payments for the item or service in the 15 months prior to posting the file." }, { "payer_name": "MERITAIN HEALTH", "plan_name": "AETNA ALL OTHER PLANS", "methodology": "percent of total billed charges", "standard_charge_dollar": 561.6, "standard_charge_percentage": 52.0, "count": "0", "additional_payer_notes": "Zero final payments for the item or service in the 15 months prior to posting the file." }, { "payer_name": "BLUE SHIELD OUT OF STATE", "plan_name": "STANFORD HEALTHCARE ALLIANCE PLAN", "methodology": "percent of total billed charges", "standard_charge_dollar": 524.77, "standard_charge_percentage": 48.59, "count": "0", "additional_payer_notes": "Zero final payments for the item or service in the 15 months prior to posting the file." }, { "payer_name": "BLUE SHIELD", "plan_name": "STANFORD HEALTHCARE ALLIANCE PLAN", "methodology": "percent of total billed charges", "standard_charge_dollar": 524.77, "standard_charge_percentage": 48.59, "median_amount": 68.24, "10th_percentile": 13.6, "90th_percentile": 1043.06, "count": "30" }, { "payer_name": "BLUE SHIELD", "plan_name": "STANFORD HEALTHCARE ALLIANCE PLAN", "methodology": "percent of total billed charges", "standard_charge_dollar": 524.77, "standard_charge_percentage": 48.59, "count": "0", "additional_payer_notes": "Zero final payments for the item or service in the 15 months prior to posting the file." }, { "payer_name": "BLUE SHIELD", "plan_name": "STANFORD HEALTHCARE ALLIANCE PLAN", "methodology": "percent of total billed charges", "standard_charge_dollar": 524.77, "standard_charge_percentage": 48.59, "count": "0", "additional_payer_notes": "Zero final payments for the item or service in the 15 months prior to posting the file." }, { "payer_name": "CIGNA", "plan_name": "CIGNA COM ALT HMO PLAN", "methodology": "percent of total billed charges", "standard_charge_dollar": 455.76, "standard_charge_percentage": 42.2, "count": "0", "additional_payer_notes": "Zero final payments for the item or service in the 15 months prior to posting the file." }, { "payer_name": "CIGNA", "plan_name": "CIGNA COM ALT HMO PLAN", "methodology": "percent of total billed charges", "standard_charge_dollar": 455.76, "standard_charge_percentage": 42.2, "count": "0", "additional_payer_notes": "Zero final payments for the item or service in the 15 months prior to posting the file." }, { "payer_name": "HEALTH NET", "plan_name": "HEALTHNET HMO, PPO, POS, EPO, CANOPY HEALTHNET HMO, OTHER-IN-NETWORK PLANS", "methodology": "per diem", "standard_charge_dollar": 8000.0, "standard_charge_algorithm": "Expected reimbursement is the lesser of Per diem ($8,000) for the length of stay and 70% of billed.", "count": "0", "additional_payer_notes": "Zero final payments for the item or service in the 15 months prior to posting the file." }, { "payer_name": "HEALTH NET", "plan_name": "HEALTHNET HMO, PPO, POS, EPO, CANOPY HEALTHNET HMO, OTHER-IN-NETWORK PLANS", "methodology": "per diem", "standard_charge_dollar": 8000.0, "standard_charge_algorithm": "Expected reimbursement is the lesser of Per diem ($8,000) for the length of stay and 70% of billed.", "count": "0", "additional_payer_notes": "Zero final payments for the item or service in the 15 months prior to posting the file." }, { "payer_name": "UNITED HEALTHCARE", "plan_name": "SUTTER SELECT & SUTTER HEALTH PLAN HMO PLANS", "methodology": "per diem", "standard_charge_dollar": 28538.0, "standard_charge_algorithm": "Per diem ($28,538).", "count": "0", "additional_payer_notes": "Zero final payments for the item or service in the 15 months prior to posting the file." }, { "payer_name": "UNITED HEALTHCARE", "plan_name": "SUTTER SELECT & SUTTER HEALTH PLAN HMO PLANS", "methodology": "per diem", "standard_charge_dollar": 28538.0, "standard_charge_algorithm": "Per diem ($28,538).", "count": "0", "additional_payer_notes": "Zero final payments for the item or service in the 15 months prior to posting the file." }, { "payer_name": "SUTTER", "plan_name": "SUTTER SELECT & SUTTER HEALTH PLAN HMO PLANS", "methodology": "per diem", "standard_charge_dollar": 28538.0, "standard_charge_algorithm": "Per diem ($28,538).", "count": "0", "additional_payer_notes": "Zero final payments for the item or service in the 15 months prior to posting the file." }, { "payer_name": "UNITED HEALTHCARE", "plan_name": "SUTTER SELECT & SUTTER HEALTH PLAN HMO PLANS", "methodology": "per diem", "standard_charge_dollar": 28538.0, "standard_charge_algorithm": "Per diem ($28,538).", "count": "0", "additional_payer_notes": "Zero final payments for the item or service in the 15 months prior to posting the file." }, { "payer_name": "UMR", "plan_name": "SUTTER SELECT & SUTTER HEALTH PLAN HMO PLANS", "methodology": "per diem", "standard_charge_dollar": 28538.0, "standard_charge_algorithm": "Per diem ($28,538).", "count": "0", "additional_payer_notes": "Zero final payments for the item or service in the 15 months prior to posting the file." } ] } ] }, { "description": "HC Syringe Assembly Alliance 60ml", "code_information": [ { "code": "PX-2110000007", "type": "CDM" }, { "code": "99999", "type": "CPT" }, { "code": "0272", "type": "RC" } ], "standard_charges": [ { "setting": "outpatient", "gross_charge": 380.0, "discounted_cash": 190.0, "minimum": 160.36, "maximum": 197.6, "additional_generic_notes": "Zero final payments for the item or service in the 15 months prior to posting the file.", "payers_information": [ { "payer_name": "AETNA", "plan_name": "AETNA ALL OTHER PLANS", "methodology": "percent of total billed charges", "standard_charge_dollar": 197.6, "standard_charge_percentage": 52.0, "count": "0", "additional_payer_notes": "Zero final payments for the item or service in the 15 months prior to posting the file." }, { "payer_name": "AETNA", "plan_name": "AETNA ALL OTHER PLANS", "methodology": "percent of total billed charges", "standard_charge_dollar": 197.6, "standard_charge_percentage": 52.0, "count": "0", "additional_payer_notes": "Zero final payments for the item or service in the 15 months prior to posting the file." }, { "payer_name": "MERITAIN HEALTH", "plan_name": "AETNA ALL OTHER PLANS", "methodology": "percent of total billed charges", "standard_charge_dollar": 197.6, "standard_charge_percentage": 52.0, "count": "0", "additional_payer_notes": "Zero final payments for the item or service in the 15 months prior to posting the file." }, { "payer_name": "BLUE SHIELD OUT OF STATE", "plan_name": "STANFORD HEALTHCARE ALLIANCE PLAN", "methodology": "percent of total billed charges", "standard_charge_dollar": 184.64, "standard_charge_percentage": 48.59, "count": "0", "additional_payer_notes": "Zero final payments for the item or service in the 15 months prior to posting the file." }, { "payer_name": "BLUE SHIELD", "plan_name": "STANFORD HEALTHCARE ALLIANCE PLAN", "methodology": "percent of total billed charges", "standard_charge_dollar": 184.64, "standard_charge_percentage": 48.59, "count": "0", "additional_payer_notes": "Zero final payments for the item or service in the 15 months prior to posting the file." }, { "payer_name": "BLUE SHIELD", "plan_name": "STANFORD HEALTHCARE ALLIANCE PLAN", "methodology": "percent of total billed charges", "standard_charge_dollar": 184.64, "standard_charge_percentage": 48.59, "count": "0", "additional_payer_notes": "Zero final payments for the item or service in the 15 months prior to posting the file." }, { "payer_name": "CIGNA", "plan_name": "CIGNA COM ALT HMO PLAN", "methodology": "percent of total billed charges", "standard_charge_dollar": 160.36, "standard_charge_percentage": 42.2, "count": "0", "additional_payer_notes": "Zero final payments for the item or service in the 15 months prior to posting the file." }, { "payer_name": "CIGNA", "plan_name": "CIGNA COM ALT HMO PLAN", "methodology": "percent of total billed charges", "standard_charge_dollar": 160.36, "standard_charge_percentage": 42.2, "count": "0", "additional_payer_notes": "Zero final payments for the item or service in the 15 months prior to posting the file." }, { "payer_name": "HEALTH NET", "plan_name": "HEALTHNET HMO, PPO, POS, EPO, CANOPY HEALTHNET HMO, OTHER-IN-NETWORK PLANS", "methodology": "per diem", "standard_charge_dollar": 8000.0, "standard_charge_algorithm": "Expected reimbursement is the lesser of Per diem ($8,000) for the length of stay and 70% of billed.", "count": "0", "additional_payer_notes": "Zero final payments for the item or service in the 15 months prior to posting the file." }, { "payer_name": "HEALTH NET", "plan_name": "HEALTHNET HMO, PPO, POS, EPO, CANOPY HEALTHNET HMO, OTHER-IN-NETWORK PLANS", "methodology": "per diem", "standard_charge_dollar": 8000.0, "standard_charge_algorithm": "Expected reimbursement is the lesser of Per diem ($8,000) for the length of stay and 70% of billed.", "count": "0", "additional_payer_notes": "Zero final payments for the item or service in the 15 months prior to posting the file." }, { "payer_name": "UNITED HEALTHCARE", "plan_name": "SUTTER SELECT & SUTTER HEALTH PLAN HMO PLANS", "methodology": "per diem", "standard_charge_dollar": 28538.0, "standard_charge_algorithm": "Per diem ($28,538).", "count": "0", "additional_payer_notes": "Zero final payments for the item or service in the 15 months prior to posting the file." }, { "payer_name": "UNITED HEALTHCARE", "plan_name": "SUTTER SELECT & SUTTER HEALTH PLAN HMO PLANS", "methodology": "per diem", "standard_charge_dollar": 28538.0, "standard_charge_algorithm": "Per diem ($28,538).", "count": "0", "additional_payer_notes": "Zero final payments for the item or service in the 15 months prior to posting the file." }, { "payer_name": "SUTTER", "plan_name": "SUTTER SELECT & SUTTER HEALTH PLAN HMO PLANS", "methodology": "per diem", "standard_charge_dollar": 28538.0, "standard_charge_algorithm": "Per diem ($28,538).", "count": "0", "additional_payer_notes": "Zero final payments for the item or service in the 15 months prior to posting the file." }, { "payer_name": "UNITED HEALTHCARE", "plan_name": "SUTTER SELECT & SUTTER HEALTH PLAN HMO PLANS", "methodology": "per diem", "standard_charge_dollar": 28538.0, "standard_charge_algorithm": "Per diem ($28,538).", "count": "0", "additional_payer_notes": "Zero final payments for the item or service in the 15 months prior to posting the file." }, { "payer_name": "UMR", "plan_name": "SUTTER SELECT & SUTTER HEALTH PLAN HMO PLANS", "methodology": "per diem", "standard_charge_dollar": 28538.0, "standard_charge_algorithm": "Per diem ($28,538).", "count": "0", "additional_payer_notes": "Zero final payments for the item or service in the 15 months prior to posting the file." } ] } ] }, { "description": "HC Bag Consolidated Hmii", "code_information": [ { "code": "PX-2110000014", "type": "CDM" }, { "code": "99999", "type": "CPT" }, { "code": "0270", "type": "RC" } ], "standard_charges": [ { "setting": "outpatient", "gross_charge": 2550.0, "discounted_cash": 1275.0, "minimum": 1076.1, "maximum": 1326.0, "additional_generic_notes": "Zero final payments for the item or service in the 15 months prior to posting the file.", "payers_information": [ { "payer_name": "AETNA", "plan_name": "AETNA ALL OTHER PLANS", "methodology": "percent of total billed charges", "standard_charge_dollar": 1326.0, "standard_charge_percentage": 52.0, "count": "0", "additional_payer_notes": "Zero final payments for the item or service in the 15 months prior to posting the file." }, { "payer_name": "AETNA", "plan_name": "AETNA ALL OTHER PLANS", "methodology": "percent of total billed charges", "standard_charge_dollar": 1326.0, "standard_charge_percentage": 52.0, "count": "0", "additional_payer_notes": "Zero final payments for the item or service in the 15 months prior to posting the file." }, { "payer_name": "MERITAIN HEALTH", "plan_name": "AETNA ALL OTHER PLANS", "methodology": "percent of total billed charges", "standard_charge_dollar": 1326.0, "standard_charge_percentage": 52.0, "count": "0", "additional_payer_notes": "Zero final payments for the item or service in the 15 months prior to posting the file." }, { "payer_name": "BLUE SHIELD OUT OF STATE", "plan_name": "STANFORD HEALTHCARE ALLIANCE PLAN", "methodology": "percent of total billed charges", "standard_charge_dollar": 1239.05, "standard_charge_percentage": 48.59, "count": "0", "additional_payer_notes": "Zero final payments for the item or service in the 15 months prior to posting the file." }, { "payer_name": "BLUE SHIELD", "plan_name": "STANFORD HEALTHCARE ALLIANCE PLAN", "methodology": "percent of total billed charges", "standard_charge_dollar": 1239.05, "standard_charge_percentage": 48.59, "median_amount": 68.24, "10th_percentile": 13.6, "90th_percentile": 1043.06, "count": "30" }, { "payer_name": "BLUE SHIELD", "plan_name": "STANFORD HEALTHCARE ALLIANCE PLAN", "methodology": "percent of total billed charges", "standard_charge_dollar": 1239.05, "standard_charge_percentage": 48.59, "count": "0", "additional_payer_notes": "Zero final payments for the item or service in the 15 months prior to posting the file." }, { "payer_name": "BLUE SHIELD", "plan_name": "STANFORD HEALTHCARE ALLIANCE PLAN", "methodology": "percent of total billed charges", "standard_charge_dollar": 1239.05, "standard_charge_percentage": 48.59, "count": "0", "additional_payer_notes": "Zero final payments for the item or service in the 15 months prior to posting the file." }, { "payer_name": "CIGNA", "plan_name": "CIGNA COM ALT HMO PLAN", "methodology": "percent of total billed charges", "standard_charge_dollar": 1076.1, "standard_charge_percentage": 42.2, "count": "0", "additional_payer_notes": "Zero final payments for the item or service in the 15 months prior to posting the file." }, { "payer_name": "CIGNA", "plan_name": "CIGNA COM ALT HMO PLAN", "methodology": "percent of total billed charges", "standard_charge_dollar": 1076.1, "standard_charge_percentage": 42.2, "count": "0", "additional_payer_notes": "Zero final payments for the item or service in the 15 months prior to posting the file." }, { "payer_name": "HEALTH NET", "plan_name": "HEALTHNET HMO, PPO, POS, EPO, CANOPY HEALTHNET HMO, OTHER-IN-NETWORK PLANS", "methodology": "per diem", "standard_charge_dollar": 8000.0, "standard_charge_algorithm": "Expected reimbursement is the lesser of Per diem ($8,000) for the length of stay and 70% of billed.", "count": "0", "additional_payer_notes": "Zero final payments for the item or service in the 15 months prior to posting the file." }, { "payer_name": "HEALTH NET", "plan_name": "HEALTHNET HMO, PPO, POS, EPO, CANOPY HEALTHNET HMO, OTHER-IN-NETWORK PLANS", "methodology": "per diem", "standard_charge_dollar": 8000.0, "standard_charge_algorithm": "Expected reimbursement is the lesser of Per diem ($8,000) for the length of stay and 70% of billed.", "count": "0", "additional_payer_notes": "Zero final payments for the item or service in the 15 months prior to posting the file." }, { "payer_name": "UNITED HEALTHCARE", "plan_name": "SUTTER SELECT & SUTTER HEALTH PLAN HMO PLANS", "methodology": "per diem", "standard_charge_dollar": 28538.0, "standard_charge_algorithm": "Per diem ($28,538).", "count": "0", "additional_payer_notes": "Zero final payments for the item or service in the 15 months prior to posting the file." }, { "payer_name": "UNITED HEALTHCARE", "plan_name": "SUTTER SELECT & SUTTER HEALTH PLAN HMO PLANS", "methodology": "per diem", "standard_charge_dollar": 28538.0, "standard_charge_algorithm": "Per diem ($28,538).", "count": "0", "additional_payer_notes": "Zero final payments for the item or service in the 15 months prior to posting the file." }, { "payer_name": "SUTTER", "plan_name": "SUTTER SELECT & SUTTER HEALTH PLAN HMO PLANS", "methodology": "per diem", "standard_charge_dollar": 28538.0, "standard_charge_algorithm": "Per diem ($28,538).", "count": "0", "additional_payer_notes": "Zero final payments for the item or service in the 15 months prior to posting the file." }, { "payer_name": "UNITED HEALTHCARE", "plan_name": "SUTTER SELECT & SUTTER HEALTH PLAN HMO PLANS", "methodology": "per diem", "standard_charge_dollar": 28538.0, "standard_charge_algorithm": "Per diem ($28,538).", "count": "0", "additional_payer_notes": "Zero final payments for the item or service in the 15 months prior to posting the file." }, { "payer_name": "UMR", "plan_name": "SUTTER SELECT & SUTTER HEALTH PLAN HMO PLANS", "methodology": "per diem", "standard_charge_dollar": 28538.0, "standard_charge_algorithm": "Per diem ($28,538).", "count": "0", "additional_payer_notes": "Zero final payments for the item or service in the 15 months prior to posting the file." } ] } ] }, { "description": "HC Avitene Powder 1gm", "code_information": [ { "code": "PX-2110000015", "type": "CDM" }, { "code": "99999", "type": "CPT" }, { "code": "0270", "type": "RC" } ], "standard_charges": [ { "setting": "outpatient", "gross_charge": 28000.0, "discounted_cash": 14000.0, "minimum": 11816.0, "maximum": 14560.0, "additional_generic_notes": "Zero final payments for the item or service in the 15 months prior to posting the file.", "payers_information": [ { "payer_name": "AETNA", "plan_name": "AETNA ALL OTHER PLANS", "methodology": "percent of total billed charges", "standard_charge_dollar": 14560.0, "standard_charge_percentage": 52.0, "count": "0", "additional_payer_notes": "Zero final payments for the item or service in the 15 months prior to posting the file." }, { "payer_name": "AETNA", "plan_name": "AETNA ALL OTHER PLANS", "methodology": "percent of total billed charges", "standard_charge_dollar": 14560.0, "standard_charge_percentage": 52.0, "count": "0", "additional_payer_notes": "Zero final payments for the item or service in the 15 months prior to posting the file." }, { "payer_name": "MERITAIN HEALTH", "plan_name": "AETNA ALL OTHER PLANS", "methodology": "percent of total billed charges", "standard_charge_dollar": 14560.0, "standard_charge_percentage": 52.0, "count": "0", "additional_payer_notes": "Zero final payments for the item or service in the 15 months prior to posting the file." }, { "payer_name": "BLUE SHIELD OUT OF STATE", "plan_name": "STANFORD HEALTHCARE ALLIANCE PLAN", "methodology": "percent of total billed charges", "standard_charge_dollar": 13605.2, "standard_charge_percentage": 48.59, "count": "0", "additional_payer_notes": "Zero final payments for the item or service in the 15 months prior to posting the file." }, { "payer_name": "BLUE SHIELD", "plan_name": "STANFORD HEALTHCARE ALLIANCE PLAN", "methodology": "percent of total billed charges", "standard_charge_dollar": 13605.2, "standard_charge_percentage": 48.59, "median_amount": 68.24, "10th_percentile": 13.6, "90th_percentile": 1043.06, "count": "30" }, { "payer_name": "BLUE SHIELD", "plan_name": "STANFORD HEALTHCARE ALLIANCE PLAN", "methodology": "percent of total billed charges", "standard_charge_dollar": 13605.2, "standard_charge_percentage": 48.59, "count": "0", "additional_payer_notes": "Zero final payments for the item or service in the 15 months prior to posting the file." }, { "payer_name": "BLUE SHIELD", "plan_name": "STANFORD HEALTHCARE ALLIANCE PLAN", "methodology": "percent of total billed charges", "standard_charge_dollar": 13605.2, "standard_charge_percentage": 48.59, "count": "0", "additional_payer_notes": "Zero final payments for the item or service in the 15 months prior to posting the file." }, { "payer_name": "CIGNA", "plan_name": "CIGNA COM ALT HMO PLAN", "methodology": "percent of total billed charges", "standard_charge_dollar": 11816.0, "standard_charge_percentage": 42.2, "count": "0", "additional_payer_notes": "Zero final payments for the item or service in the 15 months prior to posting the file." }, { "payer_name": "CIGNA", "plan_name": "CIGNA COM ALT HMO PLAN", "methodology": "percent of total billed charges", "standard_charge_dollar": 11816.0, "standard_charge_percentage": 42.2, "count": "0", "additional_payer_notes": "Zero final payments for the item or service in the 15 months prior to posting the file." }, { "payer_name": "HEALTH NET", "plan_name": "HEALTHNET HMO, PPO, POS, EPO, CANOPY HEALTHNET HMO, OTHER-IN-NETWORK PLANS", "methodology": "per diem", "standard_charge_dollar": 8000.0, "standard_charge_algorithm": "Expected reimbursement is the lesser of Per diem ($8,000) for the length of stay and 70% of billed.", "count": "0", "additional_payer_notes": "Zero final payments for the item or service in the 15 months prior to posting the file." }, { "payer_name": "HEALTH NET", "plan_name": "HEALTHNET HMO, PPO, POS, EPO, CANOPY HEALTHNET HMO, OTHER-IN-NETWORK PLANS", "methodology": "per diem", "standard_charge_dollar": 8000.0, "standard_charge_algorithm": "Expected reimbursement is the lesser of Per diem ($8,000) for the length of stay and 70% of billed.", "count": "0", "additional_payer_notes": "Zero final payments for the item or service in the 15 months prior to posting the file." }, { "payer_name": "UNITED HEALTHCARE", "plan_name": "SUTTER SELECT & SUTTER HEALTH PLAN HMO PLANS", "methodology": "per diem", "standard_charge_dollar": 28538.0, "standard_charge_algorithm": "Per diem ($28,538).", "count": "0", "additional_payer_notes": "Zero final payments for the item or service in the 15 months prior to posting the file." }, { "payer_name": "UNITED HEALTHCARE", "plan_name": "SUTTER SELECT & SUTTER HEALTH PLAN HMO PLANS", "methodology": "per diem", "standard_charge_dollar": 28538.0, "standard_charge_algorithm": "Per diem ($28,538).", "count": "0", "additional_payer_notes": "Zero final payments for the item or service in the 15 months prior to posting the file." }, { "payer_name": "SUTTER", "plan_name": "SUTTER SELECT & SUTTER HEALTH PLAN HMO PLANS", "methodology": "per diem", "standard_charge_dollar": 28538.0, "standard_charge_algorithm": "Per diem ($28,538).", "count": "0", "additional_payer_notes": "Zero final payments for the item or service in the 15 months prior to posting the file." }, { "payer_name": "UNITED HEALTHCARE", "plan_name": "SUTTER SELECT & SUTTER HEALTH PLAN HMO PLANS", "methodology": "per diem", "standard_charge_dollar": 28538.0, "standard_charge_algorithm": "Per diem ($28,538).", "count": "0", "additional_payer_notes": "Zero final payments for the item or service in the 15 months prior to posting the file." }, { "payer_name": "UMR", "plan_name": "SUTTER SELECT & SUTTER HEALTH PLAN HMO PLANS", "methodology": "per diem", "standard_charge_dollar": 28538.0, "standard_charge_algorithm": "Per diem ($28,538).", "count": "0", "additional_payer_notes": "Zero final payments for the item or service in the 15 months prior to posting the file." }, { "payer_name": "UNITED HEALTHCARE", "plan_name": "SUTTER SELECT & SUTTER HEALTH PLAN HMO PLANS", "methodology": "per diem", "standard_charge_dollar": 28538.0, "standard_charge_algorithm": "Per diem ($28,538).", "median_amount": 21329.69, "10th_percentile": 21329.69, "90th_percentile": 21329.69, "count": "1 through 10" } ] } ] }, { "description": "HC Battery Module Sys Hmii", "code_information": [ { "code": "PX-2110000016", "type": "CDM" }, { "code": "99999", "type": "CPT" }, { "code": "0270", "type": "RC" } ], "standard_charges": [ { "setting": "outpatient", "gross_charge": 2125.0, "discounted_cash": 1062.5, "minimum": 896.75, "maximum": 1105.0, "additional_generic_notes": "Zero final payments for the item or service in the 15 months prior to posting the file.", "payers_information": [ { "payer_name": "AETNA", "plan_name": "AETNA ALL OTHER PLANS", "methodology": "percent of total billed charges", "standard_charge_dollar": 1105.0, "standard_charge_percentage": 52.0, "count": "0", "additional_payer_notes": "Zero final payments for the item or service in the 15 months prior to posting the file." }, { "payer_name": "AETNA", "plan_name": "AETNA ALL OTHER PLANS", "methodology": "percent of total billed charges", "standard_charge_dollar": 1105.0, "standard_charge_percentage": 52.0, "count": "0", "additional_payer_notes": "Zero final payments for the item or service in the 15 months prior to posting the file." }, { "payer_name": "MERITAIN HEALTH", "plan_name": "AETNA ALL OTHER PLANS", "methodology": "percent of total billed charges", "standard_charge_dollar": 1105.0, "standard_charge_percentage": 52.0, "count": "0", "additional_payer_notes": "Zero final payments for the item or service in the 15 months prior to posting the file." }, { "payer_name": "BLUE SHIELD OUT OF STATE", "plan_name": "STANFORD HEALTHCARE ALLIANCE PLAN", "methodology": "percent of total billed charges", "standard_charge_dollar": 1032.54, "standard_charge_percentage": 48.59, "count": "0", "additional_payer_notes": "Zero final payments for the item or service in the 15 months prior to posting the file." }, { "payer_name": "BLUE SHIELD", "plan_name": "STANFORD HEALTHCARE ALLIANCE PLAN", "methodology": "percent of total billed charges", "standard_charge_dollar": 1032.54, "standard_charge_percentage": 48.59, "median_amount": 68.24, "10th_percentile": 13.6, "90th_percentile": 1043.06, "count": "30" }, { "payer_name": "BLUE SHIELD", "plan_name": "STANFORD HEALTHCARE ALLIANCE PLAN", "methodology": "percent of total billed charges", "standard_charge_dollar": 1032.54, "standard_charge_percentage": 48.59, "count": "0", "additional_payer_notes": "Zero final payments for the item or service in the 15 months prior to posting the file." }, { "payer_name": "BLUE SHIELD", "plan_name": "STANFORD HEALTHCARE ALLIANCE PLAN", "methodology": "percent of total billed charges", "standard_charge_dollar": 1032.54, "standard_charge_percentage": 48.59, "count": "0", "additional_payer_notes": "Zero final payments for the item or service in the 15 months prior to posting the file." }, { "payer_name": "CIGNA", "plan_name": "CIGNA COM ALT HMO PLAN", "methodology": "percent of total billed charges", "standard_charge_dollar": 896.75, "standard_charge_percentage": 42.2, "count": "0", "additional_payer_notes": "Zero final payments for the item or service in the 15 months prior to posting the file." }, { "payer_name": "CIGNA", "plan_name": "CIGNA COM ALT HMO PLAN", "methodology": "percent of total billed charges", "standard_charge_dollar": 896.75, "standard_charge_percentage": 42.2, "count": "0", "additional_payer_notes": "Zero final payments for the item or service in the 15 months prior to posting the file." }, { "payer_name": "HEALTH NET", "plan_name": "HEALTHNET HMO, PPO, POS, EPO, CANOPY HEALTHNET HMO, OTHER-IN-NETWORK PLANS", "methodology": "per diem", "standard_charge_dollar": 8000.0, "standard_charge_algorithm": "Expected reimbursement is the lesser of Per diem ($8,000) for the length of stay and 70% of billed.", "count": "0", "additional_payer_notes": "Zero final payments for the item or service in the 15 months prior to posting the file." }, { "payer_name": "HEALTH NET", "plan_name": "HEALTHNET HMO, PPO, POS, EPO, CANOPY HEALTHNET HMO, OTHER-IN-NETWORK PLANS", "methodology": "per diem", "standard_charge_dollar": 8000.0, "standard_charge_algorithm": "Expected reimbursement is the lesser of Per diem ($8,000) for the length of stay and 70% of billed.", "count": "0", "additional_payer_notes": "Zero final payments for the item or service in the 15 months prior to posting the file." }, { "payer_name": "UNITED HEALTHCARE", "plan_name": "SUTTER SELECT & SUTTER HEALTH PLAN HMO PLANS", "methodology": "per diem", "standard_charge_dollar": 28538.0, "standard_charge_algorithm": "Per diem ($28,538).", "count": "0", "additional_payer_notes": "Zero final payments for the item or service in the 15 months prior to posting the file." }, { "payer_name": "UNITED HEALTHCARE", "plan_name": "SUTTER SELECT & SUTTER HEALTH PLAN HMO PLANS", "methodology": "per diem", "standard_charge_dollar": 28538.0, "standard_charge_algorithm": "Per diem ($28,538).", "count": "0", "additional_payer_notes": "Zero final payments for the item or service in the 15 months prior to posting the file." }, { "payer_name": "SUTTER", "plan_name": "SUTTER SELECT & SUTTER HEALTH PLAN HMO PLANS", "methodology": "per diem", "standard_charge_dollar": 28538.0, "standard_charge_algorithm": "Per diem ($28,538).", "count": "0", "additional_payer_notes": "Zero final payments for the item or service in the 15 months prior to posting the file." }, { "payer_name": "UNITED HEALTHCARE", "plan_name": "SUTTER SELECT & SUTTER HEALTH PLAN HMO PLANS", "methodology": "per diem", "standard_charge_dollar": 28538.0, "standard_charge_algorithm": "Per diem ($28,538).", "count": "0", "additional_payer_notes": "Zero final payments for the item or service in the 15 months prior to posting the file." }, { "payer_name": "UMR", "plan_name": "SUTTER SELECT & SUTTER HEALTH PLAN HMO PLANS", "methodology": "per diem", "standard_charge_dollar": 28538.0, "standard_charge_algorithm": "Per diem ($28,538).", "count": "0", "additional_payer_notes": "Zero final payments for the item or service in the 15 months prior to posting the file." } ] } ] }, { "description": "HC Module Display Hmii", "code_information": [ { "code": "PX-2110000017", "type": "CDM" }, { "code": "99999", "type": "CPT" }, { "code": "0270", "type": "RC" } ], "standard_charges": [ { "setting": "outpatient", "gross_charge": 13000.0, "discounted_cash": 6500.0, "minimum": 5486.0, "maximum": 6760.0, "additional_generic_notes": "Zero final payments for the item or service in the 15 months prior to posting the file.", "payers_information": [ { "payer_name": "AETNA", "plan_name": "AETNA ALL OTHER PLANS", "methodology": "percent of total billed charges", "standard_charge_dollar": 6760.0, "standard_charge_percentage": 52.0, "count": "0", "additional_payer_notes": "Zero final payments for the item or service in the 15 months prior to posting the file." }, { "payer_name": "AETNA", "plan_name": "AETNA ALL OTHER PLANS", "methodology": "percent of total billed charges", "standard_charge_dollar": 6760.0, "standard_charge_percentage": 52.0, "count": "0", "additional_payer_notes": "Zero final payments for the item or service in the 15 months prior to posting the file." }, { "payer_name": "MERITAIN HEALTH", "plan_name": "AETNA ALL OTHER PLANS", "methodology": "percent of total billed charges", "standard_charge_dollar": 6760.0, "standard_charge_percentage": 52.0, "count": "0", "additional_payer_notes": "Zero final payments for the item or service in the 15 months prior to posting the file." }, { "payer_name": "BLUE SHIELD OUT OF STATE", "plan_name": "STANFORD HEALTHCARE ALLIANCE PLAN", "methodology": "percent of total billed charges", "standard_charge_dollar": 6316.7, "standard_charge_percentage": 48.59, "count": "0", "additional_payer_notes": "Zero final payments for the item or service in the 15 months prior to posting the file." }, { "payer_name": "BLUE SHIELD", "plan_name": "STANFORD HEALTHCARE ALLIANCE PLAN", "methodology": "percent of total billed charges", "standard_charge_dollar": 6316.7, "standard_charge_percentage": 48.59, "median_amount": 68.24, "10th_percentile": 13.6, "90th_percentile": 1043.06, "count": "30" }, { "payer_name": "BLUE SHIELD", "plan_name": "STANFORD HEALTHCARE ALLIANCE PLAN", "methodology": "percent of total billed charges", "standard_charge_dollar": 6316.7, "standard_charge_percentage": 48.59, "count": "0", "additional_payer_notes": "Zero final payments for the item or service in the 15 months prior to posting the file." }, { "payer_name": "BLUE SHIELD", "plan_name": "STANFORD HEALTHCARE ALLIANCE PLAN", "methodology": "percent of total billed charges", "standard_charge_dollar": 6316.7, "standard_charge_percentage": 48.59, "count": "0", "additional_payer_notes": "Zero final payments for the item or service in the 15 months prior to posting the file." }, { "payer_name": "CIGNA", "plan_name": "CIGNA COM ALT HMO PLAN", "methodology": "percent of total billed charges", "standard_charge_dollar": 5486.0, "standard_charge_percentage": 42.2, "count": "0", "additional_payer_notes": "Zero final payments for the item or service in the 15 months prior to posting the file." }, { "payer_name": "CIGNA", "plan_name": "CIGNA COM ALT HMO PLAN", "methodology": "percent of total billed charges", "standard_charge_dollar": 5486.0, "standard_charge_percentage": 42.2, "count": "0", "additional_payer_notes": "Zero final payments for the item or service in the 15 months prior to posting the file." }, { "payer_name": "HEALTH NET", "plan_name": "HEALTHNET HMO, PPO, POS, EPO, CANOPY HEALTHNET HMO, OTHER-IN-NETWORK PLANS", "methodology": "per diem", "standard_charge_dollar": 8000.0, "standard_charge_algorithm": "Expected reimbursement is the lesser of Per diem ($8,000) for the length of stay and 70% of billed.", "count": "0", "additional_payer_notes": "Zero final payments for the item or service in the 15 months prior to posting the file." }, { "payer_name": "HEALTH NET", "plan_name": "HEALTHNET HMO, PPO, POS, EPO, CANOPY HEALTHNET HMO, OTHER-IN-NETWORK PLANS", "methodology": "per diem", "standard_charge_dollar": 8000.0, "standard_charge_algorithm": "Expected reimbursement is the lesser of Per diem ($8,000) for the length of stay and 70% of billed.", "count": "0", "additional_payer_notes": "Zero final payments for the item or service in the 15 months prior to posting the file." }, { "payer_name": "UNITED HEALTHCARE", "plan_name": "SUTTER SELECT & SUTTER HEALTH PLAN HMO PLANS", "methodology": "per diem", "standard_charge_dollar": 28538.0, "standard_charge_algorithm": "Per diem ($28,538).", "count": "0", "additional_payer_notes": "Zero final payments for the item or service in the 15 months prior to posting the file." }, { "payer_name": "UNITED HEALTHCARE", "plan_name": "SUTTER SELECT & SUTTER HEALTH PLAN HMO PLANS", "methodology": "per diem", "standard_charge_dollar": 28538.0, "standard_charge_algorithm": "Per diem ($28,538).", "count": "0", "additional_payer_notes": "Zero final payments for the item or service in the 15 months prior to posting the file." }, { "payer_name": "SUTTER", "plan_name": "SUTTER SELECT & SUTTER HEALTH PLAN HMO PLANS", "methodology": "per diem", "standard_charge_dollar": 28538.0, "standard_charge_algorithm": "Per diem ($28,538).", "count": "0", "additional_payer_notes": "Zero final payments for the item or service in the 15 months prior to posting the file." }, { "payer_name": "UNITED HEALTHCARE", "plan_name": "SUTTER SELECT & SUTTER HEALTH PLAN HMO PLANS", "methodology": "per diem", "standard_charge_dollar": 28538.0, "standard_charge_algorithm": "Per diem ($28,538).", "count": "0", "additional_payer_notes": "Zero final payments for the item or service in the 15 months prior to posting the file." }, { "payer_name": "UMR", "plan_name": "SUTTER SELECT & SUTTER HEALTH PLAN HMO PLANS", "methodology": "per diem", "standard_charge_dollar": 28538.0, "standard_charge_algorithm": "Per diem ($28,538).", "count": "0", "additional_payer_notes": "Zero final payments for the item or service in the 15 months prior to posting the file." } ] } ] }, { "description": "HC Module Power Cable Dc Inpt", "code_information": [ { "code": "PX-2110000018", "type": "CDM" }, { "code": "99999", "type": "CPT" }, { "code": "0270", "type": "RC" } ], "standard_charges": [ { "setting": "outpatient", "gross_charge": 1750.0, "discounted_cash": 875.0, "minimum": 738.5, "maximum": 910.0, "additional_generic_notes": "Zero final payments for the item or service in the 15 months prior to posting the file.", "payers_information": [ { "payer_name": "AETNA", "plan_name": "AETNA ALL OTHER PLANS", "methodology": "percent of total billed charges", "standard_charge_dollar": 910.0, "standard_charge_percentage": 52.0, "count": "0", "additional_payer_notes": "Zero final payments for the item or service in the 15 months prior to posting the file." }, { "payer_name": "AETNA", "plan_name": "AETNA ALL OTHER PLANS", "methodology": "percent of total billed charges", "standard_charge_dollar": 910.0, "standard_charge_percentage": 52.0, "count": "0", "additional_payer_notes": "Zero final payments for the item or service in the 15 months prior to posting the file." }, { "payer_name": "MERITAIN HEALTH", "plan_name": "AETNA ALL OTHER PLANS", "methodology": "percent of total billed charges", "standard_charge_dollar": 910.0, "standard_charge_percentage": 52.0, "count": "0", "additional_payer_notes": "Zero final payments for the item or service in the 15 months prior to posting the file." }, { "payer_name": "BLUE SHIELD OUT OF STATE", "plan_name": "STANFORD HEALTHCARE ALLIANCE PLAN", "methodology": "percent of total billed charges", "standard_charge_dollar": 850.33, "standard_charge_percentage": 48.59, "count": "0", "additional_payer_notes": "Zero final payments for the item or service in the 15 months prior to posting the file." }, { "payer_name": "BLUE SHIELD", "plan_name": "STANFORD HEALTHCARE ALLIANCE PLAN", "methodology": "percent of total billed charges", "standard_charge_dollar": 850.33, "standard_charge_percentage": 48.59, "median_amount": 68.24, "10th_percentile": 13.6, "90th_percentile": 1043.06, "count": "30" }, { "payer_name": "BLUE SHIELD", "plan_name": "STANFORD HEALTHCARE ALLIANCE PLAN", "methodology": "percent of total billed charges", "standard_charge_dollar": 850.33, "standard_charge_percentage": 48.59, "count": "0", "additional_payer_notes": "Zero final payments for the item or service in the 15 months prior to posting the file." }, { "payer_name": "BLUE SHIELD", "plan_name": "STANFORD HEALTHCARE ALLIANCE PLAN", "methodology": "percent of total billed charges", "standard_charge_dollar": 850.33, "standard_charge_percentage": 48.59, "count": "0", "additional_payer_notes": "Zero final payments for the item or service in the 15 months prior to posting the file." }, { "payer_name": "CIGNA", "plan_name": "CIGNA COM ALT HMO PLAN", "methodology": "percent of total billed charges", "standard_charge_dollar": 738.5, "standard_charge_percentage": 42.2, "count": "0", "additional_payer_notes": "Zero final payments for the item or service in the 15 months prior to posting the file." }, { "payer_name": "CIGNA", "plan_name": "CIGNA COM ALT HMO PLAN", "methodology": "percent of total billed charges", "standard_charge_dollar": 738.5, "standard_charge_percentage": 42.2, "count": "0", "additional_payer_notes": "Zero final payments for the item or service in the 15 months prior to posting the file." }, { "payer_name": "HEALTH NET", "plan_name": "HEALTHNET HMO, PPO, POS, EPO, CANOPY HEALTHNET HMO, OTHER-IN-NETWORK PLANS", "methodology": "per diem", "standard_charge_dollar": 8000.0, "standard_charge_algorithm": "Expected reimbursement is the lesser of Per diem ($8,000) for the length of stay and 70% of billed.", "count": "0", "additional_payer_notes": "Zero final payments for the item or service in the 15 months prior to posting the file." }, { "payer_name": "HEALTH NET", "plan_name": "HEALTHNET HMO, PPO, POS, EPO, CANOPY HEALTHNET HMO, OTHER-IN-NETWORK PLANS", "methodology": "per diem", "standard_charge_dollar": 8000.0, "standard_charge_algorithm": "Expected reimbursement is the lesser of Per diem ($8,000) for the length of stay and 70% of billed.", "count": "0", "additional_payer_notes": "Zero final payments for the item or service in the 15 months prior to posting the file." }, { "payer_name": "UNITED HEALTHCARE", "plan_name": "SUTTER SELECT & SUTTER HEALTH PLAN HMO PLANS", "methodology": "per diem", "standard_charge_dollar": 28538.0, "standard_charge_algorithm": "Per diem ($28,538).", "count": "0", "additional_payer_notes": "Zero final payments for the item or service in the 15 months prior to posting the file." }, { "payer_name": "UNITED HEALTHCARE", "plan_name": "SUTTER SELECT & SUTTER HEALTH PLAN HMO PLANS", "methodology": "per diem", "standard_charge_dollar": 28538.0, "standard_charge_algorithm": "Per diem ($28,538).", "count": "0", "additional_payer_notes": "Zero final payments for the item or service in the 15 months prior to posting the file." }, { "payer_name": "SUTTER", "plan_name": "SUTTER SELECT & SUTTER HEALTH PLAN HMO PLANS", "methodology": "per diem", "standard_charge_dollar": 28538.0, "standard_charge_algorithm": "Per diem ($28,538).", "count": "0", "additional_payer_notes": "Zero final payments for the item or service in the 15 months prior to posting the file." }, { "payer_name": "UNITED HEALTHCARE", "plan_name": "SUTTER SELECT & SUTTER HEALTH PLAN HMO PLANS", "methodology": "per diem", "standard_charge_dollar": 28538.0, "standard_charge_algorithm": "Per diem ($28,538).", "count": "0", "additional_payer_notes": "Zero final payments for the item or service in the 15 months prior to posting the file." }, { "payer_name": "UMR", "plan_name": "SUTTER SELECT & SUTTER HEALTH PLAN HMO PLANS", "methodology": "per diem", "standard_charge_dollar": 28538.0, "standard_charge_algorithm": "Per diem ($28,538).", "count": "0", "additional_payer_notes": "Zero final payments for the item or service in the 15 months prior to posting the file." } ] } ] }, { "description": "HC Module Power Cable Hmii", "code_information": [ { "code": "PX-2110000019", "type": "CDM" }, { "code": "99999", "type": "CPT" }, { "code": "0270", "type": "RC" } ], "standard_charges": [ { "setting": "outpatient", "gross_charge": 6300.0, "discounted_cash": 3150.0, "minimum": 2658.6, "maximum": 3276.0, "additional_generic_notes": "Zero final payments for the item or service in the 15 months prior to posting the file.", "payers_information": [ { "payer_name": "AETNA", "plan_name": "AETNA ALL OTHER PLANS", "methodology": "percent of total billed charges", "standard_charge_dollar": 3276.0, "standard_charge_percentage": 52.0, "count": "0", "additional_payer_notes": "Zero final payments for the item or service in the 15 months prior to posting the file." }, { "payer_name": "AETNA", "plan_name": "AETNA ALL OTHER PLANS", "methodology": "percent of total billed charges", "standard_charge_dollar": 3276.0, "standard_charge_percentage": 52.0, "count": "0", "additional_payer_notes": "Zero final payments for the item or service in the 15 months prior to posting the file." }, { "payer_name": "MERITAIN HEALTH", "plan_name": "AETNA ALL OTHER PLANS", "methodology": "percent of total billed charges", "standard_charge_dollar": 3276.0, "standard_charge_percentage": 52.0, "count": "0", "additional_payer_notes": "Zero final payments for the item or service in the 15 months prior to posting the file." }, { "payer_name": "BLUE SHIELD OUT OF STATE", "plan_name": "STANFORD HEALTHCARE ALLIANCE PLAN", "methodology": "percent of total billed charges", "standard_charge_dollar": 3061.17, "standard_charge_percentage": 48.59, "count": "0", "additional_payer_notes": "Zero final payments for the item or service in the 15 months prior to posting the file." }, { "payer_name": "BLUE SHIELD", "plan_name": "STANFORD HEALTHCARE ALLIANCE PLAN", "methodology": "percent of total billed charges", "standard_charge_dollar": 3061.17, "standard_charge_percentage": 48.59, "median_amount": 68.24, "10th_percentile": 13.6, "90th_percentile": 1043.06, "count": "30" }, { "payer_name": "BLUE SHIELD", "plan_name": "STANFORD HEALTHCARE ALLIANCE PLAN", "methodology": "percent of total billed charges", "standard_charge_dollar": 3061.17, "standard_charge_percentage": 48.59, "count": "0", "additional_payer_notes": "Zero final payments for the item or service in the 15 months prior to posting the file." }, { "payer_name": "BLUE SHIELD", "plan_name": "STANFORD HEALTHCARE ALLIANCE PLAN", "methodology": "percent of total billed charges", "standard_charge_dollar": 3061.17, "standard_charge_percentage": 48.59, "count": "0", "additional_payer_notes": "Zero final payments for the item or service in the 15 months prior to posting the file." }, { "payer_name": "CIGNA", "plan_name": "CIGNA COM ALT HMO PLAN", "methodology": "percent of total billed charges", "standard_charge_dollar": 2658.6, "standard_charge_percentage": 42.2, "count": "0", "additional_payer_notes": "Zero final payments for the item or service in the 15 months prior to posting the file." }, { "payer_name": "CIGNA", "plan_name": "CIGNA COM ALT HMO PLAN", "methodology": "percent of total billed charges", "standard_charge_dollar": 2658.6, "standard_charge_percentage": 42.2, "count": "0", "additional_payer_notes": "Zero final payments for the item or service in the 15 months prior to posting the file." }, { "payer_name": "HEALTH NET", "plan_name": "HEALTHNET HMO, PPO, POS, EPO, CANOPY HEALTHNET HMO, OTHER-IN-NETWORK PLANS", "methodology": "per diem", "standard_charge_dollar": 8000.0, "standard_charge_algorithm": "Expected reimbursement is the lesser of Per diem ($8,000) for the length of stay and 70% of billed.", "count": "0", "additional_payer_notes": "Zero final payments for the item or service in the 15 months prior to posting the file." }, { "payer_name": "HEALTH NET", "plan_name": "HEALTHNET HMO, PPO, POS, EPO, CANOPY HEALTHNET HMO, OTHER-IN-NETWORK PLANS", "methodology": "per diem", "standard_charge_dollar": 8000.0, "standard_charge_algorithm": "Expected reimbursement is the lesser of Per diem ($8,000) for the length of stay and 70% of billed.", "count": "0", "additional_payer_notes": "Zero final payments for the item or service in the 15 months prior to posting the file." }, { "payer_name": "UNITED HEALTHCARE", "plan_name": "SUTTER SELECT & SUTTER HEALTH PLAN HMO PLANS", "methodology": "per diem", "standard_charge_dollar": 28538.0, "standard_charge_algorithm": "Per diem ($28,538).", "count": "0", "additional_payer_notes": "Zero final payments for the item or service in the 15 months prior to posting the file." }, { "payer_name": "UNITED HEALTHCARE", "plan_name": "SUTTER SELECT & SUTTER HEALTH PLAN HMO PLANS", "methodology": "per diem", "standard_charge_dollar": 28538.0, "standard_charge_algorithm": "Per diem ($28,538).", "count": "0", "additional_payer_notes": "Zero final payments for the item or service in the 15 months prior to posting the file." }, { "payer_name": "SUTTER", "plan_name": "SUTTER SELECT & SUTTER HEALTH PLAN HMO PLANS", "methodology": "per diem", "standard_charge_dollar": 28538.0, "standard_charge_algorithm": "Per diem ($28,538).", "count": "0", "additional_payer_notes": "Zero final payments for the item or service in the 15 months prior to posting the file." }, { "payer_name": "UNITED HEALTHCARE", "plan_name": "SUTTER SELECT & SUTTER HEALTH PLAN HMO PLANS", "methodology": "per diem", "standard_charge_dollar": 28538.0, "standard_charge_algorithm": "Per diem ($28,538).", "count": "0", "additional_payer_notes": "Zero final payments for the item or service in the 15 months prior to posting the file." }, { "payer_name": "UMR", "plan_name": "SUTTER SELECT & SUTTER HEALTH PLAN HMO PLANS", "methodology": "per diem", "standard_charge_dollar": 28538.0, "standard_charge_algorithm": "Per diem ($28,538).", "count": "0", "additional_payer_notes": "Zero final payments for the item or service in the 15 months prior to posting the file." } ] } ] }, { "description": "HC Module Power Hmii", "code_information": [ { "code": "PX-2110000020", "type": "CDM" }, { "code": "99999", "type": "CPT" }, { "code": "0270", "type": "RC" } ], "standard_charges": [ { "setting": "outpatient", "gross_charge": 30400.0, "discounted_cash": 15200.0, "minimum": 12828.8, "maximum": 15808.0, "additional_generic_notes": "Zero final payments for the item or service in the 15 months prior to posting the file.", "payers_information": [ { "payer_name": "AETNA", "plan_name": "AETNA ALL OTHER PLANS", "methodology": "percent of total billed charges", "standard_charge_dollar": 15808.0, "standard_charge_percentage": 52.0, "count": "0", "additional_payer_notes": "Zero final payments for the item or service in the 15 months prior to posting the file." }, { "payer_name": "AETNA", "plan_name": "AETNA ALL OTHER PLANS", "methodology": "percent of total billed charges", "standard_charge_dollar": 15808.0, "standard_charge_percentage": 52.0, "count": "0", "additional_payer_notes": "Zero final payments for the item or service in the 15 months prior to posting the file." }, { "payer_name": "MERITAIN HEALTH", "plan_name": "AETNA ALL OTHER PLANS", "methodology": "percent of total billed charges", "standard_charge_dollar": 15808.0, "standard_charge_percentage": 52.0, "count": "0", "additional_payer_notes": "Zero final payments for the item or service in the 15 months prior to posting the file." }, { "payer_name": "BLUE SHIELD OUT OF STATE", "plan_name": "STANFORD HEALTHCARE ALLIANCE PLAN", "methodology": "percent of total billed charges", "standard_charge_dollar": 14771.36, "standard_charge_percentage": 48.59, "count": "0", "additional_payer_notes": "Zero final payments for the item or service in the 15 months prior to posting the file." }, { "payer_name": "BLUE SHIELD", "plan_name": "STANFORD HEALTHCARE ALLIANCE PLAN", "methodology": "percent of total billed charges", "standard_charge_dollar": 14771.36, "standard_charge_percentage": 48.59, "median_amount": 68.24, "10th_percentile": 13.6, "90th_percentile": 1043.06, "count": "30" }, { "payer_name": "BLUE SHIELD", "plan_name": "STANFORD HEALTHCARE ALLIANCE PLAN", "methodology": "percent of total billed charges", "standard_charge_dollar": 14771.36, "standard_charge_percentage": 48.59, "count": "0", "additional_payer_notes": "Zero final payments for the item or service in the 15 months prior to posting the file." }, { "payer_name": "BLUE SHIELD", "plan_name": "STANFORD HEALTHCARE ALLIANCE PLAN", "methodology": "percent of total billed charges", "standard_charge_dollar": 14771.36, "standard_charge_percentage": 48.59, "count": "0", "additional_payer_notes": "Zero final payments for the item or service in the 15 months prior to posting the file." }, { "payer_name": "CIGNA", "plan_name": "CIGNA COM ALT HMO PLAN", "methodology": "percent of total billed charges", "standard_charge_dollar": 12828.8, "standard_charge_percentage": 42.2, "count": "0", "additional_payer_notes": "Zero final payments for the item or service in the 15 months prior to posting the file." }, { "payer_name": "CIGNA", "plan_name": "CIGNA COM ALT HMO PLAN", "methodology": "percent of total billed charges", "standard_charge_dollar": 12828.8, "standard_charge_percentage": 42.2, "count": "0", "additional_payer_notes": "Zero final payments for the item or service in the 15 months prior to posting the file." }, { "payer_name": "HEALTH NET", "plan_name": "HEALTHNET HMO, PPO, POS, EPO, CANOPY HEALTHNET HMO, OTHER-IN-NETWORK PLANS", "methodology": "per diem", "standard_charge_dollar": 8000.0, "standard_charge_algorithm": "Expected reimbursement is the lesser of Per diem ($8,000) for the length of stay and 70% of billed.", "count": "0", "additional_payer_notes": "Zero final payments for the item or service in the 15 months prior to posting the file." }, { "payer_name": "HEALTH NET", "plan_name": "HEALTHNET HMO, PPO, POS, EPO, CANOPY HEALTHNET HMO, OTHER-IN-NETWORK PLANS", "methodology": "per diem", "standard_charge_dollar": 8000.0, "standard_charge_algorithm": "Expected reimbursement is the lesser of Per diem ($8,000) for the length of stay and 70% of billed.", "count": "0", "additional_payer_notes": "Zero final payments for the item or service in the 15 months prior to posting the file." }, { "payer_name": "UNITED HEALTHCARE", "plan_name": "SUTTER SELECT & SUTTER HEALTH PLAN HMO PLANS", "methodology": "per diem", "standard_charge_dollar": 28538.0, "standard_charge_algorithm": "Per diem ($28,538).", "count": "0", "additional_payer_notes": "Zero final payments for the item or service in the 15 months prior to posting the file." }, { "payer_name": "UNITED HEALTHCARE", "plan_name": "SUTTER SELECT & SUTTER HEALTH PLAN HMO PLANS", "methodology": "per diem", "standard_charge_dollar": 28538.0, "standard_charge_algorithm": "Per diem ($28,538).", "count": "0", "additional_payer_notes": "Zero final payments for the item or service in the 15 months prior to posting the file." }, { "payer_name": "SUTTER", "plan_name": "SUTTER SELECT & SUTTER HEALTH PLAN HMO PLANS", "methodology": "per diem", "standard_charge_dollar": 28538.0, "standard_charge_algorithm": "Per diem ($28,538).", "count": "0", "additional_payer_notes": "Zero final payments for the item or service in the 15 months prior to posting the file." }, { "payer_name": "UNITED HEALTHCARE", "plan_name": "SUTTER SELECT & SUTTER HEALTH PLAN HMO PLANS", "methodology": "per diem", "standard_charge_dollar": 28538.0, "standard_charge_algorithm": "Per diem ($28,538).", "count": "0", "additional_payer_notes": "Zero final payments for the item or service in the 15 months prior to posting the file." }, { "payer_name": "UMR", "plan_name": "SUTTER SELECT & SUTTER HEALTH PLAN HMO PLANS", "methodology": "per diem", "standard_charge_dollar": 28538.0, "standard_charge_algorithm": "Per diem ($28,538).", "count": "0", "additional_payer_notes": "Zero final payments for the item or service in the 15 months prior to posting the file." }, { "payer_name": "UNITED HEALTHCARE", "plan_name": "SUTTER SELECT & SUTTER HEALTH PLAN HMO PLANS", "methodology": "per diem", "standard_charge_dollar": 28538.0, "standard_charge_algorithm": "Per diem ($28,538).", "median_amount": 21329.69, "10th_percentile": 21329.69, "90th_percentile": 21329.69, "count": "1 through 10" } ] } ] }, { "description": "HC Power Pack Emergency Hmii", "code_information": [ { "code": "PX-2110000021", "type": "CDM" }, { "code": "99999", "type": "CPT" }, { "code": "0270", "type": "RC" } ], "standard_charges": [ { "setting": "outpatient", "gross_charge": 5800.0, "discounted_cash": 2900.0, "minimum": 2447.6, "maximum": 3016.0, "additional_generic_notes": "Zero final payments for the item or service in the 15 months prior to posting the file.", "payers_information": [ { "payer_name": "AETNA", "plan_name": "AETNA ALL OTHER PLANS", "methodology": "percent of total billed charges", "standard_charge_dollar": 3016.0, "standard_charge_percentage": 52.0, "count": "0", "additional_payer_notes": "Zero final payments for the item or service in the 15 months prior to posting the file." }, { "payer_name": "AETNA", "plan_name": "AETNA ALL OTHER PLANS", "methodology": "percent of total billed charges", "standard_charge_dollar": 3016.0, "standard_charge_percentage": 52.0, "count": "0", "additional_payer_notes": "Zero final payments for the item or service in the 15 months prior to posting the file." }, { "payer_name": "MERITAIN HEALTH", "plan_name": "AETNA ALL OTHER PLANS", "methodology": "percent of total billed charges", "standard_charge_dollar": 3016.0, "standard_charge_percentage": 52.0, "count": "0", "additional_payer_notes": "Zero final payments for the item or service in the 15 months prior to posting the file." }, { "payer_name": "BLUE SHIELD OUT OF STATE", "plan_name": "STANFORD HEALTHCARE ALLIANCE PLAN", "methodology": "percent of total billed charges", "standard_charge_dollar": 2818.22, "standard_charge_percentage": 48.59, "count": "0", "additional_payer_notes": "Zero final payments for the item or service in the 15 months prior to posting the file." }, { "payer_name": "BLUE SHIELD", "plan_name": "STANFORD HEALTHCARE ALLIANCE PLAN", "methodology": "percent of total billed charges", "standard_charge_dollar": 2818.22, "standard_charge_percentage": 48.59, "median_amount": 68.24, "10th_percentile": 13.6, "90th_percentile": 1043.06, "count": "30" }, { "payer_name": "BLUE SHIELD", "plan_name": "STANFORD HEALTHCARE ALLIANCE PLAN", "methodology": "percent of total billed charges", "standard_charge_dollar": 2818.22, "standard_charge_percentage": 48.59, "count": "0", "additional_payer_notes": "Zero final payments for the item or service in the 15 months prior to posting the file." }, { "payer_name": "BLUE SHIELD", "plan_name": "STANFORD HEALTHCARE ALLIANCE PLAN", "methodology": "percent of total billed charges", "standard_charge_dollar": 2818.22, "standard_charge_percentage": 48.59, "count": "0", "additional_payer_notes": "Zero final payments for the item or service in the 15 months prior to posting the file." }, { "payer_name": "CIGNA", "plan_name": "CIGNA COM ALT HMO PLAN", "methodology": "percent of total billed charges", "standard_charge_dollar": 2447.6, "standard_charge_percentage": 42.2, "count": "0", "additional_payer_notes": "Zero final payments for the item or service in the 15 months prior to posting the file." }, { "payer_name": "CIGNA", "plan_name": "CIGNA COM ALT HMO PLAN", "methodology": "percent of total billed charges", "standard_charge_dollar": 2447.6, "standard_charge_percentage": 42.2, "count": "0", "additional_payer_notes": "Zero final payments for the item or service in the 15 months prior to posting the file." }, { "payer_name": "HEALTH NET", "plan_name": "HEALTHNET HMO, PPO, POS, EPO, CANOPY HEALTHNET HMO, OTHER-IN-NETWORK PLANS", "methodology": "per diem", "standard_charge_dollar": 8000.0, "standard_charge_algorithm": "Expected reimbursement is the lesser of Per diem ($8,000) for the length of stay and 70% of billed.", "count": "0", "additional_payer_notes": "Zero final payments for the item or service in the 15 months prior to posting the file." }, { "payer_name": "HEALTH NET", "plan_name": "HEALTHNET HMO, PPO, POS, EPO, CANOPY HEALTHNET HMO, OTHER-IN-NETWORK PLANS", "methodology": "per diem", "standard_charge_dollar": 8000.0, "standard_charge_algorithm": "Expected reimbursement is the lesser of Per diem ($8,000) for the length of stay and 70% of billed.", "count": "0", "additional_payer_notes": "Zero final payments for the item or service in the 15 months prior to posting the file." }, { "payer_name": "UNITED HEALTHCARE", "plan_name": "SUTTER SELECT & SUTTER HEALTH PLAN HMO PLANS", "methodology": "per diem", "standard_charge_dollar": 28538.0, "standard_charge_algorithm": "Per diem ($28,538).", "count": "0", "additional_payer_notes": "Zero final payments for the item or service in the 15 months prior to posting the file." }, { "payer_name": "UNITED HEALTHCARE", "plan_name": "SUTTER SELECT & SUTTER HEALTH PLAN HMO PLANS", "methodology": "per diem", "standard_charge_dollar": 28538.0, "standard_charge_algorithm": "Per diem ($28,538).", "count": "0", "additional_payer_notes": "Zero final payments for the item or service in the 15 months prior to posting the file." }, { "payer_name": "SUTTER", "plan_name": "SUTTER SELECT & SUTTER HEALTH PLAN HMO PLANS", "methodology": "per diem", "standard_charge_dollar": 28538.0, "standard_charge_algorithm": "Per diem ($28,538).", "count": "0", "additional_payer_notes": "Zero final payments for the item or service in the 15 months prior to posting the file." }, { "payer_name": "UNITED HEALTHCARE", "plan_name": "SUTTER SELECT & SUTTER HEALTH PLAN HMO PLANS", "methodology": "per diem", "standard_charge_dollar": 28538.0, "standard_charge_algorithm": "Per diem ($28,538).", "count": "0", "additional_payer_notes": "Zero final payments for the item or service in the 15 months prior to posting the file." }, { "payer_name": "UMR", "plan_name": "SUTTER SELECT & SUTTER HEALTH PLAN HMO PLANS", "methodology": "per diem", "standard_charge_dollar": 28538.0, "standard_charge_algorithm": "Per diem ($28,538).", "count": "0", "additional_payer_notes": "Zero final payments for the item or service in the 15 months prior to posting the file." } ] } ] }, { "description": "HC Set Battery Li on Hmii", "code_information": [ { "code": "PX-2110000022", "type": "CDM" }, { "code": "99999", "type": "CPT" }, { "code": "0270", "type": "RC" } ], "standard_charges": [ { "setting": "outpatient", "gross_charge": 3300.0, "discounted_cash": 1650.0, "minimum": 1392.6, "maximum": 1716.0, "additional_generic_notes": "Zero final payments for the item or service in the 15 months prior to posting the file.", "payers_information": [ { "payer_name": "AETNA", "plan_name": "AETNA ALL OTHER PLANS", "methodology": "percent of total billed charges", "standard_charge_dollar": 1716.0, "standard_charge_percentage": 52.0, "count": "0", "additional_payer_notes": "Zero final payments for the item or service in the 15 months prior to posting the file." }, { "payer_name": "AETNA", "plan_name": "AETNA ALL OTHER PLANS", "methodology": "percent of total billed charges", "standard_charge_dollar": 1716.0, "standard_charge_percentage": 52.0, "count": "0", "additional_payer_notes": "Zero final payments for the item or service in the 15 months prior to posting the file." }, { "payer_name": "MERITAIN HEALTH", "plan_name": "AETNA ALL OTHER PLANS", "methodology": "percent of total billed charges", "standard_charge_dollar": 1716.0, "standard_charge_percentage": 52.0, "count": "0", "additional_payer_notes": "Zero final payments for the item or service in the 15 months prior to posting the file." }, { "payer_name": "BLUE SHIELD OUT OF STATE", "plan_name": "STANFORD HEALTHCARE ALLIANCE PLAN", "methodology": "percent of total billed charges", "standard_charge_dollar": 1603.47, "standard_charge_percentage": 48.59, "count": "0", "additional_payer_notes": "Zero final payments for the item or service in the 15 months prior to posting the file." }, { "payer_name": "BLUE SHIELD", "plan_name": "STANFORD HEALTHCARE ALLIANCE PLAN", "methodology": "percent of total billed charges", "standard_charge_dollar": 1603.47, "standard_charge_percentage": 48.59, "median_amount": 68.24, "10th_percentile": 13.6, "90th_percentile": 1043.06, "count": "30" }, { "payer_name": "BLUE SHIELD", "plan_name": "STANFORD HEALTHCARE ALLIANCE PLAN", "methodology": "percent of total billed charges", "standard_charge_dollar": 1603.47, "standard_charge_percentage": 48.59, "count": "0", "additional_payer_notes": "Zero final payments for the item or service in the 15 months prior to posting the file." }, { "payer_name": "BLUE SHIELD", "plan_name": "STANFORD HEALTHCARE ALLIANCE PLAN", "methodology": "percent of total billed charges", "standard_charge_dollar": 1603.47, "standard_charge_percentage": 48.59, "count": "0", "additional_payer_notes": "Zero final payments for the item or service in the 15 months prior to posting the file." }, { "payer_name": "CIGNA", "plan_name": "CIGNA COM ALT HMO PLAN", "methodology": "percent of total billed charges", "standard_charge_dollar": 1392.6, "standard_charge_percentage": 42.2, "count": "0", "additional_payer_notes": "Zero final payments for the item or service in the 15 months prior to posting the file." }, { "payer_name": "CIGNA", "plan_name": "CIGNA COM ALT HMO PLAN", "methodology": "percent of total billed charges", "standard_charge_dollar": 1392.6, "standard_charge_percentage": 42.2, "count": "0", "additional_payer_notes": "Zero final payments for the item or service in the 15 months prior to posting the file." }, { "payer_name": "HEALTH NET", "plan_name": "HEALTHNET HMO, PPO, POS, EPO, CANOPY HEALTHNET HMO, OTHER-IN-NETWORK PLANS", "methodology": "per diem", "standard_charge_dollar": 8000.0, "standard_charge_algorithm": "Expected reimbursement is the lesser of Per diem ($8,000) for the length of stay and 70% of billed.", "count": "0", "additional_payer_notes": "Zero final payments for the item or service in the 15 months prior to posting the file." }, { "payer_name": "HEALTH NET", "plan_name": "HEALTHNET HMO, PPO, POS, EPO, CANOPY HEALTHNET HMO, OTHER-IN-NETWORK PLANS", "methodology": "per diem", "standard_charge_dollar": 8000.0, "standard_charge_algorithm": "Expected reimbursement is the lesser of Per diem ($8,000) for the length of stay and 70% of billed.", "count": "0", "additional_payer_notes": "Zero final payments for the item or service in the 15 months prior to posting the file." }, { "payer_name": "UNITED HEALTHCARE", "plan_name": "SUTTER SELECT & SUTTER HEALTH PLAN HMO PLANS", "methodology": "per diem", "standard_charge_dollar": 28538.0, "standard_charge_algorithm": "Per diem ($28,538).", "count": "0", "additional_payer_notes": "Zero final payments for the item or service in the 15 months prior to posting the file." }, { "payer_name": "UNITED HEALTHCARE", "plan_name": "SUTTER SELECT & SUTTER HEALTH PLAN HMO PLANS", "methodology": "per diem", "standard_charge_dollar": 28538.0, "standard_charge_algorithm": "Per diem ($28,538).", "count": "0", "additional_payer_notes": "Zero final payments for the item or service in the 15 months prior to posting the file." }, { "payer_name": "SUTTER", "plan_name": "SUTTER SELECT & SUTTER HEALTH PLAN HMO PLANS", "methodology": "per diem", "standard_charge_dollar": 28538.0, "standard_charge_algorithm": "Per diem ($28,538).", "count": "0", "additional_payer_notes": "Zero final payments for the item or service in the 15 months prior to posting the file." }, { "payer_name": "UNITED HEALTHCARE", "plan_name": "SUTTER SELECT & SUTTER HEALTH PLAN HMO PLANS", "methodology": "per diem", "standard_charge_dollar": 28538.0, "standard_charge_algorithm": "Per diem ($28,538).", "count": "0", "additional_payer_notes": "Zero final payments for the item or service in the 15 months prior to posting the file." }, { "payer_name": "UMR", "plan_name": "SUTTER SELECT & SUTTER HEALTH PLAN HMO PLANS", "methodology": "per diem", "standard_charge_dollar": 28538.0, "standard_charge_algorithm": "Per diem ($28,538).", "count": "0", "additional_payer_notes": "Zero final payments for the item or service in the 15 months prior to posting the file." } ] } ] }, { "description": "HC Set Clip Li on Hmii", "code_information": [ { "code": "PX-2110000023", "type": "CDM" }, { "code": "99999", "type": "CPT" }, { "code": "0270", "type": "RC" } ], "standard_charges": [ { "setting": "outpatient", "gross_charge": 6750.0, "discounted_cash": 3375.0, "minimum": 2848.5, "maximum": 3510.0, "additional_generic_notes": "Zero final payments for the item or service in the 15 months prior to posting the file.", "payers_information": [ { "payer_name": "AETNA", "plan_name": "AETNA ALL OTHER PLANS", "methodology": "percent of total billed charges", "standard_charge_dollar": 3510.0, "standard_charge_percentage": 52.0, "count": "0", "additional_payer_notes": "Zero final payments for the item or service in the 15 months prior to posting the file." }, { "payer_name": "AETNA", "plan_name": "AETNA ALL OTHER PLANS", "methodology": "percent of total billed charges", "standard_charge_dollar": 3510.0, "standard_charge_percentage": 52.0, "count": "0", "additional_payer_notes": "Zero final payments for the item or service in the 15 months prior to posting the file." }, { "payer_name": "MERITAIN HEALTH", "plan_name": "AETNA ALL OTHER PLANS", "methodology": "percent of total billed charges", "standard_charge_dollar": 3510.0, "standard_charge_percentage": 52.0, "count": "0", "additional_payer_notes": "Zero final payments for the item or service in the 15 months prior to posting the file." }, { "payer_name": "BLUE SHIELD OUT OF STATE", "plan_name": "STANFORD HEALTHCARE ALLIANCE PLAN", "methodology": "percent of total billed charges", "standard_charge_dollar": 3279.83, "standard_charge_percentage": 48.59, "count": "0", "additional_payer_notes": "Zero final payments for the item or service in the 15 months prior to posting the file." }, { "payer_name": "BLUE SHIELD", "plan_name": "STANFORD HEALTHCARE ALLIANCE PLAN", "methodology": "percent of total billed charges", "standard_charge_dollar": 3279.83, "standard_charge_percentage": 48.59, "median_amount": 68.24, "10th_percentile": 13.6, "90th_percentile": 1043.06, "count": "30" }, { "payer_name": "BLUE SHIELD", "plan_name": "STANFORD HEALTHCARE ALLIANCE PLAN", "methodology": "percent of total billed charges", "standard_charge_dollar": 3279.83, "standard_charge_percentage": 48.59, "count": "0", "additional_payer_notes": "Zero final payments for the item or service in the 15 months prior to posting the file." }, { "payer_name": "BLUE SHIELD", "plan_name": "STANFORD HEALTHCARE ALLIANCE PLAN", "methodology": "percent of total billed charges", "standard_charge_dollar": 3279.83, "standard_charge_percentage": 48.59, "count": "0", "additional_payer_notes": "Zero final payments for the item or service in the 15 months prior to posting the file." }, { "payer_name": "CIGNA", "plan_name": "CIGNA COM ALT HMO PLAN", "methodology": "percent of total billed charges", "standard_charge_dollar": 2848.5, "standard_charge_percentage": 42.2, "count": "0", "additional_payer_notes": "Zero final payments for the item or service in the 15 months prior to posting the file." }, { "payer_name": "CIGNA", "plan_name": "CIGNA COM ALT HMO PLAN", "methodology": "percent of total billed charges", "standard_charge_dollar": 2848.5, "standard_charge_percentage": 42.2, "count": "0", "additional_payer_notes": "Zero final payments for the item or service in the 15 months prior to posting the file." }, { "payer_name": "HEALTH NET", "plan_name": "HEALTHNET HMO, PPO, POS, EPO, CANOPY HEALTHNET HMO, OTHER-IN-NETWORK PLANS", "methodology": "per diem", "standard_charge_dollar": 8000.0, "standard_charge_algorithm": "Expected reimbursement is the lesser of Per diem ($8,000) for the length of stay and 70% of billed.", "count": "0", "additional_payer_notes": "Zero final payments for the item or service in the 15 months prior to posting the file." }, { "payer_name": "HEALTH NET", "plan_name": "HEALTHNET HMO, PPO, POS, EPO, CANOPY HEALTHNET HMO, OTHER-IN-NETWORK PLANS", "methodology": "per diem", "standard_charge_dollar": 8000.0, "standard_charge_algorithm": "Expected reimbursement is the lesser of Per diem ($8,000) for the length of stay and 70% of billed.", "count": "0", "additional_payer_notes": "Zero final payments for the item or service in the 15 months prior to posting the file." }, { "payer_name": "UNITED HEALTHCARE", "plan_name": "SUTTER SELECT & SUTTER HEALTH PLAN HMO PLANS", "methodology": "per diem", "standard_charge_dollar": 28538.0, "standard_charge_algorithm": "Per diem ($28,538).", "count": "0", "additional_payer_notes": "Zero final payments for the item or service in the 15 months prior to posting the file." }, { "payer_name": "UNITED HEALTHCARE", "plan_name": "SUTTER SELECT & SUTTER HEALTH PLAN HMO PLANS", "methodology": "per diem", "standard_charge_dollar": 28538.0, "standard_charge_algorithm": "Per diem ($28,538).", "count": "0", "additional_payer_notes": "Zero final payments for the item or service in the 15 months prior to posting the file." }, { "payer_name": "SUTTER", "plan_name": "SUTTER SELECT & SUTTER HEALTH PLAN HMO PLANS", "methodology": "per diem", "standard_charge_dollar": 28538.0, "standard_charge_algorithm": "Per diem ($28,538).", "count": "0", "additional_payer_notes": "Zero final payments for the item or service in the 15 months prior to posting the file." }, { "payer_name": "UNITED HEALTHCARE", "plan_name": "SUTTER SELECT & SUTTER HEALTH PLAN HMO PLANS", "methodology": "per diem", "standard_charge_dollar": 28538.0, "standard_charge_algorithm": "Per diem ($28,538).", "count": "0", "additional_payer_notes": "Zero final payments for the item or service in the 15 months prior to posting the file." }, { "payer_name": "UMR", "plan_name": "SUTTER SELECT & SUTTER HEALTH PLAN HMO PLANS", "methodology": "per diem", "standard_charge_dollar": 28538.0, "standard_charge_algorithm": "Per diem ($28,538).", "count": "0", "additional_payer_notes": "Zero final payments for the item or service in the 15 months prior to posting the file." } ] } ] }, { "description": "HC Shower Cover Hmii", "code_information": [ { "code": "PX-2110000024", "type": "CDM" }, { "code": "99999", "type": "CPT" }, { "code": "0270", "type": "RC" } ], "standard_charges": [ { "setting": "outpatient", "gross_charge": 3300.0, "discounted_cash": 1650.0, "minimum": 1392.6, "maximum": 1716.0, "additional_generic_notes": "Zero final payments for the item or service in the 15 months prior to posting the file.", "payers_information": [ { "payer_name": "AETNA", "plan_name": "AETNA ALL OTHER PLANS", "methodology": "percent of total billed charges", "standard_charge_dollar": 1716.0, "standard_charge_percentage": 52.0, "count": "0", "additional_payer_notes": "Zero final payments for the item or service in the 15 months prior to posting the file." }, { "payer_name": "AETNA", "plan_name": "AETNA ALL OTHER PLANS", "methodology": "percent of total billed charges", "standard_charge_dollar": 1716.0, "standard_charge_percentage": 52.0, "count": "0", "additional_payer_notes": "Zero final payments for the item or service in the 15 months prior to posting the file." }, { "payer_name": "MERITAIN HEALTH", "plan_name": "AETNA ALL OTHER PLANS", "methodology": "percent of total billed charges", "standard_charge_dollar": 1716.0, "standard_charge_percentage": 52.0, "count": "0", "additional_payer_notes": "Zero final payments for the item or service in the 15 months prior to posting the file." }, { "payer_name": "BLUE SHIELD OUT OF STATE", "plan_name": "STANFORD HEALTHCARE ALLIANCE PLAN", "methodology": "percent of total billed charges", "standard_charge_dollar": 1603.47, "standard_charge_percentage": 48.59, "count": "0", "additional_payer_notes": "Zero final payments for the item or service in the 15 months prior to posting the file." }, { "payer_name": "BLUE SHIELD", "plan_name": "STANFORD HEALTHCARE ALLIANCE PLAN", "methodology": "percent of total billed charges", "standard_charge_dollar": 1603.47, "standard_charge_percentage": 48.59, "median_amount": 68.24, "10th_percentile": 13.6, "90th_percentile": 1043.06, "count": "30" }, { "payer_name": "BLUE SHIELD", "plan_name": "STANFORD HEALTHCARE ALLIANCE PLAN", "methodology": "percent of total billed charges", "standard_charge_dollar": 1603.47, "standard_charge_percentage": 48.59, "count": "0", "additional_payer_notes": "Zero final payments for the item or service in the 15 months prior to posting the file." }, { "payer_name": "BLUE SHIELD", "plan_name": "STANFORD HEALTHCARE ALLIANCE PLAN", "methodology": "percent of total billed charges", "standard_charge_dollar": 1603.47, "standard_charge_percentage": 48.59, "count": "0", "additional_payer_notes": "Zero final payments for the item or service in the 15 months prior to posting the file." }, { "payer_name": "CIGNA", "plan_name": "CIGNA COM ALT HMO PLAN", "methodology": "percent of total billed charges", "standard_charge_dollar": 1392.6, "standard_charge_percentage": 42.2, "count": "0", "additional_payer_notes": "Zero final payments for the item or service in the 15 months prior to posting the file." }, { "payer_name": "CIGNA", "plan_name": "CIGNA COM ALT HMO PLAN", "methodology": "percent of total billed charges", "standard_charge_dollar": 1392.6, "standard_charge_percentage": 42.2, "count": "0", "additional_payer_notes": "Zero final payments for the item or service in the 15 months prior to posting the file." }, { "payer_name": "HEALTH NET", "plan_name": "HEALTHNET HMO, PPO, POS, EPO, CANOPY HEALTHNET HMO, OTHER-IN-NETWORK PLANS", "methodology": "per diem", "standard_charge_dollar": 8000.0, "standard_charge_algorithm": "Expected reimbursement is the lesser of Per diem ($8,000) for the length of stay and 70% of billed.", "count": "0", "additional_payer_notes": "Zero final payments for the item or service in the 15 months prior to posting the file." }, { "payer_name": "HEALTH NET", "plan_name": "HEALTHNET HMO, PPO, POS, EPO, CANOPY HEALTHNET HMO, OTHER-IN-NETWORK PLANS", "methodology": "per diem", "standard_charge_dollar": 8000.0, "standard_charge_algorithm": "Expected reimbursement is the lesser of Per diem ($8,000) for the length of stay and 70% of billed.", "count": "0", "additional_payer_notes": "Zero final payments for the item or service in the 15 months prior to posting the file." }, { "payer_name": "UNITED HEALTHCARE", "plan_name": "SUTTER SELECT & SUTTER HEALTH PLAN HMO PLANS", "methodology": "per diem", "standard_charge_dollar": 28538.0, "standard_charge_algorithm": "Per diem ($28,538).", "count": "0", "additional_payer_notes": "Zero final payments for the item or service in the 15 months prior to posting the file." }, { "payer_name": "UNITED HEALTHCARE", "plan_name": "SUTTER SELECT & SUTTER HEALTH PLAN HMO PLANS", "methodology": "per diem", "standard_charge_dollar": 28538.0, "standard_charge_algorithm": "Per diem ($28,538).", "count": "0", "additional_payer_notes": "Zero final payments for the item or service in the 15 months prior to posting the file." }, { "payer_name": "SUTTER", "plan_name": "SUTTER SELECT & SUTTER HEALTH PLAN HMO PLANS", "methodology": "per diem", "standard_charge_dollar": 28538.0, "standard_charge_algorithm": "Per diem ($28,538).", "count": "0", "additional_payer_notes": "Zero final payments for the item or service in the 15 months prior to posting the file." }, { "payer_name": "UNITED HEALTHCARE", "plan_name": "SUTTER SELECT & SUTTER HEALTH PLAN HMO PLANS", "methodology": "per diem", "standard_charge_dollar": 28538.0, "standard_charge_algorithm": "Per diem ($28,538).", "count": "0", "additional_payer_notes": "Zero final payments for the item or service in the 15 months prior to posting the file." }, { "payer_name": "UMR", "plan_name": "SUTTER SELECT & SUTTER HEALTH PLAN HMO PLANS", "methodology": "per diem", "standard_charge_dollar": 28538.0, "standard_charge_algorithm": "Per diem ($28,538).", "count": "0", "additional_payer_notes": "Zero final payments for the item or service in the 15 months prior to posting the file." } ] } ] }, { "description": "HC Vest Holster Hmii", "code_information": [ { "code": "PX-2110000025", "type": "CDM" }, { "code": "99999", "type": "CPT" }, { "code": "0270", "type": "RC" } ], "standard_charges": [ { "setting": "outpatient", "gross_charge": 2888.0, "discounted_cash": 1444.0, "minimum": 1218.74, "maximum": 1501.76, "additional_generic_notes": "Zero final payments for the item or service in the 15 months prior to posting the file.", "payers_information": [ { "payer_name": "AETNA", "plan_name": "AETNA ALL OTHER PLANS", "methodology": "percent of total billed charges", "standard_charge_dollar": 1501.76, "standard_charge_percentage": 52.0, "count": "0", "additional_payer_notes": "Zero final payments for the item or service in the 15 months prior to posting the file." }, { "payer_name": "AETNA", "plan_name": "AETNA ALL OTHER PLANS", "methodology": "percent of total billed charges", "standard_charge_dollar": 1501.76, "standard_charge_percentage": 52.0, "count": "0", "additional_payer_notes": "Zero final payments for the item or service in the 15 months prior to posting the file." }, { "payer_name": "MERITAIN HEALTH", "plan_name": "AETNA ALL OTHER PLANS", "methodology": "percent of total billed charges", "standard_charge_dollar": 1501.76, "standard_charge_percentage": 52.0, "count": "0", "additional_payer_notes": "Zero final payments for the item or service in the 15 months prior to posting the file." }, { "payer_name": "BLUE SHIELD OUT OF STATE", "plan_name": "STANFORD HEALTHCARE ALLIANCE PLAN", "methodology": "percent of total billed charges", "standard_charge_dollar": 1403.28, "standard_charge_percentage": 48.59, "count": "0", "additional_payer_notes": "Zero final payments for the item or service in the 15 months prior to posting the file." }, { "payer_name": "BLUE SHIELD", "plan_name": "STANFORD HEALTHCARE ALLIANCE PLAN", "methodology": "percent of total billed charges", "standard_charge_dollar": 1403.28, "standard_charge_percentage": 48.59, "median_amount": 68.24, "10th_percentile": 13.6, "90th_percentile": 1043.06, "count": "30" }, { "payer_name": "BLUE SHIELD", "plan_name": "STANFORD HEALTHCARE ALLIANCE PLAN", "methodology": "percent of total billed charges", "standard_charge_dollar": 1403.28, "standard_charge_percentage": 48.59, "count": "0", "additional_payer_notes": "Zero final payments for the item or service in the 15 months prior to posting the file." }, { "payer_name": "BLUE SHIELD", "plan_name": "STANFORD HEALTHCARE ALLIANCE PLAN", "methodology": "percent of total billed charges", "standard_charge_dollar": 1403.28, "standard_charge_percentage": 48.59, "count": "0", "additional_payer_notes": "Zero final payments for the item or service in the 15 months prior to posting the file." }, { "payer_name": "CIGNA", "plan_name": "CIGNA COM ALT HMO PLAN", "methodology": "percent of total billed charges", "standard_charge_dollar": 1218.74, "standard_charge_percentage": 42.2, "count": "0", "additional_payer_notes": "Zero final payments for the item or service in the 15 months prior to posting the file." }, { "payer_name": "CIGNA", "plan_name": "CIGNA COM ALT HMO PLAN", "methodology": "percent of total billed charges", "standard_charge_dollar": 1218.74, "standard_charge_percentage": 42.2, "count": "0", "additional_payer_notes": "Zero final payments for the item or service in the 15 months prior to posting the file." }, { "payer_name": "HEALTH NET", "plan_name": "HEALTHNET HMO, PPO, POS, EPO, CANOPY HEALTHNET HMO, OTHER-IN-NETWORK PLANS", "methodology": "per diem", "standard_charge_dollar": 8000.0, "standard_charge_algorithm": "Expected reimbursement is the lesser of Per diem ($8,000) for the length of stay and 70% of billed.", "count": "0", "additional_payer_notes": "Zero final payments for the item or service in the 15 months prior to posting the file." }, { "payer_name": "HEALTH NET", "plan_name": "HEALTHNET HMO, PPO, POS, EPO, CANOPY HEALTHNET HMO, OTHER-IN-NETWORK PLANS", "methodology": "per diem", "standard_charge_dollar": 8000.0, "standard_charge_algorithm": "Expected reimbursement is the lesser of Per diem ($8,000) for the length of stay and 70% of billed.", "count": "0", "additional_payer_notes": "Zero final payments for the item or service in the 15 months prior to posting the file." }, { "payer_name": "UNITED HEALTHCARE", "plan_name": "SUTTER SELECT & SUTTER HEALTH PLAN HMO PLANS", "methodology": "per diem", "standard_charge_dollar": 28538.0, "standard_charge_algorithm": "Per diem ($28,538).", "count": "0", "additional_payer_notes": "Zero final payments for the item or service in the 15 months prior to posting the file." }, { "payer_name": "UNITED HEALTHCARE", "plan_name": "SUTTER SELECT & SUTTER HEALTH PLAN HMO PLANS", "methodology": "per diem", "standard_charge_dollar": 28538.0, "standard_charge_algorithm": "Per diem ($28,538).", "count": "0", "additional_payer_notes": "Zero final payments for the item or service in the 15 months prior to posting the file." }, { "payer_name": "SUTTER", "plan_name": "SUTTER SELECT & SUTTER HEALTH PLAN HMO PLANS", "methodology": "per diem", "standard_charge_dollar": 28538.0, "standard_charge_algorithm": "Per diem ($28,538).", "count": "0", "additional_payer_notes": "Zero final payments for the item or service in the 15 months prior to posting the file." }, { "payer_name": "UNITED HEALTHCARE", "plan_name": "SUTTER SELECT & SUTTER HEALTH PLAN HMO PLANS", "methodology": "per diem", "standard_charge_dollar": 28538.0, "standard_charge_algorithm": "Per diem ($28,538).", "count": "0", "additional_payer_notes": "Zero final payments for the item or service in the 15 months prior to posting the file." }, { "payer_name": "UMR", "plan_name": "SUTTER SELECT & SUTTER HEALTH PLAN HMO PLANS", "methodology": "per diem", "standard_charge_dollar": 28538.0, "standard_charge_algorithm": "Per diem ($28,538).", "count": "0", "additional_payer_notes": "Zero final payments for the item or service in the 15 months prior to posting the file." } ] } ] }, { "description": "HC Syringe Assembly Alliance 60ml", "code_information": [ { "code": "PX-2110000026", "type": "CDM" }, { "code": "99999", "type": "CPT" }, { "code": "0272", "type": "RC" } ], "standard_charges": [ { "setting": "outpatient", "gross_charge": 293.0, "discounted_cash": 146.5, "minimum": 123.65, "maximum": 152.36, "additional_generic_notes": "Zero final payments for the item or service in the 15 months prior to posting the file.", "payers_information": [ { "payer_name": "AETNA", "plan_name": "AETNA ALL OTHER PLANS", "methodology": "percent of total billed charges", "standard_charge_dollar": 152.36, "standard_charge_percentage": 52.0, "count": "0", "additional_payer_notes": "Zero final payments for the item or service in the 15 months prior to posting the file." }, { "payer_name": "AETNA", "plan_name": "AETNA ALL OTHER PLANS", "methodology": "percent of total billed charges", "standard_charge_dollar": 152.36, "standard_charge_percentage": 52.0, "count": "0", "additional_payer_notes": "Zero final payments for the item or service in the 15 months prior to posting the file." }, { "payer_name": "MERITAIN HEALTH", "plan_name": "AETNA ALL OTHER PLANS", "methodology": "percent of total billed charges", "standard_charge_dollar": 152.36, "standard_charge_percentage": 52.0, "count": "0", "additional_payer_notes": "Zero final payments for the item or service in the 15 months prior to posting the file." }, { "payer_name": "BLUE SHIELD OUT OF STATE", "plan_name": "STANFORD HEALTHCARE ALLIANCE PLAN", "methodology": "percent of total billed charges", "standard_charge_dollar": 142.37, "standard_charge_percentage": 48.59, "count": "0", "additional_payer_notes": "Zero final payments for the item or service in the 15 months prior to posting the file." }, { "payer_name": "BLUE SHIELD", "plan_name": "STANFORD HEALTHCARE ALLIANCE PLAN", "methodology": "percent of total billed charges", "standard_charge_dollar": 142.37, "standard_charge_percentage": 48.59, "count": "0", "additional_payer_notes": "Zero final payments for the item or service in the 15 months prior to posting the file." }, { "payer_name": "BLUE SHIELD", "plan_name": "STANFORD HEALTHCARE ALLIANCE PLAN", "methodology": "percent of total billed charges", "standard_charge_dollar": 142.37, "standard_charge_percentage": 48.59, "count": "0", "additional_payer_notes": "Zero final payments for the item or service in the 15 months prior to posting the file." }, { "payer_name": "CIGNA", "plan_name": "CIGNA COM ALT HMO PLAN", "methodology": "percent of total billed charges", "standard_charge_dollar": 123.65, "standard_charge_percentage": 42.2, "count": "0", "additional_payer_notes": "Zero final payments for the item or service in the 15 months prior to posting the file." }, { "payer_name": "CIGNA", "plan_name": "CIGNA COM ALT HMO PLAN", "methodology": "percent of total billed charges", "standard_charge_dollar": 123.65, "standard_charge_percentage": 42.2, "count": "0", "additional_payer_notes": "Zero final payments for the item or service in the 15 months prior to posting the file." }, { "payer_name": "HEALTH NET", "plan_name": "HEALTHNET HMO, PPO, POS, EPO, CANOPY HEALTHNET HMO, OTHER-IN-NETWORK PLANS", "methodology": "per diem", "standard_charge_dollar": 8000.0, "standard_charge_algorithm": "Expected reimbursement is the lesser of Per diem ($8,000) for the length of stay and 70% of billed.", "count": "0", "additional_payer_notes": "Zero final payments for the item or service in the 15 months prior to posting the file." }, { "payer_name": "HEALTH NET", "plan_name": "HEALTHNET HMO, PPO, POS, EPO, CANOPY HEALTHNET HMO, OTHER-IN-NETWORK PLANS", "methodology": "per diem", "standard_charge_dollar": 8000.0, "standard_charge_algorithm": "Expected reimbursement is the lesser of Per diem ($8,000) for the length of stay and 70% of billed.", "count": "0", "additional_payer_notes": "Zero final payments for the item or service in the 15 months prior to posting the file." }, { "payer_name": "UNITED HEALTHCARE", "plan_name": "SUTTER SELECT & SUTTER HEALTH PLAN HMO PLANS", "methodology": "per diem", "standard_charge_dollar": 28538.0, "standard_charge_algorithm": "Per diem ($28,538).", "count": "0", "additional_payer_notes": "Zero final payments for the item or service in the 15 months prior to posting the file." }, { "payer_name": "UNITED HEALTHCARE", "plan_name": "SUTTER SELECT & SUTTER HEALTH PLAN HMO PLANS", "methodology": "per diem", "standard_charge_dollar": 28538.0, "standard_charge_algorithm": "Per diem ($28,538).", "count": "0", "additional_payer_notes": "Zero final payments for the item or service in the 15 months prior to posting the file." }, { "payer_name": "SUTTER", "plan_name": "SUTTER SELECT & SUTTER HEALTH PLAN HMO PLANS", "methodology": "per diem", "standard_charge_dollar": 28538.0, "standard_charge_algorithm": "Per diem ($28,538).", "count": "0", "additional_payer_notes": "Zero final payments for the item or service in the 15 months prior to posting the file." }, { "payer_name": "UNITED HEALTHCARE", "plan_name": "SUTTER SELECT & SUTTER HEALTH PLAN HMO PLANS", "methodology": "per diem", "standard_charge_dollar": 28538.0, "standard_charge_algorithm": "Per diem ($28,538).", "count": "0", "additional_payer_notes": "Zero final payments for the item or service in the 15 months prior to posting the file." }, { "payer_name": "UMR", "plan_name": "SUTTER SELECT & SUTTER HEALTH PLAN HMO PLANS", "methodology": "per diem", "standard_charge_dollar": 28538.0, "standard_charge_algorithm": "Per diem ($28,538).", "count": "0", "additional_payer_notes": "Zero final payments for the item or service in the 15 months prior to posting the file." } ] } ] }, { "description": "HC Heartware Power Cable Ext", "code_information": [ { "code": "PX-2110000027", "type": "CDM" }, { "code": "99999", "type": "CPT" }, { "code": "0270", "type": "RC" } ], "standard_charges": [ { "setting": "outpatient", "gross_charge": 12600.0, "discounted_cash": 6300.0, "minimum": 5317.2, "maximum": 6552.0, "additional_generic_notes": "Zero final payments for the item or service in the 15 months prior to posting the file.", "payers_information": [ { "payer_name": "AETNA", "plan_name": "AETNA ALL OTHER PLANS", "methodology": "percent of total billed charges", "standard_charge_dollar": 6552.0, "standard_charge_percentage": 52.0, "count": "0", "additional_payer_notes": "Zero final payments for the item or service in the 15 months prior to posting the file." }, { "payer_name": "AETNA", "plan_name": "AETNA ALL OTHER PLANS", "methodology": "percent of total billed charges", "standard_charge_dollar": 6552.0, "standard_charge_percentage": 52.0, "count": "0", "additional_payer_notes": "Zero final payments for the item or service in the 15 months prior to posting the file." }, { "payer_name": "MERITAIN HEALTH", "plan_name": "AETNA ALL OTHER PLANS", "methodology": "percent of total billed charges", "standard_charge_dollar": 6552.0, "standard_charge_percentage": 52.0, "count": "0", "additional_payer_notes": "Zero final payments for the item or service in the 15 months prior to posting the file." }, { "payer_name": "BLUE SHIELD OUT OF STATE", "plan_name": "STANFORD HEALTHCARE ALLIANCE PLAN", "methodology": "percent of total billed charges", "standard_charge_dollar": 6122.34, "standard_charge_percentage": 48.59, "count": "0", "additional_payer_notes": "Zero final payments for the item or service in the 15 months prior to posting the file." }, { "payer_name": "BLUE SHIELD", "plan_name": "STANFORD HEALTHCARE ALLIANCE PLAN", "methodology": "percent of total billed charges", "standard_charge_dollar": 6122.34, "standard_charge_percentage": 48.59, "median_amount": 68.24, "10th_percentile": 13.6, "90th_percentile": 1043.06, "count": "30" }, { "payer_name": "BLUE SHIELD", "plan_name": "STANFORD HEALTHCARE ALLIANCE PLAN", "methodology": "percent of total billed charges", "standard_charge_dollar": 6122.34, "standard_charge_percentage": 48.59, "count": "0", "additional_payer_notes": "Zero final payments for the item or service in the 15 months prior to posting the file." }, { "payer_name": "BLUE SHIELD", "plan_name": "STANFORD HEALTHCARE ALLIANCE PLAN", "methodology": "percent of total billed charges", "standard_charge_dollar": 6122.34, "standard_charge_percentage": 48.59, "count": "0", "additional_payer_notes": "Zero final payments for the item or service in the 15 months prior to posting the file." }, { "payer_name": "CIGNA", "plan_name": "CIGNA COM ALT HMO PLAN", "methodology": "percent of total billed charges", "standard_charge_dollar": 5317.2, "standard_charge_percentage": 42.2, "count": "0", "additional_payer_notes": "Zero final payments for the item or service in the 15 months prior to posting the file." }, { "payer_name": "CIGNA", "plan_name": "CIGNA COM ALT HMO PLAN", "methodology": "percent of total billed charges", "standard_charge_dollar": 5317.2, "standard_charge_percentage": 42.2, "count": "0", "additional_payer_notes": "Zero final payments for the item or service in the 15 months prior to posting the file." }, { "payer_name": "HEALTH NET", "plan_name": "HEALTHNET HMO, PPO, POS, EPO, CANOPY HEALTHNET HMO, OTHER-IN-NETWORK PLANS", "methodology": "per diem", "standard_charge_dollar": 8000.0, "standard_charge_algorithm": "Expected reimbursement is the lesser of Per diem ($8,000) for the length of stay and 70% of billed.", "count": "0", "additional_payer_notes": "Zero final payments for the item or service in the 15 months prior to posting the file." }, { "payer_name": "HEALTH NET", "plan_name": "HEALTHNET HMO, PPO, POS, EPO, CANOPY HEALTHNET HMO, OTHER-IN-NETWORK PLANS", "methodology": "per diem", "standard_charge_dollar": 8000.0, "standard_charge_algorithm": "Expected reimbursement is the lesser of Per diem ($8,000) for the length of stay and 70% of billed.", "count": "0", "additional_payer_notes": "Zero final payments for the item or service in the 15 months prior to posting the file." }, { "payer_name": "UNITED HEALTHCARE", "plan_name": "SUTTER SELECT & SUTTER HEALTH PLAN HMO PLANS", "methodology": "per diem", "standard_charge_dollar": 28538.0, "standard_charge_algorithm": "Per diem ($28,538).", "count": "0", "additional_payer_notes": "Zero final payments for the item or service in the 15 months prior to posting the file." }, { "payer_name": "UNITED HEALTHCARE", "plan_name": "SUTTER SELECT & SUTTER HEALTH PLAN HMO PLANS", "methodology": "per diem", "standard_charge_dollar": 28538.0, "standard_charge_algorithm": "Per diem ($28,538).", "count": "0", "additional_payer_notes": "Zero final payments for the item or service in the 15 months prior to posting the file." }, { "payer_name": "SUTTER", "plan_name": "SUTTER SELECT & SUTTER HEALTH PLAN HMO PLANS", "methodology": "per diem", "standard_charge_dollar": 28538.0, "standard_charge_algorithm": "Per diem ($28,538).", "count": "0", "additional_payer_notes": "Zero final payments for the item or service in the 15 months prior to posting the file." }, { "payer_name": "UNITED HEALTHCARE", "plan_name": "SUTTER SELECT & SUTTER HEALTH PLAN HMO PLANS", "methodology": "per diem", "standard_charge_dollar": 28538.0, "standard_charge_algorithm": "Per diem ($28,538).", "count": "0", "additional_payer_notes": "Zero final payments for the item or service in the 15 months prior to posting the file." }, { "payer_name": "UMR", "plan_name": "SUTTER SELECT & SUTTER HEALTH PLAN HMO PLANS", "methodology": "per diem", "standard_charge_dollar": 28538.0, "standard_charge_algorithm": "Per diem ($28,538).", "count": "0", "additional_payer_notes": "Zero final payments for the item or service in the 15 months prior to posting the file." } ] } ] }, { "description": "HC Heartware Battery Charger", "code_information": [ { "code": "PX-2110000028", "type": "CDM" }, { "code": "99999", "type": "CPT" }, { "code": "0270", "type": "RC" } ], "standard_charges": [ { "setting": "outpatient", "gross_charge": 24000.0, "discounted_cash": 12000.0, "minimum": 10128.0, "maximum": 12480.0, "additional_generic_notes": "Zero final payments for the item or service in the 15 months prior to posting the file.", "payers_information": [ { "payer_name": "AETNA", "plan_name": "AETNA ALL OTHER PLANS", "methodology": "percent of total billed charges", "standard_charge_dollar": 12480.0, "standard_charge_percentage": 52.0, "count": "0", "additional_payer_notes": "Zero final payments for the item or service in the 15 months prior to posting the file." }, { "payer_name": "AETNA", "plan_name": "AETNA ALL OTHER PLANS", "methodology": "percent of total billed charges", "standard_charge_dollar": 12480.0, "standard_charge_percentage": 52.0, "count": "0", "additional_payer_notes": "Zero final payments for the item or service in the 15 months prior to posting the file." }, { "payer_name": "MERITAIN HEALTH", "plan_name": "AETNA ALL OTHER PLANS", "methodology": "percent of total billed charges", "standard_charge_dollar": 12480.0, "standard_charge_percentage": 52.0, "count": "0", "additional_payer_notes": "Zero final payments for the item or service in the 15 months prior to posting the file." }, { "payer_name": "BLUE SHIELD OUT OF STATE", "plan_name": "STANFORD HEALTHCARE ALLIANCE PLAN", "methodology": "percent of total billed charges", "standard_charge_dollar": 11661.6, "standard_charge_percentage": 48.59, "count": "0", "additional_payer_notes": "Zero final payments for the item or service in the 15 months prior to posting the file." }, { "payer_name": "BLUE SHIELD", "plan_name": "STANFORD HEALTHCARE ALLIANCE PLAN", "methodology": "percent of total billed charges", "standard_charge_dollar": 11661.6, "standard_charge_percentage": 48.59, "median_amount": 68.24, "10th_percentile": 13.6, "90th_percentile": 1043.06, "count": "30" }, { "payer_name": "BLUE SHIELD", "plan_name": "STANFORD HEALTHCARE ALLIANCE PLAN", "methodology": "percent of total billed charges", "standard_charge_dollar": 11661.6, "standard_charge_percentage": 48.59, "count": "0", "additional_payer_notes": "Zero final payments for the item or service in the 15 months prior to posting the file." }, { "payer_name": "BLUE SHIELD", "plan_name": "STANFORD HEALTHCARE ALLIANCE PLAN", "methodology": "percent of total billed charges", "standard_charge_dollar": 11661.6, "standard_charge_percentage": 48.59, "count": "0", "additional_payer_notes": "Zero final payments for the item or service in the 15 months prior to posting the file." }, { "payer_name": "CIGNA", "plan_name": "CIGNA COM ALT HMO PLAN", "methodology": "percent of total billed charges", "standard_charge_dollar": 10128.0, "standard_charge_percentage": 42.2, "count": "0", "additional_payer_notes": "Zero final payments for the item or service in the 15 months prior to posting the file." }, { "payer_name": "CIGNA", "plan_name": "CIGNA COM ALT HMO PLAN", "methodology": "percent of total billed charges", "standard_charge_dollar": 10128.0, "standard_charge_percentage": 42.2, "count": "0", "additional_payer_notes": "Zero final payments for the item or service in the 15 months prior to posting the file." }, { "payer_name": "HEALTH NET", "plan_name": "HEALTHNET HMO, PPO, POS, EPO, CANOPY HEALTHNET HMO, OTHER-IN-NETWORK PLANS", "methodology": "per diem", "standard_charge_dollar": 8000.0, "standard_charge_algorithm": "Expected reimbursement is the lesser of Per diem ($8,000) for the length of stay and 70% of billed.", "count": "0", "additional_payer_notes": "Zero final payments for the item or service in the 15 months prior to posting the file." }, { "payer_name": "HEALTH NET", "plan_name": "HEALTHNET HMO, PPO, POS, EPO, CANOPY HEALTHNET HMO, OTHER-IN-NETWORK PLANS", "methodology": "per diem", "standard_charge_dollar": 8000.0, "standard_charge_algorithm": "Expected reimbursement is the lesser of Per diem ($8,000) for the length of stay and 70% of billed.", "count": "0", "additional_payer_notes": "Zero final payments for the item or service in the 15 months prior to posting the file." }, { "payer_name": "UNITED HEALTHCARE", "plan_name": "SUTTER SELECT & SUTTER HEALTH PLAN HMO PLANS", "methodology": "per diem", "standard_charge_dollar": 28538.0, "standard_charge_algorithm": "Per diem ($28,538).", "count": "0", "additional_payer_notes": "Zero final payments for the item or service in the 15 months prior to posting the file." }, { "payer_name": "UNITED HEALTHCARE", "plan_name": "SUTTER SELECT & SUTTER HEALTH PLAN HMO PLANS", "methodology": "per diem", "standard_charge_dollar": 28538.0, "standard_charge_algorithm": "Per diem ($28,538).", "count": "0", "additional_payer_notes": "Zero final payments for the item or service in the 15 months prior to posting the file." }, { "payer_name": "SUTTER", "plan_name": "SUTTER SELECT & SUTTER HEALTH PLAN HMO PLANS", "methodology": "per diem", "standard_charge_dollar": 28538.0, "standard_charge_algorithm": "Per diem ($28,538).", "count": "0", "additional_payer_notes": "Zero final payments for the item or service in the 15 months prior to posting the file." }, { "payer_name": "UNITED HEALTHCARE", "plan_name": "SUTTER SELECT & SUTTER HEALTH PLAN HMO PLANS", "methodology": "per diem", "standard_charge_dollar": 28538.0, "standard_charge_algorithm": "Per diem ($28,538).", "count": "0", "additional_payer_notes": "Zero final payments for the item or service in the 15 months prior to posting the file." }, { "payer_name": "UMR", "plan_name": "SUTTER SELECT & SUTTER HEALTH PLAN HMO PLANS", "methodology": "per diem", "standard_charge_dollar": 28538.0, "standard_charge_algorithm": "Per diem ($28,538).", "count": "0", "additional_payer_notes": "Zero final payments for the item or service in the 15 months prior to posting the file." }, { "payer_name": "UNITED HEALTHCARE", "plan_name": "SUTTER SELECT & SUTTER HEALTH PLAN HMO PLANS", "methodology": "per diem", "standard_charge_dollar": 28538.0, "standard_charge_algorithm": "Per diem ($28,538).", "median_amount": 21329.69, "10th_percentile": 21329.69, "90th_percentile": 21329.69, "count": "1 through 10" } ] } ] }, { "description": "HC Heartware Battery", "code_information": [ { "code": "PX-2110000029", "type": "CDM" }, { "code": "99999", "type": "CPT" }, { "code": "0270", "type": "RC" } ], "standard_charges": [ { "setting": "outpatient", "gross_charge": 5250.0, "discounted_cash": 2625.0, "minimum": 2215.5, "maximum": 2730.0, "additional_generic_notes": "Zero final payments for the item or service in the 15 months prior to posting the file.", "payers_information": [ { "payer_name": "AETNA", "plan_name": "AETNA ALL OTHER PLANS", "methodology": "percent of total billed charges", "standard_charge_dollar": 2730.0, "standard_charge_percentage": 52.0, "count": "0", "additional_payer_notes": "Zero final payments for the item or service in the 15 months prior to posting the file." }, { "payer_name": "AETNA", "plan_name": "AETNA ALL OTHER PLANS", "methodology": "percent of total billed charges", "standard_charge_dollar": 2730.0, "standard_charge_percentage": 52.0, "count": "0", "additional_payer_notes": "Zero final payments for the item or service in the 15 months prior to posting the file." }, { "payer_name": "MERITAIN HEALTH", "plan_name": "AETNA ALL OTHER PLANS", "methodology": "percent of total billed charges", "standard_charge_dollar": 2730.0, "standard_charge_percentage": 52.0, "count": "0", "additional_payer_notes": "Zero final payments for the item or service in the 15 months prior to posting the file." }, { "payer_name": "BLUE SHIELD OUT OF STATE", "plan_name": "STANFORD HEALTHCARE ALLIANCE PLAN", "methodology": "percent of total billed charges", "standard_charge_dollar": 2550.98, "standard_charge_percentage": 48.59, "count": "0", "additional_payer_notes": "Zero final payments for the item or service in the 15 months prior to posting the file." }, { "payer_name": "BLUE SHIELD", "plan_name": "STANFORD HEALTHCARE ALLIANCE PLAN", "methodology": "percent of total billed charges", "standard_charge_dollar": 2550.98, "standard_charge_percentage": 48.59, "median_amount": 68.24, "10th_percentile": 13.6, "90th_percentile": 1043.06, "count": "30" }, { "payer_name": "BLUE SHIELD", "plan_name": "STANFORD HEALTHCARE ALLIANCE PLAN", "methodology": "percent of total billed charges", "standard_charge_dollar": 2550.98, "standard_charge_percentage": 48.59, "count": "0", "additional_payer_notes": "Zero final payments for the item or service in the 15 months prior to posting the file." }, { "payer_name": "BLUE SHIELD", "plan_name": "STANFORD HEALTHCARE ALLIANCE PLAN", "methodology": "percent of total billed charges", "standard_charge_dollar": 2550.98, "standard_charge_percentage": 48.59, "count": "0", "additional_payer_notes": "Zero final payments for the item or service in the 15 months prior to posting the file." }, { "payer_name": "CIGNA", "plan_name": "CIGNA COM ALT HMO PLAN", "methodology": "percent of total billed charges", "standard_charge_dollar": 2215.5, "standard_charge_percentage": 42.2, "count": "0", "additional_payer_notes": "Zero final payments for the item or service in the 15 months prior to posting the file." }, { "payer_name": "CIGNA", "plan_name": "CIGNA COM ALT HMO PLAN", "methodology": "percent of total billed charges", "standard_charge_dollar": 2215.5, "standard_charge_percentage": 42.2, "count": "0", "additional_payer_notes": "Zero final payments for the item or service in the 15 months prior to posting the file." }, { "payer_name": "HEALTH NET", "plan_name": "HEALTHNET HMO, PPO, POS, EPO, CANOPY HEALTHNET HMO, OTHER-IN-NETWORK PLANS", "methodology": "per diem", "standard_charge_dollar": 8000.0, "standard_charge_algorithm": "Expected reimbursement is the lesser of Per diem ($8,000) for the length of stay and 70% of billed.", "count": "0", "additional_payer_notes": "Zero final payments for the item or service in the 15 months prior to posting the file." }, { "payer_name": "HEALTH NET", "plan_name": "HEALTHNET HMO, PPO, POS, EPO, CANOPY HEALTHNET HMO, OTHER-IN-NETWORK PLANS", "methodology": "per diem", "standard_charge_dollar": 8000.0, "standard_charge_algorithm": "Expected reimbursement is the lesser of Per diem ($8,000) for the length of stay and 70% of billed.", "count": "0", "additional_payer_notes": "Zero final payments for the item or service in the 15 months prior to posting the file." }, { "payer_name": "UNITED HEALTHCARE", "plan_name": "SUTTER SELECT & SUTTER HEALTH PLAN HMO PLANS", "methodology": "per diem", "standard_charge_dollar": 28538.0, "standard_charge_algorithm": "Per diem ($28,538).", "count": "0", "additional_payer_notes": "Zero final payments for the item or service in the 15 months prior to posting the file." }, { "payer_name": "UNITED HEALTHCARE", "plan_name": "SUTTER SELECT & SUTTER HEALTH PLAN HMO PLANS", "methodology": "per diem", "standard_charge_dollar": 28538.0, "standard_charge_algorithm": "Per diem ($28,538).", "count": "0", "additional_payer_notes": "Zero final payments for the item or service in the 15 months prior to posting the file." }, { "payer_name": "SUTTER", "plan_name": "SUTTER SELECT & SUTTER HEALTH PLAN HMO PLANS", "methodology": "per diem", "standard_charge_dollar": 28538.0, "standard_charge_algorithm": "Per diem ($28,538).", "count": "0", "additional_payer_notes": "Zero final payments for the item or service in the 15 months prior to posting the file." }, { "payer_name": "UNITED HEALTHCARE", "plan_name": "SUTTER SELECT & SUTTER HEALTH PLAN HMO PLANS", "methodology": "per diem", "standard_charge_dollar": 28538.0, "standard_charge_algorithm": "Per diem ($28,538).", "count": "0", "additional_payer_notes": "Zero final payments for the item or service in the 15 months prior to posting the file." }, { "payer_name": "UMR", "plan_name": "SUTTER SELECT & SUTTER HEALTH PLAN HMO PLANS", "methodology": "per diem", "standard_charge_dollar": 28538.0, "standard_charge_algorithm": "Per diem ($28,538).", "count": "0", "additional_payer_notes": "Zero final payments for the item or service in the 15 months prior to posting the file." } ] } ] }, { "description": "HC Heartware Monitor", "code_information": [ { "code": "PX-2110000030", "type": "CDM" }, { "code": "99999", "type": "CPT" }, { "code": "0270", "type": "RC" } ], "standard_charges": [ { "setting": "outpatient", "gross_charge": 39200.0, "discounted_cash": 19600.0, "minimum": 16542.4, "maximum": 20384.0, "additional_generic_notes": "Zero final payments for the item or service in the 15 months prior to posting the file.", "payers_information": [ { "payer_name": "AETNA", "plan_name": "AETNA ALL OTHER PLANS", "methodology": "percent of total billed charges", "standard_charge_dollar": 20384.0, "standard_charge_percentage": 52.0, "count": "0", "additional_payer_notes": "Zero final payments for the item or service in the 15 months prior to posting the file." }, { "payer_name": "AETNA", "plan_name": "AETNA ALL OTHER PLANS", "methodology": "percent of total billed charges", "standard_charge_dollar": 20384.0, "standard_charge_percentage": 52.0, "count": "0", "additional_payer_notes": "Zero final payments for the item or service in the 15 months prior to posting the file." }, { "payer_name": "MERITAIN HEALTH", "plan_name": "AETNA ALL OTHER PLANS", "methodology": "percent of total billed charges", "standard_charge_dollar": 20384.0, "standard_charge_percentage": 52.0, "count": "0", "additional_payer_notes": "Zero final payments for the item or service in the 15 months prior to posting the file." }, { "payer_name": "BLUE SHIELD OUT OF STATE", "plan_name": "STANFORD HEALTHCARE ALLIANCE PLAN", "methodology": "percent of total billed charges", "standard_charge_dollar": 19047.28, "standard_charge_percentage": 48.59, "count": "0", "additional_payer_notes": "Zero final payments for the item or service in the 15 months prior to posting the file." }, { "payer_name": "BLUE SHIELD", "plan_name": "STANFORD HEALTHCARE ALLIANCE PLAN", "methodology": "percent of total billed charges", "standard_charge_dollar": 19047.28, "standard_charge_percentage": 48.59, "median_amount": 68.24, "10th_percentile": 13.6, "90th_percentile": 1043.06, "count": "30" }, { "payer_name": "BLUE SHIELD", "plan_name": "STANFORD HEALTHCARE ALLIANCE PLAN", "methodology": "percent of total billed charges", "standard_charge_dollar": 19047.28, "standard_charge_percentage": 48.59, "count": "0", "additional_payer_notes": "Zero final payments for the item or service in the 15 months prior to posting the file." }, { "payer_name": "BLUE SHIELD", "plan_name": "STANFORD HEALTHCARE ALLIANCE PLAN", "methodology": "percent of total billed charges", "standard_charge_dollar": 19047.28, "standard_charge_percentage": 48.59, "count": "0", "additional_payer_notes": "Zero final payments for the item or service in the 15 months prior to posting the file." }, { "payer_name": "CIGNA", "plan_name": "CIGNA COM ALT HMO PLAN", "methodology": "percent of total billed charges", "standard_charge_dollar": 16542.4, "standard_charge_percentage": 42.2, "count": "0", "additional_payer_notes": "Zero final payments for the item or service in the 15 months prior to posting the file." }, { "payer_name": "CIGNA", "plan_name": "CIGNA COM ALT HMO PLAN", "methodology": "percent of total billed charges", "standard_charge_dollar": 16542.4, "standard_charge_percentage": 42.2, "count": "0", "additional_payer_notes": "Zero final payments for the item or service in the 15 months prior to posting the file." }, { "payer_name": "HEALTH NET", "plan_name": "HEALTHNET HMO, PPO, POS, EPO, CANOPY HEALTHNET HMO, OTHER-IN-NETWORK PLANS", "methodology": "per diem", "standard_charge_dollar": 8000.0, "standard_charge_algorithm": "Expected reimbursement is the lesser of Per diem ($8,000) for the length of stay and 70% of billed.", "count": "0", "additional_payer_notes": "Zero final payments for the item or service in the 15 months prior to posting the file." }, { "payer_name": "HEALTH NET", "plan_name": "HEALTHNET HMO, PPO, POS, EPO, CANOPY HEALTHNET HMO, OTHER-IN-NETWORK PLANS", "methodology": "per diem", "standard_charge_dollar": 8000.0, "standard_charge_algorithm": "Expected reimbursement is the lesser of Per diem ($8,000) for the length of stay and 70% of billed.", "count": "0", "additional_payer_notes": "Zero final payments for the item or service in the 15 months prior to posting the file." }, { "payer_name": "UNITED HEALTHCARE", "plan_name": "SUTTER SELECT & SUTTER HEALTH PLAN HMO PLANS", "methodology": "per diem", "standard_charge_dollar": 28538.0, "standard_charge_algorithm": "Per diem ($28,538).", "count": "0", "additional_payer_notes": "Zero final payments for the item or service in the 15 months prior to posting the file." }, { "payer_name": "UNITED HEALTHCARE", "plan_name": "SUTTER SELECT & SUTTER HEALTH PLAN HMO PLANS", "methodology": "per diem", "standard_charge_dollar": 28538.0, "standard_charge_algorithm": "Per diem ($28,538).", "count": "0", "additional_payer_notes": "Zero final payments for the item or service in the 15 months prior to posting the file." }, { "payer_name": "SUTTER", "plan_name": "SUTTER SELECT & SUTTER HEALTH PLAN HMO PLANS", "methodology": "per diem", "standard_charge_dollar": 28538.0, "standard_charge_algorithm": "Per diem ($28,538).", "count": "0", "additional_payer_notes": "Zero final payments for the item or service in the 15 months prior to posting the file." }, { "payer_name": "UNITED HEALTHCARE", "plan_name": "SUTTER SELECT & SUTTER HEALTH PLAN HMO PLANS", "methodology": "per diem", "standard_charge_dollar": 28538.0, "standard_charge_algorithm": "Per diem ($28,538).", "count": "0", "additional_payer_notes": "Zero final payments for the item or service in the 15 months prior to posting the file." }, { "payer_name": "UMR", "plan_name": "SUTTER SELECT & SUTTER HEALTH PLAN HMO PLANS", "methodology": "per diem", "standard_charge_dollar": 28538.0, "standard_charge_algorithm": "Per diem ($28,538).", "count": "0", "additional_payer_notes": "Zero final payments for the item or service in the 15 months prior to posting the file." }, { "payer_name": "UNITED HEALTHCARE", "plan_name": "SUTTER SELECT & SUTTER HEALTH PLAN HMO PLANS", "methodology": "per diem", "standard_charge_dollar": 28538.0, "standard_charge_algorithm": "Per diem ($28,538).", "median_amount": 21329.69, "10th_percentile": 21329.69, "90th_percentile": 21329.69, "count": "1 through 10" } ] } ] }, { "description": "HC Heartware Shower Bag", "code_information": [ { "code": "PX-2110000031", "type": "CDM" }, { "code": "99999", "type": "CPT" }, { "code": "0270", "type": "RC" } ], "standard_charges": [ { "setting": "outpatient", "gross_charge": 2125.0, "discounted_cash": 1062.5, "minimum": 896.75, "maximum": 1105.0, "additional_generic_notes": "Zero final payments for the item or service in the 15 months prior to posting the file.", "payers_information": [ { "payer_name": "AETNA", "plan_name": "AETNA ALL OTHER PLANS", "methodology": "percent of total billed charges", "standard_charge_dollar": 1105.0, "standard_charge_percentage": 52.0, "count": "0", "additional_payer_notes": "Zero final payments for the item or service in the 15 months prior to posting the file." }, { "payer_name": "AETNA", "plan_name": "AETNA ALL OTHER PLANS", "methodology": "percent of total billed charges", "standard_charge_dollar": 1105.0, "standard_charge_percentage": 52.0, "count": "0", "additional_payer_notes": "Zero final payments for the item or service in the 15 months prior to posting the file." }, { "payer_name": "MERITAIN HEALTH", "plan_name": "AETNA ALL OTHER PLANS", "methodology": "percent of total billed charges", "standard_charge_dollar": 1105.0, "standard_charge_percentage": 52.0, "count": "0", "additional_payer_notes": "Zero final payments for the item or service in the 15 months prior to posting the file." }, { "payer_name": "BLUE SHIELD OUT OF STATE", "plan_name": "STANFORD HEALTHCARE ALLIANCE PLAN", "methodology": "percent of total billed charges", "standard_charge_dollar": 1032.54, "standard_charge_percentage": 48.59, "count": "0", "additional_payer_notes": "Zero final payments for the item or service in the 15 months prior to posting the file." }, { "payer_name": "BLUE SHIELD", "plan_name": "STANFORD HEALTHCARE ALLIANCE PLAN", "methodology": "percent of total billed charges", "standard_charge_dollar": 1032.54, "standard_charge_percentage": 48.59, "median_amount": 68.24, "10th_percentile": 13.6, "90th_percentile": 1043.06, "count": "30" }, { "payer_name": "BLUE SHIELD", "plan_name": "STANFORD HEALTHCARE ALLIANCE PLAN", "methodology": "percent of total billed charges", "standard_charge_dollar": 1032.54, "standard_charge_percentage": 48.59, "count": "0", "additional_payer_notes": "Zero final payments for the item or service in the 15 months prior to posting the file." }, { "payer_name": "BLUE SHIELD", "plan_name": "STANFORD HEALTHCARE ALLIANCE PLAN", "methodology": "percent of total billed charges", "standard_charge_dollar": 1032.54, "standard_charge_percentage": 48.59, "count": "0", "additional_payer_notes": "Zero final payments for the item or service in the 15 months prior to posting the file." }, { "payer_name": "CIGNA", "plan_name": "CIGNA COM ALT HMO PLAN", "methodology": "percent of total billed charges", "standard_charge_dollar": 896.75, "standard_charge_percentage": 42.2, "count": "0", "additional_payer_notes": "Zero final payments for the item or service in the 15 months prior to posting the file." }, { "payer_name": "CIGNA", "plan_name": "CIGNA COM ALT HMO PLAN", "methodology": "percent of total billed charges", "standard_charge_dollar": 896.75, "standard_charge_percentage": 42.2, "count": "0", "additional_payer_notes": "Zero final payments for the item or service in the 15 months prior to posting the file." }, { "payer_name": "HEALTH NET", "plan_name": "HEALTHNET HMO, PPO, POS, EPO, CANOPY HEALTHNET HMO, OTHER-IN-NETWORK PLANS", "methodology": "per diem", "standard_charge_dollar": 8000.0, "standard_charge_algorithm": "Expected reimbursement is the lesser of Per diem ($8,000) for the length of stay and 70% of billed.", "count": "0", "additional_payer_notes": "Zero final payments for the item or service in the 15 months prior to posting the file." }, { "payer_name": "HEALTH NET", "plan_name": "HEALTHNET HMO, PPO, POS, EPO, CANOPY HEALTHNET HMO, OTHER-IN-NETWORK PLANS", "methodology": "per diem", "standard_charge_dollar": 8000.0, "standard_charge_algorithm": "Expected reimbursement is the lesser of Per diem ($8,000) for the length of stay and 70% of billed.", "count": "0", "additional_payer_notes": "Zero final payments for the item or service in the 15 months prior to posting the file." }, { "payer_name": "UNITED HEALTHCARE", "plan_name": "SUTTER SELECT & SUTTER HEALTH PLAN HMO PLANS", "methodology": "per diem", "standard_charge_dollar": 28538.0, "standard_charge_algorithm": "Per diem ($28,538).", "count": "0", "additional_payer_notes": "Zero final payments for the item or service in the 15 months prior to posting the file." }, { "payer_name": "UNITED HEALTHCARE", "plan_name": "SUTTER SELECT & SUTTER HEALTH PLAN HMO PLANS", "methodology": "per diem", "standard_charge_dollar": 28538.0, "standard_charge_algorithm": "Per diem ($28,538).", "count": "0", "additional_payer_notes": "Zero final payments for the item or service in the 15 months prior to posting the file." }, { "payer_name": "SUTTER", "plan_name": "SUTTER SELECT & SUTTER HEALTH PLAN HMO PLANS", "methodology": "per diem", "standard_charge_dollar": 28538.0, "standard_charge_algorithm": "Per diem ($28,538).", "count": "0", "additional_payer_notes": "Zero final payments for the item or service in the 15 months prior to posting the file." }, { "payer_name": "UNITED HEALTHCARE", "plan_name": "SUTTER SELECT & SUTTER HEALTH PLAN HMO PLANS", "methodology": "per diem", "standard_charge_dollar": 28538.0, "standard_charge_algorithm": "Per diem ($28,538).", "count": "0", "additional_payer_notes": "Zero final payments for the item or service in the 15 months prior to posting the file." }, { "payer_name": "UMR", "plan_name": "SUTTER SELECT & SUTTER HEALTH PLAN HMO PLANS", "methodology": "per diem", "standard_charge_dollar": 28538.0, "standard_charge_algorithm": "Per diem ($28,538).", "count": "0", "additional_payer_notes": "Zero final payments for the item or service in the 15 months prior to posting the file." } ] } ] }, { "description": "HC Heartware Carrying Case Pack", "code_information": [ { "code": "PX-2110000032", "type": "CDM" }, { "code": "99999", "type": "CPT" }, { "code": "0270", "type": "RC" } ], "standard_charges": [ { "setting": "outpatient", "gross_charge": 3300.0, "discounted_cash": 1650.0, "minimum": 1392.6, "maximum": 1716.0, "additional_generic_notes": "Zero final payments for the item or service in the 15 months prior to posting the file.", "payers_information": [ { "payer_name": "AETNA", "plan_name": "AETNA ALL OTHER PLANS", "methodology": "percent of total billed charges", "standard_charge_dollar": 1716.0, "standard_charge_percentage": 52.0, "count": "0", "additional_payer_notes": "Zero final payments for the item or service in the 15 months prior to posting the file." }, { "payer_name": "AETNA", "plan_name": "AETNA ALL OTHER PLANS", "methodology": "percent of total billed charges", "standard_charge_dollar": 1716.0, "standard_charge_percentage": 52.0, "count": "0", "additional_payer_notes": "Zero final payments for the item or service in the 15 months prior to posting the file." }, { "payer_name": "MERITAIN HEALTH", "plan_name": "AETNA ALL OTHER PLANS", "methodology": "percent of total billed charges", "standard_charge_dollar": 1716.0, "standard_charge_percentage": 52.0, "count": "0", "additional_payer_notes": "Zero final payments for the item or service in the 15 months prior to posting the file." }, { "payer_name": "BLUE SHIELD OUT OF STATE", "plan_name": "STANFORD HEALTHCARE ALLIANCE PLAN", "methodology": "percent of total billed charges", "standard_charge_dollar": 1603.47, "standard_charge_percentage": 48.59, "count": "0", "additional_payer_notes": "Zero final payments for the item or service in the 15 months prior to posting the file." }, { "payer_name": "BLUE SHIELD", "plan_name": "STANFORD HEALTHCARE ALLIANCE PLAN", "methodology": "percent of total billed charges", "standard_charge_dollar": 1603.47, "standard_charge_percentage": 48.59, "median_amount": 68.24, "10th_percentile": 13.6, "90th_percentile": 1043.06, "count": "30" }, { "payer_name": "BLUE SHIELD", "plan_name": "STANFORD HEALTHCARE ALLIANCE PLAN", "methodology": "percent of total billed charges", "standard_charge_dollar": 1603.47, "standard_charge_percentage": 48.59, "count": "0", "additional_payer_notes": "Zero final payments for the item or service in the 15 months prior to posting the file." }, { "payer_name": "BLUE SHIELD", "plan_name": "STANFORD HEALTHCARE ALLIANCE PLAN", "methodology": "percent of total billed charges", "standard_charge_dollar": 1603.47, "standard_charge_percentage": 48.59, "count": "0", "additional_payer_notes": "Zero final payments for the item or service in the 15 months prior to posting the file." }, { "payer_name": "CIGNA", "plan_name": "CIGNA COM ALT HMO PLAN", "methodology": "percent of total billed charges", "standard_charge_dollar": 1392.6, "standard_charge_percentage": 42.2, "count": "0", "additional_payer_notes": "Zero final payments for the item or service in the 15 months prior to posting the file." }, { "payer_name": "CIGNA", "plan_name": "CIGNA COM ALT HMO PLAN", "methodology": "percent of total billed charges", "standard_charge_dollar": 1392.6, "standard_charge_percentage": 42.2, "count": "0", "additional_payer_notes": "Zero final payments for the item or service in the 15 months prior to posting the file." }, { "payer_name": "HEALTH NET", "plan_name": "HEALTHNET HMO, PPO, POS, EPO, CANOPY HEALTHNET HMO, OTHER-IN-NETWORK PLANS", "methodology": "per diem", "standard_charge_dollar": 8000.0, "standard_charge_algorithm": "Expected reimbursement is the lesser of Per diem ($8,000) for the length of stay and 70% of billed.", "count": "0", "additional_payer_notes": "Zero final payments for the item or service in the 15 months prior to posting the file." }, { "payer_name": "HEALTH NET", "plan_name": "HEALTHNET HMO, PPO, POS, EPO, CANOPY HEALTHNET HMO, OTHER-IN-NETWORK PLANS", "methodology": "per diem", "standard_charge_dollar": 8000.0, "standard_charge_algorithm": "Expected reimbursement is the lesser of Per diem ($8,000) for the length of stay and 70% of billed.", "count": "0", "additional_payer_notes": "Zero final payments for the item or service in the 15 months prior to posting the file." }, { "payer_name": "UNITED HEALTHCARE", "plan_name": "SUTTER SELECT & SUTTER HEALTH PLAN HMO PLANS", "methodology": "per diem", "standard_charge_dollar": 28538.0, "standard_charge_algorithm": "Per diem ($28,538).", "count": "0", "additional_payer_notes": "Zero final payments for the item or service in the 15 months prior to posting the file." }, { "payer_name": "UNITED HEALTHCARE", "plan_name": "SUTTER SELECT & SUTTER HEALTH PLAN HMO PLANS", "methodology": "per diem", "standard_charge_dollar": 28538.0, "standard_charge_algorithm": "Per diem ($28,538).", "count": "0", "additional_payer_notes": "Zero final payments for the item or service in the 15 months prior to posting the file." }, { "payer_name": "SUTTER", "plan_name": "SUTTER SELECT & SUTTER HEALTH PLAN HMO PLANS", "methodology": "per diem", "standard_charge_dollar": 28538.0, "standard_charge_algorithm": "Per diem ($28,538).", "count": "0", "additional_payer_notes": "Zero final payments for the item or service in the 15 months prior to posting the file." }, { "payer_name": "UNITED HEALTHCARE", "plan_name": "SUTTER SELECT & SUTTER HEALTH PLAN HMO PLANS", "methodology": "per diem", "standard_charge_dollar": 28538.0, "standard_charge_algorithm": "Per diem ($28,538).", "count": "0", "additional_payer_notes": "Zero final payments for the item or service in the 15 months prior to posting the file." }, { "payer_name": "UMR", "plan_name": "SUTTER SELECT & SUTTER HEALTH PLAN HMO PLANS", "methodology": "per diem", "standard_charge_dollar": 28538.0, "standard_charge_algorithm": "Per diem ($28,538).", "count": "0", "additional_payer_notes": "Zero final payments for the item or service in the 15 months prior to posting the file." } ] } ] }, { "description": "HC Heartware Pt Take Home Components", "code_information": [ { "code": "PX-2110000033", "type": "CDM" }, { "code": "99999", "type": "CPT" }, { "code": "0270", "type": "RC" } ], "standard_charges": [ { "setting": "outpatient", "gross_charge": 50616.0, "discounted_cash": 25308.0, "minimum": 21359.95, "maximum": 26320.32, "additional_generic_notes": "Zero final payments for the item or service in the 15 months prior to posting the file.", "payers_information": [ { "payer_name": "AETNA", "plan_name": "AETNA ALL OTHER PLANS", "methodology": "percent of total billed charges", "standard_charge_dollar": 26320.32, "standard_charge_percentage": 52.0, "count": "0", "additional_payer_notes": "Zero final payments for the item or service in the 15 months prior to posting the file." }, { "payer_name": "AETNA", "plan_name": "AETNA ALL OTHER PLANS", "methodology": "percent of total billed charges", "standard_charge_dollar": 26320.32, "standard_charge_percentage": 52.0, "count": "0", "additional_payer_notes": "Zero final payments for the item or service in the 15 months prior to posting the file." }, { "payer_name": "MERITAIN HEALTH", "plan_name": "AETNA ALL OTHER PLANS", "methodology": "percent of total billed charges", "standard_charge_dollar": 26320.32, "standard_charge_percentage": 52.0, "count": "0", "additional_payer_notes": "Zero final payments for the item or service in the 15 months prior to posting the file." }, { "payer_name": "BLUE SHIELD OUT OF STATE", "plan_name": "STANFORD HEALTHCARE ALLIANCE PLAN", "methodology": "percent of total billed charges", "standard_charge_dollar": 24594.31, "standard_charge_percentage": 48.59, "count": "0", "additional_payer_notes": "Zero final payments for the item or service in the 15 months prior to posting the file." }, { "payer_name": "BLUE SHIELD", "plan_name": "STANFORD HEALTHCARE ALLIANCE PLAN", "methodology": "percent of total billed charges", "standard_charge_dollar": 24594.31, "standard_charge_percentage": 48.59, "median_amount": 68.24, "10th_percentile": 13.6, "90th_percentile": 1043.06, "count": "30" }, { "payer_name": "BLUE SHIELD", "plan_name": "STANFORD HEALTHCARE ALLIANCE PLAN", "methodology": "percent of total billed charges", "standard_charge_dollar": 24594.31, "standard_charge_percentage": 48.59, "count": "0", "additional_payer_notes": "Zero final payments for the item or service in the 15 months prior to posting the file." }, { "payer_name": "BLUE SHIELD", "plan_name": "STANFORD HEALTHCARE ALLIANCE PLAN", "methodology": "percent of total billed charges", "standard_charge_dollar": 24594.31, "standard_charge_percentage": 48.59, "count": "0", "additional_payer_notes": "Zero final payments for the item or service in the 15 months prior to posting the file." }, { "payer_name": "CIGNA", "plan_name": "CIGNA COM ALT HMO PLAN", "methodology": "percent of total billed charges", "standard_charge_dollar": 21359.95, "standard_charge_percentage": 42.2, "count": "0", "additional_payer_notes": "Zero final payments for the item or service in the 15 months prior to posting the file." }, { "payer_name": "CIGNA", "plan_name": "CIGNA COM ALT HMO PLAN", "methodology": "percent of total billed charges", "standard_charge_dollar": 21359.95, "standard_charge_percentage": 42.2, "count": "0", "additional_payer_notes": "Zero final payments for the item or service in the 15 months prior to posting the file." }, { "payer_name": "HEALTH NET", "plan_name": "HEALTHNET HMO, PPO, POS, EPO, CANOPY HEALTHNET HMO, OTHER-IN-NETWORK PLANS", "methodology": "per diem", "standard_charge_dollar": 8000.0, "standard_charge_algorithm": "Expected reimbursement is the lesser of Per diem ($8,000) for the length of stay and 70% of billed.", "count": "0", "additional_payer_notes": "Zero final payments for the item or service in the 15 months prior to posting the file." }, { "payer_name": "HEALTH NET", "plan_name": "HEALTHNET HMO, PPO, POS, EPO, CANOPY HEALTHNET HMO, OTHER-IN-NETWORK PLANS", "methodology": "per diem", "standard_charge_dollar": 8000.0, "standard_charge_algorithm": "Expected reimbursement is the lesser of Per diem ($8,000) for the length of stay and 70% of billed.", "count": "0", "additional_payer_notes": "Zero final payments for the item or service in the 15 months prior to posting the file." }, { "payer_name": "UNITED HEALTHCARE", "plan_name": "SUTTER SELECT & SUTTER HEALTH PLAN HMO PLANS", "methodology": "per diem", "standard_charge_dollar": 28538.0, "standard_charge_algorithm": "Per diem ($28,538).", "count": "0", "additional_payer_notes": "Zero final payments for the item or service in the 15 months prior to posting the file." }, { "payer_name": "UNITED HEALTHCARE", "plan_name": "SUTTER SELECT & SUTTER HEALTH PLAN HMO PLANS", "methodology": "per diem", "standard_charge_dollar": 28538.0, "standard_charge_algorithm": "Per diem ($28,538).", "count": "0", "additional_payer_notes": "Zero final payments for the item or service in the 15 months prior to posting the file." }, { "payer_name": "SUTTER", "plan_name": "SUTTER SELECT & SUTTER HEALTH PLAN HMO PLANS", "methodology": "per diem", "standard_charge_dollar": 28538.0, "standard_charge_algorithm": "Per diem ($28,538).", "count": "0", "additional_payer_notes": "Zero final payments for the item or service in the 15 months prior to posting the file." }, { "payer_name": "UNITED HEALTHCARE", "plan_name": "SUTTER SELECT & SUTTER HEALTH PLAN HMO PLANS", "methodology": "per diem", "standard_charge_dollar": 28538.0, "standard_charge_algorithm": "Per diem ($28,538).", "count": "0", "additional_payer_notes": "Zero final payments for the item or service in the 15 months prior to posting the file." }, { "payer_name": "UMR", "plan_name": "SUTTER SELECT & SUTTER HEALTH PLAN HMO PLANS", "methodology": "per diem", "standard_charge_dollar": 28538.0, "standard_charge_algorithm": "Per diem ($28,538).", "count": "0", "additional_payer_notes": "Zero final payments for the item or service in the 15 months prior to posting the file." }, { "payer_name": "UNITED HEALTHCARE", "plan_name": "SUTTER SELECT & SUTTER HEALTH PLAN HMO PLANS", "methodology": "per diem", "standard_charge_dollar": 28538.0, "standard_charge_algorithm": "Per diem ($28,538).", "median_amount": 21329.69, "10th_percentile": 21329.69, "90th_percentile": 21329.69, "count": "1 through 10" } ] } ] }, { "description": "HC Cath Arterial Line Gp002", "code_information": [ { "code": "PX-2111003002", "type": "CDM" }, { "code": "99999", "type": "CPT" }, { "code": "0272", "type": "RC" } ], "standard_charges": [ { "setting": "outpatient", "gross_charge": 50.0, "discounted_cash": 25.0, "minimum": 21.1, "maximum": 26.0, "additional_generic_notes": "Zero final payments for the item or service in the 15 months prior to posting the file.", "payers_information": [ { "payer_name": "AETNA", "plan_name": "AETNA ALL OTHER PLANS", "methodology": "percent of total billed charges", "standard_charge_dollar": 26.0, "standard_charge_percentage": 52.0, "count": "0", "additional_payer_notes": "Zero final payments for the item or service in the 15 months prior to posting the file." }, { "payer_name": "AETNA", "plan_name": "AETNA ALL OTHER PLANS", "methodology": "percent of total billed charges", "standard_charge_dollar": 26.0, "standard_charge_percentage": 52.0, "count": "0", "additional_payer_notes": "Zero final payments for the item or service in the 15 months prior to posting the file." }, { "payer_name": "MERITAIN HEALTH", "plan_name": "AETNA ALL OTHER PLANS", "methodology": "percent of total billed charges", "standard_charge_dollar": 26.0, "standard_charge_percentage": 52.0, "count": "0", "additional_payer_notes": "Zero final payments for the item or service in the 15 months prior to posting the file." }, { "payer_name": "BLUE SHIELD OUT OF STATE", "plan_name": "STANFORD HEALTHCARE ALLIANCE PLAN", "methodology": "percent of total billed charges", "standard_charge_dollar": 24.3, "standard_charge_percentage": 48.59, "count": "0", "additional_payer_notes": "Zero final payments for the item or service in the 15 months prior to posting the file." }, { "payer_name": "BLUE SHIELD", "plan_name": "STANFORD HEALTHCARE ALLIANCE PLAN", "methodology": "percent of total billed charges", "standard_charge_dollar": 24.3, "standard_charge_percentage": 48.59, "count": "0", "additional_payer_notes": "Zero final payments for the item or service in the 15 months prior to posting the file." }, { "payer_name": "BLUE SHIELD", "plan_name": "STANFORD HEALTHCARE ALLIANCE PLAN", "methodology": "percent of total billed charges", "standard_charge_dollar": 24.3, "standard_charge_percentage": 48.59, "count": "0", "additional_payer_notes": "Zero final payments for the item or service in the 15 months prior to posting the file." }, { "payer_name": "CIGNA", "plan_name": "CIGNA COM ALT HMO PLAN", "methodology": "percent of total billed charges", "standard_charge_dollar": 21.1, "standard_charge_percentage": 42.2, "count": "0", "additional_payer_notes": "Zero final payments for the item or service in the 15 months prior to posting the file." }, { "payer_name": "CIGNA", "plan_name": "CIGNA COM ALT HMO PLAN", "methodology": "percent of total billed charges", "standard_charge_dollar": 21.1, "standard_charge_percentage": 42.2, "count": "0", "additional_payer_notes": "Zero final payments for the item or service in the 15 months prior to posting the file." }, { "payer_name": "HEALTH NET", "plan_name": "HEALTHNET HMO, PPO, POS, EPO, CANOPY HEALTHNET HMO, OTHER-IN-NETWORK PLANS", "methodology": "per diem", "standard_charge_dollar": 8000.0, "standard_charge_algorithm": "Expected reimbursement is the lesser of Per diem ($8,000) for the length of stay and 70% of billed.", "count": "0", "additional_payer_notes": "Zero final payments for the item or service in the 15 months prior to posting the file." }, { "payer_name": "HEALTH NET", "plan_name": "HEALTHNET HMO, PPO, POS, EPO, CANOPY HEALTHNET HMO, OTHER-IN-NETWORK PLANS", "methodology": "per diem", "standard_charge_dollar": 8000.0, "standard_charge_algorithm": "Expected reimbursement is the lesser of Per diem ($8,000) for the length of stay and 70% of billed.", "count": "0", "additional_payer_notes": "Zero final payments for the item or service in the 15 months prior to posting the file." }, { "payer_name": "UNITED HEALTHCARE", "plan_name": "SUTTER SELECT & SUTTER HEALTH PLAN HMO PLANS", "methodology": "per diem", "standard_charge_dollar": 28538.0, "standard_charge_algorithm": "Per diem ($28,538).", "count": "0", "additional_payer_notes": "Zero final payments for the item or service in the 15 months prior to posting the file." }, { "payer_name": "UNITED HEALTHCARE", "plan_name": "SUTTER SELECT & SUTTER HEALTH PLAN HMO PLANS", "methodology": "per diem", "standard_charge_dollar": 28538.0, "standard_charge_algorithm": "Per diem ($28,538).", "count": "0", "additional_payer_notes": "Zero final payments for the item or service in the 15 months prior to posting the file." }, { "payer_name": "SUTTER", "plan_name": "SUTTER SELECT & SUTTER HEALTH PLAN HMO PLANS", "methodology": "per diem", "standard_charge_dollar": 28538.0, "standard_charge_algorithm": "Per diem ($28,538).", "count": "0", "additional_payer_notes": "Zero final payments for the item or service in the 15 months prior to posting the file." }, { "payer_name": "UNITED HEALTHCARE", "plan_name": "SUTTER SELECT & SUTTER HEALTH PLAN HMO PLANS", "methodology": "per diem", "standard_charge_dollar": 28538.0, "standard_charge_algorithm": "Per diem ($28,538).", "count": "0", "additional_payer_notes": "Zero final payments for the item or service in the 15 months prior to posting the file." }, { "payer_name": "UMR", "plan_name": "SUTTER SELECT & SUTTER HEALTH PLAN HMO PLANS", "methodology": "per diem", "standard_charge_dollar": 28538.0, "standard_charge_algorithm": "Per diem ($28,538).", "count": "0", "additional_payer_notes": "Zero final payments for the item or service in the 15 months prior to posting the file." } ] } ] }, { "description": "HC Cath Arterial Line Gp003", "code_information": [ { "code": "PX-2111003003", "type": "CDM" }, { "code": "99999", "type": "CPT" }, { "code": "0272", "type": "RC" } ], "standard_charges": [ { "setting": "outpatient", "gross_charge": 100.0, "discounted_cash": 50.0, "minimum": 42.2, "maximum": 52.0, "additional_generic_notes": "Zero final payments for the item or service in the 15 months prior to posting the file.", "payers_information": [ { "payer_name": "AETNA", "plan_name": "AETNA ALL OTHER PLANS", "methodology": "percent of total billed charges", "standard_charge_dollar": 52.0, "standard_charge_percentage": 52.0, "count": "0", "additional_payer_notes": "Zero final payments for the item or service in the 15 months prior to posting the file." }, { "payer_name": "AETNA", "plan_name": "AETNA ALL OTHER PLANS", "methodology": "percent of total billed charges", "standard_charge_dollar": 52.0, "standard_charge_percentage": 52.0, "count": "0", "additional_payer_notes": "Zero final payments for the item or service in the 15 months prior to posting the file." }, { "payer_name": "MERITAIN HEALTH", "plan_name": "AETNA ALL OTHER PLANS", "methodology": "percent of total billed charges", "standard_charge_dollar": 52.0, "standard_charge_percentage": 52.0, "count": "0", "additional_payer_notes": "Zero final payments for the item or service in the 15 months prior to posting the file." }, { "payer_name": "BLUE SHIELD OUT OF STATE", "plan_name": "STANFORD HEALTHCARE ALLIANCE PLAN", "methodology": "percent of total billed charges", "standard_charge_dollar": 48.59, "standard_charge_percentage": 48.59, "count": "0", "additional_payer_notes": "Zero final payments for the item or service in the 15 months prior to posting the file." }, { "payer_name": "BLUE SHIELD", "plan_name": "STANFORD HEALTHCARE ALLIANCE PLAN", "methodology": "percent of total billed charges", "standard_charge_dollar": 48.59, "standard_charge_percentage": 48.59, "count": "0", "additional_payer_notes": "Zero final payments for the item or service in the 15 months prior to posting the file." }, { "payer_name": "BLUE SHIELD", "plan_name": "STANFORD HEALTHCARE ALLIANCE PLAN", "methodology": "percent of total billed charges", "standard_charge_dollar": 48.59, "standard_charge_percentage": 48.59, "count": "0", "additional_payer_notes": "Zero final payments for the item or service in the 15 months prior to posting the file." }, { "payer_name": "CIGNA", "plan_name": "CIGNA COM ALT HMO PLAN", "methodology": "percent of total billed charges", "standard_charge_dollar": 42.2, "standard_charge_percentage": 42.2, "count": "0", "additional_payer_notes": "Zero final payments for the item or service in the 15 months prior to posting the file." }, { "payer_name": "CIGNA", "plan_name": "CIGNA COM ALT HMO PLAN", "methodology": "percent of total billed charges", "standard_charge_dollar": 42.2, "standard_charge_percentage": 42.2, "count": "0", "additional_payer_notes": "Zero final payments for the item or service in the 15 months prior to posting the file." }, { "payer_name": "HEALTH NET", "plan_name": "HEALTHNET HMO, PPO, POS, EPO, CANOPY HEALTHNET HMO, OTHER-IN-NETWORK PLANS", "methodology": "per diem", "standard_charge_dollar": 8000.0, "standard_charge_algorithm": "Expected reimbursement is the lesser of Per diem ($8,000) for the length of stay and 70% of billed.", "count": "0", "additional_payer_notes": "Zero final payments for the item or service in the 15 months prior to posting the file." }, { "payer_name": "HEALTH NET", "plan_name": "HEALTHNET HMO, PPO, POS, EPO, CANOPY HEALTHNET HMO, OTHER-IN-NETWORK PLANS", "methodology": "per diem", "standard_charge_dollar": 8000.0, "standard_charge_algorithm": "Expected reimbursement is the lesser of Per diem ($8,000) for the length of stay and 70% of billed.", "count": "0", "additional_payer_notes": "Zero final payments for the item or service in the 15 months prior to posting the file." }, { "payer_name": "UNITED HEALTHCARE", "plan_name": "SUTTER SELECT & SUTTER HEALTH PLAN HMO PLANS", "methodology": "per diem", "standard_charge_dollar": 28538.0, "standard_charge_algorithm": "Per diem ($28,538).", "count": "0", "additional_payer_notes": "Zero final payments for the item or service in the 15 months prior to posting the file." }, { "payer_name": "UNITED HEALTHCARE", "plan_name": "SUTTER SELECT & SUTTER HEALTH PLAN HMO PLANS", "methodology": "per diem", "standard_charge_dollar": 28538.0, "standard_charge_algorithm": "Per diem ($28,538).", "count": "0", "additional_payer_notes": "Zero final payments for the item or service in the 15 months prior to posting the file." }, { "payer_name": "SUTTER", "plan_name": "SUTTER SELECT & SUTTER HEALTH PLAN HMO PLANS", "methodology": "per diem", "standard_charge_dollar": 28538.0, "standard_charge_algorithm": "Per diem ($28,538).", "count": "0", "additional_payer_notes": "Zero final payments for the item or service in the 15 months prior to posting the file." }, { "payer_name": "UNITED HEALTHCARE", "plan_name": "SUTTER SELECT & SUTTER HEALTH PLAN HMO PLANS", "methodology": "per diem", "standard_charge_dollar": 28538.0, "standard_charge_algorithm": "Per diem ($28,538).", "count": "0", "additional_payer_notes": "Zero final payments for the item or service in the 15 months prior to posting the file." }, { "payer_name": "UMR", "plan_name": "SUTTER SELECT & SUTTER HEALTH PLAN HMO PLANS", "methodology": "per diem", "standard_charge_dollar": 28538.0, "standard_charge_algorithm": "Per diem ($28,538).", "count": "0", "additional_payer_notes": "Zero final payments for the item or service in the 15 months prior to posting the file." } ] } ] }, { "description": "HC Blocker Endobronchial Gp015", "code_information": [ { "code": "PX-2111004015", "type": "CDM" }, { "code": "99999", "type": "CPT" }, { "code": "0272", "type": "RC" } ], "standard_charges": [ { "setting": "outpatient", "gross_charge": 1225.0, "discounted_cash": 612.5, "minimum": 516.95, "maximum": 637.0, "additional_generic_notes": "Zero final payments for the item or service in the 15 months prior to posting the file.", "payers_information": [ { "payer_name": "AETNA", "plan_name": "AETNA ALL OTHER PLANS", "methodology": "percent of total billed charges", "standard_charge_dollar": 637.0, "standard_charge_percentage": 52.0, "count": "0", "additional_payer_notes": "Zero final payments for the item or service in the 15 months prior to posting the file." }, { "payer_name": "AETNA", "plan_name": "AETNA ALL OTHER PLANS", "methodology": "percent of total billed charges", "standard_charge_dollar": 637.0, "standard_charge_percentage": 52.0, "count": "0", "additional_payer_notes": "Zero final payments for the item or service in the 15 months prior to posting the file." }, { "payer_name": "MERITAIN HEALTH", "plan_name": "AETNA ALL OTHER PLANS", "methodology": "percent of total billed charges", "standard_charge_dollar": 637.0, "standard_charge_percentage": 52.0, "count": "0", "additional_payer_notes": "Zero final payments for the item or service in the 15 months prior to posting the file." }, { "payer_name": "BLUE SHIELD OUT OF STATE", "plan_name": "STANFORD HEALTHCARE ALLIANCE PLAN", "methodology": "percent of total billed charges", "standard_charge_dollar": 595.23, "standard_charge_percentage": 48.59, "count": "0", "additional_payer_notes": "Zero final payments for the item or service in the 15 months prior to posting the file." }, { "payer_name": "BLUE SHIELD", "plan_name": "STANFORD HEALTHCARE ALLIANCE PLAN", "methodology": "percent of total billed charges", "standard_charge_dollar": 595.23, "standard_charge_percentage": 48.59, "median_amount": 68.24, "10th_percentile": 13.6, "90th_percentile": 1043.06, "count": "30" }, { "payer_name": "BLUE SHIELD", "plan_name": "STANFORD HEALTHCARE ALLIANCE PLAN", "methodology": "percent of total billed charges", "standard_charge_dollar": 595.23, "standard_charge_percentage": 48.59, "count": "0", "additional_payer_notes": "Zero final payments for the item or service in the 15 months prior to posting the file." }, { "payer_name": "BLUE SHIELD", "plan_name": "STANFORD HEALTHCARE ALLIANCE PLAN", "methodology": "percent of total billed charges", "standard_charge_dollar": 595.23, "standard_charge_percentage": 48.59, "count": "0", "additional_payer_notes": "Zero final payments for the item or service in the 15 months prior to posting the file." }, { "payer_name": "CIGNA", "plan_name": "CIGNA COM ALT HMO PLAN", "methodology": "percent of total billed charges", "standard_charge_dollar": 516.95, "standard_charge_percentage": 42.2, "count": "0", "additional_payer_notes": "Zero final payments for the item or service in the 15 months prior to posting the file." }, { "payer_name": "CIGNA", "plan_name": "CIGNA COM ALT HMO PLAN", "methodology": "percent of total billed charges", "standard_charge_dollar": 516.95, "standard_charge_percentage": 42.2, "count": "0", "additional_payer_notes": "Zero final payments for the item or service in the 15 months prior to posting the file." }, { "payer_name": "HEALTH NET", "plan_name": "HEALTHNET HMO, PPO, POS, EPO, CANOPY HEALTHNET HMO, OTHER-IN-NETWORK PLANS", "methodology": "per diem", "standard_charge_dollar": 8000.0, "standard_charge_algorithm": "Expected reimbursement is the lesser of Per diem ($8,000) for the length of stay and 70% of billed.", "count": "0", "additional_payer_notes": "Zero final payments for the item or service in the 15 months prior to posting the file." }, { "payer_name": "HEALTH NET", "plan_name": "HEALTHNET HMO, PPO, POS, EPO, CANOPY HEALTHNET HMO, OTHER-IN-NETWORK PLANS", "methodology": "per diem", "standard_charge_dollar": 8000.0, "standard_charge_algorithm": "Expected reimbursement is the lesser of Per diem ($8,000) for the length of stay and 70% of billed.", "count": "0", "additional_payer_notes": "Zero final payments for the item or service in the 15 months prior to posting the file." }, { "payer_name": "UNITED HEALTHCARE", "plan_name": "SUTTER SELECT & SUTTER HEALTH PLAN HMO PLANS", "methodology": "per diem", "standard_charge_dollar": 28538.0, "standard_charge_algorithm": "Per diem ($28,538).", "count": "0", "additional_payer_notes": "Zero final payments for the item or service in the 15 months prior to posting the file." }, { "payer_name": "UNITED HEALTHCARE", "plan_name": "SUTTER SELECT & SUTTER HEALTH PLAN HMO PLANS", "methodology": "per diem", "standard_charge_dollar": 28538.0, "standard_charge_algorithm": "Per diem ($28,538).", "count": "0", "additional_payer_notes": "Zero final payments for the item or service in the 15 months prior to posting the file." }, { "payer_name": "SUTTER", "plan_name": "SUTTER SELECT & SUTTER HEALTH PLAN HMO PLANS", "methodology": "per diem", "standard_charge_dollar": 28538.0, "standard_charge_algorithm": "Per diem ($28,538).", "count": "0", "additional_payer_notes": "Zero final payments for the item or service in the 15 months prior to posting the file." }, { "payer_name": "UNITED HEALTHCARE", "plan_name": "SUTTER SELECT & SUTTER HEALTH PLAN HMO PLANS", "methodology": "per diem", "standard_charge_dollar": 28538.0, "standard_charge_algorithm": "Per diem ($28,538).", "count": "0", "additional_payer_notes": "Zero final payments for the item or service in the 15 months prior to posting the file." }, { "payer_name": "UMR", "plan_name": "SUTTER SELECT & SUTTER HEALTH PLAN HMO PLANS", "methodology": "per diem", "standard_charge_dollar": 28538.0, "standard_charge_algorithm": "Per diem ($28,538).", "count": "0", "additional_payer_notes": "Zero final payments for the item or service in the 15 months prior to posting the file." } ] } ] }, { "description": "HC Cath IV Gp005", "code_information": [ { "code": "PX-2111005005", "type": "CDM" }, { "code": "99999", "type": "CPT" }, { "code": "0272", "type": "RC" } ], "standard_charges": [ { "setting": "outpatient", "gross_charge": 195.0, "discounted_cash": 97.5, "minimum": 82.29, "maximum": 101.4, "additional_generic_notes": "Zero final payments for the item or service in the 15 months prior to posting the file.", "payers_information": [ { "payer_name": "AETNA", "plan_name": "AETNA ALL OTHER PLANS", "methodology": "percent of total billed charges", "standard_charge_dollar": 101.4, "standard_charge_percentage": 52.0, "count": "0", "additional_payer_notes": "Zero final payments for the item or service in the 15 months prior to posting the file." }, { "payer_name": "AETNA", "plan_name": "AETNA ALL OTHER PLANS", "methodology": "percent of total billed charges", "standard_charge_dollar": 101.4, "standard_charge_percentage": 52.0, "count": "0", "additional_payer_notes": "Zero final payments for the item or service in the 15 months prior to posting the file." }, { "payer_name": "MERITAIN HEALTH", "plan_name": "AETNA ALL OTHER PLANS", "methodology": "percent of total billed charges", "standard_charge_dollar": 101.4, "standard_charge_percentage": 52.0, "count": "0", "additional_payer_notes": "Zero final payments for the item or service in the 15 months prior to posting the file." }, { "payer_name": "BLUE SHIELD OUT OF STATE", "plan_name": "STANFORD HEALTHCARE ALLIANCE PLAN", "methodology": "percent of total billed charges", "standard_charge_dollar": 94.75, "standard_charge_percentage": 48.59, "count": "0", "additional_payer_notes": "Zero final payments for the item or service in the 15 months prior to posting the file." }, { "payer_name": "BLUE SHIELD", "plan_name": "STANFORD HEALTHCARE ALLIANCE PLAN", "methodology": "percent of total billed charges", "standard_charge_dollar": 94.75, "standard_charge_percentage": 48.59, "count": "0", "additional_payer_notes": "Zero final payments for the item or service in the 15 months prior to posting the file." }, { "payer_name": "BLUE SHIELD", "plan_name": "STANFORD HEALTHCARE ALLIANCE PLAN", "methodology": "percent of total billed charges", "standard_charge_dollar": 94.75, "standard_charge_percentage": 48.59, "count": "0", "additional_payer_notes": "Zero final payments for the item or service in the 15 months prior to posting the file." }, { "payer_name": "CIGNA", "plan_name": "CIGNA COM ALT HMO PLAN", "methodology": "percent of total billed charges", "standard_charge_dollar": 82.29, "standard_charge_percentage": 42.2, "count": "0", "additional_payer_notes": "Zero final payments for the item or service in the 15 months prior to posting the file." }, { "payer_name": "CIGNA", "plan_name": "CIGNA COM ALT HMO PLAN", "methodology": "percent of total billed charges", "standard_charge_dollar": 82.29, "standard_charge_percentage": 42.2, "count": "0", "additional_payer_notes": "Zero final payments for the item or service in the 15 months prior to posting the file." }, { "payer_name": "HEALTH NET", "plan_name": "HEALTHNET HMO, PPO, POS, EPO, CANOPY HEALTHNET HMO, OTHER-IN-NETWORK PLANS", "methodology": "per diem", "standard_charge_dollar": 8000.0, "standard_charge_algorithm": "Expected reimbursement is the lesser of Per diem ($8,000) for the length of stay and 70% of billed.", "count": "0", "additional_payer_notes": "Zero final payments for the item or service in the 15 months prior to posting the file." }, { "payer_name": "HEALTH NET", "plan_name": "HEALTHNET HMO, PPO, POS, EPO, CANOPY HEALTHNET HMO, OTHER-IN-NETWORK PLANS", "methodology": "per diem", "standard_charge_dollar": 8000.0, "standard_charge_algorithm": "Expected reimbursement is the lesser of Per diem ($8,000) for the length of stay and 70% of billed.", "count": "0", "additional_payer_notes": "Zero final payments for the item or service in the 15 months prior to posting the file." }, { "payer_name": "UNITED HEALTHCARE", "plan_name": "SUTTER SELECT & SUTTER HEALTH PLAN HMO PLANS", "methodology": "per diem", "standard_charge_dollar": 28538.0, "standard_charge_algorithm": "Per diem ($28,538).", "count": "0", "additional_payer_notes": "Zero final payments for the item or service in the 15 months prior to posting the file." }, { "payer_name": "UNITED HEALTHCARE", "plan_name": "SUTTER SELECT & SUTTER HEALTH PLAN HMO PLANS", "methodology": "per diem", "standard_charge_dollar": 28538.0, "standard_charge_algorithm": "Per diem ($28,538).", "count": "0", "additional_payer_notes": "Zero final payments for the item or service in the 15 months prior to posting the file." }, { "payer_name": "SUTTER", "plan_name": "SUTTER SELECT & SUTTER HEALTH PLAN HMO PLANS", "methodology": "per diem", "standard_charge_dollar": 28538.0, "standard_charge_algorithm": "Per diem ($28,538).", "count": "0", "additional_payer_notes": "Zero final payments for the item or service in the 15 months prior to posting the file." }, { "payer_name": "UNITED HEALTHCARE", "plan_name": "SUTTER SELECT & SUTTER HEALTH PLAN HMO PLANS", "methodology": "per diem", "standard_charge_dollar": 28538.0, "standard_charge_algorithm": "Per diem ($28,538).", "count": "0", "additional_payer_notes": "Zero final payments for the item or service in the 15 months prior to posting the file." }, { "payer_name": "UMR", "plan_name": "SUTTER SELECT & SUTTER HEALTH PLAN HMO PLANS", "methodology": "per diem", "standard_charge_dollar": 28538.0, "standard_charge_algorithm": "Per diem ($28,538).", "count": "0", "additional_payer_notes": "Zero final payments for the item or service in the 15 months prior to posting the file." } ] } ] }, { "description": "HC Cath IV Gp006", "code_information": [ { "code": "PX-2111005006", "type": "CDM" }, { "code": "99999", "type": "CPT" }, { "code": "0272", "type": "RC" } ], "standard_charges": [ { "setting": "outpatient", "gross_charge": 293.0, "discounted_cash": 146.5, "minimum": 123.65, "maximum": 152.36, "additional_generic_notes": "Zero final payments for the item or service in the 15 months prior to posting the file.", "payers_information": [ { "payer_name": "AETNA", "plan_name": "AETNA ALL OTHER PLANS", "methodology": "percent of total billed charges", "standard_charge_dollar": 152.36, "standard_charge_percentage": 52.0, "count": "0", "additional_payer_notes": "Zero final payments for the item or service in the 15 months prior to posting the file." }, { "payer_name": "AETNA", "plan_name": "AETNA ALL OTHER PLANS", "methodology": "percent of total billed charges", "standard_charge_dollar": 152.36, "standard_charge_percentage": 52.0, "count": "0", "additional_payer_notes": "Zero final payments for the item or service in the 15 months prior to posting the file." }, { "payer_name": "MERITAIN HEALTH", "plan_name": "AETNA ALL OTHER PLANS", "methodology": "percent of total billed charges", "standard_charge_dollar": 152.36, "standard_charge_percentage": 52.0, "count": "0", "additional_payer_notes": "Zero final payments for the item or service in the 15 months prior to posting the file." }, { "payer_name": "BLUE SHIELD OUT OF STATE", "plan_name": "STANFORD HEALTHCARE ALLIANCE PLAN", "methodology": "percent of total billed charges", "standard_charge_dollar": 142.37, "standard_charge_percentage": 48.59, "count": "0", "additional_payer_notes": "Zero final payments for the item or service in the 15 months prior to posting the file." }, { "payer_name": "BLUE SHIELD", "plan_name": "STANFORD HEALTHCARE ALLIANCE PLAN", "methodology": "percent of total billed charges", "standard_charge_dollar": 142.37, "standard_charge_percentage": 48.59, "count": "0", "additional_payer_notes": "Zero final payments for the item or service in the 15 months prior to posting the file." }, { "payer_name": "BLUE SHIELD", "plan_name": "STANFORD HEALTHCARE ALLIANCE PLAN", "methodology": "percent of total billed charges", "standard_charge_dollar": 142.37, "standard_charge_percentage": 48.59, "count": "0", "additional_payer_notes": "Zero final payments for the item or service in the 15 months prior to posting the file." }, { "payer_name": "CIGNA", "plan_name": "CIGNA COM ALT HMO PLAN", "methodology": "percent of total billed charges", "standard_charge_dollar": 123.65, "standard_charge_percentage": 42.2, "count": "0", "additional_payer_notes": "Zero final payments for the item or service in the 15 months prior to posting the file." }, { "payer_name": "CIGNA", "plan_name": "CIGNA COM ALT HMO PLAN", "methodology": "percent of total billed charges", "standard_charge_dollar": 123.65, "standard_charge_percentage": 42.2, "count": "0", "additional_payer_notes": "Zero final payments for the item or service in the 15 months prior to posting the file." }, { "payer_name": "HEALTH NET", "plan_name": "HEALTHNET HMO, PPO, POS, EPO, CANOPY HEALTHNET HMO, OTHER-IN-NETWORK PLANS", "methodology": "per diem", "standard_charge_dollar": 8000.0, "standard_charge_algorithm": "Expected reimbursement is the lesser of Per diem ($8,000) for the length of stay and 70% of billed.", "count": "0", "additional_payer_notes": "Zero final payments for the item or service in the 15 months prior to posting the file." }, { "payer_name": "HEALTH NET", "plan_name": "HEALTHNET HMO, PPO, POS, EPO, CANOPY HEALTHNET HMO, OTHER-IN-NETWORK PLANS", "methodology": "per diem", "standard_charge_dollar": 8000.0, "standard_charge_algorithm": "Expected reimbursement is the lesser of Per diem ($8,000) for the length of stay and 70% of billed.", "count": "0", "additional_payer_notes": "Zero final payments for the item or service in the 15 months prior to posting the file." }, { "payer_name": "UNITED HEALTHCARE", "plan_name": "SUTTER SELECT & SUTTER HEALTH PLAN HMO PLANS", "methodology": "per diem", "standard_charge_dollar": 28538.0, "standard_charge_algorithm": "Per diem ($28,538).", "count": "0", "additional_payer_notes": "Zero final payments for the item or service in the 15 months prior to posting the file." }, { "payer_name": "UNITED HEALTHCARE", "plan_name": "SUTTER SELECT & SUTTER HEALTH PLAN HMO PLANS", "methodology": "per diem", "standard_charge_dollar": 28538.0, "standard_charge_algorithm": "Per diem ($28,538).", "count": "0", "additional_payer_notes": "Zero final payments for the item or service in the 15 months prior to posting the file." }, { "payer_name": "SUTTER", "plan_name": "SUTTER SELECT & SUTTER HEALTH PLAN HMO PLANS", "methodology": "per diem", "standard_charge_dollar": 28538.0, "standard_charge_algorithm": "Per diem ($28,538).", "count": "0", "additional_payer_notes": "Zero final payments for the item or service in the 15 months prior to posting the file." }, { "payer_name": "UNITED HEALTHCARE", "plan_name": "SUTTER SELECT & SUTTER HEALTH PLAN HMO PLANS", "methodology": "per diem", "standard_charge_dollar": 28538.0, "standard_charge_algorithm": "Per diem ($28,538).", "count": "0", "additional_payer_notes": "Zero final payments for the item or service in the 15 months prior to posting the file." }, { "payer_name": "UMR", "plan_name": "SUTTER SELECT & SUTTER HEALTH PLAN HMO PLANS", "methodology": "per diem", "standard_charge_dollar": 28538.0, "standard_charge_algorithm": "Per diem ($28,538).", "count": "0", "additional_payer_notes": "Zero final payments for the item or service in the 15 months prior to posting the file." } ] } ] }, { "description": "HC Cath Thermodilation Gp006", "code_information": [ { "code": "PX-2111006006", "type": "CDM" }, { "code": "99999", "type": "CPT" }, { "code": "0272", "type": "RC" } ], "standard_charges": [ { "setting": "outpatient", "gross_charge": 293.0, "discounted_cash": 146.5, "minimum": 123.65, "maximum": 152.36, "additional_generic_notes": "Zero final payments for the item or service in the 15 months prior to posting the file.", "payers_information": [ { "payer_name": "AETNA", "plan_name": "AETNA ALL OTHER PLANS", "methodology": "percent of total billed charges", "standard_charge_dollar": 152.36, "standard_charge_percentage": 52.0, "count": "0", "additional_payer_notes": "Zero final payments for the item or service in the 15 months prior to posting the file." }, { "payer_name": "AETNA", "plan_name": "AETNA ALL OTHER PLANS", "methodology": "percent of total billed charges", "standard_charge_dollar": 152.36, "standard_charge_percentage": 52.0, "count": "0", "additional_payer_notes": "Zero final payments for the item or service in the 15 months prior to posting the file." }, { "payer_name": "MERITAIN HEALTH", "plan_name": "AETNA ALL OTHER PLANS", "methodology": "percent of total billed charges", "standard_charge_dollar": 152.36, "standard_charge_percentage": 52.0, "count": "0", "additional_payer_notes": "Zero final payments for the item or service in the 15 months prior to posting the file." }, { "payer_name": "BLUE SHIELD OUT OF STATE", "plan_name": "STANFORD HEALTHCARE ALLIANCE PLAN", "methodology": "percent of total billed charges", "standard_charge_dollar": 142.37, "standard_charge_percentage": 48.59, "count": "0", "additional_payer_notes": "Zero final payments for the item or service in the 15 months prior to posting the file." }, { "payer_name": "BLUE SHIELD", "plan_name": "STANFORD HEALTHCARE ALLIANCE PLAN", "methodology": "percent of total billed charges", "standard_charge_dollar": 142.37, "standard_charge_percentage": 48.59, "count": "0", "additional_payer_notes": "Zero final payments for the item or service in the 15 months prior to posting the file." }, { "payer_name": "BLUE SHIELD", "plan_name": "STANFORD HEALTHCARE ALLIANCE PLAN", "methodology": "percent of total billed charges", "standard_charge_dollar": 142.37, "standard_charge_percentage": 48.59, "count": "0", "additional_payer_notes": "Zero final payments for the item or service in the 15 months prior to posting the file." }, { "payer_name": "CIGNA", "plan_name": "CIGNA COM ALT HMO PLAN", "methodology": "percent of total billed charges", "standard_charge_dollar": 123.65, "standard_charge_percentage": 42.2, "count": "0", "additional_payer_notes": "Zero final payments for the item or service in the 15 months prior to posting the file." }, { "payer_name": "CIGNA", "plan_name": "CIGNA COM ALT HMO PLAN", "methodology": "percent of total billed charges", "standard_charge_dollar": 123.65, "standard_charge_percentage": 42.2, "count": "0", "additional_payer_notes": "Zero final payments for the item or service in the 15 months prior to posting the file." }, { "payer_name": "HEALTH NET", "plan_name": "HEALTHNET HMO, PPO, POS, EPO, CANOPY HEALTHNET HMO, OTHER-IN-NETWORK PLANS", "methodology": "per diem", "standard_charge_dollar": 8000.0, "standard_charge_algorithm": "Expected reimbursement is the lesser of Per diem ($8,000) for the length of stay and 70% of billed.", "count": "0", "additional_payer_notes": "Zero final payments for the item or service in the 15 months prior to posting the file." }, { "payer_name": "HEALTH NET", "plan_name": "HEALTHNET HMO, PPO, POS, EPO, CANOPY HEALTHNET HMO, OTHER-IN-NETWORK PLANS", "methodology": "per diem", "standard_charge_dollar": 8000.0, "standard_charge_algorithm": "Expected reimbursement is the lesser of Per diem ($8,000) for the length of stay and 70% of billed.", "count": "0", "additional_payer_notes": "Zero final payments for the item or service in the 15 months prior to posting the file." }, { "payer_name": "UNITED HEALTHCARE", "plan_name": "SUTTER SELECT & SUTTER HEALTH PLAN HMO PLANS", "methodology": "per diem", "standard_charge_dollar": 28538.0, "standard_charge_algorithm": "Per diem ($28,538).", "count": "0", "additional_payer_notes": "Zero final payments for the item or service in the 15 months prior to posting the file." }, { "payer_name": "UNITED HEALTHCARE", "plan_name": "SUTTER SELECT & SUTTER HEALTH PLAN HMO PLANS", "methodology": "per diem", "standard_charge_dollar": 28538.0, "standard_charge_algorithm": "Per diem ($28,538).", "count": "0", "additional_payer_notes": "Zero final payments for the item or service in the 15 months prior to posting the file." }, { "payer_name": "SUTTER", "plan_name": "SUTTER SELECT & SUTTER HEALTH PLAN HMO PLANS", "methodology": "per diem", "standard_charge_dollar": 28538.0, "standard_charge_algorithm": "Per diem ($28,538).", "count": "0", "additional_payer_notes": "Zero final payments for the item or service in the 15 months prior to posting the file." }, { "payer_name": "UNITED HEALTHCARE", "plan_name": "SUTTER SELECT & SUTTER HEALTH PLAN HMO PLANS", "methodology": "per diem", "standard_charge_dollar": 28538.0, "standard_charge_algorithm": "Per diem ($28,538).", "count": "0", "additional_payer_notes": "Zero final payments for the item or service in the 15 months prior to posting the file." }, { "payer_name": "UMR", "plan_name": "SUTTER SELECT & SUTTER HEALTH PLAN HMO PLANS", "methodology": "per diem", "standard_charge_dollar": 28538.0, "standard_charge_algorithm": "Per diem ($28,538).", "count": "0", "additional_payer_notes": "Zero final payments for the item or service in the 15 months prior to posting the file." } ] } ] }, { "description": "HC Kit Cath Oximetrix Gp019", "code_information": [ { "code": "PX-2111007019", "type": "CDM" }, { "code": "99999", "type": "CPT" }, { "code": "0272", "type": "RC" } ], "standard_charges": [ { "setting": "outpatient", "gross_charge": 2125.0, "discounted_cash": 1062.5, "minimum": 896.75, "maximum": 1105.0, "additional_generic_notes": "Zero final payments for the item or service in the 15 months prior to posting the file.", "payers_information": [ { "payer_name": "AETNA", "plan_name": "AETNA ALL OTHER PLANS", "methodology": "percent of total billed charges", "standard_charge_dollar": 1105.0, "standard_charge_percentage": 52.0, "count": "0", "additional_payer_notes": "Zero final payments for the item or service in the 15 months prior to posting the file." }, { "payer_name": "AETNA", "plan_name": "AETNA ALL OTHER PLANS", "methodology": "percent of total billed charges", "standard_charge_dollar": 1105.0, "standard_charge_percentage": 52.0, "count": "0", "additional_payer_notes": "Zero final payments for the item or service in the 15 months prior to posting the file." }, { "payer_name": "MERITAIN HEALTH", "plan_name": "AETNA ALL OTHER PLANS", "methodology": "percent of total billed charges", "standard_charge_dollar": 1105.0, "standard_charge_percentage": 52.0, "count": "0", "additional_payer_notes": "Zero final payments for the item or service in the 15 months prior to posting the file." }, { "payer_name": "BLUE SHIELD OUT OF STATE", "plan_name": "STANFORD HEALTHCARE ALLIANCE PLAN", "methodology": "percent of total billed charges", "standard_charge_dollar": 1032.54, "standard_charge_percentage": 48.59, "count": "0", "additional_payer_notes": "Zero final payments for the item or service in the 15 months prior to posting the file." }, { "payer_name": "BLUE SHIELD", "plan_name": "STANFORD HEALTHCARE ALLIANCE PLAN", "methodology": "percent of total billed charges", "standard_charge_dollar": 1032.54, "standard_charge_percentage": 48.59, "median_amount": 68.24, "10th_percentile": 13.6, "90th_percentile": 1043.06, "count": "30" }, { "payer_name": "BLUE SHIELD", "plan_name": "STANFORD HEALTHCARE ALLIANCE PLAN", "methodology": "percent of total billed charges", "standard_charge_dollar": 1032.54, "standard_charge_percentage": 48.59, "count": "0", "additional_payer_notes": "Zero final payments for the item or service in the 15 months prior to posting the file." }, { "payer_name": "BLUE SHIELD", "plan_name": "STANFORD HEALTHCARE ALLIANCE PLAN", "methodology": "percent of total billed charges", "standard_charge_dollar": 1032.54, "standard_charge_percentage": 48.59, "count": "0", "additional_payer_notes": "Zero final payments for the item or service in the 15 months prior to posting the file." }, { "payer_name": "CIGNA", "plan_name": "CIGNA COM ALT HMO PLAN", "methodology": "percent of total billed charges", "standard_charge_dollar": 896.75, "standard_charge_percentage": 42.2, "count": "0", "additional_payer_notes": "Zero final payments for the item or service in the 15 months prior to posting the file." }, { "payer_name": "CIGNA", "plan_name": "CIGNA COM ALT HMO PLAN", "methodology": "percent of total billed charges", "standard_charge_dollar": 896.75, "standard_charge_percentage": 42.2, "count": "0", "additional_payer_notes": "Zero final payments for the item or service in the 15 months prior to posting the file." }, { "payer_name": "HEALTH NET", "plan_name": "HEALTHNET HMO, PPO, POS, EPO, CANOPY HEALTHNET HMO, OTHER-IN-NETWORK PLANS", "methodology": "per diem", "standard_charge_dollar": 8000.0, "standard_charge_algorithm": "Expected reimbursement is the lesser of Per diem ($8,000) for the length of stay and 70% of billed.", "count": "0", "additional_payer_notes": "Zero final payments for the item or service in the 15 months prior to posting the file." }, { "payer_name": "HEALTH NET", "plan_name": "HEALTHNET HMO, PPO, POS, EPO, CANOPY HEALTHNET HMO, OTHER-IN-NETWORK PLANS", "methodology": "per diem", "standard_charge_dollar": 8000.0, "standard_charge_algorithm": "Expected reimbursement is the lesser of Per diem ($8,000) for the length of stay and 70% of billed.", "count": "0", "additional_payer_notes": "Zero final payments for the item or service in the 15 months prior to posting the file." }, { "payer_name": "UNITED HEALTHCARE", "plan_name": "SUTTER SELECT & SUTTER HEALTH PLAN HMO PLANS", "methodology": "per diem", "standard_charge_dollar": 28538.0, "standard_charge_algorithm": "Per diem ($28,538).", "count": "0", "additional_payer_notes": "Zero final payments for the item or service in the 15 months prior to posting the file." }, { "payer_name": "UNITED HEALTHCARE", "plan_name": "SUTTER SELECT & SUTTER HEALTH PLAN HMO PLANS", "methodology": "per diem", "standard_charge_dollar": 28538.0, "standard_charge_algorithm": "Per diem ($28,538).", "count": "0", "additional_payer_notes": "Zero final payments for the item or service in the 15 months prior to posting the file." }, { "payer_name": "SUTTER", "plan_name": "SUTTER SELECT & SUTTER HEALTH PLAN HMO PLANS", "methodology": "per diem", "standard_charge_dollar": 28538.0, "standard_charge_algorithm": "Per diem ($28,538).", "count": "0", "additional_payer_notes": "Zero final payments for the item or service in the 15 months prior to posting the file." }, { "payer_name": "UNITED HEALTHCARE", "plan_name": "SUTTER SELECT & SUTTER HEALTH PLAN HMO PLANS", "methodology": "per diem", "standard_charge_dollar": 28538.0, "standard_charge_algorithm": "Per diem ($28,538).", "count": "0", "additional_payer_notes": "Zero final payments for the item or service in the 15 months prior to posting the file." }, { "payer_name": "UMR", "plan_name": "SUTTER SELECT & SUTTER HEALTH PLAN HMO PLANS", "methodology": "per diem", "standard_charge_dollar": 28538.0, "standard_charge_algorithm": "Per diem ($28,538).", "count": "0", "additional_payer_notes": "Zero final payments for the item or service in the 15 months prior to posting the file." } ] } ] }, { "description": "HC Kit Introducer Gp009", "code_information": [ { "code": "PX-2111008009", "type": "CDM" }, { "code": "99999", "type": "CPT" }, { "code": "0272", "type": "RC" } ], "standard_charges": [ { "setting": "outpatient", "gross_charge": 570.0, "discounted_cash": 285.0, "minimum": 240.54, "maximum": 296.4, "additional_generic_notes": "Zero final payments for the item or service in the 15 months prior to posting the file.", "payers_information": [ { "payer_name": "AETNA", "plan_name": "AETNA ALL OTHER PLANS", "methodology": "percent of total billed charges", "standard_charge_dollar": 296.4, "standard_charge_percentage": 52.0, "count": "0", "additional_payer_notes": "Zero final payments for the item or service in the 15 months prior to posting the file." }, { "payer_name": "AETNA", "plan_name": "AETNA ALL OTHER PLANS", "methodology": "percent of total billed charges", "standard_charge_dollar": 296.4, "standard_charge_percentage": 52.0, "count": "0", "additional_payer_notes": "Zero final payments for the item or service in the 15 months prior to posting the file." }, { "payer_name": "MERITAIN HEALTH", "plan_name": "AETNA ALL OTHER PLANS", "methodology": "percent of total billed charges", "standard_charge_dollar": 296.4, "standard_charge_percentage": 52.0, "count": "0", "additional_payer_notes": "Zero final payments for the item or service in the 15 months prior to posting the file." }, { "payer_name": "BLUE SHIELD OUT OF STATE", "plan_name": "STANFORD HEALTHCARE ALLIANCE PLAN", "methodology": "percent of total billed charges", "standard_charge_dollar": 276.96, "standard_charge_percentage": 48.59, "count": "0", "additional_payer_notes": "Zero final payments for the item or service in the 15 months prior to posting the file." }, { "payer_name": "BLUE SHIELD", "plan_name": "STANFORD HEALTHCARE ALLIANCE PLAN", "methodology": "percent of total billed charges", "standard_charge_dollar": 276.96, "standard_charge_percentage": 48.59, "count": "0", "additional_payer_notes": "Zero final payments for the item or service in the 15 months prior to posting the file." }, { "payer_name": "BLUE SHIELD", "plan_name": "STANFORD HEALTHCARE ALLIANCE PLAN", "methodology": "percent of total billed charges", "standard_charge_dollar": 276.96, "standard_charge_percentage": 48.59, "count": "0", "additional_payer_notes": "Zero final payments for the item or service in the 15 months prior to posting the file." }, { "payer_name": "CIGNA", "plan_name": "CIGNA COM ALT HMO PLAN", "methodology": "percent of total billed charges", "standard_charge_dollar": 240.54, "standard_charge_percentage": 42.2, "count": "0", "additional_payer_notes": "Zero final payments for the item or service in the 15 months prior to posting the file." }, { "payer_name": "CIGNA", "plan_name": "CIGNA COM ALT HMO PLAN", "methodology": "percent of total billed charges", "standard_charge_dollar": 240.54, "standard_charge_percentage": 42.2, "count": "0", "additional_payer_notes": "Zero final payments for the item or service in the 15 months prior to posting the file." }, { "payer_name": "HEALTH NET", "plan_name": "HEALTHNET HMO, PPO, POS, EPO, CANOPY HEALTHNET HMO, OTHER-IN-NETWORK PLANS", "methodology": "per diem", "standard_charge_dollar": 8000.0, "standard_charge_algorithm": "Expected reimbursement is the lesser of Per diem ($8,000) for the length of stay and 70% of billed.", "count": "0", "additional_payer_notes": "Zero final payments for the item or service in the 15 months prior to posting the file." }, { "payer_name": "HEALTH NET", "plan_name": "HEALTHNET HMO, PPO, POS, EPO, CANOPY HEALTHNET HMO, OTHER-IN-NETWORK PLANS", "methodology": "per diem", "standard_charge_dollar": 8000.0, "standard_charge_algorithm": "Expected reimbursement is the lesser of Per diem ($8,000) for the length of stay and 70% of billed.", "count": "0", "additional_payer_notes": "Zero final payments for the item or service in the 15 months prior to posting the file." }, { "payer_name": "UNITED HEALTHCARE", "plan_name": "SUTTER SELECT & SUTTER HEALTH PLAN HMO PLANS", "methodology": "per diem", "standard_charge_dollar": 28538.0, "standard_charge_algorithm": "Per diem ($28,538).", "count": "0", "additional_payer_notes": "Zero final payments for the item or service in the 15 months prior to posting the file." }, { "payer_name": "UNITED HEALTHCARE", "plan_name": "SUTTER SELECT & SUTTER HEALTH PLAN HMO PLANS", "methodology": "per diem", "standard_charge_dollar": 28538.0, "standard_charge_algorithm": "Per diem ($28,538).", "count": "0", "additional_payer_notes": "Zero final payments for the item or service in the 15 months prior to posting the file." }, { "payer_name": "SUTTER", "plan_name": "SUTTER SELECT & SUTTER HEALTH PLAN HMO PLANS", "methodology": "per diem", "standard_charge_dollar": 28538.0, "standard_charge_algorithm": "Per diem ($28,538).", "count": "0", "additional_payer_notes": "Zero final payments for the item or service in the 15 months prior to posting the file." }, { "payer_name": "UNITED HEALTHCARE", "plan_name": "SUTTER SELECT & SUTTER HEALTH PLAN HMO PLANS", "methodology": "per diem", "standard_charge_dollar": 28538.0, "standard_charge_algorithm": "Per diem ($28,538).", "count": "0", "additional_payer_notes": "Zero final payments for the item or service in the 15 months prior to posting the file." }, { "payer_name": "UMR", "plan_name": "SUTTER SELECT & SUTTER HEALTH PLAN HMO PLANS", "methodology": "per diem", "standard_charge_dollar": 28538.0, "standard_charge_algorithm": "Per diem ($28,538).", "count": "0", "additional_payer_notes": "Zero final payments for the item or service in the 15 months prior to posting the file." } ] } ] }, { "description": "HC Kit Introducer Gp012", "code_information": [ { "code": "PX-2111008012", "type": "CDM" }, { "code": "99999", "type": "CPT" }, { "code": "0270", "type": "RC" } ], "standard_charges": [ { "setting": "outpatient", "gross_charge": 810.0, "discounted_cash": 405.0, "minimum": 341.82, "maximum": 421.2, "additional_generic_notes": "Zero final payments for the item or service in the 15 months prior to posting the file.", "payers_information": [ { "payer_name": "AETNA", "plan_name": "AETNA ALL OTHER PLANS", "methodology": "percent of total billed charges", "standard_charge_dollar": 421.2, "standard_charge_percentage": 52.0, "count": "0", "additional_payer_notes": "Zero final payments for the item or service in the 15 months prior to posting the file." }, { "payer_name": "AETNA", "plan_name": "AETNA ALL OTHER PLANS", "methodology": "percent of total billed charges", "standard_charge_dollar": 421.2, "standard_charge_percentage": 52.0, "count": "0", "additional_payer_notes": "Zero final payments for the item or service in the 15 months prior to posting the file." }, { "payer_name": "MERITAIN HEALTH", "plan_name": "AETNA ALL OTHER PLANS", "methodology": "percent of total billed charges", "standard_charge_dollar": 421.2, "standard_charge_percentage": 52.0, "count": "0", "additional_payer_notes": "Zero final payments for the item or service in the 15 months prior to posting the file." }, { "payer_name": "BLUE SHIELD OUT OF STATE", "plan_name": "STANFORD HEALTHCARE ALLIANCE PLAN", "methodology": "percent of total billed charges", "standard_charge_dollar": 393.58, "standard_charge_percentage": 48.59, "count": "0", "additional_payer_notes": "Zero final payments for the item or service in the 15 months prior to posting the file." }, { "payer_name": "BLUE SHIELD", "plan_name": "STANFORD HEALTHCARE ALLIANCE PLAN", "methodology": "percent of total billed charges", "standard_charge_dollar": 393.58, "standard_charge_percentage": 48.59, "count": "0", "additional_payer_notes": "Zero final payments for the item or service in the 15 months prior to posting the file." }, { "payer_name": "BLUE SHIELD", "plan_name": "STANFORD HEALTHCARE ALLIANCE PLAN", "methodology": "percent of total billed charges", "standard_charge_dollar": 393.58, "standard_charge_percentage": 48.59, "count": "0", "additional_payer_notes": "Zero final payments for the item or service in the 15 months prior to posting the file." }, { "payer_name": "CIGNA", "plan_name": "CIGNA COM ALT HMO PLAN", "methodology": "percent of total billed charges", "standard_charge_dollar": 341.82, "standard_charge_percentage": 42.2, "count": "0", "additional_payer_notes": "Zero final payments for the item or service in the 15 months prior to posting the file." }, { "payer_name": "CIGNA", "plan_name": "CIGNA COM ALT HMO PLAN", "methodology": "percent of total billed charges", "standard_charge_dollar": 341.82, "standard_charge_percentage": 42.2, "count": "0", "additional_payer_notes": "Zero final payments for the item or service in the 15 months prior to posting the file." }, { "payer_name": "HEALTH NET", "plan_name": "HEALTHNET HMO, PPO, POS, EPO, CANOPY HEALTHNET HMO, OTHER-IN-NETWORK PLANS", "methodology": "per diem", "standard_charge_dollar": 8000.0, "standard_charge_algorithm": "Expected reimbursement is the lesser of Per diem ($8,000) for the length of stay and 70% of billed.", "count": "0", "additional_payer_notes": "Zero final payments for the item or service in the 15 months prior to posting the file." }, { "payer_name": "HEALTH NET", "plan_name": "HEALTHNET HMO, PPO, POS, EPO, CANOPY HEALTHNET HMO, OTHER-IN-NETWORK PLANS", "methodology": "per diem", "standard_charge_dollar": 8000.0, "standard_charge_algorithm": "Expected reimbursement is the lesser of Per diem ($8,000) for the length of stay and 70% of billed.", "count": "0", "additional_payer_notes": "Zero final payments for the item or service in the 15 months prior to posting the file." }, { "payer_name": "UNITED HEALTHCARE", "plan_name": "SUTTER SELECT & SUTTER HEALTH PLAN HMO PLANS", "methodology": "per diem", "standard_charge_dollar": 28538.0, "standard_charge_algorithm": "Per diem ($28,538).", "count": "0", "additional_payer_notes": "Zero final payments for the item or service in the 15 months prior to posting the file." }, { "payer_name": "UNITED HEALTHCARE", "plan_name": "SUTTER SELECT & SUTTER HEALTH PLAN HMO PLANS", "methodology": "per diem", "standard_charge_dollar": 28538.0, "standard_charge_algorithm": "Per diem ($28,538).", "count": "0", "additional_payer_notes": "Zero final payments for the item or service in the 15 months prior to posting the file." }, { "payer_name": "SUTTER", "plan_name": "SUTTER SELECT & SUTTER HEALTH PLAN HMO PLANS", "methodology": "per diem", "standard_charge_dollar": 28538.0, "standard_charge_algorithm": "Per diem ($28,538).", "count": "0", "additional_payer_notes": "Zero final payments for the item or service in the 15 months prior to posting the file." }, { "payer_name": "UNITED HEALTHCARE", "plan_name": "SUTTER SELECT & SUTTER HEALTH PLAN HMO PLANS", "methodology": "per diem", "standard_charge_dollar": 28538.0, "standard_charge_algorithm": "Per diem ($28,538).", "count": "0", "additional_payer_notes": "Zero final payments for the item or service in the 15 months prior to posting the file." }, { "payer_name": "UMR", "plan_name": "SUTTER SELECT & SUTTER HEALTH PLAN HMO PLANS", "methodology": "per diem", "standard_charge_dollar": 28538.0, "standard_charge_algorithm": "Per diem ($28,538).", "count": "0", "additional_payer_notes": "Zero final payments for the item or service in the 15 months prior to posting the file." } ] } ] }, { "description": "HC Form Cell Saver Gp004", "code_information": [ { "code": "PX-2111009004", "type": "CDM" }, { "code": "99999", "type": "CPT" }, { "code": "0270", "type": "RC" } ], "standard_charges": [ { "setting": "outpatient", "gross_charge": 146.0, "discounted_cash": 73.0, "minimum": 61.61, "maximum": 75.92, "additional_generic_notes": "Zero final payments for the item or service in the 15 months prior to posting the file.", "payers_information": [ { "payer_name": "AETNA", "plan_name": "AETNA ALL OTHER PLANS", "methodology": "percent of total billed charges", "standard_charge_dollar": 75.92, "standard_charge_percentage": 52.0, "count": "0", "additional_payer_notes": "Zero final payments for the item or service in the 15 months prior to posting the file." }, { "payer_name": "AETNA", "plan_name": "AETNA ALL OTHER PLANS", "methodology": "percent of total billed charges", "standard_charge_dollar": 75.92, "standard_charge_percentage": 52.0, "count": "0", "additional_payer_notes": "Zero final payments for the item or service in the 15 months prior to posting the file." }, { "payer_name": "MERITAIN HEALTH", "plan_name": "AETNA ALL OTHER PLANS", "methodology": "percent of total billed charges", "standard_charge_dollar": 75.92, "standard_charge_percentage": 52.0, "count": "0", "additional_payer_notes": "Zero final payments for the item or service in the 15 months prior to posting the file." }, { "payer_name": "BLUE SHIELD OUT OF STATE", "plan_name": "STANFORD HEALTHCARE ALLIANCE PLAN", "methodology": "percent of total billed charges", "standard_charge_dollar": 70.94, "standard_charge_percentage": 48.59, "count": "0", "additional_payer_notes": "Zero final payments for the item or service in the 15 months prior to posting the file." }, { "payer_name": "BLUE SHIELD", "plan_name": "STANFORD HEALTHCARE ALLIANCE PLAN", "methodology": "percent of total billed charges", "standard_charge_dollar": 70.94, "standard_charge_percentage": 48.59, "count": "0", "additional_payer_notes": "Zero final payments for the item or service in the 15 months prior to posting the file." }, { "payer_name": "BLUE SHIELD", "plan_name": "STANFORD HEALTHCARE ALLIANCE PLAN", "methodology": "percent of total billed charges", "standard_charge_dollar": 70.94, "standard_charge_percentage": 48.59, "count": "0", "additional_payer_notes": "Zero final payments for the item or service in the 15 months prior to posting the file." }, { "payer_name": "CIGNA", "plan_name": "CIGNA COM ALT HMO PLAN", "methodology": "percent of total billed charges", "standard_charge_dollar": 61.61, "standard_charge_percentage": 42.2, "count": "0", "additional_payer_notes": "Zero final payments for the item or service in the 15 months prior to posting the file." }, { "payer_name": "CIGNA", "plan_name": "CIGNA COM ALT HMO PLAN", "methodology": "percent of total billed charges", "standard_charge_dollar": 61.61, "standard_charge_percentage": 42.2, "count": "0", "additional_payer_notes": "Zero final payments for the item or service in the 15 months prior to posting the file." }, { "payer_name": "HEALTH NET", "plan_name": "HEALTHNET HMO, PPO, POS, EPO, CANOPY HEALTHNET HMO, OTHER-IN-NETWORK PLANS", "methodology": "per diem", "standard_charge_dollar": 8000.0, "standard_charge_algorithm": "Expected reimbursement is the lesser of Per diem ($8,000) for the length of stay and 70% of billed.", "count": "0", "additional_payer_notes": "Zero final payments for the item or service in the 15 months prior to posting the file." }, { "payer_name": "HEALTH NET", "plan_name": "HEALTHNET HMO, PPO, POS, EPO, CANOPY HEALTHNET HMO, OTHER-IN-NETWORK PLANS", "methodology": "per diem", "standard_charge_dollar": 8000.0, "standard_charge_algorithm": "Expected reimbursement is the lesser of Per diem ($8,000) for the length of stay and 70% of billed.", "count": "0", "additional_payer_notes": "Zero final payments for the item or service in the 15 months prior to posting the file." }, { "payer_name": "UNITED HEALTHCARE", "plan_name": "SUTTER SELECT & SUTTER HEALTH PLAN HMO PLANS", "methodology": "per diem", "standard_charge_dollar": 28538.0, "standard_charge_algorithm": "Per diem ($28,538).", "count": "0", "additional_payer_notes": "Zero final payments for the item or service in the 15 months prior to posting the file." }, { "payer_name": "UNITED HEALTHCARE", "plan_name": "SUTTER SELECT & SUTTER HEALTH PLAN HMO PLANS", "methodology": "per diem", "standard_charge_dollar": 28538.0, "standard_charge_algorithm": "Per diem ($28,538).", "count": "0", "additional_payer_notes": "Zero final payments for the item or service in the 15 months prior to posting the file." }, { "payer_name": "SUTTER", "plan_name": "SUTTER SELECT & SUTTER HEALTH PLAN HMO PLANS", "methodology": "per diem", "standard_charge_dollar": 28538.0, "standard_charge_algorithm": "Per diem ($28,538).", "count": "0", "additional_payer_notes": "Zero final payments for the item or service in the 15 months prior to posting the file." }, { "payer_name": "UNITED HEALTHCARE", "plan_name": "SUTTER SELECT & SUTTER HEALTH PLAN HMO PLANS", "methodology": "per diem", "standard_charge_dollar": 28538.0, "standard_charge_algorithm": "Per diem ($28,538).", "count": "0", "additional_payer_notes": "Zero final payments for the item or service in the 15 months prior to posting the file." }, { "payer_name": "UMR", "plan_name": "SUTTER SELECT & SUTTER HEALTH PLAN HMO PLANS", "methodology": "per diem", "standard_charge_dollar": 28538.0, "standard_charge_algorithm": "Per diem ($28,538).", "count": "0", "additional_payer_notes": "Zero final payments for the item or service in the 15 months prior to posting the file." } ] } ] }, { "description": "HC Reservoir Cell Saver Gp006", "code_information": [ { "code": "PX-2111009006", "type": "CDM" }, { "code": "99999", "type": "CPT" }, { "code": "0272", "type": "RC" } ], "standard_charges": [ { "setting": "outpatient", "gross_charge": 293.0, "discounted_cash": 146.5, "minimum": 123.65, "maximum": 152.36, "additional_generic_notes": "Zero final payments for the item or service in the 15 months prior to posting the file.", "payers_information": [ { "payer_name": "AETNA", "plan_name": "AETNA ALL OTHER PLANS", "methodology": "percent of total billed charges", "standard_charge_dollar": 152.36, "standard_charge_percentage": 52.0, "count": "0", "additional_payer_notes": "Zero final payments for the item or service in the 15 months prior to posting the file." }, { "payer_name": "AETNA", "plan_name": "AETNA ALL OTHER PLANS", "methodology": "percent of total billed charges", "standard_charge_dollar": 152.36, "standard_charge_percentage": 52.0, "count": "0", "additional_payer_notes": "Zero final payments for the item or service in the 15 months prior to posting the file." }, { "payer_name": "MERITAIN HEALTH", "plan_name": "AETNA ALL OTHER PLANS", "methodology": "percent of total billed charges", "standard_charge_dollar": 152.36, "standard_charge_percentage": 52.0, "count": "0", "additional_payer_notes": "Zero final payments for the item or service in the 15 months prior to posting the file." }, { "payer_name": "BLUE SHIELD OUT OF STATE", "plan_name": "STANFORD HEALTHCARE ALLIANCE PLAN", "methodology": "percent of total billed charges", "standard_charge_dollar": 142.37, "standard_charge_percentage": 48.59, "count": "0", "additional_payer_notes": "Zero final payments for the item or service in the 15 months prior to posting the file." }, { "payer_name": "BLUE SHIELD", "plan_name": "STANFORD HEALTHCARE ALLIANCE PLAN", "methodology": "percent of total billed charges", "standard_charge_dollar": 142.37, "standard_charge_percentage": 48.59, "count": "0", "additional_payer_notes": "Zero final payments for the item or service in the 15 months prior to posting the file." }, { "payer_name": "BLUE SHIELD", "plan_name": "STANFORD HEALTHCARE ALLIANCE PLAN", "methodology": "percent of total billed charges", "standard_charge_dollar": 142.37, "standard_charge_percentage": 48.59, "count": "0", "additional_payer_notes": "Zero final payments for the item or service in the 15 months prior to posting the file." }, { "payer_name": "CIGNA", "plan_name": "CIGNA COM ALT HMO PLAN", "methodology": "percent of total billed charges", "standard_charge_dollar": 123.65, "standard_charge_percentage": 42.2, "count": "0", "additional_payer_notes": "Zero final payments for the item or service in the 15 months prior to posting the file." }, { "payer_name": "CIGNA", "plan_name": "CIGNA COM ALT HMO PLAN", "methodology": "percent of total billed charges", "standard_charge_dollar": 123.65, "standard_charge_percentage": 42.2, "count": "0", "additional_payer_notes": "Zero final payments for the item or service in the 15 months prior to posting the file." }, { "payer_name": "HEALTH NET", "plan_name": "HEALTHNET HMO, PPO, POS, EPO, CANOPY HEALTHNET HMO, OTHER-IN-NETWORK PLANS", "methodology": "per diem", "standard_charge_dollar": 8000.0, "standard_charge_algorithm": "Expected reimbursement is the lesser of Per diem ($8,000) for the length of stay and 70% of billed.", "count": "0", "additional_payer_notes": "Zero final payments for the item or service in the 15 months prior to posting the file." }, { "payer_name": "HEALTH NET", "plan_name": "HEALTHNET HMO, PPO, POS, EPO, CANOPY HEALTHNET HMO, OTHER-IN-NETWORK PLANS", "methodology": "per diem", "standard_charge_dollar": 8000.0, "standard_charge_algorithm": "Expected reimbursement is the lesser of Per diem ($8,000) for the length of stay and 70% of billed.", "count": "0", "additional_payer_notes": "Zero final payments for the item or service in the 15 months prior to posting the file." }, { "payer_name": "UNITED HEALTHCARE", "plan_name": "SUTTER SELECT & SUTTER HEALTH PLAN HMO PLANS", "methodology": "per diem", "standard_charge_dollar": 28538.0, "standard_charge_algorithm": "Per diem ($28,538).", "count": "0", "additional_payer_notes": "Zero final payments for the item or service in the 15 months prior to posting the file." }, { "payer_name": "UNITED HEALTHCARE", "plan_name": "SUTTER SELECT & SUTTER HEALTH PLAN HMO PLANS", "methodology": "per diem", "standard_charge_dollar": 28538.0, "standard_charge_algorithm": "Per diem ($28,538).", "count": "0", "additional_payer_notes": "Zero final payments for the item or service in the 15 months prior to posting the file." }, { "payer_name": "SUTTER", "plan_name": "SUTTER SELECT & SUTTER HEALTH PLAN HMO PLANS", "methodology": "per diem", "standard_charge_dollar": 28538.0, "standard_charge_algorithm": "Per diem ($28,538).", "count": "0", "additional_payer_notes": "Zero final payments for the item or service in the 15 months prior to posting the file." }, { "payer_name": "UNITED HEALTHCARE", "plan_name": "SUTTER SELECT & SUTTER HEALTH PLAN HMO PLANS", "methodology": "per diem", "standard_charge_dollar": 28538.0, "standard_charge_algorithm": "Per diem ($28,538).", "count": "0", "additional_payer_notes": "Zero final payments for the item or service in the 15 months prior to posting the file." }, { "payer_name": "UMR", "plan_name": "SUTTER SELECT & SUTTER HEALTH PLAN HMO PLANS", "methodology": "per diem", "standard_charge_dollar": 28538.0, "standard_charge_algorithm": "Per diem ($28,538).", "count": "0", "additional_payer_notes": "Zero final payments for the item or service in the 15 months prior to posting the file." } ] } ] }, { "description": "HC Set Warmer Ranger Fluid Gp002", "code_information": [ { "code": "PX-2111010002", "type": "CDM" }, { "code": "99999", "type": "CPT" }, { "code": "0270", "type": "RC" } ], "standard_charges": [ { "setting": "outpatient", "gross_charge": 50.0, "discounted_cash": 25.0, "minimum": 21.1, "maximum": 26.0, "additional_generic_notes": "Zero final payments for the item or service in the 15 months prior to posting the file.", "payers_information": [ { "payer_name": "AETNA", "plan_name": "AETNA ALL OTHER PLANS", "methodology": "percent of total billed charges", "standard_charge_dollar": 26.0, "standard_charge_percentage": 52.0, "count": "0", "additional_payer_notes": "Zero final payments for the item or service in the 15 months prior to posting the file." }, { "payer_name": "AETNA", "plan_name": "AETNA ALL OTHER PLANS", "methodology": "percent of total billed charges", "standard_charge_dollar": 26.0, "standard_charge_percentage": 52.0, "count": "0", "additional_payer_notes": "Zero final payments for the item or service in the 15 months prior to posting the file." }, { "payer_name": "MERITAIN HEALTH", "plan_name": "AETNA ALL OTHER PLANS", "methodology": "percent of total billed charges", "standard_charge_dollar": 26.0, "standard_charge_percentage": 52.0, "count": "0", "additional_payer_notes": "Zero final payments for the item or service in the 15 months prior to posting the file." }, { "payer_name": "BLUE SHIELD OUT OF STATE", "plan_name": "STANFORD HEALTHCARE ALLIANCE PLAN", "methodology": "percent of total billed charges", "standard_charge_dollar": 24.3, "standard_charge_percentage": 48.59, "count": "0", "additional_payer_notes": "Zero final payments for the item or service in the 15 months prior to posting the file." }, { "payer_name": "BLUE SHIELD", "plan_name": "STANFORD HEALTHCARE ALLIANCE PLAN", "methodology": "percent of total billed charges", "standard_charge_dollar": 24.3, "standard_charge_percentage": 48.59, "count": "0", "additional_payer_notes": "Zero final payments for the item or service in the 15 months prior to posting the file." }, { "payer_name": "BLUE SHIELD", "plan_name": "STANFORD HEALTHCARE ALLIANCE PLAN", "methodology": "percent of total billed charges", "standard_charge_dollar": 24.3, "standard_charge_percentage": 48.59, "count": "0", "additional_payer_notes": "Zero final payments for the item or service in the 15 months prior to posting the file." }, { "payer_name": "CIGNA", "plan_name": "CIGNA COM ALT HMO PLAN", "methodology": "percent of total billed charges", "standard_charge_dollar": 21.1, "standard_charge_percentage": 42.2, "count": "0", "additional_payer_notes": "Zero final payments for the item or service in the 15 months prior to posting the file." }, { "payer_name": "CIGNA", "plan_name": "CIGNA COM ALT HMO PLAN", "methodology": "percent of total billed charges", "standard_charge_dollar": 21.1, "standard_charge_percentage": 42.2, "count": "0", "additional_payer_notes": "Zero final payments for the item or service in the 15 months prior to posting the file." }, { "payer_name": "HEALTH NET", "plan_name": "HEALTHNET HMO, PPO, POS, EPO, CANOPY HEALTHNET HMO, OTHER-IN-NETWORK PLANS", "methodology": "per diem", "standard_charge_dollar": 8000.0, "standard_charge_algorithm": "Expected reimbursement is the lesser of Per diem ($8,000) for the length of stay and 70% of billed.", "count": "0", "additional_payer_notes": "Zero final payments for the item or service in the 15 months prior to posting the file." }, { "payer_name": "HEALTH NET", "plan_name": "HEALTHNET HMO, PPO, POS, EPO, CANOPY HEALTHNET HMO, OTHER-IN-NETWORK PLANS", "methodology": "per diem", "standard_charge_dollar": 8000.0, "standard_charge_algorithm": "Expected reimbursement is the lesser of Per diem ($8,000) for the length of stay and 70% of billed.", "count": "0", "additional_payer_notes": "Zero final payments for the item or service in the 15 months prior to posting the file." }, { "payer_name": "UNITED HEALTHCARE", "plan_name": "SUTTER SELECT & SUTTER HEALTH PLAN HMO PLANS", "methodology": "per diem", "standard_charge_dollar": 28538.0, "standard_charge_algorithm": "Per diem ($28,538).", "count": "0", "additional_payer_notes": "Zero final payments for the item or service in the 15 months prior to posting the file." }, { "payer_name": "UNITED HEALTHCARE", "plan_name": "SUTTER SELECT & SUTTER HEALTH PLAN HMO PLANS", "methodology": "per diem", "standard_charge_dollar": 28538.0, "standard_charge_algorithm": "Per diem ($28,538).", "count": "0", "additional_payer_notes": "Zero final payments for the item or service in the 15 months prior to posting the file." }, { "payer_name": "SUTTER", "plan_name": "SUTTER SELECT & SUTTER HEALTH PLAN HMO PLANS", "methodology": "per diem", "standard_charge_dollar": 28538.0, "standard_charge_algorithm": "Per diem ($28,538).", "count": "0", "additional_payer_notes": "Zero final payments for the item or service in the 15 months prior to posting the file." }, { "payer_name": "UNITED HEALTHCARE", "plan_name": "SUTTER SELECT & SUTTER HEALTH PLAN HMO PLANS", "methodology": "per diem", "standard_charge_dollar": 28538.0, "standard_charge_algorithm": "Per diem ($28,538).", "count": "0", "additional_payer_notes": "Zero final payments for the item or service in the 15 months prior to posting the file." }, { "payer_name": "UMR", "plan_name": "SUTTER SELECT & SUTTER HEALTH PLAN HMO PLANS", "methodology": "per diem", "standard_charge_dollar": 28538.0, "standard_charge_algorithm": "Per diem ($28,538).", "count": "0", "additional_payer_notes": "Zero final payments for the item or service in the 15 months prior to posting the file." } ] } ] }, { "description": "HC Set Warmer Ranger Fluid Gp007", "code_information": [ { "code": "PX-2111010007", "type": "CDM" }, { "code": "99999", "type": "CPT" }, { "code": "0272", "type": "RC" } ], "standard_charges": [ { "setting": "outpatient", "gross_charge": 380.0, "discounted_cash": 190.0, "minimum": 160.36, "maximum": 197.6, "additional_generic_notes": "Zero final payments for the item or service in the 15 months prior to posting the file.", "payers_information": [ { "payer_name": "AETNA", "plan_name": "AETNA ALL OTHER PLANS", "methodology": "percent of total billed charges", "standard_charge_dollar": 197.6, "standard_charge_percentage": 52.0, "count": "0", "additional_payer_notes": "Zero final payments for the item or service in the 15 months prior to posting the file." }, { "payer_name": "AETNA", "plan_name": "AETNA ALL OTHER PLANS", "methodology": "percent of total billed charges", "standard_charge_dollar": 197.6, "standard_charge_percentage": 52.0, "count": "0", "additional_payer_notes": "Zero final payments for the item or service in the 15 months prior to posting the file." }, { "payer_name": "MERITAIN HEALTH", "plan_name": "AETNA ALL OTHER PLANS", "methodology": "percent of total billed charges", "standard_charge_dollar": 197.6, "standard_charge_percentage": 52.0, "count": "0", "additional_payer_notes": "Zero final payments for the item or service in the 15 months prior to posting the file." }, { "payer_name": "BLUE SHIELD OUT OF STATE", "plan_name": "STANFORD HEALTHCARE ALLIANCE PLAN", "methodology": "percent of total billed charges", "standard_charge_dollar": 184.64, "standard_charge_percentage": 48.59, "count": "0", "additional_payer_notes": "Zero final payments for the item or service in the 15 months prior to posting the file." }, { "payer_name": "BLUE SHIELD", "plan_name": "STANFORD HEALTHCARE ALLIANCE PLAN", "methodology": "percent of total billed charges", "standard_charge_dollar": 184.64, "standard_charge_percentage": 48.59, "count": "0", "additional_payer_notes": "Zero final payments for the item or service in the 15 months prior to posting the file." }, { "payer_name": "BLUE SHIELD", "plan_name": "STANFORD HEALTHCARE ALLIANCE PLAN", "methodology": "percent of total billed charges", "standard_charge_dollar": 184.64, "standard_charge_percentage": 48.59, "count": "0", "additional_payer_notes": "Zero final payments for the item or service in the 15 months prior to posting the file." }, { "payer_name": "CIGNA", "plan_name": "CIGNA COM ALT HMO PLAN", "methodology": "percent of total billed charges", "standard_charge_dollar": 160.36, "standard_charge_percentage": 42.2, "count": "0", "additional_payer_notes": "Zero final payments for the item or service in the 15 months prior to posting the file." }, { "payer_name": "CIGNA", "plan_name": "CIGNA COM ALT HMO PLAN", "methodology": "percent of total billed charges", "standard_charge_dollar": 160.36, "standard_charge_percentage": 42.2, "count": "0", "additional_payer_notes": "Zero final payments for the item or service in the 15 months prior to posting the file." }, { "payer_name": "HEALTH NET", "plan_name": "HEALTHNET HMO, PPO, POS, EPO, CANOPY HEALTHNET HMO, OTHER-IN-NETWORK PLANS", "methodology": "per diem", "standard_charge_dollar": 8000.0, "standard_charge_algorithm": "Expected reimbursement is the lesser of Per diem ($8,000) for the length of stay and 70% of billed.", "count": "0", "additional_payer_notes": "Zero final payments for the item or service in the 15 months prior to posting the file." }, { "payer_name": "HEALTH NET", "plan_name": "HEALTHNET HMO, PPO, POS, EPO, CANOPY HEALTHNET HMO, OTHER-IN-NETWORK PLANS", "methodology": "per diem", "standard_charge_dollar": 8000.0, "standard_charge_algorithm": "Expected reimbursement is the lesser of Per diem ($8,000) for the length of stay and 70% of billed.", "count": "0", "additional_payer_notes": "Zero final payments for the item or service in the 15 months prior to posting the file." }, { "payer_name": "UNITED HEALTHCARE", "plan_name": "SUTTER SELECT & SUTTER HEALTH PLAN HMO PLANS", "methodology": "per diem", "standard_charge_dollar": 28538.0, "standard_charge_algorithm": "Per diem ($28,538).", "count": "0", "additional_payer_notes": "Zero final payments for the item or service in the 15 months prior to posting the file." }, { "payer_name": "UNITED HEALTHCARE", "plan_name": "SUTTER SELECT & SUTTER HEALTH PLAN HMO PLANS", "methodology": "per diem", "standard_charge_dollar": 28538.0, "standard_charge_algorithm": "Per diem ($28,538).", "count": "0", "additional_payer_notes": "Zero final payments for the item or service in the 15 months prior to posting the file." }, { "payer_name": "SUTTER", "plan_name": "SUTTER SELECT & SUTTER HEALTH PLAN HMO PLANS", "methodology": "per diem", "standard_charge_dollar": 28538.0, "standard_charge_algorithm": "Per diem ($28,538).", "count": "0", "additional_payer_notes": "Zero final payments for the item or service in the 15 months prior to posting the file." }, { "payer_name": "UNITED HEALTHCARE", "plan_name": "SUTTER SELECT & SUTTER HEALTH PLAN HMO PLANS", "methodology": "per diem", "standard_charge_dollar": 28538.0, "standard_charge_algorithm": "Per diem ($28,538).", "count": "0", "additional_payer_notes": "Zero final payments for the item or service in the 15 months prior to posting the file." }, { "payer_name": "UMR", "plan_name": "SUTTER SELECT & SUTTER HEALTH PLAN HMO PLANS", "methodology": "per diem", "standard_charge_dollar": 28538.0, "standard_charge_algorithm": "Per diem ($28,538).", "count": "0", "additional_payer_notes": "Zero final payments for the item or service in the 15 months prior to posting the file." } ] } ] }, { "description": "HC Set Warmer Ranger Fluid Gp008", "code_information": [ { "code": "PX-2111010008", "type": "CDM" }, { "code": "99999", "type": "CPT" }, { "code": "0272", "type": "RC" } ], "standard_charges": [ { "setting": "outpatient", "gross_charge": 475.0, "discounted_cash": 237.5, "minimum": 200.45, "maximum": 247.0, "additional_generic_notes": "Zero final payments for the item or service in the 15 months prior to posting the file.", "payers_information": [ { "payer_name": "AETNA", "plan_name": "AETNA ALL OTHER PLANS", "methodology": "percent of total billed charges", "standard_charge_dollar": 247.0, "standard_charge_percentage": 52.0, "count": "0", "additional_payer_notes": "Zero final payments for the item or service in the 15 months prior to posting the file." }, { "payer_name": "AETNA", "plan_name": "AETNA ALL OTHER PLANS", "methodology": "percent of total billed charges", "standard_charge_dollar": 247.0, "standard_charge_percentage": 52.0, "count": "0", "additional_payer_notes": "Zero final payments for the item or service in the 15 months prior to posting the file." }, { "payer_name": "MERITAIN HEALTH", "plan_name": "AETNA ALL OTHER PLANS", "methodology": "percent of total billed charges", "standard_charge_dollar": 247.0, "standard_charge_percentage": 52.0, "count": "0", "additional_payer_notes": "Zero final payments for the item or service in the 15 months prior to posting the file." }, { "payer_name": "BLUE SHIELD OUT OF STATE", "plan_name": "STANFORD HEALTHCARE ALLIANCE PLAN", "methodology": "percent of total billed charges", "standard_charge_dollar": 230.8, "standard_charge_percentage": 48.59, "count": "0", "additional_payer_notes": "Zero final payments for the item or service in the 15 months prior to posting the file." }, { "payer_name": "BLUE SHIELD", "plan_name": "STANFORD HEALTHCARE ALLIANCE PLAN", "methodology": "percent of total billed charges", "standard_charge_dollar": 230.8, "standard_charge_percentage": 48.59, "count": "0", "additional_payer_notes": "Zero final payments for the item or service in the 15 months prior to posting the file." }, { "payer_name": "BLUE SHIELD", "plan_name": "STANFORD HEALTHCARE ALLIANCE PLAN", "methodology": "percent of total billed charges", "standard_charge_dollar": 230.8, "standard_charge_percentage": 48.59, "count": "0", "additional_payer_notes": "Zero final payments for the item or service in the 15 months prior to posting the file." }, { "payer_name": "CIGNA", "plan_name": "CIGNA COM ALT HMO PLAN", "methodology": "percent of total billed charges", "standard_charge_dollar": 200.45, "standard_charge_percentage": 42.2, "count": "0", "additional_payer_notes": "Zero final payments for the item or service in the 15 months prior to posting the file." }, { "payer_name": "CIGNA", "plan_name": "CIGNA COM ALT HMO PLAN", "methodology": "percent of total billed charges", "standard_charge_dollar": 200.45, "standard_charge_percentage": 42.2, "count": "0", "additional_payer_notes": "Zero final payments for the item or service in the 15 months prior to posting the file." }, { "payer_name": "HEALTH NET", "plan_name": "HEALTHNET HMO, PPO, POS, EPO, CANOPY HEALTHNET HMO, OTHER-IN-NETWORK PLANS", "methodology": "per diem", "standard_charge_dollar": 8000.0, "standard_charge_algorithm": "Expected reimbursement is the lesser of Per diem ($8,000) for the length of stay and 70% of billed.", "count": "0", "additional_payer_notes": "Zero final payments for the item or service in the 15 months prior to posting the file." }, { "payer_name": "HEALTH NET", "plan_name": "HEALTHNET HMO, PPO, POS, EPO, CANOPY HEALTHNET HMO, OTHER-IN-NETWORK PLANS", "methodology": "per diem", "standard_charge_dollar": 8000.0, "standard_charge_algorithm": "Expected reimbursement is the lesser of Per diem ($8,000) for the length of stay and 70% of billed.", "count": "0", "additional_payer_notes": "Zero final payments for the item or service in the 15 months prior to posting the file." }, { "payer_name": "UNITED HEALTHCARE", "plan_name": "SUTTER SELECT & SUTTER HEALTH PLAN HMO PLANS", "methodology": "per diem", "standard_charge_dollar": 28538.0, "standard_charge_algorithm": "Per diem ($28,538).", "count": "0", "additional_payer_notes": "Zero final payments for the item or service in the 15 months prior to posting the file." }, { "payer_name": "UNITED HEALTHCARE", "plan_name": "SUTTER SELECT & SUTTER HEALTH PLAN HMO PLANS", "methodology": "per diem", "standard_charge_dollar": 28538.0, "standard_charge_algorithm": "Per diem ($28,538).", "count": "0", "additional_payer_notes": "Zero final payments for the item or service in the 15 months prior to posting the file." }, { "payer_name": "SUTTER", "plan_name": "SUTTER SELECT & SUTTER HEALTH PLAN HMO PLANS", "methodology": "per diem", "standard_charge_dollar": 28538.0, "standard_charge_algorithm": "Per diem ($28,538).", "count": "0", "additional_payer_notes": "Zero final payments for the item or service in the 15 months prior to posting the file." }, { "payer_name": "UNITED HEALTHCARE", "plan_name": "SUTTER SELECT & SUTTER HEALTH PLAN HMO PLANS", "methodology": "per diem", "standard_charge_dollar": 28538.0, "standard_charge_algorithm": "Per diem ($28,538).", "count": "0", "additional_payer_notes": "Zero final payments for the item or service in the 15 months prior to posting the file." }, { "payer_name": "UMR", "plan_name": "SUTTER SELECT & SUTTER HEALTH PLAN HMO PLANS", "methodology": "per diem", "standard_charge_dollar": 28538.0, "standard_charge_algorithm": "Per diem ($28,538).", "count": "0", "additional_payer_notes": "Zero final payments for the item or service in the 15 months prior to posting the file." } ] } ] }, { "description": "HC Adapter Dial Gp016", "code_information": [ { "code": "PX-2120001016", "type": "CDM" }, { "code": "99999", "type": "CPT" }, { "code": "0272", "type": "RC" } ], "standard_charges": [ { "setting": "outpatient", "gross_charge": 1400.0, "discounted_cash": 700.0, "minimum": 590.8, "maximum": 728.0, "additional_generic_notes": "Zero final payments for the item or service in the 15 months prior to posting the file.", "payers_information": [ { "payer_name": "AETNA", "plan_name": "AETNA ALL OTHER PLANS", "methodology": "percent of total billed charges", "standard_charge_dollar": 728.0, "standard_charge_percentage": 52.0, "count": "0", "additional_payer_notes": "Zero final payments for the item or service in the 15 months prior to posting the file." }, { "payer_name": "AETNA", "plan_name": "AETNA ALL OTHER PLANS", "methodology": "percent of total billed charges", "standard_charge_dollar": 728.0, "standard_charge_percentage": 52.0, "count": "0", "additional_payer_notes": "Zero final payments for the item or service in the 15 months prior to posting the file." }, { "payer_name": "MERITAIN HEALTH", "plan_name": "AETNA ALL OTHER PLANS", "methodology": "percent of total billed charges", "standard_charge_dollar": 728.0, "standard_charge_percentage": 52.0, "count": "0", "additional_payer_notes": "Zero final payments for the item or service in the 15 months prior to posting the file." }, { "payer_name": "BLUE SHIELD OUT OF STATE", "plan_name": "STANFORD HEALTHCARE ALLIANCE PLAN", "methodology": "percent of total billed charges", "standard_charge_dollar": 680.26, "standard_charge_percentage": 48.59, "count": "0", "additional_payer_notes": "Zero final payments for the item or service in the 15 months prior to posting the file." }, { "payer_name": "BLUE SHIELD", "plan_name": "STANFORD HEALTHCARE ALLIANCE PLAN", "methodology": "percent of total billed charges", "standard_charge_dollar": 680.26, "standard_charge_percentage": 48.59, "median_amount": 68.24, "10th_percentile": 13.6, "90th_percentile": 1043.06, "count": "30" }, { "payer_name": "BLUE SHIELD", "plan_name": "STANFORD HEALTHCARE ALLIANCE PLAN", "methodology": "percent of total billed charges", "standard_charge_dollar": 680.26, "standard_charge_percentage": 48.59, "count": "0", "additional_payer_notes": "Zero final payments for the item or service in the 15 months prior to posting the file." }, { "payer_name": "BLUE SHIELD", "plan_name": "STANFORD HEALTHCARE ALLIANCE PLAN", "methodology": "percent of total billed charges", "standard_charge_dollar": 680.26, "standard_charge_percentage": 48.59, "count": "0", "additional_payer_notes": "Zero final payments for the item or service in the 15 months prior to posting the file." }, { "payer_name": "CIGNA", "plan_name": "CIGNA COM ALT HMO PLAN", "methodology": "percent of total billed charges", "standard_charge_dollar": 590.8, "standard_charge_percentage": 42.2, "count": "0", "additional_payer_notes": "Zero final payments for the item or service in the 15 months prior to posting the file." }, { "payer_name": "CIGNA", "plan_name": "CIGNA COM ALT HMO PLAN", "methodology": "percent of total billed charges", "standard_charge_dollar": 590.8, "standard_charge_percentage": 42.2, "count": "0", "additional_payer_notes": "Zero final payments for the item or service in the 15 months prior to posting the file." }, { "payer_name": "HEALTH NET", "plan_name": "HEALTHNET HMO, PPO, POS, EPO, CANOPY HEALTHNET HMO, OTHER-IN-NETWORK PLANS", "methodology": "per diem", "standard_charge_dollar": 8000.0, "standard_charge_algorithm": "Expected reimbursement is the lesser of Per diem ($8,000) for the length of stay and 70% of billed.", "count": "0", "additional_payer_notes": "Zero final payments for the item or service in the 15 months prior to posting the file." }, { "payer_name": "HEALTH NET", "plan_name": "HEALTHNET HMO, PPO, POS, EPO, CANOPY HEALTHNET HMO, OTHER-IN-NETWORK PLANS", "methodology": "per diem", "standard_charge_dollar": 8000.0, "standard_charge_algorithm": "Expected reimbursement is the lesser of Per diem ($8,000) for the length of stay and 70% of billed.", "count": "0", "additional_payer_notes": "Zero final payments for the item or service in the 15 months prior to posting the file." }, { "payer_name": "UNITED HEALTHCARE", "plan_name": "SUTTER SELECT & SUTTER HEALTH PLAN HMO PLANS", "methodology": "per diem", "standard_charge_dollar": 28538.0, "standard_charge_algorithm": "Per diem ($28,538).", "count": "0", "additional_payer_notes": "Zero final payments for the item or service in the 15 months prior to posting the file." }, { "payer_name": "UNITED HEALTHCARE", "plan_name": "SUTTER SELECT & SUTTER HEALTH PLAN HMO PLANS", "methodology": "per diem", "standard_charge_dollar": 28538.0, "standard_charge_algorithm": "Per diem ($28,538).", "count": "0", "additional_payer_notes": "Zero final payments for the item or service in the 15 months prior to posting the file." }, { "payer_name": "SUTTER", "plan_name": "SUTTER SELECT & SUTTER HEALTH PLAN HMO PLANS", "methodology": "per diem", "standard_charge_dollar": 28538.0, "standard_charge_algorithm": "Per diem ($28,538).", "count": "0", "additional_payer_notes": "Zero final payments for the item or service in the 15 months prior to posting the file." }, { "payer_name": "UNITED HEALTHCARE", "plan_name": "SUTTER SELECT & SUTTER HEALTH PLAN HMO PLANS", "methodology": "per diem", "standard_charge_dollar": 28538.0, "standard_charge_algorithm": "Per diem ($28,538).", "count": "0", "additional_payer_notes": "Zero final payments for the item or service in the 15 months prior to posting the file." }, { "payer_name": "UMR", "plan_name": "SUTTER SELECT & SUTTER HEALTH PLAN HMO PLANS", "methodology": "per diem", "standard_charge_dollar": 28538.0, "standard_charge_algorithm": "Per diem ($28,538).", "count": "0", "additional_payer_notes": "Zero final payments for the item or service in the 15 months prior to posting the file." } ] } ] }, { "description": "HC Adapter Dial Gp017", "code_information": [ { "code": "PX-2120001017", "type": "CDM" }, { "code": "99999", "type": "CPT" }, { "code": "0272", "type": "RC" } ], "standard_charges": [ { "setting": "outpatient", "gross_charge": 1575.0, "discounted_cash": 787.5, "minimum": 664.65, "maximum": 819.0, "additional_generic_notes": "Zero final payments for the item or service in the 15 months prior to posting the file.", "payers_information": [ { "payer_name": "AETNA", "plan_name": "AETNA ALL OTHER PLANS", "methodology": "percent of total billed charges", "standard_charge_dollar": 819.0, "standard_charge_percentage": 52.0, "count": "0", "additional_payer_notes": "Zero final payments for the item or service in the 15 months prior to posting the file." }, { "payer_name": "AETNA", "plan_name": "AETNA ALL OTHER PLANS", "methodology": "percent of total billed charges", "standard_charge_dollar": 819.0, "standard_charge_percentage": 52.0, "count": "0", "additional_payer_notes": "Zero final payments for the item or service in the 15 months prior to posting the file." }, { "payer_name": "MERITAIN HEALTH", "plan_name": "AETNA ALL OTHER PLANS", "methodology": "percent of total billed charges", "standard_charge_dollar": 819.0, "standard_charge_percentage": 52.0, "count": "0", "additional_payer_notes": "Zero final payments for the item or service in the 15 months prior to posting the file." }, { "payer_name": "BLUE SHIELD OUT OF STATE", "plan_name": "STANFORD HEALTHCARE ALLIANCE PLAN", "methodology": "percent of total billed charges", "standard_charge_dollar": 765.29, "standard_charge_percentage": 48.59, "count": "0", "additional_payer_notes": "Zero final payments for the item or service in the 15 months prior to posting the file." }, { "payer_name": "BLUE SHIELD", "plan_name": "STANFORD HEALTHCARE ALLIANCE PLAN", "methodology": "percent of total billed charges", "standard_charge_dollar": 765.29, "standard_charge_percentage": 48.59, "median_amount": 68.24, "10th_percentile": 13.6, "90th_percentile": 1043.06, "count": "30" }, { "payer_name": "BLUE SHIELD", "plan_name": "STANFORD HEALTHCARE ALLIANCE PLAN", "methodology": "percent of total billed charges", "standard_charge_dollar": 765.29, "standard_charge_percentage": 48.59, "count": "0", "additional_payer_notes": "Zero final payments for the item or service in the 15 months prior to posting the file." }, { "payer_name": "BLUE SHIELD", "plan_name": "STANFORD HEALTHCARE ALLIANCE PLAN", "methodology": "percent of total billed charges", "standard_charge_dollar": 765.29, "standard_charge_percentage": 48.59, "count": "0", "additional_payer_notes": "Zero final payments for the item or service in the 15 months prior to posting the file." }, { "payer_name": "CIGNA", "plan_name": "CIGNA COM ALT HMO PLAN", "methodology": "percent of total billed charges", "standard_charge_dollar": 664.65, "standard_charge_percentage": 42.2, "count": "0", "additional_payer_notes": "Zero final payments for the item or service in the 15 months prior to posting the file." }, { "payer_name": "CIGNA", "plan_name": "CIGNA COM ALT HMO PLAN", "methodology": "percent of total billed charges", "standard_charge_dollar": 664.65, "standard_charge_percentage": 42.2, "count": "0", "additional_payer_notes": "Zero final payments for the item or service in the 15 months prior to posting the file." }, { "payer_name": "HEALTH NET", "plan_name": "HEALTHNET HMO, PPO, POS, EPO, CANOPY HEALTHNET HMO, OTHER-IN-NETWORK PLANS", "methodology": "per diem", "standard_charge_dollar": 8000.0, "standard_charge_algorithm": "Expected reimbursement is the lesser of Per diem ($8,000) for the length of stay and 70% of billed.", "count": "0", "additional_payer_notes": "Zero final payments for the item or service in the 15 months prior to posting the file." }, { "payer_name": "HEALTH NET", "plan_name": "HEALTHNET HMO, PPO, POS, EPO, CANOPY HEALTHNET HMO, OTHER-IN-NETWORK PLANS", "methodology": "per diem", "standard_charge_dollar": 8000.0, "standard_charge_algorithm": "Expected reimbursement is the lesser of Per diem ($8,000) for the length of stay and 70% of billed.", "count": "0", "additional_payer_notes": "Zero final payments for the item or service in the 15 months prior to posting the file." }, { "payer_name": "UNITED HEALTHCARE", "plan_name": "SUTTER SELECT & SUTTER HEALTH PLAN HMO PLANS", "methodology": "per diem", "standard_charge_dollar": 28538.0, "standard_charge_algorithm": "Per diem ($28,538).", "count": "0", "additional_payer_notes": "Zero final payments for the item or service in the 15 months prior to posting the file." }, { "payer_name": "UNITED HEALTHCARE", "plan_name": "SUTTER SELECT & SUTTER HEALTH PLAN HMO PLANS", "methodology": "per diem", "standard_charge_dollar": 28538.0, "standard_charge_algorithm": "Per diem ($28,538).", "count": "0", "additional_payer_notes": "Zero final payments for the item or service in the 15 months prior to posting the file." }, { "payer_name": "SUTTER", "plan_name": "SUTTER SELECT & SUTTER HEALTH PLAN HMO PLANS", "methodology": "per diem", "standard_charge_dollar": 28538.0, "standard_charge_algorithm": "Per diem ($28,538).", "count": "0", "additional_payer_notes": "Zero final payments for the item or service in the 15 months prior to posting the file." }, { "payer_name": "UNITED HEALTHCARE", "plan_name": "SUTTER SELECT & SUTTER HEALTH PLAN HMO PLANS", "methodology": "per diem", "standard_charge_dollar": 28538.0, "standard_charge_algorithm": "Per diem ($28,538).", "count": "0", "additional_payer_notes": "Zero final payments for the item or service in the 15 months prior to posting the file." }, { "payer_name": "UMR", "plan_name": "SUTTER SELECT & SUTTER HEALTH PLAN HMO PLANS", "methodology": "per diem", "standard_charge_dollar": 28538.0, "standard_charge_algorithm": "Per diem ($28,538).", "count": "0", "additional_payer_notes": "Zero final payments for the item or service in the 15 months prior to posting the file." } ] } ] }, { "description": "HC Adapter Dial Gp018", "code_information": [ { "code": "PX-2120001018", "type": "CDM" }, { "code": "99999", "type": "CPT" }, { "code": "0272", "type": "RC" } ], "standard_charges": [ { "setting": "outpatient", "gross_charge": 1750.0, "discounted_cash": 875.0, "minimum": 738.5, "maximum": 910.0, "additional_generic_notes": "Zero final payments for the item or service in the 15 months prior to posting the file.", "payers_information": [ { "payer_name": "AETNA", "plan_name": "AETNA ALL OTHER PLANS", "methodology": "percent of total billed charges", "standard_charge_dollar": 910.0, "standard_charge_percentage": 52.0, "count": "0", "additional_payer_notes": "Zero final payments for the item or service in the 15 months prior to posting the file." }, { "payer_name": "AETNA", "plan_name": "AETNA ALL OTHER PLANS", "methodology": "percent of total billed charges", "standard_charge_dollar": 910.0, "standard_charge_percentage": 52.0, "count": "0", "additional_payer_notes": "Zero final payments for the item or service in the 15 months prior to posting the file." }, { "payer_name": "MERITAIN HEALTH", "plan_name": "AETNA ALL OTHER PLANS", "methodology": "percent of total billed charges", "standard_charge_dollar": 910.0, "standard_charge_percentage": 52.0, "count": "0", "additional_payer_notes": "Zero final payments for the item or service in the 15 months prior to posting the file." }, { "payer_name": "BLUE SHIELD OUT OF STATE", "plan_name": "STANFORD HEALTHCARE ALLIANCE PLAN", "methodology": "percent of total billed charges", "standard_charge_dollar": 850.33, "standard_charge_percentage": 48.59, "count": "0", "additional_payer_notes": "Zero final payments for the item or service in the 15 months prior to posting the file." }, { "payer_name": "BLUE SHIELD", "plan_name": "STANFORD HEALTHCARE ALLIANCE PLAN", "methodology": "percent of total billed charges", "standard_charge_dollar": 850.33, "standard_charge_percentage": 48.59, "median_amount": 68.24, "10th_percentile": 13.6, "90th_percentile": 1043.06, "count": "30" }, { "payer_name": "BLUE SHIELD", "plan_name": "STANFORD HEALTHCARE ALLIANCE PLAN", "methodology": "percent of total billed charges", "standard_charge_dollar": 850.33, "standard_charge_percentage": 48.59, "count": "0", "additional_payer_notes": "Zero final payments for the item or service in the 15 months prior to posting the file." }, { "payer_name": "BLUE SHIELD", "plan_name": "STANFORD HEALTHCARE ALLIANCE PLAN", "methodology": "percent of total billed charges", "standard_charge_dollar": 850.33, "standard_charge_percentage": 48.59, "count": "0", "additional_payer_notes": "Zero final payments for the item or service in the 15 months prior to posting the file." }, { "payer_name": "CIGNA", "plan_name": "CIGNA COM ALT HMO PLAN", "methodology": "percent of total billed charges", "standard_charge_dollar": 738.5, "standard_charge_percentage": 42.2, "count": "0", "additional_payer_notes": "Zero final payments for the item or service in the 15 months prior to posting the file." }, { "payer_name": "CIGNA", "plan_name": "CIGNA COM ALT HMO PLAN", "methodology": "percent of total billed charges", "standard_charge_dollar": 738.5, "standard_charge_percentage": 42.2, "count": "0", "additional_payer_notes": "Zero final payments for the item or service in the 15 months prior to posting the file." }, { "payer_name": "HEALTH NET", "plan_name": "HEALTHNET HMO, PPO, POS, EPO, CANOPY HEALTHNET HMO, OTHER-IN-NETWORK PLANS", "methodology": "per diem", "standard_charge_dollar": 8000.0, "standard_charge_algorithm": "Expected reimbursement is the lesser of Per diem ($8,000) for the length of stay and 70% of billed.", "count": "0", "additional_payer_notes": "Zero final payments for the item or service in the 15 months prior to posting the file." }, { "payer_name": "HEALTH NET", "plan_name": "HEALTHNET HMO, PPO, POS, EPO, CANOPY HEALTHNET HMO, OTHER-IN-NETWORK PLANS", "methodology": "per diem", "standard_charge_dollar": 8000.0, "standard_charge_algorithm": "Expected reimbursement is the lesser of Per diem ($8,000) for the length of stay and 70% of billed.", "count": "0", "additional_payer_notes": "Zero final payments for the item or service in the 15 months prior to posting the file." }, { "payer_name": "UNITED HEALTHCARE", "plan_name": "SUTTER SELECT & SUTTER HEALTH PLAN HMO PLANS", "methodology": "per diem", "standard_charge_dollar": 28538.0, "standard_charge_algorithm": "Per diem ($28,538).", "count": "0", "additional_payer_notes": "Zero final payments for the item or service in the 15 months prior to posting the file." }, { "payer_name": "UNITED HEALTHCARE", "plan_name": "SUTTER SELECT & SUTTER HEALTH PLAN HMO PLANS", "methodology": "per diem", "standard_charge_dollar": 28538.0, "standard_charge_algorithm": "Per diem ($28,538).", "count": "0", "additional_payer_notes": "Zero final payments for the item or service in the 15 months prior to posting the file." }, { "payer_name": "SUTTER", "plan_name": "SUTTER SELECT & SUTTER HEALTH PLAN HMO PLANS", "methodology": "per diem", "standard_charge_dollar": 28538.0, "standard_charge_algorithm": "Per diem ($28,538).", "count": "0", "additional_payer_notes": "Zero final payments for the item or service in the 15 months prior to posting the file." }, { "payer_name": "UNITED HEALTHCARE", "plan_name": "SUTTER SELECT & SUTTER HEALTH PLAN HMO PLANS", "methodology": "per diem", "standard_charge_dollar": 28538.0, "standard_charge_algorithm": "Per diem ($28,538).", "count": "0", "additional_payer_notes": "Zero final payments for the item or service in the 15 months prior to posting the file." }, { "payer_name": "UMR", "plan_name": "SUTTER SELECT & SUTTER HEALTH PLAN HMO PLANS", "methodology": "per diem", "standard_charge_dollar": 28538.0, "standard_charge_algorithm": "Per diem ($28,538).", "count": "0", "additional_payer_notes": "Zero final payments for the item or service in the 15 months prior to posting the file." } ] } ] }, { "description": "HC Bioglue Adh Gp025", "code_information": [ { "code": "PX-2120002025", "type": "CDM" }, { "code": "99999", "type": "CPT" }, { "code": "0272", "type": "RC" } ], "standard_charges": [ { "setting": "outpatient", "gross_charge": 4263.0, "discounted_cash": 2131.5, "minimum": 1798.99, "maximum": 2216.76, "additional_generic_notes": "Zero final payments for the item or service in the 15 months prior to posting the file.", "payers_information": [ { "payer_name": "AETNA", "plan_name": "AETNA ALL OTHER PLANS", "methodology": "percent of total billed charges", "standard_charge_dollar": 2216.76, "standard_charge_percentage": 52.0, "count": "0", "additional_payer_notes": "Zero final payments for the item or service in the 15 months prior to posting the file." }, { "payer_name": "AETNA", "plan_name": "AETNA ALL OTHER PLANS", "methodology": "percent of total billed charges", "standard_charge_dollar": 2216.76, "standard_charge_percentage": 52.0, "count": "0", "additional_payer_notes": "Zero final payments for the item or service in the 15 months prior to posting the file." }, { "payer_name": "MERITAIN HEALTH", "plan_name": "AETNA ALL OTHER PLANS", "methodology": "percent of total billed charges", "standard_charge_dollar": 2216.76, "standard_charge_percentage": 52.0, "count": "0", "additional_payer_notes": "Zero final payments for the item or service in the 15 months prior to posting the file." }, { "payer_name": "BLUE SHIELD OUT OF STATE", "plan_name": "STANFORD HEALTHCARE ALLIANCE PLAN", "methodology": "percent of total billed charges", "standard_charge_dollar": 2071.39, "standard_charge_percentage": 48.59, "count": "0", "additional_payer_notes": "Zero final payments for the item or service in the 15 months prior to posting the file." }, { "payer_name": "BLUE SHIELD", "plan_name": "STANFORD HEALTHCARE ALLIANCE PLAN", "methodology": "percent of total billed charges", "standard_charge_dollar": 2071.39, "standard_charge_percentage": 48.59, "median_amount": 68.24, "10th_percentile": 13.6, "90th_percentile": 1043.06, "count": "30" }, { "payer_name": "BLUE SHIELD", "plan_name": "STANFORD HEALTHCARE ALLIANCE PLAN", "methodology": "percent of total billed charges", "standard_charge_dollar": 2071.39, "standard_charge_percentage": 48.59, "count": "0", "additional_payer_notes": "Zero final payments for the item or service in the 15 months prior to posting the file." }, { "payer_name": "BLUE SHIELD", "plan_name": "STANFORD HEALTHCARE ALLIANCE PLAN", "methodology": "percent of total billed charges", "standard_charge_dollar": 2071.39, "standard_charge_percentage": 48.59, "count": "0", "additional_payer_notes": "Zero final payments for the item or service in the 15 months prior to posting the file." }, { "payer_name": "CIGNA", "plan_name": "CIGNA COM ALT HMO PLAN", "methodology": "percent of total billed charges", "standard_charge_dollar": 1798.99, "standard_charge_percentage": 42.2, "count": "0", "additional_payer_notes": "Zero final payments for the item or service in the 15 months prior to posting the file." }, { "payer_name": "CIGNA", "plan_name": "CIGNA COM ALT HMO PLAN", "methodology": "percent of total billed charges", "standard_charge_dollar": 1798.99, "standard_charge_percentage": 42.2, "count": "0", "additional_payer_notes": "Zero final payments for the item or service in the 15 months prior to posting the file." }, { "payer_name": "HEALTH NET", "plan_name": "HEALTHNET HMO, PPO, POS, EPO, CANOPY HEALTHNET HMO, OTHER-IN-NETWORK PLANS", "methodology": "per diem", "standard_charge_dollar": 8000.0, "standard_charge_algorithm": "Expected reimbursement is the lesser of Per diem ($8,000) for the length of stay and 70% of billed.", "count": "0", "additional_payer_notes": "Zero final payments for the item or service in the 15 months prior to posting the file." }, { "payer_name": "HEALTH NET", "plan_name": "HEALTHNET HMO, PPO, POS, EPO, CANOPY HEALTHNET HMO, OTHER-IN-NETWORK PLANS", "methodology": "per diem", "standard_charge_dollar": 8000.0, "standard_charge_algorithm": "Expected reimbursement is the lesser of Per diem ($8,000) for the length of stay and 70% of billed.", "count": "0", "additional_payer_notes": "Zero final payments for the item or service in the 15 months prior to posting the file." }, { "payer_name": "UNITED HEALTHCARE", "plan_name": "SUTTER SELECT & SUTTER HEALTH PLAN HMO PLANS", "methodology": "per diem", "standard_charge_dollar": 28538.0, "standard_charge_algorithm": "Per diem ($28,538).", "count": "0", "additional_payer_notes": "Zero final payments for the item or service in the 15 months prior to posting the file." }, { "payer_name": "UNITED HEALTHCARE", "plan_name": "SUTTER SELECT & SUTTER HEALTH PLAN HMO PLANS", "methodology": "per diem", "standard_charge_dollar": 28538.0, "standard_charge_algorithm": "Per diem ($28,538).", "count": "0", "additional_payer_notes": "Zero final payments for the item or service in the 15 months prior to posting the file." }, { "payer_name": "SUTTER", "plan_name": "SUTTER SELECT & SUTTER HEALTH PLAN HMO PLANS", "methodology": "per diem", "standard_charge_dollar": 28538.0, "standard_charge_algorithm": "Per diem ($28,538).", "count": "0", "additional_payer_notes": "Zero final payments for the item or service in the 15 months prior to posting the file." }, { "payer_name": "UNITED HEALTHCARE", "plan_name": "SUTTER SELECT & SUTTER HEALTH PLAN HMO PLANS", "methodology": "per diem", "standard_charge_dollar": 28538.0, "standard_charge_algorithm": "Per diem ($28,538).", "count": "0", "additional_payer_notes": "Zero final payments for the item or service in the 15 months prior to posting the file." }, { "payer_name": "UMR", "plan_name": "SUTTER SELECT & SUTTER HEALTH PLAN HMO PLANS", "methodology": "per diem", "standard_charge_dollar": 28538.0, "standard_charge_algorithm": "Per diem ($28,538).", "count": "0", "additional_payer_notes": "Zero final payments for the item or service in the 15 months prior to posting the file." } ] } ] }, { "description": "HC Bioglue Adh Gp026", "code_information": [ { "code": "PX-2120002026", "type": "CDM" }, { "code": "99999", "type": "CPT" }, { "code": "0272", "type": "RC" } ], "standard_charges": [ { "setting": "outpatient", "gross_charge": 4650.0, "discounted_cash": 2325.0, "minimum": 1962.3, "maximum": 2418.0, "additional_generic_notes": "Zero final payments for the item or service in the 15 months prior to posting the file.", "payers_information": [ { "payer_name": "AETNA", "plan_name": "AETNA ALL OTHER PLANS", "methodology": "percent of total billed charges", "standard_charge_dollar": 2418.0, "standard_charge_percentage": 52.0, "count": "0", "additional_payer_notes": "Zero final payments for the item or service in the 15 months prior to posting the file." }, { "payer_name": "AETNA", "plan_name": "AETNA ALL OTHER PLANS", "methodology": "percent of total billed charges", "standard_charge_dollar": 2418.0, "standard_charge_percentage": 52.0, "count": "0", "additional_payer_notes": "Zero final payments for the item or service in the 15 months prior to posting the file." }, { "payer_name": "MERITAIN HEALTH", "plan_name": "AETNA ALL OTHER PLANS", "methodology": "percent of total billed charges", "standard_charge_dollar": 2418.0, "standard_charge_percentage": 52.0, "count": "0", "additional_payer_notes": "Zero final payments for the item or service in the 15 months prior to posting the file." }, { "payer_name": "BLUE SHIELD OUT OF STATE", "plan_name": "STANFORD HEALTHCARE ALLIANCE PLAN", "methodology": "percent of total billed charges", "standard_charge_dollar": 2259.44, "standard_charge_percentage": 48.59, "count": "0", "additional_payer_notes": "Zero final payments for the item or service in the 15 months prior to posting the file." }, { "payer_name": "BLUE SHIELD", "plan_name": "STANFORD HEALTHCARE ALLIANCE PLAN", "methodology": "percent of total billed charges", "standard_charge_dollar": 2259.44, "standard_charge_percentage": 48.59, "median_amount": 68.24, "10th_percentile": 13.6, "90th_percentile": 1043.06, "count": "30" }, { "payer_name": "BLUE SHIELD", "plan_name": "STANFORD HEALTHCARE ALLIANCE PLAN", "methodology": "percent of total billed charges", "standard_charge_dollar": 2259.44, "standard_charge_percentage": 48.59, "count": "0", "additional_payer_notes": "Zero final payments for the item or service in the 15 months prior to posting the file." }, { "payer_name": "BLUE SHIELD", "plan_name": "STANFORD HEALTHCARE ALLIANCE PLAN", "methodology": "percent of total billed charges", "standard_charge_dollar": 2259.44, "standard_charge_percentage": 48.59, "count": "0", "additional_payer_notes": "Zero final payments for the item or service in the 15 months prior to posting the file." }, { "payer_name": "CIGNA", "plan_name": "CIGNA COM ALT HMO PLAN", "methodology": "percent of total billed charges", "standard_charge_dollar": 1962.3, "standard_charge_percentage": 42.2, "count": "0", "additional_payer_notes": "Zero final payments for the item or service in the 15 months prior to posting the file." }, { "payer_name": "CIGNA", "plan_name": "CIGNA COM ALT HMO PLAN", "methodology": "percent of total billed charges", "standard_charge_dollar": 1962.3, "standard_charge_percentage": 42.2, "count": "0", "additional_payer_notes": "Zero final payments for the item or service in the 15 months prior to posting the file." }, { "payer_name": "HEALTH NET", "plan_name": "HEALTHNET HMO, PPO, POS, EPO, CANOPY HEALTHNET HMO, OTHER-IN-NETWORK PLANS", "methodology": "per diem", "standard_charge_dollar": 8000.0, "standard_charge_algorithm": "Expected reimbursement is the lesser of Per diem ($8,000) for the length of stay and 70% of billed.", "count": "0", "additional_payer_notes": "Zero final payments for the item or service in the 15 months prior to posting the file." }, { "payer_name": "HEALTH NET", "plan_name": "HEALTHNET HMO, PPO, POS, EPO, CANOPY HEALTHNET HMO, OTHER-IN-NETWORK PLANS", "methodology": "per diem", "standard_charge_dollar": 8000.0, "standard_charge_algorithm": "Expected reimbursement is the lesser of Per diem ($8,000) for the length of stay and 70% of billed.", "count": "0", "additional_payer_notes": "Zero final payments for the item or service in the 15 months prior to posting the file." }, { "payer_name": "UNITED HEALTHCARE", "plan_name": "SUTTER SELECT & SUTTER HEALTH PLAN HMO PLANS", "methodology": "per diem", "standard_charge_dollar": 28538.0, "standard_charge_algorithm": "Per diem ($28,538).", "count": "0", "additional_payer_notes": "Zero final payments for the item or service in the 15 months prior to posting the file." }, { "payer_name": "UNITED HEALTHCARE", "plan_name": "SUTTER SELECT & SUTTER HEALTH PLAN HMO PLANS", "methodology": "per diem", "standard_charge_dollar": 28538.0, "standard_charge_algorithm": "Per diem ($28,538).", "count": "0", "additional_payer_notes": "Zero final payments for the item or service in the 15 months prior to posting the file." }, { "payer_name": "SUTTER", "plan_name": "SUTTER SELECT & SUTTER HEALTH PLAN HMO PLANS", "methodology": "per diem", "standard_charge_dollar": 28538.0, "standard_charge_algorithm": "Per diem ($28,538).", "count": "0", "additional_payer_notes": "Zero final payments for the item or service in the 15 months prior to posting the file." }, { "payer_name": "UNITED HEALTHCARE", "plan_name": "SUTTER SELECT & SUTTER HEALTH PLAN HMO PLANS", "methodology": "per diem", "standard_charge_dollar": 28538.0, "standard_charge_algorithm": "Per diem ($28,538).", "count": "0", "additional_payer_notes": "Zero final payments for the item or service in the 15 months prior to posting the file." }, { "payer_name": "UMR", "plan_name": "SUTTER SELECT & SUTTER HEALTH PLAN HMO PLANS", "methodology": "per diem", "standard_charge_dollar": 28538.0, "standard_charge_algorithm": "Per diem ($28,538).", "count": "0", "additional_payer_notes": "Zero final payments for the item or service in the 15 months prior to posting the file." } ] } ] }, { "description": "HC Bioglue Adh Gp038", "code_information": [ { "code": "PX-2120002038", "type": "CDM" }, { "code": "99999", "type": "CPT" }, { "code": "0272", "type": "RC" } ], "standard_charges": [ { "setting": "outpatient", "gross_charge": 8750.0, "discounted_cash": 4375.0, "minimum": 3692.5, "maximum": 4550.0, "additional_generic_notes": "Zero final payments for the item or service in the 15 months prior to posting the file.", "payers_information": [ { "payer_name": "AETNA", "plan_name": "AETNA ALL OTHER PLANS", "methodology": "percent of total billed charges", "standard_charge_dollar": 4550.0, "standard_charge_percentage": 52.0, "count": "0", "additional_payer_notes": "Zero final payments for the item or service in the 15 months prior to posting the file." }, { "payer_name": "AETNA", "plan_name": "AETNA ALL OTHER PLANS", "methodology": "percent of total billed charges", "standard_charge_dollar": 4550.0, "standard_charge_percentage": 52.0, "count": "0", "additional_payer_notes": "Zero final payments for the item or service in the 15 months prior to posting the file." }, { "payer_name": "MERITAIN HEALTH", "plan_name": "AETNA ALL OTHER PLANS", "methodology": "percent of total billed charges", "standard_charge_dollar": 4550.0, "standard_charge_percentage": 52.0, "count": "0", "additional_payer_notes": "Zero final payments for the item or service in the 15 months prior to posting the file." }, { "payer_name": "BLUE SHIELD OUT OF STATE", "plan_name": "STANFORD HEALTHCARE ALLIANCE PLAN", "methodology": "percent of total billed charges", "standard_charge_dollar": 4251.63, "standard_charge_percentage": 48.59, "count": "0", "additional_payer_notes": "Zero final payments for the item or service in the 15 months prior to posting the file." }, { "payer_name": "BLUE SHIELD", "plan_name": "STANFORD HEALTHCARE ALLIANCE PLAN", "methodology": "percent of total billed charges", "standard_charge_dollar": 4251.63, "standard_charge_percentage": 48.59, "median_amount": 68.24, "10th_percentile": 13.6, "90th_percentile": 1043.06, "count": "30" }, { "payer_name": "BLUE SHIELD", "plan_name": "STANFORD HEALTHCARE ALLIANCE PLAN", "methodology": "percent of total billed charges", "standard_charge_dollar": 4251.63, "standard_charge_percentage": 48.59, "count": "0", "additional_payer_notes": "Zero final payments for the item or service in the 15 months prior to posting the file." }, { "payer_name": "BLUE SHIELD", "plan_name": "STANFORD HEALTHCARE ALLIANCE PLAN", "methodology": "percent of total billed charges", "standard_charge_dollar": 4251.63, "standard_charge_percentage": 48.59, "count": "0", "additional_payer_notes": "Zero final payments for the item or service in the 15 months prior to posting the file." }, { "payer_name": "CIGNA", "plan_name": "CIGNA COM ALT HMO PLAN", "methodology": "percent of total billed charges", "standard_charge_dollar": 3692.5, "standard_charge_percentage": 42.2, "count": "0", "additional_payer_notes": "Zero final payments for the item or service in the 15 months prior to posting the file." }, { "payer_name": "CIGNA", "plan_name": "CIGNA COM ALT HMO PLAN", "methodology": "percent of total billed charges", "standard_charge_dollar": 3692.5, "standard_charge_percentage": 42.2, "count": "0", "additional_payer_notes": "Zero final payments for the item or service in the 15 months prior to posting the file." }, { "payer_name": "HEALTH NET", "plan_name": "HEALTHNET HMO, PPO, POS, EPO, CANOPY HEALTHNET HMO, OTHER-IN-NETWORK PLANS", "methodology": "per diem", "standard_charge_dollar": 8000.0, "standard_charge_algorithm": "Expected reimbursement is the lesser of Per diem ($8,000) for the length of stay and 70% of billed.", "count": "0", "additional_payer_notes": "Zero final payments for the item or service in the 15 months prior to posting the file." }, { "payer_name": "HEALTH NET", "plan_name": "HEALTHNET HMO, PPO, POS, EPO, CANOPY HEALTHNET HMO, OTHER-IN-NETWORK PLANS", "methodology": "per diem", "standard_charge_dollar": 8000.0, "standard_charge_algorithm": "Expected reimbursement is the lesser of Per diem ($8,000) for the length of stay and 70% of billed.", "count": "0", "additional_payer_notes": "Zero final payments for the item or service in the 15 months prior to posting the file." }, { "payer_name": "UNITED HEALTHCARE", "plan_name": "SUTTER SELECT & SUTTER HEALTH PLAN HMO PLANS", "methodology": "per diem", "standard_charge_dollar": 28538.0, "standard_charge_algorithm": "Per diem ($28,538).", "count": "0", "additional_payer_notes": "Zero final payments for the item or service in the 15 months prior to posting the file." }, { "payer_name": "UNITED HEALTHCARE", "plan_name": "SUTTER SELECT & SUTTER HEALTH PLAN HMO PLANS", "methodology": "per diem", "standard_charge_dollar": 28538.0, "standard_charge_algorithm": "Per diem ($28,538).", "count": "0", "additional_payer_notes": "Zero final payments for the item or service in the 15 months prior to posting the file." }, { "payer_name": "SUTTER", "plan_name": "SUTTER SELECT & SUTTER HEALTH PLAN HMO PLANS", "methodology": "per diem", "standard_charge_dollar": 28538.0, "standard_charge_algorithm": "Per diem ($28,538).", "count": "0", "additional_payer_notes": "Zero final payments for the item or service in the 15 months prior to posting the file." }, { "payer_name": "UNITED HEALTHCARE", "plan_name": "SUTTER SELECT & SUTTER HEALTH PLAN HMO PLANS", "methodology": "per diem", "standard_charge_dollar": 28538.0, "standard_charge_algorithm": "Per diem ($28,538).", "count": "0", "additional_payer_notes": "Zero final payments for the item or service in the 15 months prior to posting the file." }, { "payer_name": "UMR", "plan_name": "SUTTER SELECT & SUTTER HEALTH PLAN HMO PLANS", "methodology": "per diem", "standard_charge_dollar": 28538.0, "standard_charge_algorithm": "Per diem ($28,538).", "count": "0", "additional_payer_notes": "Zero final payments for the item or service in the 15 months prior to posting the file." } ] } ] }, { "description": "HC Bioglue Adh Gp045", "code_information": [ { "code": "PX-2120002045", "type": "CDM" }, { "code": "99999", "type": "CPT" }, { "code": "0272", "type": "RC" } ], "standard_charges": [ { "setting": "outpatient", "gross_charge": 11550.0, "discounted_cash": 5775.0, "minimum": 4874.1, "maximum": 6006.0, "additional_generic_notes": "Zero final payments for the item or service in the 15 months prior to posting the file.", "payers_information": [ { "payer_name": "AETNA", "plan_name": "AETNA ALL OTHER PLANS", "methodology": "percent of total billed charges", "standard_charge_dollar": 6006.0, "standard_charge_percentage": 52.0, "count": "0", "additional_payer_notes": "Zero final payments for the item or service in the 15 months prior to posting the file." }, { "payer_name": "AETNA", "plan_name": "AETNA ALL OTHER PLANS", "methodology": "percent of total billed charges", "standard_charge_dollar": 6006.0, "standard_charge_percentage": 52.0, "count": "0", "additional_payer_notes": "Zero final payments for the item or service in the 15 months prior to posting the file." }, { "payer_name": "MERITAIN HEALTH", "plan_name": "AETNA ALL OTHER PLANS", "methodology": "percent of total billed charges", "standard_charge_dollar": 6006.0, "standard_charge_percentage": 52.0, "count": "0", "additional_payer_notes": "Zero final payments for the item or service in the 15 months prior to posting the file." }, { "payer_name": "BLUE SHIELD OUT OF STATE", "plan_name": "STANFORD HEALTHCARE ALLIANCE PLAN", "methodology": "percent of total billed charges", "standard_charge_dollar": 5612.15, "standard_charge_percentage": 48.59, "count": "0", "additional_payer_notes": "Zero final payments for the item or service in the 15 months prior to posting the file." }, { "payer_name": "BLUE SHIELD", "plan_name": "STANFORD HEALTHCARE ALLIANCE PLAN", "methodology": "percent of total billed charges", "standard_charge_dollar": 5612.15, "standard_charge_percentage": 48.59, "median_amount": 68.24, "10th_percentile": 13.6, "90th_percentile": 1043.06, "count": "30" }, { "payer_name": "BLUE SHIELD", "plan_name": "STANFORD HEALTHCARE ALLIANCE PLAN", "methodology": "percent of total billed charges", "standard_charge_dollar": 5612.15, "standard_charge_percentage": 48.59, "count": "0", "additional_payer_notes": "Zero final payments for the item or service in the 15 months prior to posting the file." }, { "payer_name": "BLUE SHIELD", "plan_name": "STANFORD HEALTHCARE ALLIANCE PLAN", "methodology": "percent of total billed charges", "standard_charge_dollar": 5612.15, "standard_charge_percentage": 48.59, "count": "0", "additional_payer_notes": "Zero final payments for the item or service in the 15 months prior to posting the file." }, { "payer_name": "CIGNA", "plan_name": "CIGNA COM ALT HMO PLAN", "methodology": "percent of total billed charges", "standard_charge_dollar": 4874.1, "standard_charge_percentage": 42.2, "count": "0", "additional_payer_notes": "Zero final payments for the item or service in the 15 months prior to posting the file." }, { "payer_name": "CIGNA", "plan_name": "CIGNA COM ALT HMO PLAN", "methodology": "percent of total billed charges", "standard_charge_dollar": 4874.1, "standard_charge_percentage": 42.2, "count": "0", "additional_payer_notes": "Zero final payments for the item or service in the 15 months prior to posting the file." }, { "payer_name": "HEALTH NET", "plan_name": "HEALTHNET HMO, PPO, POS, EPO, CANOPY HEALTHNET HMO, OTHER-IN-NETWORK PLANS", "methodology": "per diem", "standard_charge_dollar": 8000.0, "standard_charge_algorithm": "Expected reimbursement is the lesser of Per diem ($8,000) for the length of stay and 70% of billed.", "count": "0", "additional_payer_notes": "Zero final payments for the item or service in the 15 months prior to posting the file." }, { "payer_name": "HEALTH NET", "plan_name": "HEALTHNET HMO, PPO, POS, EPO, CANOPY HEALTHNET HMO, OTHER-IN-NETWORK PLANS", "methodology": "per diem", "standard_charge_dollar": 8000.0, "standard_charge_algorithm": "Expected reimbursement is the lesser of Per diem ($8,000) for the length of stay and 70% of billed.", "count": "0", "additional_payer_notes": "Zero final payments for the item or service in the 15 months prior to posting the file." }, { "payer_name": "UNITED HEALTHCARE", "plan_name": "SUTTER SELECT & SUTTER HEALTH PLAN HMO PLANS", "methodology": "per diem", "standard_charge_dollar": 28538.0, "standard_charge_algorithm": "Per diem ($28,538).", "count": "0", "additional_payer_notes": "Zero final payments for the item or service in the 15 months prior to posting the file." }, { "payer_name": "UNITED HEALTHCARE", "plan_name": "SUTTER SELECT & SUTTER HEALTH PLAN HMO PLANS", "methodology": "per diem", "standard_charge_dollar": 28538.0, "standard_charge_algorithm": "Per diem ($28,538).", "count": "0", "additional_payer_notes": "Zero final payments for the item or service in the 15 months prior to posting the file." }, { "payer_name": "SUTTER", "plan_name": "SUTTER SELECT & SUTTER HEALTH PLAN HMO PLANS", "methodology": "per diem", "standard_charge_dollar": 28538.0, "standard_charge_algorithm": "Per diem ($28,538).", "count": "0", "additional_payer_notes": "Zero final payments for the item or service in the 15 months prior to posting the file." }, { "payer_name": "UNITED HEALTHCARE", "plan_name": "SUTTER SELECT & SUTTER HEALTH PLAN HMO PLANS", "methodology": "per diem", "standard_charge_dollar": 28538.0, "standard_charge_algorithm": "Per diem ($28,538).", "count": "0", "additional_payer_notes": "Zero final payments for the item or service in the 15 months prior to posting the file." }, { "payer_name": "UMR", "plan_name": "SUTTER SELECT & SUTTER HEALTH PLAN HMO PLANS", "methodology": "per diem", "standard_charge_dollar": 28538.0, "standard_charge_algorithm": "Per diem ($28,538).", "count": "0", "additional_payer_notes": "Zero final payments for the item or service in the 15 months prior to posting the file." } ] } ] }, { "description": "HC Bioglue Adh Gp050", "code_information": [ { "code": "PX-2120002050", "type": "CDM" }, { "code": "99999", "type": "CPT" }, { "code": "0272", "type": "RC" } ], "standard_charges": [ { "setting": "outpatient", "gross_charge": 15200.0, "discounted_cash": 7600.0, "minimum": 6414.4, "maximum": 7904.0, "additional_generic_notes": "Zero final payments for the item or service in the 15 months prior to posting the file.", "payers_information": [ { "payer_name": "AETNA", "plan_name": "AETNA ALL OTHER PLANS", "methodology": "percent of total billed charges", "standard_charge_dollar": 7904.0, "standard_charge_percentage": 52.0, "count": "0", "additional_payer_notes": "Zero final payments for the item or service in the 15 months prior to posting the file." }, { "payer_name": "AETNA", "plan_name": "AETNA ALL OTHER PLANS", "methodology": "percent of total billed charges", "standard_charge_dollar": 7904.0, "standard_charge_percentage": 52.0, "count": "0", "additional_payer_notes": "Zero final payments for the item or service in the 15 months prior to posting the file." }, { "payer_name": "MERITAIN HEALTH", "plan_name": "AETNA ALL OTHER PLANS", "methodology": "percent of total billed charges", "standard_charge_dollar": 7904.0, "standard_charge_percentage": 52.0, "count": "0", "additional_payer_notes": "Zero final payments for the item or service in the 15 months prior to posting the file." }, { "payer_name": "BLUE SHIELD OUT OF STATE", "plan_name": "STANFORD HEALTHCARE ALLIANCE PLAN", "methodology": "percent of total billed charges", "standard_charge_dollar": 7385.68, "standard_charge_percentage": 48.59, "count": "0", "additional_payer_notes": "Zero final payments for the item or service in the 15 months prior to posting the file." }, { "payer_name": "BLUE SHIELD", "plan_name": "STANFORD HEALTHCARE ALLIANCE PLAN", "methodology": "percent of total billed charges", "standard_charge_dollar": 7385.68, "standard_charge_percentage": 48.59, "median_amount": 68.24, "10th_percentile": 13.6, "90th_percentile": 1043.06, "count": "30" }, { "payer_name": "BLUE SHIELD", "plan_name": "STANFORD HEALTHCARE ALLIANCE PLAN", "methodology": "percent of total billed charges", "standard_charge_dollar": 7385.68, "standard_charge_percentage": 48.59, "count": "0", "additional_payer_notes": "Zero final payments for the item or service in the 15 months prior to posting the file." }, { "payer_name": "BLUE SHIELD", "plan_name": "STANFORD HEALTHCARE ALLIANCE PLAN", "methodology": "percent of total billed charges", "standard_charge_dollar": 7385.68, "standard_charge_percentage": 48.59, "count": "0", "additional_payer_notes": "Zero final payments for the item or service in the 15 months prior to posting the file." }, { "payer_name": "CIGNA", "plan_name": "CIGNA COM ALT HMO PLAN", "methodology": "percent of total billed charges", "standard_charge_dollar": 6414.4, "standard_charge_percentage": 42.2, "count": "0", "additional_payer_notes": "Zero final payments for the item or service in the 15 months prior to posting the file." }, { "payer_name": "CIGNA", "plan_name": "CIGNA COM ALT HMO PLAN", "methodology": "percent of total billed charges", "standard_charge_dollar": 6414.4, "standard_charge_percentage": 42.2, "count": "0", "additional_payer_notes": "Zero final payments for the item or service in the 15 months prior to posting the file." }, { "payer_name": "HEALTH NET", "plan_name": "HEALTHNET HMO, PPO, POS, EPO, CANOPY HEALTHNET HMO, OTHER-IN-NETWORK PLANS", "methodology": "per diem", "standard_charge_dollar": 8000.0, "standard_charge_algorithm": "Expected reimbursement is the lesser of Per diem ($8,000) for the length of stay and 70% of billed.", "count": "0", "additional_payer_notes": "Zero final payments for the item or service in the 15 months prior to posting the file." }, { "payer_name": "HEALTH NET", "plan_name": "HEALTHNET HMO, PPO, POS, EPO, CANOPY HEALTHNET HMO, OTHER-IN-NETWORK PLANS", "methodology": "per diem", "standard_charge_dollar": 8000.0, "standard_charge_algorithm": "Expected reimbursement is the lesser of Per diem ($8,000) for the length of stay and 70% of billed.", "count": "0", "additional_payer_notes": "Zero final payments for the item or service in the 15 months prior to posting the file." }, { "payer_name": "UNITED HEALTHCARE", "plan_name": "SUTTER SELECT & SUTTER HEALTH PLAN HMO PLANS", "methodology": "per diem", "standard_charge_dollar": 28538.0, "standard_charge_algorithm": "Per diem ($28,538).", "count": "0", "additional_payer_notes": "Zero final payments for the item or service in the 15 months prior to posting the file." }, { "payer_name": "UNITED HEALTHCARE", "plan_name": "SUTTER SELECT & SUTTER HEALTH PLAN HMO PLANS", "methodology": "per diem", "standard_charge_dollar": 28538.0, "standard_charge_algorithm": "Per diem ($28,538).", "count": "0", "additional_payer_notes": "Zero final payments for the item or service in the 15 months prior to posting the file." }, { "payer_name": "SUTTER", "plan_name": "SUTTER SELECT & SUTTER HEALTH PLAN HMO PLANS", "methodology": "per diem", "standard_charge_dollar": 28538.0, "standard_charge_algorithm": "Per diem ($28,538).", "count": "0", "additional_payer_notes": "Zero final payments for the item or service in the 15 months prior to posting the file." }, { "payer_name": "UNITED HEALTHCARE", "plan_name": "SUTTER SELECT & SUTTER HEALTH PLAN HMO PLANS", "methodology": "per diem", "standard_charge_dollar": 28538.0, "standard_charge_algorithm": "Per diem ($28,538).", "count": "0", "additional_payer_notes": "Zero final payments for the item or service in the 15 months prior to posting the file." }, { "payer_name": "UMR", "plan_name": "SUTTER SELECT & SUTTER HEALTH PLAN HMO PLANS", "methodology": "per diem", "standard_charge_dollar": 28538.0, "standard_charge_algorithm": "Per diem ($28,538).", "count": "0", "additional_payer_notes": "Zero final payments for the item or service in the 15 months prior to posting the file." } ] } ] }, { "description": "HC Adh Dermabond Gp003", "code_information": [ { "code": "PX-2120003003", "type": "CDM" }, { "code": "99999", "type": "CPT" }, { "code": "0272", "type": "RC" } ], "standard_charges": [ { "setting": "outpatient", "gross_charge": 100.0, "discounted_cash": 50.0, "minimum": 42.2, "maximum": 52.0, "additional_generic_notes": "Zero final payments for the item or service in the 15 months prior to posting the file.", "payers_information": [ { "payer_name": "AETNA", "plan_name": "AETNA ALL OTHER PLANS", "methodology": "percent of total billed charges", "standard_charge_dollar": 52.0, "standard_charge_percentage": 52.0, "count": "0", "additional_payer_notes": "Zero final payments for the item or service in the 15 months prior to posting the file." }, { "payer_name": "AETNA", "plan_name": "AETNA ALL OTHER PLANS", "methodology": "percent of total billed charges", "standard_charge_dollar": 52.0, "standard_charge_percentage": 52.0, "count": "0", "additional_payer_notes": "Zero final payments for the item or service in the 15 months prior to posting the file." }, { "payer_name": "MERITAIN HEALTH", "plan_name": "AETNA ALL OTHER PLANS", "methodology": "percent of total billed charges", "standard_charge_dollar": 52.0, "standard_charge_percentage": 52.0, "count": "0", "additional_payer_notes": "Zero final payments for the item or service in the 15 months prior to posting the file." }, { "payer_name": "BLUE SHIELD OUT OF STATE", "plan_name": "STANFORD HEALTHCARE ALLIANCE PLAN", "methodology": "percent of total billed charges", "standard_charge_dollar": 48.59, "standard_charge_percentage": 48.59, "count": "0", "additional_payer_notes": "Zero final payments for the item or service in the 15 months prior to posting the file." }, { "payer_name": "BLUE SHIELD", "plan_name": "STANFORD HEALTHCARE ALLIANCE PLAN", "methodology": "percent of total billed charges", "standard_charge_dollar": 48.59, "standard_charge_percentage": 48.59, "count": "0", "additional_payer_notes": "Zero final payments for the item or service in the 15 months prior to posting the file." }, { "payer_name": "BLUE SHIELD", "plan_name": "STANFORD HEALTHCARE ALLIANCE PLAN", "methodology": "percent of total billed charges", "standard_charge_dollar": 48.59, "standard_charge_percentage": 48.59, "count": "0", "additional_payer_notes": "Zero final payments for the item or service in the 15 months prior to posting the file." }, { "payer_name": "CIGNA", "plan_name": "CIGNA COM ALT HMO PLAN", "methodology": "percent of total billed charges", "standard_charge_dollar": 42.2, "standard_charge_percentage": 42.2, "count": "0", "additional_payer_notes": "Zero final payments for the item or service in the 15 months prior to posting the file." }, { "payer_name": "CIGNA", "plan_name": "CIGNA COM ALT HMO PLAN", "methodology": "percent of total billed charges", "standard_charge_dollar": 42.2, "standard_charge_percentage": 42.2, "count": "0", "additional_payer_notes": "Zero final payments for the item or service in the 15 months prior to posting the file." }, { "payer_name": "HEALTH NET", "plan_name": "HEALTHNET HMO, PPO, POS, EPO, CANOPY HEALTHNET HMO, OTHER-IN-NETWORK PLANS", "methodology": "per diem", "standard_charge_dollar": 8000.0, "standard_charge_algorithm": "Expected reimbursement is the lesser of Per diem ($8,000) for the length of stay and 70% of billed.", "count": "0", "additional_payer_notes": "Zero final payments for the item or service in the 15 months prior to posting the file." }, { "payer_name": "HEALTH NET", "plan_name": "HEALTHNET HMO, PPO, POS, EPO, CANOPY HEALTHNET HMO, OTHER-IN-NETWORK PLANS", "methodology": "per diem", "standard_charge_dollar": 8000.0, "standard_charge_algorithm": "Expected reimbursement is the lesser of Per diem ($8,000) for the length of stay and 70% of billed.", "count": "0", "additional_payer_notes": "Zero final payments for the item or service in the 15 months prior to posting the file." }, { "payer_name": "UNITED HEALTHCARE", "plan_name": "SUTTER SELECT & SUTTER HEALTH PLAN HMO PLANS", "methodology": "per diem", "standard_charge_dollar": 28538.0, "standard_charge_algorithm": "Per diem ($28,538).", "count": "0", "additional_payer_notes": "Zero final payments for the item or service in the 15 months prior to posting the file." }, { "payer_name": "UNITED HEALTHCARE", "plan_name": "SUTTER SELECT & SUTTER HEALTH PLAN HMO PLANS", "methodology": "per diem", "standard_charge_dollar": 28538.0, "standard_charge_algorithm": "Per diem ($28,538).", "count": "0", "additional_payer_notes": "Zero final payments for the item or service in the 15 months prior to posting the file." }, { "payer_name": "SUTTER", "plan_name": "SUTTER SELECT & SUTTER HEALTH PLAN HMO PLANS", "methodology": "per diem", "standard_charge_dollar": 28538.0, "standard_charge_algorithm": "Per diem ($28,538).", "count": "0", "additional_payer_notes": "Zero final payments for the item or service in the 15 months prior to posting the file." }, { "payer_name": "UNITED HEALTHCARE", "plan_name": "SUTTER SELECT & SUTTER HEALTH PLAN HMO PLANS", "methodology": "per diem", "standard_charge_dollar": 28538.0, "standard_charge_algorithm": "Per diem ($28,538).", "count": "0", "additional_payer_notes": "Zero final payments for the item or service in the 15 months prior to posting the file." }, { "payer_name": "UMR", "plan_name": "SUTTER SELECT & SUTTER HEALTH PLAN HMO PLANS", "methodology": "per diem", "standard_charge_dollar": 28538.0, "standard_charge_algorithm": "Per diem ($28,538).", "count": "0", "additional_payer_notes": "Zero final payments for the item or service in the 15 months prior to posting the file." } ] } ] }, { "description": "HC Adh Dermabond Gp004", "code_information": [ { "code": "PX-2120003004", "type": "CDM" }, { "code": "99999", "type": "CPT" }, { "code": "0272", "type": "RC" } ], "standard_charges": [ { "setting": "outpatient", "gross_charge": 146.0, "discounted_cash": 73.0, "minimum": 61.61, "maximum": 75.92, "additional_generic_notes": "Zero final payments for the item or service in the 15 months prior to posting the file.", "payers_information": [ { "payer_name": "AETNA", "plan_name": "AETNA ALL OTHER PLANS", "methodology": "percent of total billed charges", "standard_charge_dollar": 75.92, "standard_charge_percentage": 52.0, "count": "0", "additional_payer_notes": "Zero final payments for the item or service in the 15 months prior to posting the file." }, { "payer_name": "AETNA", "plan_name": "AETNA ALL OTHER PLANS", "methodology": "percent of total billed charges", "standard_charge_dollar": 75.92, "standard_charge_percentage": 52.0, "count": "0", "additional_payer_notes": "Zero final payments for the item or service in the 15 months prior to posting the file." }, { "payer_name": "MERITAIN HEALTH", "plan_name": "AETNA ALL OTHER PLANS", "methodology": "percent of total billed charges", "standard_charge_dollar": 75.92, "standard_charge_percentage": 52.0, "count": "0", "additional_payer_notes": "Zero final payments for the item or service in the 15 months prior to posting the file." }, { "payer_name": "BLUE SHIELD OUT OF STATE", "plan_name": "STANFORD HEALTHCARE ALLIANCE PLAN", "methodology": "percent of total billed charges", "standard_charge_dollar": 70.94, "standard_charge_percentage": 48.59, "count": "0", "additional_payer_notes": "Zero final payments for the item or service in the 15 months prior to posting the file." }, { "payer_name": "BLUE SHIELD", "plan_name": "STANFORD HEALTHCARE ALLIANCE PLAN", "methodology": "percent of total billed charges", "standard_charge_dollar": 70.94, "standard_charge_percentage": 48.59, "count": "0", "additional_payer_notes": "Zero final payments for the item or service in the 15 months prior to posting the file." }, { "payer_name": "BLUE SHIELD", "plan_name": "STANFORD HEALTHCARE ALLIANCE PLAN", "methodology": "percent of total billed charges", "standard_charge_dollar": 70.94, "standard_charge_percentage": 48.59, "count": "0", "additional_payer_notes": "Zero final payments for the item or service in the 15 months prior to posting the file." }, { "payer_name": "CIGNA", "plan_name": "CIGNA COM ALT HMO PLAN", "methodology": "percent of total billed charges", "standard_charge_dollar": 61.61, "standard_charge_percentage": 42.2, "count": "0", "additional_payer_notes": "Zero final payments for the item or service in the 15 months prior to posting the file." }, { "payer_name": "CIGNA", "plan_name": "CIGNA COM ALT HMO PLAN", "methodology": "percent of total billed charges", "standard_charge_dollar": 61.61, "standard_charge_percentage": 42.2, "count": "0", "additional_payer_notes": "Zero final payments for the item or service in the 15 months prior to posting the file." }, { "payer_name": "HEALTH NET", "plan_name": "HEALTHNET HMO, PPO, POS, EPO, CANOPY HEALTHNET HMO, OTHER-IN-NETWORK PLANS", "methodology": "per diem", "standard_charge_dollar": 8000.0, "standard_charge_algorithm": "Expected reimbursement is the lesser of Per diem ($8,000) for the length of stay and 70% of billed.", "count": "0", "additional_payer_notes": "Zero final payments for the item or service in the 15 months prior to posting the file." }, { "payer_name": "HEALTH NET", "plan_name": "HEALTHNET HMO, PPO, POS, EPO, CANOPY HEALTHNET HMO, OTHER-IN-NETWORK PLANS", "methodology": "per diem", "standard_charge_dollar": 8000.0, "standard_charge_algorithm": "Expected reimbursement is the lesser of Per diem ($8,000) for the length of stay and 70% of billed.", "count": "0", "additional_payer_notes": "Zero final payments for the item or service in the 15 months prior to posting the file." }, { "payer_name": "UNITED HEALTHCARE", "plan_name": "SUTTER SELECT & SUTTER HEALTH PLAN HMO PLANS", "methodology": "per diem", "standard_charge_dollar": 28538.0, "standard_charge_algorithm": "Per diem ($28,538).", "count": "0", "additional_payer_notes": "Zero final payments for the item or service in the 15 months prior to posting the file." }, { "payer_name": "UNITED HEALTHCARE", "plan_name": "SUTTER SELECT & SUTTER HEALTH PLAN HMO PLANS", "methodology": "per diem", "standard_charge_dollar": 28538.0, "standard_charge_algorithm": "Per diem ($28,538).", "count": "0", "additional_payer_notes": "Zero final payments for the item or service in the 15 months prior to posting the file." }, { "payer_name": "SUTTER", "plan_name": "SUTTER SELECT & SUTTER HEALTH PLAN HMO PLANS", "methodology": "per diem", "standard_charge_dollar": 28538.0, "standard_charge_algorithm": "Per diem ($28,538).", "count": "0", "additional_payer_notes": "Zero final payments for the item or service in the 15 months prior to posting the file." }, { "payer_name": "UNITED HEALTHCARE", "plan_name": "SUTTER SELECT & SUTTER HEALTH PLAN HMO PLANS", "methodology": "per diem", "standard_charge_dollar": 28538.0, "standard_charge_algorithm": "Per diem ($28,538).", "count": "0", "additional_payer_notes": "Zero final payments for the item or service in the 15 months prior to posting the file." }, { "payer_name": "UMR", "plan_name": "SUTTER SELECT & SUTTER HEALTH PLAN HMO PLANS", "methodology": "per diem", "standard_charge_dollar": 28538.0, "standard_charge_algorithm": "Per diem ($28,538).", "count": "0", "additional_payer_notes": "Zero final payments for the item or service in the 15 months prior to posting the file." } ] } ] }, { "description": "HC Adh Dermabond Gp005", "code_information": [ { "code": "PX-2120003005", "type": "CDM" }, { "code": "99999", "type": "CPT" }, { "code": "0272", "type": "RC" } ], "standard_charges": [ { "setting": "outpatient", "gross_charge": 195.0, "discounted_cash": 97.5, "minimum": 82.29, "maximum": 101.4, "additional_generic_notes": "Zero final payments for the item or service in the 15 months prior to posting the file.", "payers_information": [ { "payer_name": "AETNA", "plan_name": "AETNA ALL OTHER PLANS", "methodology": "percent of total billed charges", "standard_charge_dollar": 101.4, "standard_charge_percentage": 52.0, "count": "0", "additional_payer_notes": "Zero final payments for the item or service in the 15 months prior to posting the file." }, { "payer_name": "AETNA", "plan_name": "AETNA ALL OTHER PLANS", "methodology": "percent of total billed charges", "standard_charge_dollar": 101.4, "standard_charge_percentage": 52.0, "count": "0", "additional_payer_notes": "Zero final payments for the item or service in the 15 months prior to posting the file." }, { "payer_name": "MERITAIN HEALTH", "plan_name": "AETNA ALL OTHER PLANS", "methodology": "percent of total billed charges", "standard_charge_dollar": 101.4, "standard_charge_percentage": 52.0, "count": "0", "additional_payer_notes": "Zero final payments for the item or service in the 15 months prior to posting the file." }, { "payer_name": "BLUE SHIELD OUT OF STATE", "plan_name": "STANFORD HEALTHCARE ALLIANCE PLAN", "methodology": "percent of total billed charges", "standard_charge_dollar": 94.75, "standard_charge_percentage": 48.59, "count": "0", "additional_payer_notes": "Zero final payments for the item or service in the 15 months prior to posting the file." }, { "payer_name": "BLUE SHIELD", "plan_name": "STANFORD HEALTHCARE ALLIANCE PLAN", "methodology": "percent of total billed charges", "standard_charge_dollar": 94.75, "standard_charge_percentage": 48.59, "count": "0", "additional_payer_notes": "Zero final payments for the item or service in the 15 months prior to posting the file." }, { "payer_name": "BLUE SHIELD", "plan_name": "STANFORD HEALTHCARE ALLIANCE PLAN", "methodology": "percent of total billed charges", "standard_charge_dollar": 94.75, "standard_charge_percentage": 48.59, "count": "0", "additional_payer_notes": "Zero final payments for the item or service in the 15 months prior to posting the file." }, { "payer_name": "CIGNA", "plan_name": "CIGNA COM ALT HMO PLAN", "methodology": "percent of total billed charges", "standard_charge_dollar": 82.29, "standard_charge_percentage": 42.2, "count": "0", "additional_payer_notes": "Zero final payments for the item or service in the 15 months prior to posting the file." }, { "payer_name": "CIGNA", "plan_name": "CIGNA COM ALT HMO PLAN", "methodology": "percent of total billed charges", "standard_charge_dollar": 82.29, "standard_charge_percentage": 42.2, "count": "0", "additional_payer_notes": "Zero final payments for the item or service in the 15 months prior to posting the file." }, { "payer_name": "HEALTH NET", "plan_name": "HEALTHNET HMO, PPO, POS, EPO, CANOPY HEALTHNET HMO, OTHER-IN-NETWORK PLANS", "methodology": "per diem", "standard_charge_dollar": 8000.0, "standard_charge_algorithm": "Expected reimbursement is the lesser of Per diem ($8,000) for the length of stay and 70% of billed.", "count": "0", "additional_payer_notes": "Zero final payments for the item or service in the 15 months prior to posting the file." }, { "payer_name": "HEALTH NET", "plan_name": "HEALTHNET HMO, PPO, POS, EPO, CANOPY HEALTHNET HMO, OTHER-IN-NETWORK PLANS", "methodology": "per diem", "standard_charge_dollar": 8000.0, "standard_charge_algorithm": "Expected reimbursement is the lesser of Per diem ($8,000) for the length of stay and 70% of billed.", "count": "0", "additional_payer_notes": "Zero final payments for the item or service in the 15 months prior to posting the file." }, { "payer_name": "UNITED HEALTHCARE", "plan_name": "SUTTER SELECT & SUTTER HEALTH PLAN HMO PLANS", "methodology": "per diem", "standard_charge_dollar": 28538.0, "standard_charge_algorithm": "Per diem ($28,538).", "count": "0", "additional_payer_notes": "Zero final payments for the item or service in the 15 months prior to posting the file." }, { "payer_name": "UNITED HEALTHCARE", "plan_name": "SUTTER SELECT & SUTTER HEALTH PLAN HMO PLANS", "methodology": "per diem", "standard_charge_dollar": 28538.0, "standard_charge_algorithm": "Per diem ($28,538).", "count": "0", "additional_payer_notes": "Zero final payments for the item or service in the 15 months prior to posting the file." }, { "payer_name": "SUTTER", "plan_name": "SUTTER SELECT & SUTTER HEALTH PLAN HMO PLANS", "methodology": "per diem", "standard_charge_dollar": 28538.0, "standard_charge_algorithm": "Per diem ($28,538).", "count": "0", "additional_payer_notes": "Zero final payments for the item or service in the 15 months prior to posting the file." }, { "payer_name": "UNITED HEALTHCARE", "plan_name": "SUTTER SELECT & SUTTER HEALTH PLAN HMO PLANS", "methodology": "per diem", "standard_charge_dollar": 28538.0, "standard_charge_algorithm": "Per diem ($28,538).", "count": "0", "additional_payer_notes": "Zero final payments for the item or service in the 15 months prior to posting the file." }, { "payer_name": "UMR", "plan_name": "SUTTER SELECT & SUTTER HEALTH PLAN HMO PLANS", "methodology": "per diem", "standard_charge_dollar": 28538.0, "standard_charge_algorithm": "Per diem ($28,538).", "count": "0", "additional_payer_notes": "Zero final payments for the item or service in the 15 months prior to posting the file." } ] } ] }, { "description": "HC Adh Dermabond Gp010", "code_information": [ { "code": "PX-2120003010", "type": "CDM" }, { "code": "99999", "type": "CPT" }, { "code": "0272", "type": "RC" } ], "standard_charges": [ { "setting": "outpatient", "gross_charge": 665.0, "discounted_cash": 332.5, "minimum": 280.63, "maximum": 345.8, "additional_generic_notes": "Zero final payments for the item or service in the 15 months prior to posting the file.", "payers_information": [ { "payer_name": "AETNA", "plan_name": "AETNA ALL OTHER PLANS", "methodology": "percent of total billed charges", "standard_charge_dollar": 345.8, "standard_charge_percentage": 52.0, "count": "0", "additional_payer_notes": "Zero final payments for the item or service in the 15 months prior to posting the file." }, { "payer_name": "AETNA", "plan_name": "AETNA ALL OTHER PLANS", "methodology": "percent of total billed charges", "standard_charge_dollar": 345.8, "standard_charge_percentage": 52.0, "count": "0", "additional_payer_notes": "Zero final payments for the item or service in the 15 months prior to posting the file." }, { "payer_name": "MERITAIN HEALTH", "plan_name": "AETNA ALL OTHER PLANS", "methodology": "percent of total billed charges", "standard_charge_dollar": 345.8, "standard_charge_percentage": 52.0, "count": "0", "additional_payer_notes": "Zero final payments for the item or service in the 15 months prior to posting the file." }, { "payer_name": "BLUE SHIELD OUT OF STATE", "plan_name": "STANFORD HEALTHCARE ALLIANCE PLAN", "methodology": "percent of total billed charges", "standard_charge_dollar": 323.12, "standard_charge_percentage": 48.59, "count": "0", "additional_payer_notes": "Zero final payments for the item or service in the 15 months prior to posting the file." }, { "payer_name": "BLUE SHIELD", "plan_name": "STANFORD HEALTHCARE ALLIANCE PLAN", "methodology": "percent of total billed charges", "standard_charge_dollar": 323.12, "standard_charge_percentage": 48.59, "count": "0", "additional_payer_notes": "Zero final payments for the item or service in the 15 months prior to posting the file." }, { "payer_name": "BLUE SHIELD", "plan_name": "STANFORD HEALTHCARE ALLIANCE PLAN", "methodology": "percent of total billed charges", "standard_charge_dollar": 323.12, "standard_charge_percentage": 48.59, "count": "0", "additional_payer_notes": "Zero final payments for the item or service in the 15 months prior to posting the file." }, { "payer_name": "CIGNA", "plan_name": "CIGNA COM ALT HMO PLAN", "methodology": "percent of total billed charges", "standard_charge_dollar": 280.63, "standard_charge_percentage": 42.2, "count": "0", "additional_payer_notes": "Zero final payments for the item or service in the 15 months prior to posting the file." }, { "payer_name": "CIGNA", "plan_name": "CIGNA COM ALT HMO PLAN", "methodology": "percent of total billed charges", "standard_charge_dollar": 280.63, "standard_charge_percentage": 42.2, "count": "0", "additional_payer_notes": "Zero final payments for the item or service in the 15 months prior to posting the file." }, { "payer_name": "HEALTH NET", "plan_name": "HEALTHNET HMO, PPO, POS, EPO, CANOPY HEALTHNET HMO, OTHER-IN-NETWORK PLANS", "methodology": "per diem", "standard_charge_dollar": 8000.0, "standard_charge_algorithm": "Expected reimbursement is the lesser of Per diem ($8,000) for the length of stay and 70% of billed.", "count": "0", "additional_payer_notes": "Zero final payments for the item or service in the 15 months prior to posting the file." }, { "payer_name": "HEALTH NET", "plan_name": "HEALTHNET HMO, PPO, POS, EPO, CANOPY HEALTHNET HMO, OTHER-IN-NETWORK PLANS", "methodology": "per diem", "standard_charge_dollar": 8000.0, "standard_charge_algorithm": "Expected reimbursement is the lesser of Per diem ($8,000) for the length of stay and 70% of billed.", "count": "0", "additional_payer_notes": "Zero final payments for the item or service in the 15 months prior to posting the file." }, { "payer_name": "UNITED HEALTHCARE", "plan_name": "SUTTER SELECT & SUTTER HEALTH PLAN HMO PLANS", "methodology": "per diem", "standard_charge_dollar": 28538.0, "standard_charge_algorithm": "Per diem ($28,538).", "count": "0", "additional_payer_notes": "Zero final payments for the item or service in the 15 months prior to posting the file." }, { "payer_name": "UNITED HEALTHCARE", "plan_name": "SUTTER SELECT & SUTTER HEALTH PLAN HMO PLANS", "methodology": "per diem", "standard_charge_dollar": 28538.0, "standard_charge_algorithm": "Per diem ($28,538).", "count": "0", "additional_payer_notes": "Zero final payments for the item or service in the 15 months prior to posting the file." }, { "payer_name": "SUTTER", "plan_name": "SUTTER SELECT & SUTTER HEALTH PLAN HMO PLANS", "methodology": "per diem", "standard_charge_dollar": 28538.0, "standard_charge_algorithm": "Per diem ($28,538).", "count": "0", "additional_payer_notes": "Zero final payments for the item or service in the 15 months prior to posting the file." }, { "payer_name": "UNITED HEALTHCARE", "plan_name": "SUTTER SELECT & SUTTER HEALTH PLAN HMO PLANS", "methodology": "per diem", "standard_charge_dollar": 28538.0, "standard_charge_algorithm": "Per diem ($28,538).", "count": "0", "additional_payer_notes": "Zero final payments for the item or service in the 15 months prior to posting the file." }, { "payer_name": "UMR", "plan_name": "SUTTER SELECT & SUTTER HEALTH PLAN HMO PLANS", "methodology": "per diem", "standard_charge_dollar": 28538.0, "standard_charge_algorithm": "Per diem ($28,538).", "count": "0", "additional_payer_notes": "Zero final payments for the item or service in the 15 months prior to posting the file." } ] } ] }, { "description": "HC Adh Dermabond Gp011", "code_information": [ { "code": "PX-2120003011", "type": "CDM" }, { "code": "99999", "type": "CPT" }, { "code": "0272", "type": "RC" } ], "standard_charges": [ { "setting": "outpatient", "gross_charge": 740.0, "discounted_cash": 370.0, "minimum": 312.28, "maximum": 384.8, "additional_generic_notes": "Zero final payments for the item or service in the 15 months prior to posting the file.", "payers_information": [ { "payer_name": "AETNA", "plan_name": "AETNA ALL OTHER PLANS", "methodology": "percent of total billed charges", "standard_charge_dollar": 384.8, "standard_charge_percentage": 52.0, "count": "0", "additional_payer_notes": "Zero final payments for the item or service in the 15 months prior to posting the file." }, { "payer_name": "AETNA", "plan_name": "AETNA ALL OTHER PLANS", "methodology": "percent of total billed charges", "standard_charge_dollar": 384.8, "standard_charge_percentage": 52.0, "count": "0", "additional_payer_notes": "Zero final payments for the item or service in the 15 months prior to posting the file." }, { "payer_name": "MERITAIN HEALTH", "plan_name": "AETNA ALL OTHER PLANS", "methodology": "percent of total billed charges", "standard_charge_dollar": 384.8, "standard_charge_percentage": 52.0, "count": "0", "additional_payer_notes": "Zero final payments for the item or service in the 15 months prior to posting the file." }, { "payer_name": "BLUE SHIELD OUT OF STATE", "plan_name": "STANFORD HEALTHCARE ALLIANCE PLAN", "methodology": "percent of total billed charges", "standard_charge_dollar": 359.57, "standard_charge_percentage": 48.59, "count": "0", "additional_payer_notes": "Zero final payments for the item or service in the 15 months prior to posting the file." }, { "payer_name": "BLUE SHIELD", "plan_name": "STANFORD HEALTHCARE ALLIANCE PLAN", "methodology": "percent of total billed charges", "standard_charge_dollar": 359.57, "standard_charge_percentage": 48.59, "count": "0", "additional_payer_notes": "Zero final payments for the item or service in the 15 months prior to posting the file." }, { "payer_name": "BLUE SHIELD", "plan_name": "STANFORD HEALTHCARE ALLIANCE PLAN", "methodology": "percent of total billed charges", "standard_charge_dollar": 359.57, "standard_charge_percentage": 48.59, "count": "0", "additional_payer_notes": "Zero final payments for the item or service in the 15 months prior to posting the file." }, { "payer_name": "CIGNA", "plan_name": "CIGNA COM ALT HMO PLAN", "methodology": "percent of total billed charges", "standard_charge_dollar": 312.28, "standard_charge_percentage": 42.2, "count": "0", "additional_payer_notes": "Zero final payments for the item or service in the 15 months prior to posting the file." }, { "payer_name": "CIGNA", "plan_name": "CIGNA COM ALT HMO PLAN", "methodology": "percent of total billed charges", "standard_charge_dollar": 312.28, "standard_charge_percentage": 42.2, "count": "0", "additional_payer_notes": "Zero final payments for the item or service in the 15 months prior to posting the file." }, { "payer_name": "HEALTH NET", "plan_name": "HEALTHNET HMO, PPO, POS, EPO, CANOPY HEALTHNET HMO, OTHER-IN-NETWORK PLANS", "methodology": "per diem", "standard_charge_dollar": 8000.0, "standard_charge_algorithm": "Expected reimbursement is the lesser of Per diem ($8,000) for the length of stay and 70% of billed.", "count": "0", "additional_payer_notes": "Zero final payments for the item or service in the 15 months prior to posting the file." }, { "payer_name": "HEALTH NET", "plan_name": "HEALTHNET HMO, PPO, POS, EPO, CANOPY HEALTHNET HMO, OTHER-IN-NETWORK PLANS", "methodology": "per diem", "standard_charge_dollar": 8000.0, "standard_charge_algorithm": "Expected reimbursement is the lesser of Per diem ($8,000) for the length of stay and 70% of billed.", "count": "0", "additional_payer_notes": "Zero final payments for the item or service in the 15 months prior to posting the file." }, { "payer_name": "UNITED HEALTHCARE", "plan_name": "SUTTER SELECT & SUTTER HEALTH PLAN HMO PLANS", "methodology": "per diem", "standard_charge_dollar": 28538.0, "standard_charge_algorithm": "Per diem ($28,538).", "count": "0", "additional_payer_notes": "Zero final payments for the item or service in the 15 months prior to posting the file." }, { "payer_name": "UNITED HEALTHCARE", "plan_name": "SUTTER SELECT & SUTTER HEALTH PLAN HMO PLANS", "methodology": "per diem", "standard_charge_dollar": 28538.0, "standard_charge_algorithm": "Per diem ($28,538).", "count": "0", "additional_payer_notes": "Zero final payments for the item or service in the 15 months prior to posting the file." }, { "payer_name": "SUTTER", "plan_name": "SUTTER SELECT & SUTTER HEALTH PLAN HMO PLANS", "methodology": "per diem", "standard_charge_dollar": 28538.0, "standard_charge_algorithm": "Per diem ($28,538).", "count": "0", "additional_payer_notes": "Zero final payments for the item or service in the 15 months prior to posting the file." }, { "payer_name": "UNITED HEALTHCARE", "plan_name": "SUTTER SELECT & SUTTER HEALTH PLAN HMO PLANS", "methodology": "per diem", "standard_charge_dollar": 28538.0, "standard_charge_algorithm": "Per diem ($28,538).", "count": "0", "additional_payer_notes": "Zero final payments for the item or service in the 15 months prior to posting the file." }, { "payer_name": "UMR", "plan_name": "SUTTER SELECT & SUTTER HEALTH PLAN HMO PLANS", "methodology": "per diem", "standard_charge_dollar": 28538.0, "standard_charge_algorithm": "Per diem ($28,538).", "count": "0", "additional_payer_notes": "Zero final payments for the item or service in the 15 months prior to posting the file." } ] } ] }, { "description": "HC Adh Indermil Gp004", "code_information": [ { "code": "PX-2120004004", "type": "CDM" }, { "code": "99999", "type": "CPT" }, { "code": "0272", "type": "RC" } ], "standard_charges": [ { "setting": "outpatient", "gross_charge": 146.0, "discounted_cash": 73.0, "minimum": 61.61, "maximum": 75.92, "additional_generic_notes": "Zero final payments for the item or service in the 15 months prior to posting the file.", "payers_information": [ { "payer_name": "AETNA", "plan_name": "AETNA ALL OTHER PLANS", "methodology": "percent of total billed charges", "standard_charge_dollar": 75.92, "standard_charge_percentage": 52.0, "count": "0", "additional_payer_notes": "Zero final payments for the item or service in the 15 months prior to posting the file." }, { "payer_name": "AETNA", "plan_name": "AETNA ALL OTHER PLANS", "methodology": "percent of total billed charges", "standard_charge_dollar": 75.92, "standard_charge_percentage": 52.0, "count": "0", "additional_payer_notes": "Zero final payments for the item or service in the 15 months prior to posting the file." }, { "payer_name": "MERITAIN HEALTH", "plan_name": "AETNA ALL OTHER PLANS", "methodology": "percent of total billed charges", "standard_charge_dollar": 75.92, "standard_charge_percentage": 52.0, "count": "0", "additional_payer_notes": "Zero final payments for the item or service in the 15 months prior to posting the file." }, { "payer_name": "BLUE SHIELD OUT OF STATE", "plan_name": "STANFORD HEALTHCARE ALLIANCE PLAN", "methodology": "percent of total billed charges", "standard_charge_dollar": 70.94, "standard_charge_percentage": 48.59, "count": "0", "additional_payer_notes": "Zero final payments for the item or service in the 15 months prior to posting the file." }, { "payer_name": "BLUE SHIELD", "plan_name": "STANFORD HEALTHCARE ALLIANCE PLAN", "methodology": "percent of total billed charges", "standard_charge_dollar": 70.94, "standard_charge_percentage": 48.59, "count": "0", "additional_payer_notes": "Zero final payments for the item or service in the 15 months prior to posting the file." }, { "payer_name": "BLUE SHIELD", "plan_name": "STANFORD HEALTHCARE ALLIANCE PLAN", "methodology": "percent of total billed charges", "standard_charge_dollar": 70.94, "standard_charge_percentage": 48.59, "count": "0", "additional_payer_notes": "Zero final payments for the item or service in the 15 months prior to posting the file." }, { "payer_name": "CIGNA", "plan_name": "CIGNA COM ALT HMO PLAN", "methodology": "percent of total billed charges", "standard_charge_dollar": 61.61, "standard_charge_percentage": 42.2, "count": "0", "additional_payer_notes": "Zero final payments for the item or service in the 15 months prior to posting the file." }, { "payer_name": "CIGNA", "plan_name": "CIGNA COM ALT HMO PLAN", "methodology": "percent of total billed charges", "standard_charge_dollar": 61.61, "standard_charge_percentage": 42.2, "count": "0", "additional_payer_notes": "Zero final payments for the item or service in the 15 months prior to posting the file." }, { "payer_name": "HEALTH NET", "plan_name": "HEALTHNET HMO, PPO, POS, EPO, CANOPY HEALTHNET HMO, OTHER-IN-NETWORK PLANS", "methodology": "per diem", "standard_charge_dollar": 8000.0, "standard_charge_algorithm": "Expected reimbursement is the lesser of Per diem ($8,000) for the length of stay and 70% of billed.", "count": "0", "additional_payer_notes": "Zero final payments for the item or service in the 15 months prior to posting the file." }, { "payer_name": "HEALTH NET", "plan_name": "HEALTHNET HMO, PPO, POS, EPO, CANOPY HEALTHNET HMO, OTHER-IN-NETWORK PLANS", "methodology": "per diem", "standard_charge_dollar": 8000.0, "standard_charge_algorithm": "Expected reimbursement is the lesser of Per diem ($8,000) for the length of stay and 70% of billed.", "count": "0", "additional_payer_notes": "Zero final payments for the item or service in the 15 months prior to posting the file." }, { "payer_name": "UNITED HEALTHCARE", "plan_name": "SUTTER SELECT & SUTTER HEALTH PLAN HMO PLANS", "methodology": "per diem", "standard_charge_dollar": 28538.0, "standard_charge_algorithm": "Per diem ($28,538).", "count": "0", "additional_payer_notes": "Zero final payments for the item or service in the 15 months prior to posting the file." }, { "payer_name": "UNITED HEALTHCARE", "plan_name": "SUTTER SELECT & SUTTER HEALTH PLAN HMO PLANS", "methodology": "per diem", "standard_charge_dollar": 28538.0, "standard_charge_algorithm": "Per diem ($28,538).", "count": "0", "additional_payer_notes": "Zero final payments for the item or service in the 15 months prior to posting the file." }, { "payer_name": "SUTTER", "plan_name": "SUTTER SELECT & SUTTER HEALTH PLAN HMO PLANS", "methodology": "per diem", "standard_charge_dollar": 28538.0, "standard_charge_algorithm": "Per diem ($28,538).", "count": "0", "additional_payer_notes": "Zero final payments for the item or service in the 15 months prior to posting the file." }, { "payer_name": "UNITED HEALTHCARE", "plan_name": "SUTTER SELECT & SUTTER HEALTH PLAN HMO PLANS", "methodology": "per diem", "standard_charge_dollar": 28538.0, "standard_charge_algorithm": "Per diem ($28,538).", "count": "0", "additional_payer_notes": "Zero final payments for the item or service in the 15 months prior to posting the file." }, { "payer_name": "UMR", "plan_name": "SUTTER SELECT & SUTTER HEALTH PLAN HMO PLANS", "methodology": "per diem", "standard_charge_dollar": 28538.0, "standard_charge_algorithm": "Per diem ($28,538).", "count": "0", "additional_payer_notes": "Zero final payments for the item or service in the 15 months prior to posting the file." } ] } ] }, { "description": "HC Adh Indermil Gp005", "code_information": [ { "code": "PX-2120004005", "type": "CDM" }, { "code": "99999", "type": "CPT" }, { "code": "0272", "type": "RC" } ], "standard_charges": [ { "setting": "outpatient", "gross_charge": 195.0, "discounted_cash": 97.5, "minimum": 82.29, "maximum": 101.4, "additional_generic_notes": "Zero final payments for the item or service in the 15 months prior to posting the file.", "payers_information": [ { "payer_name": "AETNA", "plan_name": "AETNA ALL OTHER PLANS", "methodology": "percent of total billed charges", "standard_charge_dollar": 101.4, "standard_charge_percentage": 52.0, "count": "0", "additional_payer_notes": "Zero final payments for the item or service in the 15 months prior to posting the file." }, { "payer_name": "AETNA", "plan_name": "AETNA ALL OTHER PLANS", "methodology": "percent of total billed charges", "standard_charge_dollar": 101.4, "standard_charge_percentage": 52.0, "count": "0", "additional_payer_notes": "Zero final payments for the item or service in the 15 months prior to posting the file." }, { "payer_name": "MERITAIN HEALTH", "plan_name": "AETNA ALL OTHER PLANS", "methodology": "percent of total billed charges", "standard_charge_dollar": 101.4, "standard_charge_percentage": 52.0, "count": "0", "additional_payer_notes": "Zero final payments for the item or service in the 15 months prior to posting the file." }, { "payer_name": "BLUE SHIELD OUT OF STATE", "plan_name": "STANFORD HEALTHCARE ALLIANCE PLAN", "methodology": "percent of total billed charges", "standard_charge_dollar": 94.75, "standard_charge_percentage": 48.59, "count": "0", "additional_payer_notes": "Zero final payments for the item or service in the 15 months prior to posting the file." }, { "payer_name": "BLUE SHIELD", "plan_name": "STANFORD HEALTHCARE ALLIANCE PLAN", "methodology": "percent of total billed charges", "standard_charge_dollar": 94.75, "standard_charge_percentage": 48.59, "count": "0", "additional_payer_notes": "Zero final payments for the item or service in the 15 months prior to posting the file." }, { "payer_name": "BLUE SHIELD", "plan_name": "STANFORD HEALTHCARE ALLIANCE PLAN", "methodology": "percent of total billed charges", "standard_charge_dollar": 94.75, "standard_charge_percentage": 48.59, "count": "0", "additional_payer_notes": "Zero final payments for the item or service in the 15 months prior to posting the file." }, { "payer_name": "CIGNA", "plan_name": "CIGNA COM ALT HMO PLAN", "methodology": "percent of total billed charges", "standard_charge_dollar": 82.29, "standard_charge_percentage": 42.2, "count": "0", "additional_payer_notes": "Zero final payments for the item or service in the 15 months prior to posting the file." }, { "payer_name": "CIGNA", "plan_name": "CIGNA COM ALT HMO PLAN", "methodology": "percent of total billed charges", "standard_charge_dollar": 82.29, "standard_charge_percentage": 42.2, "count": "0", "additional_payer_notes": "Zero final payments for the item or service in the 15 months prior to posting the file." }, { "payer_name": "HEALTH NET", "plan_name": "HEALTHNET HMO, PPO, POS, EPO, CANOPY HEALTHNET HMO, OTHER-IN-NETWORK PLANS", "methodology": "per diem", "standard_charge_dollar": 8000.0, "standard_charge_algorithm": "Expected reimbursement is the lesser of Per diem ($8,000) for the length of stay and 70% of billed.", "count": "0", "additional_payer_notes": "Zero final payments for the item or service in the 15 months prior to posting the file." }, { "payer_name": "HEALTH NET", "plan_name": "HEALTHNET HMO, PPO, POS, EPO, CANOPY HEALTHNET HMO, OTHER-IN-NETWORK PLANS", "methodology": "per diem", "standard_charge_dollar": 8000.0, "standard_charge_algorithm": "Expected reimbursement is the lesser of Per diem ($8,000) for the length of stay and 70% of billed.", "count": "0", "additional_payer_notes": "Zero final payments for the item or service in the 15 months prior to posting the file." }, { "payer_name": "UNITED HEALTHCARE", "plan_name": "SUTTER SELECT & SUTTER HEALTH PLAN HMO PLANS", "methodology": "per diem", "standard_charge_dollar": 28538.0, "standard_charge_algorithm": "Per diem ($28,538).", "count": "0", "additional_payer_notes": "Zero final payments for the item or service in the 15 months prior to posting the file." }, { "payer_name": "UNITED HEALTHCARE", "plan_name": "SUTTER SELECT & SUTTER HEALTH PLAN HMO PLANS", "methodology": "per diem", "standard_charge_dollar": 28538.0, "standard_charge_algorithm": "Per diem ($28,538).", "count": "0", "additional_payer_notes": "Zero final payments for the item or service in the 15 months prior to posting the file." }, { "payer_name": "SUTTER", "plan_name": "SUTTER SELECT & SUTTER HEALTH PLAN HMO PLANS", "methodology": "per diem", "standard_charge_dollar": 28538.0, "standard_charge_algorithm": "Per diem ($28,538).", "count": "0", "additional_payer_notes": "Zero final payments for the item or service in the 15 months prior to posting the file." }, { "payer_name": "UNITED HEALTHCARE", "plan_name": "SUTTER SELECT & SUTTER HEALTH PLAN HMO PLANS", "methodology": "per diem", "standard_charge_dollar": 28538.0, "standard_charge_algorithm": "Per diem ($28,538).", "count": "0", "additional_payer_notes": "Zero final payments for the item or service in the 15 months prior to posting the file." }, { "payer_name": "UMR", "plan_name": "SUTTER SELECT & SUTTER HEALTH PLAN HMO PLANS", "methodology": "per diem", "standard_charge_dollar": 28538.0, "standard_charge_algorithm": "Per diem ($28,538).", "count": "0", "additional_payer_notes": "Zero final payments for the item or service in the 15 months prior to posting the file." } ] } ] }, { "description": "HC Applier Endoclip Gp011", "code_information": [ { "code": "PX-2120006011", "type": "CDM" }, { "code": "99999", "type": "CPT" }, { "code": "0272", "type": "RC" } ], "standard_charges": [ { "setting": "outpatient", "gross_charge": 740.0, "discounted_cash": 370.0, "minimum": 312.28, "maximum": 384.8, "additional_generic_notes": "Zero final payments for the item or service in the 15 months prior to posting the file.", "payers_information": [ { "payer_name": "AETNA", "plan_name": "AETNA ALL OTHER PLANS", "methodology": "percent of total billed charges", "standard_charge_dollar": 384.8, "standard_charge_percentage": 52.0, "count": "0", "additional_payer_notes": "Zero final payments for the item or service in the 15 months prior to posting the file." }, { "payer_name": "AETNA", "plan_name": "AETNA ALL OTHER PLANS", "methodology": "percent of total billed charges", "standard_charge_dollar": 384.8, "standard_charge_percentage": 52.0, "count": "0", "additional_payer_notes": "Zero final payments for the item or service in the 15 months prior to posting the file." }, { "payer_name": "MERITAIN HEALTH", "plan_name": "AETNA ALL OTHER PLANS", "methodology": "percent of total billed charges", "standard_charge_dollar": 384.8, "standard_charge_percentage": 52.0, "count": "0", "additional_payer_notes": "Zero final payments for the item or service in the 15 months prior to posting the file." }, { "payer_name": "BLUE SHIELD OUT OF STATE", "plan_name": "STANFORD HEALTHCARE ALLIANCE PLAN", "methodology": "percent of total billed charges", "standard_charge_dollar": 359.57, "standard_charge_percentage": 48.59, "count": "0", "additional_payer_notes": "Zero final payments for the item or service in the 15 months prior to posting the file." }, { "payer_name": "BLUE SHIELD", "plan_name": "STANFORD HEALTHCARE ALLIANCE PLAN", "methodology": "percent of total billed charges", "standard_charge_dollar": 359.57, "standard_charge_percentage": 48.59, "count": "0", "additional_payer_notes": "Zero final payments for the item or service in the 15 months prior to posting the file." }, { "payer_name": "BLUE SHIELD", "plan_name": "STANFORD HEALTHCARE ALLIANCE PLAN", "methodology": "percent of total billed charges", "standard_charge_dollar": 359.57, "standard_charge_percentage": 48.59, "count": "0", "additional_payer_notes": "Zero final payments for the item or service in the 15 months prior to posting the file." }, { "payer_name": "CIGNA", "plan_name": "CIGNA COM ALT HMO PLAN", "methodology": "percent of total billed charges", "standard_charge_dollar": 312.28, "standard_charge_percentage": 42.2, "count": "0", "additional_payer_notes": "Zero final payments for the item or service in the 15 months prior to posting the file." }, { "payer_name": "CIGNA", "plan_name": "CIGNA COM ALT HMO PLAN", "methodology": "percent of total billed charges", "standard_charge_dollar": 312.28, "standard_charge_percentage": 42.2, "count": "0", "additional_payer_notes": "Zero final payments for the item or service in the 15 months prior to posting the file." }, { "payer_name": "HEALTH NET", "plan_name": "HEALTHNET HMO, PPO, POS, EPO, CANOPY HEALTHNET HMO, OTHER-IN-NETWORK PLANS", "methodology": "per diem", "standard_charge_dollar": 8000.0, "standard_charge_algorithm": "Expected reimbursement is the lesser of Per diem ($8,000) for the length of stay and 70% of billed.", "count": "0", "additional_payer_notes": "Zero final payments for the item or service in the 15 months prior to posting the file." }, { "payer_name": "HEALTH NET", "plan_name": "HEALTHNET HMO, PPO, POS, EPO, CANOPY HEALTHNET HMO, OTHER-IN-NETWORK PLANS", "methodology": "per diem", "standard_charge_dollar": 8000.0, "standard_charge_algorithm": "Expected reimbursement is the lesser of Per diem ($8,000) for the length of stay and 70% of billed.", "count": "0", "additional_payer_notes": "Zero final payments for the item or service in the 15 months prior to posting the file." }, { "payer_name": "UNITED HEALTHCARE", "plan_name": "SUTTER SELECT & SUTTER HEALTH PLAN HMO PLANS", "methodology": "per diem", "standard_charge_dollar": 28538.0, "standard_charge_algorithm": "Per diem ($28,538).", "count": "0", "additional_payer_notes": "Zero final payments for the item or service in the 15 months prior to posting the file." }, { "payer_name": "UNITED HEALTHCARE", "plan_name": "SUTTER SELECT & SUTTER HEALTH PLAN HMO PLANS", "methodology": "per diem", "standard_charge_dollar": 28538.0, "standard_charge_algorithm": "Per diem ($28,538).", "count": "0", "additional_payer_notes": "Zero final payments for the item or service in the 15 months prior to posting the file." }, { "payer_name": "SUTTER", "plan_name": "SUTTER SELECT & SUTTER HEALTH PLAN HMO PLANS", "methodology": "per diem", "standard_charge_dollar": 28538.0, "standard_charge_algorithm": "Per diem ($28,538).", "count": "0", "additional_payer_notes": "Zero final payments for the item or service in the 15 months prior to posting the file." }, { "payer_name": "UNITED HEALTHCARE", "plan_name": "SUTTER SELECT & SUTTER HEALTH PLAN HMO PLANS", "methodology": "per diem", "standard_charge_dollar": 28538.0, "standard_charge_algorithm": "Per diem ($28,538).", "count": "0", "additional_payer_notes": "Zero final payments for the item or service in the 15 months prior to posting the file." }, { "payer_name": "UMR", "plan_name": "SUTTER SELECT & SUTTER HEALTH PLAN HMO PLANS", "methodology": "per diem", "standard_charge_dollar": 28538.0, "standard_charge_algorithm": "Per diem ($28,538).", "count": "0", "additional_payer_notes": "Zero final payments for the item or service in the 15 months prior to posting the file." } ] } ] }, { "description": "HC Applier Endoclip Gp012", "code_information": [ { "code": "PX-2120006012", "type": "CDM" }, { "code": "99999", "type": "CPT" }, { "code": "0272", "type": "RC" } ], "standard_charges": [ { "setting": "outpatient", "gross_charge": 810.0, "discounted_cash": 405.0, "minimum": 341.82, "maximum": 421.2, "additional_generic_notes": "Zero final payments for the item or service in the 15 months prior to posting the file.", "payers_information": [ { "payer_name": "AETNA", "plan_name": "AETNA ALL OTHER PLANS", "methodology": "percent of total billed charges", "standard_charge_dollar": 421.2, "standard_charge_percentage": 52.0, "count": "0", "additional_payer_notes": "Zero final payments for the item or service in the 15 months prior to posting the file." }, { "payer_name": "AETNA", "plan_name": "AETNA ALL OTHER PLANS", "methodology": "percent of total billed charges", "standard_charge_dollar": 421.2, "standard_charge_percentage": 52.0, "count": "0", "additional_payer_notes": "Zero final payments for the item or service in the 15 months prior to posting the file." }, { "payer_name": "MERITAIN HEALTH", "plan_name": "AETNA ALL OTHER PLANS", "methodology": "percent of total billed charges", "standard_charge_dollar": 421.2, "standard_charge_percentage": 52.0, "count": "0", "additional_payer_notes": "Zero final payments for the item or service in the 15 months prior to posting the file." }, { "payer_name": "BLUE SHIELD OUT OF STATE", "plan_name": "STANFORD HEALTHCARE ALLIANCE PLAN", "methodology": "percent of total billed charges", "standard_charge_dollar": 393.58, "standard_charge_percentage": 48.59, "count": "0", "additional_payer_notes": "Zero final payments for the item or service in the 15 months prior to posting the file." }, { "payer_name": "BLUE SHIELD", "plan_name": "STANFORD HEALTHCARE ALLIANCE PLAN", "methodology": "percent of total billed charges", "standard_charge_dollar": 393.58, "standard_charge_percentage": 48.59, "count": "0", "additional_payer_notes": "Zero final payments for the item or service in the 15 months prior to posting the file." }, { "payer_name": "BLUE SHIELD", "plan_name": "STANFORD HEALTHCARE ALLIANCE PLAN", "methodology": "percent of total billed charges", "standard_charge_dollar": 393.58, "standard_charge_percentage": 48.59, "count": "0", "additional_payer_notes": "Zero final payments for the item or service in the 15 months prior to posting the file." }, { "payer_name": "CIGNA", "plan_name": "CIGNA COM ALT HMO PLAN", "methodology": "percent of total billed charges", "standard_charge_dollar": 341.82, "standard_charge_percentage": 42.2, "count": "0", "additional_payer_notes": "Zero final payments for the item or service in the 15 months prior to posting the file." }, { "payer_name": "CIGNA", "plan_name": "CIGNA COM ALT HMO PLAN", "methodology": "percent of total billed charges", "standard_charge_dollar": 341.82, "standard_charge_percentage": 42.2, "count": "0", "additional_payer_notes": "Zero final payments for the item or service in the 15 months prior to posting the file." }, { "payer_name": "HEALTH NET", "plan_name": "HEALTHNET HMO, PPO, POS, EPO, CANOPY HEALTHNET HMO, OTHER-IN-NETWORK PLANS", "methodology": "per diem", "standard_charge_dollar": 8000.0, "standard_charge_algorithm": "Expected reimbursement is the lesser of Per diem ($8,000) for the length of stay and 70% of billed.", "count": "0", "additional_payer_notes": "Zero final payments for the item or service in the 15 months prior to posting the file." }, { "payer_name": "HEALTH NET", "plan_name": "HEALTHNET HMO, PPO, POS, EPO, CANOPY HEALTHNET HMO, OTHER-IN-NETWORK PLANS", "methodology": "per diem", "standard_charge_dollar": 8000.0, "standard_charge_algorithm": "Expected reimbursement is the lesser of Per diem ($8,000) for the length of stay and 70% of billed.", "count": "0", "additional_payer_notes": "Zero final payments for the item or service in the 15 months prior to posting the file." }, { "payer_name": "UNITED HEALTHCARE", "plan_name": "SUTTER SELECT & SUTTER HEALTH PLAN HMO PLANS", "methodology": "per diem", "standard_charge_dollar": 28538.0, "standard_charge_algorithm": "Per diem ($28,538).", "count": "0", "additional_payer_notes": "Zero final payments for the item or service in the 15 months prior to posting the file." }, { "payer_name": "UNITED HEALTHCARE", "plan_name": "SUTTER SELECT & SUTTER HEALTH PLAN HMO PLANS", "methodology": "per diem", "standard_charge_dollar": 28538.0, "standard_charge_algorithm": "Per diem ($28,538).", "count": "0", "additional_payer_notes": "Zero final payments for the item or service in the 15 months prior to posting the file." }, { "payer_name": "SUTTER", "plan_name": "SUTTER SELECT & SUTTER HEALTH PLAN HMO PLANS", "methodology": "per diem", "standard_charge_dollar": 28538.0, "standard_charge_algorithm": "Per diem ($28,538).", "count": "0", "additional_payer_notes": "Zero final payments for the item or service in the 15 months prior to posting the file." }, { "payer_name": "UNITED HEALTHCARE", "plan_name": "SUTTER SELECT & SUTTER HEALTH PLAN HMO PLANS", "methodology": "per diem", "standard_charge_dollar": 28538.0, "standard_charge_algorithm": "Per diem ($28,538).", "count": "0", "additional_payer_notes": "Zero final payments for the item or service in the 15 months prior to posting the file." }, { "payer_name": "UMR", "plan_name": "SUTTER SELECT & SUTTER HEALTH PLAN HMO PLANS", "methodology": "per diem", "standard_charge_dollar": 28538.0, "standard_charge_algorithm": "Per diem ($28,538).", "count": "0", "additional_payer_notes": "Zero final payments for the item or service in the 15 months prior to posting the file." } ] } ] }, { "description": "HC Applier Endoclip Gp013", "code_information": [ { "code": "PX-2120006013", "type": "CDM" }, { "code": "99999", "type": "CPT" }, { "code": "0272", "type": "RC" } ], "standard_charges": [ { "setting": "outpatient", "gross_charge": 900.0, "discounted_cash": 450.0, "minimum": 379.8, "maximum": 468.0, "additional_generic_notes": "Zero final payments for the item or service in the 15 months prior to posting the file.", "payers_information": [ { "payer_name": "AETNA", "plan_name": "AETNA ALL OTHER PLANS", "methodology": "percent of total billed charges", "standard_charge_dollar": 468.0, "standard_charge_percentage": 52.0, "count": "0", "additional_payer_notes": "Zero final payments for the item or service in the 15 months prior to posting the file." }, { "payer_name": "AETNA", "plan_name": "AETNA ALL OTHER PLANS", "methodology": "percent of total billed charges", "standard_charge_dollar": 468.0, "standard_charge_percentage": 52.0, "count": "0", "additional_payer_notes": "Zero final payments for the item or service in the 15 months prior to posting the file." }, { "payer_name": "MERITAIN HEALTH", "plan_name": "AETNA ALL OTHER PLANS", "methodology": "percent of total billed charges", "standard_charge_dollar": 468.0, "standard_charge_percentage": 52.0, "count": "0", "additional_payer_notes": "Zero final payments for the item or service in the 15 months prior to posting the file." }, { "payer_name": "BLUE SHIELD OUT OF STATE", "plan_name": "STANFORD HEALTHCARE ALLIANCE PLAN", "methodology": "percent of total billed charges", "standard_charge_dollar": 437.31, "standard_charge_percentage": 48.59, "count": "0", "additional_payer_notes": "Zero final payments for the item or service in the 15 months prior to posting the file." }, { "payer_name": "BLUE SHIELD", "plan_name": "STANFORD HEALTHCARE ALLIANCE PLAN", "methodology": "percent of total billed charges", "standard_charge_dollar": 437.31, "standard_charge_percentage": 48.59, "count": "0", "additional_payer_notes": "Zero final payments for the item or service in the 15 months prior to posting the file." }, { "payer_name": "BLUE SHIELD", "plan_name": "STANFORD HEALTHCARE ALLIANCE PLAN", "methodology": "percent of total billed charges", "standard_charge_dollar": 437.31, "standard_charge_percentage": 48.59, "count": "0", "additional_payer_notes": "Zero final payments for the item or service in the 15 months prior to posting the file." }, { "payer_name": "CIGNA", "plan_name": "CIGNA COM ALT HMO PLAN", "methodology": "percent of total billed charges", "standard_charge_dollar": 379.8, "standard_charge_percentage": 42.2, "count": "0", "additional_payer_notes": "Zero final payments for the item or service in the 15 months prior to posting the file." }, { "payer_name": "CIGNA", "plan_name": "CIGNA COM ALT HMO PLAN", "methodology": "percent of total billed charges", "standard_charge_dollar": 379.8, "standard_charge_percentage": 42.2, "count": "0", "additional_payer_notes": "Zero final payments for the item or service in the 15 months prior to posting the file." }, { "payer_name": "HEALTH NET", "plan_name": "HEALTHNET HMO, PPO, POS, EPO, CANOPY HEALTHNET HMO, OTHER-IN-NETWORK PLANS", "methodology": "per diem", "standard_charge_dollar": 8000.0, "standard_charge_algorithm": "Expected reimbursement is the lesser of Per diem ($8,000) for the length of stay and 70% of billed.", "count": "0", "additional_payer_notes": "Zero final payments for the item or service in the 15 months prior to posting the file." }, { "payer_name": "HEALTH NET", "plan_name": "HEALTHNET HMO, PPO, POS, EPO, CANOPY HEALTHNET HMO, OTHER-IN-NETWORK PLANS", "methodology": "per diem", "standard_charge_dollar": 8000.0, "standard_charge_algorithm": "Expected reimbursement is the lesser of Per diem ($8,000) for the length of stay and 70% of billed.", "count": "0", "additional_payer_notes": "Zero final payments for the item or service in the 15 months prior to posting the file." }, { "payer_name": "UNITED HEALTHCARE", "plan_name": "SUTTER SELECT & SUTTER HEALTH PLAN HMO PLANS", "methodology": "per diem", "standard_charge_dollar": 28538.0, "standard_charge_algorithm": "Per diem ($28,538).", "count": "0", "additional_payer_notes": "Zero final payments for the item or service in the 15 months prior to posting the file." }, { "payer_name": "UNITED HEALTHCARE", "plan_name": "SUTTER SELECT & SUTTER HEALTH PLAN HMO PLANS", "methodology": "per diem", "standard_charge_dollar": 28538.0, "standard_charge_algorithm": "Per diem ($28,538).", "count": "0", "additional_payer_notes": "Zero final payments for the item or service in the 15 months prior to posting the file." }, { "payer_name": "SUTTER", "plan_name": "SUTTER SELECT & SUTTER HEALTH PLAN HMO PLANS", "methodology": "per diem", "standard_charge_dollar": 28538.0, "standard_charge_algorithm": "Per diem ($28,538).", "count": "0", "additional_payer_notes": "Zero final payments for the item or service in the 15 months prior to posting the file." }, { "payer_name": "UNITED HEALTHCARE", "plan_name": "SUTTER SELECT & SUTTER HEALTH PLAN HMO PLANS", "methodology": "per diem", "standard_charge_dollar": 28538.0, "standard_charge_algorithm": "Per diem ($28,538).", "count": "0", "additional_payer_notes": "Zero final payments for the item or service in the 15 months prior to posting the file." }, { "payer_name": "UMR", "plan_name": "SUTTER SELECT & SUTTER HEALTH PLAN HMO PLANS", "methodology": "per diem", "standard_charge_dollar": 28538.0, "standard_charge_algorithm": "Per diem ($28,538).", "count": "0", "additional_payer_notes": "Zero final payments for the item or service in the 15 months prior to posting the file." } ] } ] }, { "description": "HC Applier Endoclip Gp014", "code_information": [ { "code": "PX-2120006014", "type": "CDM" }, { "code": "99999", "type": "CPT" }, { "code": "0272", "type": "RC" } ], "standard_charges": [ { "setting": "outpatient", "gross_charge": 1080.0, "discounted_cash": 540.0, "minimum": 455.76, "maximum": 561.6, "additional_generic_notes": "Zero final payments for the item or service in the 15 months prior to posting the file.", "payers_information": [ { "payer_name": "AETNA", "plan_name": "AETNA ALL OTHER PLANS", "methodology": "percent of total billed charges", "standard_charge_dollar": 561.6, "standard_charge_percentage": 52.0, "count": "0", "additional_payer_notes": "Zero final payments for the item or service in the 15 months prior to posting the file." }, { "payer_name": "AETNA", "plan_name": "AETNA ALL OTHER PLANS", "methodology": "percent of total billed charges", "standard_charge_dollar": 561.6, "standard_charge_percentage": 52.0, "count": "0", "additional_payer_notes": "Zero final payments for the item or service in the 15 months prior to posting the file." }, { "payer_name": "MERITAIN HEALTH", "plan_name": "AETNA ALL OTHER PLANS", "methodology": "percent of total billed charges", "standard_charge_dollar": 561.6, "standard_charge_percentage": 52.0, "count": "0", "additional_payer_notes": "Zero final payments for the item or service in the 15 months prior to posting the file." }, { "payer_name": "BLUE SHIELD OUT OF STATE", "plan_name": "STANFORD HEALTHCARE ALLIANCE PLAN", "methodology": "percent of total billed charges", "standard_charge_dollar": 524.77, "standard_charge_percentage": 48.59, "count": "0", "additional_payer_notes": "Zero final payments for the item or service in the 15 months prior to posting the file." }, { "payer_name": "BLUE SHIELD", "plan_name": "STANFORD HEALTHCARE ALLIANCE PLAN", "methodology": "percent of total billed charges", "standard_charge_dollar": 524.77, "standard_charge_percentage": 48.59, "median_amount": 68.24, "10th_percentile": 13.6, "90th_percentile": 1043.06, "count": "30" }, { "payer_name": "BLUE SHIELD", "plan_name": "STANFORD HEALTHCARE ALLIANCE PLAN", "methodology": "percent of total billed charges", "standard_charge_dollar": 524.77, "standard_charge_percentage": 48.59, "count": "0", "additional_payer_notes": "Zero final payments for the item or service in the 15 months prior to posting the file." }, { "payer_name": "BLUE SHIELD", "plan_name": "STANFORD HEALTHCARE ALLIANCE PLAN", "methodology": "percent of total billed charges", "standard_charge_dollar": 524.77, "standard_charge_percentage": 48.59, "count": "0", "additional_payer_notes": "Zero final payments for the item or service in the 15 months prior to posting the file." }, { "payer_name": "CIGNA", "plan_name": "CIGNA COM ALT HMO PLAN", "methodology": "percent of total billed charges", "standard_charge_dollar": 455.76, "standard_charge_percentage": 42.2, "count": "0", "additional_payer_notes": "Zero final payments for the item or service in the 15 months prior to posting the file." }, { "payer_name": "CIGNA", "plan_name": "CIGNA COM ALT HMO PLAN", "methodology": "percent of total billed charges", "standard_charge_dollar": 455.76, "standard_charge_percentage": 42.2, "count": "0", "additional_payer_notes": "Zero final payments for the item or service in the 15 months prior to posting the file." }, { "payer_name": "HEALTH NET", "plan_name": "HEALTHNET HMO, PPO, POS, EPO, CANOPY HEALTHNET HMO, OTHER-IN-NETWORK PLANS", "methodology": "per diem", "standard_charge_dollar": 8000.0, "standard_charge_algorithm": "Expected reimbursement is the lesser of Per diem ($8,000) for the length of stay and 70% of billed.", "count": "0", "additional_payer_notes": "Zero final payments for the item or service in the 15 months prior to posting the file." }, { "payer_name": "HEALTH NET", "plan_name": "HEALTHNET HMO, PPO, POS, EPO, CANOPY HEALTHNET HMO, OTHER-IN-NETWORK PLANS", "methodology": "per diem", "standard_charge_dollar": 8000.0, "standard_charge_algorithm": "Expected reimbursement is the lesser of Per diem ($8,000) for the length of stay and 70% of billed.", "count": "0", "additional_payer_notes": "Zero final payments for the item or service in the 15 months prior to posting the file." }, { "payer_name": "UNITED HEALTHCARE", "plan_name": "SUTTER SELECT & SUTTER HEALTH PLAN HMO PLANS", "methodology": "per diem", "standard_charge_dollar": 28538.0, "standard_charge_algorithm": "Per diem ($28,538).", "count": "0", "additional_payer_notes": "Zero final payments for the item or service in the 15 months prior to posting the file." }, { "payer_name": "UNITED HEALTHCARE", "plan_name": "SUTTER SELECT & SUTTER HEALTH PLAN HMO PLANS", "methodology": "per diem", "standard_charge_dollar": 28538.0, "standard_charge_algorithm": "Per diem ($28,538).", "count": "0", "additional_payer_notes": "Zero final payments for the item or service in the 15 months prior to posting the file." }, { "payer_name": "SUTTER", "plan_name": "SUTTER SELECT & SUTTER HEALTH PLAN HMO PLANS", "methodology": "per diem", "standard_charge_dollar": 28538.0, "standard_charge_algorithm": "Per diem ($28,538).", "count": "0", "additional_payer_notes": "Zero final payments for the item or service in the 15 months prior to posting the file." }, { "payer_name": "UNITED HEALTHCARE", "plan_name": "SUTTER SELECT & SUTTER HEALTH PLAN HMO PLANS", "methodology": "per diem", "standard_charge_dollar": 28538.0, "standard_charge_algorithm": "Per diem ($28,538).", "count": "0", "additional_payer_notes": "Zero final payments for the item or service in the 15 months prior to posting the file." }, { "payer_name": "UMR", "plan_name": "SUTTER SELECT & SUTTER HEALTH PLAN HMO PLANS", "methodology": "per diem", "standard_charge_dollar": 28538.0, "standard_charge_algorithm": "Per diem ($28,538).", "count": "0", "additional_payer_notes": "Zero final payments for the item or service in the 15 months prior to posting the file." } ] } ] }, { "description": "HC Applier Endoclip Gp015", "code_information": [ { "code": "PX-2120006015", "type": "CDM" }, { "code": "99999", "type": "CPT" }, { "code": "0272", "type": "RC" } ], "standard_charges": [ { "setting": "outpatient", "gross_charge": 1225.0, "discounted_cash": 612.5, "minimum": 516.95, "maximum": 637.0, "additional_generic_notes": "Zero final payments for the item or service in the 15 months prior to posting the file.", "payers_information": [ { "payer_name": "AETNA", "plan_name": "AETNA ALL OTHER PLANS", "methodology": "percent of total billed charges", "standard_charge_dollar": 637.0, "standard_charge_percentage": 52.0, "count": "0", "additional_payer_notes": "Zero final payments for the item or service in the 15 months prior to posting the file." }, { "payer_name": "AETNA", "plan_name": "AETNA ALL OTHER PLANS", "methodology": "percent of total billed charges", "standard_charge_dollar": 637.0, "standard_charge_percentage": 52.0, "count": "0", "additional_payer_notes": "Zero final payments for the item or service in the 15 months prior to posting the file." }, { "payer_name": "MERITAIN HEALTH", "plan_name": "AETNA ALL OTHER PLANS", "methodology": "percent of total billed charges", "standard_charge_dollar": 637.0, "standard_charge_percentage": 52.0, "count": "0", "additional_payer_notes": "Zero final payments for the item or service in the 15 months prior to posting the file." }, { "payer_name": "BLUE SHIELD OUT OF STATE", "plan_name": "STANFORD HEALTHCARE ALLIANCE PLAN", "methodology": "percent of total billed charges", "standard_charge_dollar": 595.23, "standard_charge_percentage": 48.59, "count": "0", "additional_payer_notes": "Zero final payments for the item or service in the 15 months prior to posting the file." }, { "payer_name": "BLUE SHIELD", "plan_name": "STANFORD HEALTHCARE ALLIANCE PLAN", "methodology": "percent of total billed charges", "standard_charge_dollar": 595.23, "standard_charge_percentage": 48.59, "median_amount": 68.24, "10th_percentile": 13.6, "90th_percentile": 1043.06, "count": "30" }, { "payer_name": "BLUE SHIELD", "plan_name": "STANFORD HEALTHCARE ALLIANCE PLAN", "methodology": "percent of total billed charges", "standard_charge_dollar": 595.23, "standard_charge_percentage": 48.59, "count": "0", "additional_payer_notes": "Zero final payments for the item or service in the 15 months prior to posting the file." }, { "payer_name": "BLUE SHIELD", "plan_name": "STANFORD HEALTHCARE ALLIANCE PLAN", "methodology": "percent of total billed charges", "standard_charge_dollar": 595.23, "standard_charge_percentage": 48.59, "count": "0", "additional_payer_notes": "Zero final payments for the item or service in the 15 months prior to posting the file." }, { "payer_name": "CIGNA", "plan_name": "CIGNA COM ALT HMO PLAN", "methodology": "percent of total billed charges", "standard_charge_dollar": 516.95, "standard_charge_percentage": 42.2, "count": "0", "additional_payer_notes": "Zero final payments for the item or service in the 15 months prior to posting the file." }, { "payer_name": "CIGNA", "plan_name": "CIGNA COM ALT HMO PLAN", "methodology": "percent of total billed charges", "standard_charge_dollar": 516.95, "standard_charge_percentage": 42.2, "count": "0", "additional_payer_notes": "Zero final payments for the item or service in the 15 months prior to posting the file." }, { "payer_name": "HEALTH NET", "plan_name": "HEALTHNET HMO, PPO, POS, EPO, CANOPY HEALTHNET HMO, OTHER-IN-NETWORK PLANS", "methodology": "per diem", "standard_charge_dollar": 8000.0, "standard_charge_algorithm": "Expected reimbursement is the lesser of Per diem ($8,000) for the length of stay and 70% of billed.", "count": "0", "additional_payer_notes": "Zero final payments for the item or service in the 15 months prior to posting the file." }, { "payer_name": "HEALTH NET", "plan_name": "HEALTHNET HMO, PPO, POS, EPO, CANOPY HEALTHNET HMO, OTHER-IN-NETWORK PLANS", "methodology": "per diem", "standard_charge_dollar": 8000.0, "standard_charge_algorithm": "Expected reimbursement is the lesser of Per diem ($8,000) for the length of stay and 70% of billed.", "count": "0", "additional_payer_notes": "Zero final payments for the item or service in the 15 months prior to posting the file." }, { "payer_name": "UNITED HEALTHCARE", "plan_name": "SUTTER SELECT & SUTTER HEALTH PLAN HMO PLANS", "methodology": "per diem", "standard_charge_dollar": 28538.0, "standard_charge_algorithm": "Per diem ($28,538).", "count": "0", "additional_payer_notes": "Zero final payments for the item or service in the 15 months prior to posting the file." }, { "payer_name": "UNITED HEALTHCARE", "plan_name": "SUTTER SELECT & SUTTER HEALTH PLAN HMO PLANS", "methodology": "per diem", "standard_charge_dollar": 28538.0, "standard_charge_algorithm": "Per diem ($28,538).", "count": "0", "additional_payer_notes": "Zero final payments for the item or service in the 15 months prior to posting the file." }, { "payer_name": "SUTTER", "plan_name": "SUTTER SELECT & SUTTER HEALTH PLAN HMO PLANS", "methodology": "per diem", "standard_charge_dollar": 28538.0, "standard_charge_algorithm": "Per diem ($28,538).", "count": "0", "additional_payer_notes": "Zero final payments for the item or service in the 15 months prior to posting the file." }, { "payer_name": "UNITED HEALTHCARE", "plan_name": "SUTTER SELECT & SUTTER HEALTH PLAN HMO PLANS", "methodology": "per diem", "standard_charge_dollar": 28538.0, "standard_charge_algorithm": "Per diem ($28,538).", "count": "0", "additional_payer_notes": "Zero final payments for the item or service in the 15 months prior to posting the file." }, { "payer_name": "UMR", "plan_name": "SUTTER SELECT & SUTTER HEALTH PLAN HMO PLANS", "methodology": "per diem", "standard_charge_dollar": 28538.0, "standard_charge_algorithm": "Per diem ($28,538).", "count": "0", "additional_payer_notes": "Zero final payments for the item or service in the 15 months prior to posting the file." } ] } ] }, { "description": "HC Applier Endoclip Gp016", "code_information": [ { "code": "PX-2120006016", "type": "CDM" }, { "code": "99999", "type": "CPT" }, { "code": "0272", "type": "RC" } ], "standard_charges": [ { "setting": "outpatient", "gross_charge": 1400.0, "discounted_cash": 700.0, "minimum": 590.8, "maximum": 728.0, "additional_generic_notes": "Zero final payments for the item or service in the 15 months prior to posting the file.", "payers_information": [ { "payer_name": "AETNA", "plan_name": "AETNA ALL OTHER PLANS", "methodology": "percent of total billed charges", "standard_charge_dollar": 728.0, "standard_charge_percentage": 52.0, "count": "0", "additional_payer_notes": "Zero final payments for the item or service in the 15 months prior to posting the file." }, { "payer_name": "AETNA", "plan_name": "AETNA ALL OTHER PLANS", "methodology": "percent of total billed charges", "standard_charge_dollar": 728.0, "standard_charge_percentage": 52.0, "count": "0", "additional_payer_notes": "Zero final payments for the item or service in the 15 months prior to posting the file." }, { "payer_name": "MERITAIN HEALTH", "plan_name": "AETNA ALL OTHER PLANS", "methodology": "percent of total billed charges", "standard_charge_dollar": 728.0, "standard_charge_percentage": 52.0, "count": "0", "additional_payer_notes": "Zero final payments for the item or service in the 15 months prior to posting the file." }, { "payer_name": "BLUE SHIELD OUT OF STATE", "plan_name": "STANFORD HEALTHCARE ALLIANCE PLAN", "methodology": "percent of total billed charges", "standard_charge_dollar": 680.26, "standard_charge_percentage": 48.59, "count": "0", "additional_payer_notes": "Zero final payments for the item or service in the 15 months prior to posting the file." }, { "payer_name": "BLUE SHIELD", "plan_name": "STANFORD HEALTHCARE ALLIANCE PLAN", "methodology": "percent of total billed charges", "standard_charge_dollar": 680.26, "standard_charge_percentage": 48.59, "median_amount": 68.24, "10th_percentile": 13.6, "90th_percentile": 1043.06, "count": "30" }, { "payer_name": "BLUE SHIELD", "plan_name": "STANFORD HEALTHCARE ALLIANCE PLAN", "methodology": "percent of total billed charges", "standard_charge_dollar": 680.26, "standard_charge_percentage": 48.59, "count": "0", "additional_payer_notes": "Zero final payments for the item or service in the 15 months prior to posting the file." }, { "payer_name": "BLUE SHIELD", "plan_name": "STANFORD HEALTHCARE ALLIANCE PLAN", "methodology": "percent of total billed charges", "standard_charge_dollar": 680.26, "standard_charge_percentage": 48.59, "count": "0", "additional_payer_notes": "Zero final payments for the item or service in the 15 months prior to posting the file." }, { "payer_name": "CIGNA", "plan_name": "CIGNA COM ALT HMO PLAN", "methodology": "percent of total billed charges", "standard_charge_dollar": 590.8, "standard_charge_percentage": 42.2, "count": "0", "additional_payer_notes": "Zero final payments for the item or service in the 15 months prior to posting the file." }, { "payer_name": "CIGNA", "plan_name": "CIGNA COM ALT HMO PLAN", "methodology": "percent of total billed charges", "standard_charge_dollar": 590.8, "standard_charge_percentage": 42.2, "count": "0", "additional_payer_notes": "Zero final payments for the item or service in the 15 months prior to posting the file." }, { "payer_name": "HEALTH NET", "plan_name": "HEALTHNET HMO, PPO, POS, EPO, CANOPY HEALTHNET HMO, OTHER-IN-NETWORK PLANS", "methodology": "per diem", "standard_charge_dollar": 8000.0, "standard_charge_algorithm": "Expected reimbursement is the lesser of Per diem ($8,000) for the length of stay and 70% of billed.", "count": "0", "additional_payer_notes": "Zero final payments for the item or service in the 15 months prior to posting the file." }, { "payer_name": "HEALTH NET", "plan_name": "HEALTHNET HMO, PPO, POS, EPO, CANOPY HEALTHNET HMO, OTHER-IN-NETWORK PLANS", "methodology": "per diem", "standard_charge_dollar": 8000.0, "standard_charge_algorithm": "Expected reimbursement is the lesser of Per diem ($8,000) for the length of stay and 70% of billed.", "count": "0", "additional_payer_notes": "Zero final payments for the item or service in the 15 months prior to posting the file." }, { "payer_name": "UNITED HEALTHCARE", "plan_name": "SUTTER SELECT & SUTTER HEALTH PLAN HMO PLANS", "methodology": "per diem", "standard_charge_dollar": 28538.0, "standard_charge_algorithm": "Per diem ($28,538).", "count": "0", "additional_payer_notes": "Zero final payments for the item or service in the 15 months prior to posting the file." }, { "payer_name": "UNITED HEALTHCARE", "plan_name": "SUTTER SELECT & SUTTER HEALTH PLAN HMO PLANS", "methodology": "per diem", "standard_charge_dollar": 28538.0, "standard_charge_algorithm": "Per diem ($28,538).", "count": "0", "additional_payer_notes": "Zero final payments for the item or service in the 15 months prior to posting the file." }, { "payer_name": "SUTTER", "plan_name": "SUTTER SELECT & SUTTER HEALTH PLAN HMO PLANS", "methodology": "per diem", "standard_charge_dollar": 28538.0, "standard_charge_algorithm": "Per diem ($28,538).", "count": "0", "additional_payer_notes": "Zero final payments for the item or service in the 15 months prior to posting the file." }, { "payer_name": "UNITED HEALTHCARE", "plan_name": "SUTTER SELECT & SUTTER HEALTH PLAN HMO PLANS", "methodology": "per diem", "standard_charge_dollar": 28538.0, "standard_charge_algorithm": "Per diem ($28,538).", "count": "0", "additional_payer_notes": "Zero final payments for the item or service in the 15 months prior to posting the file." }, { "payer_name": "UMR", "plan_name": "SUTTER SELECT & SUTTER HEALTH PLAN HMO PLANS", "methodology": "per diem", "standard_charge_dollar": 28538.0, "standard_charge_algorithm": "Per diem ($28,538).", "count": "0", "additional_payer_notes": "Zero final payments for the item or service in the 15 months prior to posting the file." } ] } ] }, { "description": "Hc Applier Endoclip Gp019", "code_information": [ { "code": "PX-2120006019", "type": "CDM" }, { "code": "99999", "type": "CPT" }, { "code": "0272", "type": "RC" } ], "standard_charges": [ { "setting": "outpatient", "gross_charge": 2125.0, "discounted_cash": 1062.5, "minimum": 896.75, "maximum": 1105.0, "additional_generic_notes": "Zero final payments for the item or service in the 15 months prior to posting the file.", "payers_information": [ { "payer_name": "AETNA", "plan_name": "AETNA ALL OTHER PLANS", "methodology": "percent of total billed charges", "standard_charge_dollar": 1105.0, "standard_charge_percentage": 52.0, "count": "0", "additional_payer_notes": "Zero final payments for the item or service in the 15 months prior to posting the file." }, { "payer_name": "AETNA", "plan_name": "AETNA ALL OTHER PLANS", "methodology": "percent of total billed charges", "standard_charge_dollar": 1105.0, "standard_charge_percentage": 52.0, "count": "0", "additional_payer_notes": "Zero final payments for the item or service in the 15 months prior to posting the file." }, { "payer_name": "MERITAIN HEALTH", "plan_name": "AETNA ALL OTHER PLANS", "methodology": "percent of total billed charges", "standard_charge_dollar": 1105.0, "standard_charge_percentage": 52.0, "count": "0", "additional_payer_notes": "Zero final payments for the item or service in the 15 months prior to posting the file." }, { "payer_name": "BLUE SHIELD OUT OF STATE", "plan_name": "STANFORD HEALTHCARE ALLIANCE PLAN", "methodology": "percent of total billed charges", "standard_charge_dollar": 1032.54, "standard_charge_percentage": 48.59, "count": "0", "additional_payer_notes": "Zero final payments for the item or service in the 15 months prior to posting the file." }, { "payer_name": "BLUE SHIELD", "plan_name": "STANFORD HEALTHCARE ALLIANCE PLAN", "methodology": "percent of total billed charges", "standard_charge_dollar": 1032.54, "standard_charge_percentage": 48.59, "median_amount": 68.24, "10th_percentile": 13.6, "90th_percentile": 1043.06, "count": "30" }, { "payer_name": "BLUE SHIELD", "plan_name": "STANFORD HEALTHCARE ALLIANCE PLAN", "methodology": "percent of total billed charges", "standard_charge_dollar": 1032.54, "standard_charge_percentage": 48.59, "count": "0", "additional_payer_notes": "Zero final payments for the item or service in the 15 months prior to posting the file." }, { "payer_name": "BLUE SHIELD", "plan_name": "STANFORD HEALTHCARE ALLIANCE PLAN", "methodology": "percent of total billed charges", "standard_charge_dollar": 1032.54, "standard_charge_percentage": 48.59, "count": "0", "additional_payer_notes": "Zero final payments for the item or service in the 15 months prior to posting the file." }, { "payer_name": "CIGNA", "plan_name": "CIGNA COM ALT HMO PLAN", "methodology": "percent of total billed charges", "standard_charge_dollar": 896.75, "standard_charge_percentage": 42.2, "count": "0", "additional_payer_notes": "Zero final payments for the item or service in the 15 months prior to posting the file." }, { "payer_name": "CIGNA", "plan_name": "CIGNA COM ALT HMO PLAN", "methodology": "percent of total billed charges", "standard_charge_dollar": 896.75, "standard_charge_percentage": 42.2, "count": "0", "additional_payer_notes": "Zero final payments for the item or service in the 15 months prior to posting the file." }, { "payer_name": "HEALTH NET", "plan_name": "HEALTHNET HMO, PPO, POS, EPO, CANOPY HEALTHNET HMO, OTHER-IN-NETWORK PLANS", "methodology": "per diem", "standard_charge_dollar": 8000.0, "standard_charge_algorithm": "Expected reimbursement is the lesser of Per diem ($8,000) for the length of stay and 70% of billed.", "count": "0", "additional_payer_notes": "Zero final payments for the item or service in the 15 months prior to posting the file." }, { "payer_name": "HEALTH NET", "plan_name": "HEALTHNET HMO, PPO, POS, EPO, CANOPY HEALTHNET HMO, OTHER-IN-NETWORK PLANS", "methodology": "per diem", "standard_charge_dollar": 8000.0, "standard_charge_algorithm": "Expected reimbursement is the lesser of Per diem ($8,000) for the length of stay and 70% of billed.", "count": "0", "additional_payer_notes": "Zero final payments for the item or service in the 15 months prior to posting the file." }, { "payer_name": "UNITED HEALTHCARE", "plan_name": "SUTTER SELECT & SUTTER HEALTH PLAN HMO PLANS", "methodology": "per diem", "standard_charge_dollar": 28538.0, "standard_charge_algorithm": "Per diem ($28,538).", "count": "0", "additional_payer_notes": "Zero final payments for the item or service in the 15 months prior to posting the file." }, { "payer_name": "UNITED HEALTHCARE", "plan_name": "SUTTER SELECT & SUTTER HEALTH PLAN HMO PLANS", "methodology": "per diem", "standard_charge_dollar": 28538.0, "standard_charge_algorithm": "Per diem ($28,538).", "count": "0", "additional_payer_notes": "Zero final payments for the item or service in the 15 months prior to posting the file." }, { "payer_name": "SUTTER", "plan_name": "SUTTER SELECT & SUTTER HEALTH PLAN HMO PLANS", "methodology": "per diem", "standard_charge_dollar": 28538.0, "standard_charge_algorithm": "Per diem ($28,538).", "count": "0", "additional_payer_notes": "Zero final payments for the item or service in the 15 months prior to posting the file." }, { "payer_name": "UNITED HEALTHCARE", "plan_name": "SUTTER SELECT & SUTTER HEALTH PLAN HMO PLANS", "methodology": "per diem", "standard_charge_dollar": 28538.0, "standard_charge_algorithm": "Per diem ($28,538).", "count": "0", "additional_payer_notes": "Zero final payments for the item or service in the 15 months prior to posting the file." }, { "payer_name": "UMR", "plan_name": "SUTTER SELECT & SUTTER HEALTH PLAN HMO PLANS", "methodology": "per diem", "standard_charge_dollar": 28538.0, "standard_charge_algorithm": "Per diem ($28,538).", "count": "0", "additional_payer_notes": "Zero final payments for the item or service in the 15 months prior to posting the file." } ] } ] }, { "description": "HC Bag Drainage Gp002", "code_information": [ { "code": "PX-2120007002", "type": "CDM" }, { "code": "99999", "type": "CPT" }, { "code": "0272", "type": "RC" } ], "standard_charges": [ { "setting": "outpatient", "gross_charge": 50.0, "discounted_cash": 25.0, "minimum": 21.1, "maximum": 26.0, "additional_generic_notes": "Zero final payments for the item or service in the 15 months prior to posting the file.", "payers_information": [ { "payer_name": "AETNA", "plan_name": "AETNA ALL OTHER PLANS", "methodology": "percent of total billed charges", "standard_charge_dollar": 26.0, "standard_charge_percentage": 52.0, "count": "0", "additional_payer_notes": "Zero final payments for the item or service in the 15 months prior to posting the file." }, { "payer_name": "AETNA", "plan_name": "AETNA ALL OTHER PLANS", "methodology": "percent of total billed charges", "standard_charge_dollar": 26.0, "standard_charge_percentage": 52.0, "count": "0", "additional_payer_notes": "Zero final payments for the item or service in the 15 months prior to posting the file." }, { "payer_name": "MERITAIN HEALTH", "plan_name": "AETNA ALL OTHER PLANS", "methodology": "percent of total billed charges", "standard_charge_dollar": 26.0, "standard_charge_percentage": 52.0, "count": "0", "additional_payer_notes": "Zero final payments for the item or service in the 15 months prior to posting the file." }, { "payer_name": "BLUE SHIELD OUT OF STATE", "plan_name": "STANFORD HEALTHCARE ALLIANCE PLAN", "methodology": "percent of total billed charges", "standard_charge_dollar": 24.3, "standard_charge_percentage": 48.59, "count": "0", "additional_payer_notes": "Zero final payments for the item or service in the 15 months prior to posting the file." }, { "payer_name": "BLUE SHIELD", "plan_name": "STANFORD HEALTHCARE ALLIANCE PLAN", "methodology": "percent of total billed charges", "standard_charge_dollar": 24.3, "standard_charge_percentage": 48.59, "count": "0", "additional_payer_notes": "Zero final payments for the item or service in the 15 months prior to posting the file." }, { "payer_name": "BLUE SHIELD", "plan_name": "STANFORD HEALTHCARE ALLIANCE PLAN", "methodology": "percent of total billed charges", "standard_charge_dollar": 24.3, "standard_charge_percentage": 48.59, "count": "0", "additional_payer_notes": "Zero final payments for the item or service in the 15 months prior to posting the file." }, { "payer_name": "CIGNA", "plan_name": "CIGNA COM ALT HMO PLAN", "methodology": "percent of total billed charges", "standard_charge_dollar": 21.1, "standard_charge_percentage": 42.2, "count": "0", "additional_payer_notes": "Zero final payments for the item or service in the 15 months prior to posting the file." }, { "payer_name": "CIGNA", "plan_name": "CIGNA COM ALT HMO PLAN", "methodology": "percent of total billed charges", "standard_charge_dollar": 21.1, "standard_charge_percentage": 42.2, "count": "0", "additional_payer_notes": "Zero final payments for the item or service in the 15 months prior to posting the file." }, { "payer_name": "HEALTH NET", "plan_name": "HEALTHNET HMO, PPO, POS, EPO, CANOPY HEALTHNET HMO, OTHER-IN-NETWORK PLANS", "methodology": "per diem", "standard_charge_dollar": 8000.0, "standard_charge_algorithm": "Expected reimbursement is the lesser of Per diem ($8,000) for the length of stay and 70% of billed.", "count": "0", "additional_payer_notes": "Zero final payments for the item or service in the 15 months prior to posting the file." }, { "payer_name": "HEALTH NET", "plan_name": "HEALTHNET HMO, PPO, POS, EPO, CANOPY HEALTHNET HMO, OTHER-IN-NETWORK PLANS", "methodology": "per diem", "standard_charge_dollar": 8000.0, "standard_charge_algorithm": "Expected reimbursement is the lesser of Per diem ($8,000) for the length of stay and 70% of billed.", "count": "0", "additional_payer_notes": "Zero final payments for the item or service in the 15 months prior to posting the file." }, { "payer_name": "UNITED HEALTHCARE", "plan_name": "SUTTER SELECT & SUTTER HEALTH PLAN HMO PLANS", "methodology": "per diem", "standard_charge_dollar": 28538.0, "standard_charge_algorithm": "Per diem ($28,538).", "count": "0", "additional_payer_notes": "Zero final payments for the item or service in the 15 months prior to posting the file." }, { "payer_name": "UNITED HEALTHCARE", "plan_name": "SUTTER SELECT & SUTTER HEALTH PLAN HMO PLANS", "methodology": "per diem", "standard_charge_dollar": 28538.0, "standard_charge_algorithm": "Per diem ($28,538).", "count": "0", "additional_payer_notes": "Zero final payments for the item or service in the 15 months prior to posting the file." }, { "payer_name": "SUTTER", "plan_name": "SUTTER SELECT & SUTTER HEALTH PLAN HMO PLANS", "methodology": "per diem", "standard_charge_dollar": 28538.0, "standard_charge_algorithm": "Per diem ($28,538).", "count": "0", "additional_payer_notes": "Zero final payments for the item or service in the 15 months prior to posting the file." }, { "payer_name": "UNITED HEALTHCARE", "plan_name": "SUTTER SELECT & SUTTER HEALTH PLAN HMO PLANS", "methodology": "per diem", "standard_charge_dollar": 28538.0, "standard_charge_algorithm": "Per diem ($28,538).", "count": "0", "additional_payer_notes": "Zero final payments for the item or service in the 15 months prior to posting the file." }, { "payer_name": "UMR", "plan_name": "SUTTER SELECT & SUTTER HEALTH PLAN HMO PLANS", "methodology": "per diem", "standard_charge_dollar": 28538.0, "standard_charge_algorithm": "Per diem ($28,538).", "count": "0", "additional_payer_notes": "Zero final payments for the item or service in the 15 months prior to posting the file." } ] } ] }, { "description": "HC Bag Drainage Gp003", "code_information": [ { "code": "PX-2120007003", "type": "CDM" }, { "code": "99999", "type": "CPT" }, { "code": "0272", "type": "RC" } ], "standard_charges": [ { "setting": "outpatient", "gross_charge": 100.0, "discounted_cash": 50.0, "minimum": 42.2, "maximum": 52.0, "additional_generic_notes": "Zero final payments for the item or service in the 15 months prior to posting the file.", "payers_information": [ { "payer_name": "AETNA", "plan_name": "AETNA ALL OTHER PLANS", "methodology": "percent of total billed charges", "standard_charge_dollar": 52.0, "standard_charge_percentage": 52.0, "count": "0", "additional_payer_notes": "Zero final payments for the item or service in the 15 months prior to posting the file." }, { "payer_name": "AETNA", "plan_name": "AETNA ALL OTHER PLANS", "methodology": "percent of total billed charges", "standard_charge_dollar": 52.0, "standard_charge_percentage": 52.0, "count": "0", "additional_payer_notes": "Zero final payments for the item or service in the 15 months prior to posting the file." }, { "payer_name": "MERITAIN HEALTH", "plan_name": "AETNA ALL OTHER PLANS", "methodology": "percent of total billed charges", "standard_charge_dollar": 52.0, "standard_charge_percentage": 52.0, "count": "0", "additional_payer_notes": "Zero final payments for the item or service in the 15 months prior to posting the file." }, { "payer_name": "BLUE SHIELD OUT OF STATE", "plan_name": "STANFORD HEALTHCARE ALLIANCE PLAN", "methodology": "percent of total billed charges", "standard_charge_dollar": 48.59, "standard_charge_percentage": 48.59, "count": "0", "additional_payer_notes": "Zero final payments for the item or service in the 15 months prior to posting the file." }, { "payer_name": "BLUE SHIELD", "plan_name": "STANFORD HEALTHCARE ALLIANCE PLAN", "methodology": "percent of total billed charges", "standard_charge_dollar": 48.59, "standard_charge_percentage": 48.59, "count": "0", "additional_payer_notes": "Zero final payments for the item or service in the 15 months prior to posting the file." }, { "payer_name": "BLUE SHIELD", "plan_name": "STANFORD HEALTHCARE ALLIANCE PLAN", "methodology": "percent of total billed charges", "standard_charge_dollar": 48.59, "standard_charge_percentage": 48.59, "count": "0", "additional_payer_notes": "Zero final payments for the item or service in the 15 months prior to posting the file." }, { "payer_name": "CIGNA", "plan_name": "CIGNA COM ALT HMO PLAN", "methodology": "percent of total billed charges", "standard_charge_dollar": 42.2, "standard_charge_percentage": 42.2, "count": "0", "additional_payer_notes": "Zero final payments for the item or service in the 15 months prior to posting the file." }, { "payer_name": "CIGNA", "plan_name": "CIGNA COM ALT HMO PLAN", "methodology": "percent of total billed charges", "standard_charge_dollar": 42.2, "standard_charge_percentage": 42.2, "count": "0", "additional_payer_notes": "Zero final payments for the item or service in the 15 months prior to posting the file." }, { "payer_name": "HEALTH NET", "plan_name": "HEALTHNET HMO, PPO, POS, EPO, CANOPY HEALTHNET HMO, OTHER-IN-NETWORK PLANS", "methodology": "per diem", "standard_charge_dollar": 8000.0, "standard_charge_algorithm": "Expected reimbursement is the lesser of Per diem ($8,000) for the length of stay and 70% of billed.", "count": "0", "additional_payer_notes": "Zero final payments for the item or service in the 15 months prior to posting the file." }, { "payer_name": "HEALTH NET", "plan_name": "HEALTHNET HMO, PPO, POS, EPO, CANOPY HEALTHNET HMO, OTHER-IN-NETWORK PLANS", "methodology": "per diem", "standard_charge_dollar": 8000.0, "standard_charge_algorithm": "Expected reimbursement is the lesser of Per diem ($8,000) for the length of stay and 70% of billed.", "count": "0", "additional_payer_notes": "Zero final payments for the item or service in the 15 months prior to posting the file." }, { "payer_name": "UNITED HEALTHCARE", "plan_name": "SUTTER SELECT & SUTTER HEALTH PLAN HMO PLANS", "methodology": "per diem", "standard_charge_dollar": 28538.0, "standard_charge_algorithm": "Per diem ($28,538).", "count": "0", "additional_payer_notes": "Zero final payments for the item or service in the 15 months prior to posting the file." }, { "payer_name": "UNITED HEALTHCARE", "plan_name": "SUTTER SELECT & SUTTER HEALTH PLAN HMO PLANS", "methodology": "per diem", "standard_charge_dollar": 28538.0, "standard_charge_algorithm": "Per diem ($28,538).", "count": "0", "additional_payer_notes": "Zero final payments for the item or service in the 15 months prior to posting the file." }, { "payer_name": "SUTTER", "plan_name": "SUTTER SELECT & SUTTER HEALTH PLAN HMO PLANS", "methodology": "per diem", "standard_charge_dollar": 28538.0, "standard_charge_algorithm": "Per diem ($28,538).", "count": "0", "additional_payer_notes": "Zero final payments for the item or service in the 15 months prior to posting the file." }, { "payer_name": "UNITED HEALTHCARE", "plan_name": "SUTTER SELECT & SUTTER HEALTH PLAN HMO PLANS", "methodology": "per diem", "standard_charge_dollar": 28538.0, "standard_charge_algorithm": "Per diem ($28,538).", "count": "0", "additional_payer_notes": "Zero final payments for the item or service in the 15 months prior to posting the file." }, { "payer_name": "UMR", "plan_name": "SUTTER SELECT & SUTTER HEALTH PLAN HMO PLANS", "methodology": "per diem", "standard_charge_dollar": 28538.0, "standard_charge_algorithm": "Per diem ($28,538).", "count": "0", "additional_payer_notes": "Zero final payments for the item or service in the 15 months prior to posting the file." } ] } ] }, { "description": "HC Bag Drainage Gp004", "code_information": [ { "code": "PX-2120007004", "type": "CDM" }, { "code": "99999", "type": "CPT" }, { "code": "0272", "type": "RC" } ], "standard_charges": [ { "setting": "outpatient", "gross_charge": 146.0, "discounted_cash": 73.0, "minimum": 61.61, "maximum": 75.92, "additional_generic_notes": "Zero final payments for the item or service in the 15 months prior to posting the file.", "payers_information": [ { "payer_name": "AETNA", "plan_name": "AETNA ALL OTHER PLANS", "methodology": "percent of total billed charges", "standard_charge_dollar": 75.92, "standard_charge_percentage": 52.0, "count": "0", "additional_payer_notes": "Zero final payments for the item or service in the 15 months prior to posting the file." }, { "payer_name": "AETNA", "plan_name": "AETNA ALL OTHER PLANS", "methodology": "percent of total billed charges", "standard_charge_dollar": 75.92, "standard_charge_percentage": 52.0, "count": "0", "additional_payer_notes": "Zero final payments for the item or service in the 15 months prior to posting the file." }, { "payer_name": "MERITAIN HEALTH", "plan_name": "AETNA ALL OTHER PLANS", "methodology": "percent of total billed charges", "standard_charge_dollar": 75.92, "standard_charge_percentage": 52.0, "count": "0", "additional_payer_notes": "Zero final payments for the item or service in the 15 months prior to posting the file." }, { "payer_name": "BLUE SHIELD OUT OF STATE", "plan_name": "STANFORD HEALTHCARE ALLIANCE PLAN", "methodology": "percent of total billed charges", "standard_charge_dollar": 70.94, "standard_charge_percentage": 48.59, "count": "0", "additional_payer_notes": "Zero final payments for the item or service in the 15 months prior to posting the file." }, { "payer_name": "BLUE SHIELD", "plan_name": "STANFORD HEALTHCARE ALLIANCE PLAN", "methodology": "percent of total billed charges", "standard_charge_dollar": 70.94, "standard_charge_percentage": 48.59, "count": "0", "additional_payer_notes": "Zero final payments for the item or service in the 15 months prior to posting the file." }, { "payer_name": "BLUE SHIELD", "plan_name": "STANFORD HEALTHCARE ALLIANCE PLAN", "methodology": "percent of total billed charges", "standard_charge_dollar": 70.94, "standard_charge_percentage": 48.59, "count": "0", "additional_payer_notes": "Zero final payments for the item or service in the 15 months prior to posting the file." }, { "payer_name": "CIGNA", "plan_name": "CIGNA COM ALT HMO PLAN", "methodology": "percent of total billed charges", "standard_charge_dollar": 61.61, "standard_charge_percentage": 42.2, "count": "0", "additional_payer_notes": "Zero final payments for the item or service in the 15 months prior to posting the file." }, { "payer_name": "CIGNA", "plan_name": "CIGNA COM ALT HMO PLAN", "methodology": "percent of total billed charges", "standard_charge_dollar": 61.61, "standard_charge_percentage": 42.2, "count": "0", "additional_payer_notes": "Zero final payments for the item or service in the 15 months prior to posting the file." }, { "payer_name": "HEALTH NET", "plan_name": "HEALTHNET HMO, PPO, POS, EPO, CANOPY HEALTHNET HMO, OTHER-IN-NETWORK PLANS", "methodology": "per diem", "standard_charge_dollar": 8000.0, "standard_charge_algorithm": "Expected reimbursement is the lesser of Per diem ($8,000) for the length of stay and 70% of billed.", "count": "0", "additional_payer_notes": "Zero final payments for the item or service in the 15 months prior to posting the file." }, { "payer_name": "HEALTH NET", "plan_name": "HEALTHNET HMO, PPO, POS, EPO, CANOPY HEALTHNET HMO, OTHER-IN-NETWORK PLANS", "methodology": "per diem", "standard_charge_dollar": 8000.0, "standard_charge_algorithm": "Expected reimbursement is the lesser of Per diem ($8,000) for the length of stay and 70% of billed.", "count": "0", "additional_payer_notes": "Zero final payments for the item or service in the 15 months prior to posting the file." }, { "payer_name": "UNITED HEALTHCARE", "plan_name": "SUTTER SELECT & SUTTER HEALTH PLAN HMO PLANS", "methodology": "per diem", "standard_charge_dollar": 28538.0, "standard_charge_algorithm": "Per diem ($28,538).", "count": "0", "additional_payer_notes": "Zero final payments for the item or service in the 15 months prior to posting the file." }, { "payer_name": "UNITED HEALTHCARE", "plan_name": "SUTTER SELECT & SUTTER HEALTH PLAN HMO PLANS", "methodology": "per diem", "standard_charge_dollar": 28538.0, "standard_charge_algorithm": "Per diem ($28,538).", "count": "0", "additional_payer_notes": "Zero final payments for the item or service in the 15 months prior to posting the file." }, { "payer_name": "SUTTER", "plan_name": "SUTTER SELECT & SUTTER HEALTH PLAN HMO PLANS", "methodology": "per diem", "standard_charge_dollar": 28538.0, "standard_charge_algorithm": "Per diem ($28,538).", "count": "0", "additional_payer_notes": "Zero final payments for the item or service in the 15 months prior to posting the file." }, { "payer_name": "UNITED HEALTHCARE", "plan_name": "SUTTER SELECT & SUTTER HEALTH PLAN HMO PLANS", "methodology": "per diem", "standard_charge_dollar": 28538.0, "standard_charge_algorithm": "Per diem ($28,538).", "count": "0", "additional_payer_notes": "Zero final payments for the item or service in the 15 months prior to posting the file." }, { "payer_name": "UMR", "plan_name": "SUTTER SELECT & SUTTER HEALTH PLAN HMO PLANS", "methodology": "per diem", "standard_charge_dollar": 28538.0, "standard_charge_algorithm": "Per diem ($28,538).", "count": "0", "additional_payer_notes": "Zero final payments for the item or service in the 15 months prior to posting the file." } ] } ] }, { "description": "HC Bag Drainage Gp005", "code_information": [ { "code": "PX-2120007005", "type": "CDM" }, { "code": "99999", "type": "CPT" }, { "code": "0272", "type": "RC" } ], "standard_charges": [ { "setting": "outpatient", "gross_charge": 195.0, "discounted_cash": 97.5, "minimum": 82.29, "maximum": 101.4, "additional_generic_notes": "Zero final payments for the item or service in the 15 months prior to posting the file.", "payers_information": [ { "payer_name": "AETNA", "plan_name": "AETNA ALL OTHER PLANS", "methodology": "percent of total billed charges", "standard_charge_dollar": 101.4, "standard_charge_percentage": 52.0, "count": "0", "additional_payer_notes": "Zero final payments for the item or service in the 15 months prior to posting the file." }, { "payer_name": "AETNA", "plan_name": "AETNA ALL OTHER PLANS", "methodology": "percent of total billed charges", "standard_charge_dollar": 101.4, "standard_charge_percentage": 52.0, "count": "0", "additional_payer_notes": "Zero final payments for the item or service in the 15 months prior to posting the file." }, { "payer_name": "MERITAIN HEALTH", "plan_name": "AETNA ALL OTHER PLANS", "methodology": "percent of total billed charges", "standard_charge_dollar": 101.4, "standard_charge_percentage": 52.0, "count": "0", "additional_payer_notes": "Zero final payments for the item or service in the 15 months prior to posting the file." }, { "payer_name": "BLUE SHIELD OUT OF STATE", "plan_name": "STANFORD HEALTHCARE ALLIANCE PLAN", "methodology": "percent of total billed charges", "standard_charge_dollar": 94.75, "standard_charge_percentage": 48.59, "count": "0", "additional_payer_notes": "Zero final payments for the item or service in the 15 months prior to posting the file." }, { "payer_name": "BLUE SHIELD", "plan_name": "STANFORD HEALTHCARE ALLIANCE PLAN", "methodology": "percent of total billed charges", "standard_charge_dollar": 94.75, "standard_charge_percentage": 48.59, "count": "0", "additional_payer_notes": "Zero final payments for the item or service in the 15 months prior to posting the file." }, { "payer_name": "BLUE SHIELD", "plan_name": "STANFORD HEALTHCARE ALLIANCE PLAN", "methodology": "percent of total billed charges", "standard_charge_dollar": 94.75, "standard_charge_percentage": 48.59, "count": "0", "additional_payer_notes": "Zero final payments for the item or service in the 15 months prior to posting the file." }, { "payer_name": "CIGNA", "plan_name": "CIGNA COM ALT HMO PLAN", "methodology": "percent of total billed charges", "standard_charge_dollar": 82.29, "standard_charge_percentage": 42.2, "count": "0", "additional_payer_notes": "Zero final payments for the item or service in the 15 months prior to posting the file." }, { "payer_name": "CIGNA", "plan_name": "CIGNA COM ALT HMO PLAN", "methodology": "percent of total billed charges", "standard_charge_dollar": 82.29, "standard_charge_percentage": 42.2, "count": "0", "additional_payer_notes": "Zero final payments for the item or service in the 15 months prior to posting the file." }, { "payer_name": "HEALTH NET", "plan_name": "HEALTHNET HMO, PPO, POS, EPO, CANOPY HEALTHNET HMO, OTHER-IN-NETWORK PLANS", "methodology": "per diem", "standard_charge_dollar": 8000.0, "standard_charge_algorithm": "Expected reimbursement is the lesser of Per diem ($8,000) for the length of stay and 70% of billed.", "count": "0", "additional_payer_notes": "Zero final payments for the item or service in the 15 months prior to posting the file." }, { "payer_name": "HEALTH NET", "plan_name": "HEALTHNET HMO, PPO, POS, EPO, CANOPY HEALTHNET HMO, OTHER-IN-NETWORK PLANS", "methodology": "per diem", "standard_charge_dollar": 8000.0, "standard_charge_algorithm": "Expected reimbursement is the lesser of Per diem ($8,000) for the length of stay and 70% of billed.", "count": "0", "additional_payer_notes": "Zero final payments for the item or service in the 15 months prior to posting the file." }, { "payer_name": "UNITED HEALTHCARE", "plan_name": "SUTTER SELECT & SUTTER HEALTH PLAN HMO PLANS", "methodology": "per diem", "standard_charge_dollar": 28538.0, "standard_charge_algorithm": "Per diem ($28,538).", "count": "0", "additional_payer_notes": "Zero final payments for the item or service in the 15 months prior to posting the file." }, { "payer_name": "UNITED HEALTHCARE", "plan_name": "SUTTER SELECT & SUTTER HEALTH PLAN HMO PLANS", "methodology": "per diem", "standard_charge_dollar": 28538.0, "standard_charge_algorithm": "Per diem ($28,538).", "count": "0", "additional_payer_notes": "Zero final payments for the item or service in the 15 months prior to posting the file." }, { "payer_name": "SUTTER", "plan_name": "SUTTER SELECT & SUTTER HEALTH PLAN HMO PLANS", "methodology": "per diem", "standard_charge_dollar": 28538.0, "standard_charge_algorithm": "Per diem ($28,538).", "count": "0", "additional_payer_notes": "Zero final payments for the item or service in the 15 months prior to posting the file." }, { "payer_name": "UNITED HEALTHCARE", "plan_name": "SUTTER SELECT & SUTTER HEALTH PLAN HMO PLANS", "methodology": "per diem", "standard_charge_dollar": 28538.0, "standard_charge_algorithm": "Per diem ($28,538).", "count": "0", "additional_payer_notes": "Zero final payments for the item or service in the 15 months prior to posting the file." }, { "payer_name": "UMR", "plan_name": "SUTTER SELECT & SUTTER HEALTH PLAN HMO PLANS", "methodology": "per diem", "standard_charge_dollar": 28538.0, "standard_charge_algorithm": "Per diem ($28,538).", "count": "0", "additional_payer_notes": "Zero final payments for the item or service in the 15 months prior to posting the file." } ] } ] }, { "description": "HC Bag Drainage Gp006", "code_information": [ { "code": "PX-2120007006", "type": "CDM" }, { "code": "99999", "type": "CPT" }, { "code": "0272", "type": "RC" } ], "standard_charges": [ { "setting": "outpatient", "gross_charge": 293.0, "discounted_cash": 146.5, "minimum": 123.65, "maximum": 152.36, "additional_generic_notes": "Zero final payments for the item or service in the 15 months prior to posting the file.", "payers_information": [ { "payer_name": "AETNA", "plan_name": "AETNA ALL OTHER PLANS", "methodology": "percent of total billed charges", "standard_charge_dollar": 152.36, "standard_charge_percentage": 52.0, "count": "0", "additional_payer_notes": "Zero final payments for the item or service in the 15 months prior to posting the file." }, { "payer_name": "AETNA", "plan_name": "AETNA ALL OTHER PLANS", "methodology": "percent of total billed charges", "standard_charge_dollar": 152.36, "standard_charge_percentage": 52.0, "count": "0", "additional_payer_notes": "Zero final payments for the item or service in the 15 months prior to posting the file." }, { "payer_name": "MERITAIN HEALTH", "plan_name": "AETNA ALL OTHER PLANS", "methodology": "percent of total billed charges", "standard_charge_dollar": 152.36, "standard_charge_percentage": 52.0, "count": "0", "additional_payer_notes": "Zero final payments for the item or service in the 15 months prior to posting the file." }, { "payer_name": "BLUE SHIELD OUT OF STATE", "plan_name": "STANFORD HEALTHCARE ALLIANCE PLAN", "methodology": "percent of total billed charges", "standard_charge_dollar": 142.37, "standard_charge_percentage": 48.59, "count": "0", "additional_payer_notes": "Zero final payments for the item or service in the 15 months prior to posting the file." }, { "payer_name": "BLUE SHIELD", "plan_name": "STANFORD HEALTHCARE ALLIANCE PLAN", "methodology": "percent of total billed charges", "standard_charge_dollar": 142.37, "standard_charge_percentage": 48.59, "count": "0", "additional_payer_notes": "Zero final payments for the item or service in the 15 months prior to posting the file." }, { "payer_name": "BLUE SHIELD", "plan_name": "STANFORD HEALTHCARE ALLIANCE PLAN", "methodology": "percent of total billed charges", "standard_charge_dollar": 142.37, "standard_charge_percentage": 48.59, "count": "0", "additional_payer_notes": "Zero final payments for the item or service in the 15 months prior to posting the file." }, { "payer_name": "CIGNA", "plan_name": "CIGNA COM ALT HMO PLAN", "methodology": "percent of total billed charges", "standard_charge_dollar": 123.65, "standard_charge_percentage": 42.2, "count": "0", "additional_payer_notes": "Zero final payments for the item or service in the 15 months prior to posting the file." }, { "payer_name": "CIGNA", "plan_name": "CIGNA COM ALT HMO PLAN", "methodology": "percent of total billed charges", "standard_charge_dollar": 123.65, "standard_charge_percentage": 42.2, "count": "0", "additional_payer_notes": "Zero final payments for the item or service in the 15 months prior to posting the file." }, { "payer_name": "HEALTH NET", "plan_name": "HEALTHNET HMO, PPO, POS, EPO, CANOPY HEALTHNET HMO, OTHER-IN-NETWORK PLANS", "methodology": "per diem", "standard_charge_dollar": 8000.0, "standard_charge_algorithm": "Expected reimbursement is the lesser of Per diem ($8,000) for the length of stay and 70% of billed.", "count": "0", "additional_payer_notes": "Zero final payments for the item or service in the 15 months prior to posting the file." }, { "payer_name": "HEALTH NET", "plan_name": "HEALTHNET HMO, PPO, POS, EPO, CANOPY HEALTHNET HMO, OTHER-IN-NETWORK PLANS", "methodology": "per diem", "standard_charge_dollar": 8000.0, "standard_charge_algorithm": "Expected reimbursement is the lesser of Per diem ($8,000) for the length of stay and 70% of billed.", "count": "0", "additional_payer_notes": "Zero final payments for the item or service in the 15 months prior to posting the file." }, { "payer_name": "UNITED HEALTHCARE", "plan_name": "SUTTER SELECT & SUTTER HEALTH PLAN HMO PLANS", "methodology": "per diem", "standard_charge_dollar": 28538.0, "standard_charge_algorithm": "Per diem ($28,538).", "count": "0", "additional_payer_notes": "Zero final payments for the item or service in the 15 months prior to posting the file." }, { "payer_name": "UNITED HEALTHCARE", "plan_name": "SUTTER SELECT & SUTTER HEALTH PLAN HMO PLANS", "methodology": "per diem", "standard_charge_dollar": 28538.0, "standard_charge_algorithm": "Per diem ($28,538).", "count": "0", "additional_payer_notes": "Zero final payments for the item or service in the 15 months prior to posting the file." }, { "payer_name": "SUTTER", "plan_name": "SUTTER SELECT & SUTTER HEALTH PLAN HMO PLANS", "methodology": "per diem", "standard_charge_dollar": 28538.0, "standard_charge_algorithm": "Per diem ($28,538).", "count": "0", "additional_payer_notes": "Zero final payments for the item or service in the 15 months prior to posting the file." }, { "payer_name": "UNITED HEALTHCARE", "plan_name": "SUTTER SELECT & SUTTER HEALTH PLAN HMO PLANS", "methodology": "per diem", "standard_charge_dollar": 28538.0, "standard_charge_algorithm": "Per diem ($28,538).", "count": "0", "additional_payer_notes": "Zero final payments for the item or service in the 15 months prior to posting the file." }, { "payer_name": "UMR", "plan_name": "SUTTER SELECT & SUTTER HEALTH PLAN HMO PLANS", "methodology": "per diem", "standard_charge_dollar": 28538.0, "standard_charge_algorithm": "Per diem ($28,538).", "count": "0", "additional_payer_notes": "Zero final payments for the item or service in the 15 months prior to posting the file." } ] } ] }, { "description": "HC Bag Drainage Gp007", "code_information": [ { "code": "PX-2120007007", "type": "CDM" }, { "code": "99999", "type": "CPT" }, { "code": "0272", "type": "RC" } ], "standard_charges": [ { "setting": "outpatient", "gross_charge": 380.0, "discounted_cash": 190.0, "minimum": 160.36, "maximum": 197.6, "additional_generic_notes": "Zero final payments for the item or service in the 15 months prior to posting the file.", "payers_information": [ { "payer_name": "AETNA", "plan_name": "AETNA ALL OTHER PLANS", "methodology": "percent of total billed charges", "standard_charge_dollar": 197.6, "standard_charge_percentage": 52.0, "count": "0", "additional_payer_notes": "Zero final payments for the item or service in the 15 months prior to posting the file." }, { "payer_name": "AETNA", "plan_name": "AETNA ALL OTHER PLANS", "methodology": "percent of total billed charges", "standard_charge_dollar": 197.6, "standard_charge_percentage": 52.0, "count": "0", "additional_payer_notes": "Zero final payments for the item or service in the 15 months prior to posting the file." }, { "payer_name": "MERITAIN HEALTH", "plan_name": "AETNA ALL OTHER PLANS", "methodology": "percent of total billed charges", "standard_charge_dollar": 197.6, "standard_charge_percentage": 52.0, "count": "0", "additional_payer_notes": "Zero final payments for the item or service in the 15 months prior to posting the file." }, { "payer_name": "BLUE SHIELD OUT OF STATE", "plan_name": "STANFORD HEALTHCARE ALLIANCE PLAN", "methodology": "percent of total billed charges", "standard_charge_dollar": 184.64, "standard_charge_percentage": 48.59, "count": "0", "additional_payer_notes": "Zero final payments for the item or service in the 15 months prior to posting the file." }, { "payer_name": "BLUE SHIELD", "plan_name": "STANFORD HEALTHCARE ALLIANCE PLAN", "methodology": "percent of total billed charges", "standard_charge_dollar": 184.64, "standard_charge_percentage": 48.59, "count": "0", "additional_payer_notes": "Zero final payments for the item or service in the 15 months prior to posting the file." }, { "payer_name": "BLUE SHIELD", "plan_name": "STANFORD HEALTHCARE ALLIANCE PLAN", "methodology": "percent of total billed charges", "standard_charge_dollar": 184.64, "standard_charge_percentage": 48.59, "count": "0", "additional_payer_notes": "Zero final payments for the item or service in the 15 months prior to posting the file." }, { "payer_name": "CIGNA", "plan_name": "CIGNA COM ALT HMO PLAN", "methodology": "percent of total billed charges", "standard_charge_dollar": 160.36, "standard_charge_percentage": 42.2, "count": "0", "additional_payer_notes": "Zero final payments for the item or service in the 15 months prior to posting the file." }, { "payer_name": "CIGNA", "plan_name": "CIGNA COM ALT HMO PLAN", "methodology": "percent of total billed charges", "standard_charge_dollar": 160.36, "standard_charge_percentage": 42.2, "count": "0", "additional_payer_notes": "Zero final payments for the item or service in the 15 months prior to posting the file." }, { "payer_name": "HEALTH NET", "plan_name": "HEALTHNET HMO, PPO, POS, EPO, CANOPY HEALTHNET HMO, OTHER-IN-NETWORK PLANS", "methodology": "per diem", "standard_charge_dollar": 8000.0, "standard_charge_algorithm": "Expected reimbursement is the lesser of Per diem ($8,000) for the length of stay and 70% of billed.", "count": "0", "additional_payer_notes": "Zero final payments for the item or service in the 15 months prior to posting the file." }, { "payer_name": "HEALTH NET", "plan_name": "HEALTHNET HMO, PPO, POS, EPO, CANOPY HEALTHNET HMO, OTHER-IN-NETWORK PLANS", "methodology": "per diem", "standard_charge_dollar": 8000.0, "standard_charge_algorithm": "Expected reimbursement is the lesser of Per diem ($8,000) for the length of stay and 70% of billed.", "count": "0", "additional_payer_notes": "Zero final payments for the item or service in the 15 months prior to posting the file." }, { "payer_name": "UNITED HEALTHCARE", "plan_name": "SUTTER SELECT & SUTTER HEALTH PLAN HMO PLANS", "methodology": "per diem", "standard_charge_dollar": 28538.0, "standard_charge_algorithm": "Per diem ($28,538).", "count": "0", "additional_payer_notes": "Zero final payments for the item or service in the 15 months prior to posting the file." }, { "payer_name": "UNITED HEALTHCARE", "plan_name": "SUTTER SELECT & SUTTER HEALTH PLAN HMO PLANS", "methodology": "per diem", "standard_charge_dollar": 28538.0, "standard_charge_algorithm": "Per diem ($28,538).", "count": "0", "additional_payer_notes": "Zero final payments for the item or service in the 15 months prior to posting the file." }, { "payer_name": "SUTTER", "plan_name": "SUTTER SELECT & SUTTER HEALTH PLAN HMO PLANS", "methodology": "per diem", "standard_charge_dollar": 28538.0, "standard_charge_algorithm": "Per diem ($28,538).", "count": "0", "additional_payer_notes": "Zero final payments for the item or service in the 15 months prior to posting the file." }, { "payer_name": "UNITED HEALTHCARE", "plan_name": "SUTTER SELECT & SUTTER HEALTH PLAN HMO PLANS", "methodology": "per diem", "standard_charge_dollar": 28538.0, "standard_charge_algorithm": "Per diem ($28,538).", "count": "0", "additional_payer_notes": "Zero final payments for the item or service in the 15 months prior to posting the file." }, { "payer_name": "UMR", "plan_name": "SUTTER SELECT & SUTTER HEALTH PLAN HMO PLANS", "methodology": "per diem", "standard_charge_dollar": 28538.0, "standard_charge_algorithm": "Per diem ($28,538).", "count": "0", "additional_payer_notes": "Zero final payments for the item or service in the 15 months prior to posting the file." } ] } ] }, { "description": "HC Bag Drainage Gp008", "code_information": [ { "code": "PX-2120007008", "type": "CDM" }, { "code": "99999", "type": "CPT" }, { "code": "0272", "type": "RC" } ], "standard_charges": [ { "setting": "outpatient", "gross_charge": 475.0, "discounted_cash": 237.5, "minimum": 200.45, "maximum": 247.0, "additional_generic_notes": "Zero final payments for the item or service in the 15 months prior to posting the file.", "payers_information": [ { "payer_name": "AETNA", "plan_name": "AETNA ALL OTHER PLANS", "methodology": "percent of total billed charges", "standard_charge_dollar": 247.0, "standard_charge_percentage": 52.0, "count": "0", "additional_payer_notes": "Zero final payments for the item or service in the 15 months prior to posting the file." }, { "payer_name": "AETNA", "plan_name": "AETNA ALL OTHER PLANS", "methodology": "percent of total billed charges", "standard_charge_dollar": 247.0, "standard_charge_percentage": 52.0, "count": "0", "additional_payer_notes": "Zero final payments for the item or service in the 15 months prior to posting the file." }, { "payer_name": "MERITAIN HEALTH", "plan_name": "AETNA ALL OTHER PLANS", "methodology": "percent of total billed charges", "standard_charge_dollar": 247.0, "standard_charge_percentage": 52.0, "count": "0", "additional_payer_notes": "Zero final payments for the item or service in the 15 months prior to posting the file." }, { "payer_name": "BLUE SHIELD OUT OF STATE", "plan_name": "STANFORD HEALTHCARE ALLIANCE PLAN", "methodology": "percent of total billed charges", "standard_charge_dollar": 230.8, "standard_charge_percentage": 48.59, "count": "0", "additional_payer_notes": "Zero final payments for the item or service in the 15 months prior to posting the file." }, { "payer_name": "BLUE SHIELD", "plan_name": "STANFORD HEALTHCARE ALLIANCE PLAN", "methodology": "percent of total billed charges", "standard_charge_dollar": 230.8, "standard_charge_percentage": 48.59, "count": "0", "additional_payer_notes": "Zero final payments for the item or service in the 15 months prior to posting the file." }, { "payer_name": "BLUE SHIELD", "plan_name": "STANFORD HEALTHCARE ALLIANCE PLAN", "methodology": "percent of total billed charges", "standard_charge_dollar": 230.8, "standard_charge_percentage": 48.59, "count": "0", "additional_payer_notes": "Zero final payments for the item or service in the 15 months prior to posting the file." }, { "payer_name": "CIGNA", "plan_name": "CIGNA COM ALT HMO PLAN", "methodology": "percent of total billed charges", "standard_charge_dollar": 200.45, "standard_charge_percentage": 42.2, "count": "0", "additional_payer_notes": "Zero final payments for the item or service in the 15 months prior to posting the file." }, { "payer_name": "CIGNA", "plan_name": "CIGNA COM ALT HMO PLAN", "methodology": "percent of total billed charges", "standard_charge_dollar": 200.45, "standard_charge_percentage": 42.2, "count": "0", "additional_payer_notes": "Zero final payments for the item or service in the 15 months prior to posting the file." }, { "payer_name": "HEALTH NET", "plan_name": "HEALTHNET HMO, PPO, POS, EPO, CANOPY HEALTHNET HMO, OTHER-IN-NETWORK PLANS", "methodology": "per diem", "standard_charge_dollar": 8000.0, "standard_charge_algorithm": "Expected reimbursement is the lesser of Per diem ($8,000) for the length of stay and 70% of billed.", "count": "0", "additional_payer_notes": "Zero final payments for the item or service in the 15 months prior to posting the file." }, { "payer_name": "HEALTH NET", "plan_name": "HEALTHNET HMO, PPO, POS, EPO, CANOPY HEALTHNET HMO, OTHER-IN-NETWORK PLANS", "methodology": "per diem", "standard_charge_dollar": 8000.0, "standard_charge_algorithm": "Expected reimbursement is the lesser of Per diem ($8,000) for the length of stay and 70% of billed.", "count": "0", "additional_payer_notes": "Zero final payments for the item or service in the 15 months prior to posting the file." }, { "payer_name": "UNITED HEALTHCARE", "plan_name": "SUTTER SELECT & SUTTER HEALTH PLAN HMO PLANS", "methodology": "per diem", "standard_charge_dollar": 28538.0, "standard_charge_algorithm": "Per diem ($28,538).", "count": "0", "additional_payer_notes": "Zero final payments for the item or service in the 15 months prior to posting the file." }, { "payer_name": "UNITED HEALTHCARE", "plan_name": "SUTTER SELECT & SUTTER HEALTH PLAN HMO PLANS", "methodology": "per diem", "standard_charge_dollar": 28538.0, "standard_charge_algorithm": "Per diem ($28,538).", "count": "0", "additional_payer_notes": "Zero final payments for the item or service in the 15 months prior to posting the file." }, { "payer_name": "SUTTER", "plan_name": "SUTTER SELECT & SUTTER HEALTH PLAN HMO PLANS", "methodology": "per diem", "standard_charge_dollar": 28538.0, "standard_charge_algorithm": "Per diem ($28,538).", "count": "0", "additional_payer_notes": "Zero final payments for the item or service in the 15 months prior to posting the file." }, { "payer_name": "UNITED HEALTHCARE", "plan_name": "SUTTER SELECT & SUTTER HEALTH PLAN HMO PLANS", "methodology": "per diem", "standard_charge_dollar": 28538.0, "standard_charge_algorithm": "Per diem ($28,538).", "count": "0", "additional_payer_notes": "Zero final payments for the item or service in the 15 months prior to posting the file." }, { "payer_name": "UMR", "plan_name": "SUTTER SELECT & SUTTER HEALTH PLAN HMO PLANS", "methodology": "per diem", "standard_charge_dollar": 28538.0, "standard_charge_algorithm": "Per diem ($28,538).", "count": "0", "additional_payer_notes": "Zero final payments for the item or service in the 15 months prior to posting the file." } ] } ] }, { "description": "HC Bag Drainage Gp009", "code_information": [ { "code": "PX-2120007009", "type": "CDM" }, { "code": "99999", "type": "CPT" }, { "code": "0272", "type": "RC" } ], "standard_charges": [ { "setting": "outpatient", "gross_charge": 570.0, "discounted_cash": 285.0, "minimum": 240.54, "maximum": 296.4, "additional_generic_notes": "Zero final payments for the item or service in the 15 months prior to posting the file.", "payers_information": [ { "payer_name": "AETNA", "plan_name": "AETNA ALL OTHER PLANS", "methodology": "percent of total billed charges", "standard_charge_dollar": 296.4, "standard_charge_percentage": 52.0, "count": "0", "additional_payer_notes": "Zero final payments for the item or service in the 15 months prior to posting the file." }, { "payer_name": "AETNA", "plan_name": "AETNA ALL OTHER PLANS", "methodology": "percent of total billed charges", "standard_charge_dollar": 296.4, "standard_charge_percentage": 52.0, "count": "0", "additional_payer_notes": "Zero final payments for the item or service in the 15 months prior to posting the file." }, { "payer_name": "MERITAIN HEALTH", "plan_name": "AETNA ALL OTHER PLANS", "methodology": "percent of total billed charges", "standard_charge_dollar": 296.4, "standard_charge_percentage": 52.0, "count": "0", "additional_payer_notes": "Zero final payments for the item or service in the 15 months prior to posting the file." }, { "payer_name": "BLUE SHIELD OUT OF STATE", "plan_name": "STANFORD HEALTHCARE ALLIANCE PLAN", "methodology": "percent of total billed charges", "standard_charge_dollar": 276.96, "standard_charge_percentage": 48.59, "count": "0", "additional_payer_notes": "Zero final payments for the item or service in the 15 months prior to posting the file." }, { "payer_name": "BLUE SHIELD", "plan_name": "STANFORD HEALTHCARE ALLIANCE PLAN", "methodology": "percent of total billed charges", "standard_charge_dollar": 276.96, "standard_charge_percentage": 48.59, "count": "0", "additional_payer_notes": "Zero final payments for the item or service in the 15 months prior to posting the file." }, { "payer_name": "BLUE SHIELD", "plan_name": "STANFORD HEALTHCARE ALLIANCE PLAN", "methodology": "percent of total billed charges", "standard_charge_dollar": 276.96, "standard_charge_percentage": 48.59, "count": "0", "additional_payer_notes": "Zero final payments for the item or service in the 15 months prior to posting the file." }, { "payer_name": "CIGNA", "plan_name": "CIGNA COM ALT HMO PLAN", "methodology": "percent of total billed charges", "standard_charge_dollar": 240.54, "standard_charge_percentage": 42.2, "count": "0", "additional_payer_notes": "Zero final payments for the item or service in the 15 months prior to posting the file." }, { "payer_name": "CIGNA", "plan_name": "CIGNA COM ALT HMO PLAN", "methodology": "percent of total billed charges", "standard_charge_dollar": 240.54, "standard_charge_percentage": 42.2, "count": "0", "additional_payer_notes": "Zero final payments for the item or service in the 15 months prior to posting the file." }, { "payer_name": "HEALTH NET", "plan_name": "HEALTHNET HMO, PPO, POS, EPO, CANOPY HEALTHNET HMO, OTHER-IN-NETWORK PLANS", "methodology": "per diem", "standard_charge_dollar": 8000.0, "standard_charge_algorithm": "Expected reimbursement is the lesser of Per diem ($8,000) for the length of stay and 70% of billed.", "count": "0", "additional_payer_notes": "Zero final payments for the item or service in the 15 months prior to posting the file." }, { "payer_name": "HEALTH NET", "plan_name": "HEALTHNET HMO, PPO, POS, EPO, CANOPY HEALTHNET HMO, OTHER-IN-NETWORK PLANS", "methodology": "per diem", "standard_charge_dollar": 8000.0, "standard_charge_algorithm": "Expected reimbursement is the lesser of Per diem ($8,000) for the length of stay and 70% of billed.", "count": "0", "additional_payer_notes": "Zero final payments for the item or service in the 15 months prior to posting the file." }, { "payer_name": "UNITED HEALTHCARE", "plan_name": "SUTTER SELECT & SUTTER HEALTH PLAN HMO PLANS", "methodology": "per diem", "standard_charge_dollar": 28538.0, "standard_charge_algorithm": "Per diem ($28,538).", "count": "0", "additional_payer_notes": "Zero final payments for the item or service in the 15 months prior to posting the file." }, { "payer_name": "UNITED HEALTHCARE", "plan_name": "SUTTER SELECT & SUTTER HEALTH PLAN HMO PLANS", "methodology": "per diem", "standard_charge_dollar": 28538.0, "standard_charge_algorithm": "Per diem ($28,538).", "count": "0", "additional_payer_notes": "Zero final payments for the item or service in the 15 months prior to posting the file." }, { "payer_name": "SUTTER", "plan_name": "SUTTER SELECT & SUTTER HEALTH PLAN HMO PLANS", "methodology": "per diem", "standard_charge_dollar": 28538.0, "standard_charge_algorithm": "Per diem ($28,538).", "count": "0", "additional_payer_notes": "Zero final payments for the item or service in the 15 months prior to posting the file." }, { "payer_name": "UNITED HEALTHCARE", "plan_name": "SUTTER SELECT & SUTTER HEALTH PLAN HMO PLANS", "methodology": "per diem", "standard_charge_dollar": 28538.0, "standard_charge_algorithm": "Per diem ($28,538).", "count": "0", "additional_payer_notes": "Zero final payments for the item or service in the 15 months prior to posting the file." }, { "payer_name": "UMR", "plan_name": "SUTTER SELECT & SUTTER HEALTH PLAN HMO PLANS", "methodology": "per diem", "standard_charge_dollar": 28538.0, "standard_charge_algorithm": "Per diem ($28,538).", "count": "0", "additional_payer_notes": "Zero final payments for the item or service in the 15 months prior to posting the file." } ] } ] }, { "description": "HC Bag Drainage Gp010", "code_information": [ { "code": "PX-2120007010", "type": "CDM" }, { "code": "99999", "type": "CPT" }, { "code": "0272", "type": "RC" } ], "standard_charges": [ { "setting": "outpatient", "gross_charge": 665.0, "discounted_cash": 332.5, "minimum": 280.63, "maximum": 345.8, "additional_generic_notes": "Zero final payments for the item or service in the 15 months prior to posting the file.", "payers_information": [ { "payer_name": "AETNA", "plan_name": "AETNA ALL OTHER PLANS", "methodology": "percent of total billed charges", "standard_charge_dollar": 345.8, "standard_charge_percentage": 52.0, "count": "0", "additional_payer_notes": "Zero final payments for the item or service in the 15 months prior to posting the file." }, { "payer_name": "AETNA", "plan_name": "AETNA ALL OTHER PLANS", "methodology": "percent of total billed charges", "standard_charge_dollar": 345.8, "standard_charge_percentage": 52.0, "count": "0", "additional_payer_notes": "Zero final payments for the item or service in the 15 months prior to posting the file." }, { "payer_name": "MERITAIN HEALTH", "plan_name": "AETNA ALL OTHER PLANS", "methodology": "percent of total billed charges", "standard_charge_dollar": 345.8, "standard_charge_percentage": 52.0, "count": "0", "additional_payer_notes": "Zero final payments for the item or service in the 15 months prior to posting the file." }, { "payer_name": "BLUE SHIELD OUT OF STATE", "plan_name": "STANFORD HEALTHCARE ALLIANCE PLAN", "methodology": "percent of total billed charges", "standard_charge_dollar": 323.12, "standard_charge_percentage": 48.59, "count": "0", "additional_payer_notes": "Zero final payments for the item or service in the 15 months prior to posting the file." }, { "payer_name": "BLUE SHIELD", "plan_name": "STANFORD HEALTHCARE ALLIANCE PLAN", "methodology": "percent of total billed charges", "standard_charge_dollar": 323.12, "standard_charge_percentage": 48.59, "count": "0", "additional_payer_notes": "Zero final payments for the item or service in the 15 months prior to posting the file." }, { "payer_name": "BLUE SHIELD", "plan_name": "STANFORD HEALTHCARE ALLIANCE PLAN", "methodology": "percent of total billed charges", "standard_charge_dollar": 323.12, "standard_charge_percentage": 48.59, "count": "0", "additional_payer_notes": "Zero final payments for the item or service in the 15 months prior to posting the file." }, { "payer_name": "CIGNA", "plan_name": "CIGNA COM ALT HMO PLAN", "methodology": "percent of total billed charges", "standard_charge_dollar": 280.63, "standard_charge_percentage": 42.2, "count": "0", "additional_payer_notes": "Zero final payments for the item or service in the 15 months prior to posting the file." }, { "payer_name": "CIGNA", "plan_name": "CIGNA COM ALT HMO PLAN", "methodology": "percent of total billed charges", "standard_charge_dollar": 280.63, "standard_charge_percentage": 42.2, "count": "0", "additional_payer_notes": "Zero final payments for the item or service in the 15 months prior to posting the file." }, { "payer_name": "HEALTH NET", "plan_name": "HEALTHNET HMO, PPO, POS, EPO, CANOPY HEALTHNET HMO, OTHER-IN-NETWORK PLANS", "methodology": "per diem", "standard_charge_dollar": 8000.0, "standard_charge_algorithm": "Expected reimbursement is the lesser of Per diem ($8,000) for the length of stay and 70% of billed.", "count": "0", "additional_payer_notes": "Zero final payments for the item or service in the 15 months prior to posting the file." }, { "payer_name": "HEALTH NET", "plan_name": "HEALTHNET HMO, PPO, POS, EPO, CANOPY HEALTHNET HMO, OTHER-IN-NETWORK PLANS", "methodology": "per diem", "standard_charge_dollar": 8000.0, "standard_charge_algorithm": "Expected reimbursement is the lesser of Per diem ($8,000) for the length of stay and 70% of billed.", "count": "0", "additional_payer_notes": "Zero final payments for the item or service in the 15 months prior to posting the file." }, { "payer_name": "UNITED HEALTHCARE", "plan_name": "SUTTER SELECT & SUTTER HEALTH PLAN HMO PLANS", "methodology": "per diem", "standard_charge_dollar": 28538.0, "standard_charge_algorithm": "Per diem ($28,538).", "count": "0", "additional_payer_notes": "Zero final payments for the item or service in the 15 months prior to posting the file." }, { "payer_name": "UNITED HEALTHCARE", "plan_name": "SUTTER SELECT & SUTTER HEALTH PLAN HMO PLANS", "methodology": "per diem", "standard_charge_dollar": 28538.0, "standard_charge_algorithm": "Per diem ($28,538).", "count": "0", "additional_payer_notes": "Zero final payments for the item or service in the 15 months prior to posting the file." }, { "payer_name": "SUTTER", "plan_name": "SUTTER SELECT & SUTTER HEALTH PLAN HMO PLANS", "methodology": "per diem", "standard_charge_dollar": 28538.0, "standard_charge_algorithm": "Per diem ($28,538).", "count": "0", "additional_payer_notes": "Zero final payments for the item or service in the 15 months prior to posting the file." }, { "payer_name": "UNITED HEALTHCARE", "plan_name": "SUTTER SELECT & SUTTER HEALTH PLAN HMO PLANS", "methodology": "per diem", "standard_charge_dollar": 28538.0, "standard_charge_algorithm": "Per diem ($28,538).", "count": "0", "additional_payer_notes": "Zero final payments for the item or service in the 15 months prior to posting the file." }, { "payer_name": "UMR", "plan_name": "SUTTER SELECT & SUTTER HEALTH PLAN HMO PLANS", "methodology": "per diem", "standard_charge_dollar": 28538.0, "standard_charge_algorithm": "Per diem ($28,538).", "count": "0", "additional_payer_notes": "Zero final payments for the item or service in the 15 months prior to posting the file." } ] } ] }, { "description": "HC Bag Drainage Gp011", "code_information": [ { "code": "PX-2120007011", "type": "CDM" }, { "code": "99999", "type": "CPT" }, { "code": "0272", "type": "RC" } ], "standard_charges": [ { "setting": "outpatient", "gross_charge": 740.0, "discounted_cash": 370.0, "minimum": 312.28, "maximum": 384.8, "additional_generic_notes": "Zero final payments for the item or service in the 15 months prior to posting the file.", "payers_information": [ { "payer_name": "AETNA", "plan_name": "AETNA ALL OTHER PLANS", "methodology": "percent of total billed charges", "standard_charge_dollar": 384.8, "standard_charge_percentage": 52.0, "count": "0", "additional_payer_notes": "Zero final payments for the item or service in the 15 months prior to posting the file." }, { "payer_name": "AETNA", "plan_name": "AETNA ALL OTHER PLANS", "methodology": "percent of total billed charges", "standard_charge_dollar": 384.8, "standard_charge_percentage": 52.0, "count": "0", "additional_payer_notes": "Zero final payments for the item or service in the 15 months prior to posting the file." }, { "payer_name": "MERITAIN HEALTH", "plan_name": "AETNA ALL OTHER PLANS", "methodology": "percent of total billed charges", "standard_charge_dollar": 384.8, "standard_charge_percentage": 52.0, "count": "0", "additional_payer_notes": "Zero final payments for the item or service in the 15 months prior to posting the file." }, { "payer_name": "BLUE SHIELD OUT OF STATE", "plan_name": "STANFORD HEALTHCARE ALLIANCE PLAN", "methodology": "percent of total billed charges", "standard_charge_dollar": 359.57, "standard_charge_percentage": 48.59, "count": "0", "additional_payer_notes": "Zero final payments for the item or service in the 15 months prior to posting the file." }, { "payer_name": "BLUE SHIELD", "plan_name": "STANFORD HEALTHCARE ALLIANCE PLAN", "methodology": "percent of total billed charges", "standard_charge_dollar": 359.57, "standard_charge_percentage": 48.59, "count": "0", "additional_payer_notes": "Zero final payments for the item or service in the 15 months prior to posting the file." }, { "payer_name": "BLUE SHIELD", "plan_name": "STANFORD HEALTHCARE ALLIANCE PLAN", "methodology": "percent of total billed charges", "standard_charge_dollar": 359.57, "standard_charge_percentage": 48.59, "count": "0", "additional_payer_notes": "Zero final payments for the item or service in the 15 months prior to posting the file." }, { "payer_name": "CIGNA", "plan_name": "CIGNA COM ALT HMO PLAN", "methodology": "percent of total billed charges", "standard_charge_dollar": 312.28, "standard_charge_percentage": 42.2, "count": "0", "additional_payer_notes": "Zero final payments for the item or service in the 15 months prior to posting the file." }, { "payer_name": "CIGNA", "plan_name": "CIGNA COM ALT HMO PLAN", "methodology": "percent of total billed charges", "standard_charge_dollar": 312.28, "standard_charge_percentage": 42.2, "count": "0", "additional_payer_notes": "Zero final payments for the item or service in the 15 months prior to posting the file." }, { "payer_name": "HEALTH NET", "plan_name": "HEALTHNET HMO, PPO, POS, EPO, CANOPY HEALTHNET HMO, OTHER-IN-NETWORK PLANS", "methodology": "per diem", "standard_charge_dollar": 8000.0, "standard_charge_algorithm": "Expected reimbursement is the lesser of Per diem ($8,000) for the length of stay and 70% of billed.", "count": "0", "additional_payer_notes": "Zero final payments for the item or service in the 15 months prior to posting the file." }, { "payer_name": "HEALTH NET", "plan_name": "HEALTHNET HMO, PPO, POS, EPO, CANOPY HEALTHNET HMO, OTHER-IN-NETWORK PLANS", "methodology": "per diem", "standard_charge_dollar": 8000.0, "standard_charge_algorithm": "Expected reimbursement is the lesser of Per diem ($8,000) for the length of stay and 70% of billed.", "count": "0", "additional_payer_notes": "Zero final payments for the item or service in the 15 months prior to posting the file." }, { "payer_name": "UNITED HEALTHCARE", "plan_name": "SUTTER SELECT & SUTTER HEALTH PLAN HMO PLANS", "methodology": "per diem", "standard_charge_dollar": 28538.0, "standard_charge_algorithm": "Per diem ($28,538).", "count": "0", "additional_payer_notes": "Zero final payments for the item or service in the 15 months prior to posting the file." }, { "payer_name": "UNITED HEALTHCARE", "plan_name": "SUTTER SELECT & SUTTER HEALTH PLAN HMO PLANS", "methodology": "per diem", "standard_charge_dollar": 28538.0, "standard_charge_algorithm": "Per diem ($28,538).", "count": "0", "additional_payer_notes": "Zero final payments for the item or service in the 15 months prior to posting the file." }, { "payer_name": "SUTTER", "plan_name": "SUTTER SELECT & SUTTER HEALTH PLAN HMO PLANS", "methodology": "per diem", "standard_charge_dollar": 28538.0, "standard_charge_algorithm": "Per diem ($28,538).", "count": "0", "additional_payer_notes": "Zero final payments for the item or service in the 15 months prior to posting the file." }, { "payer_name": "UNITED HEALTHCARE", "plan_name": "SUTTER SELECT & SUTTER HEALTH PLAN HMO PLANS", "methodology": "per diem", "standard_charge_dollar": 28538.0, "standard_charge_algorithm": "Per diem ($28,538).", "count": "0", "additional_payer_notes": "Zero final payments for the item or service in the 15 months prior to posting the file." }, { "payer_name": "UMR", "plan_name": "SUTTER SELECT & SUTTER HEALTH PLAN HMO PLANS", "methodology": "per diem", "standard_charge_dollar": 28538.0, "standard_charge_algorithm": "Per diem ($28,538).", "count": "0", "additional_payer_notes": "Zero final payments for the item or service in the 15 months prior to posting the file." } ] } ] }, { "description": "HC Bag Drainage Gp012", "code_information": [ { "code": "PX-2120007012", "type": "CDM" }, { "code": "99999", "type": "CPT" }, { "code": "0272", "type": "RC" } ], "standard_charges": [ { "setting": "outpatient", "gross_charge": 810.0, "discounted_cash": 405.0, "minimum": 341.82, "maximum": 421.2, "additional_generic_notes": "Zero final payments for the item or service in the 15 months prior to posting the file.", "payers_information": [ { "payer_name": "AETNA", "plan_name": "AETNA ALL OTHER PLANS", "methodology": "percent of total billed charges", "standard_charge_dollar": 421.2, "standard_charge_percentage": 52.0, "count": "0", "additional_payer_notes": "Zero final payments for the item or service in the 15 months prior to posting the file." }, { "payer_name": "AETNA", "plan_name": "AETNA ALL OTHER PLANS", "methodology": "percent of total billed charges", "standard_charge_dollar": 421.2, "standard_charge_percentage": 52.0, "count": "0", "additional_payer_notes": "Zero final payments for the item or service in the 15 months prior to posting the file." }, { "payer_name": "MERITAIN HEALTH", "plan_name": "AETNA ALL OTHER PLANS", "methodology": "percent of total billed charges", "standard_charge_dollar": 421.2, "standard_charge_percentage": 52.0, "count": "0", "additional_payer_notes": "Zero final payments for the item or service in the 15 months prior to posting the file." }, { "payer_name": "BLUE SHIELD OUT OF STATE", "plan_name": "STANFORD HEALTHCARE ALLIANCE PLAN", "methodology": "percent of total billed charges", "standard_charge_dollar": 393.58, "standard_charge_percentage": 48.59, "count": "0", "additional_payer_notes": "Zero final payments for the item or service in the 15 months prior to posting the file." }, { "payer_name": "BLUE SHIELD", "plan_name": "STANFORD HEALTHCARE ALLIANCE PLAN", "methodology": "percent of total billed charges", "standard_charge_dollar": 393.58, "standard_charge_percentage": 48.59, "count": "0", "additional_payer_notes": "Zero final payments for the item or service in the 15 months prior to posting the file." }, { "payer_name": "BLUE SHIELD", "plan_name": "STANFORD HEALTHCARE ALLIANCE PLAN", "methodology": "percent of total billed charges", "standard_charge_dollar": 393.58, "standard_charge_percentage": 48.59, "count": "0", "additional_payer_notes": "Zero final payments for the item or service in the 15 months prior to posting the file." }, { "payer_name": "CIGNA", "plan_name": "CIGNA COM ALT HMO PLAN", "methodology": "percent of total billed charges", "standard_charge_dollar": 341.82, "standard_charge_percentage": 42.2, "count": "0", "additional_payer_notes": "Zero final payments for the item or service in the 15 months prior to posting the file." }, { "payer_name": "CIGNA", "plan_name": "CIGNA COM ALT HMO PLAN", "methodology": "percent of total billed charges", "standard_charge_dollar": 341.82, "standard_charge_percentage": 42.2, "count": "0", "additional_payer_notes": "Zero final payments for the item or service in the 15 months prior to posting the file." }, { "payer_name": "HEALTH NET", "plan_name": "HEALTHNET HMO, PPO, POS, EPO, CANOPY HEALTHNET HMO, OTHER-IN-NETWORK PLANS", "methodology": "per diem", "standard_charge_dollar": 8000.0, "standard_charge_algorithm": "Expected reimbursement is the lesser of Per diem ($8,000) for the length of stay and 70% of billed.", "count": "0", "additional_payer_notes": "Zero final payments for the item or service in the 15 months prior to posting the file." }, { "payer_name": "HEALTH NET", "plan_name": "HEALTHNET HMO, PPO, POS, EPO, CANOPY HEALTHNET HMO, OTHER-IN-NETWORK PLANS", "methodology": "per diem", "standard_charge_dollar": 8000.0, "standard_charge_algorithm": "Expected reimbursement is the lesser of Per diem ($8,000) for the length of stay and 70% of billed.", "count": "0", "additional_payer_notes": "Zero final payments for the item or service in the 15 months prior to posting the file." }, { "payer_name": "UNITED HEALTHCARE", "plan_name": "SUTTER SELECT & SUTTER HEALTH PLAN HMO PLANS", "methodology": "per diem", "standard_charge_dollar": 28538.0, "standard_charge_algorithm": "Per diem ($28,538).", "count": "0", "additional_payer_notes": "Zero final payments for the item or service in the 15 months prior to posting the file." }, { "payer_name": "UNITED HEALTHCARE", "plan_name": "SUTTER SELECT & SUTTER HEALTH PLAN HMO PLANS", "methodology": "per diem", "standard_charge_dollar": 28538.0, "standard_charge_algorithm": "Per diem ($28,538).", "count": "0", "additional_payer_notes": "Zero final payments for the item or service in the 15 months prior to posting the file." }, { "payer_name": "SUTTER", "plan_name": "SUTTER SELECT & SUTTER HEALTH PLAN HMO PLANS", "methodology": "per diem", "standard_charge_dollar": 28538.0, "standard_charge_algorithm": "Per diem ($28,538).", "count": "0", "additional_payer_notes": "Zero final payments for the item or service in the 15 months prior to posting the file." }, { "payer_name": "UNITED HEALTHCARE", "plan_name": "SUTTER SELECT & SUTTER HEALTH PLAN HMO PLANS", "methodology": "per diem", "standard_charge_dollar": 28538.0, "standard_charge_algorithm": "Per diem ($28,538).", "count": "0", "additional_payer_notes": "Zero final payments for the item or service in the 15 months prior to posting the file." }, { "payer_name": "UMR", "plan_name": "SUTTER SELECT & SUTTER HEALTH PLAN HMO PLANS", "methodology": "per diem", "standard_charge_dollar": 28538.0, "standard_charge_algorithm": "Per diem ($28,538).", "count": "0", "additional_payer_notes": "Zero final payments for the item or service in the 15 months prior to posting the file." } ] } ] }, { "description": "HC Bag Drainage Gp013", "code_information": [ { "code": "PX-2120007013", "type": "CDM" }, { "code": "99999", "type": "CPT" }, { "code": "0272", "type": "RC" } ], "standard_charges": [ { "setting": "outpatient", "gross_charge": 900.0, "discounted_cash": 450.0, "minimum": 379.8, "maximum": 468.0, "additional_generic_notes": "Zero final payments for the item or service in the 15 months prior to posting the file.", "payers_information": [ { "payer_name": "AETNA", "plan_name": "AETNA ALL OTHER PLANS", "methodology": "percent of total billed charges", "standard_charge_dollar": 468.0, "standard_charge_percentage": 52.0, "count": "0", "additional_payer_notes": "Zero final payments for the item or service in the 15 months prior to posting the file." }, { "payer_name": "AETNA", "plan_name": "AETNA ALL OTHER PLANS", "methodology": "percent of total billed charges", "standard_charge_dollar": 468.0, "standard_charge_percentage": 52.0, "count": "0", "additional_payer_notes": "Zero final payments for the item or service in the 15 months prior to posting the file." }, { "payer_name": "MERITAIN HEALTH", "plan_name": "AETNA ALL OTHER PLANS", "methodology": "percent of total billed charges", "standard_charge_dollar": 468.0, "standard_charge_percentage": 52.0, "count": "0", "additional_payer_notes": "Zero final payments for the item or service in the 15 months prior to posting the file." }, { "payer_name": "BLUE SHIELD OUT OF STATE", "plan_name": "STANFORD HEALTHCARE ALLIANCE PLAN", "methodology": "percent of total billed charges", "standard_charge_dollar": 437.31, "standard_charge_percentage": 48.59, "count": "0", "additional_payer_notes": "Zero final payments for the item or service in the 15 months prior to posting the file." }, { "payer_name": "BLUE SHIELD", "plan_name": "STANFORD HEALTHCARE ALLIANCE PLAN", "methodology": "percent of total billed charges", "standard_charge_dollar": 437.31, "standard_charge_percentage": 48.59, "count": "0", "additional_payer_notes": "Zero final payments for the item or service in the 15 months prior to posting the file." }, { "payer_name": "BLUE SHIELD", "plan_name": "STANFORD HEALTHCARE ALLIANCE PLAN", "methodology": "percent of total billed charges", "standard_charge_dollar": 437.31, "standard_charge_percentage": 48.59, "count": "0", "additional_payer_notes": "Zero final payments for the item or service in the 15 months prior to posting the file." }, { "payer_name": "CIGNA", "plan_name": "CIGNA COM ALT HMO PLAN", "methodology": "percent of total billed charges", "standard_charge_dollar": 379.8, "standard_charge_percentage": 42.2, "count": "0", "additional_payer_notes": "Zero final payments for the item or service in the 15 months prior to posting the file." }, { "payer_name": "CIGNA", "plan_name": "CIGNA COM ALT HMO PLAN", "methodology": "percent of total billed charges", "standard_charge_dollar": 379.8, "standard_charge_percentage": 42.2, "count": "0", "additional_payer_notes": "Zero final payments for the item or service in the 15 months prior to posting the file." }, { "payer_name": "HEALTH NET", "plan_name": "HEALTHNET HMO, PPO, POS, EPO, CANOPY HEALTHNET HMO, OTHER-IN-NETWORK PLANS", "methodology": "per diem", "standard_charge_dollar": 8000.0, "standard_charge_algorithm": "Expected reimbursement is the lesser of Per diem ($8,000) for the length of stay and 70% of billed.", "count": "0", "additional_payer_notes": "Zero final payments for the item or service in the 15 months prior to posting the file." }, { "payer_name": "HEALTH NET", "plan_name": "HEALTHNET HMO, PPO, POS, EPO, CANOPY HEALTHNET HMO, OTHER-IN-NETWORK PLANS", "methodology": "per diem", "standard_charge_dollar": 8000.0, "standard_charge_algorithm": "Expected reimbursement is the lesser of Per diem ($8,000) for the length of stay and 70% of billed.", "count": "0", "additional_payer_notes": "Zero final payments for the item or service in the 15 months prior to posting the file." }, { "payer_name": "UNITED HEALTHCARE", "plan_name": "SUTTER SELECT & SUTTER HEALTH PLAN HMO PLANS", "methodology": "per diem", "standard_charge_dollar": 28538.0, "standard_charge_algorithm": "Per diem ($28,538).", "count": "0", "additional_payer_notes": "Zero final payments for the item or service in the 15 months prior to posting the file." }, { "payer_name": "UNITED HEALTHCARE", "plan_name": "SUTTER SELECT & SUTTER HEALTH PLAN HMO PLANS", "methodology": "per diem", "standard_charge_dollar": 28538.0, "standard_charge_algorithm": "Per diem ($28,538).", "count": "0", "additional_payer_notes": "Zero final payments for the item or service in the 15 months prior to posting the file." }, { "payer_name": "SUTTER", "plan_name": "SUTTER SELECT & SUTTER HEALTH PLAN HMO PLANS", "methodology": "per diem", "standard_charge_dollar": 28538.0, "standard_charge_algorithm": "Per diem ($28,538).", "count": "0", "additional_payer_notes": "Zero final payments for the item or service in the 15 months prior to posting the file." }, { "payer_name": "UNITED HEALTHCARE", "plan_name": "SUTTER SELECT & SUTTER HEALTH PLAN HMO PLANS", "methodology": "per diem", "standard_charge_dollar": 28538.0, "standard_charge_algorithm": "Per diem ($28,538).", "count": "0", "additional_payer_notes": "Zero final payments for the item or service in the 15 months prior to posting the file." }, { "payer_name": "UMR", "plan_name": "SUTTER SELECT & SUTTER HEALTH PLAN HMO PLANS", "methodology": "per diem", "standard_charge_dollar": 28538.0, "standard_charge_algorithm": "Per diem ($28,538).", "count": "0", "additional_payer_notes": "Zero final payments for the item or service in the 15 months prior to posting the file." } ] } ] }, { "description": "HC Bag Drainage Gp014", "code_information": [ { "code": "PX-2120007014", "type": "CDM" }, { "code": "99999", "type": "CPT" }, { "code": "0272", "type": "RC" } ], "standard_charges": [ { "setting": "outpatient", "gross_charge": 1080.0, "discounted_cash": 540.0, "minimum": 455.76, "maximum": 561.6, "additional_generic_notes": "Zero final payments for the item or service in the 15 months prior to posting the file.", "payers_information": [ { "payer_name": "AETNA", "plan_name": "AETNA ALL OTHER PLANS", "methodology": "percent of total billed charges", "standard_charge_dollar": 561.6, "standard_charge_percentage": 52.0, "count": "0", "additional_payer_notes": "Zero final payments for the item or service in the 15 months prior to posting the file." }, { "payer_name": "AETNA", "plan_name": "AETNA ALL OTHER PLANS", "methodology": "percent of total billed charges", "standard_charge_dollar": 561.6, "standard_charge_percentage": 52.0, "count": "0", "additional_payer_notes": "Zero final payments for the item or service in the 15 months prior to posting the file." }, { "payer_name": "MERITAIN HEALTH", "plan_name": "AETNA ALL OTHER PLANS", "methodology": "percent of total billed charges", "standard_charge_dollar": 561.6, "standard_charge_percentage": 52.0, "count": "0", "additional_payer_notes": "Zero final payments for the item or service in the 15 months prior to posting the file." }, { "payer_name": "BLUE SHIELD OUT OF STATE", "plan_name": "STANFORD HEALTHCARE ALLIANCE PLAN", "methodology": "percent of total billed charges", "standard_charge_dollar": 524.77, "standard_charge_percentage": 48.59, "count": "0", "additional_payer_notes": "Zero final payments for the item or service in the 15 months prior to posting the file." }, { "payer_name": "BLUE SHIELD", "plan_name": "STANFORD HEALTHCARE ALLIANCE PLAN", "methodology": "percent of total billed charges", "standard_charge_dollar": 524.77, "standard_charge_percentage": 48.59, "median_amount": 68.24, "10th_percentile": 13.6, "90th_percentile": 1043.06, "count": "30" }, { "payer_name": "BLUE SHIELD", "plan_name": "STANFORD HEALTHCARE ALLIANCE PLAN", "methodology": "percent of total billed charges", "standard_charge_dollar": 524.77, "standard_charge_percentage": 48.59, "count": "0", "additional_payer_notes": "Zero final payments for the item or service in the 15 months prior to posting the file." }, { "payer_name": "BLUE SHIELD", "plan_name": "STANFORD HEALTHCARE ALLIANCE PLAN", "methodology": "percent of total billed charges", "standard_charge_dollar": 524.77, "standard_charge_percentage": 48.59, "count": "0", "additional_payer_notes": "Zero final payments for the item or service in the 15 months prior to posting the file." }, { "payer_name": "CIGNA", "plan_name": "CIGNA COM ALT HMO PLAN", "methodology": "percent of total billed charges", "standard_charge_dollar": 455.76, "standard_charge_percentage": 42.2, "count": "0", "additional_payer_notes": "Zero final payments for the item or service in the 15 months prior to posting the file." }, { "payer_name": "CIGNA", "plan_name": "CIGNA COM ALT HMO PLAN", "methodology": "percent of total billed charges", "standard_charge_dollar": 455.76, "standard_charge_percentage": 42.2, "count": "0", "additional_payer_notes": "Zero final payments for the item or service in the 15 months prior to posting the file." }, { "payer_name": "HEALTH NET", "plan_name": "HEALTHNET HMO, PPO, POS, EPO, CANOPY HEALTHNET HMO, OTHER-IN-NETWORK PLANS", "methodology": "per diem", "standard_charge_dollar": 8000.0, "standard_charge_algorithm": "Expected reimbursement is the lesser of Per diem ($8,000) for the length of stay and 70% of billed.", "count": "0", "additional_payer_notes": "Zero final payments for the item or service in the 15 months prior to posting the file." }, { "payer_name": "HEALTH NET", "plan_name": "HEALTHNET HMO, PPO, POS, EPO, CANOPY HEALTHNET HMO, OTHER-IN-NETWORK PLANS", "methodology": "per diem", "standard_charge_dollar": 8000.0, "standard_charge_algorithm": "Expected reimbursement is the lesser of Per diem ($8,000) for the length of stay and 70% of billed.", "count": "0", "additional_payer_notes": "Zero final payments for the item or service in the 15 months prior to posting the file." }, { "payer_name": "UNITED HEALTHCARE", "plan_name": "SUTTER SELECT & SUTTER HEALTH PLAN HMO PLANS", "methodology": "per diem", "standard_charge_dollar": 28538.0, "standard_charge_algorithm": "Per diem ($28,538).", "count": "0", "additional_payer_notes": "Zero final payments for the item or service in the 15 months prior to posting the file." }, { "payer_name": "UNITED HEALTHCARE", "plan_name": "SUTTER SELECT & SUTTER HEALTH PLAN HMO PLANS", "methodology": "per diem", "standard_charge_dollar": 28538.0, "standard_charge_algorithm": "Per diem ($28,538).", "count": "0", "additional_payer_notes": "Zero final payments for the item or service in the 15 months prior to posting the file." }, { "payer_name": "SUTTER", "plan_name": "SUTTER SELECT & SUTTER HEALTH PLAN HMO PLANS", "methodology": "per diem", "standard_charge_dollar": 28538.0, "standard_charge_algorithm": "Per diem ($28,538).", "count": "0", "additional_payer_notes": "Zero final payments for the item or service in the 15 months prior to posting the file." }, { "payer_name": "UNITED HEALTHCARE", "plan_name": "SUTTER SELECT & SUTTER HEALTH PLAN HMO PLANS", "methodology": "per diem", "standard_charge_dollar": 28538.0, "standard_charge_algorithm": "Per diem ($28,538).", "count": "0", "additional_payer_notes": "Zero final payments for the item or service in the 15 months prior to posting the file." }, { "payer_name": "UMR", "plan_name": "SUTTER SELECT & SUTTER HEALTH PLAN HMO PLANS", "methodology": "per diem", "standard_charge_dollar": 28538.0, "standard_charge_algorithm": "Per diem ($28,538).", "count": "0", "additional_payer_notes": "Zero final payments for the item or service in the 15 months prior to posting the file." } ] } ] }, { "description": "HC Bag Drainage Gp015", "code_information": [ { "code": "PX-2120007015", "type": "CDM" }, { "code": "99999", "type": "CPT" }, { "code": "0272", "type": "RC" } ], "standard_charges": [ { "setting": "outpatient", "gross_charge": 1225.0, "discounted_cash": 612.5, "minimum": 516.95, "maximum": 637.0, "additional_generic_notes": "Zero final payments for the item or service in the 15 months prior to posting the file.", "payers_information": [ { "payer_name": "AETNA", "plan_name": "AETNA ALL OTHER PLANS", "methodology": "percent of total billed charges", "standard_charge_dollar": 637.0, "standard_charge_percentage": 52.0, "count": "0", "additional_payer_notes": "Zero final payments for the item or service in the 15 months prior to posting the file." }, { "payer_name": "AETNA", "plan_name": "AETNA ALL OTHER PLANS", "methodology": "percent of total billed charges", "standard_charge_dollar": 637.0, "standard_charge_percentage": 52.0, "count": "0", "additional_payer_notes": "Zero final payments for the item or service in the 15 months prior to posting the file." }, { "payer_name": "MERITAIN HEALTH", "plan_name": "AETNA ALL OTHER PLANS", "methodology": "percent of total billed charges", "standard_charge_dollar": 637.0, "standard_charge_percentage": 52.0, "count": "0", "additional_payer_notes": "Zero final payments for the item or service in the 15 months prior to posting the file." }, { "payer_name": "BLUE SHIELD OUT OF STATE", "plan_name": "STANFORD HEALTHCARE ALLIANCE PLAN", "methodology": "percent of total billed charges", "standard_charge_dollar": 595.23, "standard_charge_percentage": 48.59, "count": "0", "additional_payer_notes": "Zero final payments for the item or service in the 15 months prior to posting the file." }, { "payer_name": "BLUE SHIELD", "plan_name": "STANFORD HEALTHCARE ALLIANCE PLAN", "methodology": "percent of total billed charges", "standard_charge_dollar": 595.23, "standard_charge_percentage": 48.59, "median_amount": 68.24, "10th_percentile": 13.6, "90th_percentile": 1043.06, "count": "30" }, { "payer_name": "BLUE SHIELD", "plan_name": "STANFORD HEALTHCARE ALLIANCE PLAN", "methodology": "percent of total billed charges", "standard_charge_dollar": 595.23, "standard_charge_percentage": 48.59, "count": "0", "additional_payer_notes": "Zero final payments for the item or service in the 15 months prior to posting the file." }, { "payer_name": "BLUE SHIELD", "plan_name": "STANFORD HEALTHCARE ALLIANCE PLAN", "methodology": "percent of total billed charges", "standard_charge_dollar": 595.23, "standard_charge_percentage": 48.59, "count": "0", "additional_payer_notes": "Zero final payments for the item or service in the 15 months prior to posting the file." }, { "payer_name": "CIGNA", "plan_name": "CIGNA COM ALT HMO PLAN", "methodology": "percent of total billed charges", "standard_charge_dollar": 516.95, "standard_charge_percentage": 42.2, "count": "0", "additional_payer_notes": "Zero final payments for the item or service in the 15 months prior to posting the file." }, { "payer_name": "CIGNA", "plan_name": "CIGNA COM ALT HMO PLAN", "methodology": "percent of total billed charges", "standard_charge_dollar": 516.95, "standard_charge_percentage": 42.2, "count": "0", "additional_payer_notes": "Zero final payments for the item or service in the 15 months prior to posting the file." }, { "payer_name": "HEALTH NET", "plan_name": "HEALTHNET HMO, PPO, POS, EPO, CANOPY HEALTHNET HMO, OTHER-IN-NETWORK PLANS", "methodology": "per diem", "standard_charge_dollar": 8000.0, "standard_charge_algorithm": "Expected reimbursement is the lesser of Per diem ($8,000) for the length of stay and 70% of billed.", "count": "0", "additional_payer_notes": "Zero final payments for the item or service in the 15 months prior to posting the file." }, { "payer_name": "HEALTH NET", "plan_name": "HEALTHNET HMO, PPO, POS, EPO, CANOPY HEALTHNET HMO, OTHER-IN-NETWORK PLANS", "methodology": "per diem", "standard_charge_dollar": 8000.0, "standard_charge_algorithm": "Expected reimbursement is the lesser of Per diem ($8,000) for the length of stay and 70% of billed.", "count": "0", "additional_payer_notes": "Zero final payments for the item or service in the 15 months prior to posting the file." }, { "payer_name": "UNITED HEALTHCARE", "plan_name": "SUTTER SELECT & SUTTER HEALTH PLAN HMO PLANS", "methodology": "per diem", "standard_charge_dollar": 28538.0, "standard_charge_algorithm": "Per diem ($28,538).", "count": "0", "additional_payer_notes": "Zero final payments for the item or service in the 15 months prior to posting the file." }, { "payer_name": "UNITED HEALTHCARE", "plan_name": "SUTTER SELECT & SUTTER HEALTH PLAN HMO PLANS", "methodology": "per diem", "standard_charge_dollar": 28538.0, "standard_charge_algorithm": "Per diem ($28,538).", "count": "0", "additional_payer_notes": "Zero final payments for the item or service in the 15 months prior to posting the file." }, { "payer_name": "SUTTER", "plan_name": "SUTTER SELECT & SUTTER HEALTH PLAN HMO PLANS", "methodology": "per diem", "standard_charge_dollar": 28538.0, "standard_charge_algorithm": "Per diem ($28,538).", "count": "0", "additional_payer_notes": "Zero final payments for the item or service in the 15 months prior to posting the file." }, { "payer_name": "UNITED HEALTHCARE", "plan_name": "SUTTER SELECT & SUTTER HEALTH PLAN HMO PLANS", "methodology": "per diem", "standard_charge_dollar": 28538.0, "standard_charge_algorithm": "Per diem ($28,538).", "count": "0", "additional_payer_notes": "Zero final payments for the item or service in the 15 months prior to posting the file." }, { "payer_name": "UMR", "plan_name": "SUTTER SELECT & SUTTER HEALTH PLAN HMO PLANS", "methodology": "per diem", "standard_charge_dollar": 28538.0, "standard_charge_algorithm": "Per diem ($28,538).", "count": "0", "additional_payer_notes": "Zero final payments for the item or service in the 15 months prior to posting the file." } ] } ] }, { "description": "HC Bag Drainage Gp016", "code_information": [ { "code": "PX-2120007016", "type": "CDM" }, { "code": "99999", "type": "CPT" }, { "code": "0272", "type": "RC" } ], "standard_charges": [ { "setting": "outpatient", "gross_charge": 1400.0, "discounted_cash": 700.0, "minimum": 590.8, "maximum": 728.0, "additional_generic_notes": "Zero final payments for the item or service in the 15 months prior to posting the file.", "payers_information": [ { "payer_name": "AETNA", "plan_name": "AETNA ALL OTHER PLANS", "methodology": "percent of total billed charges", "standard_charge_dollar": 728.0, "standard_charge_percentage": 52.0, "count": "0", "additional_payer_notes": "Zero final payments for the item or service in the 15 months prior to posting the file." }, { "payer_name": "AETNA", "plan_name": "AETNA ALL OTHER PLANS", "methodology": "percent of total billed charges", "standard_charge_dollar": 728.0, "standard_charge_percentage": 52.0, "count": "0", "additional_payer_notes": "Zero final payments for the item or service in the 15 months prior to posting the file." }, { "payer_name": "MERITAIN HEALTH", "plan_name": "AETNA ALL OTHER PLANS", "methodology": "percent of total billed charges", "standard_charge_dollar": 728.0, "standard_charge_percentage": 52.0, "count": "0", "additional_payer_notes": "Zero final payments for the item or service in the 15 months prior to posting the file." }, { "payer_name": "BLUE SHIELD OUT OF STATE", "plan_name": "STANFORD HEALTHCARE ALLIANCE PLAN", "methodology": "percent of total billed charges", "standard_charge_dollar": 680.26, "standard_charge_percentage": 48.59, "count": "0", "additional_payer_notes": "Zero final payments for the item or service in the 15 months prior to posting the file." }, { "payer_name": "BLUE SHIELD", "plan_name": "STANFORD HEALTHCARE ALLIANCE PLAN", "methodology": "percent of total billed charges", "standard_charge_dollar": 680.26, "standard_charge_percentage": 48.59, "median_amount": 68.24, "10th_percentile": 13.6, "90th_percentile": 1043.06, "count": "30" }, { "payer_name": "BLUE SHIELD", "plan_name": "STANFORD HEALTHCARE ALLIANCE PLAN", "methodology": "percent of total billed charges", "standard_charge_dollar": 680.26, "standard_charge_percentage": 48.59, "count": "0", "additional_payer_notes": "Zero final payments for the item or service in the 15 months prior to posting the file." }, { "payer_name": "BLUE SHIELD", "plan_name": "STANFORD HEALTHCARE ALLIANCE PLAN", "methodology": "percent of total billed charges", "standard_charge_dollar": 680.26, "standard_charge_percentage": 48.59, "count": "0", "additional_payer_notes": "Zero final payments for the item or service in the 15 months prior to posting the file." }, { "payer_name": "CIGNA", "plan_name": "CIGNA COM ALT HMO PLAN", "methodology": "percent of total billed charges", "standard_charge_dollar": 590.8, "standard_charge_percentage": 42.2, "count": "0", "additional_payer_notes": "Zero final payments for the item or service in the 15 months prior to posting the file." }, { "payer_name": "CIGNA", "plan_name": "CIGNA COM ALT HMO PLAN", "methodology": "percent of total billed charges", "standard_charge_dollar": 590.8, "standard_charge_percentage": 42.2, "count": "0", "additional_payer_notes": "Zero final payments for the item or service in the 15 months prior to posting the file." }, { "payer_name": "HEALTH NET", "plan_name": "HEALTHNET HMO, PPO, POS, EPO, CANOPY HEALTHNET HMO, OTHER-IN-NETWORK PLANS", "methodology": "per diem", "standard_charge_dollar": 8000.0, "standard_charge_algorithm": "Expected reimbursement is the lesser of Per diem ($8,000) for the length of stay and 70% of billed.", "count": "0", "additional_payer_notes": "Zero final payments for the item or service in the 15 months prior to posting the file." }, { "payer_name": "HEALTH NET", "plan_name": "HEALTHNET HMO, PPO, POS, EPO, CANOPY HEALTHNET HMO, OTHER-IN-NETWORK PLANS", "methodology": "per diem", "standard_charge_dollar": 8000.0, "standard_charge_algorithm": "Expected reimbursement is the lesser of Per diem ($8,000) for the length of stay and 70% of billed.", "count": "0", "additional_payer_notes": "Zero final payments for the item or service in the 15 months prior to posting the file." }, { "payer_name": "UNITED HEALTHCARE", "plan_name": "SUTTER SELECT & SUTTER HEALTH PLAN HMO PLANS", "methodology": "per diem", "standard_charge_dollar": 28538.0, "standard_charge_algorithm": "Per diem ($28,538).", "count": "0", "additional_payer_notes": "Zero final payments for the item or service in the 15 months prior to posting the file." }, { "payer_name": "UNITED HEALTHCARE", "plan_name": "SUTTER SELECT & SUTTER HEALTH PLAN HMO PLANS", "methodology": "per diem", "standard_charge_dollar": 28538.0, "standard_charge_algorithm": "Per diem ($28,538).", "count": "0", "additional_payer_notes": "Zero final payments for the item or service in the 15 months prior to posting the file." }, { "payer_name": "SUTTER", "plan_name": "SUTTER SELECT & SUTTER HEALTH PLAN HMO PLANS", "methodology": "per diem", "standard_charge_dollar": 28538.0, "standard_charge_algorithm": "Per diem ($28,538).", "count": "0", "additional_payer_notes": "Zero final payments for the item or service in the 15 months prior to posting the file." }, { "payer_name": "UNITED HEALTHCARE", "plan_name": "SUTTER SELECT & SUTTER HEALTH PLAN HMO PLANS", "methodology": "per diem", "standard_charge_dollar": 28538.0, "standard_charge_algorithm": "Per diem ($28,538).", "count": "0", "additional_payer_notes": "Zero final payments for the item or service in the 15 months prior to posting the file." }, { "payer_name": "UMR", "plan_name": "SUTTER SELECT & SUTTER HEALTH PLAN HMO PLANS", "methodology": "per diem", "standard_charge_dollar": 28538.0, "standard_charge_algorithm": "Per diem ($28,538).", "count": "0", "additional_payer_notes": "Zero final payments for the item or service in the 15 months prior to posting the file." } ] } ] }, { "description": "HC Bag Drainage Gp017", "code_information": [ { "code": "PX-2120007017", "type": "CDM" }, { "code": "99999", "type": "CPT" }, { "code": "0272", "type": "RC" } ], "standard_charges": [ { "setting": "outpatient", "gross_charge": 1575.0, "discounted_cash": 787.5, "minimum": 664.65, "maximum": 819.0, "additional_generic_notes": "Zero final payments for the item or service in the 15 months prior to posting the file.", "payers_information": [ { "payer_name": "AETNA", "plan_name": "AETNA ALL OTHER PLANS", "methodology": "percent of total billed charges", "standard_charge_dollar": 819.0, "standard_charge_percentage": 52.0, "count": "0", "additional_payer_notes": "Zero final payments for the item or service in the 15 months prior to posting the file." }, { "payer_name": "AETNA", "plan_name": "AETNA ALL OTHER PLANS", "methodology": "percent of total billed charges", "standard_charge_dollar": 819.0, "standard_charge_percentage": 52.0, "count": "0", "additional_payer_notes": "Zero final payments for the item or service in the 15 months prior to posting the file." }, { "payer_name": "MERITAIN HEALTH", "plan_name": "AETNA ALL OTHER PLANS", "methodology": "percent of total billed charges", "standard_charge_dollar": 819.0, "standard_charge_percentage": 52.0, "count": "0", "additional_payer_notes": "Zero final payments for the item or service in the 15 months prior to posting the file." }, { "payer_name": "BLUE SHIELD OUT OF STATE", "plan_name": "STANFORD HEALTHCARE ALLIANCE PLAN", "methodology": "percent of total billed charges", "standard_charge_dollar": 765.29, "standard_charge_percentage": 48.59, "count": "0", "additional_payer_notes": "Zero final payments for the item or service in the 15 months prior to posting the file." }, { "payer_name": "BLUE SHIELD", "plan_name": "STANFORD HEALTHCARE ALLIANCE PLAN", "methodology": "percent of total billed charges", "standard_charge_dollar": 765.29, "standard_charge_percentage": 48.59, "median_amount": 68.24, "10th_percentile": 13.6, "90th_percentile": 1043.06, "count": "30" }, { "payer_name": "BLUE SHIELD", "plan_name": "STANFORD HEALTHCARE ALLIANCE PLAN", "methodology": "percent of total billed charges", "standard_charge_dollar": 765.29, "standard_charge_percentage": 48.59, "count": "0", "additional_payer_notes": "Zero final payments for the item or service in the 15 months prior to posting the file." }, { "payer_name": "BLUE SHIELD", "plan_name": "STANFORD HEALTHCARE ALLIANCE PLAN", "methodology": "percent of total billed charges", "standard_charge_dollar": 765.29, "standard_charge_percentage": 48.59, "count": "0", "additional_payer_notes": "Zero final payments for the item or service in the 15 months prior to posting the file." }, { "payer_name": "CIGNA", "plan_name": "CIGNA COM ALT HMO PLAN", "methodology": "percent of total billed charges", "standard_charge_dollar": 664.65, "standard_charge_percentage": 42.2, "count": "0", "additional_payer_notes": "Zero final payments for the item or service in the 15 months prior to posting the file." }, { "payer_name": "CIGNA", "plan_name": "CIGNA COM ALT HMO PLAN", "methodology": "percent of total billed charges", "standard_charge_dollar": 664.65, "standard_charge_percentage": 42.2, "count": "0", "additional_payer_notes": "Zero final payments for the item or service in the 15 months prior to posting the file." }, { "payer_name": "HEALTH NET", "plan_name": "HEALTHNET HMO, PPO, POS, EPO, CANOPY HEALTHNET HMO, OTHER-IN-NETWORK PLANS", "methodology": "per diem", "standard_charge_dollar": 8000.0, "standard_charge_algorithm": "Expected reimbursement is the lesser of Per diem ($8,000) for the length of stay and 70% of billed.", "count": "0", "additional_payer_notes": "Zero final payments for the item or service in the 15 months prior to posting the file." }, { "payer_name": "HEALTH NET", "plan_name": "HEALTHNET HMO, PPO, POS, EPO, CANOPY HEALTHNET HMO, OTHER-IN-NETWORK PLANS", "methodology": "per diem", "standard_charge_dollar": 8000.0, "standard_charge_algorithm": "Expected reimbursement is the lesser of Per diem ($8,000) for the length of stay and 70% of billed.", "count": "0", "additional_payer_notes": "Zero final payments for the item or service in the 15 months prior to posting the file." }, { "payer_name": "UNITED HEALTHCARE", "plan_name": "SUTTER SELECT & SUTTER HEALTH PLAN HMO PLANS", "methodology": "per diem", "standard_charge_dollar": 28538.0, "standard_charge_algorithm": "Per diem ($28,538).", "count": "0", "additional_payer_notes": "Zero final payments for the item or service in the 15 months prior to posting the file." }, { "payer_name": "UNITED HEALTHCARE", "plan_name": "SUTTER SELECT & SUTTER HEALTH PLAN HMO PLANS", "methodology": "per diem", "standard_charge_dollar": 28538.0, "standard_charge_algorithm": "Per diem ($28,538).", "count": "0", "additional_payer_notes": "Zero final payments for the item or service in the 15 months prior to posting the file." }, { "payer_name": "SUTTER", "plan_name": "SUTTER SELECT & SUTTER HEALTH PLAN HMO PLANS", "methodology": "per diem", "standard_charge_dollar": 28538.0, "standard_charge_algorithm": "Per diem ($28,538).", "count": "0", "additional_payer_notes": "Zero final payments for the item or service in the 15 months prior to posting the file." }, { "payer_name": "UNITED HEALTHCARE", "plan_name": "SUTTER SELECT & SUTTER HEALTH PLAN HMO PLANS", "methodology": "per diem", "standard_charge_dollar": 28538.0, "standard_charge_algorithm": "Per diem ($28,538).", "count": "0", "additional_payer_notes": "Zero final payments for the item or service in the 15 months prior to posting the file." }, { "payer_name": "UMR", "plan_name": "SUTTER SELECT & SUTTER HEALTH PLAN HMO PLANS", "methodology": "per diem", "standard_charge_dollar": 28538.0, "standard_charge_algorithm": "Per diem ($28,538).", "count": "0", "additional_payer_notes": "Zero final payments for the item or service in the 15 months prior to posting the file." } ] } ] }, { "description": "HC Bag Drainage Gp018", "code_information": [ { "code": "PX-2120007018", "type": "CDM" }, { "code": "99999", "type": "CPT" }, { "code": "0272", "type": "RC" } ], "standard_charges": [ { "setting": "outpatient", "gross_charge": 1750.0, "discounted_cash": 875.0, "minimum": 738.5, "maximum": 910.0, "additional_generic_notes": "Zero final payments for the item or service in the 15 months prior to posting the file.", "payers_information": [ { "payer_name": "AETNA", "plan_name": "AETNA ALL OTHER PLANS", "methodology": "percent of total billed charges", "standard_charge_dollar": 910.0, "standard_charge_percentage": 52.0, "count": "0", "additional_payer_notes": "Zero final payments for the item or service in the 15 months prior to posting the file." }, { "payer_name": "AETNA", "plan_name": "AETNA ALL OTHER PLANS", "methodology": "percent of total billed charges", "standard_charge_dollar": 910.0, "standard_charge_percentage": 52.0, "count": "0", "additional_payer_notes": "Zero final payments for the item or service in the 15 months prior to posting the file." }, { "payer_name": "MERITAIN HEALTH", "plan_name": "AETNA ALL OTHER PLANS", "methodology": "percent of total billed charges", "standard_charge_dollar": 910.0, "standard_charge_percentage": 52.0, "count": "0", "additional_payer_notes": "Zero final payments for the item or service in the 15 months prior to posting the file." }, { "payer_name": "BLUE SHIELD OUT OF STATE", "plan_name": "STANFORD HEALTHCARE ALLIANCE PLAN", "methodology": "percent of total billed charges", "standard_charge_dollar": 850.33, "standard_charge_percentage": 48.59, "count": "0", "additional_payer_notes": "Zero final payments for the item or service in the 15 months prior to posting the file." }, { "payer_name": "BLUE SHIELD", "plan_name": "STANFORD HEALTHCARE ALLIANCE PLAN", "methodology": "percent of total billed charges", "standard_charge_dollar": 850.33, "standard_charge_percentage": 48.59, "median_amount": 68.24, "10th_percentile": 13.6, "90th_percentile": 1043.06, "count": "30" }, { "payer_name": "BLUE SHIELD", "plan_name": "STANFORD HEALTHCARE ALLIANCE PLAN", "methodology": "percent of total billed charges", "standard_charge_dollar": 850.33, "standard_charge_percentage": 48.59, "count": "0", "additional_payer_notes": "Zero final payments for the item or service in the 15 months prior to posting the file." }, { "payer_name": "BLUE SHIELD", "plan_name": "STANFORD HEALTHCARE ALLIANCE PLAN", "methodology": "percent of total billed charges", "standard_charge_dollar": 850.33, "standard_charge_percentage": 48.59, "count": "0", "additional_payer_notes": "Zero final payments for the item or service in the 15 months prior to posting the file." }, { "payer_name": "CIGNA", "plan_name": "CIGNA COM ALT HMO PLAN", "methodology": "percent of total billed charges", "standard_charge_dollar": 738.5, "standard_charge_percentage": 42.2, "count": "0", "additional_payer_notes": "Zero final payments for the item or service in the 15 months prior to posting the file." }, { "payer_name": "CIGNA", "plan_name": "CIGNA COM ALT HMO PLAN", "methodology": "percent of total billed charges", "standard_charge_dollar": 738.5, "standard_charge_percentage": 42.2, "count": "0", "additional_payer_notes": "Zero final payments for the item or service in the 15 months prior to posting the file." }, { "payer_name": "HEALTH NET", "plan_name": "HEALTHNET HMO, PPO, POS, EPO, CANOPY HEALTHNET HMO, OTHER-IN-NETWORK PLANS", "methodology": "per diem", "standard_charge_dollar": 8000.0, "standard_charge_algorithm": "Expected reimbursement is the lesser of Per diem ($8,000) for the length of stay and 70% of billed.", "count": "0", "additional_payer_notes": "Zero final payments for the item or service in the 15 months prior to posting the file." }, { "payer_name": "HEALTH NET", "plan_name": "HEALTHNET HMO, PPO, POS, EPO, CANOPY HEALTHNET HMO, OTHER-IN-NETWORK PLANS", "methodology": "per diem", "standard_charge_dollar": 8000.0, "standard_charge_algorithm": "Expected reimbursement is the lesser of Per diem ($8,000) for the length of stay and 70% of billed.", "count": "0", "additional_payer_notes": "Zero final payments for the item or service in the 15 months prior to posting the file." }, { "payer_name": "UNITED HEALTHCARE", "plan_name": "SUTTER SELECT & SUTTER HEALTH PLAN HMO PLANS", "methodology": "per diem", "standard_charge_dollar": 28538.0, "standard_charge_algorithm": "Per diem ($28,538).", "count": "0", "additional_payer_notes": "Zero final payments for the item or service in the 15 months prior to posting the file." }, { "payer_name": "UNITED HEALTHCARE", "plan_name": "SUTTER SELECT & SUTTER HEALTH PLAN HMO PLANS", "methodology": "per diem", "standard_charge_dollar": 28538.0, "standard_charge_algorithm": "Per diem ($28,538).", "count": "0", "additional_payer_notes": "Zero final payments for the item or service in the 15 months prior to posting the file." }, { "payer_name": "SUTTER", "plan_name": "SUTTER SELECT & SUTTER HEALTH PLAN HMO PLANS", "methodology": "per diem", "standard_charge_dollar": 28538.0, "standard_charge_algorithm": "Per diem ($28,538).", "count": "0", "additional_payer_notes": "Zero final payments for the item or service in the 15 months prior to posting the file." }, { "payer_name": "UNITED HEALTHCARE", "plan_name": "SUTTER SELECT & SUTTER HEALTH PLAN HMO PLANS", "methodology": "per diem", "standard_charge_dollar": 28538.0, "standard_charge_algorithm": "Per diem ($28,538).", "count": "0", "additional_payer_notes": "Zero final payments for the item or service in the 15 months prior to posting the file." }, { "payer_name": "UMR", "plan_name": "SUTTER SELECT & SUTTER HEALTH PLAN HMO PLANS", "methodology": "per diem", "standard_charge_dollar": 28538.0, "standard_charge_algorithm": "Per diem ($28,538).", "count": "0", "additional_payer_notes": "Zero final payments for the item or service in the 15 months prior to posting the file." } ] } ] }, { "description": "HC Ball Dissect Rnd Gp018", "code_information": [ { "code": "PX-2120008018", "type": "CDM" }, { "code": "99999", "type": "CPT" }, { "code": "0272", "type": "RC" } ], "standard_charges": [ { "setting": "outpatient", "gross_charge": 1750.0, "discounted_cash": 875.0, "minimum": 738.5, "maximum": 910.0, "additional_generic_notes": "Zero final payments for the item or service in the 15 months prior to posting the file.", "payers_information": [ { "payer_name": "AETNA", "plan_name": "AETNA ALL OTHER PLANS", "methodology": "percent of total billed charges", "standard_charge_dollar": 910.0, "standard_charge_percentage": 52.0, "count": "0", "additional_payer_notes": "Zero final payments for the item or service in the 15 months prior to posting the file." }, { "payer_name": "AETNA", "plan_name": "AETNA ALL OTHER PLANS", "methodology": "percent of total billed charges", "standard_charge_dollar": 910.0, "standard_charge_percentage": 52.0, "count": "0", "additional_payer_notes": "Zero final payments for the item or service in the 15 months prior to posting the file." }, { "payer_name": "MERITAIN HEALTH", "plan_name": "AETNA ALL OTHER PLANS", "methodology": "percent of total billed charges", "standard_charge_dollar": 910.0, "standard_charge_percentage": 52.0, "count": "0", "additional_payer_notes": "Zero final payments for the item or service in the 15 months prior to posting the file." }, { "payer_name": "BLUE SHIELD OUT OF STATE", "plan_name": "STANFORD HEALTHCARE ALLIANCE PLAN", "methodology": "percent of total billed charges", "standard_charge_dollar": 850.33, "standard_charge_percentage": 48.59, "count": "0", "additional_payer_notes": "Zero final payments for the item or service in the 15 months prior to posting the file." }, { "payer_name": "BLUE SHIELD", "plan_name": "STANFORD HEALTHCARE ALLIANCE PLAN", "methodology": "percent of total billed charges", "standard_charge_dollar": 850.33, "standard_charge_percentage": 48.59, "median_amount": 68.24, "10th_percentile": 13.6, "90th_percentile": 1043.06, "count": "30" }, { "payer_name": "BLUE SHIELD", "plan_name": "STANFORD HEALTHCARE ALLIANCE PLAN", "methodology": "percent of total billed charges", "standard_charge_dollar": 850.33, "standard_charge_percentage": 48.59, "count": "0", "additional_payer_notes": "Zero final payments for the item or service in the 15 months prior to posting the file." }, { "payer_name": "BLUE SHIELD", "plan_name": "STANFORD HEALTHCARE ALLIANCE PLAN", "methodology": "percent of total billed charges", "standard_charge_dollar": 850.33, "standard_charge_percentage": 48.59, "count": "0", "additional_payer_notes": "Zero final payments for the item or service in the 15 months prior to posting the file." }, { "payer_name": "CIGNA", "plan_name": "CIGNA COM ALT HMO PLAN", "methodology": "percent of total billed charges", "standard_charge_dollar": 738.5, "standard_charge_percentage": 42.2, "count": "0", "additional_payer_notes": "Zero final payments for the item or service in the 15 months prior to posting the file." }, { "payer_name": "CIGNA", "plan_name": "CIGNA COM ALT HMO PLAN", "methodology": "percent of total billed charges", "standard_charge_dollar": 738.5, "standard_charge_percentage": 42.2, "count": "0", "additional_payer_notes": "Zero final payments for the item or service in the 15 months prior to posting the file." }, { "payer_name": "HEALTH NET", "plan_name": "HEALTHNET HMO, PPO, POS, EPO, CANOPY HEALTHNET HMO, OTHER-IN-NETWORK PLANS", "methodology": "per diem", "standard_charge_dollar": 8000.0, "standard_charge_algorithm": "Expected reimbursement is the lesser of Per diem ($8,000) for the length of stay and 70% of billed.", "count": "0", "additional_payer_notes": "Zero final payments for the item or service in the 15 months prior to posting the file." }, { "payer_name": "HEALTH NET", "plan_name": "HEALTHNET HMO, PPO, POS, EPO, CANOPY HEALTHNET HMO, OTHER-IN-NETWORK PLANS", "methodology": "per diem", "standard_charge_dollar": 8000.0, "standard_charge_algorithm": "Expected reimbursement is the lesser of Per diem ($8,000) for the length of stay and 70% of billed.", "count": "0", "additional_payer_notes": "Zero final payments for the item or service in the 15 months prior to posting the file." }, { "payer_name": "UNITED HEALTHCARE", "plan_name": "SUTTER SELECT & SUTTER HEALTH PLAN HMO PLANS", "methodology": "per diem", "standard_charge_dollar": 28538.0, "standard_charge_algorithm": "Per diem ($28,538).", "count": "0", "additional_payer_notes": "Zero final payments for the item or service in the 15 months prior to posting the file." }, { "payer_name": "UNITED HEALTHCARE", "plan_name": "SUTTER SELECT & SUTTER HEALTH PLAN HMO PLANS", "methodology": "per diem", "standard_charge_dollar": 28538.0, "standard_charge_algorithm": "Per diem ($28,538).", "count": "0", "additional_payer_notes": "Zero final payments for the item or service in the 15 months prior to posting the file." }, { "payer_name": "SUTTER", "plan_name": "SUTTER SELECT & SUTTER HEALTH PLAN HMO PLANS", "methodology": "per diem", "standard_charge_dollar": 28538.0, "standard_charge_algorithm": "Per diem ($28,538).", "count": "0", "additional_payer_notes": "Zero final payments for the item or service in the 15 months prior to posting the file." }, { "payer_name": "UNITED HEALTHCARE", "plan_name": "SUTTER SELECT & SUTTER HEALTH PLAN HMO PLANS", "methodology": "per diem", "standard_charge_dollar": 28538.0, "standard_charge_algorithm": "Per diem ($28,538).", "count": "0", "additional_payer_notes": "Zero final payments for the item or service in the 15 months prior to posting the file." }, { "payer_name": "UMR", "plan_name": "SUTTER SELECT & SUTTER HEALTH PLAN HMO PLANS", "methodology": "per diem", "standard_charge_dollar": 28538.0, "standard_charge_algorithm": "Per diem ($28,538).", "count": "0", "additional_payer_notes": "Zero final payments for the item or service in the 15 months prior to posting the file." } ] } ] }, { "description": "HC Ball Dissect Rnd Gp019", "code_information": [ { "code": "PX-2120008019", "type": "CDM" }, { "code": "99999", "type": "CPT" }, { "code": "0272", "type": "RC" } ], "standard_charges": [ { "setting": "outpatient", "gross_charge": 2125.0, "discounted_cash": 1062.5, "minimum": 896.75, "maximum": 1105.0, "additional_generic_notes": "Zero final payments for the item or service in the 15 months prior to posting the file.", "payers_information": [ { "payer_name": "AETNA", "plan_name": "AETNA ALL OTHER PLANS", "methodology": "percent of total billed charges", "standard_charge_dollar": 1105.0, "standard_charge_percentage": 52.0, "count": "0", "additional_payer_notes": "Zero final payments for the item or service in the 15 months prior to posting the file." }, { "payer_name": "AETNA", "plan_name": "AETNA ALL OTHER PLANS", "methodology": "percent of total billed charges", "standard_charge_dollar": 1105.0, "standard_charge_percentage": 52.0, "count": "0", "additional_payer_notes": "Zero final payments for the item or service in the 15 months prior to posting the file." }, { "payer_name": "MERITAIN HEALTH", "plan_name": "AETNA ALL OTHER PLANS", "methodology": "percent of total billed charges", "standard_charge_dollar": 1105.0, "standard_charge_percentage": 52.0, "count": "0", "additional_payer_notes": "Zero final payments for the item or service in the 15 months prior to posting the file." }, { "payer_name": "BLUE SHIELD OUT OF STATE", "plan_name": "STANFORD HEALTHCARE ALLIANCE PLAN", "methodology": "percent of total billed charges", "standard_charge_dollar": 1032.54, "standard_charge_percentage": 48.59, "count": "0", "additional_payer_notes": "Zero final payments for the item or service in the 15 months prior to posting the file." }, { "payer_name": "BLUE SHIELD", "plan_name": "STANFORD HEALTHCARE ALLIANCE PLAN", "methodology": "percent of total billed charges", "standard_charge_dollar": 1032.54, "standard_charge_percentage": 48.59, "median_amount": 68.24, "10th_percentile": 13.6, "90th_percentile": 1043.06, "count": "30" }, { "payer_name": "BLUE SHIELD", "plan_name": "STANFORD HEALTHCARE ALLIANCE PLAN", "methodology": "percent of total billed charges", "standard_charge_dollar": 1032.54, "standard_charge_percentage": 48.59, "count": "0", "additional_payer_notes": "Zero final payments for the item or service in the 15 months prior to posting the file." }, { "payer_name": "BLUE SHIELD", "plan_name": "STANFORD HEALTHCARE ALLIANCE PLAN", "methodology": "percent of total billed charges", "standard_charge_dollar": 1032.54, "standard_charge_percentage": 48.59, "count": "0", "additional_payer_notes": "Zero final payments for the item or service in the 15 months prior to posting the file." }, { "payer_name": "CIGNA", "plan_name": "CIGNA COM ALT HMO PLAN", "methodology": "percent of total billed charges", "standard_charge_dollar": 896.75, "standard_charge_percentage": 42.2, "count": "0", "additional_payer_notes": "Zero final payments for the item or service in the 15 months prior to posting the file." }, { "payer_name": "CIGNA", "plan_name": "CIGNA COM ALT HMO PLAN", "methodology": "percent of total billed charges", "standard_charge_dollar": 896.75, "standard_charge_percentage": 42.2, "count": "0", "additional_payer_notes": "Zero final payments for the item or service in the 15 months prior to posting the file." }, { "payer_name": "HEALTH NET", "plan_name": "HEALTHNET HMO, PPO, POS, EPO, CANOPY HEALTHNET HMO, OTHER-IN-NETWORK PLANS", "methodology": "per diem", "standard_charge_dollar": 8000.0, "standard_charge_algorithm": "Expected reimbursement is the lesser of Per diem ($8,000) for the length of stay and 70% of billed.", "count": "0", "additional_payer_notes": "Zero final payments for the item or service in the 15 months prior to posting the file." }, { "payer_name": "HEALTH NET", "plan_name": "HEALTHNET HMO, PPO, POS, EPO, CANOPY HEALTHNET HMO, OTHER-IN-NETWORK PLANS", "methodology": "per diem", "standard_charge_dollar": 8000.0, "standard_charge_algorithm": "Expected reimbursement is the lesser of Per diem ($8,000) for the length of stay and 70% of billed.", "count": "0", "additional_payer_notes": "Zero final payments for the item or service in the 15 months prior to posting the file." }, { "payer_name": "UNITED HEALTHCARE", "plan_name": "SUTTER SELECT & SUTTER HEALTH PLAN HMO PLANS", "methodology": "per diem", "standard_charge_dollar": 28538.0, "standard_charge_algorithm": "Per diem ($28,538).", "count": "0", "additional_payer_notes": "Zero final payments for the item or service in the 15 months prior to posting the file." }, { "payer_name": "UNITED HEALTHCARE", "plan_name": "SUTTER SELECT & SUTTER HEALTH PLAN HMO PLANS", "methodology": "per diem", "standard_charge_dollar": 28538.0, "standard_charge_algorithm": "Per diem ($28,538).", "count": "0", "additional_payer_notes": "Zero final payments for the item or service in the 15 months prior to posting the file." }, { "payer_name": "SUTTER", "plan_name": "SUTTER SELECT & SUTTER HEALTH PLAN HMO PLANS", "methodology": "per diem", "standard_charge_dollar": 28538.0, "standard_charge_algorithm": "Per diem ($28,538).", "count": "0", "additional_payer_notes": "Zero final payments for the item or service in the 15 months prior to posting the file." }, { "payer_name": "UNITED HEALTHCARE", "plan_name": "SUTTER SELECT & SUTTER HEALTH PLAN HMO PLANS", "methodology": "per diem", "standard_charge_dollar": 28538.0, "standard_charge_algorithm": "Per diem ($28,538).", "count": "0", "additional_payer_notes": "Zero final payments for the item or service in the 15 months prior to posting the file." }, { "payer_name": "UMR", "plan_name": "SUTTER SELECT & SUTTER HEALTH PLAN HMO PLANS", "methodology": "per diem", "standard_charge_dollar": 28538.0, "standard_charge_algorithm": "Per diem ($28,538).", "count": "0", "additional_payer_notes": "Zero final payments for the item or service in the 15 months prior to posting the file." } ] } ] }, { "description": "HC Ball Dissect Rnd Gp020", "code_information": [ { "code": "PX-2120008020", "type": "CDM" }, { "code": "99999", "type": "CPT" }, { "code": "0272", "type": "RC" } ], "standard_charges": [ { "setting": "outpatient", "gross_charge": 2550.0, "discounted_cash": 1275.0, "minimum": 1076.1, "maximum": 1326.0, "additional_generic_notes": "Zero final payments for the item or service in the 15 months prior to posting the file.", "payers_information": [ { "payer_name": "AETNA", "plan_name": "AETNA ALL OTHER PLANS", "methodology": "percent of total billed charges", "standard_charge_dollar": 1326.0, "standard_charge_percentage": 52.0, "count": "0", "additional_payer_notes": "Zero final payments for the item or service in the 15 months prior to posting the file." }, { "payer_name": "AETNA", "plan_name": "AETNA ALL OTHER PLANS", "methodology": "percent of total billed charges", "standard_charge_dollar": 1326.0, "standard_charge_percentage": 52.0, "count": "0", "additional_payer_notes": "Zero final payments for the item or service in the 15 months prior to posting the file." }, { "payer_name": "MERITAIN HEALTH", "plan_name": "AETNA ALL OTHER PLANS", "methodology": "percent of total billed charges", "standard_charge_dollar": 1326.0, "standard_charge_percentage": 52.0, "count": "0", "additional_payer_notes": "Zero final payments for the item or service in the 15 months prior to posting the file." }, { "payer_name": "BLUE SHIELD OUT OF STATE", "plan_name": "STANFORD HEALTHCARE ALLIANCE PLAN", "methodology": "percent of total billed charges", "standard_charge_dollar": 1239.05, "standard_charge_percentage": 48.59, "count": "0", "additional_payer_notes": "Zero final payments for the item or service in the 15 months prior to posting the file." }, { "payer_name": "BLUE SHIELD", "plan_name": "STANFORD HEALTHCARE ALLIANCE PLAN", "methodology": "percent of total billed charges", "standard_charge_dollar": 1239.05, "standard_charge_percentage": 48.59, "median_amount": 68.24, "10th_percentile": 13.6, "90th_percentile": 1043.06, "count": "30" }, { "payer_name": "BLUE SHIELD", "plan_name": "STANFORD HEALTHCARE ALLIANCE PLAN", "methodology": "percent of total billed charges", "standard_charge_dollar": 1239.05, "standard_charge_percentage": 48.59, "count": "0", "additional_payer_notes": "Zero final payments for the item or service in the 15 months prior to posting the file." }, { "payer_name": "BLUE SHIELD", "plan_name": "STANFORD HEALTHCARE ALLIANCE PLAN", "methodology": "percent of total billed charges", "standard_charge_dollar": 1239.05, "standard_charge_percentage": 48.59, "count": "0", "additional_payer_notes": "Zero final payments for the item or service in the 15 months prior to posting the file." }, { "payer_name": "CIGNA", "plan_name": "CIGNA COM ALT HMO PLAN", "methodology": "percent of total billed charges", "standard_charge_dollar": 1076.1, "standard_charge_percentage": 42.2, "count": "0", "additional_payer_notes": "Zero final payments for the item or service in the 15 months prior to posting the file." }, { "payer_name": "CIGNA", "plan_name": "CIGNA COM ALT HMO PLAN", "methodology": "percent of total billed charges", "standard_charge_dollar": 1076.1, "standard_charge_percentage": 42.2, "count": "0", "additional_payer_notes": "Zero final payments for the item or service in the 15 months prior to posting the file." }, { "payer_name": "HEALTH NET", "plan_name": "HEALTHNET HMO, PPO, POS, EPO, CANOPY HEALTHNET HMO, OTHER-IN-NETWORK PLANS", "methodology": "per diem", "standard_charge_dollar": 8000.0, "standard_charge_algorithm": "Expected reimbursement is the lesser of Per diem ($8,000) for the length of stay and 70% of billed.", "count": "0", "additional_payer_notes": "Zero final payments for the item or service in the 15 months prior to posting the file." }, { "payer_name": "HEALTH NET", "plan_name": "HEALTHNET HMO, PPO, POS, EPO, CANOPY HEALTHNET HMO, OTHER-IN-NETWORK PLANS", "methodology": "per diem", "standard_charge_dollar": 8000.0, "standard_charge_algorithm": "Expected reimbursement is the lesser of Per diem ($8,000) for the length of stay and 70% of billed.", "count": "0", "additional_payer_notes": "Zero final payments for the item or service in the 15 months prior to posting the file." }, { "payer_name": "UNITED HEALTHCARE", "plan_name": "SUTTER SELECT & SUTTER HEALTH PLAN HMO PLANS", "methodology": "per diem", "standard_charge_dollar": 28538.0, "standard_charge_algorithm": "Per diem ($28,538).", "count": "0", "additional_payer_notes": "Zero final payments for the item or service in the 15 months prior to posting the file." }, { "payer_name": "UNITED HEALTHCARE", "plan_name": "SUTTER SELECT & SUTTER HEALTH PLAN HMO PLANS", "methodology": "per diem", "standard_charge_dollar": 28538.0, "standard_charge_algorithm": "Per diem ($28,538).", "count": "0", "additional_payer_notes": "Zero final payments for the item or service in the 15 months prior to posting the file." }, { "payer_name": "SUTTER", "plan_name": "SUTTER SELECT & SUTTER HEALTH PLAN HMO PLANS", "methodology": "per diem", "standard_charge_dollar": 28538.0, "standard_charge_algorithm": "Per diem ($28,538).", "count": "0", "additional_payer_notes": "Zero final payments for the item or service in the 15 months prior to posting the file." }, { "payer_name": "UNITED HEALTHCARE", "plan_name": "SUTTER SELECT & SUTTER HEALTH PLAN HMO PLANS", "methodology": "per diem", "standard_charge_dollar": 28538.0, "standard_charge_algorithm": "Per diem ($28,538).", "count": "0", "additional_payer_notes": "Zero final payments for the item or service in the 15 months prior to posting the file." }, { "payer_name": "UMR", "plan_name": "SUTTER SELECT & SUTTER HEALTH PLAN HMO PLANS", "methodology": "per diem", "standard_charge_dollar": 28538.0, "standard_charge_algorithm": "Per diem ($28,538).", "count": "0", "additional_payer_notes": "Zero final payments for the item or service in the 15 months prior to posting the file." } ] } ] }, { "description": "HC Ball Flut Shrt Gp009", "code_information": [ { "code": "PX-2120009009", "type": "CDM" }, { "code": "99999", "type": "CPT" }, { "code": "0272", "type": "RC" } ], "standard_charges": [ { "setting": "outpatient", "gross_charge": 570.0, "discounted_cash": 285.0, "minimum": 240.54, "maximum": 296.4, "additional_generic_notes": "Zero final payments for the item or service in the 15 months prior to posting the file.", "payers_information": [ { "payer_name": "AETNA", "plan_name": "AETNA ALL OTHER PLANS", "methodology": "percent of total billed charges", "standard_charge_dollar": 296.4, "standard_charge_percentage": 52.0, "count": "0", "additional_payer_notes": "Zero final payments for the item or service in the 15 months prior to posting the file." }, { "payer_name": "AETNA", "plan_name": "AETNA ALL OTHER PLANS", "methodology": "percent of total billed charges", "standard_charge_dollar": 296.4, "standard_charge_percentage": 52.0, "count": "0", "additional_payer_notes": "Zero final payments for the item or service in the 15 months prior to posting the file." }, { "payer_name": "MERITAIN HEALTH", "plan_name": "AETNA ALL OTHER PLANS", "methodology": "percent of total billed charges", "standard_charge_dollar": 296.4, "standard_charge_percentage": 52.0, "count": "0", "additional_payer_notes": "Zero final payments for the item or service in the 15 months prior to posting the file." }, { "payer_name": "BLUE SHIELD OUT OF STATE", "plan_name": "STANFORD HEALTHCARE ALLIANCE PLAN", "methodology": "percent of total billed charges", "standard_charge_dollar": 276.96, "standard_charge_percentage": 48.59, "count": "0", "additional_payer_notes": "Zero final payments for the item or service in the 15 months prior to posting the file." }, { "payer_name": "BLUE SHIELD", "plan_name": "STANFORD HEALTHCARE ALLIANCE PLAN", "methodology": "percent of total billed charges", "standard_charge_dollar": 276.96, "standard_charge_percentage": 48.59, "count": "0", "additional_payer_notes": "Zero final payments for the item or service in the 15 months prior to posting the file." }, { "payer_name": "BLUE SHIELD", "plan_name": "STANFORD HEALTHCARE ALLIANCE PLAN", "methodology": "percent of total billed charges", "standard_charge_dollar": 276.96, "standard_charge_percentage": 48.59, "count": "0", "additional_payer_notes": "Zero final payments for the item or service in the 15 months prior to posting the file." }, { "payer_name": "CIGNA", "plan_name": "CIGNA COM ALT HMO PLAN", "methodology": "percent of total billed charges", "standard_charge_dollar": 240.54, "standard_charge_percentage": 42.2, "count": "0", "additional_payer_notes": "Zero final payments for the item or service in the 15 months prior to posting the file." }, { "payer_name": "CIGNA", "plan_name": "CIGNA COM ALT HMO PLAN", "methodology": "percent of total billed charges", "standard_charge_dollar": 240.54, "standard_charge_percentage": 42.2, "count": "0", "additional_payer_notes": "Zero final payments for the item or service in the 15 months prior to posting the file." }, { "payer_name": "HEALTH NET", "plan_name": "HEALTHNET HMO, PPO, POS, EPO, CANOPY HEALTHNET HMO, OTHER-IN-NETWORK PLANS", "methodology": "per diem", "standard_charge_dollar": 8000.0, "standard_charge_algorithm": "Expected reimbursement is the lesser of Per diem ($8,000) for the length of stay and 70% of billed.", "count": "0", "additional_payer_notes": "Zero final payments for the item or service in the 15 months prior to posting the file." }, { "payer_name": "HEALTH NET", "plan_name": "HEALTHNET HMO, PPO, POS, EPO, CANOPY HEALTHNET HMO, OTHER-IN-NETWORK PLANS", "methodology": "per diem", "standard_charge_dollar": 8000.0, "standard_charge_algorithm": "Expected reimbursement is the lesser of Per diem ($8,000) for the length of stay and 70% of billed.", "count": "0", "additional_payer_notes": "Zero final payments for the item or service in the 15 months prior to posting the file." }, { "payer_name": "UNITED HEALTHCARE", "plan_name": "SUTTER SELECT & SUTTER HEALTH PLAN HMO PLANS", "methodology": "per diem", "standard_charge_dollar": 28538.0, "standard_charge_algorithm": "Per diem ($28,538).", "count": "0", "additional_payer_notes": "Zero final payments for the item or service in the 15 months prior to posting the file." }, { "payer_name": "UNITED HEALTHCARE", "plan_name": "SUTTER SELECT & SUTTER HEALTH PLAN HMO PLANS", "methodology": "per diem", "standard_charge_dollar": 28538.0, "standard_charge_algorithm": "Per diem ($28,538).", "count": "0", "additional_payer_notes": "Zero final payments for the item or service in the 15 months prior to posting the file." }, { "payer_name": "SUTTER", "plan_name": "SUTTER SELECT & SUTTER HEALTH PLAN HMO PLANS", "methodology": "per diem", "standard_charge_dollar": 28538.0, "standard_charge_algorithm": "Per diem ($28,538).", "count": "0", "additional_payer_notes": "Zero final payments for the item or service in the 15 months prior to posting the file." }, { "payer_name": "UNITED HEALTHCARE", "plan_name": "SUTTER SELECT & SUTTER HEALTH PLAN HMO PLANS", "methodology": "per diem", "standard_charge_dollar": 28538.0, "standard_charge_algorithm": "Per diem ($28,538).", "count": "0", "additional_payer_notes": "Zero final payments for the item or service in the 15 months prior to posting the file." }, { "payer_name": "UMR", "plan_name": "SUTTER SELECT & SUTTER HEALTH PLAN HMO PLANS", "methodology": "per diem", "standard_charge_dollar": 28538.0, "standard_charge_algorithm": "Per diem ($28,538).", "count": "0", "additional_payer_notes": "Zero final payments for the item or service in the 15 months prior to posting the file." } ] } ] }, { "description": "HC Ball Flut Shrt Gp010", "code_information": [ { "code": "PX-2120009010", "type": "CDM" }, { "code": "99999", "type": "CPT" }, { "code": "0272", "type": "RC" } ], "standard_charges": [ { "setting": "outpatient", "gross_charge": 665.0, "discounted_cash": 332.5, "minimum": 280.63, "maximum": 345.8, "additional_generic_notes": "Zero final payments for the item or service in the 15 months prior to posting the file.", "payers_information": [ { "payer_name": "AETNA", "plan_name": "AETNA ALL OTHER PLANS", "methodology": "percent of total billed charges", "standard_charge_dollar": 345.8, "standard_charge_percentage": 52.0, "count": "0", "additional_payer_notes": "Zero final payments for the item or service in the 15 months prior to posting the file." }, { "payer_name": "AETNA", "plan_name": "AETNA ALL OTHER PLANS", "methodology": "percent of total billed charges", "standard_charge_dollar": 345.8, "standard_charge_percentage": 52.0, "count": "0", "additional_payer_notes": "Zero final payments for the item or service in the 15 months prior to posting the file." }, { "payer_name": "MERITAIN HEALTH", "plan_name": "AETNA ALL OTHER PLANS", "methodology": "percent of total billed charges", "standard_charge_dollar": 345.8, "standard_charge_percentage": 52.0, "count": "0", "additional_payer_notes": "Zero final payments for the item or service in the 15 months prior to posting the file." }, { "payer_name": "BLUE SHIELD OUT OF STATE", "plan_name": "STANFORD HEALTHCARE ALLIANCE PLAN", "methodology": "percent of total billed charges", "standard_charge_dollar": 323.12, "standard_charge_percentage": 48.59, "count": "0", "additional_payer_notes": "Zero final payments for the item or service in the 15 months prior to posting the file." }, { "payer_name": "BLUE SHIELD", "plan_name": "STANFORD HEALTHCARE ALLIANCE PLAN", "methodology": "percent of total billed charges", "standard_charge_dollar": 323.12, "standard_charge_percentage": 48.59, "count": "0", "additional_payer_notes": "Zero final payments for the item or service in the 15 months prior to posting the file." }, { "payer_name": "BLUE SHIELD", "plan_name": "STANFORD HEALTHCARE ALLIANCE PLAN", "methodology": "percent of total billed charges", "standard_charge_dollar": 323.12, "standard_charge_percentage": 48.59, "count": "0", "additional_payer_notes": "Zero final payments for the item or service in the 15 months prior to posting the file." }, { "payer_name": "CIGNA", "plan_name": "CIGNA COM ALT HMO PLAN", "methodology": "percent of total billed charges", "standard_charge_dollar": 280.63, "standard_charge_percentage": 42.2, "count": "0", "additional_payer_notes": "Zero final payments for the item or service in the 15 months prior to posting the file." }, { "payer_name": "CIGNA", "plan_name": "CIGNA COM ALT HMO PLAN", "methodology": "percent of total billed charges", "standard_charge_dollar": 280.63, "standard_charge_percentage": 42.2, "count": "0", "additional_payer_notes": "Zero final payments for the item or service in the 15 months prior to posting the file." }, { "payer_name": "HEALTH NET", "plan_name": "HEALTHNET HMO, PPO, POS, EPO, CANOPY HEALTHNET HMO, OTHER-IN-NETWORK PLANS", "methodology": "per diem", "standard_charge_dollar": 8000.0, "standard_charge_algorithm": "Expected reimbursement is the lesser of Per diem ($8,000) for the length of stay and 70% of billed.", "count": "0", "additional_payer_notes": "Zero final payments for the item or service in the 15 months prior to posting the file." }, { "payer_name": "HEALTH NET", "plan_name": "HEALTHNET HMO, PPO, POS, EPO, CANOPY HEALTHNET HMO, OTHER-IN-NETWORK PLANS", "methodology": "per diem", "standard_charge_dollar": 8000.0, "standard_charge_algorithm": "Expected reimbursement is the lesser of Per diem ($8,000) for the length of stay and 70% of billed.", "count": "0", "additional_payer_notes": "Zero final payments for the item or service in the 15 months prior to posting the file." }, { "payer_name": "UNITED HEALTHCARE", "plan_name": "SUTTER SELECT & SUTTER HEALTH PLAN HMO PLANS", "methodology": "per diem", "standard_charge_dollar": 28538.0, "standard_charge_algorithm": "Per diem ($28,538).", "count": "0", "additional_payer_notes": "Zero final payments for the item or service in the 15 months prior to posting the file." }, { "payer_name": "UNITED HEALTHCARE", "plan_name": "SUTTER SELECT & SUTTER HEALTH PLAN HMO PLANS", "methodology": "per diem", "standard_charge_dollar": 28538.0, "standard_charge_algorithm": "Per diem ($28,538).", "count": "0", "additional_payer_notes": "Zero final payments for the item or service in the 15 months prior to posting the file." }, { "payer_name": "SUTTER", "plan_name": "SUTTER SELECT & SUTTER HEALTH PLAN HMO PLANS", "methodology": "per diem", "standard_charge_dollar": 28538.0, "standard_charge_algorithm": "Per diem ($28,538).", "count": "0", "additional_payer_notes": "Zero final payments for the item or service in the 15 months prior to posting the file." }, { "payer_name": "UNITED HEALTHCARE", "plan_name": "SUTTER SELECT & SUTTER HEALTH PLAN HMO PLANS", "methodology": "per diem", "standard_charge_dollar": 28538.0, "standard_charge_algorithm": "Per diem ($28,538).", "count": "0", "additional_payer_notes": "Zero final payments for the item or service in the 15 months prior to posting the file." }, { "payer_name": "UMR", "plan_name": "SUTTER SELECT & SUTTER HEALTH PLAN HMO PLANS", "methodology": "per diem", "standard_charge_dollar": 28538.0, "standard_charge_algorithm": "Per diem ($28,538).", "count": "0", "additional_payer_notes": "Zero final payments for the item or service in the 15 months prior to posting the file." } ] } ] }, { "description": "HC Binder Breast Gp003", "code_information": [ { "code": "PX-2120010003", "type": "CDM" }, { "code": "99999", "type": "CPT" }, { "code": "0272", "type": "RC" } ], "standard_charges": [ { "setting": "outpatient", "gross_charge": 100.0, "discounted_cash": 50.0, "minimum": 42.2, "maximum": 52.0, "additional_generic_notes": "Zero final payments for the item or service in the 15 months prior to posting the file.", "payers_information": [ { "payer_name": "AETNA", "plan_name": "AETNA ALL OTHER PLANS", "methodology": "percent of total billed charges", "standard_charge_dollar": 52.0, "standard_charge_percentage": 52.0, "count": "0", "additional_payer_notes": "Zero final payments for the item or service in the 15 months prior to posting the file." }, { "payer_name": "AETNA", "plan_name": "AETNA ALL OTHER PLANS", "methodology": "percent of total billed charges", "standard_charge_dollar": 52.0, "standard_charge_percentage": 52.0, "count": "0", "additional_payer_notes": "Zero final payments for the item or service in the 15 months prior to posting the file." }, { "payer_name": "MERITAIN HEALTH", "plan_name": "AETNA ALL OTHER PLANS", "methodology": "percent of total billed charges", "standard_charge_dollar": 52.0, "standard_charge_percentage": 52.0, "count": "0", "additional_payer_notes": "Zero final payments for the item or service in the 15 months prior to posting the file." }, { "payer_name": "BLUE SHIELD OUT OF STATE", "plan_name": "STANFORD HEALTHCARE ALLIANCE PLAN", "methodology": "percent of total billed charges", "standard_charge_dollar": 48.59, "standard_charge_percentage": 48.59, "count": "0", "additional_payer_notes": "Zero final payments for the item or service in the 15 months prior to posting the file." }, { "payer_name": "BLUE SHIELD", "plan_name": "STANFORD HEALTHCARE ALLIANCE PLAN", "methodology": "percent of total billed charges", "standard_charge_dollar": 48.59, "standard_charge_percentage": 48.59, "count": "0", "additional_payer_notes": "Zero final payments for the item or service in the 15 months prior to posting the file." }, { "payer_name": "BLUE SHIELD", "plan_name": "STANFORD HEALTHCARE ALLIANCE PLAN", "methodology": "percent of total billed charges", "standard_charge_dollar": 48.59, "standard_charge_percentage": 48.59, "count": "0", "additional_payer_notes": "Zero final payments for the item or service in the 15 months prior to posting the file." }, { "payer_name": "CIGNA", "plan_name": "CIGNA COM ALT HMO PLAN", "methodology": "percent of total billed charges", "standard_charge_dollar": 42.2, "standard_charge_percentage": 42.2, "count": "0", "additional_payer_notes": "Zero final payments for the item or service in the 15 months prior to posting the file." }, { "payer_name": "CIGNA", "plan_name": "CIGNA COM ALT HMO PLAN", "methodology": "percent of total billed charges", "standard_charge_dollar": 42.2, "standard_charge_percentage": 42.2, "count": "0", "additional_payer_notes": "Zero final payments for the item or service in the 15 months prior to posting the file." }, { "payer_name": "HEALTH NET", "plan_name": "HEALTHNET HMO, PPO, POS, EPO, CANOPY HEALTHNET HMO, OTHER-IN-NETWORK PLANS", "methodology": "per diem", "standard_charge_dollar": 8000.0, "standard_charge_algorithm": "Expected reimbursement is the lesser of Per diem ($8,000) for the length of stay and 70% of billed.", "count": "0", "additional_payer_notes": "Zero final payments for the item or service in the 15 months prior to posting the file." }, { "payer_name": "HEALTH NET", "plan_name": "HEALTHNET HMO, PPO, POS, EPO, CANOPY HEALTHNET HMO, OTHER-IN-NETWORK PLANS", "methodology": "per diem", "standard_charge_dollar": 8000.0, "standard_charge_algorithm": "Expected reimbursement is the lesser of Per diem ($8,000) for the length of stay and 70% of billed.", "count": "0", "additional_payer_notes": "Zero final payments for the item or service in the 15 months prior to posting the file." }, { "payer_name": "UNITED HEALTHCARE", "plan_name": "SUTTER SELECT & SUTTER HEALTH PLAN HMO PLANS", "methodology": "per diem", "standard_charge_dollar": 28538.0, "standard_charge_algorithm": "Per diem ($28,538).", "count": "0", "additional_payer_notes": "Zero final payments for the item or service in the 15 months prior to posting the file." }, { "payer_name": "UNITED HEALTHCARE", "plan_name": "SUTTER SELECT & SUTTER HEALTH PLAN HMO PLANS", "methodology": "per diem", "standard_charge_dollar": 28538.0, "standard_charge_algorithm": "Per diem ($28,538).", "count": "0", "additional_payer_notes": "Zero final payments for the item or service in the 15 months prior to posting the file." }, { "payer_name": "SUTTER", "plan_name": "SUTTER SELECT & SUTTER HEALTH PLAN HMO PLANS", "methodology": "per diem", "standard_charge_dollar": 28538.0, "standard_charge_algorithm": "Per diem ($28,538).", "count": "0", "additional_payer_notes": "Zero final payments for the item or service in the 15 months prior to posting the file." }, { "payer_name": "UNITED HEALTHCARE", "plan_name": "SUTTER SELECT & SUTTER HEALTH PLAN HMO PLANS", "methodology": "per diem", "standard_charge_dollar": 28538.0, "standard_charge_algorithm": "Per diem ($28,538).", "count": "0", "additional_payer_notes": "Zero final payments for the item or service in the 15 months prior to posting the file." }, { "payer_name": "UMR", "plan_name": "SUTTER SELECT & SUTTER HEALTH PLAN HMO PLANS", "methodology": "per diem", "standard_charge_dollar": 28538.0, "standard_charge_algorithm": "Per diem ($28,538).", "count": "0", "additional_payer_notes": "Zero final payments for the item or service in the 15 months prior to posting the file." } ] } ] }, { "description": "HC Binder Breast Gp004", "code_information": [ { "code": "PX-2120010004", "type": "CDM" }, { "code": "99999", "type": "CPT" }, { "code": "0272", "type": "RC" } ], "standard_charges": [ { "setting": "outpatient", "gross_charge": 146.0, "discounted_cash": 73.0, "minimum": 61.61, "maximum": 75.92, "additional_generic_notes": "Zero final payments for the item or service in the 15 months prior to posting the file.", "payers_information": [ { "payer_name": "AETNA", "plan_name": "AETNA ALL OTHER PLANS", "methodology": "percent of total billed charges", "standard_charge_dollar": 75.92, "standard_charge_percentage": 52.0, "count": "0", "additional_payer_notes": "Zero final payments for the item or service in the 15 months prior to posting the file." }, { "payer_name": "AETNA", "plan_name": "AETNA ALL OTHER PLANS", "methodology": "percent of total billed charges", "standard_charge_dollar": 75.92, "standard_charge_percentage": 52.0, "count": "0", "additional_payer_notes": "Zero final payments for the item or service in the 15 months prior to posting the file." }, { "payer_name": "MERITAIN HEALTH", "plan_name": "AETNA ALL OTHER PLANS", "methodology": "percent of total billed charges", "standard_charge_dollar": 75.92, "standard_charge_percentage": 52.0, "count": "0", "additional_payer_notes": "Zero final payments for the item or service in the 15 months prior to posting the file." }, { "payer_name": "BLUE SHIELD OUT OF STATE", "plan_name": "STANFORD HEALTHCARE ALLIANCE PLAN", "methodology": "percent of total billed charges", "standard_charge_dollar": 70.94, "standard_charge_percentage": 48.59, "count": "0", "additional_payer_notes": "Zero final payments for the item or service in the 15 months prior to posting the file." }, { "payer_name": "BLUE SHIELD", "plan_name": "STANFORD HEALTHCARE ALLIANCE PLAN", "methodology": "percent of total billed charges", "standard_charge_dollar": 70.94, "standard_charge_percentage": 48.59, "count": "0", "additional_payer_notes": "Zero final payments for the item or service in the 15 months prior to posting the file." }, { "payer_name": "BLUE SHIELD", "plan_name": "STANFORD HEALTHCARE ALLIANCE PLAN", "methodology": "percent of total billed charges", "standard_charge_dollar": 70.94, "standard_charge_percentage": 48.59, "count": "0", "additional_payer_notes": "Zero final payments for the item or service in the 15 months prior to posting the file." }, { "payer_name": "CIGNA", "plan_name": "CIGNA COM ALT HMO PLAN", "methodology": "percent of total billed charges", "standard_charge_dollar": 61.61, "standard_charge_percentage": 42.2, "count": "0", "additional_payer_notes": "Zero final payments for the item or service in the 15 months prior to posting the file." }, { "payer_name": "CIGNA", "plan_name": "CIGNA COM ALT HMO PLAN", "methodology": "percent of total billed charges", "standard_charge_dollar": 61.61, "standard_charge_percentage": 42.2, "count": "0", "additional_payer_notes": "Zero final payments for the item or service in the 15 months prior to posting the file." }, { "payer_name": "HEALTH NET", "plan_name": "HEALTHNET HMO, PPO, POS, EPO, CANOPY HEALTHNET HMO, OTHER-IN-NETWORK PLANS", "methodology": "per diem", "standard_charge_dollar": 8000.0, "standard_charge_algorithm": "Expected reimbursement is the lesser of Per diem ($8,000) for the length of stay and 70% of billed.", "count": "0", "additional_payer_notes": "Zero final payments for the item or service in the 15 months prior to posting the file." }, { "payer_name": "HEALTH NET", "plan_name": "HEALTHNET HMO, PPO, POS, EPO, CANOPY HEALTHNET HMO, OTHER-IN-NETWORK PLANS", "methodology": "per diem", "standard_charge_dollar": 8000.0, "standard_charge_algorithm": "Expected reimbursement is the lesser of Per diem ($8,000) for the length of stay and 70% of billed.", "count": "0", "additional_payer_notes": "Zero final payments for the item or service in the 15 months prior to posting the file." }, { "payer_name": "UNITED HEALTHCARE", "plan_name": "SUTTER SELECT & SUTTER HEALTH PLAN HMO PLANS", "methodology": "per diem", "standard_charge_dollar": 28538.0, "standard_charge_algorithm": "Per diem ($28,538).", "count": "0", "additional_payer_notes": "Zero final payments for the item or service in the 15 months prior to posting the file." }, { "payer_name": "UNITED HEALTHCARE", "plan_name": "SUTTER SELECT & SUTTER HEALTH PLAN HMO PLANS", "methodology": "per diem", "standard_charge_dollar": 28538.0, "standard_charge_algorithm": "Per diem ($28,538).", "count": "0", "additional_payer_notes": "Zero final payments for the item or service in the 15 months prior to posting the file." }, { "payer_name": "SUTTER", "plan_name": "SUTTER SELECT & SUTTER HEALTH PLAN HMO PLANS", "methodology": "per diem", "standard_charge_dollar": 28538.0, "standard_charge_algorithm": "Per diem ($28,538).", "count": "0", "additional_payer_notes": "Zero final payments for the item or service in the 15 months prior to posting the file." }, { "payer_name": "UNITED HEALTHCARE", "plan_name": "SUTTER SELECT & SUTTER HEALTH PLAN HMO PLANS", "methodology": "per diem", "standard_charge_dollar": 28538.0, "standard_charge_algorithm": "Per diem ($28,538).", "count": "0", "additional_payer_notes": "Zero final payments for the item or service in the 15 months prior to posting the file." }, { "payer_name": "UMR", "plan_name": "SUTTER SELECT & SUTTER HEALTH PLAN HMO PLANS", "methodology": "per diem", "standard_charge_dollar": 28538.0, "standard_charge_algorithm": "Per diem ($28,538).", "count": "0", "additional_payer_notes": "Zero final payments for the item or service in the 15 months prior to posting the file." } ] } ] }, { "description": "HC Binder Breast Gp005", "code_information": [ { "code": "PX-2120010005", "type": "CDM" }, { "code": "99999", "type": "CPT" }, { "code": "0272", "type": "RC" } ], "standard_charges": [ { "setting": "outpatient", "gross_charge": 195.0, "discounted_cash": 97.5, "minimum": 82.29, "maximum": 101.4, "additional_generic_notes": "Zero final payments for the item or service in the 15 months prior to posting the file.", "payers_information": [ { "payer_name": "AETNA", "plan_name": "AETNA ALL OTHER PLANS", "methodology": "percent of total billed charges", "standard_charge_dollar": 101.4, "standard_charge_percentage": 52.0, "count": "0", "additional_payer_notes": "Zero final payments for the item or service in the 15 months prior to posting the file." }, { "payer_name": "AETNA", "plan_name": "AETNA ALL OTHER PLANS", "methodology": "percent of total billed charges", "standard_charge_dollar": 101.4, "standard_charge_percentage": 52.0, "count": "0", "additional_payer_notes": "Zero final payments for the item or service in the 15 months prior to posting the file." }, { "payer_name": "MERITAIN HEALTH", "plan_name": "AETNA ALL OTHER PLANS", "methodology": "percent of total billed charges", "standard_charge_dollar": 101.4, "standard_charge_percentage": 52.0, "count": "0", "additional_payer_notes": "Zero final payments for the item or service in the 15 months prior to posting the file." }, { "payer_name": "BLUE SHIELD OUT OF STATE", "plan_name": "STANFORD HEALTHCARE ALLIANCE PLAN", "methodology": "percent of total billed charges", "standard_charge_dollar": 94.75, "standard_charge_percentage": 48.59, "count": "0", "additional_payer_notes": "Zero final payments for the item or service in the 15 months prior to posting the file." }, { "payer_name": "BLUE SHIELD", "plan_name": "STANFORD HEALTHCARE ALLIANCE PLAN", "methodology": "percent of total billed charges", "standard_charge_dollar": 94.75, "standard_charge_percentage": 48.59, "count": "0", "additional_payer_notes": "Zero final payments for the item or service in the 15 months prior to posting the file." }, { "payer_name": "BLUE SHIELD", "plan_name": "STANFORD HEALTHCARE ALLIANCE PLAN", "methodology": "percent of total billed charges", "standard_charge_dollar": 94.75, "standard_charge_percentage": 48.59, "count": "0", "additional_payer_notes": "Zero final payments for the item or service in the 15 months prior to posting the file." }, { "payer_name": "CIGNA", "plan_name": "CIGNA COM ALT HMO PLAN", "methodology": "percent of total billed charges", "standard_charge_dollar": 82.29, "standard_charge_percentage": 42.2, "count": "0", "additional_payer_notes": "Zero final payments for the item or service in the 15 months prior to posting the file." }, { "payer_name": "CIGNA", "plan_name": "CIGNA COM ALT HMO PLAN", "methodology": "percent of total billed charges", "standard_charge_dollar": 82.29, "standard_charge_percentage": 42.2, "count": "0", "additional_payer_notes": "Zero final payments for the item or service in the 15 months prior to posting the file." }, { "payer_name": "HEALTH NET", "plan_name": "HEALTHNET HMO, PPO, POS, EPO, CANOPY HEALTHNET HMO, OTHER-IN-NETWORK PLANS", "methodology": "per diem", "standard_charge_dollar": 8000.0, "standard_charge_algorithm": "Expected reimbursement is the lesser of Per diem ($8,000) for the length of stay and 70% of billed.", "count": "0", "additional_payer_notes": "Zero final payments for the item or service in the 15 months prior to posting the file." }, { "payer_name": "HEALTH NET", "plan_name": "HEALTHNET HMO, PPO, POS, EPO, CANOPY HEALTHNET HMO, OTHER-IN-NETWORK PLANS", "methodology": "per diem", "standard_charge_dollar": 8000.0, "standard_charge_algorithm": "Expected reimbursement is the lesser of Per diem ($8,000) for the length of stay and 70% of billed.", "count": "0", "additional_payer_notes": "Zero final payments for the item or service in the 15 months prior to posting the file." }, { "payer_name": "UNITED HEALTHCARE", "plan_name": "SUTTER SELECT & SUTTER HEALTH PLAN HMO PLANS", "methodology": "per diem", "standard_charge_dollar": 28538.0, "standard_charge_algorithm": "Per diem ($28,538).", "count": "0", "additional_payer_notes": "Zero final payments for the item or service in the 15 months prior to posting the file." }, { "payer_name": "UNITED HEALTHCARE", "plan_name": "SUTTER SELECT & SUTTER HEALTH PLAN HMO PLANS", "methodology": "per diem", "standard_charge_dollar": 28538.0, "standard_charge_algorithm": "Per diem ($28,538).", "count": "0", "additional_payer_notes": "Zero final payments for the item or service in the 15 months prior to posting the file." }, { "payer_name": "SUTTER", "plan_name": "SUTTER SELECT & SUTTER HEALTH PLAN HMO PLANS", "methodology": "per diem", "standard_charge_dollar": 28538.0, "standard_charge_algorithm": "Per diem ($28,538).", "count": "0", "additional_payer_notes": "Zero final payments for the item or service in the 15 months prior to posting the file." }, { "payer_name": "UNITED HEALTHCARE", "plan_name": "SUTTER SELECT & SUTTER HEALTH PLAN HMO PLANS", "methodology": "per diem", "standard_charge_dollar": 28538.0, "standard_charge_algorithm": "Per diem ($28,538).", "count": "0", "additional_payer_notes": "Zero final payments for the item or service in the 15 months prior to posting the file." }, { "payer_name": "UMR", "plan_name": "SUTTER SELECT & SUTTER HEALTH PLAN HMO PLANS", "methodology": "per diem", "standard_charge_dollar": 28538.0, "standard_charge_algorithm": "Per diem ($28,538).", "count": "0", "additional_payer_notes": "Zero final payments for the item or service in the 15 months prior to posting the file." } ] } ] }, { "description": "HC Blade Gp002", "code_information": [ { "code": "PX-2120011002", "type": "CDM" }, { "code": "99999", "type": "CPT" }, { "code": "0272", "type": "RC" } ], "standard_charges": [ { "setting": "outpatient", "gross_charge": 50.0, "discounted_cash": 25.0, "minimum": 21.1, "maximum": 26.0, "additional_generic_notes": "Zero final payments for the item or service in the 15 months prior to posting the file.", "payers_information": [ { "payer_name": "AETNA", "plan_name": "AETNA ALL OTHER PLANS", "methodology": "percent of total billed charges", "standard_charge_dollar": 26.0, "standard_charge_percentage": 52.0, "count": "0", "additional_payer_notes": "Zero final payments for the item or service in the 15 months prior to posting the file." }, { "payer_name": "AETNA", "plan_name": "AETNA ALL OTHER PLANS", "methodology": "percent of total billed charges", "standard_charge_dollar": 26.0, "standard_charge_percentage": 52.0, "count": "0", "additional_payer_notes": "Zero final payments for the item or service in the 15 months prior to posting the file." }, { "payer_name": "MERITAIN HEALTH", "plan_name": "AETNA ALL OTHER PLANS", "methodology": "percent of total billed charges", "standard_charge_dollar": 26.0, "standard_charge_percentage": 52.0, "count": "0", "additional_payer_notes": "Zero final payments for the item or service in the 15 months prior to posting the file." }, { "payer_name": "BLUE SHIELD OUT OF STATE", "plan_name": "STANFORD HEALTHCARE ALLIANCE PLAN", "methodology": "percent of total billed charges", "standard_charge_dollar": 24.3, "standard_charge_percentage": 48.59, "count": "0", "additional_payer_notes": "Zero final payments for the item or service in the 15 months prior to posting the file." }, { "payer_name": "BLUE SHIELD", "plan_name": "STANFORD HEALTHCARE ALLIANCE PLAN", "methodology": "percent of total billed charges", "standard_charge_dollar": 24.3, "standard_charge_percentage": 48.59, "count": "0", "additional_payer_notes": "Zero final payments for the item or service in the 15 months prior to posting the file." }, { "payer_name": "BLUE SHIELD", "plan_name": "STANFORD HEALTHCARE ALLIANCE PLAN", "methodology": "percent of total billed charges", "standard_charge_dollar": 24.3, "standard_charge_percentage": 48.59, "count": "0", "additional_payer_notes": "Zero final payments for the item or service in the 15 months prior to posting the file." }, { "payer_name": "CIGNA", "plan_name": "CIGNA COM ALT HMO PLAN", "methodology": "percent of total billed charges", "standard_charge_dollar": 21.1, "standard_charge_percentage": 42.2, "count": "0", "additional_payer_notes": "Zero final payments for the item or service in the 15 months prior to posting the file." }, { "payer_name": "CIGNA", "plan_name": "CIGNA COM ALT HMO PLAN", "methodology": "percent of total billed charges", "standard_charge_dollar": 21.1, "standard_charge_percentage": 42.2, "count": "0", "additional_payer_notes": "Zero final payments for the item or service in the 15 months prior to posting the file." }, { "payer_name": "HEALTH NET", "plan_name": "HEALTHNET HMO, PPO, POS, EPO, CANOPY HEALTHNET HMO, OTHER-IN-NETWORK PLANS", "methodology": "per diem", "standard_charge_dollar": 8000.0, "standard_charge_algorithm": "Expected reimbursement is the lesser of Per diem ($8,000) for the length of stay and 70% of billed.", "count": "0", "additional_payer_notes": "Zero final payments for the item or service in the 15 months prior to posting the file." }, { "payer_name": "HEALTH NET", "plan_name": "HEALTHNET HMO, PPO, POS, EPO, CANOPY HEALTHNET HMO, OTHER-IN-NETWORK PLANS", "methodology": "per diem", "standard_charge_dollar": 8000.0, "standard_charge_algorithm": "Expected reimbursement is the lesser of Per diem ($8,000) for the length of stay and 70% of billed.", "count": "0", "additional_payer_notes": "Zero final payments for the item or service in the 15 months prior to posting the file." }, { "payer_name": "UNITED HEALTHCARE", "plan_name": "SUTTER SELECT & SUTTER HEALTH PLAN HMO PLANS", "methodology": "per diem", "standard_charge_dollar": 28538.0, "standard_charge_algorithm": "Per diem ($28,538).", "count": "0", "additional_payer_notes": "Zero final payments for the item or service in the 15 months prior to posting the file." }, { "payer_name": "UNITED HEALTHCARE", "plan_name": "SUTTER SELECT & SUTTER HEALTH PLAN HMO PLANS", "methodology": "per diem", "standard_charge_dollar": 28538.0, "standard_charge_algorithm": "Per diem ($28,538).", "count": "0", "additional_payer_notes": "Zero final payments for the item or service in the 15 months prior to posting the file." }, { "payer_name": "SUTTER", "plan_name": "SUTTER SELECT & SUTTER HEALTH PLAN HMO PLANS", "methodology": "per diem", "standard_charge_dollar": 28538.0, "standard_charge_algorithm": "Per diem ($28,538).", "count": "0", "additional_payer_notes": "Zero final payments for the item or service in the 15 months prior to posting the file." }, { "payer_name": "UNITED HEALTHCARE", "plan_name": "SUTTER SELECT & SUTTER HEALTH PLAN HMO PLANS", "methodology": "per diem", "standard_charge_dollar": 28538.0, "standard_charge_algorithm": "Per diem ($28,538).", "count": "0", "additional_payer_notes": "Zero final payments for the item or service in the 15 months prior to posting the file." }, { "payer_name": "UMR", "plan_name": "SUTTER SELECT & SUTTER HEALTH PLAN HMO PLANS", "methodology": "per diem", "standard_charge_dollar": 28538.0, "standard_charge_algorithm": "Per diem ($28,538).", "count": "0", "additional_payer_notes": "Zero final payments for the item or service in the 15 months prior to posting the file." } ] } ] }, { "description": "HC Blade Gp003", "code_information": [ { "code": "PX-2120011003", "type": "CDM" }, { "code": "99999", "type": "CPT" }, { "code": "0272", "type": "RC" } ], "standard_charges": [ { "setting": "outpatient", "gross_charge": 100.0, "discounted_cash": 50.0, "minimum": 42.2, "maximum": 52.0, "additional_generic_notes": "Zero final payments for the item or service in the 15 months prior to posting the file.", "payers_information": [ { "payer_name": "AETNA", "plan_name": "AETNA ALL OTHER PLANS", "methodology": "percent of total billed charges", "standard_charge_dollar": 52.0, "standard_charge_percentage": 52.0, "count": "0", "additional_payer_notes": "Zero final payments for the item or service in the 15 months prior to posting the file." }, { "payer_name": "AETNA", "plan_name": "AETNA ALL OTHER PLANS", "methodology": "percent of total billed charges", "standard_charge_dollar": 52.0, "standard_charge_percentage": 52.0, "count": "0", "additional_payer_notes": "Zero final payments for the item or service in the 15 months prior to posting the file." }, { "payer_name": "MERITAIN HEALTH", "plan_name": "AETNA ALL OTHER PLANS", "methodology": "percent of total billed charges", "standard_charge_dollar": 52.0, "standard_charge_percentage": 52.0, "count": "0", "additional_payer_notes": "Zero final payments for the item or service in the 15 months prior to posting the file." }, { "payer_name": "BLUE SHIELD OUT OF STATE", "plan_name": "STANFORD HEALTHCARE ALLIANCE PLAN", "methodology": "percent of total billed charges", "standard_charge_dollar": 48.59, "standard_charge_percentage": 48.59, "count": "0", "additional_payer_notes": "Zero final payments for the item or service in the 15 months prior to posting the file." }, { "payer_name": "BLUE SHIELD", "plan_name": "STANFORD HEALTHCARE ALLIANCE PLAN", "methodology": "percent of total billed charges", "standard_charge_dollar": 48.59, "standard_charge_percentage": 48.59, "count": "0", "additional_payer_notes": "Zero final payments for the item or service in the 15 months prior to posting the file." }, { "payer_name": "BLUE SHIELD", "plan_name": "STANFORD HEALTHCARE ALLIANCE PLAN", "methodology": "percent of total billed charges", "standard_charge_dollar": 48.59, "standard_charge_percentage": 48.59, "count": "0", "additional_payer_notes": "Zero final payments for the item or service in the 15 months prior to posting the file." }, { "payer_name": "CIGNA", "plan_name": "CIGNA COM ALT HMO PLAN", "methodology": "percent of total billed charges", "standard_charge_dollar": 42.2, "standard_charge_percentage": 42.2, "count": "0", "additional_payer_notes": "Zero final payments for the item or service in the 15 months prior to posting the file." }, { "payer_name": "CIGNA", "plan_name": "CIGNA COM ALT HMO PLAN", "methodology": "percent of total billed charges", "standard_charge_dollar": 42.2, "standard_charge_percentage": 42.2, "count": "0", "additional_payer_notes": "Zero final payments for the item or service in the 15 months prior to posting the file." }, { "payer_name": "HEALTH NET", "plan_name": "HEALTHNET HMO, PPO, POS, EPO, CANOPY HEALTHNET HMO, OTHER-IN-NETWORK PLANS", "methodology": "per diem", "standard_charge_dollar": 8000.0, "standard_charge_algorithm": "Expected reimbursement is the lesser of Per diem ($8,000) for the length of stay and 70% of billed.", "count": "0", "additional_payer_notes": "Zero final payments for the item or service in the 15 months prior to posting the file." }, { "payer_name": "HEALTH NET", "plan_name": "HEALTHNET HMO, PPO, POS, EPO, CANOPY HEALTHNET HMO, OTHER-IN-NETWORK PLANS", "methodology": "per diem", "standard_charge_dollar": 8000.0, "standard_charge_algorithm": "Expected reimbursement is the lesser of Per diem ($8,000) for the length of stay and 70% of billed.", "count": "0", "additional_payer_notes": "Zero final payments for the item or service in the 15 months prior to posting the file." }, { "payer_name": "UNITED HEALTHCARE", "plan_name": "SUTTER SELECT & SUTTER HEALTH PLAN HMO PLANS", "methodology": "per diem", "standard_charge_dollar": 28538.0, "standard_charge_algorithm": "Per diem ($28,538).", "count": "0", "additional_payer_notes": "Zero final payments for the item or service in the 15 months prior to posting the file." }, { "payer_name": "UNITED HEALTHCARE", "plan_name": "SUTTER SELECT & SUTTER HEALTH PLAN HMO PLANS", "methodology": "per diem", "standard_charge_dollar": 28538.0, "standard_charge_algorithm": "Per diem ($28,538).", "count": "0", "additional_payer_notes": "Zero final payments for the item or service in the 15 months prior to posting the file." }, { "payer_name": "SUTTER", "plan_name": "SUTTER SELECT & SUTTER HEALTH PLAN HMO PLANS", "methodology": "per diem", "standard_charge_dollar": 28538.0, "standard_charge_algorithm": "Per diem ($28,538).", "count": "0", "additional_payer_notes": "Zero final payments for the item or service in the 15 months prior to posting the file." }, { "payer_name": "UNITED HEALTHCARE", "plan_name": "SUTTER SELECT & SUTTER HEALTH PLAN HMO PLANS", "methodology": "per diem", "standard_charge_dollar": 28538.0, "standard_charge_algorithm": "Per diem ($28,538).", "count": "0", "additional_payer_notes": "Zero final payments for the item or service in the 15 months prior to posting the file." }, { "payer_name": "UMR", "plan_name": "SUTTER SELECT & SUTTER HEALTH PLAN HMO PLANS", "methodology": "per diem", "standard_charge_dollar": 28538.0, "standard_charge_algorithm": "Per diem ($28,538).", "count": "0", "additional_payer_notes": "Zero final payments for the item or service in the 15 months prior to posting the file." } ] } ] }, { "description": "HC Blade Gp004", "code_information": [ { "code": "PX-2120011004", "type": "CDM" }, { "code": "99999", "type": "CPT" }, { "code": "0272", "type": "RC" } ], "standard_charges": [ { "setting": "outpatient", "gross_charge": 146.0, "discounted_cash": 73.0, "minimum": 61.61, "maximum": 75.92, "additional_generic_notes": "Zero final payments for the item or service in the 15 months prior to posting the file.", "payers_information": [ { "payer_name": "AETNA", "plan_name": "AETNA ALL OTHER PLANS", "methodology": "percent of total billed charges", "standard_charge_dollar": 75.92, "standard_charge_percentage": 52.0, "count": "0", "additional_payer_notes": "Zero final payments for the item or service in the 15 months prior to posting the file." }, { "payer_name": "AETNA", "plan_name": "AETNA ALL OTHER PLANS", "methodology": "percent of total billed charges", "standard_charge_dollar": 75.92, "standard_charge_percentage": 52.0, "count": "0", "additional_payer_notes": "Zero final payments for the item or service in the 15 months prior to posting the file." }, { "payer_name": "MERITAIN HEALTH", "plan_name": "AETNA ALL OTHER PLANS", "methodology": "percent of total billed charges", "standard_charge_dollar": 75.92, "standard_charge_percentage": 52.0, "count": "0", "additional_payer_notes": "Zero final payments for the item or service in the 15 months prior to posting the file." }, { "payer_name": "BLUE SHIELD OUT OF STATE", "plan_name": "STANFORD HEALTHCARE ALLIANCE PLAN", "methodology": "percent of total billed charges", "standard_charge_dollar": 70.94, "standard_charge_percentage": 48.59, "count": "0", "additional_payer_notes": "Zero final payments for the item or service in the 15 months prior to posting the file." }, { "payer_name": "BLUE SHIELD", "plan_name": "STANFORD HEALTHCARE ALLIANCE PLAN", "methodology": "percent of total billed charges", "standard_charge_dollar": 70.94, "standard_charge_percentage": 48.59, "count": "0", "additional_payer_notes": "Zero final payments for the item or service in the 15 months prior to posting the file." }, { "payer_name": "BLUE SHIELD", "plan_name": "STANFORD HEALTHCARE ALLIANCE PLAN", "methodology": "percent of total billed charges", "standard_charge_dollar": 70.94, "standard_charge_percentage": 48.59, "count": "0", "additional_payer_notes": "Zero final payments for the item or service in the 15 months prior to posting the file." }, { "payer_name": "CIGNA", "plan_name": "CIGNA COM ALT HMO PLAN", "methodology": "percent of total billed charges", "standard_charge_dollar": 61.61, "standard_charge_percentage": 42.2, "count": "0", "additional_payer_notes": "Zero final payments for the item or service in the 15 months prior to posting the file." }, { "payer_name": "CIGNA", "plan_name": "CIGNA COM ALT HMO PLAN", "methodology": "percent of total billed charges", "standard_charge_dollar": 61.61, "standard_charge_percentage": 42.2, "count": "0", "additional_payer_notes": "Zero final payments for the item or service in the 15 months prior to posting the file." }, { "payer_name": "HEALTH NET", "plan_name": "HEALTHNET HMO, PPO, POS, EPO, CANOPY HEALTHNET HMO, OTHER-IN-NETWORK PLANS", "methodology": "per diem", "standard_charge_dollar": 8000.0, "standard_charge_algorithm": "Expected reimbursement is the lesser of Per diem ($8,000) for the length of stay and 70% of billed.", "count": "0", "additional_payer_notes": "Zero final payments for the item or service in the 15 months prior to posting the file." }, { "payer_name": "HEALTH NET", "plan_name": "HEALTHNET HMO, PPO, POS, EPO, CANOPY HEALTHNET HMO, OTHER-IN-NETWORK PLANS", "methodology": "per diem", "standard_charge_dollar": 8000.0, "standard_charge_algorithm": "Expected reimbursement is the lesser of Per diem ($8,000) for the length of stay and 70% of billed.", "count": "0", "additional_payer_notes": "Zero final payments for the item or service in the 15 months prior to posting the file." }, { "payer_name": "UNITED HEALTHCARE", "plan_name": "SUTTER SELECT & SUTTER HEALTH PLAN HMO PLANS", "methodology": "per diem", "standard_charge_dollar": 28538.0, "standard_charge_algorithm": "Per diem ($28,538).", "count": "0", "additional_payer_notes": "Zero final payments for the item or service in the 15 months prior to posting the file." }, { "payer_name": "UNITED HEALTHCARE", "plan_name": "SUTTER SELECT & SUTTER HEALTH PLAN HMO PLANS", "methodology": "per diem", "standard_charge_dollar": 28538.0, "standard_charge_algorithm": "Per diem ($28,538).", "count": "0", "additional_payer_notes": "Zero final payments for the item or service in the 15 months prior to posting the file." }, { "payer_name": "SUTTER", "plan_name": "SUTTER SELECT & SUTTER HEALTH PLAN HMO PLANS", "methodology": "per diem", "standard_charge_dollar": 28538.0, "standard_charge_algorithm": "Per diem ($28,538).", "count": "0", "additional_payer_notes": "Zero final payments for the item or service in the 15 months prior to posting the file." }, { "payer_name": "UNITED HEALTHCARE", "plan_name": "SUTTER SELECT & SUTTER HEALTH PLAN HMO PLANS", "methodology": "per diem", "standard_charge_dollar": 28538.0, "standard_charge_algorithm": "Per diem ($28,538).", "count": "0", "additional_payer_notes": "Zero final payments for the item or service in the 15 months prior to posting the file." }, { "payer_name": "UMR", "plan_name": "SUTTER SELECT & SUTTER HEALTH PLAN HMO PLANS", "methodology": "per diem", "standard_charge_dollar": 28538.0, "standard_charge_algorithm": "Per diem ($28,538).", "count": "0", "additional_payer_notes": "Zero final payments for the item or service in the 15 months prior to posting the file." } ] } ] }, { "description": "HC Blade Gp005", "code_information": [ { "code": "PX-2120011005", "type": "CDM" }, { "code": "99999", "type": "CPT" }, { "code": "0272", "type": "RC" } ], "standard_charges": [ { "setting": "outpatient", "gross_charge": 195.0, "discounted_cash": 97.5, "minimum": 82.29, "maximum": 101.4, "additional_generic_notes": "Zero final payments for the item or service in the 15 months prior to posting the file.", "payers_information": [ { "payer_name": "AETNA", "plan_name": "AETNA ALL OTHER PLANS", "methodology": "percent of total billed charges", "standard_charge_dollar": 101.4, "standard_charge_percentage": 52.0, "count": "0", "additional_payer_notes": "Zero final payments for the item or service in the 15 months prior to posting the file." }, { "payer_name": "AETNA", "plan_name": "AETNA ALL OTHER PLANS", "methodology": "percent of total billed charges", "standard_charge_dollar": 101.4, "standard_charge_percentage": 52.0, "count": "0", "additional_payer_notes": "Zero final payments for the item or service in the 15 months prior to posting the file." }, { "payer_name": "MERITAIN HEALTH", "plan_name": "AETNA ALL OTHER PLANS", "methodology": "percent of total billed charges", "standard_charge_dollar": 101.4, "standard_charge_percentage": 52.0, "count": "0", "additional_payer_notes": "Zero final payments for the item or service in the 15 months prior to posting the file." }, { "payer_name": "BLUE SHIELD OUT OF STATE", "plan_name": "STANFORD HEALTHCARE ALLIANCE PLAN", "methodology": "percent of total billed charges", "standard_charge_dollar": 94.75, "standard_charge_percentage": 48.59, "count": "0", "additional_payer_notes": "Zero final payments for the item or service in the 15 months prior to posting the file." }, { "payer_name": "BLUE SHIELD", "plan_name": "STANFORD HEALTHCARE ALLIANCE PLAN", "methodology": "percent of total billed charges", "standard_charge_dollar": 94.75, "standard_charge_percentage": 48.59, "count": "0", "additional_payer_notes": "Zero final payments for the item or service in the 15 months prior to posting the file." }, { "payer_name": "BLUE SHIELD", "plan_name": "STANFORD HEALTHCARE ALLIANCE PLAN", "methodology": "percent of total billed charges", "standard_charge_dollar": 94.75, "standard_charge_percentage": 48.59, "count": "0", "additional_payer_notes": "Zero final payments for the item or service in the 15 months prior to posting the file." }, { "payer_name": "CIGNA", "plan_name": "CIGNA COM ALT HMO PLAN", "methodology": "percent of total billed charges", "standard_charge_dollar": 82.29, "standard_charge_percentage": 42.2, "count": "0", "additional_payer_notes": "Zero final payments for the item or service in the 15 months prior to posting the file." }, { "payer_name": "CIGNA", "plan_name": "CIGNA COM ALT HMO PLAN", "methodology": "percent of total billed charges", "standard_charge_dollar": 82.29, "standard_charge_percentage": 42.2, "count": "0", "additional_payer_notes": "Zero final payments for the item or service in the 15 months prior to posting the file." }, { "payer_name": "HEALTH NET", "plan_name": "HEALTHNET HMO, PPO, POS, EPO, CANOPY HEALTHNET HMO, OTHER-IN-NETWORK PLANS", "methodology": "per diem", "standard_charge_dollar": 8000.0, "standard_charge_algorithm": "Expected reimbursement is the lesser of Per diem ($8,000) for the length of stay and 70% of billed.", "count": "0", "additional_payer_notes": "Zero final payments for the item or service in the 15 months prior to posting the file." }, { "payer_name": "HEALTH NET", "plan_name": "HEALTHNET HMO, PPO, POS, EPO, CANOPY HEALTHNET HMO, OTHER-IN-NETWORK PLANS", "methodology": "per diem", "standard_charge_dollar": 8000.0, "standard_charge_algorithm": "Expected reimbursement is the lesser of Per diem ($8,000) for the length of stay and 70% of billed.", "count": "0", "additional_payer_notes": "Zero final payments for the item or service in the 15 months prior to posting the file." }, { "payer_name": "UNITED HEALTHCARE", "plan_name": "SUTTER SELECT & SUTTER HEALTH PLAN HMO PLANS", "methodology": "per diem", "standard_charge_dollar": 28538.0, "standard_charge_algorithm": "Per diem ($28,538).", "count": "0", "additional_payer_notes": "Zero final payments for the item or service in the 15 months prior to posting the file." }, { "payer_name": "UNITED HEALTHCARE", "plan_name": "SUTTER SELECT & SUTTER HEALTH PLAN HMO PLANS", "methodology": "per diem", "standard_charge_dollar": 28538.0, "standard_charge_algorithm": "Per diem ($28,538).", "count": "0", "additional_payer_notes": "Zero final payments for the item or service in the 15 months prior to posting the file." }, { "payer_name": "SUTTER", "plan_name": "SUTTER SELECT & SUTTER HEALTH PLAN HMO PLANS", "methodology": "per diem", "standard_charge_dollar": 28538.0, "standard_charge_algorithm": "Per diem ($28,538).", "count": "0", "additional_payer_notes": "Zero final payments for the item or service in the 15 months prior to posting the file." }, { "payer_name": "UNITED HEALTHCARE", "plan_name": "SUTTER SELECT & SUTTER HEALTH PLAN HMO PLANS", "methodology": "per diem", "standard_charge_dollar": 28538.0, "standard_charge_algorithm": "Per diem ($28,538).", "count": "0", "additional_payer_notes": "Zero final payments for the item or service in the 15 months prior to posting the file." }, { "payer_name": "UMR", "plan_name": "SUTTER SELECT & SUTTER HEALTH PLAN HMO PLANS", "methodology": "per diem", "standard_charge_dollar": 28538.0, "standard_charge_algorithm": "Per diem ($28,538).", "count": "0", "additional_payer_notes": "Zero final payments for the item or service in the 15 months prior to posting the file." } ] } ] }, { "description": "HC Blade Gp006", "code_information": [ { "code": "PX-2120011006", "type": "CDM" }, { "code": "99999", "type": "CPT" }, { "code": "0272", "type": "RC" } ], "standard_charges": [ { "setting": "outpatient", "gross_charge": 293.0, "discounted_cash": 146.5, "minimum": 123.65, "maximum": 152.36, "additional_generic_notes": "Zero final payments for the item or service in the 15 months prior to posting the file.", "payers_information": [ { "payer_name": "AETNA", "plan_name": "AETNA ALL OTHER PLANS", "methodology": "percent of total billed charges", "standard_charge_dollar": 152.36, "standard_charge_percentage": 52.0, "count": "0", "additional_payer_notes": "Zero final payments for the item or service in the 15 months prior to posting the file." }, { "payer_name": "AETNA", "plan_name": "AETNA ALL OTHER PLANS", "methodology": "percent of total billed charges", "standard_charge_dollar": 152.36, "standard_charge_percentage": 52.0, "count": "0", "additional_payer_notes": "Zero final payments for the item or service in the 15 months prior to posting the file." }, { "payer_name": "MERITAIN HEALTH", "plan_name": "AETNA ALL OTHER PLANS", "methodology": "percent of total billed charges", "standard_charge_dollar": 152.36, "standard_charge_percentage": 52.0, "count": "0", "additional_payer_notes": "Zero final payments for the item or service in the 15 months prior to posting the file." }, { "payer_name": "BLUE SHIELD OUT OF STATE", "plan_name": "STANFORD HEALTHCARE ALLIANCE PLAN", "methodology": "percent of total billed charges", "standard_charge_dollar": 142.37, "standard_charge_percentage": 48.59, "count": "0", "additional_payer_notes": "Zero final payments for the item or service in the 15 months prior to posting the file." }, { "payer_name": "BLUE SHIELD", "plan_name": "STANFORD HEALTHCARE ALLIANCE PLAN", "methodology": "percent of total billed charges", "standard_charge_dollar": 142.37, "standard_charge_percentage": 48.59, "count": "0", "additional_payer_notes": "Zero final payments for the item or service in the 15 months prior to posting the file." }, { "payer_name": "BLUE SHIELD", "plan_name": "STANFORD HEALTHCARE ALLIANCE PLAN", "methodology": "percent of total billed charges", "standard_charge_dollar": 142.37, "standard_charge_percentage": 48.59, "count": "0", "additional_payer_notes": "Zero final payments for the item or service in the 15 months prior to posting the file." }, { "payer_name": "CIGNA", "plan_name": "CIGNA COM ALT HMO PLAN", "methodology": "percent of total billed charges", "standard_charge_dollar": 123.65, "standard_charge_percentage": 42.2, "count": "0", "additional_payer_notes": "Zero final payments for the item or service in the 15 months prior to posting the file." }, { "payer_name": "CIGNA", "plan_name": "CIGNA COM ALT HMO PLAN", "methodology": "percent of total billed charges", "standard_charge_dollar": 123.65, "standard_charge_percentage": 42.2, "count": "0", "additional_payer_notes": "Zero final payments for the item or service in the 15 months prior to posting the file." }, { "payer_name": "HEALTH NET", "plan_name": "HEALTHNET HMO, PPO, POS, EPO, CANOPY HEALTHNET HMO, OTHER-IN-NETWORK PLANS", "methodology": "per diem", "standard_charge_dollar": 8000.0, "standard_charge_algorithm": "Expected reimbursement is the lesser of Per diem ($8,000) for the length of stay and 70% of billed.", "count": "0", "additional_payer_notes": "Zero final payments for the item or service in the 15 months prior to posting the file." }, { "payer_name": "HEALTH NET", "plan_name": "HEALTHNET HMO, PPO, POS, EPO, CANOPY HEALTHNET HMO, OTHER-IN-NETWORK PLANS", "methodology": "per diem", "standard_charge_dollar": 8000.0, "standard_charge_algorithm": "Expected reimbursement is the lesser of Per diem ($8,000) for the length of stay and 70% of billed.", "count": "0", "additional_payer_notes": "Zero final payments for the item or service in the 15 months prior to posting the file." }, { "payer_name": "UNITED HEALTHCARE", "plan_name": "SUTTER SELECT & SUTTER HEALTH PLAN HMO PLANS", "methodology": "per diem", "standard_charge_dollar": 28538.0, "standard_charge_algorithm": "Per diem ($28,538).", "count": "0", "additional_payer_notes": "Zero final payments for the item or service in the 15 months prior to posting the file." }, { "payer_name": "UNITED HEALTHCARE", "plan_name": "SUTTER SELECT & SUTTER HEALTH PLAN HMO PLANS", "methodology": "per diem", "standard_charge_dollar": 28538.0, "standard_charge_algorithm": "Per diem ($28,538).", "count": "0", "additional_payer_notes": "Zero final payments for the item or service in the 15 months prior to posting the file." }, { "payer_name": "SUTTER", "plan_name": "SUTTER SELECT & SUTTER HEALTH PLAN HMO PLANS", "methodology": "per diem", "standard_charge_dollar": 28538.0, "standard_charge_algorithm": "Per diem ($28,538).", "count": "0", "additional_payer_notes": "Zero final payments for the item or service in the 15 months prior to posting the file." }, { "payer_name": "UNITED HEALTHCARE", "plan_name": "SUTTER SELECT & SUTTER HEALTH PLAN HMO PLANS", "methodology": "per diem", "standard_charge_dollar": 28538.0, "standard_charge_algorithm": "Per diem ($28,538).", "count": "0", "additional_payer_notes": "Zero final payments for the item or service in the 15 months prior to posting the file." }, { "payer_name": "UMR", "plan_name": "SUTTER SELECT & SUTTER HEALTH PLAN HMO PLANS", "methodology": "per diem", "standard_charge_dollar": 28538.0, "standard_charge_algorithm": "Per diem ($28,538).", "count": "0", "additional_payer_notes": "Zero final payments for the item or service in the 15 months prior to posting the file." } ] } ] }, { "description": "HC Blade Gp007", "code_information": [ { "code": "PX-2120011007", "type": "CDM" }, { "code": "99999", "type": "CPT" }, { "code": "0272", "type": "RC" } ], "standard_charges": [ { "setting": "outpatient", "gross_charge": 380.0, "discounted_cash": 190.0, "minimum": 160.36, "maximum": 197.6, "additional_generic_notes": "Zero final payments for the item or service in the 15 months prior to posting the file.", "payers_information": [ { "payer_name": "AETNA", "plan_name": "AETNA ALL OTHER PLANS", "methodology": "percent of total billed charges", "standard_charge_dollar": 197.6, "standard_charge_percentage": 52.0, "count": "0", "additional_payer_notes": "Zero final payments for the item or service in the 15 months prior to posting the file." }, { "payer_name": "AETNA", "plan_name": "AETNA ALL OTHER PLANS", "methodology": "percent of total billed charges", "standard_charge_dollar": 197.6, "standard_charge_percentage": 52.0, "count": "0", "additional_payer_notes": "Zero final payments for the item or service in the 15 months prior to posting the file." }, { "payer_name": "MERITAIN HEALTH", "plan_name": "AETNA ALL OTHER PLANS", "methodology": "percent of total billed charges", "standard_charge_dollar": 197.6, "standard_charge_percentage": 52.0, "count": "0", "additional_payer_notes": "Zero final payments for the item or service in the 15 months prior to posting the file." }, { "payer_name": "BLUE SHIELD OUT OF STATE", "plan_name": "STANFORD HEALTHCARE ALLIANCE PLAN", "methodology": "percent of total billed charges", "standard_charge_dollar": 184.64, "standard_charge_percentage": 48.59, "count": "0", "additional_payer_notes": "Zero final payments for the item or service in the 15 months prior to posting the file." }, { "payer_name": "BLUE SHIELD", "plan_name": "STANFORD HEALTHCARE ALLIANCE PLAN", "methodology": "percent of total billed charges", "standard_charge_dollar": 184.64, "standard_charge_percentage": 48.59, "count": "0", "additional_payer_notes": "Zero final payments for the item or service in the 15 months prior to posting the file." }, { "payer_name": "BLUE SHIELD", "plan_name": "STANFORD HEALTHCARE ALLIANCE PLAN", "methodology": "percent of total billed charges", "standard_charge_dollar": 184.64, "standard_charge_percentage": 48.59, "count": "0", "additional_payer_notes": "Zero final payments for the item or service in the 15 months prior to posting the file." }, { "payer_name": "CIGNA", "plan_name": "CIGNA COM ALT HMO PLAN", "methodology": "percent of total billed charges", "standard_charge_dollar": 160.36, "standard_charge_percentage": 42.2, "count": "0", "additional_payer_notes": "Zero final payments for the item or service in the 15 months prior to posting the file." }, { "payer_name": "CIGNA", "plan_name": "CIGNA COM ALT HMO PLAN", "methodology": "percent of total billed charges", "standard_charge_dollar": 160.36, "standard_charge_percentage": 42.2, "count": "0", "additional_payer_notes": "Zero final payments for the item or service in the 15 months prior to posting the file." }, { "payer_name": "HEALTH NET", "plan_name": "HEALTHNET HMO, PPO, POS, EPO, CANOPY HEALTHNET HMO, OTHER-IN-NETWORK PLANS", "methodology": "per diem", "standard_charge_dollar": 8000.0, "standard_charge_algorithm": "Expected reimbursement is the lesser of Per diem ($8,000) for the length of stay and 70% of billed.", "count": "0", "additional_payer_notes": "Zero final payments for the item or service in the 15 months prior to posting the file." }, { "payer_name": "HEALTH NET", "plan_name": "HEALTHNET HMO, PPO, POS, EPO, CANOPY HEALTHNET HMO, OTHER-IN-NETWORK PLANS", "methodology": "per diem", "standard_charge_dollar": 8000.0, "standard_charge_algorithm": "Expected reimbursement is the lesser of Per diem ($8,000) for the length of stay and 70% of billed.", "count": "0", "additional_payer_notes": "Zero final payments for the item or service in the 15 months prior to posting the file." }, { "payer_name": "UNITED HEALTHCARE", "plan_name": "SUTTER SELECT & SUTTER HEALTH PLAN HMO PLANS", "methodology": "per diem", "standard_charge_dollar": 28538.0, "standard_charge_algorithm": "Per diem ($28,538).", "count": "0", "additional_payer_notes": "Zero final payments for the item or service in the 15 months prior to posting the file." }, { "payer_name": "UNITED HEALTHCARE", "plan_name": "SUTTER SELECT & SUTTER HEALTH PLAN HMO PLANS", "methodology": "per diem", "standard_charge_dollar": 28538.0, "standard_charge_algorithm": "Per diem ($28,538).", "count": "0", "additional_payer_notes": "Zero final payments for the item or service in the 15 months prior to posting the file." }, { "payer_name": "SUTTER", "plan_name": "SUTTER SELECT & SUTTER HEALTH PLAN HMO PLANS", "methodology": "per diem", "standard_charge_dollar": 28538.0, "standard_charge_algorithm": "Per diem ($28,538).", "count": "0", "additional_payer_notes": "Zero final payments for the item or service in the 15 months prior to posting the file." }, { "payer_name": "UNITED HEALTHCARE", "plan_name": "SUTTER SELECT & SUTTER HEALTH PLAN HMO PLANS", "methodology": "per diem", "standard_charge_dollar": 28538.0, "standard_charge_algorithm": "Per diem ($28,538).", "count": "0", "additional_payer_notes": "Zero final payments for the item or service in the 15 months prior to posting the file." }, { "payer_name": "UMR", "plan_name": "SUTTER SELECT & SUTTER HEALTH PLAN HMO PLANS", "methodology": "per diem", "standard_charge_dollar": 28538.0, "standard_charge_algorithm": "Per diem ($28,538).", "count": "0", "additional_payer_notes": "Zero final payments for the item or service in the 15 months prior to posting the file." } ] } ] }, { "description": "HC Blade Gp008", "code_information": [ { "code": "PX-2120011008", "type": "CDM" }, { "code": "99999", "type": "CPT" }, { "code": "0272", "type": "RC" } ], "standard_charges": [ { "setting": "outpatient", "gross_charge": 475.0, "discounted_cash": 237.5, "minimum": 200.45, "maximum": 247.0, "additional_generic_notes": "Zero final payments for the item or service in the 15 months prior to posting the file.", "payers_information": [ { "payer_name": "AETNA", "plan_name": "AETNA ALL OTHER PLANS", "methodology": "percent of total billed charges", "standard_charge_dollar": 247.0, "standard_charge_percentage": 52.0, "count": "0", "additional_payer_notes": "Zero final payments for the item or service in the 15 months prior to posting the file." }, { "payer_name": "AETNA", "plan_name": "AETNA ALL OTHER PLANS", "methodology": "percent of total billed charges", "standard_charge_dollar": 247.0, "standard_charge_percentage": 52.0, "count": "0", "additional_payer_notes": "Zero final payments for the item or service in the 15 months prior to posting the file." }, { "payer_name": "MERITAIN HEALTH", "plan_name": "AETNA ALL OTHER PLANS", "methodology": "percent of total billed charges", "standard_charge_dollar": 247.0, "standard_charge_percentage": 52.0, "count": "0", "additional_payer_notes": "Zero final payments for the item or service in the 15 months prior to posting the file." }, { "payer_name": "BLUE SHIELD OUT OF STATE", "plan_name": "STANFORD HEALTHCARE ALLIANCE PLAN", "methodology": "percent of total billed charges", "standard_charge_dollar": 230.8, "standard_charge_percentage": 48.59, "count": "0", "additional_payer_notes": "Zero final payments for the item or service in the 15 months prior to posting the file." }, { "payer_name": "BLUE SHIELD", "plan_name": "STANFORD HEALTHCARE ALLIANCE PLAN", "methodology": "percent of total billed charges", "standard_charge_dollar": 230.8, "standard_charge_percentage": 48.59, "count": "0", "additional_payer_notes": "Zero final payments for the item or service in the 15 months prior to posting the file." }, { "payer_name": "BLUE SHIELD", "plan_name": "STANFORD HEALTHCARE ALLIANCE PLAN", "methodology": "percent of total billed charges", "standard_charge_dollar": 230.8, "standard_charge_percentage": 48.59, "count": "0", "additional_payer_notes": "Zero final payments for the item or service in the 15 months prior to posting the file." }, { "payer_name": "CIGNA", "plan_name": "CIGNA COM ALT HMO PLAN", "methodology": "percent of total billed charges", "standard_charge_dollar": 200.45, "standard_charge_percentage": 42.2, "count": "0", "additional_payer_notes": "Zero final payments for the item or service in the 15 months prior to posting the file." }, { "payer_name": "CIGNA", "plan_name": "CIGNA COM ALT HMO PLAN", "methodology": "percent of total billed charges", "standard_charge_dollar": 200.45, "standard_charge_percentage": 42.2, "count": "0", "additional_payer_notes": "Zero final payments for the item or service in the 15 months prior to posting the file." }, { "payer_name": "HEALTH NET", "plan_name": "HEALTHNET HMO, PPO, POS, EPO, CANOPY HEALTHNET HMO, OTHER-IN-NETWORK PLANS", "methodology": "per diem", "standard_charge_dollar": 8000.0, "standard_charge_algorithm": "Expected reimbursement is the lesser of Per diem ($8,000) for the length of stay and 70% of billed.", "count": "0", "additional_payer_notes": "Zero final payments for the item or service in the 15 months prior to posting the file." }, { "payer_name": "HEALTH NET", "plan_name": "HEALTHNET HMO, PPO, POS, EPO, CANOPY HEALTHNET HMO, OTHER-IN-NETWORK PLANS", "methodology": "per diem", "standard_charge_dollar": 8000.0, "standard_charge_algorithm": "Expected reimbursement is the lesser of Per diem ($8,000) for the length of stay and 70% of billed.", "count": "0", "additional_payer_notes": "Zero final payments for the item or service in the 15 months prior to posting the file." }, { "payer_name": "UNITED HEALTHCARE", "plan_name": "SUTTER SELECT & SUTTER HEALTH PLAN HMO PLANS", "methodology": "per diem", "standard_charge_dollar": 28538.0, "standard_charge_algorithm": "Per diem ($28,538).", "count": "0", "additional_payer_notes": "Zero final payments for the item or service in the 15 months prior to posting the file." }, { "payer_name": "UNITED HEALTHCARE", "plan_name": "SUTTER SELECT & SUTTER HEALTH PLAN HMO PLANS", "methodology": "per diem", "standard_charge_dollar": 28538.0, "standard_charge_algorithm": "Per diem ($28,538).", "count": "0", "additional_payer_notes": "Zero final payments for the item or service in the 15 months prior to posting the file." }, { "payer_name": "SUTTER", "plan_name": "SUTTER SELECT & SUTTER HEALTH PLAN HMO PLANS", "methodology": "per diem", "standard_charge_dollar": 28538.0, "standard_charge_algorithm": "Per diem ($28,538).", "count": "0", "additional_payer_notes": "Zero final payments for the item or service in the 15 months prior to posting the file." }, { "payer_name": "UNITED HEALTHCARE", "plan_name": "SUTTER SELECT & SUTTER HEALTH PLAN HMO PLANS", "methodology": "per diem", "standard_charge_dollar": 28538.0, "standard_charge_algorithm": "Per diem ($28,538).", "count": "0", "additional_payer_notes": "Zero final payments for the item or service in the 15 months prior to posting the file." }, { "payer_name": "UMR", "plan_name": "SUTTER SELECT & SUTTER HEALTH PLAN HMO PLANS", "methodology": "per diem", "standard_charge_dollar": 28538.0, "standard_charge_algorithm": "Per diem ($28,538).", "count": "0", "additional_payer_notes": "Zero final payments for the item or service in the 15 months prior to posting the file." } ] } ] }, { "description": "HC Blade Gp009", "code_information": [ { "code": "PX-2120011009", "type": "CDM" }, { "code": "99999", "type": "CPT" }, { "code": "0272", "type": "RC" } ], "standard_charges": [ { "setting": "outpatient", "gross_charge": 570.0, "discounted_cash": 285.0, "minimum": 240.54, "maximum": 296.4, "additional_generic_notes": "Zero final payments for the item or service in the 15 months prior to posting the file.", "payers_information": [ { "payer_name": "AETNA", "plan_name": "AETNA ALL OTHER PLANS", "methodology": "percent of total billed charges", "standard_charge_dollar": 296.4, "standard_charge_percentage": 52.0, "count": "0", "additional_payer_notes": "Zero final payments for the item or service in the 15 months prior to posting the file." }, { "payer_name": "AETNA", "plan_name": "AETNA ALL OTHER PLANS", "methodology": "percent of total billed charges", "standard_charge_dollar": 296.4, "standard_charge_percentage": 52.0, "count": "0", "additional_payer_notes": "Zero final payments for the item or service in the 15 months prior to posting the file." }, { "payer_name": "MERITAIN HEALTH", "plan_name": "AETNA ALL OTHER PLANS", "methodology": "percent of total billed charges", "standard_charge_dollar": 296.4, "standard_charge_percentage": 52.0, "count": "0", "additional_payer_notes": "Zero final payments for the item or service in the 15 months prior to posting the file." }, { "payer_name": "BLUE SHIELD OUT OF STATE", "plan_name": "STANFORD HEALTHCARE ALLIANCE PLAN", "methodology": "percent of total billed charges", "standard_charge_dollar": 276.96, "standard_charge_percentage": 48.59, "count": "0", "additional_payer_notes": "Zero final payments for the item or service in the 15 months prior to posting the file." }, { "payer_name": "BLUE SHIELD", "plan_name": "STANFORD HEALTHCARE ALLIANCE PLAN", "methodology": "percent of total billed charges", "standard_charge_dollar": 276.96, "standard_charge_percentage": 48.59, "count": "0", "additional_payer_notes": "Zero final payments for the item or service in the 15 months prior to posting the file." }, { "payer_name": "BLUE SHIELD", "plan_name": "STANFORD HEALTHCARE ALLIANCE PLAN", "methodology": "percent of total billed charges", "standard_charge_dollar": 276.96, "standard_charge_percentage": 48.59, "count": "0", "additional_payer_notes": "Zero final payments for the item or service in the 15 months prior to posting the file." }, { "payer_name": "CIGNA", "plan_name": "CIGNA COM ALT HMO PLAN", "methodology": "percent of total billed charges", "standard_charge_dollar": 240.54, "standard_charge_percentage": 42.2, "count": "0", "additional_payer_notes": "Zero final payments for the item or service in the 15 months prior to posting the file." }, { "payer_name": "CIGNA", "plan_name": "CIGNA COM ALT HMO PLAN", "methodology": "percent of total billed charges", "standard_charge_dollar": 240.54, "standard_charge_percentage": 42.2, "count": "0", "additional_payer_notes": "Zero final payments for the item or service in the 15 months prior to posting the file." }, { "payer_name": "HEALTH NET", "plan_name": "HEALTHNET HMO, PPO, POS, EPO, CANOPY HEALTHNET HMO, OTHER-IN-NETWORK PLANS", "methodology": "per diem", "standard_charge_dollar": 8000.0, "standard_charge_algorithm": "Expected reimbursement is the lesser of Per diem ($8,000) for the length of stay and 70% of billed.", "count": "0", "additional_payer_notes": "Zero final payments for the item or service in the 15 months prior to posting the file." }, { "payer_name": "HEALTH NET", "plan_name": "HEALTHNET HMO, PPO, POS, EPO, CANOPY HEALTHNET HMO, OTHER-IN-NETWORK PLANS", "methodology": "per diem", "standard_charge_dollar": 8000.0, "standard_charge_algorithm": "Expected reimbursement is the lesser of Per diem ($8,000) for the length of stay and 70% of billed.", "count": "0", "additional_payer_notes": "Zero final payments for the item or service in the 15 months prior to posting the file." }, { "payer_name": "UNITED HEALTHCARE", "plan_name": "SUTTER SELECT & SUTTER HEALTH PLAN HMO PLANS", "methodology": "per diem", "standard_charge_dollar": 28538.0, "standard_charge_algorithm": "Per diem ($28,538).", "count": "0", "additional_payer_notes": "Zero final payments for the item or service in the 15 months prior to posting the file." }, { "payer_name": "UNITED HEALTHCARE", "plan_name": "SUTTER SELECT & SUTTER HEALTH PLAN HMO PLANS", "methodology": "per diem", "standard_charge_dollar": 28538.0, "standard_charge_algorithm": "Per diem ($28,538).", "count": "0", "additional_payer_notes": "Zero final payments for the item or service in the 15 months prior to posting the file." }, { "payer_name": "SUTTER", "plan_name": "SUTTER SELECT & SUTTER HEALTH PLAN HMO PLANS", "methodology": "per diem", "standard_charge_dollar": 28538.0, "standard_charge_algorithm": "Per diem ($28,538).", "count": "0", "additional_payer_notes": "Zero final payments for the item or service in the 15 months prior to posting the file." }, { "payer_name": "UNITED HEALTHCARE", "plan_name": "SUTTER SELECT & SUTTER HEALTH PLAN HMO PLANS", "methodology": "per diem", "standard_charge_dollar": 28538.0, "standard_charge_algorithm": "Per diem ($28,538).", "count": "0", "additional_payer_notes": "Zero final payments for the item or service in the 15 months prior to posting the file." }, { "payer_name": "UMR", "plan_name": "SUTTER SELECT & SUTTER HEALTH PLAN HMO PLANS", "methodology": "per diem", "standard_charge_dollar": 28538.0, "standard_charge_algorithm": "Per diem ($28,538).", "count": "0", "additional_payer_notes": "Zero final payments for the item or service in the 15 months prior to posting the file." } ] } ] }, { "description": "HC Blade Gp010", "code_information": [ { "code": "PX-2120011010", "type": "CDM" }, { "code": "99999", "type": "CPT" }, { "code": "0272", "type": "RC" } ], "standard_charges": [ { "setting": "outpatient", "gross_charge": 665.0, "discounted_cash": 332.5, "minimum": 280.63, "maximum": 345.8, "additional_generic_notes": "Zero final payments for the item or service in the 15 months prior to posting the file.", "payers_information": [ { "payer_name": "AETNA", "plan_name": "AETNA ALL OTHER PLANS", "methodology": "percent of total billed charges", "standard_charge_dollar": 345.8, "standard_charge_percentage": 52.0, "count": "0", "additional_payer_notes": "Zero final payments for the item or service in the 15 months prior to posting the file." }, { "payer_name": "AETNA", "plan_name": "AETNA ALL OTHER PLANS", "methodology": "percent of total billed charges", "standard_charge_dollar": 345.8, "standard_charge_percentage": 52.0, "count": "0", "additional_payer_notes": "Zero final payments for the item or service in the 15 months prior to posting the file." }, { "payer_name": "MERITAIN HEALTH", "plan_name": "AETNA ALL OTHER PLANS", "methodology": "percent of total billed charges", "standard_charge_dollar": 345.8, "standard_charge_percentage": 52.0, "count": "0", "additional_payer_notes": "Zero final payments for the item or service in the 15 months prior to posting the file." }, { "payer_name": "BLUE SHIELD OUT OF STATE", "plan_name": "STANFORD HEALTHCARE ALLIANCE PLAN", "methodology": "percent of total billed charges", "standard_charge_dollar": 323.12, "standard_charge_percentage": 48.59, "count": "0", "additional_payer_notes": "Zero final payments for the item or service in the 15 months prior to posting the file." }, { "payer_name": "BLUE SHIELD", "plan_name": "STANFORD HEALTHCARE ALLIANCE PLAN", "methodology": "percent of total billed charges", "standard_charge_dollar": 323.12, "standard_charge_percentage": 48.59, "count": "0", "additional_payer_notes": "Zero final payments for the item or service in the 15 months prior to posting the file." }, { "payer_name": "BLUE SHIELD", "plan_name": "STANFORD HEALTHCARE ALLIANCE PLAN", "methodology": "percent of total billed charges", "standard_charge_dollar": 323.12, "standard_charge_percentage": 48.59, "count": "0", "additional_payer_notes": "Zero final payments for the item or service in the 15 months prior to posting the file." }, { "payer_name": "CIGNA", "plan_name": "CIGNA COM ALT HMO PLAN", "methodology": "percent of total billed charges", "standard_charge_dollar": 280.63, "standard_charge_percentage": 42.2, "count": "0", "additional_payer_notes": "Zero final payments for the item or service in the 15 months prior to posting the file." }, { "payer_name": "CIGNA", "plan_name": "CIGNA COM ALT HMO PLAN", "methodology": "percent of total billed charges", "standard_charge_dollar": 280.63, "standard_charge_percentage": 42.2, "count": "0", "additional_payer_notes": "Zero final payments for the item or service in the 15 months prior to posting the file." }, { "payer_name": "HEALTH NET", "plan_name": "HEALTHNET HMO, PPO, POS, EPO, CANOPY HEALTHNET HMO, OTHER-IN-NETWORK PLANS", "methodology": "per diem", "standard_charge_dollar": 8000.0, "standard_charge_algorithm": "Expected reimbursement is the lesser of Per diem ($8,000) for the length of stay and 70% of billed.", "count": "0", "additional_payer_notes": "Zero final payments for the item or service in the 15 months prior to posting the file." }, { "payer_name": "HEALTH NET", "plan_name": "HEALTHNET HMO, PPO, POS, EPO, CANOPY HEALTHNET HMO, OTHER-IN-NETWORK PLANS", "methodology": "per diem", "standard_charge_dollar": 8000.0, "standard_charge_algorithm": "Expected reimbursement is the lesser of Per diem ($8,000) for the length of stay and 70% of billed.", "count": "0", "additional_payer_notes": "Zero final payments for the item or service in the 15 months prior to posting the file." }, { "payer_name": "UNITED HEALTHCARE", "plan_name": "SUTTER SELECT & SUTTER HEALTH PLAN HMO PLANS", "methodology": "per diem", "standard_charge_dollar": 28538.0, "standard_charge_algorithm": "Per diem ($28,538).", "count": "0", "additional_payer_notes": "Zero final payments for the item or service in the 15 months prior to posting the file." }, { "payer_name": "UNITED HEALTHCARE", "plan_name": "SUTTER SELECT & SUTTER HEALTH PLAN HMO PLANS", "methodology": "per diem", "standard_charge_dollar": 28538.0, "standard_charge_algorithm": "Per diem ($28,538).", "count": "0", "additional_payer_notes": "Zero final payments for the item or service in the 15 months prior to posting the file." }, { "payer_name": "SUTTER", "plan_name": "SUTTER SELECT & SUTTER HEALTH PLAN HMO PLANS", "methodology": "per diem", "standard_charge_dollar": 28538.0, "standard_charge_algorithm": "Per diem ($28,538).", "count": "0", "additional_payer_notes": "Zero final payments for the item or service in the 15 months prior to posting the file." }, { "payer_name": "UNITED HEALTHCARE", "plan_name": "SUTTER SELECT & SUTTER HEALTH PLAN HMO PLANS", "methodology": "per diem", "standard_charge_dollar": 28538.0, "standard_charge_algorithm": "Per diem ($28,538).", "count": "0", "additional_payer_notes": "Zero final payments for the item or service in the 15 months prior to posting the file." }, { "payer_name": "UMR", "plan_name": "SUTTER SELECT & SUTTER HEALTH PLAN HMO PLANS", "methodology": "per diem", "standard_charge_dollar": 28538.0, "standard_charge_algorithm": "Per diem ($28,538).", "count": "0", "additional_payer_notes": "Zero final payments for the item or service in the 15 months prior to posting the file." } ] } ] }, { "description": "HC Blade Gp011", "code_information": [ { "code": "PX-2120011011", "type": "CDM" }, { "code": "99999", "type": "CPT" }, { "code": "0272", "type": "RC" } ], "standard_charges": [ { "setting": "outpatient", "gross_charge": 740.0, "discounted_cash": 370.0, "minimum": 312.28, "maximum": 384.8, "additional_generic_notes": "Zero final payments for the item or service in the 15 months prior to posting the file.", "payers_information": [ { "payer_name": "AETNA", "plan_name": "AETNA ALL OTHER PLANS", "methodology": "percent of total billed charges", "standard_charge_dollar": 384.8, "standard_charge_percentage": 52.0, "count": "0", "additional_payer_notes": "Zero final payments for the item or service in the 15 months prior to posting the file." }, { "payer_name": "AETNA", "plan_name": "AETNA ALL OTHER PLANS", "methodology": "percent of total billed charges", "standard_charge_dollar": 384.8, "standard_charge_percentage": 52.0, "count": "0", "additional_payer_notes": "Zero final payments for the item or service in the 15 months prior to posting the file." }, { "payer_name": "MERITAIN HEALTH", "plan_name": "AETNA ALL OTHER PLANS", "methodology": "percent of total billed charges", "standard_charge_dollar": 384.8, "standard_charge_percentage": 52.0, "count": "0", "additional_payer_notes": "Zero final payments for the item or service in the 15 months prior to posting the file." }, { "payer_name": "BLUE SHIELD OUT OF STATE", "plan_name": "STANFORD HEALTHCARE ALLIANCE PLAN", "methodology": "percent of total billed charges", "standard_charge_dollar": 359.57, "standard_charge_percentage": 48.59, "count": "0", "additional_payer_notes": "Zero final payments for the item or service in the 15 months prior to posting the file." }, { "payer_name": "BLUE SHIELD", "plan_name": "STANFORD HEALTHCARE ALLIANCE PLAN", "methodology": "percent of total billed charges", "standard_charge_dollar": 359.57, "standard_charge_percentage": 48.59, "count": "0", "additional_payer_notes": "Zero final payments for the item or service in the 15 months prior to posting the file." }, { "payer_name": "BLUE SHIELD", "plan_name": "STANFORD HEALTHCARE ALLIANCE PLAN", "methodology": "percent of total billed charges", "standard_charge_dollar": 359.57, "standard_charge_percentage": 48.59, "count": "0", "additional_payer_notes": "Zero final payments for the item or service in the 15 months prior to posting the file." }, { "payer_name": "CIGNA", "plan_name": "CIGNA COM ALT HMO PLAN", "methodology": "percent of total billed charges", "standard_charge_dollar": 312.28, "standard_charge_percentage": 42.2, "count": "0", "additional_payer_notes": "Zero final payments for the item or service in the 15 months prior to posting the file." }, { "payer_name": "CIGNA", "plan_name": "CIGNA COM ALT HMO PLAN", "methodology": "percent of total billed charges", "standard_charge_dollar": 312.28, "standard_charge_percentage": 42.2, "count": "0", "additional_payer_notes": "Zero final payments for the item or service in the 15 months prior to posting the file." }, { "payer_name": "HEALTH NET", "plan_name": "HEALTHNET HMO, PPO, POS, EPO, CANOPY HEALTHNET HMO, OTHER-IN-NETWORK PLANS", "methodology": "per diem", "standard_charge_dollar": 8000.0, "standard_charge_algorithm": "Expected reimbursement is the lesser of Per diem ($8,000) for the length of stay and 70% of billed.", "count": "0", "additional_payer_notes": "Zero final payments for the item or service in the 15 months prior to posting the file." }, { "payer_name": "HEALTH NET", "plan_name": "HEALTHNET HMO, PPO, POS, EPO, CANOPY HEALTHNET HMO, OTHER-IN-NETWORK PLANS", "methodology": "per diem", "standard_charge_dollar": 8000.0, "standard_charge_algorithm": "Expected reimbursement is the lesser of Per diem ($8,000) for the length of stay and 70% of billed.", "count": "0", "additional_payer_notes": "Zero final payments for the item or service in the 15 months prior to posting the file." }, { "payer_name": "UNITED HEALTHCARE", "plan_name": "SUTTER SELECT & SUTTER HEALTH PLAN HMO PLANS", "methodology": "per diem", "standard_charge_dollar": 28538.0, "standard_charge_algorithm": "Per diem ($28,538).", "count": "0", "additional_payer_notes": "Zero final payments for the item or service in the 15 months prior to posting the file." }, { "payer_name": "UNITED HEALTHCARE", "plan_name": "SUTTER SELECT & SUTTER HEALTH PLAN HMO PLANS", "methodology": "per diem", "standard_charge_dollar": 28538.0, "standard_charge_algorithm": "Per diem ($28,538).", "count": "0", "additional_payer_notes": "Zero final payments for the item or service in the 15 months prior to posting the file." }, { "payer_name": "SUTTER", "plan_name": "SUTTER SELECT & SUTTER HEALTH PLAN HMO PLANS", "methodology": "per diem", "standard_charge_dollar": 28538.0, "standard_charge_algorithm": "Per diem ($28,538).", "count": "0", "additional_payer_notes": "Zero final payments for the item or service in the 15 months prior to posting the file." }, { "payer_name": "UNITED HEALTHCARE", "plan_name": "SUTTER SELECT & SUTTER HEALTH PLAN HMO PLANS", "methodology": "per diem", "standard_charge_dollar": 28538.0, "standard_charge_algorithm": "Per diem ($28,538).", "count": "0", "additional_payer_notes": "Zero final payments for the item or service in the 15 months prior to posting the file." }, { "payer_name": "UMR", "plan_name": "SUTTER SELECT & SUTTER HEALTH PLAN HMO PLANS", "methodology": "per diem", "standard_charge_dollar": 28538.0, "standard_charge_algorithm": "Per diem ($28,538).", "count": "0", "additional_payer_notes": "Zero final payments for the item or service in the 15 months prior to posting the file." } ] } ] }, { "description": "HC Blade Gp012", "code_information": [ { "code": "PX-2120011012", "type": "CDM" }, { "code": "99999", "type": "CPT" }, { "code": "0272", "type": "RC" } ], "standard_charges": [ { "setting": "outpatient", "gross_charge": 810.0, "discounted_cash": 405.0, "minimum": 341.82, "maximum": 421.2, "additional_generic_notes": "Zero final payments for the item or service in the 15 months prior to posting the file.", "payers_information": [ { "payer_name": "AETNA", "plan_name": "AETNA ALL OTHER PLANS", "methodology": "percent of total billed charges", "standard_charge_dollar": 421.2, "standard_charge_percentage": 52.0, "count": "0", "additional_payer_notes": "Zero final payments for the item or service in the 15 months prior to posting the file." }, { "payer_name": "AETNA", "plan_name": "AETNA ALL OTHER PLANS", "methodology": "percent of total billed charges", "standard_charge_dollar": 421.2, "standard_charge_percentage": 52.0, "count": "0", "additional_payer_notes": "Zero final payments for the item or service in the 15 months prior to posting the file." }, { "payer_name": "MERITAIN HEALTH", "plan_name": "AETNA ALL OTHER PLANS", "methodology": "percent of total billed charges", "standard_charge_dollar": 421.2, "standard_charge_percentage": 52.0, "count": "0", "additional_payer_notes": "Zero final payments for the item or service in the 15 months prior to posting the file." }, { "payer_name": "BLUE SHIELD OUT OF STATE", "plan_name": "STANFORD HEALTHCARE ALLIANCE PLAN", "methodology": "percent of total billed charges", "standard_charge_dollar": 393.58, "standard_charge_percentage": 48.59, "count": "0", "additional_payer_notes": "Zero final payments for the item or service in the 15 months prior to posting the file." }, { "payer_name": "BLUE SHIELD", "plan_name": "STANFORD HEALTHCARE ALLIANCE PLAN", "methodology": "percent of total billed charges", "standard_charge_dollar": 393.58, "standard_charge_percentage": 48.59, "count": "0", "additional_payer_notes": "Zero final payments for the item or service in the 15 months prior to posting the file." }, { "payer_name": "BLUE SHIELD", "plan_name": "STANFORD HEALTHCARE ALLIANCE PLAN", "methodology": "percent of total billed charges", "standard_charge_dollar": 393.58, "standard_charge_percentage": 48.59, "count": "0", "additional_payer_notes": "Zero final payments for the item or service in the 15 months prior to posting the file." }, { "payer_name": "CIGNA", "plan_name": "CIGNA COM ALT HMO PLAN", "methodology": "percent of total billed charges", "standard_charge_dollar": 341.82, "standard_charge_percentage": 42.2, "count": "0", "additional_payer_notes": "Zero final payments for the item or service in the 15 months prior to posting the file." }, { "payer_name": "CIGNA", "plan_name": "CIGNA COM ALT HMO PLAN", "methodology": "percent of total billed charges", "standard_charge_dollar": 341.82, "standard_charge_percentage": 42.2, "count": "0", "additional_payer_notes": "Zero final payments for the item or service in the 15 months prior to posting the file." }, { "payer_name": "HEALTH NET", "plan_name": "HEALTHNET HMO, PPO, POS, EPO, CANOPY HEALTHNET HMO, OTHER-IN-NETWORK PLANS", "methodology": "per diem", "standard_charge_dollar": 8000.0, "standard_charge_algorithm": "Expected reimbursement is the lesser of Per diem ($8,000) for the length of stay and 70% of billed.", "count": "0", "additional_payer_notes": "Zero final payments for the item or service in the 15 months prior to posting the file." }, { "payer_name": "HEALTH NET", "plan_name": "HEALTHNET HMO, PPO, POS, EPO, CANOPY HEALTHNET HMO, OTHER-IN-NETWORK PLANS", "methodology": "per diem", "standard_charge_dollar": 8000.0, "standard_charge_algorithm": "Expected reimbursement is the lesser of Per diem ($8,000) for the length of stay and 70% of billed.", "count": "0", "additional_payer_notes": "Zero final payments for the item or service in the 15 months prior to posting the file." }, { "payer_name": "UNITED HEALTHCARE", "plan_name": "SUTTER SELECT & SUTTER HEALTH PLAN HMO PLANS", "methodology": "per diem", "standard_charge_dollar": 28538.0, "standard_charge_algorithm": "Per diem ($28,538).", "count": "0", "additional_payer_notes": "Zero final payments for the item or service in the 15 months prior to posting the file." }, { "payer_name": "UNITED HEALTHCARE", "plan_name": "SUTTER SELECT & SUTTER HEALTH PLAN HMO PLANS", "methodology": "per diem", "standard_charge_dollar": 28538.0, "standard_charge_algorithm": "Per diem ($28,538).", "count": "0", "additional_payer_notes": "Zero final payments for the item or service in the 15 months prior to posting the file." }, { "payer_name": "SUTTER", "plan_name": "SUTTER SELECT & SUTTER HEALTH PLAN HMO PLANS", "methodology": "per diem", "standard_charge_dollar": 28538.0, "standard_charge_algorithm": "Per diem ($28,538).", "count": "0", "additional_payer_notes": "Zero final payments for the item or service in the 15 months prior to posting the file." }, { "payer_name": "UNITED HEALTHCARE", "plan_name": "SUTTER SELECT & SUTTER HEALTH PLAN HMO PLANS", "methodology": "per diem", "standard_charge_dollar": 28538.0, "standard_charge_algorithm": "Per diem ($28,538).", "count": "0", "additional_payer_notes": "Zero final payments for the item or service in the 15 months prior to posting the file." }, { "payer_name": "UMR", "plan_name": "SUTTER SELECT & SUTTER HEALTH PLAN HMO PLANS", "methodology": "per diem", "standard_charge_dollar": 28538.0, "standard_charge_algorithm": "Per diem ($28,538).", "count": "0", "additional_payer_notes": "Zero final payments for the item or service in the 15 months prior to posting the file." } ] } ] }, { "description": "HC Blade Gp013", "code_information": [ { "code": "PX-2120011013", "type": "CDM" }, { "code": "99999", "type": "CPT" }, { "code": "0272", "type": "RC" } ], "standard_charges": [ { "setting": "outpatient", "gross_charge": 900.0, "discounted_cash": 450.0, "minimum": 379.8, "maximum": 468.0, "additional_generic_notes": "Zero final payments for the item or service in the 15 months prior to posting the file.", "payers_information": [ { "payer_name": "AETNA", "plan_name": "AETNA ALL OTHER PLANS", "methodology": "percent of total billed charges", "standard_charge_dollar": 468.0, "standard_charge_percentage": 52.0, "count": "0", "additional_payer_notes": "Zero final payments for the item or service in the 15 months prior to posting the file." }, { "payer_name": "AETNA", "plan_name": "AETNA ALL OTHER PLANS", "methodology": "percent of total billed charges", "standard_charge_dollar": 468.0, "standard_charge_percentage": 52.0, "count": "0", "additional_payer_notes": "Zero final payments for the item or service in the 15 months prior to posting the file." }, { "payer_name": "MERITAIN HEALTH", "plan_name": "AETNA ALL OTHER PLANS", "methodology": "percent of total billed charges", "standard_charge_dollar": 468.0, "standard_charge_percentage": 52.0, "count": "0", "additional_payer_notes": "Zero final payments for the item or service in the 15 months prior to posting the file." }, { "payer_name": "BLUE SHIELD OUT OF STATE", "plan_name": "STANFORD HEALTHCARE ALLIANCE PLAN", "methodology": "percent of total billed charges", "standard_charge_dollar": 437.31, "standard_charge_percentage": 48.59, "count": "0", "additional_payer_notes": "Zero final payments for the item or service in the 15 months prior to posting the file." }, { "payer_name": "BLUE SHIELD", "plan_name": "STANFORD HEALTHCARE ALLIANCE PLAN", "methodology": "percent of total billed charges", "standard_charge_dollar": 437.31, "standard_charge_percentage": 48.59, "count": "0", "additional_payer_notes": "Zero final payments for the item or service in the 15 months prior to posting the file." }, { "payer_name": "BLUE SHIELD", "plan_name": "STANFORD HEALTHCARE ALLIANCE PLAN", "methodology": "percent of total billed charges", "standard_charge_dollar": 437.31, "standard_charge_percentage": 48.59, "count": "0", "additional_payer_notes": "Zero final payments for the item or service in the 15 months prior to posting the file." }, { "payer_name": "CIGNA", "plan_name": "CIGNA COM ALT HMO PLAN", "methodology": "percent of total billed charges", "standard_charge_dollar": 379.8, "standard_charge_percentage": 42.2, "count": "0", "additional_payer_notes": "Zero final payments for the item or service in the 15 months prior to posting the file." }, { "payer_name": "CIGNA", "plan_name": "CIGNA COM ALT HMO PLAN", "methodology": "percent of total billed charges", "standard_charge_dollar": 379.8, "standard_charge_percentage": 42.2, "count": "0", "additional_payer_notes": "Zero final payments for the item or service in the 15 months prior to posting the file." }, { "payer_name": "HEALTH NET", "plan_name": "HEALTHNET HMO, PPO, POS, EPO, CANOPY HEALTHNET HMO, OTHER-IN-NETWORK PLANS", "methodology": "per diem", "standard_charge_dollar": 8000.0, "standard_charge_algorithm": "Expected reimbursement is the lesser of Per diem ($8,000) for the length of stay and 70% of billed.", "count": "0", "additional_payer_notes": "Zero final payments for the item or service in the 15 months prior to posting the file." }, { "payer_name": "HEALTH NET", "plan_name": "HEALTHNET HMO, PPO, POS, EPO, CANOPY HEALTHNET HMO, OTHER-IN-NETWORK PLANS", "methodology": "per diem", "standard_charge_dollar": 8000.0, "standard_charge_algorithm": "Expected reimbursement is the lesser of Per diem ($8,000) for the length of stay and 70% of billed.", "count": "0", "additional_payer_notes": "Zero final payments for the item or service in the 15 months prior to posting the file." }, { "payer_name": "UNITED HEALTHCARE", "plan_name": "SUTTER SELECT & SUTTER HEALTH PLAN HMO PLANS", "methodology": "per diem", "standard_charge_dollar": 28538.0, "standard_charge_algorithm": "Per diem ($28,538).", "count": "0", "additional_payer_notes": "Zero final payments for the item or service in the 15 months prior to posting the file." }, { "payer_name": "UNITED HEALTHCARE", "plan_name": "SUTTER SELECT & SUTTER HEALTH PLAN HMO PLANS", "methodology": "per diem", "standard_charge_dollar": 28538.0, "standard_charge_algorithm": "Per diem ($28,538).", "count": "0", "additional_payer_notes": "Zero final payments for the item or service in the 15 months prior to posting the file." }, { "payer_name": "SUTTER", "plan_name": "SUTTER SELECT & SUTTER HEALTH PLAN HMO PLANS", "methodology": "per diem", "standard_charge_dollar": 28538.0, "standard_charge_algorithm": "Per diem ($28,538).", "count": "0", "additional_payer_notes": "Zero final payments for the item or service in the 15 months prior to posting the file." }, { "payer_name": "UNITED HEALTHCARE", "plan_name": "SUTTER SELECT & SUTTER HEALTH PLAN HMO PLANS", "methodology": "per diem", "standard_charge_dollar": 28538.0, "standard_charge_algorithm": "Per diem ($28,538).", "count": "0", "additional_payer_notes": "Zero final payments for the item or service in the 15 months prior to posting the file." }, { "payer_name": "UMR", "plan_name": "SUTTER SELECT & SUTTER HEALTH PLAN HMO PLANS", "methodology": "per diem", "standard_charge_dollar": 28538.0, "standard_charge_algorithm": "Per diem ($28,538).", "count": "0", "additional_payer_notes": "Zero final payments for the item or service in the 15 months prior to posting the file." } ] } ] }, { "description": "HC Blade Gp014", "code_information": [ { "code": "PX-2120011014", "type": "CDM" }, { "code": "99999", "type": "CPT" }, { "code": "0272", "type": "RC" } ], "standard_charges": [ { "setting": "outpatient", "gross_charge": 1080.0, "discounted_cash": 540.0, "minimum": 455.76, "maximum": 561.6, "additional_generic_notes": "Zero final payments for the item or service in the 15 months prior to posting the file.", "payers_information": [ { "payer_name": "AETNA", "plan_name": "AETNA ALL OTHER PLANS", "methodology": "percent of total billed charges", "standard_charge_dollar": 561.6, "standard_charge_percentage": 52.0, "count": "0", "additional_payer_notes": "Zero final payments for the item or service in the 15 months prior to posting the file." }, { "payer_name": "AETNA", "plan_name": "AETNA ALL OTHER PLANS", "methodology": "percent of total billed charges", "standard_charge_dollar": 561.6, "standard_charge_percentage": 52.0, "count": "0", "additional_payer_notes": "Zero final payments for the item or service in the 15 months prior to posting the file." }, { "payer_name": "MERITAIN HEALTH", "plan_name": "AETNA ALL OTHER PLANS", "methodology": "percent of total billed charges", "standard_charge_dollar": 561.6, "standard_charge_percentage": 52.0, "count": "0", "additional_payer_notes": "Zero final payments for the item or service in the 15 months prior to posting the file." }, { "payer_name": "BLUE SHIELD OUT OF STATE", "plan_name": "STANFORD HEALTHCARE ALLIANCE PLAN", "methodology": "percent of total billed charges", "standard_charge_dollar": 524.77, "standard_charge_percentage": 48.59, "count": "0", "additional_payer_notes": "Zero final payments for the item or service in the 15 months prior to posting the file." }, { "payer_name": "BLUE SHIELD", "plan_name": "STANFORD HEALTHCARE ALLIANCE PLAN", "methodology": "percent of total billed charges", "standard_charge_dollar": 524.77, "standard_charge_percentage": 48.59, "median_amount": 68.24, "10th_percentile": 13.6, "90th_percentile": 1043.06, "count": "30" }, { "payer_name": "BLUE SHIELD", "plan_name": "STANFORD HEALTHCARE ALLIANCE PLAN", "methodology": "percent of total billed charges", "standard_charge_dollar": 524.77, "standard_charge_percentage": 48.59, "count": "0", "additional_payer_notes": "Zero final payments for the item or service in the 15 months prior to posting the file." }, { "payer_name": "BLUE SHIELD", "plan_name": "STANFORD HEALTHCARE ALLIANCE PLAN", "methodology": "percent of total billed charges", "standard_charge_dollar": 524.77, "standard_charge_percentage": 48.59, "count": "0", "additional_payer_notes": "Zero final payments for the item or service in the 15 months prior to posting the file." }, { "payer_name": "CIGNA", "plan_name": "CIGNA COM ALT HMO PLAN", "methodology": "percent of total billed charges", "standard_charge_dollar": 455.76, "standard_charge_percentage": 42.2, "count": "0", "additional_payer_notes": "Zero final payments for the item or service in the 15 months prior to posting the file." }, { "payer_name": "CIGNA", "plan_name": "CIGNA COM ALT HMO PLAN", "methodology": "percent of total billed charges", "standard_charge_dollar": 455.76, "standard_charge_percentage": 42.2, "count": "0", "additional_payer_notes": "Zero final payments for the item or service in the 15 months prior to posting the file." }, { "payer_name": "HEALTH NET", "plan_name": "HEALTHNET HMO, PPO, POS, EPO, CANOPY HEALTHNET HMO, OTHER-IN-NETWORK PLANS", "methodology": "per diem", "standard_charge_dollar": 8000.0, "standard_charge_algorithm": "Expected reimbursement is the lesser of Per diem ($8,000) for the length of stay and 70% of billed.", "count": "0", "additional_payer_notes": "Zero final payments for the item or service in the 15 months prior to posting the file." }, { "payer_name": "HEALTH NET", "plan_name": "HEALTHNET HMO, PPO, POS, EPO, CANOPY HEALTHNET HMO, OTHER-IN-NETWORK PLANS", "methodology": "per diem", "standard_charge_dollar": 8000.0, "standard_charge_algorithm": "Expected reimbursement is the lesser of Per diem ($8,000) for the length of stay and 70% of billed.", "count": "0", "additional_payer_notes": "Zero final payments for the item or service in the 15 months prior to posting the file." }, { "payer_name": "UNITED HEALTHCARE", "plan_name": "SUTTER SELECT & SUTTER HEALTH PLAN HMO PLANS", "methodology": "per diem", "standard_charge_dollar": 28538.0, "standard_charge_algorithm": "Per diem ($28,538).", "count": "0", "additional_payer_notes": "Zero final payments for the item or service in the 15 months prior to posting the file." }, { "payer_name": "UNITED HEALTHCARE", "plan_name": "SUTTER SELECT & SUTTER HEALTH PLAN HMO PLANS", "methodology": "per diem", "standard_charge_dollar": 28538.0, "standard_charge_algorithm": "Per diem ($28,538).", "count": "0", "additional_payer_notes": "Zero final payments for the item or service in the 15 months prior to posting the file." }, { "payer_name": "SUTTER", "plan_name": "SUTTER SELECT & SUTTER HEALTH PLAN HMO PLANS", "methodology": "per diem", "standard_charge_dollar": 28538.0, "standard_charge_algorithm": "Per diem ($28,538).", "count": "0", "additional_payer_notes": "Zero final payments for the item or service in the 15 months prior to posting the file." }, { "payer_name": "UNITED HEALTHCARE", "plan_name": "SUTTER SELECT & SUTTER HEALTH PLAN HMO PLANS", "methodology": "per diem", "standard_charge_dollar": 28538.0, "standard_charge_algorithm": "Per diem ($28,538).", "count": "0", "additional_payer_notes": "Zero final payments for the item or service in the 15 months prior to posting the file." }, { "payer_name": "UMR", "plan_name": "SUTTER SELECT & SUTTER HEALTH PLAN HMO PLANS", "methodology": "per diem", "standard_charge_dollar": 28538.0, "standard_charge_algorithm": "Per diem ($28,538).", "count": "0", "additional_payer_notes": "Zero final payments for the item or service in the 15 months prior to posting the file." } ] } ] }, { "description": "HC Blade Gp015", "code_information": [ { "code": "PX-2120011015", "type": "CDM" }, { "code": "99999", "type": "CPT" }, { "code": "0272", "type": "RC" } ], "standard_charges": [ { "setting": "outpatient", "gross_charge": 1225.0, "discounted_cash": 612.5, "minimum": 516.95, "maximum": 637.0, "additional_generic_notes": "Zero final payments for the item or service in the 15 months prior to posting the file.", "payers_information": [ { "payer_name": "AETNA", "plan_name": "AETNA ALL OTHER PLANS", "methodology": "percent of total billed charges", "standard_charge_dollar": 637.0, "standard_charge_percentage": 52.0, "count": "0", "additional_payer_notes": "Zero final payments for the item or service in the 15 months prior to posting the file." }, { "payer_name": "AETNA", "plan_name": "AETNA ALL OTHER PLANS", "methodology": "percent of total billed charges", "standard_charge_dollar": 637.0, "standard_charge_percentage": 52.0, "count": "0", "additional_payer_notes": "Zero final payments for the item or service in the 15 months prior to posting the file." }, { "payer_name": "MERITAIN HEALTH", "plan_name": "AETNA ALL OTHER PLANS", "methodology": "percent of total billed charges", "standard_charge_dollar": 637.0, "standard_charge_percentage": 52.0, "count": "0", "additional_payer_notes": "Zero final payments for the item or service in the 15 months prior to posting the file." }, { "payer_name": "BLUE SHIELD OUT OF STATE", "plan_name": "STANFORD HEALTHCARE ALLIANCE PLAN", "methodology": "percent of total billed charges", "standard_charge_dollar": 595.23, "standard_charge_percentage": 48.59, "count": "0", "additional_payer_notes": "Zero final payments for the item or service in the 15 months prior to posting the file." }, { "payer_name": "BLUE SHIELD", "plan_name": "STANFORD HEALTHCARE ALLIANCE PLAN", "methodology": "percent of total billed charges", "standard_charge_dollar": 595.23, "standard_charge_percentage": 48.59, "median_amount": 68.24, "10th_percentile": 13.6, "90th_percentile": 1043.06, "count": "30" }, { "payer_name": "BLUE SHIELD", "plan_name": "STANFORD HEALTHCARE ALLIANCE PLAN", "methodology": "percent of total billed charges", "standard_charge_dollar": 595.23, "standard_charge_percentage": 48.59, "count": "0", "additional_payer_notes": "Zero final payments for the item or service in the 15 months prior to posting the file." }, { "payer_name": "BLUE SHIELD", "plan_name": "STANFORD HEALTHCARE ALLIANCE PLAN", "methodology": "percent of total billed charges", "standard_charge_dollar": 595.23, "standard_charge_percentage": 48.59, "count": "0", "additional_payer_notes": "Zero final payments for the item or service in the 15 months prior to posting the file." }, { "payer_name": "CIGNA", "plan_name": "CIGNA COM ALT HMO PLAN", "methodology": "percent of total billed charges", "standard_charge_dollar": 516.95, "standard_charge_percentage": 42.2, "count": "0", "additional_payer_notes": "Zero final payments for the item or service in the 15 months prior to posting the file." }, { "payer_name": "CIGNA", "plan_name": "CIGNA COM ALT HMO PLAN", "methodology": "percent of total billed charges", "standard_charge_dollar": 516.95, "standard_charge_percentage": 42.2, "count": "0", "additional_payer_notes": "Zero final payments for the item or service in the 15 months prior to posting the file." }, { "payer_name": "HEALTH NET", "plan_name": "HEALTHNET HMO, PPO, POS, EPO, CANOPY HEALTHNET HMO, OTHER-IN-NETWORK PLANS", "methodology": "per diem", "standard_charge_dollar": 8000.0, "standard_charge_algorithm": "Expected reimbursement is the lesser of Per diem ($8,000) for the length of stay and 70% of billed.", "count": "0", "additional_payer_notes": "Zero final payments for the item or service in the 15 months prior to posting the file." }, { "payer_name": "HEALTH NET", "plan_name": "HEALTHNET HMO, PPO, POS, EPO, CANOPY HEALTHNET HMO, OTHER-IN-NETWORK PLANS", "methodology": "per diem", "standard_charge_dollar": 8000.0, "standard_charge_algorithm": "Expected reimbursement is the lesser of Per diem ($8,000) for the length of stay and 70% of billed.", "count": "0", "additional_payer_notes": "Zero final payments for the item or service in the 15 months prior to posting the file." }, { "payer_name": "UNITED HEALTHCARE", "plan_name": "SUTTER SELECT & SUTTER HEALTH PLAN HMO PLANS", "methodology": "per diem", "standard_charge_dollar": 28538.0, "standard_charge_algorithm": "Per diem ($28,538).", "count": "0", "additional_payer_notes": "Zero final payments for the item or service in the 15 months prior to posting the file." }, { "payer_name": "UNITED HEALTHCARE", "plan_name": "SUTTER SELECT & SUTTER HEALTH PLAN HMO PLANS", "methodology": "per diem", "standard_charge_dollar": 28538.0, "standard_charge_algorithm": "Per diem ($28,538).", "count": "0", "additional_payer_notes": "Zero final payments for the item or service in the 15 months prior to posting the file." }, { "payer_name": "SUTTER", "plan_name": "SUTTER SELECT & SUTTER HEALTH PLAN HMO PLANS", "methodology": "per diem", "standard_charge_dollar": 28538.0, "standard_charge_algorithm": "Per diem ($28,538).", "count": "0", "additional_payer_notes": "Zero final payments for the item or service in the 15 months prior to posting the file." }, { "payer_name": "UNITED HEALTHCARE", "plan_name": "SUTTER SELECT & SUTTER HEALTH PLAN HMO PLANS", "methodology": "per diem", "standard_charge_dollar": 28538.0, "standard_charge_algorithm": "Per diem ($28,538).", "count": "0", "additional_payer_notes": "Zero final payments for the item or service in the 15 months prior to posting the file." }, { "payer_name": "UMR", "plan_name": "SUTTER SELECT & SUTTER HEALTH PLAN HMO PLANS", "methodology": "per diem", "standard_charge_dollar": 28538.0, "standard_charge_algorithm": "Per diem ($28,538).", "count": "0", "additional_payer_notes": "Zero final payments for the item or service in the 15 months prior to posting the file." } ] } ] }, { "description": "HC Blade Gp016", "code_information": [ { "code": "PX-2120011016", "type": "CDM" }, { "code": "99999", "type": "CPT" }, { "code": "0272", "type": "RC" } ], "standard_charges": [ { "setting": "outpatient", "gross_charge": 1400.0, "discounted_cash": 700.0, "minimum": 590.8, "maximum": 728.0, "additional_generic_notes": "Zero final payments for the item or service in the 15 months prior to posting the file.", "payers_information": [ { "payer_name": "AETNA", "plan_name": "AETNA ALL OTHER PLANS", "methodology": "percent of total billed charges", "standard_charge_dollar": 728.0, "standard_charge_percentage": 52.0, "count": "0", "additional_payer_notes": "Zero final payments for the item or service in the 15 months prior to posting the file." }, { "payer_name": "AETNA", "plan_name": "AETNA ALL OTHER PLANS", "methodology": "percent of total billed charges", "standard_charge_dollar": 728.0, "standard_charge_percentage": 52.0, "count": "0", "additional_payer_notes": "Zero final payments for the item or service in the 15 months prior to posting the file." }, { "payer_name": "MERITAIN HEALTH", "plan_name": "AETNA ALL OTHER PLANS", "methodology": "percent of total billed charges", "standard_charge_dollar": 728.0, "standard_charge_percentage": 52.0, "count": "0", "additional_payer_notes": "Zero final payments for the item or service in the 15 months prior to posting the file." }, { "payer_name": "BLUE SHIELD OUT OF STATE", "plan_name": "STANFORD HEALTHCARE ALLIANCE PLAN", "methodology": "percent of total billed charges", "standard_charge_dollar": 680.26, "standard_charge_percentage": 48.59, "count": "0", "additional_payer_notes": "Zero final payments for the item or service in the 15 months prior to posting the file." }, { "payer_name": "BLUE SHIELD", "plan_name": "STANFORD HEALTHCARE ALLIANCE PLAN", "methodology": "percent of total billed charges", "standard_charge_dollar": 680.26, "standard_charge_percentage": 48.59, "median_amount": 68.24, "10th_percentile": 13.6, "90th_percentile": 1043.06, "count": "30" }, { "payer_name": "BLUE SHIELD", "plan_name": "STANFORD HEALTHCARE ALLIANCE PLAN", "methodology": "percent of total billed charges", "standard_charge_dollar": 680.26, "standard_charge_percentage": 48.59, "count": "0", "additional_payer_notes": "Zero final payments for the item or service in the 15 months prior to posting the file." }, { "payer_name": "BLUE SHIELD", "plan_name": "STANFORD HEALTHCARE ALLIANCE PLAN", "methodology": "percent of total billed charges", "standard_charge_dollar": 680.26, "standard_charge_percentage": 48.59, "count": "0", "additional_payer_notes": "Zero final payments for the item or service in the 15 months prior to posting the file." }, { "payer_name": "CIGNA", "plan_name": "CIGNA COM ALT HMO PLAN", "methodology": "percent of total billed charges", "standard_charge_dollar": 590.8, "standard_charge_percentage": 42.2, "count": "0", "additional_payer_notes": "Zero final payments for the item or service in the 15 months prior to posting the file." }, { "payer_name": "CIGNA", "plan_name": "CIGNA COM ALT HMO PLAN", "methodology": "percent of total billed charges", "standard_charge_dollar": 590.8, "standard_charge_percentage": 42.2, "count": "0", "additional_payer_notes": "Zero final payments for the item or service in the 15 months prior to posting the file." }, { "payer_name": "HEALTH NET", "plan_name": "HEALTHNET HMO, PPO, POS, EPO, CANOPY HEALTHNET HMO, OTHER-IN-NETWORK PLANS", "methodology": "per diem", "standard_charge_dollar": 8000.0, "standard_charge_algorithm": "Expected reimbursement is the lesser of Per diem ($8,000) for the length of stay and 70% of billed.", "count": "0", "additional_payer_notes": "Zero final payments for the item or service in the 15 months prior to posting the file." }, { "payer_name": "HEALTH NET", "plan_name": "HEALTHNET HMO, PPO, POS, EPO, CANOPY HEALTHNET HMO, OTHER-IN-NETWORK PLANS", "methodology": "per diem", "standard_charge_dollar": 8000.0, "standard_charge_algorithm": "Expected reimbursement is the lesser of Per diem ($8,000) for the length of stay and 70% of billed.", "count": "0", "additional_payer_notes": "Zero final payments for the item or service in the 15 months prior to posting the file." }, { "payer_name": "UNITED HEALTHCARE", "plan_name": "SUTTER SELECT & SUTTER HEALTH PLAN HMO PLANS", "methodology": "per diem", "standard_charge_dollar": 28538.0, "standard_charge_algorithm": "Per diem ($28,538).", "count": "0", "additional_payer_notes": "Zero final payments for the item or service in the 15 months prior to posting the file." }, { "payer_name": "UNITED HEALTHCARE", "plan_name": "SUTTER SELECT & SUTTER HEALTH PLAN HMO PLANS", "methodology": "per diem", "standard_charge_dollar": 28538.0, "standard_charge_algorithm": "Per diem ($28,538).", "count": "0", "additional_payer_notes": "Zero final payments for the item or service in the 15 months prior to posting the file." }, { "payer_name": "SUTTER", "plan_name": "SUTTER SELECT & SUTTER HEALTH PLAN HMO PLANS", "methodology": "per diem", "standard_charge_dollar": 28538.0, "standard_charge_algorithm": "Per diem ($28,538).", "count": "0", "additional_payer_notes": "Zero final payments for the item or service in the 15 months prior to posting the file." }, { "payer_name": "UNITED HEALTHCARE", "plan_name": "SUTTER SELECT & SUTTER HEALTH PLAN HMO PLANS", "methodology": "per diem", "standard_charge_dollar": 28538.0, "standard_charge_algorithm": "Per diem ($28,538).", "count": "0", "additional_payer_notes": "Zero final payments for the item or service in the 15 months prior to posting the file." }, { "payer_name": "UMR", "plan_name": "SUTTER SELECT & SUTTER HEALTH PLAN HMO PLANS", "methodology": "per diem", "standard_charge_dollar": 28538.0, "standard_charge_algorithm": "Per diem ($28,538).", "count": "0", "additional_payer_notes": "Zero final payments for the item or service in the 15 months prior to posting the file." } ] } ] }, { "description": "HC Blade Gp017", "code_information": [ { "code": "PX-2120011017", "type": "CDM" }, { "code": "99999", "type": "CPT" }, { "code": "0272", "type": "RC" } ], "standard_charges": [ { "setting": "outpatient", "gross_charge": 1575.0, "discounted_cash": 787.5, "minimum": 664.65, "maximum": 819.0, "additional_generic_notes": "Zero final payments for the item or service in the 15 months prior to posting the file.", "payers_information": [ { "payer_name": "AETNA", "plan_name": "AETNA ALL OTHER PLANS", "methodology": "percent of total billed charges", "standard_charge_dollar": 819.0, "standard_charge_percentage": 52.0, "count": "0", "additional_payer_notes": "Zero final payments for the item or service in the 15 months prior to posting the file." }, { "payer_name": "AETNA", "plan_name": "AETNA ALL OTHER PLANS", "methodology": "percent of total billed charges", "standard_charge_dollar": 819.0, "standard_charge_percentage": 52.0, "count": "0", "additional_payer_notes": "Zero final payments for the item or service in the 15 months prior to posting the file." }, { "payer_name": "MERITAIN HEALTH", "plan_name": "AETNA ALL OTHER PLANS", "methodology": "percent of total billed charges", "standard_charge_dollar": 819.0, "standard_charge_percentage": 52.0, "count": "0", "additional_payer_notes": "Zero final payments for the item or service in the 15 months prior to posting the file." }, { "payer_name": "BLUE SHIELD OUT OF STATE", "plan_name": "STANFORD HEALTHCARE ALLIANCE PLAN", "methodology": "percent of total billed charges", "standard_charge_dollar": 765.29, "standard_charge_percentage": 48.59, "count": "0", "additional_payer_notes": "Zero final payments for the item or service in the 15 months prior to posting the file." }, { "payer_name": "BLUE SHIELD", "plan_name": "STANFORD HEALTHCARE ALLIANCE PLAN", "methodology": "percent of total billed charges", "standard_charge_dollar": 765.29, "standard_charge_percentage": 48.59, "median_amount": 68.24, "10th_percentile": 13.6, "90th_percentile": 1043.06, "count": "30" }, { "payer_name": "BLUE SHIELD", "plan_name": "STANFORD HEALTHCARE ALLIANCE PLAN", "methodology": "percent of total billed charges", "standard_charge_dollar": 765.29, "standard_charge_percentage": 48.59, "count": "0", "additional_payer_notes": "Zero final payments for the item or service in the 15 months prior to posting the file." }, { "payer_name": "BLUE SHIELD", "plan_name": "STANFORD HEALTHCARE ALLIANCE PLAN", "methodology": "percent of total billed charges", "standard_charge_dollar": 765.29, "standard_charge_percentage": 48.59, "count": "0", "additional_payer_notes": "Zero final payments for the item or service in the 15 months prior to posting the file." }, { "payer_name": "CIGNA", "plan_name": "CIGNA COM ALT HMO PLAN", "methodology": "percent of total billed charges", "standard_charge_dollar": 664.65, "standard_charge_percentage": 42.2, "count": "0", "additional_payer_notes": "Zero final payments for the item or service in the 15 months prior to posting the file." }, { "payer_name": "CIGNA", "plan_name": "CIGNA COM ALT HMO PLAN", "methodology": "percent of total billed charges", "standard_charge_dollar": 664.65, "standard_charge_percentage": 42.2, "count": "0", "additional_payer_notes": "Zero final payments for the item or service in the 15 months prior to posting the file." }, { "payer_name": "HEALTH NET", "plan_name": "HEALTHNET HMO, PPO, POS, EPO, CANOPY HEALTHNET HMO, OTHER-IN-NETWORK PLANS", "methodology": "per diem", "standard_charge_dollar": 8000.0, "standard_charge_algorithm": "Expected reimbursement is the lesser of Per diem ($8,000) for the length of stay and 70% of billed.", "count": "0", "additional_payer_notes": "Zero final payments for the item or service in the 15 months prior to posting the file." }, { "payer_name": "HEALTH NET", "plan_name": "HEALTHNET HMO, PPO, POS, EPO, CANOPY HEALTHNET HMO, OTHER-IN-NETWORK PLANS", "methodology": "per diem", "standard_charge_dollar": 8000.0, "standard_charge_algorithm": "Expected reimbursement is the lesser of Per diem ($8,000) for the length of stay and 70% of billed.", "count": "0", "additional_payer_notes": "Zero final payments for the item or service in the 15 months prior to posting the file." }, { "payer_name": "UNITED HEALTHCARE", "plan_name": "SUTTER SELECT & SUTTER HEALTH PLAN HMO PLANS", "methodology": "per diem", "standard_charge_dollar": 28538.0, "standard_charge_algorithm": "Per diem ($28,538).", "count": "0", "additional_payer_notes": "Zero final payments for the item or service in the 15 months prior to posting the file." }, { "payer_name": "UNITED HEALTHCARE", "plan_name": "SUTTER SELECT & SUTTER HEALTH PLAN HMO PLANS", "methodology": "per diem", "standard_charge_dollar": 28538.0, "standard_charge_algorithm": "Per diem ($28,538).", "count": "0", "additional_payer_notes": "Zero final payments for the item or service in the 15 months prior to posting the file." }, { "payer_name": "SUTTER", "plan_name": "SUTTER SELECT & SUTTER HEALTH PLAN HMO PLANS", "methodology": "per diem", "standard_charge_dollar": 28538.0, "standard_charge_algorithm": "Per diem ($28,538).", "count": "0", "additional_payer_notes": "Zero final payments for the item or service in the 15 months prior to posting the file." }, { "payer_name": "UNITED HEALTHCARE", "plan_name": "SUTTER SELECT & SUTTER HEALTH PLAN HMO PLANS", "methodology": "per diem", "standard_charge_dollar": 28538.0, "standard_charge_algorithm": "Per diem ($28,538).", "count": "0", "additional_payer_notes": "Zero final payments for the item or service in the 15 months prior to posting the file." }, { "payer_name": "UMR", "plan_name": "SUTTER SELECT & SUTTER HEALTH PLAN HMO PLANS", "methodology": "per diem", "standard_charge_dollar": 28538.0, "standard_charge_algorithm": "Per diem ($28,538).", "count": "0", "additional_payer_notes": "Zero final payments for the item or service in the 15 months prior to posting the file." } ] } ] }, { "description": "HC Blade Gp018", "code_information": [ { "code": "PX-2120011018", "type": "CDM" }, { "code": "99999", "type": "CPT" }, { "code": "0272", "type": "RC" } ], "standard_charges": [ { "setting": "outpatient", "gross_charge": 1750.0, "discounted_cash": 875.0, "minimum": 738.5, "maximum": 910.0, "additional_generic_notes": "Zero final payments for the item or service in the 15 months prior to posting the file.", "payers_information": [ { "payer_name": "AETNA", "plan_name": "AETNA ALL OTHER PLANS", "methodology": "percent of total billed charges", "standard_charge_dollar": 910.0, "standard_charge_percentage": 52.0, "count": "0", "additional_payer_notes": "Zero final payments for the item or service in the 15 months prior to posting the file." }, { "payer_name": "AETNA", "plan_name": "AETNA ALL OTHER PLANS", "methodology": "percent of total billed charges", "standard_charge_dollar": 910.0, "standard_charge_percentage": 52.0, "count": "0", "additional_payer_notes": "Zero final payments for the item or service in the 15 months prior to posting the file." }, { "payer_name": "MERITAIN HEALTH", "plan_name": "AETNA ALL OTHER PLANS", "methodology": "percent of total billed charges", "standard_charge_dollar": 910.0, "standard_charge_percentage": 52.0, "count": "0", "additional_payer_notes": "Zero final payments for the item or service in the 15 months prior to posting the file." }, { "payer_name": "BLUE SHIELD OUT OF STATE", "plan_name": "STANFORD HEALTHCARE ALLIANCE PLAN", "methodology": "percent of total billed charges", "standard_charge_dollar": 850.33, "standard_charge_percentage": 48.59, "count": "0", "additional_payer_notes": "Zero final payments for the item or service in the 15 months prior to posting the file." }, { "payer_name": "BLUE SHIELD", "plan_name": "STANFORD HEALTHCARE ALLIANCE PLAN", "methodology": "percent of total billed charges", "standard_charge_dollar": 850.33, "standard_charge_percentage": 48.59, "median_amount": 68.24, "10th_percentile": 13.6, "90th_percentile": 1043.06, "count": "30" }, { "payer_name": "BLUE SHIELD", "plan_name": "STANFORD HEALTHCARE ALLIANCE PLAN", "methodology": "percent of total billed charges", "standard_charge_dollar": 850.33, "standard_charge_percentage": 48.59, "count": "0", "additional_payer_notes": "Zero final payments for the item or service in the 15 months prior to posting the file." }, { "payer_name": "BLUE SHIELD", "plan_name": "STANFORD HEALTHCARE ALLIANCE PLAN", "methodology": "percent of total billed charges", "standard_charge_dollar": 850.33, "standard_charge_percentage": 48.59, "count": "0", "additional_payer_notes": "Zero final payments for the item or service in the 15 months prior to posting the file." }, { "payer_name": "CIGNA", "plan_name": "CIGNA COM ALT HMO PLAN", "methodology": "percent of total billed charges", "standard_charge_dollar": 738.5, "standard_charge_percentage": 42.2, "count": "0", "additional_payer_notes": "Zero final payments for the item or service in the 15 months prior to posting the file." }, { "payer_name": "CIGNA", "plan_name": "CIGNA COM ALT HMO PLAN", "methodology": "percent of total billed charges", "standard_charge_dollar": 738.5, "standard_charge_percentage": 42.2, "count": "0", "additional_payer_notes": "Zero final payments for the item or service in the 15 months prior to posting the file." }, { "payer_name": "HEALTH NET", "plan_name": "HEALTHNET HMO, PPO, POS, EPO, CANOPY HEALTHNET HMO, OTHER-IN-NETWORK PLANS", "methodology": "per diem", "standard_charge_dollar": 8000.0, "standard_charge_algorithm": "Expected reimbursement is the lesser of Per diem ($8,000) for the length of stay and 70% of billed.", "count": "0", "additional_payer_notes": "Zero final payments for the item or service in the 15 months prior to posting the file." }, { "payer_name": "HEALTH NET", "plan_name": "HEALTHNET HMO, PPO, POS, EPO, CANOPY HEALTHNET HMO, OTHER-IN-NETWORK PLANS", "methodology": "per diem", "standard_charge_dollar": 8000.0, "standard_charge_algorithm": "Expected reimbursement is the lesser of Per diem ($8,000) for the length of stay and 70% of billed.", "count": "0", "additional_payer_notes": "Zero final payments for the item or service in the 15 months prior to posting the file." }, { "payer_name": "UNITED HEALTHCARE", "plan_name": "SUTTER SELECT & SUTTER HEALTH PLAN HMO PLANS", "methodology": "per diem", "standard_charge_dollar": 28538.0, "standard_charge_algorithm": "Per diem ($28,538).", "count": "0", "additional_payer_notes": "Zero final payments for the item or service in the 15 months prior to posting the file." }, { "payer_name": "UNITED HEALTHCARE", "plan_name": "SUTTER SELECT & SUTTER HEALTH PLAN HMO PLANS", "methodology": "per diem", "standard_charge_dollar": 28538.0, "standard_charge_algorithm": "Per diem ($28,538).", "count": "0", "additional_payer_notes": "Zero final payments for the item or service in the 15 months prior to posting the file." }, { "payer_name": "SUTTER", "plan_name": "SUTTER SELECT & SUTTER HEALTH PLAN HMO PLANS", "methodology": "per diem", "standard_charge_dollar": 28538.0, "standard_charge_algorithm": "Per diem ($28,538).", "count": "0", "additional_payer_notes": "Zero final payments for the item or service in the 15 months prior to posting the file." }, { "payer_name": "UNITED HEALTHCARE", "plan_name": "SUTTER SELECT & SUTTER HEALTH PLAN HMO PLANS", "methodology": "per diem", "standard_charge_dollar": 28538.0, "standard_charge_algorithm": "Per diem ($28,538).", "count": "0", "additional_payer_notes": "Zero final payments for the item or service in the 15 months prior to posting the file." }, { "payer_name": "UMR", "plan_name": "SUTTER SELECT & SUTTER HEALTH PLAN HMO PLANS", "methodology": "per diem", "standard_charge_dollar": 28538.0, "standard_charge_algorithm": "Per diem ($28,538).", "count": "0", "additional_payer_notes": "Zero final payments for the item or service in the 15 months prior to posting the file." } ] } ] }, { "description": "HC Blade Gp019", "code_information": [ { "code": "PX-2120011019", "type": "CDM" }, { "code": "99999", "type": "CPT" }, { "code": "0272", "type": "RC" } ], "standard_charges": [ { "setting": "outpatient", "gross_charge": 2125.0, "discounted_cash": 1062.5, "minimum": 896.75, "maximum": 1105.0, "additional_generic_notes": "Zero final payments for the item or service in the 15 months prior to posting the file.", "payers_information": [ { "payer_name": "AETNA", "plan_name": "AETNA ALL OTHER PLANS", "methodology": "percent of total billed charges", "standard_charge_dollar": 1105.0, "standard_charge_percentage": 52.0, "count": "0", "additional_payer_notes": "Zero final payments for the item or service in the 15 months prior to posting the file." }, { "payer_name": "AETNA", "plan_name": "AETNA ALL OTHER PLANS", "methodology": "percent of total billed charges", "standard_charge_dollar": 1105.0, "standard_charge_percentage": 52.0, "count": "0", "additional_payer_notes": "Zero final payments for the item or service in the 15 months prior to posting the file." }, { "payer_name": "MERITAIN HEALTH", "plan_name": "AETNA ALL OTHER PLANS", "methodology": "percent of total billed charges", "standard_charge_dollar": 1105.0, "standard_charge_percentage": 52.0, "count": "0", "additional_payer_notes": "Zero final payments for the item or service in the 15 months prior to posting the file." }, { "payer_name": "BLUE SHIELD OUT OF STATE", "plan_name": "STANFORD HEALTHCARE ALLIANCE PLAN", "methodology": "percent of total billed charges", "standard_charge_dollar": 1032.54, "standard_charge_percentage": 48.59, "count": "0", "additional_payer_notes": "Zero final payments for the item or service in the 15 months prior to posting the file." }, { "payer_name": "BLUE SHIELD", "plan_name": "STANFORD HEALTHCARE ALLIANCE PLAN", "methodology": "percent of total billed charges", "standard_charge_dollar": 1032.54, "standard_charge_percentage": 48.59, "median_amount": 68.24, "10th_percentile": 13.6, "90th_percentile": 1043.06, "count": "30" }, { "payer_name": "BLUE SHIELD", "plan_name": "STANFORD HEALTHCARE ALLIANCE PLAN", "methodology": "percent of total billed charges", "standard_charge_dollar": 1032.54, "standard_charge_percentage": 48.59, "count": "0", "additional_payer_notes": "Zero final payments for the item or service in the 15 months prior to posting the file." }, { "payer_name": "BLUE SHIELD", "plan_name": "STANFORD HEALTHCARE ALLIANCE PLAN", "methodology": "percent of total billed charges", "standard_charge_dollar": 1032.54, "standard_charge_percentage": 48.59, "count": "0", "additional_payer_notes": "Zero final payments for the item or service in the 15 months prior to posting the file." }, { "payer_name": "CIGNA", "plan_name": "CIGNA COM ALT HMO PLAN", "methodology": "percent of total billed charges", "standard_charge_dollar": 896.75, "standard_charge_percentage": 42.2, "count": "0", "additional_payer_notes": "Zero final payments for the item or service in the 15 months prior to posting the file." }, { "payer_name": "CIGNA", "plan_name": "CIGNA COM ALT HMO PLAN", "methodology": "percent of total billed charges", "standard_charge_dollar": 896.75, "standard_charge_percentage": 42.2, "count": "0", "additional_payer_notes": "Zero final payments for the item or service in the 15 months prior to posting the file." }, { "payer_name": "HEALTH NET", "plan_name": "HEALTHNET HMO, PPO, POS, EPO, CANOPY HEALTHNET HMO, OTHER-IN-NETWORK PLANS", "methodology": "per diem", "standard_charge_dollar": 8000.0, "standard_charge_algorithm": "Expected reimbursement is the lesser of Per diem ($8,000) for the length of stay and 70% of billed.", "count": "0", "additional_payer_notes": "Zero final payments for the item or service in the 15 months prior to posting the file." }, { "payer_name": "HEALTH NET", "plan_name": "HEALTHNET HMO, PPO, POS, EPO, CANOPY HEALTHNET HMO, OTHER-IN-NETWORK PLANS", "methodology": "per diem", "standard_charge_dollar": 8000.0, "standard_charge_algorithm": "Expected reimbursement is the lesser of Per diem ($8,000) for the length of stay and 70% of billed.", "count": "0", "additional_payer_notes": "Zero final payments for the item or service in the 15 months prior to posting the file." }, { "payer_name": "UNITED HEALTHCARE", "plan_name": "SUTTER SELECT & SUTTER HEALTH PLAN HMO PLANS", "methodology": "per diem", "standard_charge_dollar": 28538.0, "standard_charge_algorithm": "Per diem ($28,538).", "count": "0", "additional_payer_notes": "Zero final payments for the item or service in the 15 months prior to posting the file." }, { "payer_name": "UNITED HEALTHCARE", "plan_name": "SUTTER SELECT & SUTTER HEALTH PLAN HMO PLANS", "methodology": "per diem", "standard_charge_dollar": 28538.0, "standard_charge_algorithm": "Per diem ($28,538).", "count": "0", "additional_payer_notes": "Zero final payments for the item or service in the 15 months prior to posting the file." }, { "payer_name": "SUTTER", "plan_name": "SUTTER SELECT & SUTTER HEALTH PLAN HMO PLANS", "methodology": "per diem", "standard_charge_dollar": 28538.0, "standard_charge_algorithm": "Per diem ($28,538).", "count": "0", "additional_payer_notes": "Zero final payments for the item or service in the 15 months prior to posting the file." }, { "payer_name": "UNITED HEALTHCARE", "plan_name": "SUTTER SELECT & SUTTER HEALTH PLAN HMO PLANS", "methodology": "per diem", "standard_charge_dollar": 28538.0, "standard_charge_algorithm": "Per diem ($28,538).", "count": "0", "additional_payer_notes": "Zero final payments for the item or service in the 15 months prior to posting the file." }, { "payer_name": "UMR", "plan_name": "SUTTER SELECT & SUTTER HEALTH PLAN HMO PLANS", "methodology": "per diem", "standard_charge_dollar": 28538.0, "standard_charge_algorithm": "Per diem ($28,538).", "count": "0", "additional_payer_notes": "Zero final payments for the item or service in the 15 months prior to posting the file." } ] } ] }, { "description": "HC Blade Gp020", "code_information": [ { "code": "PX-2120011020", "type": "CDM" }, { "code": "99999", "type": "CPT" }, { "code": "0272", "type": "RC" } ], "standard_charges": [ { "setting": "outpatient", "gross_charge": 2550.0, "discounted_cash": 1275.0, "minimum": 1076.1, "maximum": 1326.0, "additional_generic_notes": "Zero final payments for the item or service in the 15 months prior to posting the file.", "payers_information": [ { "payer_name": "AETNA", "plan_name": "AETNA ALL OTHER PLANS", "methodology": "percent of total billed charges", "standard_charge_dollar": 1326.0, "standard_charge_percentage": 52.0, "count": "0", "additional_payer_notes": "Zero final payments for the item or service in the 15 months prior to posting the file." }, { "payer_name": "AETNA", "plan_name": "AETNA ALL OTHER PLANS", "methodology": "percent of total billed charges", "standard_charge_dollar": 1326.0, "standard_charge_percentage": 52.0, "count": "0", "additional_payer_notes": "Zero final payments for the item or service in the 15 months prior to posting the file." }, { "payer_name": "MERITAIN HEALTH", "plan_name": "AETNA ALL OTHER PLANS", "methodology": "percent of total billed charges", "standard_charge_dollar": 1326.0, "standard_charge_percentage": 52.0, "count": "0", "additional_payer_notes": "Zero final payments for the item or service in the 15 months prior to posting the file." }, { "payer_name": "BLUE SHIELD OUT OF STATE", "plan_name": "STANFORD HEALTHCARE ALLIANCE PLAN", "methodology": "percent of total billed charges", "standard_charge_dollar": 1239.05, "standard_charge_percentage": 48.59, "count": "0", "additional_payer_notes": "Zero final payments for the item or service in the 15 months prior to posting the file." }, { "payer_name": "BLUE SHIELD", "plan_name": "STANFORD HEALTHCARE ALLIANCE PLAN", "methodology": "percent of total billed charges", "standard_charge_dollar": 1239.05, "standard_charge_percentage": 48.59, "median_amount": 68.24, "10th_percentile": 13.6, "90th_percentile": 1043.06, "count": "30" }, { "payer_name": "BLUE SHIELD", "plan_name": "STANFORD HEALTHCARE ALLIANCE PLAN", "methodology": "percent of total billed charges", "standard_charge_dollar": 1239.05, "standard_charge_percentage": 48.59, "count": "0", "additional_payer_notes": "Zero final payments for the item or service in the 15 months prior to posting the file." }, { "payer_name": "BLUE SHIELD", "plan_name": "STANFORD HEALTHCARE ALLIANCE PLAN", "methodology": "percent of total billed charges", "standard_charge_dollar": 1239.05, "standard_charge_percentage": 48.59, "count": "0", "additional_payer_notes": "Zero final payments for the item or service in the 15 months prior to posting the file." }, { "payer_name": "CIGNA", "plan_name": "CIGNA COM ALT HMO PLAN", "methodology": "percent of total billed charges", "standard_charge_dollar": 1076.1, "standard_charge_percentage": 42.2, "count": "0", "additional_payer_notes": "Zero final payments for the item or service in the 15 months prior to posting the file." }, { "payer_name": "CIGNA", "plan_name": "CIGNA COM ALT HMO PLAN", "methodology": "percent of total billed charges", "standard_charge_dollar": 1076.1, "standard_charge_percentage": 42.2, "count": "0", "additional_payer_notes": "Zero final payments for the item or service in the 15 months prior to posting the file." }, { "payer_name": "HEALTH NET", "plan_name": "HEALTHNET HMO, PPO, POS, EPO, CANOPY HEALTHNET HMO, OTHER-IN-NETWORK PLANS", "methodology": "per diem", "standard_charge_dollar": 8000.0, "standard_charge_algorithm": "Expected reimbursement is the lesser of Per diem ($8,000) for the length of stay and 70% of billed.", "count": "0", "additional_payer_notes": "Zero final payments for the item or service in the 15 months prior to posting the file." }, { "payer_name": "HEALTH NET", "plan_name": "HEALTHNET HMO, PPO, POS, EPO, CANOPY HEALTHNET HMO, OTHER-IN-NETWORK PLANS", "methodology": "per diem", "standard_charge_dollar": 8000.0, "standard_charge_algorithm": "Expected reimbursement is the lesser of Per diem ($8,000) for the length of stay and 70% of billed.", "count": "0", "additional_payer_notes": "Zero final payments for the item or service in the 15 months prior to posting the file." }, { "payer_name": "UNITED HEALTHCARE", "plan_name": "SUTTER SELECT & SUTTER HEALTH PLAN HMO PLANS", "methodology": "per diem", "standard_charge_dollar": 28538.0, "standard_charge_algorithm": "Per diem ($28,538).", "count": "0", "additional_payer_notes": "Zero final payments for the item or service in the 15 months prior to posting the file." }, { "payer_name": "UNITED HEALTHCARE", "plan_name": "SUTTER SELECT & SUTTER HEALTH PLAN HMO PLANS", "methodology": "per diem", "standard_charge_dollar": 28538.0, "standard_charge_algorithm": "Per diem ($28,538).", "count": "0", "additional_payer_notes": "Zero final payments for the item or service in the 15 months prior to posting the file." }, { "payer_name": "SUTTER", "plan_name": "SUTTER SELECT & SUTTER HEALTH PLAN HMO PLANS", "methodology": "per diem", "standard_charge_dollar": 28538.0, "standard_charge_algorithm": "Per diem ($28,538).", "count": "0", "additional_payer_notes": "Zero final payments for the item or service in the 15 months prior to posting the file." }, { "payer_name": "UNITED HEALTHCARE", "plan_name": "SUTTER SELECT & SUTTER HEALTH PLAN HMO PLANS", "methodology": "per diem", "standard_charge_dollar": 28538.0, "standard_charge_algorithm": "Per diem ($28,538).", "count": "0", "additional_payer_notes": "Zero final payments for the item or service in the 15 months prior to posting the file." }, { "payer_name": "UMR", "plan_name": "SUTTER SELECT & SUTTER HEALTH PLAN HMO PLANS", "methodology": "per diem", "standard_charge_dollar": 28538.0, "standard_charge_algorithm": "Per diem ($28,538).", "count": "0", "additional_payer_notes": "Zero final payments for the item or service in the 15 months prior to posting the file." } ] } ] }, { "description": "HC Blade Gp021", "code_information": [ { "code": "PX-2120011021", "type": "CDM" }, { "code": "99999", "type": "CPT" }, { "code": "0272", "type": "RC" } ], "standard_charges": [ { "setting": "outpatient", "gross_charge": 2888.0, "discounted_cash": 1444.0, "minimum": 1218.74, "maximum": 1501.76, "additional_generic_notes": "Zero final payments for the item or service in the 15 months prior to posting the file.", "payers_information": [ { "payer_name": "AETNA", "plan_name": "AETNA ALL OTHER PLANS", "methodology": "percent of total billed charges", "standard_charge_dollar": 1501.76, "standard_charge_percentage": 52.0, "count": "0", "additional_payer_notes": "Zero final payments for the item or service in the 15 months prior to posting the file." }, { "payer_name": "AETNA", "plan_name": "AETNA ALL OTHER PLANS", "methodology": "percent of total billed charges", "standard_charge_dollar": 1501.76, "standard_charge_percentage": 52.0, "count": "0", "additional_payer_notes": "Zero final payments for the item or service in the 15 months prior to posting the file." }, { "payer_name": "MERITAIN HEALTH", "plan_name": "AETNA ALL OTHER PLANS", "methodology": "percent of total billed charges", "standard_charge_dollar": 1501.76, "standard_charge_percentage": 52.0, "count": "0", "additional_payer_notes": "Zero final payments for the item or service in the 15 months prior to posting the file." }, { "payer_name": "BLUE SHIELD OUT OF STATE", "plan_name": "STANFORD HEALTHCARE ALLIANCE PLAN", "methodology": "percent of total billed charges", "standard_charge_dollar": 1403.28, "standard_charge_percentage": 48.59, "count": "0", "additional_payer_notes": "Zero final payments for the item or service in the 15 months prior to posting the file." }, { "payer_name": "BLUE SHIELD", "plan_name": "STANFORD HEALTHCARE ALLIANCE PLAN", "methodology": "percent of total billed charges", "standard_charge_dollar": 1403.28, "standard_charge_percentage": 48.59, "median_amount": 68.24, "10th_percentile": 13.6, "90th_percentile": 1043.06, "count": "30" }, { "payer_name": "BLUE SHIELD", "plan_name": "STANFORD HEALTHCARE ALLIANCE PLAN", "methodology": "percent of total billed charges", "standard_charge_dollar": 1403.28, "standard_charge_percentage": 48.59, "count": "0", "additional_payer_notes": "Zero final payments for the item or service in the 15 months prior to posting the file." }, { "payer_name": "BLUE SHIELD", "plan_name": "STANFORD HEALTHCARE ALLIANCE PLAN", "methodology": "percent of total billed charges", "standard_charge_dollar": 1403.28, "standard_charge_percentage": 48.59, "count": "0", "additional_payer_notes": "Zero final payments for the item or service in the 15 months prior to posting the file." }, { "payer_name": "CIGNA", "plan_name": "CIGNA COM ALT HMO PLAN", "methodology": "percent of total billed charges", "standard_charge_dollar": 1218.74, "standard_charge_percentage": 42.2, "count": "0", "additional_payer_notes": "Zero final payments for the item or service in the 15 months prior to posting the file." }, { "payer_name": "CIGNA", "plan_name": "CIGNA COM ALT HMO PLAN", "methodology": "percent of total billed charges", "standard_charge_dollar": 1218.74, "standard_charge_percentage": 42.2, "count": "0", "additional_payer_notes": "Zero final payments for the item or service in the 15 months prior to posting the file." }, { "payer_name": "HEALTH NET", "plan_name": "HEALTHNET HMO, PPO, POS, EPO, CANOPY HEALTHNET HMO, OTHER-IN-NETWORK PLANS", "methodology": "per diem", "standard_charge_dollar": 8000.0, "standard_charge_algorithm": "Expected reimbursement is the lesser of Per diem ($8,000) for the length of stay and 70% of billed.", "count": "0", "additional_payer_notes": "Zero final payments for the item or service in the 15 months prior to posting the file." }, { "payer_name": "HEALTH NET", "plan_name": "HEALTHNET HMO, PPO, POS, EPO, CANOPY HEALTHNET HMO, OTHER-IN-NETWORK PLANS", "methodology": "per diem", "standard_charge_dollar": 8000.0, "standard_charge_algorithm": "Expected reimbursement is the lesser of Per diem ($8,000) for the length of stay and 70% of billed.", "count": "0", "additional_payer_notes": "Zero final payments for the item or service in the 15 months prior to posting the file." }, { "payer_name": "UNITED HEALTHCARE", "plan_name": "SUTTER SELECT & SUTTER HEALTH PLAN HMO PLANS", "methodology": "per diem", "standard_charge_dollar": 28538.0, "standard_charge_algorithm": "Per diem ($28,538).", "count": "0", "additional_payer_notes": "Zero final payments for the item or service in the 15 months prior to posting the file." }, { "payer_name": "UNITED HEALTHCARE", "plan_name": "SUTTER SELECT & SUTTER HEALTH PLAN HMO PLANS", "methodology": "per diem", "standard_charge_dollar": 28538.0, "standard_charge_algorithm": "Per diem ($28,538).", "count": "0", "additional_payer_notes": "Zero final payments for the item or service in the 15 months prior to posting the file." }, { "payer_name": "SUTTER", "plan_name": "SUTTER SELECT & SUTTER HEALTH PLAN HMO PLANS", "methodology": "per diem", "standard_charge_dollar": 28538.0, "standard_charge_algorithm": "Per diem ($28,538).", "count": "0", "additional_payer_notes": "Zero final payments for the item or service in the 15 months prior to posting the file." }, { "payer_name": "UNITED HEALTHCARE", "plan_name": "SUTTER SELECT & SUTTER HEALTH PLAN HMO PLANS", "methodology": "per diem", "standard_charge_dollar": 28538.0, "standard_charge_algorithm": "Per diem ($28,538).", "count": "0", "additional_payer_notes": "Zero final payments for the item or service in the 15 months prior to posting the file." }, { "payer_name": "UMR", "plan_name": "SUTTER SELECT & SUTTER HEALTH PLAN HMO PLANS", "methodology": "per diem", "standard_charge_dollar": 28538.0, "standard_charge_algorithm": "Per diem ($28,538).", "count": "0", "additional_payer_notes": "Zero final payments for the item or service in the 15 months prior to posting the file." } ] } ] }, { "description": "HC Blade Gp022", "code_information": [ { "code": "PX-2120011022", "type": "CDM" }, { "code": "99999", "type": "CPT" }, { "code": "0272", "type": "RC" } ], "standard_charges": [ { "setting": "outpatient", "gross_charge": 3300.0, "discounted_cash": 1650.0, "minimum": 1392.6, "maximum": 1716.0, "additional_generic_notes": "Zero final payments for the item or service in the 15 months prior to posting the file.", "payers_information": [ { "payer_name": "AETNA", "plan_name": "AETNA ALL OTHER PLANS", "methodology": "percent of total billed charges", "standard_charge_dollar": 1716.0, "standard_charge_percentage": 52.0, "count": "0", "additional_payer_notes": "Zero final payments for the item or service in the 15 months prior to posting the file." }, { "payer_name": "AETNA", "plan_name": "AETNA ALL OTHER PLANS", "methodology": "percent of total billed charges", "standard_charge_dollar": 1716.0, "standard_charge_percentage": 52.0, "count": "0", "additional_payer_notes": "Zero final payments for the item or service in the 15 months prior to posting the file." }, { "payer_name": "MERITAIN HEALTH", "plan_name": "AETNA ALL OTHER PLANS", "methodology": "percent of total billed charges", "standard_charge_dollar": 1716.0, "standard_charge_percentage": 52.0, "count": "0", "additional_payer_notes": "Zero final payments for the item or service in the 15 months prior to posting the file." }, { "payer_name": "BLUE SHIELD OUT OF STATE", "plan_name": "STANFORD HEALTHCARE ALLIANCE PLAN", "methodology": "percent of total billed charges", "standard_charge_dollar": 1603.47, "standard_charge_percentage": 48.59, "count": "0", "additional_payer_notes": "Zero final payments for the item or service in the 15 months prior to posting the file." }, { "payer_name": "BLUE SHIELD", "plan_name": "STANFORD HEALTHCARE ALLIANCE PLAN", "methodology": "percent of total billed charges", "standard_charge_dollar": 1603.47, "standard_charge_percentage": 48.59, "median_amount": 68.24, "10th_percentile": 13.6, "90th_percentile": 1043.06, "count": "30" }, { "payer_name": "BLUE SHIELD", "plan_name": "STANFORD HEALTHCARE ALLIANCE PLAN", "methodology": "percent of total billed charges", "standard_charge_dollar": 1603.47, "standard_charge_percentage": 48.59, "count": "0", "additional_payer_notes": "Zero final payments for the item or service in the 15 months prior to posting the file." }, { "payer_name": "BLUE SHIELD", "plan_name": "STANFORD HEALTHCARE ALLIANCE PLAN", "methodology": "percent of total billed charges", "standard_charge_dollar": 1603.47, "standard_charge_percentage": 48.59, "count": "0", "additional_payer_notes": "Zero final payments for the item or service in the 15 months prior to posting the file." }, { "payer_name": "CIGNA", "plan_name": "CIGNA COM ALT HMO PLAN", "methodology": "percent of total billed charges", "standard_charge_dollar": 1392.6, "standard_charge_percentage": 42.2, "count": "0", "additional_payer_notes": "Zero final payments for the item or service in the 15 months prior to posting the file." }, { "payer_name": "CIGNA", "plan_name": "CIGNA COM ALT HMO PLAN", "methodology": "percent of total billed charges", "standard_charge_dollar": 1392.6, "standard_charge_percentage": 42.2, "count": "0", "additional_payer_notes": "Zero final payments for the item or service in the 15 months prior to posting the file." }, { "payer_name": "HEALTH NET", "plan_name": "HEALTHNET HMO, PPO, POS, EPO, CANOPY HEALTHNET HMO, OTHER-IN-NETWORK PLANS", "methodology": "per diem", "standard_charge_dollar": 8000.0, "standard_charge_algorithm": "Expected reimbursement is the lesser of Per diem ($8,000) for the length of stay and 70% of billed.", "count": "0", "additional_payer_notes": "Zero final payments for the item or service in the 15 months prior to posting the file." }, { "payer_name": "HEALTH NET", "plan_name": "HEALTHNET HMO, PPO, POS, EPO, CANOPY HEALTHNET HMO, OTHER-IN-NETWORK PLANS", "methodology": "per diem", "standard_charge_dollar": 8000.0, "standard_charge_algorithm": "Expected reimbursement is the lesser of Per diem ($8,000) for the length of stay and 70% of billed.", "count": "0", "additional_payer_notes": "Zero final payments for the item or service in the 15 months prior to posting the file." }, { "payer_name": "UNITED HEALTHCARE", "plan_name": "SUTTER SELECT & SUTTER HEALTH PLAN HMO PLANS", "methodology": "per diem", "standard_charge_dollar": 28538.0, "standard_charge_algorithm": "Per diem ($28,538).", "count": "0", "additional_payer_notes": "Zero final payments for the item or service in the 15 months prior to posting the file." }, { "payer_name": "UNITED HEALTHCARE", "plan_name": "SUTTER SELECT & SUTTER HEALTH PLAN HMO PLANS", "methodology": "per diem", "standard_charge_dollar": 28538.0, "standard_charge_algorithm": "Per diem ($28,538).", "count": "0", "additional_payer_notes": "Zero final payments for the item or service in the 15 months prior to posting the file." }, { "payer_name": "SUTTER", "plan_name": "SUTTER SELECT & SUTTER HEALTH PLAN HMO PLANS", "methodology": "per diem", "standard_charge_dollar": 28538.0, "standard_charge_algorithm": "Per diem ($28,538).", "count": "0", "additional_payer_notes": "Zero final payments for the item or service in the 15 months prior to posting the file." }, { "payer_name": "UNITED HEALTHCARE", "plan_name": "SUTTER SELECT & SUTTER HEALTH PLAN HMO PLANS", "methodology": "per diem", "standard_charge_dollar": 28538.0, "standard_charge_algorithm": "Per diem ($28,538).", "count": "0", "additional_payer_notes": "Zero final payments for the item or service in the 15 months prior to posting the file." }, { "payer_name": "UMR", "plan_name": "SUTTER SELECT & SUTTER HEALTH PLAN HMO PLANS", "methodology": "per diem", "standard_charge_dollar": 28538.0, "standard_charge_algorithm": "Per diem ($28,538).", "count": "0", "additional_payer_notes": "Zero final payments for the item or service in the 15 months prior to posting the file." } ] } ] }, { "description": "HC Blade Gp023", "code_information": [ { "code": "PX-2120011023", "type": "CDM" }, { "code": "99999", "type": "CPT" }, { "code": "0272", "type": "RC" } ], "standard_charges": [ { "setting": "outpatient", "gross_charge": 3600.0, "discounted_cash": 1800.0, "minimum": 1519.2, "maximum": 1872.0, "additional_generic_notes": "Zero final payments for the item or service in the 15 months prior to posting the file.", "payers_information": [ { "payer_name": "AETNA", "plan_name": "AETNA ALL OTHER PLANS", "methodology": "percent of total billed charges", "standard_charge_dollar": 1872.0, "standard_charge_percentage": 52.0, "count": "0", "additional_payer_notes": "Zero final payments for the item or service in the 15 months prior to posting the file." }, { "payer_name": "AETNA", "plan_name": "AETNA ALL OTHER PLANS", "methodology": "percent of total billed charges", "standard_charge_dollar": 1872.0, "standard_charge_percentage": 52.0, "count": "0", "additional_payer_notes": "Zero final payments for the item or service in the 15 months prior to posting the file." }, { "payer_name": "MERITAIN HEALTH", "plan_name": "AETNA ALL OTHER PLANS", "methodology": "percent of total billed charges", "standard_charge_dollar": 1872.0, "standard_charge_percentage": 52.0, "count": "0", "additional_payer_notes": "Zero final payments for the item or service in the 15 months prior to posting the file." }, { "payer_name": "BLUE SHIELD OUT OF STATE", "plan_name": "STANFORD HEALTHCARE ALLIANCE PLAN", "methodology": "percent of total billed charges", "standard_charge_dollar": 1749.24, "standard_charge_percentage": 48.59, "count": "0", "additional_payer_notes": "Zero final payments for the item or service in the 15 months prior to posting the file." }, { "payer_name": "BLUE SHIELD", "plan_name": "STANFORD HEALTHCARE ALLIANCE PLAN", "methodology": "percent of total billed charges", "standard_charge_dollar": 1749.24, "standard_charge_percentage": 48.59, "median_amount": 68.24, "10th_percentile": 13.6, "90th_percentile": 1043.06, "count": "30" }, { "payer_name": "BLUE SHIELD", "plan_name": "STANFORD HEALTHCARE ALLIANCE PLAN", "methodology": "percent of total billed charges", "standard_charge_dollar": 1749.24, "standard_charge_percentage": 48.59, "count": "0", "additional_payer_notes": "Zero final payments for the item or service in the 15 months prior to posting the file." }, { "payer_name": "BLUE SHIELD", "plan_name": "STANFORD HEALTHCARE ALLIANCE PLAN", "methodology": "percent of total billed charges", "standard_charge_dollar": 1749.24, "standard_charge_percentage": 48.59, "count": "0", "additional_payer_notes": "Zero final payments for the item or service in the 15 months prior to posting the file." }, { "payer_name": "CIGNA", "plan_name": "CIGNA COM ALT HMO PLAN", "methodology": "percent of total billed charges", "standard_charge_dollar": 1519.2, "standard_charge_percentage": 42.2, "count": "0", "additional_payer_notes": "Zero final payments for the item or service in the 15 months prior to posting the file." }, { "payer_name": "CIGNA", "plan_name": "CIGNA COM ALT HMO PLAN", "methodology": "percent of total billed charges", "standard_charge_dollar": 1519.2, "standard_charge_percentage": 42.2, "count": "0", "additional_payer_notes": "Zero final payments for the item or service in the 15 months prior to posting the file." }, { "payer_name": "HEALTH NET", "plan_name": "HEALTHNET HMO, PPO, POS, EPO, CANOPY HEALTHNET HMO, OTHER-IN-NETWORK PLANS", "methodology": "per diem", "standard_charge_dollar": 8000.0, "standard_charge_algorithm": "Expected reimbursement is the lesser of Per diem ($8,000) for the length of stay and 70% of billed.", "count": "0", "additional_payer_notes": "Zero final payments for the item or service in the 15 months prior to posting the file." }, { "payer_name": "HEALTH NET", "plan_name": "HEALTHNET HMO, PPO, POS, EPO, CANOPY HEALTHNET HMO, OTHER-IN-NETWORK PLANS", "methodology": "per diem", "standard_charge_dollar": 8000.0, "standard_charge_algorithm": "Expected reimbursement is the lesser of Per diem ($8,000) for the length of stay and 70% of billed.", "count": "0", "additional_payer_notes": "Zero final payments for the item or service in the 15 months prior to posting the file." }, { "payer_name": "UNITED HEALTHCARE", "plan_name": "SUTTER SELECT & SUTTER HEALTH PLAN HMO PLANS", "methodology": "per diem", "standard_charge_dollar": 28538.0, "standard_charge_algorithm": "Per diem ($28,538).", "count": "0", "additional_payer_notes": "Zero final payments for the item or service in the 15 months prior to posting the file." }, { "payer_name": "UNITED HEALTHCARE", "plan_name": "SUTTER SELECT & SUTTER HEALTH PLAN HMO PLANS", "methodology": "per diem", "standard_charge_dollar": 28538.0, "standard_charge_algorithm": "Per diem ($28,538).", "count": "0", "additional_payer_notes": "Zero final payments for the item or service in the 15 months prior to posting the file." }, { "payer_name": "SUTTER", "plan_name": "SUTTER SELECT & SUTTER HEALTH PLAN HMO PLANS", "methodology": "per diem", "standard_charge_dollar": 28538.0, "standard_charge_algorithm": "Per diem ($28,538).", "count": "0", "additional_payer_notes": "Zero final payments for the item or service in the 15 months prior to posting the file." }, { "payer_name": "UNITED HEALTHCARE", "plan_name": "SUTTER SELECT & SUTTER HEALTH PLAN HMO PLANS", "methodology": "per diem", "standard_charge_dollar": 28538.0, "standard_charge_algorithm": "Per diem ($28,538).", "count": "0", "additional_payer_notes": "Zero final payments for the item or service in the 15 months prior to posting the file." }, { "payer_name": "UMR", "plan_name": "SUTTER SELECT & SUTTER HEALTH PLAN HMO PLANS", "methodology": "per diem", "standard_charge_dollar": 28538.0, "standard_charge_algorithm": "Per diem ($28,538).", "count": "0", "additional_payer_notes": "Zero final payments for the item or service in the 15 months prior to posting the file." } ] } ] }, { "description": "HC Blade Gp025", "code_information": [ { "code": "PX-2120011025", "type": "CDM" }, { "code": "99999", "type": "CPT" }, { "code": "0272", "type": "RC" } ], "standard_charges": [ { "setting": "outpatient", "gross_charge": 4263.0, "discounted_cash": 2131.5, "minimum": 1798.99, "maximum": 2216.76, "additional_generic_notes": "Zero final payments for the item or service in the 15 months prior to posting the file.", "payers_information": [ { "payer_name": "AETNA", "plan_name": "AETNA ALL OTHER PLANS", "methodology": "percent of total billed charges", "standard_charge_dollar": 2216.76, "standard_charge_percentage": 52.0, "count": "0", "additional_payer_notes": "Zero final payments for the item or service in the 15 months prior to posting the file." }, { "payer_name": "AETNA", "plan_name": "AETNA ALL OTHER PLANS", "methodology": "percent of total billed charges", "standard_charge_dollar": 2216.76, "standard_charge_percentage": 52.0, "count": "0", "additional_payer_notes": "Zero final payments for the item or service in the 15 months prior to posting the file." }, { "payer_name": "MERITAIN HEALTH", "plan_name": "AETNA ALL OTHER PLANS", "methodology": "percent of total billed charges", "standard_charge_dollar": 2216.76, "standard_charge_percentage": 52.0, "count": "0", "additional_payer_notes": "Zero final payments for the item or service in the 15 months prior to posting the file." }, { "payer_name": "BLUE SHIELD OUT OF STATE", "plan_name": "STANFORD HEALTHCARE ALLIANCE PLAN", "methodology": "percent of total billed charges", "standard_charge_dollar": 2071.39, "standard_charge_percentage": 48.59, "count": "0", "additional_payer_notes": "Zero final payments for the item or service in the 15 months prior to posting the file." }, { "payer_name": "BLUE SHIELD", "plan_name": "STANFORD HEALTHCARE ALLIANCE PLAN", "methodology": "percent of total billed charges", "standard_charge_dollar": 2071.39, "standard_charge_percentage": 48.59, "median_amount": 68.24, "10th_percentile": 13.6, "90th_percentile": 1043.06, "count": "30" }, { "payer_name": "BLUE SHIELD", "plan_name": "STANFORD HEALTHCARE ALLIANCE PLAN", "methodology": "percent of total billed charges", "standard_charge_dollar": 2071.39, "standard_charge_percentage": 48.59, "count": "0", "additional_payer_notes": "Zero final payments for the item or service in the 15 months prior to posting the file." }, { "payer_name": "BLUE SHIELD", "plan_name": "STANFORD HEALTHCARE ALLIANCE PLAN", "methodology": "percent of total billed charges", "standard_charge_dollar": 2071.39, "standard_charge_percentage": 48.59, "count": "0", "additional_payer_notes": "Zero final payments for the item or service in the 15 months prior to posting the file." }, { "payer_name": "CIGNA", "plan_name": "CIGNA COM ALT HMO PLAN", "methodology": "percent of total billed charges", "standard_charge_dollar": 1798.99, "standard_charge_percentage": 42.2, "count": "0", "additional_payer_notes": "Zero final payments for the item or service in the 15 months prior to posting the file." }, { "payer_name": "CIGNA", "plan_name": "CIGNA COM ALT HMO PLAN", "methodology": "percent of total billed charges", "standard_charge_dollar": 1798.99, "standard_charge_percentage": 42.2, "count": "0", "additional_payer_notes": "Zero final payments for the item or service in the 15 months prior to posting the file." }, { "payer_name": "HEALTH NET", "plan_name": "HEALTHNET HMO, PPO, POS, EPO, CANOPY HEALTHNET HMO, OTHER-IN-NETWORK PLANS", "methodology": "per diem", "standard_charge_dollar": 8000.0, "standard_charge_algorithm": "Expected reimbursement is the lesser of Per diem ($8,000) for the length of stay and 70% of billed.", "count": "0", "additional_payer_notes": "Zero final payments for the item or service in the 15 months prior to posting the file." }, { "payer_name": "HEALTH NET", "plan_name": "HEALTHNET HMO, PPO, POS, EPO, CANOPY HEALTHNET HMO, OTHER-IN-NETWORK PLANS", "methodology": "per diem", "standard_charge_dollar": 8000.0, "standard_charge_algorithm": "Expected reimbursement is the lesser of Per diem ($8,000) for the length of stay and 70% of billed.", "count": "0", "additional_payer_notes": "Zero final payments for the item or service in the 15 months prior to posting the file." }, { "payer_name": "UNITED HEALTHCARE", "plan_name": "SUTTER SELECT & SUTTER HEALTH PLAN HMO PLANS", "methodology": "per diem", "standard_charge_dollar": 28538.0, "standard_charge_algorithm": "Per diem ($28,538).", "count": "0", "additional_payer_notes": "Zero final payments for the item or service in the 15 months prior to posting the file." }, { "payer_name": "UNITED HEALTHCARE", "plan_name": "SUTTER SELECT & SUTTER HEALTH PLAN HMO PLANS", "methodology": "per diem", "standard_charge_dollar": 28538.0, "standard_charge_algorithm": "Per diem ($28,538).", "count": "0", "additional_payer_notes": "Zero final payments for the item or service in the 15 months prior to posting the file." }, { "payer_name": "SUTTER", "plan_name": "SUTTER SELECT & SUTTER HEALTH PLAN HMO PLANS", "methodology": "per diem", "standard_charge_dollar": 28538.0, "standard_charge_algorithm": "Per diem ($28,538).", "count": "0", "additional_payer_notes": "Zero final payments for the item or service in the 15 months prior to posting the file." }, { "payer_name": "UNITED HEALTHCARE", "plan_name": "SUTTER SELECT & SUTTER HEALTH PLAN HMO PLANS", "methodology": "per diem", "standard_charge_dollar": 28538.0, "standard_charge_algorithm": "Per diem ($28,538).", "count": "0", "additional_payer_notes": "Zero final payments for the item or service in the 15 months prior to posting the file." }, { "payer_name": "UMR", "plan_name": "SUTTER SELECT & SUTTER HEALTH PLAN HMO PLANS", "methodology": "per diem", "standard_charge_dollar": 28538.0, "standard_charge_algorithm": "Per diem ($28,538).", "count": "0", "additional_payer_notes": "Zero final payments for the item or service in the 15 months prior to posting the file." } ] } ] }, { "description": "Hc Blade Gp026", "code_information": [ { "code": "PX-2120011026", "type": "CDM" }, { "code": "99999", "type": "CPT" }, { "code": "0272", "type": "RC" } ], "standard_charges": [ { "setting": "outpatient", "gross_charge": 4650.0, "discounted_cash": 2325.0, "minimum": 1962.3, "maximum": 2418.0, "additional_generic_notes": "Zero final payments for the item or service in the 15 months prior to posting the file.", "payers_information": [ { "payer_name": "AETNA", "plan_name": "AETNA ALL OTHER PLANS", "methodology": "percent of total billed charges", "standard_charge_dollar": 2418.0, "standard_charge_percentage": 52.0, "count": "0", "additional_payer_notes": "Zero final payments for the item or service in the 15 months prior to posting the file." }, { "payer_name": "AETNA", "plan_name": "AETNA ALL OTHER PLANS", "methodology": "percent of total billed charges", "standard_charge_dollar": 2418.0, "standard_charge_percentage": 52.0, "count": "0", "additional_payer_notes": "Zero final payments for the item or service in the 15 months prior to posting the file." }, { "payer_name": "MERITAIN HEALTH", "plan_name": "AETNA ALL OTHER PLANS", "methodology": "percent of total billed charges", "standard_charge_dollar": 2418.0, "standard_charge_percentage": 52.0, "count": "0", "additional_payer_notes": "Zero final payments for the item or service in the 15 months prior to posting the file." }, { "payer_name": "BLUE SHIELD OUT OF STATE", "plan_name": "STANFORD HEALTHCARE ALLIANCE PLAN", "methodology": "percent of total billed charges", "standard_charge_dollar": 2259.44, "standard_charge_percentage": 48.59, "count": "0", "additional_payer_notes": "Zero final payments for the item or service in the 15 months prior to posting the file." }, { "payer_name": "BLUE SHIELD", "plan_name": "STANFORD HEALTHCARE ALLIANCE PLAN", "methodology": "percent of total billed charges", "standard_charge_dollar": 2259.44, "standard_charge_percentage": 48.59, "median_amount": 68.24, "10th_percentile": 13.6, "90th_percentile": 1043.06, "count": "30" }, { "payer_name": "BLUE SHIELD", "plan_name": "STANFORD HEALTHCARE ALLIANCE PLAN", "methodology": "percent of total billed charges", "standard_charge_dollar": 2259.44, "standard_charge_percentage": 48.59, "count": "0", "additional_payer_notes": "Zero final payments for the item or service in the 15 months prior to posting the file." }, { "payer_name": "BLUE SHIELD", "plan_name": "STANFORD HEALTHCARE ALLIANCE PLAN", "methodology": "percent of total billed charges", "standard_charge_dollar": 2259.44, "standard_charge_percentage": 48.59, "count": "0", "additional_payer_notes": "Zero final payments for the item or service in the 15 months prior to posting the file." }, { "payer_name": "CIGNA", "plan_name": "CIGNA COM ALT HMO PLAN", "methodology": "percent of total billed charges", "standard_charge_dollar": 1962.3, "standard_charge_percentage": 42.2, "count": "0", "additional_payer_notes": "Zero final payments for the item or service in the 15 months prior to posting the file." }, { "payer_name": "CIGNA", "plan_name": "CIGNA COM ALT HMO PLAN", "methodology": "percent of total billed charges", "standard_charge_dollar": 1962.3, "standard_charge_percentage": 42.2, "count": "0", "additional_payer_notes": "Zero final payments for the item or service in the 15 months prior to posting the file." }, { "payer_name": "HEALTH NET", "plan_name": "HEALTHNET HMO, PPO, POS, EPO, CANOPY HEALTHNET HMO, OTHER-IN-NETWORK PLANS", "methodology": "per diem", "standard_charge_dollar": 8000.0, "standard_charge_algorithm": "Expected reimbursement is the lesser of Per diem ($8,000) for the length of stay and 70% of billed.", "count": "0", "additional_payer_notes": "Zero final payments for the item or service in the 15 months prior to posting the file." }, { "payer_name": "HEALTH NET", "plan_name": "HEALTHNET HMO, PPO, POS, EPO, CANOPY HEALTHNET HMO, OTHER-IN-NETWORK PLANS", "methodology": "per diem", "standard_charge_dollar": 8000.0, "standard_charge_algorithm": "Expected reimbursement is the lesser of Per diem ($8,000) for the length of stay and 70% of billed.", "count": "0", "additional_payer_notes": "Zero final payments for the item or service in the 15 months prior to posting the file." }, { "payer_name": "UNITED HEALTHCARE", "plan_name": "SUTTER SELECT & SUTTER HEALTH PLAN HMO PLANS", "methodology": "per diem", "standard_charge_dollar": 28538.0, "standard_charge_algorithm": "Per diem ($28,538).", "count": "0", "additional_payer_notes": "Zero final payments for the item or service in the 15 months prior to posting the file." }, { "payer_name": "UNITED HEALTHCARE", "plan_name": "SUTTER SELECT & SUTTER HEALTH PLAN HMO PLANS", "methodology": "per diem", "standard_charge_dollar": 28538.0, "standard_charge_algorithm": "Per diem ($28,538).", "count": "0", "additional_payer_notes": "Zero final payments for the item or service in the 15 months prior to posting the file." }, { "payer_name": "SUTTER", "plan_name": "SUTTER SELECT & SUTTER HEALTH PLAN HMO PLANS", "methodology": "per diem", "standard_charge_dollar": 28538.0, "standard_charge_algorithm": "Per diem ($28,538).", "count": "0", "additional_payer_notes": "Zero final payments for the item or service in the 15 months prior to posting the file." }, { "payer_name": "UNITED HEALTHCARE", "plan_name": "SUTTER SELECT & SUTTER HEALTH PLAN HMO PLANS", "methodology": "per diem", "standard_charge_dollar": 28538.0, "standard_charge_algorithm": "Per diem ($28,538).", "count": "0", "additional_payer_notes": "Zero final payments for the item or service in the 15 months prior to posting the file." }, { "payer_name": "UMR", "plan_name": "SUTTER SELECT & SUTTER HEALTH PLAN HMO PLANS", "methodology": "per diem", "standard_charge_dollar": 28538.0, "standard_charge_algorithm": "Per diem ($28,538).", "count": "0", "additional_payer_notes": "Zero final payments for the item or service in the 15 months prior to posting the file." } ] } ] }, { "description": "HC Blade Gp027", "code_information": [ { "code": "PX-2120011027", "type": "CDM" }, { "code": "99999", "type": "CPT" }, { "code": "0272", "type": "RC" } ], "standard_charges": [ { "setting": "outpatient", "gross_charge": 4875.0, "discounted_cash": 2437.5, "minimum": 2057.25, "maximum": 2535.0, "additional_generic_notes": "Zero final payments for the item or service in the 15 months prior to posting the file.", "payers_information": [ { "payer_name": "AETNA", "plan_name": "AETNA ALL OTHER PLANS", "methodology": "percent of total billed charges", "standard_charge_dollar": 2535.0, "standard_charge_percentage": 52.0, "count": "0", "additional_payer_notes": "Zero final payments for the item or service in the 15 months prior to posting the file." }, { "payer_name": "AETNA", "plan_name": "AETNA ALL OTHER PLANS", "methodology": "percent of total billed charges", "standard_charge_dollar": 2535.0, "standard_charge_percentage": 52.0, "count": "0", "additional_payer_notes": "Zero final payments for the item or service in the 15 months prior to posting the file." }, { "payer_name": "MERITAIN HEALTH", "plan_name": "AETNA ALL OTHER PLANS", "methodology": "percent of total billed charges", "standard_charge_dollar": 2535.0, "standard_charge_percentage": 52.0, "count": "0", "additional_payer_notes": "Zero final payments for the item or service in the 15 months prior to posting the file." }, { "payer_name": "BLUE SHIELD OUT OF STATE", "plan_name": "STANFORD HEALTHCARE ALLIANCE PLAN", "methodology": "percent of total billed charges", "standard_charge_dollar": 2368.76, "standard_charge_percentage": 48.59, "count": "0", "additional_payer_notes": "Zero final payments for the item or service in the 15 months prior to posting the file." }, { "payer_name": "BLUE SHIELD", "plan_name": "STANFORD HEALTHCARE ALLIANCE PLAN", "methodology": "percent of total billed charges", "standard_charge_dollar": 2368.76, "standard_charge_percentage": 48.59, "median_amount": 68.24, "10th_percentile": 13.6, "90th_percentile": 1043.06, "count": "30" }, { "payer_name": "BLUE SHIELD", "plan_name": "STANFORD HEALTHCARE ALLIANCE PLAN", "methodology": "percent of total billed charges", "standard_charge_dollar": 2368.76, "standard_charge_percentage": 48.59, "count": "0", "additional_payer_notes": "Zero final payments for the item or service in the 15 months prior to posting the file." }, { "payer_name": "BLUE SHIELD", "plan_name": "STANFORD HEALTHCARE ALLIANCE PLAN", "methodology": "percent of total billed charges", "standard_charge_dollar": 2368.76, "standard_charge_percentage": 48.59, "count": "0", "additional_payer_notes": "Zero final payments for the item or service in the 15 months prior to posting the file." }, { "payer_name": "CIGNA", "plan_name": "CIGNA COM ALT HMO PLAN", "methodology": "percent of total billed charges", "standard_charge_dollar": 2057.25, "standard_charge_percentage": 42.2, "count": "0", "additional_payer_notes": "Zero final payments for the item or service in the 15 months prior to posting the file." }, { "payer_name": "CIGNA", "plan_name": "CIGNA COM ALT HMO PLAN", "methodology": "percent of total billed charges", "standard_charge_dollar": 2057.25, "standard_charge_percentage": 42.2, "count": "0", "additional_payer_notes": "Zero final payments for the item or service in the 15 months prior to posting the file." }, { "payer_name": "HEALTH NET", "plan_name": "HEALTHNET HMO, PPO, POS, EPO, CANOPY HEALTHNET HMO, OTHER-IN-NETWORK PLANS", "methodology": "per diem", "standard_charge_dollar": 8000.0, "standard_charge_algorithm": "Expected reimbursement is the lesser of Per diem ($8,000) for the length of stay and 70% of billed.", "count": "0", "additional_payer_notes": "Zero final payments for the item or service in the 15 months prior to posting the file." }, { "payer_name": "HEALTH NET", "plan_name": "HEALTHNET HMO, PPO, POS, EPO, CANOPY HEALTHNET HMO, OTHER-IN-NETWORK PLANS", "methodology": "per diem", "standard_charge_dollar": 8000.0, "standard_charge_algorithm": "Expected reimbursement is the lesser of Per diem ($8,000) for the length of stay and 70% of billed.", "count": "0", "additional_payer_notes": "Zero final payments for the item or service in the 15 months prior to posting the file." }, { "payer_name": "UNITED HEALTHCARE", "plan_name": "SUTTER SELECT & SUTTER HEALTH PLAN HMO PLANS", "methodology": "per diem", "standard_charge_dollar": 28538.0, "standard_charge_algorithm": "Per diem ($28,538).", "count": "0", "additional_payer_notes": "Zero final payments for the item or service in the 15 months prior to posting the file." }, { "payer_name": "UNITED HEALTHCARE", "plan_name": "SUTTER SELECT & SUTTER HEALTH PLAN HMO PLANS", "methodology": "per diem", "standard_charge_dollar": 28538.0, "standard_charge_algorithm": "Per diem ($28,538).", "count": "0", "additional_payer_notes": "Zero final payments for the item or service in the 15 months prior to posting the file." }, { "payer_name": "SUTTER", "plan_name": "SUTTER SELECT & SUTTER HEALTH PLAN HMO PLANS", "methodology": "per diem", "standard_charge_dollar": 28538.0, "standard_charge_algorithm": "Per diem ($28,538).", "count": "0", "additional_payer_notes": "Zero final payments for the item or service in the 15 months prior to posting the file." }, { "payer_name": "UNITED HEALTHCARE", "plan_name": "SUTTER SELECT & SUTTER HEALTH PLAN HMO PLANS", "methodology": "per diem", "standard_charge_dollar": 28538.0, "standard_charge_algorithm": "Per diem ($28,538).", "count": "0", "additional_payer_notes": "Zero final payments for the item or service in the 15 months prior to posting the file." }, { "payer_name": "UMR", "plan_name": "SUTTER SELECT & SUTTER HEALTH PLAN HMO PLANS", "methodology": "per diem", "standard_charge_dollar": 28538.0, "standard_charge_algorithm": "Per diem ($28,538).", "count": "0", "additional_payer_notes": "Zero final payments for the item or service in the 15 months prior to posting the file." } ] } ] }, { "description": "HC Blade Gp035", "code_information": [ { "code": "PX-2120011035", "type": "CDM" }, { "code": "99999", "type": "CPT" }, { "code": "0272", "type": "RC" } ], "standard_charges": [ { "setting": "outpatient", "gross_charge": 7150.0, "discounted_cash": 3575.0, "minimum": 3017.3, "maximum": 3718.0, "additional_generic_notes": "Zero final payments for the item or service in the 15 months prior to posting the file.", "payers_information": [ { "payer_name": "AETNA", "plan_name": "AETNA ALL OTHER PLANS", "methodology": "percent of total billed charges", "standard_charge_dollar": 3718.0, "standard_charge_percentage": 52.0, "count": "0", "additional_payer_notes": "Zero final payments for the item or service in the 15 months prior to posting the file." }, { "payer_name": "AETNA", "plan_name": "AETNA ALL OTHER PLANS", "methodology": "percent of total billed charges", "standard_charge_dollar": 3718.0, "standard_charge_percentage": 52.0, "count": "0", "additional_payer_notes": "Zero final payments for the item or service in the 15 months prior to posting the file." }, { "payer_name": "MERITAIN HEALTH", "plan_name": "AETNA ALL OTHER PLANS", "methodology": "percent of total billed charges", "standard_charge_dollar": 3718.0, "standard_charge_percentage": 52.0, "count": "0", "additional_payer_notes": "Zero final payments for the item or service in the 15 months prior to posting the file." }, { "payer_name": "BLUE SHIELD OUT OF STATE", "plan_name": "STANFORD HEALTHCARE ALLIANCE PLAN", "methodology": "percent of total billed charges", "standard_charge_dollar": 3474.19, "standard_charge_percentage": 48.59, "count": "0", "additional_payer_notes": "Zero final payments for the item or service in the 15 months prior to posting the file." }, { "payer_name": "BLUE SHIELD", "plan_name": "STANFORD HEALTHCARE ALLIANCE PLAN", "methodology": "percent of total billed charges", "standard_charge_dollar": 3474.19, "standard_charge_percentage": 48.59, "median_amount": 68.24, "10th_percentile": 13.6, "90th_percentile": 1043.06, "count": "30" }, { "payer_name": "BLUE SHIELD", "plan_name": "STANFORD HEALTHCARE ALLIANCE PLAN", "methodology": "percent of total billed charges", "standard_charge_dollar": 3474.19, "standard_charge_percentage": 48.59, "count": "0", "additional_payer_notes": "Zero final payments for the item or service in the 15 months prior to posting the file." }, { "payer_name": "BLUE SHIELD", "plan_name": "STANFORD HEALTHCARE ALLIANCE PLAN", "methodology": "percent of total billed charges", "standard_charge_dollar": 3474.19, "standard_charge_percentage": 48.59, "count": "0", "additional_payer_notes": "Zero final payments for the item or service in the 15 months prior to posting the file." }, { "payer_name": "CIGNA", "plan_name": "CIGNA COM ALT HMO PLAN", "methodology": "percent of total billed charges", "standard_charge_dollar": 3017.3, "standard_charge_percentage": 42.2, "count": "0", "additional_payer_notes": "Zero final payments for the item or service in the 15 months prior to posting the file." }, { "payer_name": "CIGNA", "plan_name": "CIGNA COM ALT HMO PLAN", "methodology": "percent of total billed charges", "standard_charge_dollar": 3017.3, "standard_charge_percentage": 42.2, "count": "0", "additional_payer_notes": "Zero final payments for the item or service in the 15 months prior to posting the file." }, { "payer_name": "HEALTH NET", "plan_name": "HEALTHNET HMO, PPO, POS, EPO, CANOPY HEALTHNET HMO, OTHER-IN-NETWORK PLANS", "methodology": "per diem", "standard_charge_dollar": 8000.0, "standard_charge_algorithm": "Expected reimbursement is the lesser of Per diem ($8,000) for the length of stay and 70% of billed.", "count": "0", "additional_payer_notes": "Zero final payments for the item or service in the 15 months prior to posting the file." }, { "payer_name": "HEALTH NET", "plan_name": "HEALTHNET HMO, PPO, POS, EPO, CANOPY HEALTHNET HMO, OTHER-IN-NETWORK PLANS", "methodology": "per diem", "standard_charge_dollar": 8000.0, "standard_charge_algorithm": "Expected reimbursement is the lesser of Per diem ($8,000) for the length of stay and 70% of billed.", "count": "0", "additional_payer_notes": "Zero final payments for the item or service in the 15 months prior to posting the file." }, { "payer_name": "UNITED HEALTHCARE", "plan_name": "SUTTER SELECT & SUTTER HEALTH PLAN HMO PLANS", "methodology": "per diem", "standard_charge_dollar": 28538.0, "standard_charge_algorithm": "Per diem ($28,538).", "count": "0", "additional_payer_notes": "Zero final payments for the item or service in the 15 months prior to posting the file." }, { "payer_name": "UNITED HEALTHCARE", "plan_name": "SUTTER SELECT & SUTTER HEALTH PLAN HMO PLANS", "methodology": "per diem", "standard_charge_dollar": 28538.0, "standard_charge_algorithm": "Per diem ($28,538).", "count": "0", "additional_payer_notes": "Zero final payments for the item or service in the 15 months prior to posting the file." }, { "payer_name": "SUTTER", "plan_name": "SUTTER SELECT & SUTTER HEALTH PLAN HMO PLANS", "methodology": "per diem", "standard_charge_dollar": 28538.0, "standard_charge_algorithm": "Per diem ($28,538).", "count": "0", "additional_payer_notes": "Zero final payments for the item or service in the 15 months prior to posting the file." }, { "payer_name": "UNITED HEALTHCARE", "plan_name": "SUTTER SELECT & SUTTER HEALTH PLAN HMO PLANS", "methodology": "per diem", "standard_charge_dollar": 28538.0, "standard_charge_algorithm": "Per diem ($28,538).", "count": "0", "additional_payer_notes": "Zero final payments for the item or service in the 15 months prior to posting the file." }, { "payer_name": "UMR", "plan_name": "SUTTER SELECT & SUTTER HEALTH PLAN HMO PLANS", "methodology": "per diem", "standard_charge_dollar": 28538.0, "standard_charge_algorithm": "Per diem ($28,538).", "count": "0", "additional_payer_notes": "Zero final payments for the item or service in the 15 months prior to posting the file." } ] } ] }, { "description": "HC Blade Saw Gp002", "code_information": [ { "code": "PX-2120012002", "type": "CDM" }, { "code": "99999", "type": "CPT" }, { "code": "0272", "type": "RC" } ], "standard_charges": [ { "setting": "outpatient", "gross_charge": 50.0, "discounted_cash": 25.0, "minimum": 21.1, "maximum": 26.0, "additional_generic_notes": "Zero final payments for the item or service in the 15 months prior to posting the file.", "payers_information": [ { "payer_name": "AETNA", "plan_name": "AETNA ALL OTHER PLANS", "methodology": "percent of total billed charges", "standard_charge_dollar": 26.0, "standard_charge_percentage": 52.0, "count": "0", "additional_payer_notes": "Zero final payments for the item or service in the 15 months prior to posting the file." }, { "payer_name": "AETNA", "plan_name": "AETNA ALL OTHER PLANS", "methodology": "percent of total billed charges", "standard_charge_dollar": 26.0, "standard_charge_percentage": 52.0, "count": "0", "additional_payer_notes": "Zero final payments for the item or service in the 15 months prior to posting the file." }, { "payer_name": "MERITAIN HEALTH", "plan_name": "AETNA ALL OTHER PLANS", "methodology": "percent of total billed charges", "standard_charge_dollar": 26.0, "standard_charge_percentage": 52.0, "count": "0", "additional_payer_notes": "Zero final payments for the item or service in the 15 months prior to posting the file." }, { "payer_name": "BLUE SHIELD OUT OF STATE", "plan_name": "STANFORD HEALTHCARE ALLIANCE PLAN", "methodology": "percent of total billed charges", "standard_charge_dollar": 24.3, "standard_charge_percentage": 48.59, "count": "0", "additional_payer_notes": "Zero final payments for the item or service in the 15 months prior to posting the file." }, { "payer_name": "BLUE SHIELD", "plan_name": "STANFORD HEALTHCARE ALLIANCE PLAN", "methodology": "percent of total billed charges", "standard_charge_dollar": 24.3, "standard_charge_percentage": 48.59, "count": "0", "additional_payer_notes": "Zero final payments for the item or service in the 15 months prior to posting the file." }, { "payer_name": "BLUE SHIELD", "plan_name": "STANFORD HEALTHCARE ALLIANCE PLAN", "methodology": "percent of total billed charges", "standard_charge_dollar": 24.3, "standard_charge_percentage": 48.59, "count": "0", "additional_payer_notes": "Zero final payments for the item or service in the 15 months prior to posting the file." }, { "payer_name": "CIGNA", "plan_name": "CIGNA COM ALT HMO PLAN", "methodology": "percent of total billed charges", "standard_charge_dollar": 21.1, "standard_charge_percentage": 42.2, "count": "0", "additional_payer_notes": "Zero final payments for the item or service in the 15 months prior to posting the file." }, { "payer_name": "CIGNA", "plan_name": "CIGNA COM ALT HMO PLAN", "methodology": "percent of total billed charges", "standard_charge_dollar": 21.1, "standard_charge_percentage": 42.2, "count": "0", "additional_payer_notes": "Zero final payments for the item or service in the 15 months prior to posting the file." }, { "payer_name": "HEALTH NET", "plan_name": "HEALTHNET HMO, PPO, POS, EPO, CANOPY HEALTHNET HMO, OTHER-IN-NETWORK PLANS", "methodology": "per diem", "standard_charge_dollar": 8000.0, "standard_charge_algorithm": "Expected reimbursement is the lesser of Per diem ($8,000) for the length of stay and 70% of billed.", "count": "0", "additional_payer_notes": "Zero final payments for the item or service in the 15 months prior to posting the file." }, { "payer_name": "HEALTH NET", "plan_name": "HEALTHNET HMO, PPO, POS, EPO, CANOPY HEALTHNET HMO, OTHER-IN-NETWORK PLANS", "methodology": "per diem", "standard_charge_dollar": 8000.0, "standard_charge_algorithm": "Expected reimbursement is the lesser of Per diem ($8,000) for the length of stay and 70% of billed.", "count": "0", "additional_payer_notes": "Zero final payments for the item or service in the 15 months prior to posting the file." }, { "payer_name": "UNITED HEALTHCARE", "plan_name": "SUTTER SELECT & SUTTER HEALTH PLAN HMO PLANS", "methodology": "per diem", "standard_charge_dollar": 28538.0, "standard_charge_algorithm": "Per diem ($28,538).", "count": "0", "additional_payer_notes": "Zero final payments for the item or service in the 15 months prior to posting the file." }, { "payer_name": "UNITED HEALTHCARE", "plan_name": "SUTTER SELECT & SUTTER HEALTH PLAN HMO PLANS", "methodology": "per diem", "standard_charge_dollar": 28538.0, "standard_charge_algorithm": "Per diem ($28,538).", "count": "0", "additional_payer_notes": "Zero final payments for the item or service in the 15 months prior to posting the file." }, { "payer_name": "SUTTER", "plan_name": "SUTTER SELECT & SUTTER HEALTH PLAN HMO PLANS", "methodology": "per diem", "standard_charge_dollar": 28538.0, "standard_charge_algorithm": "Per diem ($28,538).", "count": "0", "additional_payer_notes": "Zero final payments for the item or service in the 15 months prior to posting the file." }, { "payer_name": "UNITED HEALTHCARE", "plan_name": "SUTTER SELECT & SUTTER HEALTH PLAN HMO PLANS", "methodology": "per diem", "standard_charge_dollar": 28538.0, "standard_charge_algorithm": "Per diem ($28,538).", "count": "0", "additional_payer_notes": "Zero final payments for the item or service in the 15 months prior to posting the file." }, { "payer_name": "UMR", "plan_name": "SUTTER SELECT & SUTTER HEALTH PLAN HMO PLANS", "methodology": "per diem", "standard_charge_dollar": 28538.0, "standard_charge_algorithm": "Per diem ($28,538).", "count": "0", "additional_payer_notes": "Zero final payments for the item or service in the 15 months prior to posting the file." } ] } ] }, { "description": "HC Blade Saw Gp003", "code_information": [ { "code": "PX-2120012003", "type": "CDM" }, { "code": "99999", "type": "CPT" }, { "code": "0272", "type": "RC" } ], "standard_charges": [ { "setting": "outpatient", "gross_charge": 100.0, "discounted_cash": 50.0, "minimum": 42.2, "maximum": 52.0, "additional_generic_notes": "Zero final payments for the item or service in the 15 months prior to posting the file.", "payers_information": [ { "payer_name": "AETNA", "plan_name": "AETNA ALL OTHER PLANS", "methodology": "percent of total billed charges", "standard_charge_dollar": 52.0, "standard_charge_percentage": 52.0, "count": "0", "additional_payer_notes": "Zero final payments for the item or service in the 15 months prior to posting the file." }, { "payer_name": "AETNA", "plan_name": "AETNA ALL OTHER PLANS", "methodology": "percent of total billed charges", "standard_charge_dollar": 52.0, "standard_charge_percentage": 52.0, "count": "0", "additional_payer_notes": "Zero final payments for the item or service in the 15 months prior to posting the file." }, { "payer_name": "MERITAIN HEALTH", "plan_name": "AETNA ALL OTHER PLANS", "methodology": "percent of total billed charges", "standard_charge_dollar": 52.0, "standard_charge_percentage": 52.0, "count": "0", "additional_payer_notes": "Zero final payments for the item or service in the 15 months prior to posting the file." }, { "payer_name": "BLUE SHIELD OUT OF STATE", "plan_name": "STANFORD HEALTHCARE ALLIANCE PLAN", "methodology": "percent of total billed charges", "standard_charge_dollar": 48.59, "standard_charge_percentage": 48.59, "count": "0", "additional_payer_notes": "Zero final payments for the item or service in the 15 months prior to posting the file." }, { "payer_name": "BLUE SHIELD", "plan_name": "STANFORD HEALTHCARE ALLIANCE PLAN", "methodology": "percent of total billed charges", "standard_charge_dollar": 48.59, "standard_charge_percentage": 48.59, "count": "0", "additional_payer_notes": "Zero final payments for the item or service in the 15 months prior to posting the file." }, { "payer_name": "BLUE SHIELD", "plan_name": "STANFORD HEALTHCARE ALLIANCE PLAN", "methodology": "percent of total billed charges", "standard_charge_dollar": 48.59, "standard_charge_percentage": 48.59, "count": "0", "additional_payer_notes": "Zero final payments for the item or service in the 15 months prior to posting the file." }, { "payer_name": "CIGNA", "plan_name": "CIGNA COM ALT HMO PLAN", "methodology": "percent of total billed charges", "standard_charge_dollar": 42.2, "standard_charge_percentage": 42.2, "count": "0", "additional_payer_notes": "Zero final payments for the item or service in the 15 months prior to posting the file." }, { "payer_name": "CIGNA", "plan_name": "CIGNA COM ALT HMO PLAN", "methodology": "percent of total billed charges", "standard_charge_dollar": 42.2, "standard_charge_percentage": 42.2, "count": "0", "additional_payer_notes": "Zero final payments for the item or service in the 15 months prior to posting the file." }, { "payer_name": "HEALTH NET", "plan_name": "HEALTHNET HMO, PPO, POS, EPO, CANOPY HEALTHNET HMO, OTHER-IN-NETWORK PLANS", "methodology": "per diem", "standard_charge_dollar": 8000.0, "standard_charge_algorithm": "Expected reimbursement is the lesser of Per diem ($8,000) for the length of stay and 70% of billed.", "count": "0", "additional_payer_notes": "Zero final payments for the item or service in the 15 months prior to posting the file." }, { "payer_name": "HEALTH NET", "plan_name": "HEALTHNET HMO, PPO, POS, EPO, CANOPY HEALTHNET HMO, OTHER-IN-NETWORK PLANS", "methodology": "per diem", "standard_charge_dollar": 8000.0, "standard_charge_algorithm": "Expected reimbursement is the lesser of Per diem ($8,000) for the length of stay and 70% of billed.", "count": "0", "additional_payer_notes": "Zero final payments for the item or service in the 15 months prior to posting the file." }, { "payer_name": "UNITED HEALTHCARE", "plan_name": "SUTTER SELECT & SUTTER HEALTH PLAN HMO PLANS", "methodology": "per diem", "standard_charge_dollar": 28538.0, "standard_charge_algorithm": "Per diem ($28,538).", "count": "0", "additional_payer_notes": "Zero final payments for the item or service in the 15 months prior to posting the file." }, { "payer_name": "UNITED HEALTHCARE", "plan_name": "SUTTER SELECT & SUTTER HEALTH PLAN HMO PLANS", "methodology": "per diem", "standard_charge_dollar": 28538.0, "standard_charge_algorithm": "Per diem ($28,538).", "count": "0", "additional_payer_notes": "Zero final payments for the item or service in the 15 months prior to posting the file." }, { "payer_name": "SUTTER", "plan_name": "SUTTER SELECT & SUTTER HEALTH PLAN HMO PLANS", "methodology": "per diem", "standard_charge_dollar": 28538.0, "standard_charge_algorithm": "Per diem ($28,538).", "count": "0", "additional_payer_notes": "Zero final payments for the item or service in the 15 months prior to posting the file." }, { "payer_name": "UNITED HEALTHCARE", "plan_name": "SUTTER SELECT & SUTTER HEALTH PLAN HMO PLANS", "methodology": "per diem", "standard_charge_dollar": 28538.0, "standard_charge_algorithm": "Per diem ($28,538).", "count": "0", "additional_payer_notes": "Zero final payments for the item or service in the 15 months prior to posting the file." }, { "payer_name": "UMR", "plan_name": "SUTTER SELECT & SUTTER HEALTH PLAN HMO PLANS", "methodology": "per diem", "standard_charge_dollar": 28538.0, "standard_charge_algorithm": "Per diem ($28,538).", "count": "0", "additional_payer_notes": "Zero final payments for the item or service in the 15 months prior to posting the file." } ] } ] }, { "description": "HC Blade Saw Gp004", "code_information": [ { "code": "PX-2120012004", "type": "CDM" }, { "code": "99999", "type": "CPT" }, { "code": "0272", "type": "RC" } ], "standard_charges": [ { "setting": "outpatient", "gross_charge": 146.0, "discounted_cash": 73.0, "minimum": 61.61, "maximum": 75.92, "additional_generic_notes": "Zero final payments for the item or service in the 15 months prior to posting the file.", "payers_information": [ { "payer_name": "AETNA", "plan_name": "AETNA ALL OTHER PLANS", "methodology": "percent of total billed charges", "standard_charge_dollar": 75.92, "standard_charge_percentage": 52.0, "count": "0", "additional_payer_notes": "Zero final payments for the item or service in the 15 months prior to posting the file." }, { "payer_name": "AETNA", "plan_name": "AETNA ALL OTHER PLANS", "methodology": "percent of total billed charges", "standard_charge_dollar": 75.92, "standard_charge_percentage": 52.0, "count": "0", "additional_payer_notes": "Zero final payments for the item or service in the 15 months prior to posting the file." }, { "payer_name": "MERITAIN HEALTH", "plan_name": "AETNA ALL OTHER PLANS", "methodology": "percent of total billed charges", "standard_charge_dollar": 75.92, "standard_charge_percentage": 52.0, "count": "0", "additional_payer_notes": "Zero final payments for the item or service in the 15 months prior to posting the file." }, { "payer_name": "BLUE SHIELD OUT OF STATE", "plan_name": "STANFORD HEALTHCARE ALLIANCE PLAN", "methodology": "percent of total billed charges", "standard_charge_dollar": 70.94, "standard_charge_percentage": 48.59, "count": "0", "additional_payer_notes": "Zero final payments for the item or service in the 15 months prior to posting the file." }, { "payer_name": "BLUE SHIELD", "plan_name": "STANFORD HEALTHCARE ALLIANCE PLAN", "methodology": "percent of total billed charges", "standard_charge_dollar": 70.94, "standard_charge_percentage": 48.59, "count": "0", "additional_payer_notes": "Zero final payments for the item or service in the 15 months prior to posting the file." }, { "payer_name": "BLUE SHIELD", "plan_name": "STANFORD HEALTHCARE ALLIANCE PLAN", "methodology": "percent of total billed charges", "standard_charge_dollar": 70.94, "standard_charge_percentage": 48.59, "count": "0", "additional_payer_notes": "Zero final payments for the item or service in the 15 months prior to posting the file." }, { "payer_name": "CIGNA", "plan_name": "CIGNA COM ALT HMO PLAN", "methodology": "percent of total billed charges", "standard_charge_dollar": 61.61, "standard_charge_percentage": 42.2, "count": "0", "additional_payer_notes": "Zero final payments for the item or service in the 15 months prior to posting the file." }, { "payer_name": "CIGNA", "plan_name": "CIGNA COM ALT HMO PLAN", "methodology": "percent of total billed charges", "standard_charge_dollar": 61.61, "standard_charge_percentage": 42.2, "count": "0", "additional_payer_notes": "Zero final payments for the item or service in the 15 months prior to posting the file." }, { "payer_name": "HEALTH NET", "plan_name": "HEALTHNET HMO, PPO, POS, EPO, CANOPY HEALTHNET HMO, OTHER-IN-NETWORK PLANS", "methodology": "per diem", "standard_charge_dollar": 8000.0, "standard_charge_algorithm": "Expected reimbursement is the lesser of Per diem ($8,000) for the length of stay and 70% of billed.", "count": "0", "additional_payer_notes": "Zero final payments for the item or service in the 15 months prior to posting the file." }, { "payer_name": "HEALTH NET", "plan_name": "HEALTHNET HMO, PPO, POS, EPO, CANOPY HEALTHNET HMO, OTHER-IN-NETWORK PLANS", "methodology": "per diem", "standard_charge_dollar": 8000.0, "standard_charge_algorithm": "Expected reimbursement is the lesser of Per diem ($8,000) for the length of stay and 70% of billed.", "count": "0", "additional_payer_notes": "Zero final payments for the item or service in the 15 months prior to posting the file." }, { "payer_name": "UNITED HEALTHCARE", "plan_name": "SUTTER SELECT & SUTTER HEALTH PLAN HMO PLANS", "methodology": "per diem", "standard_charge_dollar": 28538.0, "standard_charge_algorithm": "Per diem ($28,538).", "count": "0", "additional_payer_notes": "Zero final payments for the item or service in the 15 months prior to posting the file." }, { "payer_name": "UNITED HEALTHCARE", "plan_name": "SUTTER SELECT & SUTTER HEALTH PLAN HMO PLANS", "methodology": "per diem", "standard_charge_dollar": 28538.0, "standard_charge_algorithm": "Per diem ($28,538).", "count": "0", "additional_payer_notes": "Zero final payments for the item or service in the 15 months prior to posting the file." }, { "payer_name": "SUTTER", "plan_name": "SUTTER SELECT & SUTTER HEALTH PLAN HMO PLANS", "methodology": "per diem", "standard_charge_dollar": 28538.0, "standard_charge_algorithm": "Per diem ($28,538).", "count": "0", "additional_payer_notes": "Zero final payments for the item or service in the 15 months prior to posting the file." }, { "payer_name": "UNITED HEALTHCARE", "plan_name": "SUTTER SELECT & SUTTER HEALTH PLAN HMO PLANS", "methodology": "per diem", "standard_charge_dollar": 28538.0, "standard_charge_algorithm": "Per diem ($28,538).", "count": "0", "additional_payer_notes": "Zero final payments for the item or service in the 15 months prior to posting the file." }, { "payer_name": "UMR", "plan_name": "SUTTER SELECT & SUTTER HEALTH PLAN HMO PLANS", "methodology": "per diem", "standard_charge_dollar": 28538.0, "standard_charge_algorithm": "Per diem ($28,538).", "count": "0", "additional_payer_notes": "Zero final payments for the item or service in the 15 months prior to posting the file." } ] } ] }, { "description": "HC Blade Saw Gp005", "code_information": [ { "code": "PX-2120012005", "type": "CDM" }, { "code": "99999", "type": "CPT" }, { "code": "0272", "type": "RC" } ], "standard_charges": [ { "setting": "outpatient", "gross_charge": 195.0, "discounted_cash": 97.5, "minimum": 82.29, "maximum": 101.4, "additional_generic_notes": "Zero final payments for the item or service in the 15 months prior to posting the file.", "payers_information": [ { "payer_name": "AETNA", "plan_name": "AETNA ALL OTHER PLANS", "methodology": "percent of total billed charges", "standard_charge_dollar": 101.4, "standard_charge_percentage": 52.0, "count": "0", "additional_payer_notes": "Zero final payments for the item or service in the 15 months prior to posting the file." }, { "payer_name": "AETNA", "plan_name": "AETNA ALL OTHER PLANS", "methodology": "percent of total billed charges", "standard_charge_dollar": 101.4, "standard_charge_percentage": 52.0, "count": "0", "additional_payer_notes": "Zero final payments for the item or service in the 15 months prior to posting the file." }, { "payer_name": "MERITAIN HEALTH", "plan_name": "AETNA ALL OTHER PLANS", "methodology": "percent of total billed charges", "standard_charge_dollar": 101.4, "standard_charge_percentage": 52.0, "count": "0", "additional_payer_notes": "Zero final payments for the item or service in the 15 months prior to posting the file." }, { "payer_name": "BLUE SHIELD OUT OF STATE", "plan_name": "STANFORD HEALTHCARE ALLIANCE PLAN", "methodology": "percent of total billed charges", "standard_charge_dollar": 94.75, "standard_charge_percentage": 48.59, "count": "0", "additional_payer_notes": "Zero final payments for the item or service in the 15 months prior to posting the file." }, { "payer_name": "BLUE SHIELD", "plan_name": "STANFORD HEALTHCARE ALLIANCE PLAN", "methodology": "percent of total billed charges", "standard_charge_dollar": 94.75, "standard_charge_percentage": 48.59, "count": "0", "additional_payer_notes": "Zero final payments for the item or service in the 15 months prior to posting the file." }, { "payer_name": "BLUE SHIELD", "plan_name": "STANFORD HEALTHCARE ALLIANCE PLAN", "methodology": "percent of total billed charges", "standard_charge_dollar": 94.75, "standard_charge_percentage": 48.59, "count": "0", "additional_payer_notes": "Zero final payments for the item or service in the 15 months prior to posting the file." }, { "payer_name": "CIGNA", "plan_name": "CIGNA COM ALT HMO PLAN", "methodology": "percent of total billed charges", "standard_charge_dollar": 82.29, "standard_charge_percentage": 42.2, "count": "0", "additional_payer_notes": "Zero final payments for the item or service in the 15 months prior to posting the file." }, { "payer_name": "CIGNA", "plan_name": "CIGNA COM ALT HMO PLAN", "methodology": "percent of total billed charges", "standard_charge_dollar": 82.29, "standard_charge_percentage": 42.2, "count": "0", "additional_payer_notes": "Zero final payments for the item or service in the 15 months prior to posting the file." }, { "payer_name": "HEALTH NET", "plan_name": "HEALTHNET HMO, PPO, POS, EPO, CANOPY HEALTHNET HMO, OTHER-IN-NETWORK PLANS", "methodology": "per diem", "standard_charge_dollar": 8000.0, "standard_charge_algorithm": "Expected reimbursement is the lesser of Per diem ($8,000) for the length of stay and 70% of billed.", "count": "0", "additional_payer_notes": "Zero final payments for the item or service in the 15 months prior to posting the file." }, { "payer_name": "HEALTH NET", "plan_name": "HEALTHNET HMO, PPO, POS, EPO, CANOPY HEALTHNET HMO, OTHER-IN-NETWORK PLANS", "methodology": "per diem", "standard_charge_dollar": 8000.0, "standard_charge_algorithm": "Expected reimbursement is the lesser of Per diem ($8,000) for the length of stay and 70% of billed.", "count": "0", "additional_payer_notes": "Zero final payments for the item or service in the 15 months prior to posting the file." }, { "payer_name": "UNITED HEALTHCARE", "plan_name": "SUTTER SELECT & SUTTER HEALTH PLAN HMO PLANS", "methodology": "per diem", "standard_charge_dollar": 28538.0, "standard_charge_algorithm": "Per diem ($28,538).", "count": "0", "additional_payer_notes": "Zero final payments for the item or service in the 15 months prior to posting the file." }, { "payer_name": "UNITED HEALTHCARE", "plan_name": "SUTTER SELECT & SUTTER HEALTH PLAN HMO PLANS", "methodology": "per diem", "standard_charge_dollar": 28538.0, "standard_charge_algorithm": "Per diem ($28,538).", "count": "0", "additional_payer_notes": "Zero final payments for the item or service in the 15 months prior to posting the file." }, { "payer_name": "SUTTER", "plan_name": "SUTTER SELECT & SUTTER HEALTH PLAN HMO PLANS", "methodology": "per diem", "standard_charge_dollar": 28538.0, "standard_charge_algorithm": "Per diem ($28,538).", "count": "0", "additional_payer_notes": "Zero final payments for the item or service in the 15 months prior to posting the file." }, { "payer_name": "UNITED HEALTHCARE", "plan_name": "SUTTER SELECT & SUTTER HEALTH PLAN HMO PLANS", "methodology": "per diem", "standard_charge_dollar": 28538.0, "standard_charge_algorithm": "Per diem ($28,538).", "count": "0", "additional_payer_notes": "Zero final payments for the item or service in the 15 months prior to posting the file." }, { "payer_name": "UMR", "plan_name": "SUTTER SELECT & SUTTER HEALTH PLAN HMO PLANS", "methodology": "per diem", "standard_charge_dollar": 28538.0, "standard_charge_algorithm": "Per diem ($28,538).", "count": "0", "additional_payer_notes": "Zero final payments for the item or service in the 15 months prior to posting the file." } ] } ] }, { "description": "HC Blade Saw Gp006", "code_information": [ { "code": "PX-2120012006", "type": "CDM" }, { "code": "99999", "type": "CPT" }, { "code": "0272", "type": "RC" } ], "standard_charges": [ { "setting": "outpatient", "gross_charge": 293.0, "discounted_cash": 146.5, "minimum": 123.65, "maximum": 152.36, "additional_generic_notes": "Zero final payments for the item or service in the 15 months prior to posting the file.", "payers_information": [ { "payer_name": "AETNA", "plan_name": "AETNA ALL OTHER PLANS", "methodology": "percent of total billed charges", "standard_charge_dollar": 152.36, "standard_charge_percentage": 52.0, "count": "0", "additional_payer_notes": "Zero final payments for the item or service in the 15 months prior to posting the file." }, { "payer_name": "AETNA", "plan_name": "AETNA ALL OTHER PLANS", "methodology": "percent of total billed charges", "standard_charge_dollar": 152.36, "standard_charge_percentage": 52.0, "count": "0", "additional_payer_notes": "Zero final payments for the item or service in the 15 months prior to posting the file." }, { "payer_name": "MERITAIN HEALTH", "plan_name": "AETNA ALL OTHER PLANS", "methodology": "percent of total billed charges", "standard_charge_dollar": 152.36, "standard_charge_percentage": 52.0, "count": "0", "additional_payer_notes": "Zero final payments for the item or service in the 15 months prior to posting the file." }, { "payer_name": "BLUE SHIELD OUT OF STATE", "plan_name": "STANFORD HEALTHCARE ALLIANCE PLAN", "methodology": "percent of total billed charges", "standard_charge_dollar": 142.37, "standard_charge_percentage": 48.59, "count": "0", "additional_payer_notes": "Zero final payments for the item or service in the 15 months prior to posting the file." }, { "payer_name": "BLUE SHIELD", "plan_name": "STANFORD HEALTHCARE ALLIANCE PLAN", "methodology": "percent of total billed charges", "standard_charge_dollar": 142.37, "standard_charge_percentage": 48.59, "count": "0", "additional_payer_notes": "Zero final payments for the item or service in the 15 months prior to posting the file." }, { "payer_name": "BLUE SHIELD", "plan_name": "STANFORD HEALTHCARE ALLIANCE PLAN", "methodology": "percent of total billed charges", "standard_charge_dollar": 142.37, "standard_charge_percentage": 48.59, "count": "0", "additional_payer_notes": "Zero final payments for the item or service in the 15 months prior to posting the file." }, { "payer_name": "CIGNA", "plan_name": "CIGNA COM ALT HMO PLAN", "methodology": "percent of total billed charges", "standard_charge_dollar": 123.65, "standard_charge_percentage": 42.2, "count": "0", "additional_payer_notes": "Zero final payments for the item or service in the 15 months prior to posting the file." }, { "payer_name": "CIGNA", "plan_name": "CIGNA COM ALT HMO PLAN", "methodology": "percent of total billed charges", "standard_charge_dollar": 123.65, "standard_charge_percentage": 42.2, "count": "0", "additional_payer_notes": "Zero final payments for the item or service in the 15 months prior to posting the file." }, { "payer_name": "HEALTH NET", "plan_name": "HEALTHNET HMO, PPO, POS, EPO, CANOPY HEALTHNET HMO, OTHER-IN-NETWORK PLANS", "methodology": "per diem", "standard_charge_dollar": 8000.0, "standard_charge_algorithm": "Expected reimbursement is the lesser of Per diem ($8,000) for the length of stay and 70% of billed.", "count": "0", "additional_payer_notes": "Zero final payments for the item or service in the 15 months prior to posting the file." }, { "payer_name": "HEALTH NET", "plan_name": "HEALTHNET HMO, PPO, POS, EPO, CANOPY HEALTHNET HMO, OTHER-IN-NETWORK PLANS", "methodology": "per diem", "standard_charge_dollar": 8000.0, "standard_charge_algorithm": "Expected reimbursement is the lesser of Per diem ($8,000) for the length of stay and 70% of billed.", "count": "0", "additional_payer_notes": "Zero final payments for the item or service in the 15 months prior to posting the file." }, { "payer_name": "UNITED HEALTHCARE", "plan_name": "SUTTER SELECT & SUTTER HEALTH PLAN HMO PLANS", "methodology": "per diem", "standard_charge_dollar": 28538.0, "standard_charge_algorithm": "Per diem ($28,538).", "count": "0", "additional_payer_notes": "Zero final payments for the item or service in the 15 months prior to posting the file." }, { "payer_name": "UNITED HEALTHCARE", "plan_name": "SUTTER SELECT & SUTTER HEALTH PLAN HMO PLANS", "methodology": "per diem", "standard_charge_dollar": 28538.0, "standard_charge_algorithm": "Per diem ($28,538).", "count": "0", "additional_payer_notes": "Zero final payments for the item or service in the 15 months prior to posting the file." }, { "payer_name": "SUTTER", "plan_name": "SUTTER SELECT & SUTTER HEALTH PLAN HMO PLANS", "methodology": "per diem", "standard_charge_dollar": 28538.0, "standard_charge_algorithm": "Per diem ($28,538).", "count": "0", "additional_payer_notes": "Zero final payments for the item or service in the 15 months prior to posting the file." }, { "payer_name": "UNITED HEALTHCARE", "plan_name": "SUTTER SELECT & SUTTER HEALTH PLAN HMO PLANS", "methodology": "per diem", "standard_charge_dollar": 28538.0, "standard_charge_algorithm": "Per diem ($28,538).", "count": "0", "additional_payer_notes": "Zero final payments for the item or service in the 15 months prior to posting the file." }, { "payer_name": "UMR", "plan_name": "SUTTER SELECT & SUTTER HEALTH PLAN HMO PLANS", "methodology": "per diem", "standard_charge_dollar": 28538.0, "standard_charge_algorithm": "Per diem ($28,538).", "count": "0", "additional_payer_notes": "Zero final payments for the item or service in the 15 months prior to posting the file." } ] } ] }, { "description": "HC Blade Saw Gp007", "code_information": [ { "code": "PX-2120012007", "type": "CDM" }, { "code": "99999", "type": "CPT" }, { "code": "0272", "type": "RC" } ], "standard_charges": [ { "setting": "outpatient", "gross_charge": 380.0, "discounted_cash": 190.0, "minimum": 160.36, "maximum": 197.6, "additional_generic_notes": "Zero final payments for the item or service in the 15 months prior to posting the file.", "payers_information": [ { "payer_name": "AETNA", "plan_name": "AETNA ALL OTHER PLANS", "methodology": "percent of total billed charges", "standard_charge_dollar": 197.6, "standard_charge_percentage": 52.0, "count": "0", "additional_payer_notes": "Zero final payments for the item or service in the 15 months prior to posting the file." }, { "payer_name": "AETNA", "plan_name": "AETNA ALL OTHER PLANS", "methodology": "percent of total billed charges", "standard_charge_dollar": 197.6, "standard_charge_percentage": 52.0, "count": "0", "additional_payer_notes": "Zero final payments for the item or service in the 15 months prior to posting the file." }, { "payer_name": "MERITAIN HEALTH", "plan_name": "AETNA ALL OTHER PLANS", "methodology": "percent of total billed charges", "standard_charge_dollar": 197.6, "standard_charge_percentage": 52.0, "count": "0", "additional_payer_notes": "Zero final payments for the item or service in the 15 months prior to posting the file." }, { "payer_name": "BLUE SHIELD OUT OF STATE", "plan_name": "STANFORD HEALTHCARE ALLIANCE PLAN", "methodology": "percent of total billed charges", "standard_charge_dollar": 184.64, "standard_charge_percentage": 48.59, "count": "0", "additional_payer_notes": "Zero final payments for the item or service in the 15 months prior to posting the file." }, { "payer_name": "BLUE SHIELD", "plan_name": "STANFORD HEALTHCARE ALLIANCE PLAN", "methodology": "percent of total billed charges", "standard_charge_dollar": 184.64, "standard_charge_percentage": 48.59, "count": "0", "additional_payer_notes": "Zero final payments for the item or service in the 15 months prior to posting the file." }, { "payer_name": "BLUE SHIELD", "plan_name": "STANFORD HEALTHCARE ALLIANCE PLAN", "methodology": "percent of total billed charges", "standard_charge_dollar": 184.64, "standard_charge_percentage": 48.59, "count": "0", "additional_payer_notes": "Zero final payments for the item or service in the 15 months prior to posting the file." }, { "payer_name": "CIGNA", "plan_name": "CIGNA COM ALT HMO PLAN", "methodology": "percent of total billed charges", "standard_charge_dollar": 160.36, "standard_charge_percentage": 42.2, "count": "0", "additional_payer_notes": "Zero final payments for the item or service in the 15 months prior to posting the file." }, { "payer_name": "CIGNA", "plan_name": "CIGNA COM ALT HMO PLAN", "methodology": "percent of total billed charges", "standard_charge_dollar": 160.36, "standard_charge_percentage": 42.2, "count": "0", "additional_payer_notes": "Zero final payments for the item or service in the 15 months prior to posting the file." }, { "payer_name": "HEALTH NET", "plan_name": "HEALTHNET HMO, PPO, POS, EPO, CANOPY HEALTHNET HMO, OTHER-IN-NETWORK PLANS", "methodology": "per diem", "standard_charge_dollar": 8000.0, "standard_charge_algorithm": "Expected reimbursement is the lesser of Per diem ($8,000) for the length of stay and 70% of billed.", "count": "0", "additional_payer_notes": "Zero final payments for the item or service in the 15 months prior to posting the file." }, { "payer_name": "HEALTH NET", "plan_name": "HEALTHNET HMO, PPO, POS, EPO, CANOPY HEALTHNET HMO, OTHER-IN-NETWORK PLANS", "methodology": "per diem", "standard_charge_dollar": 8000.0, "standard_charge_algorithm": "Expected reimbursement is the lesser of Per diem ($8,000) for the length of stay and 70% of billed.", "count": "0", "additional_payer_notes": "Zero final payments for the item or service in the 15 months prior to posting the file." }, { "payer_name": "UNITED HEALTHCARE", "plan_name": "SUTTER SELECT & SUTTER HEALTH PLAN HMO PLANS", "methodology": "per diem", "standard_charge_dollar": 28538.0, "standard_charge_algorithm": "Per diem ($28,538).", "count": "0", "additional_payer_notes": "Zero final payments for the item or service in the 15 months prior to posting the file." }, { "payer_name": "UNITED HEALTHCARE", "plan_name": "SUTTER SELECT & SUTTER HEALTH PLAN HMO PLANS", "methodology": "per diem", "standard_charge_dollar": 28538.0, "standard_charge_algorithm": "Per diem ($28,538).", "count": "0", "additional_payer_notes": "Zero final payments for the item or service in the 15 months prior to posting the file." }, { "payer_name": "SUTTER", "plan_name": "SUTTER SELECT & SUTTER HEALTH PLAN HMO PLANS", "methodology": "per diem", "standard_charge_dollar": 28538.0, "standard_charge_algorithm": "Per diem ($28,538).", "count": "0", "additional_payer_notes": "Zero final payments for the item or service in the 15 months prior to posting the file." }, { "payer_name": "UNITED HEALTHCARE", "plan_name": "SUTTER SELECT & SUTTER HEALTH PLAN HMO PLANS", "methodology": "per diem", "standard_charge_dollar": 28538.0, "standard_charge_algorithm": "Per diem ($28,538).", "count": "0", "additional_payer_notes": "Zero final payments for the item or service in the 15 months prior to posting the file." }, { "payer_name": "UMR", "plan_name": "SUTTER SELECT & SUTTER HEALTH PLAN HMO PLANS", "methodology": "per diem", "standard_charge_dollar": 28538.0, "standard_charge_algorithm": "Per diem ($28,538).", "count": "0", "additional_payer_notes": "Zero final payments for the item or service in the 15 months prior to posting the file." } ] } ] }, { "description": "HC Blade Saw Gp008", "code_information": [ { "code": "PX-2120012008", "type": "CDM" }, { "code": "99999", "type": "CPT" }, { "code": "0272", "type": "RC" } ], "standard_charges": [ { "setting": "outpatient", "gross_charge": 475.0, "discounted_cash": 237.5, "minimum": 200.45, "maximum": 247.0, "additional_generic_notes": "Zero final payments for the item or service in the 15 months prior to posting the file.", "payers_information": [ { "payer_name": "AETNA", "plan_name": "AETNA ALL OTHER PLANS", "methodology": "percent of total billed charges", "standard_charge_dollar": 247.0, "standard_charge_percentage": 52.0, "count": "0", "additional_payer_notes": "Zero final payments for the item or service in the 15 months prior to posting the file." }, { "payer_name": "AETNA", "plan_name": "AETNA ALL OTHER PLANS", "methodology": "percent of total billed charges", "standard_charge_dollar": 247.0, "standard_charge_percentage": 52.0, "count": "0", "additional_payer_notes": "Zero final payments for the item or service in the 15 months prior to posting the file." }, { "payer_name": "MERITAIN HEALTH", "plan_name": "AETNA ALL OTHER PLANS", "methodology": "percent of total billed charges", "standard_charge_dollar": 247.0, "standard_charge_percentage": 52.0, "count": "0", "additional_payer_notes": "Zero final payments for the item or service in the 15 months prior to posting the file." }, { "payer_name": "BLUE SHIELD OUT OF STATE", "plan_name": "STANFORD HEALTHCARE ALLIANCE PLAN", "methodology": "percent of total billed charges", "standard_charge_dollar": 230.8, "standard_charge_percentage": 48.59, "count": "0", "additional_payer_notes": "Zero final payments for the item or service in the 15 months prior to posting the file." }, { "payer_name": "BLUE SHIELD", "plan_name": "STANFORD HEALTHCARE ALLIANCE PLAN", "methodology": "percent of total billed charges", "standard_charge_dollar": 230.8, "standard_charge_percentage": 48.59, "count": "0", "additional_payer_notes": "Zero final payments for the item or service in the 15 months prior to posting the file." }, { "payer_name": "BLUE SHIELD", "plan_name": "STANFORD HEALTHCARE ALLIANCE PLAN", "methodology": "percent of total billed charges", "standard_charge_dollar": 230.8, "standard_charge_percentage": 48.59, "count": "0", "additional_payer_notes": "Zero final payments for the item or service in the 15 months prior to posting the file." }, { "payer_name": "CIGNA", "plan_name": "CIGNA COM ALT HMO PLAN", "methodology": "percent of total billed charges", "standard_charge_dollar": 200.45, "standard_charge_percentage": 42.2, "count": "0", "additional_payer_notes": "Zero final payments for the item or service in the 15 months prior to posting the file." }, { "payer_name": "CIGNA", "plan_name": "CIGNA COM ALT HMO PLAN", "methodology": "percent of total billed charges", "standard_charge_dollar": 200.45, "standard_charge_percentage": 42.2, "count": "0", "additional_payer_notes": "Zero final payments for the item or service in the 15 months prior to posting the file." }, { "payer_name": "HEALTH NET", "plan_name": "HEALTHNET HMO, PPO, POS, EPO, CANOPY HEALTHNET HMO, OTHER-IN-NETWORK PLANS", "methodology": "per diem", "standard_charge_dollar": 8000.0, "standard_charge_algorithm": "Expected reimbursement is the lesser of Per diem ($8,000) for the length of stay and 70% of billed.", "count": "0", "additional_payer_notes": "Zero final payments for the item or service in the 15 months prior to posting the file." }, { "payer_name": "HEALTH NET", "plan_name": "HEALTHNET HMO, PPO, POS, EPO, CANOPY HEALTHNET HMO, OTHER-IN-NETWORK PLANS", "methodology": "per diem", "standard_charge_dollar": 8000.0, "standard_charge_algorithm": "Expected reimbursement is the lesser of Per diem ($8,000) for the length of stay and 70% of billed.", "count": "0", "additional_payer_notes": "Zero final payments for the item or service in the 15 months prior to posting the file." }, { "payer_name": "UNITED HEALTHCARE", "plan_name": "SUTTER SELECT & SUTTER HEALTH PLAN HMO PLANS", "methodology": "per diem", "standard_charge_dollar": 28538.0, "standard_charge_algorithm": "Per diem ($28,538).", "count": "0", "additional_payer_notes": "Zero final payments for the item or service in the 15 months prior to posting the file." }, { "payer_name": "UNITED HEALTHCARE", "plan_name": "SUTTER SELECT & SUTTER HEALTH PLAN HMO PLANS", "methodology": "per diem", "standard_charge_dollar": 28538.0, "standard_charge_algorithm": "Per diem ($28,538).", "count": "0", "additional_payer_notes": "Zero final payments for the item or service in the 15 months prior to posting the file." }, { "payer_name": "SUTTER", "plan_name": "SUTTER SELECT & SUTTER HEALTH PLAN HMO PLANS", "methodology": "per diem", "standard_charge_dollar": 28538.0, "standard_charge_algorithm": "Per diem ($28,538).", "count": "0", "additional_payer_notes": "Zero final payments for the item or service in the 15 months prior to posting the file." }, { "payer_name": "UNITED HEALTHCARE", "plan_name": "SUTTER SELECT & SUTTER HEALTH PLAN HMO PLANS", "methodology": "per diem", "standard_charge_dollar": 28538.0, "standard_charge_algorithm": "Per diem ($28,538).", "count": "0", "additional_payer_notes": "Zero final payments for the item or service in the 15 months prior to posting the file." }, { "payer_name": "UMR", "plan_name": "SUTTER SELECT & SUTTER HEALTH PLAN HMO PLANS", "methodology": "per diem", "standard_charge_dollar": 28538.0, "standard_charge_algorithm": "Per diem ($28,538).", "count": "0", "additional_payer_notes": "Zero final payments for the item or service in the 15 months prior to posting the file." } ] } ] }, { "description": "HC Blade Saw Gp009", "code_information": [ { "code": "PX-2120012009", "type": "CDM" }, { "code": "99999", "type": "CPT" }, { "code": "0272", "type": "RC" } ], "standard_charges": [ { "setting": "outpatient", "gross_charge": 570.0, "discounted_cash": 285.0, "minimum": 240.54, "maximum": 296.4, "additional_generic_notes": "Zero final payments for the item or service in the 15 months prior to posting the file.", "payers_information": [ { "payer_name": "AETNA", "plan_name": "AETNA ALL OTHER PLANS", "methodology": "percent of total billed charges", "standard_charge_dollar": 296.4, "standard_charge_percentage": 52.0, "count": "0", "additional_payer_notes": "Zero final payments for the item or service in the 15 months prior to posting the file." }, { "payer_name": "AETNA", "plan_name": "AETNA ALL OTHER PLANS", "methodology": "percent of total billed charges", "standard_charge_dollar": 296.4, "standard_charge_percentage": 52.0, "count": "0", "additional_payer_notes": "Zero final payments for the item or service in the 15 months prior to posting the file." }, { "payer_name": "MERITAIN HEALTH", "plan_name": "AETNA ALL OTHER PLANS", "methodology": "percent of total billed charges", "standard_charge_dollar": 296.4, "standard_charge_percentage": 52.0, "count": "0", "additional_payer_notes": "Zero final payments for the item or service in the 15 months prior to posting the file." }, { "payer_name": "BLUE SHIELD OUT OF STATE", "plan_name": "STANFORD HEALTHCARE ALLIANCE PLAN", "methodology": "percent of total billed charges", "standard_charge_dollar": 276.96, "standard_charge_percentage": 48.59, "count": "0", "additional_payer_notes": "Zero final payments for the item or service in the 15 months prior to posting the file." }, { "payer_name": "BLUE SHIELD", "plan_name": "STANFORD HEALTHCARE ALLIANCE PLAN", "methodology": "percent of total billed charges", "standard_charge_dollar": 276.96, "standard_charge_percentage": 48.59, "count": "0", "additional_payer_notes": "Zero final payments for the item or service in the 15 months prior to posting the file." }, { "payer_name": "BLUE SHIELD", "plan_name": "STANFORD HEALTHCARE ALLIANCE PLAN", "methodology": "percent of total billed charges", "standard_charge_dollar": 276.96, "standard_charge_percentage": 48.59, "count": "0", "additional_payer_notes": "Zero final payments for the item or service in the 15 months prior to posting the file." }, { "payer_name": "CIGNA", "plan_name": "CIGNA COM ALT HMO PLAN", "methodology": "percent of total billed charges", "standard_charge_dollar": 240.54, "standard_charge_percentage": 42.2, "count": "0", "additional_payer_notes": "Zero final payments for the item or service in the 15 months prior to posting the file." }, { "payer_name": "CIGNA", "plan_name": "CIGNA COM ALT HMO PLAN", "methodology": "percent of total billed charges", "standard_charge_dollar": 240.54, "standard_charge_percentage": 42.2, "count": "0", "additional_payer_notes": "Zero final payments for the item or service in the 15 months prior to posting the file." }, { "payer_name": "HEALTH NET", "plan_name": "HEALTHNET HMO, PPO, POS, EPO, CANOPY HEALTHNET HMO, OTHER-IN-NETWORK PLANS", "methodology": "per diem", "standard_charge_dollar": 8000.0, "standard_charge_algorithm": "Expected reimbursement is the lesser of Per diem ($8,000) for the length of stay and 70% of billed.", "count": "0", "additional_payer_notes": "Zero final payments for the item or service in the 15 months prior to posting the file." }, { "payer_name": "HEALTH NET", "plan_name": "HEALTHNET HMO, PPO, POS, EPO, CANOPY HEALTHNET HMO, OTHER-IN-NETWORK PLANS", "methodology": "per diem", "standard_charge_dollar": 8000.0, "standard_charge_algorithm": "Expected reimbursement is the lesser of Per diem ($8,000) for the length of stay and 70% of billed.", "count": "0", "additional_payer_notes": "Zero final payments for the item or service in the 15 months prior to posting the file." }, { "payer_name": "UNITED HEALTHCARE", "plan_name": "SUTTER SELECT & SUTTER HEALTH PLAN HMO PLANS", "methodology": "per diem", "standard_charge_dollar": 28538.0, "standard_charge_algorithm": "Per diem ($28,538).", "count": "0", "additional_payer_notes": "Zero final payments for the item or service in the 15 months prior to posting the file." }, { "payer_name": "UNITED HEALTHCARE", "plan_name": "SUTTER SELECT & SUTTER HEALTH PLAN HMO PLANS", "methodology": "per diem", "standard_charge_dollar": 28538.0, "standard_charge_algorithm": "Per diem ($28,538).", "count": "0", "additional_payer_notes": "Zero final payments for the item or service in the 15 months prior to posting the file." }, { "payer_name": "SUTTER", "plan_name": "SUTTER SELECT & SUTTER HEALTH PLAN HMO PLANS", "methodology": "per diem", "standard_charge_dollar": 28538.0, "standard_charge_algorithm": "Per diem ($28,538).", "count": "0", "additional_payer_notes": "Zero final payments for the item or service in the 15 months prior to posting the file." }, { "payer_name": "UNITED HEALTHCARE", "plan_name": "SUTTER SELECT & SUTTER HEALTH PLAN HMO PLANS", "methodology": "per diem", "standard_charge_dollar": 28538.0, "standard_charge_algorithm": "Per diem ($28,538).", "count": "0", "additional_payer_notes": "Zero final payments for the item or service in the 15 months prior to posting the file." }, { "payer_name": "UMR", "plan_name": "SUTTER SELECT & SUTTER HEALTH PLAN HMO PLANS", "methodology": "per diem", "standard_charge_dollar": 28538.0, "standard_charge_algorithm": "Per diem ($28,538).", "count": "0", "additional_payer_notes": "Zero final payments for the item or service in the 15 months prior to posting the file." } ] } ] }, { "description": "HC Blade Saw Gp010", "code_information": [ { "code": "PX-2120012010", "type": "CDM" }, { "code": "99999", "type": "CPT" }, { "code": "0272", "type": "RC" } ], "standard_charges": [ { "setting": "outpatient", "gross_charge": 665.0, "discounted_cash": 332.5, "minimum": 280.63, "maximum": 345.8, "additional_generic_notes": "Zero final payments for the item or service in the 15 months prior to posting the file.", "payers_information": [ { "payer_name": "AETNA", "plan_name": "AETNA ALL OTHER PLANS", "methodology": "percent of total billed charges", "standard_charge_dollar": 345.8, "standard_charge_percentage": 52.0, "count": "0", "additional_payer_notes": "Zero final payments for the item or service in the 15 months prior to posting the file." }, { "payer_name": "AETNA", "plan_name": "AETNA ALL OTHER PLANS", "methodology": "percent of total billed charges", "standard_charge_dollar": 345.8, "standard_charge_percentage": 52.0, "count": "0", "additional_payer_notes": "Zero final payments for the item or service in the 15 months prior to posting the file." }, { "payer_name": "MERITAIN HEALTH", "plan_name": "AETNA ALL OTHER PLANS", "methodology": "percent of total billed charges", "standard_charge_dollar": 345.8, "standard_charge_percentage": 52.0, "count": "0", "additional_payer_notes": "Zero final payments for the item or service in the 15 months prior to posting the file." }, { "payer_name": "BLUE SHIELD OUT OF STATE", "plan_name": "STANFORD HEALTHCARE ALLIANCE PLAN", "methodology": "percent of total billed charges", "standard_charge_dollar": 323.12, "standard_charge_percentage": 48.59, "count": "0", "additional_payer_notes": "Zero final payments for the item or service in the 15 months prior to posting the file." }, { "payer_name": "BLUE SHIELD", "plan_name": "STANFORD HEALTHCARE ALLIANCE PLAN", "methodology": "percent of total billed charges", "standard_charge_dollar": 323.12, "standard_charge_percentage": 48.59, "count": "0", "additional_payer_notes": "Zero final payments for the item or service in the 15 months prior to posting the file." }, { "payer_name": "BLUE SHIELD", "plan_name": "STANFORD HEALTHCARE ALLIANCE PLAN", "methodology": "percent of total billed charges", "standard_charge_dollar": 323.12, "standard_charge_percentage": 48.59, "count": "0", "additional_payer_notes": "Zero final payments for the item or service in the 15 months prior to posting the file." }, { "payer_name": "CIGNA", "plan_name": "CIGNA COM ALT HMO PLAN", "methodology": "percent of total billed charges", "standard_charge_dollar": 280.63, "standard_charge_percentage": 42.2, "count": "0", "additional_payer_notes": "Zero final payments for the item or service in the 15 months prior to posting the file." }, { "payer_name": "CIGNA", "plan_name": "CIGNA COM ALT HMO PLAN", "methodology": "percent of total billed charges", "standard_charge_dollar": 280.63, "standard_charge_percentage": 42.2, "count": "0", "additional_payer_notes": "Zero final payments for the item or service in the 15 months prior to posting the file." }, { "payer_name": "HEALTH NET", "plan_name": "HEALTHNET HMO, PPO, POS, EPO, CANOPY HEALTHNET HMO, OTHER-IN-NETWORK PLANS", "methodology": "per diem", "standard_charge_dollar": 8000.0, "standard_charge_algorithm": "Expected reimbursement is the lesser of Per diem ($8,000) for the length of stay and 70% of billed.", "count": "0", "additional_payer_notes": "Zero final payments for the item or service in the 15 months prior to posting the file." }, { "payer_name": "HEALTH NET", "plan_name": "HEALTHNET HMO, PPO, POS, EPO, CANOPY HEALTHNET HMO, OTHER-IN-NETWORK PLANS", "methodology": "per diem", "standard_charge_dollar": 8000.0, "standard_charge_algorithm": "Expected reimbursement is the lesser of Per diem ($8,000) for the length of stay and 70% of billed.", "count": "0", "additional_payer_notes": "Zero final payments for the item or service in the 15 months prior to posting the file." }, { "payer_name": "UNITED HEALTHCARE", "plan_name": "SUTTER SELECT & SUTTER HEALTH PLAN HMO PLANS", "methodology": "per diem", "standard_charge_dollar": 28538.0, "standard_charge_algorithm": "Per diem ($28,538).", "count": "0", "additional_payer_notes": "Zero final payments for the item or service in the 15 months prior to posting the file." }, { "payer_name": "UNITED HEALTHCARE", "plan_name": "SUTTER SELECT & SUTTER HEALTH PLAN HMO PLANS", "methodology": "per diem", "standard_charge_dollar": 28538.0, "standard_charge_algorithm": "Per diem ($28,538).", "count": "0", "additional_payer_notes": "Zero final payments for the item or service in the 15 months prior to posting the file." }, { "payer_name": "SUTTER", "plan_name": "SUTTER SELECT & SUTTER HEALTH PLAN HMO PLANS", "methodology": "per diem", "standard_charge_dollar": 28538.0, "standard_charge_algorithm": "Per diem ($28,538).", "count": "0", "additional_payer_notes": "Zero final payments for the item or service in the 15 months prior to posting the file." }, { "payer_name": "UNITED HEALTHCARE", "plan_name": "SUTTER SELECT & SUTTER HEALTH PLAN HMO PLANS", "methodology": "per diem", "standard_charge_dollar": 28538.0, "standard_charge_algorithm": "Per diem ($28,538).", "count": "0", "additional_payer_notes": "Zero final payments for the item or service in the 15 months prior to posting the file." }, { "payer_name": "UMR", "plan_name": "SUTTER SELECT & SUTTER HEALTH PLAN HMO PLANS", "methodology": "per diem", "standard_charge_dollar": 28538.0, "standard_charge_algorithm": "Per diem ($28,538).", "count": "0", "additional_payer_notes": "Zero final payments for the item or service in the 15 months prior to posting the file." } ] } ] }, { "description": "HC Blade Saw Gp011", "code_information": [ { "code": "PX-2120012011", "type": "CDM" }, { "code": "99999", "type": "CPT" }, { "code": "0272", "type": "RC" } ], "standard_charges": [ { "setting": "outpatient", "gross_charge": 740.0, "discounted_cash": 370.0, "minimum": 312.28, "maximum": 384.8, "additional_generic_notes": "Zero final payments for the item or service in the 15 months prior to posting the file.", "payers_information": [ { "payer_name": "AETNA", "plan_name": "AETNA ALL OTHER PLANS", "methodology": "percent of total billed charges", "standard_charge_dollar": 384.8, "standard_charge_percentage": 52.0, "count": "0", "additional_payer_notes": "Zero final payments for the item or service in the 15 months prior to posting the file." }, { "payer_name": "AETNA", "plan_name": "AETNA ALL OTHER PLANS", "methodology": "percent of total billed charges", "standard_charge_dollar": 384.8, "standard_charge_percentage": 52.0, "count": "0", "additional_payer_notes": "Zero final payments for the item or service in the 15 months prior to posting the file." }, { "payer_name": "MERITAIN HEALTH", "plan_name": "AETNA ALL OTHER PLANS", "methodology": "percent of total billed charges", "standard_charge_dollar": 384.8, "standard_charge_percentage": 52.0, "count": "0", "additional_payer_notes": "Zero final payments for the item or service in the 15 months prior to posting the file." }, { "payer_name": "BLUE SHIELD OUT OF STATE", "plan_name": "STANFORD HEALTHCARE ALLIANCE PLAN", "methodology": "percent of total billed charges", "standard_charge_dollar": 359.57, "standard_charge_percentage": 48.59, "count": "0", "additional_payer_notes": "Zero final payments for the item or service in the 15 months prior to posting the file." }, { "payer_name": "BLUE SHIELD", "plan_name": "STANFORD HEALTHCARE ALLIANCE PLAN", "methodology": "percent of total billed charges", "standard_charge_dollar": 359.57, "standard_charge_percentage": 48.59, "count": "0", "additional_payer_notes": "Zero final payments for the item or service in the 15 months prior to posting the file." }, { "payer_name": "BLUE SHIELD", "plan_name": "STANFORD HEALTHCARE ALLIANCE PLAN", "methodology": "percent of total billed charges", "standard_charge_dollar": 359.57, "standard_charge_percentage": 48.59, "count": "0", "additional_payer_notes": "Zero final payments for the item or service in the 15 months prior to posting the file." }, { "payer_name": "CIGNA", "plan_name": "CIGNA COM ALT HMO PLAN", "methodology": "percent of total billed charges", "standard_charge_dollar": 312.28, "standard_charge_percentage": 42.2, "count": "0", "additional_payer_notes": "Zero final payments for the item or service in the 15 months prior to posting the file." }, { "payer_name": "CIGNA", "plan_name": "CIGNA COM ALT HMO PLAN", "methodology": "percent of total billed charges", "standard_charge_dollar": 312.28, "standard_charge_percentage": 42.2, "count": "0", "additional_payer_notes": "Zero final payments for the item or service in the 15 months prior to posting the file." }, { "payer_name": "HEALTH NET", "plan_name": "HEALTHNET HMO, PPO, POS, EPO, CANOPY HEALTHNET HMO, OTHER-IN-NETWORK PLANS", "methodology": "per diem", "standard_charge_dollar": 8000.0, "standard_charge_algorithm": "Expected reimbursement is the lesser of Per diem ($8,000) for the length of stay and 70% of billed.", "count": "0", "additional_payer_notes": "Zero final payments for the item or service in the 15 months prior to posting the file." }, { "payer_name": "HEALTH NET", "plan_name": "HEALTHNET HMO, PPO, POS, EPO, CANOPY HEALTHNET HMO, OTHER-IN-NETWORK PLANS", "methodology": "per diem", "standard_charge_dollar": 8000.0, "standard_charge_algorithm": "Expected reimbursement is the lesser of Per diem ($8,000) for the length of stay and 70% of billed.", "count": "0", "additional_payer_notes": "Zero final payments for the item or service in the 15 months prior to posting the file." }, { "payer_name": "UNITED HEALTHCARE", "plan_name": "SUTTER SELECT & SUTTER HEALTH PLAN HMO PLANS", "methodology": "per diem", "standard_charge_dollar": 28538.0, "standard_charge_algorithm": "Per diem ($28,538).", "count": "0", "additional_payer_notes": "Zero final payments for the item or service in the 15 months prior to posting the file." }, { "payer_name": "UNITED HEALTHCARE", "plan_name": "SUTTER SELECT & SUTTER HEALTH PLAN HMO PLANS", "methodology": "per diem", "standard_charge_dollar": 28538.0, "standard_charge_algorithm": "Per diem ($28,538).", "count": "0", "additional_payer_notes": "Zero final payments for the item or service in the 15 months prior to posting the file." }, { "payer_name": "SUTTER", "plan_name": "SUTTER SELECT & SUTTER HEALTH PLAN HMO PLANS", "methodology": "per diem", "standard_charge_dollar": 28538.0, "standard_charge_algorithm": "Per diem ($28,538).", "count": "0", "additional_payer_notes": "Zero final payments for the item or service in the 15 months prior to posting the file." }, { "payer_name": "UNITED HEALTHCARE", "plan_name": "SUTTER SELECT & SUTTER HEALTH PLAN HMO PLANS", "methodology": "per diem", "standard_charge_dollar": 28538.0, "standard_charge_algorithm": "Per diem ($28,538).", "count": "0", "additional_payer_notes": "Zero final payments for the item or service in the 15 months prior to posting the file." }, { "payer_name": "UMR", "plan_name": "SUTTER SELECT & SUTTER HEALTH PLAN HMO PLANS", "methodology": "per diem", "standard_charge_dollar": 28538.0, "standard_charge_algorithm": "Per diem ($28,538).", "count": "0", "additional_payer_notes": "Zero final payments for the item or service in the 15 months prior to posting the file." } ] } ] }, { "description": "HC Blade Saw Gp012", "code_information": [ { "code": "PX-2120012012", "type": "CDM" }, { "code": "99999", "type": "CPT" }, { "code": "0272", "type": "RC" } ], "standard_charges": [ { "setting": "outpatient", "gross_charge": 810.0, "discounted_cash": 405.0, "minimum": 341.82, "maximum": 421.2, "additional_generic_notes": "Zero final payments for the item or service in the 15 months prior to posting the file.", "payers_information": [ { "payer_name": "AETNA", "plan_name": "AETNA ALL OTHER PLANS", "methodology": "percent of total billed charges", "standard_charge_dollar": 421.2, "standard_charge_percentage": 52.0, "count": "0", "additional_payer_notes": "Zero final payments for the item or service in the 15 months prior to posting the file." }, { "payer_name": "AETNA", "plan_name": "AETNA ALL OTHER PLANS", "methodology": "percent of total billed charges", "standard_charge_dollar": 421.2, "standard_charge_percentage": 52.0, "count": "0", "additional_payer_notes": "Zero final payments for the item or service in the 15 months prior to posting the file." }, { "payer_name": "MERITAIN HEALTH", "plan_name": "AETNA ALL OTHER PLANS", "methodology": "percent of total billed charges", "standard_charge_dollar": 421.2, "standard_charge_percentage": 52.0, "count": "0", "additional_payer_notes": "Zero final payments for the item or service in the 15 months prior to posting the file." }, { "payer_name": "BLUE SHIELD OUT OF STATE", "plan_name": "STANFORD HEALTHCARE ALLIANCE PLAN", "methodology": "percent of total billed charges", "standard_charge_dollar": 393.58, "standard_charge_percentage": 48.59, "count": "0", "additional_payer_notes": "Zero final payments for the item or service in the 15 months prior to posting the file." }, { "payer_name": "BLUE SHIELD", "plan_name": "STANFORD HEALTHCARE ALLIANCE PLAN", "methodology": "percent of total billed charges", "standard_charge_dollar": 393.58, "standard_charge_percentage": 48.59, "count": "0", "additional_payer_notes": "Zero final payments for the item or service in the 15 months prior to posting the file." }, { "payer_name": "BLUE SHIELD", "plan_name": "STANFORD HEALTHCARE ALLIANCE PLAN", "methodology": "percent of total billed charges", "standard_charge_dollar": 393.58, "standard_charge_percentage": 48.59, "count": "0", "additional_payer_notes": "Zero final payments for the item or service in the 15 months prior to posting the file." }, { "payer_name": "CIGNA", "plan_name": "CIGNA COM ALT HMO PLAN", "methodology": "percent of total billed charges", "standard_charge_dollar": 341.82, "standard_charge_percentage": 42.2, "count": "0", "additional_payer_notes": "Zero final payments for the item or service in the 15 months prior to posting the file." }, { "payer_name": "CIGNA", "plan_name": "CIGNA COM ALT HMO PLAN", "methodology": "percent of total billed charges", "standard_charge_dollar": 341.82, "standard_charge_percentage": 42.2, "count": "0", "additional_payer_notes": "Zero final payments for the item or service in the 15 months prior to posting the file." }, { "payer_name": "HEALTH NET", "plan_name": "HEALTHNET HMO, PPO, POS, EPO, CANOPY HEALTHNET HMO, OTHER-IN-NETWORK PLANS", "methodology": "per diem", "standard_charge_dollar": 8000.0, "standard_charge_algorithm": "Expected reimbursement is the lesser of Per diem ($8,000) for the length of stay and 70% of billed.", "count": "0", "additional_payer_notes": "Zero final payments for the item or service in the 15 months prior to posting the file." }, { "payer_name": "HEALTH NET", "plan_name": "HEALTHNET HMO, PPO, POS, EPO, CANOPY HEALTHNET HMO, OTHER-IN-NETWORK PLANS", "methodology": "per diem", "standard_charge_dollar": 8000.0, "standard_charge_algorithm": "Expected reimbursement is the lesser of Per diem ($8,000) for the length of stay and 70% of billed.", "count": "0", "additional_payer_notes": "Zero final payments for the item or service in the 15 months prior to posting the file." }, { "payer_name": "UNITED HEALTHCARE", "plan_name": "SUTTER SELECT & SUTTER HEALTH PLAN HMO PLANS", "methodology": "per diem", "standard_charge_dollar": 28538.0, "standard_charge_algorithm": "Per diem ($28,538).", "count": "0", "additional_payer_notes": "Zero final payments for the item or service in the 15 months prior to posting the file." }, { "payer_name": "UNITED HEALTHCARE", "plan_name": "SUTTER SELECT & SUTTER HEALTH PLAN HMO PLANS", "methodology": "per diem", "standard_charge_dollar": 28538.0, "standard_charge_algorithm": "Per diem ($28,538).", "count": "0", "additional_payer_notes": "Zero final payments for the item or service in the 15 months prior to posting the file." }, { "payer_name": "SUTTER", "plan_name": "SUTTER SELECT & SUTTER HEALTH PLAN HMO PLANS", "methodology": "per diem", "standard_charge_dollar": 28538.0, "standard_charge_algorithm": "Per diem ($28,538).", "count": "0", "additional_payer_notes": "Zero final payments for the item or service in the 15 months prior to posting the file." }, { "payer_name": "UNITED HEALTHCARE", "plan_name": "SUTTER SELECT & SUTTER HEALTH PLAN HMO PLANS", "methodology": "per diem", "standard_charge_dollar": 28538.0, "standard_charge_algorithm": "Per diem ($28,538).", "count": "0", "additional_payer_notes": "Zero final payments for the item or service in the 15 months prior to posting the file." }, { "payer_name": "UMR", "plan_name": "SUTTER SELECT & SUTTER HEALTH PLAN HMO PLANS", "methodology": "per diem", "standard_charge_dollar": 28538.0, "standard_charge_algorithm": "Per diem ($28,538).", "count": "0", "additional_payer_notes": "Zero final payments for the item or service in the 15 months prior to posting the file." } ] } ] }, { "description": "HC Blade Saw Gp013", "code_information": [ { "code": "PX-2120012013", "type": "CDM" }, { "code": "99999", "type": "CPT" }, { "code": "0272", "type": "RC" } ], "standard_charges": [ { "setting": "outpatient", "gross_charge": 110.0, "discounted_cash": 55.0, "minimum": 46.42, "maximum": 57.2, "additional_generic_notes": "Zero final payments for the item or service in the 15 months prior to posting the file.", "payers_information": [ { "payer_name": "AETNA", "plan_name": "AETNA ALL OTHER PLANS", "methodology": "percent of total billed charges", "standard_charge_dollar": 57.2, "standard_charge_percentage": 52.0, "count": "0", "additional_payer_notes": "Zero final payments for the item or service in the 15 months prior to posting the file." }, { "payer_name": "AETNA", "plan_name": "AETNA ALL OTHER PLANS", "methodology": "percent of total billed charges", "standard_charge_dollar": 57.2, "standard_charge_percentage": 52.0, "count": "0", "additional_payer_notes": "Zero final payments for the item or service in the 15 months prior to posting the file." }, { "payer_name": "MERITAIN HEALTH", "plan_name": "AETNA ALL OTHER PLANS", "methodology": "percent of total billed charges", "standard_charge_dollar": 57.2, "standard_charge_percentage": 52.0, "count": "0", "additional_payer_notes": "Zero final payments for the item or service in the 15 months prior to posting the file." }, { "payer_name": "BLUE SHIELD OUT OF STATE", "plan_name": "STANFORD HEALTHCARE ALLIANCE PLAN", "methodology": "percent of total billed charges", "standard_charge_dollar": 53.45, "standard_charge_percentage": 48.59, "count": "0", "additional_payer_notes": "Zero final payments for the item or service in the 15 months prior to posting the file." }, { "payer_name": "BLUE SHIELD", "plan_name": "STANFORD HEALTHCARE ALLIANCE PLAN", "methodology": "percent of total billed charges", "standard_charge_dollar": 53.45, "standard_charge_percentage": 48.59, "count": "0", "additional_payer_notes": "Zero final payments for the item or service in the 15 months prior to posting the file." }, { "payer_name": "BLUE SHIELD", "plan_name": "STANFORD HEALTHCARE ALLIANCE PLAN", "methodology": "percent of total billed charges", "standard_charge_dollar": 53.45, "standard_charge_percentage": 48.59, "count": "0", "additional_payer_notes": "Zero final payments for the item or service in the 15 months prior to posting the file." }, { "payer_name": "CIGNA", "plan_name": "CIGNA COM ALT HMO PLAN", "methodology": "percent of total billed charges", "standard_charge_dollar": 46.42, "standard_charge_percentage": 42.2, "count": "0", "additional_payer_notes": "Zero final payments for the item or service in the 15 months prior to posting the file." }, { "payer_name": "CIGNA", "plan_name": "CIGNA COM ALT HMO PLAN", "methodology": "percent of total billed charges", "standard_charge_dollar": 46.42, "standard_charge_percentage": 42.2, "count": "0", "additional_payer_notes": "Zero final payments for the item or service in the 15 months prior to posting the file." }, { "payer_name": "HEALTH NET", "plan_name": "HEALTHNET HMO, PPO, POS, EPO, CANOPY HEALTHNET HMO, OTHER-IN-NETWORK PLANS", "methodology": "per diem", "standard_charge_dollar": 8000.0, "standard_charge_algorithm": "Expected reimbursement is the lesser of Per diem ($8,000) for the length of stay and 70% of billed.", "count": "0", "additional_payer_notes": "Zero final payments for the item or service in the 15 months prior to posting the file." }, { "payer_name": "HEALTH NET", "plan_name": "HEALTHNET HMO, PPO, POS, EPO, CANOPY HEALTHNET HMO, OTHER-IN-NETWORK PLANS", "methodology": "per diem", "standard_charge_dollar": 8000.0, "standard_charge_algorithm": "Expected reimbursement is the lesser of Per diem ($8,000) for the length of stay and 70% of billed.", "count": "0", "additional_payer_notes": "Zero final payments for the item or service in the 15 months prior to posting the file." }, { "payer_name": "UNITED HEALTHCARE", "plan_name": "SUTTER SELECT & SUTTER HEALTH PLAN HMO PLANS", "methodology": "per diem", "standard_charge_dollar": 28538.0, "standard_charge_algorithm": "Per diem ($28,538).", "count": "0", "additional_payer_notes": "Zero final payments for the item or service in the 15 months prior to posting the file." }, { "payer_name": "UNITED HEALTHCARE", "plan_name": "SUTTER SELECT & SUTTER HEALTH PLAN HMO PLANS", "methodology": "per diem", "standard_charge_dollar": 28538.0, "standard_charge_algorithm": "Per diem ($28,538).", "count": "0", "additional_payer_notes": "Zero final payments for the item or service in the 15 months prior to posting the file." }, { "payer_name": "SUTTER", "plan_name": "SUTTER SELECT & SUTTER HEALTH PLAN HMO PLANS", "methodology": "per diem", "standard_charge_dollar": 28538.0, "standard_charge_algorithm": "Per diem ($28,538).", "count": "0", "additional_payer_notes": "Zero final payments for the item or service in the 15 months prior to posting the file." }, { "payer_name": "UNITED HEALTHCARE", "plan_name": "SUTTER SELECT & SUTTER HEALTH PLAN HMO PLANS", "methodology": "per diem", "standard_charge_dollar": 28538.0, "standard_charge_algorithm": "Per diem ($28,538).", "count": "0", "additional_payer_notes": "Zero final payments for the item or service in the 15 months prior to posting the file." }, { "payer_name": "UMR", "plan_name": "SUTTER SELECT & SUTTER HEALTH PLAN HMO PLANS", "methodology": "per diem", "standard_charge_dollar": 28538.0, "standard_charge_algorithm": "Per diem ($28,538).", "count": "0", "additional_payer_notes": "Zero final payments for the item or service in the 15 months prior to posting the file." } ] } ] }, { "description": "HC Blade Saw Gp018", "code_information": [ { "code": "PX-2120012018", "type": "CDM" }, { "code": "99999", "type": "CPT" }, { "code": "0272", "type": "RC" } ], "standard_charges": [ { "setting": "outpatient", "gross_charge": 1750.0, "discounted_cash": 875.0, "minimum": 738.5, "maximum": 910.0, "additional_generic_notes": "Zero final payments for the item or service in the 15 months prior to posting the file.", "payers_information": [ { "payer_name": "AETNA", "plan_name": "AETNA ALL OTHER PLANS", "methodology": "percent of total billed charges", "standard_charge_dollar": 910.0, "standard_charge_percentage": 52.0, "count": "0", "additional_payer_notes": "Zero final payments for the item or service in the 15 months prior to posting the file." }, { "payer_name": "AETNA", "plan_name": "AETNA ALL OTHER PLANS", "methodology": "percent of total billed charges", "standard_charge_dollar": 910.0, "standard_charge_percentage": 52.0, "count": "0", "additional_payer_notes": "Zero final payments for the item or service in the 15 months prior to posting the file." }, { "payer_name": "MERITAIN HEALTH", "plan_name": "AETNA ALL OTHER PLANS", "methodology": "percent of total billed charges", "standard_charge_dollar": 910.0, "standard_charge_percentage": 52.0, "count": "0", "additional_payer_notes": "Zero final payments for the item or service in the 15 months prior to posting the file." }, { "payer_name": "BLUE SHIELD OUT OF STATE", "plan_name": "STANFORD HEALTHCARE ALLIANCE PLAN", "methodology": "percent of total billed charges", "standard_charge_dollar": 850.33, "standard_charge_percentage": 48.59, "count": "0", "additional_payer_notes": "Zero final payments for the item or service in the 15 months prior to posting the file." }, { "payer_name": "BLUE SHIELD", "plan_name": "STANFORD HEALTHCARE ALLIANCE PLAN", "methodology": "percent of total billed charges", "standard_charge_dollar": 850.33, "standard_charge_percentage": 48.59, "median_amount": 68.24, "10th_percentile": 13.6, "90th_percentile": 1043.06, "count": "30" }, { "payer_name": "BLUE SHIELD", "plan_name": "STANFORD HEALTHCARE ALLIANCE PLAN", "methodology": "percent of total billed charges", "standard_charge_dollar": 850.33, "standard_charge_percentage": 48.59, "count": "0", "additional_payer_notes": "Zero final payments for the item or service in the 15 months prior to posting the file." }, { "payer_name": "BLUE SHIELD", "plan_name": "STANFORD HEALTHCARE ALLIANCE PLAN", "methodology": "percent of total billed charges", "standard_charge_dollar": 850.33, "standard_charge_percentage": 48.59, "count": "0", "additional_payer_notes": "Zero final payments for the item or service in the 15 months prior to posting the file." }, { "payer_name": "CIGNA", "plan_name": "CIGNA COM ALT HMO PLAN", "methodology": "percent of total billed charges", "standard_charge_dollar": 738.5, "standard_charge_percentage": 42.2, "count": "0", "additional_payer_notes": "Zero final payments for the item or service in the 15 months prior to posting the file." }, { "payer_name": "CIGNA", "plan_name": "CIGNA COM ALT HMO PLAN", "methodology": "percent of total billed charges", "standard_charge_dollar": 738.5, "standard_charge_percentage": 42.2, "count": "0", "additional_payer_notes": "Zero final payments for the item or service in the 15 months prior to posting the file." }, { "payer_name": "HEALTH NET", "plan_name": "HEALTHNET HMO, PPO, POS, EPO, CANOPY HEALTHNET HMO, OTHER-IN-NETWORK PLANS", "methodology": "per diem", "standard_charge_dollar": 8000.0, "standard_charge_algorithm": "Expected reimbursement is the lesser of Per diem ($8,000) for the length of stay and 70% of billed.", "count": "0", "additional_payer_notes": "Zero final payments for the item or service in the 15 months prior to posting the file." }, { "payer_name": "HEALTH NET", "plan_name": "HEALTHNET HMO, PPO, POS, EPO, CANOPY HEALTHNET HMO, OTHER-IN-NETWORK PLANS", "methodology": "per diem", "standard_charge_dollar": 8000.0, "standard_charge_algorithm": "Expected reimbursement is the lesser of Per diem ($8,000) for the length of stay and 70% of billed.", "count": "0", "additional_payer_notes": "Zero final payments for the item or service in the 15 months prior to posting the file." }, { "payer_name": "UNITED HEALTHCARE", "plan_name": "SUTTER SELECT & SUTTER HEALTH PLAN HMO PLANS", "methodology": "per diem", "standard_charge_dollar": 28538.0, "standard_charge_algorithm": "Per diem ($28,538).", "count": "0", "additional_payer_notes": "Zero final payments for the item or service in the 15 months prior to posting the file." }, { "payer_name": "UNITED HEALTHCARE", "plan_name": "SUTTER SELECT & SUTTER HEALTH PLAN HMO PLANS", "methodology": "per diem", "standard_charge_dollar": 28538.0, "standard_charge_algorithm": "Per diem ($28,538).", "count": "0", "additional_payer_notes": "Zero final payments for the item or service in the 15 months prior to posting the file." }, { "payer_name": "SUTTER", "plan_name": "SUTTER SELECT & SUTTER HEALTH PLAN HMO PLANS", "methodology": "per diem", "standard_charge_dollar": 28538.0, "standard_charge_algorithm": "Per diem ($28,538).", "count": "0", "additional_payer_notes": "Zero final payments for the item or service in the 15 months prior to posting the file." }, { "payer_name": "UNITED HEALTHCARE", "plan_name": "SUTTER SELECT & SUTTER HEALTH PLAN HMO PLANS", "methodology": "per diem", "standard_charge_dollar": 28538.0, "standard_charge_algorithm": "Per diem ($28,538).", "count": "0", "additional_payer_notes": "Zero final payments for the item or service in the 15 months prior to posting the file." }, { "payer_name": "UMR", "plan_name": "SUTTER SELECT & SUTTER HEALTH PLAN HMO PLANS", "methodology": "per diem", "standard_charge_dollar": 28538.0, "standard_charge_algorithm": "Per diem ($28,538).", "count": "0", "additional_payer_notes": "Zero final payments for the item or service in the 15 months prior to posting the file." } ] } ] }, { "description": "Hc Blade Saw Gp019", "code_information": [ { "code": "PX-2120012019", "type": "CDM" }, { "code": "99999", "type": "CPT" }, { "code": "0272", "type": "RC" } ], "standard_charges": [ { "setting": "outpatient", "gross_charge": 2125.0, "discounted_cash": 1062.5, "minimum": 896.75, "maximum": 1105.0, "additional_generic_notes": "Zero final payments for the item or service in the 15 months prior to posting the file.", "payers_information": [ { "payer_name": "AETNA", "plan_name": "AETNA ALL OTHER PLANS", "methodology": "percent of total billed charges", "standard_charge_dollar": 1105.0, "standard_charge_percentage": 52.0, "count": "0", "additional_payer_notes": "Zero final payments for the item or service in the 15 months prior to posting the file." }, { "payer_name": "AETNA", "plan_name": "AETNA ALL OTHER PLANS", "methodology": "percent of total billed charges", "standard_charge_dollar": 1105.0, "standard_charge_percentage": 52.0, "count": "0", "additional_payer_notes": "Zero final payments for the item or service in the 15 months prior to posting the file." }, { "payer_name": "MERITAIN HEALTH", "plan_name": "AETNA ALL OTHER PLANS", "methodology": "percent of total billed charges", "standard_charge_dollar": 1105.0, "standard_charge_percentage": 52.0, "count": "0", "additional_payer_notes": "Zero final payments for the item or service in the 15 months prior to posting the file." }, { "payer_name": "BLUE SHIELD OUT OF STATE", "plan_name": "STANFORD HEALTHCARE ALLIANCE PLAN", "methodology": "percent of total billed charges", "standard_charge_dollar": 1032.54, "standard_charge_percentage": 48.59, "count": "0", "additional_payer_notes": "Zero final payments for the item or service in the 15 months prior to posting the file." }, { "payer_name": "BLUE SHIELD", "plan_name": "STANFORD HEALTHCARE ALLIANCE PLAN", "methodology": "percent of total billed charges", "standard_charge_dollar": 1032.54, "standard_charge_percentage": 48.59, "median_amount": 68.24, "10th_percentile": 13.6, "90th_percentile": 1043.06, "count": "30" }, { "payer_name": "BLUE SHIELD", "plan_name": "STANFORD HEALTHCARE ALLIANCE PLAN", "methodology": "percent of total billed charges", "standard_charge_dollar": 1032.54, "standard_charge_percentage": 48.59, "count": "0", "additional_payer_notes": "Zero final payments for the item or service in the 15 months prior to posting the file." }, { "payer_name": "BLUE SHIELD", "plan_name": "STANFORD HEALTHCARE ALLIANCE PLAN", "methodology": "percent of total billed charges", "standard_charge_dollar": 1032.54, "standard_charge_percentage": 48.59, "count": "0", "additional_payer_notes": "Zero final payments for the item or service in the 15 months prior to posting the file." }, { "payer_name": "CIGNA", "plan_name": "CIGNA COM ALT HMO PLAN", "methodology": "percent of total billed charges", "standard_charge_dollar": 896.75, "standard_charge_percentage": 42.2, "count": "0", "additional_payer_notes": "Zero final payments for the item or service in the 15 months prior to posting the file." }, { "payer_name": "CIGNA", "plan_name": "CIGNA COM ALT HMO PLAN", "methodology": "percent of total billed charges", "standard_charge_dollar": 896.75, "standard_charge_percentage": 42.2, "count": "0", "additional_payer_notes": "Zero final payments for the item or service in the 15 months prior to posting the file." }, { "payer_name": "HEALTH NET", "plan_name": "HEALTHNET HMO, PPO, POS, EPO, CANOPY HEALTHNET HMO, OTHER-IN-NETWORK PLANS", "methodology": "per diem", "standard_charge_dollar": 8000.0, "standard_charge_algorithm": "Expected reimbursement is the lesser of Per diem ($8,000) for the length of stay and 70% of billed.", "count": "0", "additional_payer_notes": "Zero final payments for the item or service in the 15 months prior to posting the file." }, { "payer_name": "HEALTH NET", "plan_name": "HEALTHNET HMO, PPO, POS, EPO, CANOPY HEALTHNET HMO, OTHER-IN-NETWORK PLANS", "methodology": "per diem", "standard_charge_dollar": 8000.0, "standard_charge_algorithm": "Expected reimbursement is the lesser of Per diem ($8,000) for the length of stay and 70% of billed.", "count": "0", "additional_payer_notes": "Zero final payments for the item or service in the 15 months prior to posting the file." }, { "payer_name": "UNITED HEALTHCARE", "plan_name": "SUTTER SELECT & SUTTER HEALTH PLAN HMO PLANS", "methodology": "per diem", "standard_charge_dollar": 28538.0, "standard_charge_algorithm": "Per diem ($28,538).", "count": "0", "additional_payer_notes": "Zero final payments for the item or service in the 15 months prior to posting the file." }, { "payer_name": "UNITED HEALTHCARE", "plan_name": "SUTTER SELECT & SUTTER HEALTH PLAN HMO PLANS", "methodology": "per diem", "standard_charge_dollar": 28538.0, "standard_charge_algorithm": "Per diem ($28,538).", "count": "0", "additional_payer_notes": "Zero final payments for the item or service in the 15 months prior to posting the file." }, { "payer_name": "SUTTER", "plan_name": "SUTTER SELECT & SUTTER HEALTH PLAN HMO PLANS", "methodology": "per diem", "standard_charge_dollar": 28538.0, "standard_charge_algorithm": "Per diem ($28,538).", "count": "0", "additional_payer_notes": "Zero final payments for the item or service in the 15 months prior to posting the file." }, { "payer_name": "UNITED HEALTHCARE", "plan_name": "SUTTER SELECT & SUTTER HEALTH PLAN HMO PLANS", "methodology": "per diem", "standard_charge_dollar": 28538.0, "standard_charge_algorithm": "Per diem ($28,538).", "count": "0", "additional_payer_notes": "Zero final payments for the item or service in the 15 months prior to posting the file." }, { "payer_name": "UMR", "plan_name": "SUTTER SELECT & SUTTER HEALTH PLAN HMO PLANS", "methodology": "per diem", "standard_charge_dollar": 28538.0, "standard_charge_algorithm": "Per diem ($28,538).", "count": "0", "additional_payer_notes": "Zero final payments for the item or service in the 15 months prior to posting the file." } ] } ] }, { "description": "HC Blade Saw Gp020", "code_information": [ { "code": "PX-2120012020", "type": "CDM" }, { "code": "99999", "type": "CPT" }, { "code": "0272", "type": "RC" } ], "standard_charges": [ { "setting": "outpatient", "gross_charge": 2550.0, "discounted_cash": 1275.0, "minimum": 1076.1, "maximum": 1326.0, "additional_generic_notes": "Zero final payments for the item or service in the 15 months prior to posting the file.", "payers_information": [ { "payer_name": "AETNA", "plan_name": "AETNA ALL OTHER PLANS", "methodology": "percent of total billed charges", "standard_charge_dollar": 1326.0, "standard_charge_percentage": 52.0, "count": "0", "additional_payer_notes": "Zero final payments for the item or service in the 15 months prior to posting the file." }, { "payer_name": "AETNA", "plan_name": "AETNA ALL OTHER PLANS", "methodology": "percent of total billed charges", "standard_charge_dollar": 1326.0, "standard_charge_percentage": 52.0, "count": "0", "additional_payer_notes": "Zero final payments for the item or service in the 15 months prior to posting the file." }, { "payer_name": "MERITAIN HEALTH", "plan_name": "AETNA ALL OTHER PLANS", "methodology": "percent of total billed charges", "standard_charge_dollar": 1326.0, "standard_charge_percentage": 52.0, "count": "0", "additional_payer_notes": "Zero final payments for the item or service in the 15 months prior to posting the file." }, { "payer_name": "BLUE SHIELD OUT OF STATE", "plan_name": "STANFORD HEALTHCARE ALLIANCE PLAN", "methodology": "percent of total billed charges", "standard_charge_dollar": 1239.05, "standard_charge_percentage": 48.59, "count": "0", "additional_payer_notes": "Zero final payments for the item or service in the 15 months prior to posting the file." }, { "payer_name": "BLUE SHIELD", "plan_name": "STANFORD HEALTHCARE ALLIANCE PLAN", "methodology": "percent of total billed charges", "standard_charge_dollar": 1239.05, "standard_charge_percentage": 48.59, "median_amount": 68.24, "10th_percentile": 13.6, "90th_percentile": 1043.06, "count": "30" }, { "payer_name": "BLUE SHIELD", "plan_name": "STANFORD HEALTHCARE ALLIANCE PLAN", "methodology": "percent of total billed charges", "standard_charge_dollar": 1239.05, "standard_charge_percentage": 48.59, "count": "0", "additional_payer_notes": "Zero final payments for the item or service in the 15 months prior to posting the file." }, { "payer_name": "BLUE SHIELD", "plan_name": "STANFORD HEALTHCARE ALLIANCE PLAN", "methodology": "percent of total billed charges", "standard_charge_dollar": 1239.05, "standard_charge_percentage": 48.59, "count": "0", "additional_payer_notes": "Zero final payments for the item or service in the 15 months prior to posting the file." }, { "payer_name": "CIGNA", "plan_name": "CIGNA COM ALT HMO PLAN", "methodology": "percent of total billed charges", "standard_charge_dollar": 1076.1, "standard_charge_percentage": 42.2, "count": "0", "additional_payer_notes": "Zero final payments for the item or service in the 15 months prior to posting the file." }, { "payer_name": "CIGNA", "plan_name": "CIGNA COM ALT HMO PLAN", "methodology": "percent of total billed charges", "standard_charge_dollar": 1076.1, "standard_charge_percentage": 42.2, "count": "0", "additional_payer_notes": "Zero final payments for the item or service in the 15 months prior to posting the file." }, { "payer_name": "HEALTH NET", "plan_name": "HEALTHNET HMO, PPO, POS, EPO, CANOPY HEALTHNET HMO, OTHER-IN-NETWORK PLANS", "methodology": "per diem", "standard_charge_dollar": 8000.0, "standard_charge_algorithm": "Expected reimbursement is the lesser of Per diem ($8,000) for the length of stay and 70% of billed.", "count": "0", "additional_payer_notes": "Zero final payments for the item or service in the 15 months prior to posting the file." }, { "payer_name": "HEALTH NET", "plan_name": "HEALTHNET HMO, PPO, POS, EPO, CANOPY HEALTHNET HMO, OTHER-IN-NETWORK PLANS", "methodology": "per diem", "standard_charge_dollar": 8000.0, "standard_charge_algorithm": "Expected reimbursement is the lesser of Per diem ($8,000) for the length of stay and 70% of billed.", "count": "0", "additional_payer_notes": "Zero final payments for the item or service in the 15 months prior to posting the file." }, { "payer_name": "UNITED HEALTHCARE", "plan_name": "SUTTER SELECT & SUTTER HEALTH PLAN HMO PLANS", "methodology": "per diem", "standard_charge_dollar": 28538.0, "standard_charge_algorithm": "Per diem ($28,538).", "count": "0", "additional_payer_notes": "Zero final payments for the item or service in the 15 months prior to posting the file." }, { "payer_name": "UNITED HEALTHCARE", "plan_name": "SUTTER SELECT & SUTTER HEALTH PLAN HMO PLANS", "methodology": "per diem", "standard_charge_dollar": 28538.0, "standard_charge_algorithm": "Per diem ($28,538).", "count": "0", "additional_payer_notes": "Zero final payments for the item or service in the 15 months prior to posting the file." }, { "payer_name": "SUTTER", "plan_name": "SUTTER SELECT & SUTTER HEALTH PLAN HMO PLANS", "methodology": "per diem", "standard_charge_dollar": 28538.0, "standard_charge_algorithm": "Per diem ($28,538).", "count": "0", "additional_payer_notes": "Zero final payments for the item or service in the 15 months prior to posting the file." }, { "payer_name": "UNITED HEALTHCARE", "plan_name": "SUTTER SELECT & SUTTER HEALTH PLAN HMO PLANS", "methodology": "per diem", "standard_charge_dollar": 28538.0, "standard_charge_algorithm": "Per diem ($28,538).", "count": "0", "additional_payer_notes": "Zero final payments for the item or service in the 15 months prior to posting the file." }, { "payer_name": "UMR", "plan_name": "SUTTER SELECT & SUTTER HEALTH PLAN HMO PLANS", "methodology": "per diem", "standard_charge_dollar": 28538.0, "standard_charge_algorithm": "Per diem ($28,538).", "count": "0", "additional_payer_notes": "Zero final payments for the item or service in the 15 months prior to posting the file." } ] } ] }, { "description": "HC Blade Saw Gp021", "code_information": [ { "code": "PX-2120012021", "type": "CDM" }, { "code": "99999", "type": "CPT" }, { "code": "0272", "type": "RC" } ], "standard_charges": [ { "setting": "outpatient", "gross_charge": 2888.0, "discounted_cash": 1444.0, "minimum": 1218.74, "maximum": 1501.76, "additional_generic_notes": "Zero final payments for the item or service in the 15 months prior to posting the file.", "payers_information": [ { "payer_name": "AETNA", "plan_name": "AETNA ALL OTHER PLANS", "methodology": "percent of total billed charges", "standard_charge_dollar": 1501.76, "standard_charge_percentage": 52.0, "count": "0", "additional_payer_notes": "Zero final payments for the item or service in the 15 months prior to posting the file." }, { "payer_name": "AETNA", "plan_name": "AETNA ALL OTHER PLANS", "methodology": "percent of total billed charges", "standard_charge_dollar": 1501.76, "standard_charge_percentage": 52.0, "count": "0", "additional_payer_notes": "Zero final payments for the item or service in the 15 months prior to posting the file." }, { "payer_name": "MERITAIN HEALTH", "plan_name": "AETNA ALL OTHER PLANS", "methodology": "percent of total billed charges", "standard_charge_dollar": 1501.76, "standard_charge_percentage": 52.0, "count": "0", "additional_payer_notes": "Zero final payments for the item or service in the 15 months prior to posting the file." }, { "payer_name": "BLUE SHIELD OUT OF STATE", "plan_name": "STANFORD HEALTHCARE ALLIANCE PLAN", "methodology": "percent of total billed charges", "standard_charge_dollar": 1403.28, "standard_charge_percentage": 48.59, "count": "0", "additional_payer_notes": "Zero final payments for the item or service in the 15 months prior to posting the file." }, { "payer_name": "BLUE SHIELD", "plan_name": "STANFORD HEALTHCARE ALLIANCE PLAN", "methodology": "percent of total billed charges", "standard_charge_dollar": 1403.28, "standard_charge_percentage": 48.59, "median_amount": 68.24, "10th_percentile": 13.6, "90th_percentile": 1043.06, "count": "30" }, { "payer_name": "BLUE SHIELD", "plan_name": "STANFORD HEALTHCARE ALLIANCE PLAN", "methodology": "percent of total billed charges", "standard_charge_dollar": 1403.28, "standard_charge_percentage": 48.59, "count": "0", "additional_payer_notes": "Zero final payments for the item or service in the 15 months prior to posting the file." }, { "payer_name": "BLUE SHIELD", "plan_name": "STANFORD HEALTHCARE ALLIANCE PLAN", "methodology": "percent of total billed charges", "standard_charge_dollar": 1403.28, "standard_charge_percentage": 48.59, "count": "0", "additional_payer_notes": "Zero final payments for the item or service in the 15 months prior to posting the file." }, { "payer_name": "CIGNA", "plan_name": "CIGNA COM ALT HMO PLAN", "methodology": "percent of total billed charges", "standard_charge_dollar": 1218.74, "standard_charge_percentage": 42.2, "count": "0", "additional_payer_notes": "Zero final payments for the item or service in the 15 months prior to posting the file." }, { "payer_name": "CIGNA", "plan_name": "CIGNA COM ALT HMO PLAN", "methodology": "percent of total billed charges", "standard_charge_dollar": 1218.74, "standard_charge_percentage": 42.2, "count": "0", "additional_payer_notes": "Zero final payments for the item or service in the 15 months prior to posting the file." }, { "payer_name": "HEALTH NET", "plan_name": "HEALTHNET HMO, PPO, POS, EPO, CANOPY HEALTHNET HMO, OTHER-IN-NETWORK PLANS", "methodology": "per diem", "standard_charge_dollar": 8000.0, "standard_charge_algorithm": "Expected reimbursement is the lesser of Per diem ($8,000) for the length of stay and 70% of billed.", "count": "0", "additional_payer_notes": "Zero final payments for the item or service in the 15 months prior to posting the file." }, { "payer_name": "HEALTH NET", "plan_name": "HEALTHNET HMO, PPO, POS, EPO, CANOPY HEALTHNET HMO, OTHER-IN-NETWORK PLANS", "methodology": "per diem", "standard_charge_dollar": 8000.0, "standard_charge_algorithm": "Expected reimbursement is the lesser of Per diem ($8,000) for the length of stay and 70% of billed.", "count": "0", "additional_payer_notes": "Zero final payments for the item or service in the 15 months prior to posting the file." }, { "payer_name": "UNITED HEALTHCARE", "plan_name": "SUTTER SELECT & SUTTER HEALTH PLAN HMO PLANS", "methodology": "per diem", "standard_charge_dollar": 28538.0, "standard_charge_algorithm": "Per diem ($28,538).", "count": "0", "additional_payer_notes": "Zero final payments for the item or service in the 15 months prior to posting the file." }, { "payer_name": "UNITED HEALTHCARE", "plan_name": "SUTTER SELECT & SUTTER HEALTH PLAN HMO PLANS", "methodology": "per diem", "standard_charge_dollar": 28538.0, "standard_charge_algorithm": "Per diem ($28,538).", "count": "0", "additional_payer_notes": "Zero final payments for the item or service in the 15 months prior to posting the file." }, { "payer_name": "SUTTER", "plan_name": "SUTTER SELECT & SUTTER HEALTH PLAN HMO PLANS", "methodology": "per diem", "standard_charge_dollar": 28538.0, "standard_charge_algorithm": "Per diem ($28,538).", "count": "0", "additional_payer_notes": "Zero final payments for the item or service in the 15 months prior to posting the file." }, { "payer_name": "UNITED HEALTHCARE", "plan_name": "SUTTER SELECT & SUTTER HEALTH PLAN HMO PLANS", "methodology": "per diem", "standard_charge_dollar": 28538.0, "standard_charge_algorithm": "Per diem ($28,538).", "count": "0", "additional_payer_notes": "Zero final payments for the item or service in the 15 months prior to posting the file." }, { "payer_name": "UMR", "plan_name": "SUTTER SELECT & SUTTER HEALTH PLAN HMO PLANS", "methodology": "per diem", "standard_charge_dollar": 28538.0, "standard_charge_algorithm": "Per diem ($28,538).", "count": "0", "additional_payer_notes": "Zero final payments for the item or service in the 15 months prior to posting the file." } ] } ] }, { "description": "HC Blade Saw Gp022", "code_information": [ { "code": "PX-2120012022", "type": "CDM" }, { "code": "99999", "type": "CPT" }, { "code": "0272", "type": "RC" } ], "standard_charges": [ { "setting": "outpatient", "gross_charge": 3300.0, "discounted_cash": 1650.0, "minimum": 1392.6, "maximum": 1716.0, "additional_generic_notes": "Zero final payments for the item or service in the 15 months prior to posting the file.", "payers_information": [ { "payer_name": "AETNA", "plan_name": "AETNA ALL OTHER PLANS", "methodology": "percent of total billed charges", "standard_charge_dollar": 1716.0, "standard_charge_percentage": 52.0, "count": "0", "additional_payer_notes": "Zero final payments for the item or service in the 15 months prior to posting the file." }, { "payer_name": "AETNA", "plan_name": "AETNA ALL OTHER PLANS", "methodology": "percent of total billed charges", "standard_charge_dollar": 1716.0, "standard_charge_percentage": 52.0, "count": "0", "additional_payer_notes": "Zero final payments for the item or service in the 15 months prior to posting the file." }, { "payer_name": "MERITAIN HEALTH", "plan_name": "AETNA ALL OTHER PLANS", "methodology": "percent of total billed charges", "standard_charge_dollar": 1716.0, "standard_charge_percentage": 52.0, "count": "0", "additional_payer_notes": "Zero final payments for the item or service in the 15 months prior to posting the file." }, { "payer_name": "BLUE SHIELD OUT OF STATE", "plan_name": "STANFORD HEALTHCARE ALLIANCE PLAN", "methodology": "percent of total billed charges", "standard_charge_dollar": 1603.47, "standard_charge_percentage": 48.59, "count": "0", "additional_payer_notes": "Zero final payments for the item or service in the 15 months prior to posting the file." }, { "payer_name": "BLUE SHIELD", "plan_name": "STANFORD HEALTHCARE ALLIANCE PLAN", "methodology": "percent of total billed charges", "standard_charge_dollar": 1603.47, "standard_charge_percentage": 48.59, "median_amount": 68.24, "10th_percentile": 13.6, "90th_percentile": 1043.06, "count": "30" }, { "payer_name": "BLUE SHIELD", "plan_name": "STANFORD HEALTHCARE ALLIANCE PLAN", "methodology": "percent of total billed charges", "standard_charge_dollar": 1603.47, "standard_charge_percentage": 48.59, "count": "0", "additional_payer_notes": "Zero final payments for the item or service in the 15 months prior to posting the file." }, { "payer_name": "BLUE SHIELD", "plan_name": "STANFORD HEALTHCARE ALLIANCE PLAN", "methodology": "percent of total billed charges", "standard_charge_dollar": 1603.47, "standard_charge_percentage": 48.59, "count": "0", "additional_payer_notes": "Zero final payments for the item or service in the 15 months prior to posting the file." }, { "payer_name": "CIGNA", "plan_name": "CIGNA COM ALT HMO PLAN", "methodology": "percent of total billed charges", "standard_charge_dollar": 1392.6, "standard_charge_percentage": 42.2, "count": "0", "additional_payer_notes": "Zero final payments for the item or service in the 15 months prior to posting the file." }, { "payer_name": "CIGNA", "plan_name": "CIGNA COM ALT HMO PLAN", "methodology": "percent of total billed charges", "standard_charge_dollar": 1392.6, "standard_charge_percentage": 42.2, "count": "0", "additional_payer_notes": "Zero final payments for the item or service in the 15 months prior to posting the file." }, { "payer_name": "HEALTH NET", "plan_name": "HEALTHNET HMO, PPO, POS, EPO, CANOPY HEALTHNET HMO, OTHER-IN-NETWORK PLANS", "methodology": "per diem", "standard_charge_dollar": 8000.0, "standard_charge_algorithm": "Expected reimbursement is the lesser of Per diem ($8,000) for the length of stay and 70% of billed.", "count": "0", "additional_payer_notes": "Zero final payments for the item or service in the 15 months prior to posting the file." }, { "payer_name": "HEALTH NET", "plan_name": "HEALTHNET HMO, PPO, POS, EPO, CANOPY HEALTHNET HMO, OTHER-IN-NETWORK PLANS", "methodology": "per diem", "standard_charge_dollar": 8000.0, "standard_charge_algorithm": "Expected reimbursement is the lesser of Per diem ($8,000) for the length of stay and 70% of billed.", "count": "0", "additional_payer_notes": "Zero final payments for the item or service in the 15 months prior to posting the file." }, { "payer_name": "UNITED HEALTHCARE", "plan_name": "SUTTER SELECT & SUTTER HEALTH PLAN HMO PLANS", "methodology": "per diem", "standard_charge_dollar": 28538.0, "standard_charge_algorithm": "Per diem ($28,538).", "count": "0", "additional_payer_notes": "Zero final payments for the item or service in the 15 months prior to posting the file." }, { "payer_name": "UNITED HEALTHCARE", "plan_name": "SUTTER SELECT & SUTTER HEALTH PLAN HMO PLANS", "methodology": "per diem", "standard_charge_dollar": 28538.0, "standard_charge_algorithm": "Per diem ($28,538).", "count": "0", "additional_payer_notes": "Zero final payments for the item or service in the 15 months prior to posting the file." }, { "payer_name": "SUTTER", "plan_name": "SUTTER SELECT & SUTTER HEALTH PLAN HMO PLANS", "methodology": "per diem", "standard_charge_dollar": 28538.0, "standard_charge_algorithm": "Per diem ($28,538).", "count": "0", "additional_payer_notes": "Zero final payments for the item or service in the 15 months prior to posting the file." }, { "payer_name": "UNITED HEALTHCARE", "plan_name": "SUTTER SELECT & SUTTER HEALTH PLAN HMO PLANS", "methodology": "per diem", "standard_charge_dollar": 28538.0, "standard_charge_algorithm": "Per diem ($28,538).", "count": "0", "additional_payer_notes": "Zero final payments for the item or service in the 15 months prior to posting the file." }, { "payer_name": "UMR", "plan_name": "SUTTER SELECT & SUTTER HEALTH PLAN HMO PLANS", "methodology": "per diem", "standard_charge_dollar": 28538.0, "standard_charge_algorithm": "Per diem ($28,538).", "count": "0", "additional_payer_notes": "Zero final payments for the item or service in the 15 months prior to posting the file." } ] } ] }, { "description": "HC Blade Saw Gp029", "code_information": [ { "code": "PX-2120012029", "type": "CDM" }, { "code": "99999", "type": "CPT" }, { "code": "0272", "type": "RC" } ], "standard_charges": [ { "setting": "outpatient", "gross_charge": 5438.0, "discounted_cash": 2719.0, "minimum": 2294.84, "maximum": 2827.76, "additional_generic_notes": "Zero final payments for the item or service in the 15 months prior to posting the file.", "payers_information": [ { "payer_name": "AETNA", "plan_name": "AETNA ALL OTHER PLANS", "methodology": "percent of total billed charges", "standard_charge_dollar": 2827.76, "standard_charge_percentage": 52.0, "count": "0", "additional_payer_notes": "Zero final payments for the item or service in the 15 months prior to posting the file." }, { "payer_name": "AETNA", "plan_name": "AETNA ALL OTHER PLANS", "methodology": "percent of total billed charges", "standard_charge_dollar": 2827.76, "standard_charge_percentage": 52.0, "count": "0", "additional_payer_notes": "Zero final payments for the item or service in the 15 months prior to posting the file." }, { "payer_name": "MERITAIN HEALTH", "plan_name": "AETNA ALL OTHER PLANS", "methodology": "percent of total billed charges", "standard_charge_dollar": 2827.76, "standard_charge_percentage": 52.0, "count": "0", "additional_payer_notes": "Zero final payments for the item or service in the 15 months prior to posting the file." }, { "payer_name": "BLUE SHIELD OUT OF STATE", "plan_name": "STANFORD HEALTHCARE ALLIANCE PLAN", "methodology": "percent of total billed charges", "standard_charge_dollar": 2642.32, "standard_charge_percentage": 48.59, "count": "0", "additional_payer_notes": "Zero final payments for the item or service in the 15 months prior to posting the file." }, { "payer_name": "BLUE SHIELD", "plan_name": "STANFORD HEALTHCARE ALLIANCE PLAN", "methodology": "percent of total billed charges", "standard_charge_dollar": 2642.32, "standard_charge_percentage": 48.59, "median_amount": 68.24, "10th_percentile": 13.6, "90th_percentile": 1043.06, "count": "30" }, { "payer_name": "BLUE SHIELD", "plan_name": "STANFORD HEALTHCARE ALLIANCE PLAN", "methodology": "percent of total billed charges", "standard_charge_dollar": 2642.32, "standard_charge_percentage": 48.59, "count": "0", "additional_payer_notes": "Zero final payments for the item or service in the 15 months prior to posting the file." }, { "payer_name": "BLUE SHIELD", "plan_name": "STANFORD HEALTHCARE ALLIANCE PLAN", "methodology": "percent of total billed charges", "standard_charge_dollar": 2642.32, "standard_charge_percentage": 48.59, "count": "0", "additional_payer_notes": "Zero final payments for the item or service in the 15 months prior to posting the file." }, { "payer_name": "CIGNA", "plan_name": "CIGNA COM ALT HMO PLAN", "methodology": "percent of total billed charges", "standard_charge_dollar": 2294.84, "standard_charge_percentage": 42.2, "count": "0", "additional_payer_notes": "Zero final payments for the item or service in the 15 months prior to posting the file." }, { "payer_name": "CIGNA", "plan_name": "CIGNA COM ALT HMO PLAN", "methodology": "percent of total billed charges", "standard_charge_dollar": 2294.84, "standard_charge_percentage": 42.2, "count": "0", "additional_payer_notes": "Zero final payments for the item or service in the 15 months prior to posting the file." }, { "payer_name": "HEALTH NET", "plan_name": "HEALTHNET HMO, PPO, POS, EPO, CANOPY HEALTHNET HMO, OTHER-IN-NETWORK PLANS", "methodology": "per diem", "standard_charge_dollar": 8000.0, "standard_charge_algorithm": "Expected reimbursement is the lesser of Per diem ($8,000) for the length of stay and 70% of billed.", "count": "0", "additional_payer_notes": "Zero final payments for the item or service in the 15 months prior to posting the file." }, { "payer_name": "HEALTH NET", "plan_name": "HEALTHNET HMO, PPO, POS, EPO, CANOPY HEALTHNET HMO, OTHER-IN-NETWORK PLANS", "methodology": "per diem", "standard_charge_dollar": 8000.0, "standard_charge_algorithm": "Expected reimbursement is the lesser of Per diem ($8,000) for the length of stay and 70% of billed.", "count": "0", "additional_payer_notes": "Zero final payments for the item or service in the 15 months prior to posting the file." }, { "payer_name": "UNITED HEALTHCARE", "plan_name": "SUTTER SELECT & SUTTER HEALTH PLAN HMO PLANS", "methodology": "per diem", "standard_charge_dollar": 28538.0, "standard_charge_algorithm": "Per diem ($28,538).", "count": "0", "additional_payer_notes": "Zero final payments for the item or service in the 15 months prior to posting the file." }, { "payer_name": "UNITED HEALTHCARE", "plan_name": "SUTTER SELECT & SUTTER HEALTH PLAN HMO PLANS", "methodology": "per diem", "standard_charge_dollar": 28538.0, "standard_charge_algorithm": "Per diem ($28,538).", "count": "0", "additional_payer_notes": "Zero final payments for the item or service in the 15 months prior to posting the file." }, { "payer_name": "SUTTER", "plan_name": "SUTTER SELECT & SUTTER HEALTH PLAN HMO PLANS", "methodology": "per diem", "standard_charge_dollar": 28538.0, "standard_charge_algorithm": "Per diem ($28,538).", "count": "0", "additional_payer_notes": "Zero final payments for the item or service in the 15 months prior to posting the file." }, { "payer_name": "UNITED HEALTHCARE", "plan_name": "SUTTER SELECT & SUTTER HEALTH PLAN HMO PLANS", "methodology": "per diem", "standard_charge_dollar": 28538.0, "standard_charge_algorithm": "Per diem ($28,538).", "count": "0", "additional_payer_notes": "Zero final payments for the item or service in the 15 months prior to posting the file." }, { "payer_name": "UMR", "plan_name": "SUTTER SELECT & SUTTER HEALTH PLAN HMO PLANS", "methodology": "per diem", "standard_charge_dollar": 28538.0, "standard_charge_algorithm": "Per diem ($28,538).", "count": "0", "additional_payer_notes": "Zero final payments for the item or service in the 15 months prior to posting the file." } ] } ] }, { "description": "HC Blade Saw Gp033", "code_information": [ { "code": "PX-2120012033", "type": "CDM" }, { "code": "99999", "type": "CPT" }, { "code": "0272", "type": "RC" } ], "standard_charges": [ { "setting": "outpatient", "gross_charge": 6413.0, "discounted_cash": 3206.5, "minimum": 2706.29, "maximum": 3334.76, "additional_generic_notes": "Zero final payments for the item or service in the 15 months prior to posting the file.", "payers_information": [ { "payer_name": "AETNA", "plan_name": "AETNA ALL OTHER PLANS", "methodology": "percent of total billed charges", "standard_charge_dollar": 3334.76, "standard_charge_percentage": 52.0, "count": "0", "additional_payer_notes": "Zero final payments for the item or service in the 15 months prior to posting the file." }, { "payer_name": "AETNA", "plan_name": "AETNA ALL OTHER PLANS", "methodology": "percent of total billed charges", "standard_charge_dollar": 3334.76, "standard_charge_percentage": 52.0, "count": "0", "additional_payer_notes": "Zero final payments for the item or service in the 15 months prior to posting the file." }, { "payer_name": "MERITAIN HEALTH", "plan_name": "AETNA ALL OTHER PLANS", "methodology": "percent of total billed charges", "standard_charge_dollar": 3334.76, "standard_charge_percentage": 52.0, "count": "0", "additional_payer_notes": "Zero final payments for the item or service in the 15 months prior to posting the file." }, { "payer_name": "BLUE SHIELD OUT OF STATE", "plan_name": "STANFORD HEALTHCARE ALLIANCE PLAN", "methodology": "percent of total billed charges", "standard_charge_dollar": 3116.08, "standard_charge_percentage": 48.59, "count": "0", "additional_payer_notes": "Zero final payments for the item or service in the 15 months prior to posting the file." }, { "payer_name": "BLUE SHIELD", "plan_name": "STANFORD HEALTHCARE ALLIANCE PLAN", "methodology": "percent of total billed charges", "standard_charge_dollar": 3116.08, "standard_charge_percentage": 48.59, "median_amount": 68.24, "10th_percentile": 13.6, "90th_percentile": 1043.06, "count": "30" }, { "payer_name": "BLUE SHIELD", "plan_name": "STANFORD HEALTHCARE ALLIANCE PLAN", "methodology": "percent of total billed charges", "standard_charge_dollar": 3116.08, "standard_charge_percentage": 48.59, "count": "0", "additional_payer_notes": "Zero final payments for the item or service in the 15 months prior to posting the file." }, { "payer_name": "BLUE SHIELD", "plan_name": "STANFORD HEALTHCARE ALLIANCE PLAN", "methodology": "percent of total billed charges", "standard_charge_dollar": 3116.08, "standard_charge_percentage": 48.59, "count": "0", "additional_payer_notes": "Zero final payments for the item or service in the 15 months prior to posting the file." }, { "payer_name": "CIGNA", "plan_name": "CIGNA COM ALT HMO PLAN", "methodology": "percent of total billed charges", "standard_charge_dollar": 2706.29, "standard_charge_percentage": 42.2, "count": "0", "additional_payer_notes": "Zero final payments for the item or service in the 15 months prior to posting the file." }, { "payer_name": "CIGNA", "plan_name": "CIGNA COM ALT HMO PLAN", "methodology": "percent of total billed charges", "standard_charge_dollar": 2706.29, "standard_charge_percentage": 42.2, "count": "0", "additional_payer_notes": "Zero final payments for the item or service in the 15 months prior to posting the file." }, { "payer_name": "HEALTH NET", "plan_name": "HEALTHNET HMO, PPO, POS, EPO, CANOPY HEALTHNET HMO, OTHER-IN-NETWORK PLANS", "methodology": "per diem", "standard_charge_dollar": 8000.0, "standard_charge_algorithm": "Expected reimbursement is the lesser of Per diem ($8,000) for the length of stay and 70% of billed.", "count": "0", "additional_payer_notes": "Zero final payments for the item or service in the 15 months prior to posting the file." }, { "payer_name": "HEALTH NET", "plan_name": "HEALTHNET HMO, PPO, POS, EPO, CANOPY HEALTHNET HMO, OTHER-IN-NETWORK PLANS", "methodology": "per diem", "standard_charge_dollar": 8000.0, "standard_charge_algorithm": "Expected reimbursement is the lesser of Per diem ($8,000) for the length of stay and 70% of billed.", "count": "0", "additional_payer_notes": "Zero final payments for the item or service in the 15 months prior to posting the file." }, { "payer_name": "UNITED HEALTHCARE", "plan_name": "SUTTER SELECT & SUTTER HEALTH PLAN HMO PLANS", "methodology": "per diem", "standard_charge_dollar": 28538.0, "standard_charge_algorithm": "Per diem ($28,538).", "count": "0", "additional_payer_notes": "Zero final payments for the item or service in the 15 months prior to posting the file." }, { "payer_name": "UNITED HEALTHCARE", "plan_name": "SUTTER SELECT & SUTTER HEALTH PLAN HMO PLANS", "methodology": "per diem", "standard_charge_dollar": 28538.0, "standard_charge_algorithm": "Per diem ($28,538).", "count": "0", "additional_payer_notes": "Zero final payments for the item or service in the 15 months prior to posting the file." }, { "payer_name": "SUTTER", "plan_name": "SUTTER SELECT & SUTTER HEALTH PLAN HMO PLANS", "methodology": "per diem", "standard_charge_dollar": 28538.0, "standard_charge_algorithm": "Per diem ($28,538).", "count": "0", "additional_payer_notes": "Zero final payments for the item or service in the 15 months prior to posting the file." }, { "payer_name": "UNITED HEALTHCARE", "plan_name": "SUTTER SELECT & SUTTER HEALTH PLAN HMO PLANS", "methodology": "per diem", "standard_charge_dollar": 28538.0, "standard_charge_algorithm": "Per diem ($28,538).", "count": "0", "additional_payer_notes": "Zero final payments for the item or service in the 15 months prior to posting the file." }, { "payer_name": "UMR", "plan_name": "SUTTER SELECT & SUTTER HEALTH PLAN HMO PLANS", "methodology": "per diem", "standard_charge_dollar": 28538.0, "standard_charge_algorithm": "Per diem ($28,538).", "count": "0", "additional_payer_notes": "Zero final payments for the item or service in the 15 months prior to posting the file." } ] } ] }, { "description": "HC Block Bone Gp008", "code_information": [ { "code": "PX-2120013008", "type": "CDM" }, { "code": "99999", "type": "CPT" }, { "code": "0272", "type": "RC" } ], "standard_charges": [ { "setting": "outpatient", "gross_charge": 475.0, "discounted_cash": 237.5, "minimum": 200.45, "maximum": 247.0, "additional_generic_notes": "Zero final payments for the item or service in the 15 months prior to posting the file.", "payers_information": [ { "payer_name": "AETNA", "plan_name": "AETNA ALL OTHER PLANS", "methodology": "percent of total billed charges", "standard_charge_dollar": 247.0, "standard_charge_percentage": 52.0, "count": "0", "additional_payer_notes": "Zero final payments for the item or service in the 15 months prior to posting the file." }, { "payer_name": "AETNA", "plan_name": "AETNA ALL OTHER PLANS", "methodology": "percent of total billed charges", "standard_charge_dollar": 247.0, "standard_charge_percentage": 52.0, "count": "0", "additional_payer_notes": "Zero final payments for the item or service in the 15 months prior to posting the file." }, { "payer_name": "MERITAIN HEALTH", "plan_name": "AETNA ALL OTHER PLANS", "methodology": "percent of total billed charges", "standard_charge_dollar": 247.0, "standard_charge_percentage": 52.0, "count": "0", "additional_payer_notes": "Zero final payments for the item or service in the 15 months prior to posting the file." }, { "payer_name": "BLUE SHIELD OUT OF STATE", "plan_name": "STANFORD HEALTHCARE ALLIANCE PLAN", "methodology": "percent of total billed charges", "standard_charge_dollar": 230.8, "standard_charge_percentage": 48.59, "count": "0", "additional_payer_notes": "Zero final payments for the item or service in the 15 months prior to posting the file." }, { "payer_name": "BLUE SHIELD", "plan_name": "STANFORD HEALTHCARE ALLIANCE PLAN", "methodology": "percent of total billed charges", "standard_charge_dollar": 230.8, "standard_charge_percentage": 48.59, "count": "0", "additional_payer_notes": "Zero final payments for the item or service in the 15 months prior to posting the file." }, { "payer_name": "BLUE SHIELD", "plan_name": "STANFORD HEALTHCARE ALLIANCE PLAN", "methodology": "percent of total billed charges", "standard_charge_dollar": 230.8, "standard_charge_percentage": 48.59, "count": "0", "additional_payer_notes": "Zero final payments for the item or service in the 15 months prior to posting the file." }, { "payer_name": "CIGNA", "plan_name": "CIGNA COM ALT HMO PLAN", "methodology": "percent of total billed charges", "standard_charge_dollar": 200.45, "standard_charge_percentage": 42.2, "count": "0", "additional_payer_notes": "Zero final payments for the item or service in the 15 months prior to posting the file." }, { "payer_name": "CIGNA", "plan_name": "CIGNA COM ALT HMO PLAN", "methodology": "percent of total billed charges", "standard_charge_dollar": 200.45, "standard_charge_percentage": 42.2, "count": "0", "additional_payer_notes": "Zero final payments for the item or service in the 15 months prior to posting the file." }, { "payer_name": "HEALTH NET", "plan_name": "HEALTHNET HMO, PPO, POS, EPO, CANOPY HEALTHNET HMO, OTHER-IN-NETWORK PLANS", "methodology": "per diem", "standard_charge_dollar": 8000.0, "standard_charge_algorithm": "Expected reimbursement is the lesser of Per diem ($8,000) for the length of stay and 70% of billed.", "count": "0", "additional_payer_notes": "Zero final payments for the item or service in the 15 months prior to posting the file." }, { "payer_name": "HEALTH NET", "plan_name": "HEALTHNET HMO, PPO, POS, EPO, CANOPY HEALTHNET HMO, OTHER-IN-NETWORK PLANS", "methodology": "per diem", "standard_charge_dollar": 8000.0, "standard_charge_algorithm": "Expected reimbursement is the lesser of Per diem ($8,000) for the length of stay and 70% of billed.", "count": "0", "additional_payer_notes": "Zero final payments for the item or service in the 15 months prior to posting the file." }, { "payer_name": "UNITED HEALTHCARE", "plan_name": "SUTTER SELECT & SUTTER HEALTH PLAN HMO PLANS", "methodology": "per diem", "standard_charge_dollar": 28538.0, "standard_charge_algorithm": "Per diem ($28,538).", "count": "0", "additional_payer_notes": "Zero final payments for the item or service in the 15 months prior to posting the file." }, { "payer_name": "UNITED HEALTHCARE", "plan_name": "SUTTER SELECT & SUTTER HEALTH PLAN HMO PLANS", "methodology": "per diem", "standard_charge_dollar": 28538.0, "standard_charge_algorithm": "Per diem ($28,538).", "count": "0", "additional_payer_notes": "Zero final payments for the item or service in the 15 months prior to posting the file." }, { "payer_name": "SUTTER", "plan_name": "SUTTER SELECT & SUTTER HEALTH PLAN HMO PLANS", "methodology": "per diem", "standard_charge_dollar": 28538.0, "standard_charge_algorithm": "Per diem ($28,538).", "count": "0", "additional_payer_notes": "Zero final payments for the item or service in the 15 months prior to posting the file." }, { "payer_name": "UNITED HEALTHCARE", "plan_name": "SUTTER SELECT & SUTTER HEALTH PLAN HMO PLANS", "methodology": "per diem", "standard_charge_dollar": 28538.0, "standard_charge_algorithm": "Per diem ($28,538).", "count": "0", "additional_payer_notes": "Zero final payments for the item or service in the 15 months prior to posting the file." }, { "payer_name": "UMR", "plan_name": "SUTTER SELECT & SUTTER HEALTH PLAN HMO PLANS", "methodology": "per diem", "standard_charge_dollar": 28538.0, "standard_charge_algorithm": "Per diem ($28,538).", "count": "0", "additional_payer_notes": "Zero final payments for the item or service in the 15 months prior to posting the file." } ] } ] }, { "description": "HC Block Sil Gp014", "code_information": [ { "code": "PX-2120014014", "type": "CDM" }, { "code": "99999", "type": "CPT" }, { "code": "0272", "type": "RC" } ], "standard_charges": [ { "setting": "outpatient", "gross_charge": 1080.0, "discounted_cash": 540.0, "minimum": 455.76, "maximum": 561.6, "additional_generic_notes": "Zero final payments for the item or service in the 15 months prior to posting the file.", "payers_information": [ { "payer_name": "AETNA", "plan_name": "AETNA ALL OTHER PLANS", "methodology": "percent of total billed charges", "standard_charge_dollar": 561.6, "standard_charge_percentage": 52.0, "count": "0", "additional_payer_notes": "Zero final payments for the item or service in the 15 months prior to posting the file." }, { "payer_name": "AETNA", "plan_name": "AETNA ALL OTHER PLANS", "methodology": "percent of total billed charges", "standard_charge_dollar": 561.6, "standard_charge_percentage": 52.0, "count": "0", "additional_payer_notes": "Zero final payments for the item or service in the 15 months prior to posting the file." }, { "payer_name": "MERITAIN HEALTH", "plan_name": "AETNA ALL OTHER PLANS", "methodology": "percent of total billed charges", "standard_charge_dollar": 561.6, "standard_charge_percentage": 52.0, "count": "0", "additional_payer_notes": "Zero final payments for the item or service in the 15 months prior to posting the file." }, { "payer_name": "BLUE SHIELD OUT OF STATE", "plan_name": "STANFORD HEALTHCARE ALLIANCE PLAN", "methodology": "percent of total billed charges", "standard_charge_dollar": 524.77, "standard_charge_percentage": 48.59, "count": "0", "additional_payer_notes": "Zero final payments for the item or service in the 15 months prior to posting the file." }, { "payer_name": "BLUE SHIELD", "plan_name": "STANFORD HEALTHCARE ALLIANCE PLAN", "methodology": "percent of total billed charges", "standard_charge_dollar": 524.77, "standard_charge_percentage": 48.59, "median_amount": 68.24, "10th_percentile": 13.6, "90th_percentile": 1043.06, "count": "30" }, { "payer_name": "BLUE SHIELD", "plan_name": "STANFORD HEALTHCARE ALLIANCE PLAN", "methodology": "percent of total billed charges", "standard_charge_dollar": 524.77, "standard_charge_percentage": 48.59, "count": "0", "additional_payer_notes": "Zero final payments for the item or service in the 15 months prior to posting the file." }, { "payer_name": "BLUE SHIELD", "plan_name": "STANFORD HEALTHCARE ALLIANCE PLAN", "methodology": "percent of total billed charges", "standard_charge_dollar": 524.77, "standard_charge_percentage": 48.59, "count": "0", "additional_payer_notes": "Zero final payments for the item or service in the 15 months prior to posting the file." }, { "payer_name": "CIGNA", "plan_name": "CIGNA COM ALT HMO PLAN", "methodology": "percent of total billed charges", "standard_charge_dollar": 455.76, "standard_charge_percentage": 42.2, "count": "0", "additional_payer_notes": "Zero final payments for the item or service in the 15 months prior to posting the file." }, { "payer_name": "CIGNA", "plan_name": "CIGNA COM ALT HMO PLAN", "methodology": "percent of total billed charges", "standard_charge_dollar": 455.76, "standard_charge_percentage": 42.2, "count": "0", "additional_payer_notes": "Zero final payments for the item or service in the 15 months prior to posting the file." }, { "payer_name": "HEALTH NET", "plan_name": "HEALTHNET HMO, PPO, POS, EPO, CANOPY HEALTHNET HMO, OTHER-IN-NETWORK PLANS", "methodology": "per diem", "standard_charge_dollar": 8000.0, "standard_charge_algorithm": "Expected reimbursement is the lesser of Per diem ($8,000) for the length of stay and 70% of billed.", "count": "0", "additional_payer_notes": "Zero final payments for the item or service in the 15 months prior to posting the file." }, { "payer_name": "HEALTH NET", "plan_name": "HEALTHNET HMO, PPO, POS, EPO, CANOPY HEALTHNET HMO, OTHER-IN-NETWORK PLANS", "methodology": "per diem", "standard_charge_dollar": 8000.0, "standard_charge_algorithm": "Expected reimbursement is the lesser of Per diem ($8,000) for the length of stay and 70% of billed.", "count": "0", "additional_payer_notes": "Zero final payments for the item or service in the 15 months prior to posting the file." }, { "payer_name": "UNITED HEALTHCARE", "plan_name": "SUTTER SELECT & SUTTER HEALTH PLAN HMO PLANS", "methodology": "per diem", "standard_charge_dollar": 28538.0, "standard_charge_algorithm": "Per diem ($28,538).", "count": "0", "additional_payer_notes": "Zero final payments for the item or service in the 15 months prior to posting the file." }, { "payer_name": "UNITED HEALTHCARE", "plan_name": "SUTTER SELECT & SUTTER HEALTH PLAN HMO PLANS", "methodology": "per diem", "standard_charge_dollar": 28538.0, "standard_charge_algorithm": "Per diem ($28,538).", "count": "0", "additional_payer_notes": "Zero final payments for the item or service in the 15 months prior to posting the file." }, { "payer_name": "SUTTER", "plan_name": "SUTTER SELECT & SUTTER HEALTH PLAN HMO PLANS", "methodology": "per diem", "standard_charge_dollar": 28538.0, "standard_charge_algorithm": "Per diem ($28,538).", "count": "0", "additional_payer_notes": "Zero final payments for the item or service in the 15 months prior to posting the file." }, { "payer_name": "UNITED HEALTHCARE", "plan_name": "SUTTER SELECT & SUTTER HEALTH PLAN HMO PLANS", "methodology": "per diem", "standard_charge_dollar": 28538.0, "standard_charge_algorithm": "Per diem ($28,538).", "count": "0", "additional_payer_notes": "Zero final payments for the item or service in the 15 months prior to posting the file." }, { "payer_name": "UMR", "plan_name": "SUTTER SELECT & SUTTER HEALTH PLAN HMO PLANS", "methodology": "per diem", "standard_charge_dollar": 28538.0, "standard_charge_algorithm": "Per diem ($28,538).", "count": "0", "additional_payer_notes": "Zero final payments for the item or service in the 15 months prior to posting the file." } ] } ] }, { "description": "HC Block Sil Gp015", "code_information": [ { "code": "PX-2120014015", "type": "CDM" }, { "code": "99999", "type": "CPT" }, { "code": "0272", "type": "RC" } ], "standard_charges": [ { "setting": "outpatient", "gross_charge": 1225.0, "discounted_cash": 612.5, "minimum": 516.95, "maximum": 637.0, "additional_generic_notes": "Zero final payments for the item or service in the 15 months prior to posting the file.", "payers_information": [ { "payer_name": "AETNA", "plan_name": "AETNA ALL OTHER PLANS", "methodology": "percent of total billed charges", "standard_charge_dollar": 637.0, "standard_charge_percentage": 52.0, "count": "0", "additional_payer_notes": "Zero final payments for the item or service in the 15 months prior to posting the file." }, { "payer_name": "AETNA", "plan_name": "AETNA ALL OTHER PLANS", "methodology": "percent of total billed charges", "standard_charge_dollar": 637.0, "standard_charge_percentage": 52.0, "count": "0", "additional_payer_notes": "Zero final payments for the item or service in the 15 months prior to posting the file." }, { "payer_name": "MERITAIN HEALTH", "plan_name": "AETNA ALL OTHER PLANS", "methodology": "percent of total billed charges", "standard_charge_dollar": 637.0, "standard_charge_percentage": 52.0, "count": "0", "additional_payer_notes": "Zero final payments for the item or service in the 15 months prior to posting the file." }, { "payer_name": "BLUE SHIELD OUT OF STATE", "plan_name": "STANFORD HEALTHCARE ALLIANCE PLAN", "methodology": "percent of total billed charges", "standard_charge_dollar": 595.23, "standard_charge_percentage": 48.59, "count": "0", "additional_payer_notes": "Zero final payments for the item or service in the 15 months prior to posting the file." }, { "payer_name": "BLUE SHIELD", "plan_name": "STANFORD HEALTHCARE ALLIANCE PLAN", "methodology": "percent of total billed charges", "standard_charge_dollar": 595.23, "standard_charge_percentage": 48.59, "median_amount": 68.24, "10th_percentile": 13.6, "90th_percentile": 1043.06, "count": "30" }, { "payer_name": "BLUE SHIELD", "plan_name": "STANFORD HEALTHCARE ALLIANCE PLAN", "methodology": "percent of total billed charges", "standard_charge_dollar": 595.23, "standard_charge_percentage": 48.59, "count": "0", "additional_payer_notes": "Zero final payments for the item or service in the 15 months prior to posting the file." }, { "payer_name": "BLUE SHIELD", "plan_name": "STANFORD HEALTHCARE ALLIANCE PLAN", "methodology": "percent of total billed charges", "standard_charge_dollar": 595.23, "standard_charge_percentage": 48.59, "count": "0", "additional_payer_notes": "Zero final payments for the item or service in the 15 months prior to posting the file." }, { "payer_name": "CIGNA", "plan_name": "CIGNA COM ALT HMO PLAN", "methodology": "percent of total billed charges", "standard_charge_dollar": 516.95, "standard_charge_percentage": 42.2, "count": "0", "additional_payer_notes": "Zero final payments for the item or service in the 15 months prior to posting the file." }, { "payer_name": "CIGNA", "plan_name": "CIGNA COM ALT HMO PLAN", "methodology": "percent of total billed charges", "standard_charge_dollar": 516.95, "standard_charge_percentage": 42.2, "count": "0", "additional_payer_notes": "Zero final payments for the item or service in the 15 months prior to posting the file." }, { "payer_name": "HEALTH NET", "plan_name": "HEALTHNET HMO, PPO, POS, EPO, CANOPY HEALTHNET HMO, OTHER-IN-NETWORK PLANS", "methodology": "per diem", "standard_charge_dollar": 8000.0, "standard_charge_algorithm": "Expected reimbursement is the lesser of Per diem ($8,000) for the length of stay and 70% of billed.", "count": "0", "additional_payer_notes": "Zero final payments for the item or service in the 15 months prior to posting the file." }, { "payer_name": "HEALTH NET", "plan_name": "HEALTHNET HMO, PPO, POS, EPO, CANOPY HEALTHNET HMO, OTHER-IN-NETWORK PLANS", "methodology": "per diem", "standard_charge_dollar": 8000.0, "standard_charge_algorithm": "Expected reimbursement is the lesser of Per diem ($8,000) for the length of stay and 70% of billed.", "count": "0", "additional_payer_notes": "Zero final payments for the item or service in the 15 months prior to posting the file." }, { "payer_name": "UNITED HEALTHCARE", "plan_name": "SUTTER SELECT & SUTTER HEALTH PLAN HMO PLANS", "methodology": "per diem", "standard_charge_dollar": 28538.0, "standard_charge_algorithm": "Per diem ($28,538).", "count": "0", "additional_payer_notes": "Zero final payments for the item or service in the 15 months prior to posting the file." }, { "payer_name": "UNITED HEALTHCARE", "plan_name": "SUTTER SELECT & SUTTER HEALTH PLAN HMO PLANS", "methodology": "per diem", "standard_charge_dollar": 28538.0, "standard_charge_algorithm": "Per diem ($28,538).", "count": "0", "additional_payer_notes": "Zero final payments for the item or service in the 15 months prior to posting the file." }, { "payer_name": "SUTTER", "plan_name": "SUTTER SELECT & SUTTER HEALTH PLAN HMO PLANS", "methodology": "per diem", "standard_charge_dollar": 28538.0, "standard_charge_algorithm": "Per diem ($28,538).", "count": "0", "additional_payer_notes": "Zero final payments for the item or service in the 15 months prior to posting the file." }, { "payer_name": "UNITED HEALTHCARE", "plan_name": "SUTTER SELECT & SUTTER HEALTH PLAN HMO PLANS", "methodology": "per diem", "standard_charge_dollar": 28538.0, "standard_charge_algorithm": "Per diem ($28,538).", "count": "0", "additional_payer_notes": "Zero final payments for the item or service in the 15 months prior to posting the file." }, { "payer_name": "UMR", "plan_name": "SUTTER SELECT & SUTTER HEALTH PLAN HMO PLANS", "methodology": "per diem", "standard_charge_dollar": 28538.0, "standard_charge_algorithm": "Per diem ($28,538).", "count": "0", "additional_payer_notes": "Zero final payments for the item or service in the 15 months prior to posting the file." } ] } ] }, { "description": "HC Bobbin No Wire Gp005", "code_information": [ { "code": "PX-2120015005", "type": "CDM" }, { "code": "99999", "type": "CPT" }, { "code": "0272", "type": "RC" } ], "standard_charges": [ { "setting": "outpatient", "gross_charge": 195.0, "discounted_cash": 97.5, "minimum": 82.29, "maximum": 101.4, "additional_generic_notes": "Zero final payments for the item or service in the 15 months prior to posting the file.", "payers_information": [ { "payer_name": "AETNA", "plan_name": "AETNA ALL OTHER PLANS", "methodology": "percent of total billed charges", "standard_charge_dollar": 101.4, "standard_charge_percentage": 52.0, "count": "0", "additional_payer_notes": "Zero final payments for the item or service in the 15 months prior to posting the file." }, { "payer_name": "AETNA", "plan_name": "AETNA ALL OTHER PLANS", "methodology": "percent of total billed charges", "standard_charge_dollar": 101.4, "standard_charge_percentage": 52.0, "count": "0", "additional_payer_notes": "Zero final payments for the item or service in the 15 months prior to posting the file." }, { "payer_name": "MERITAIN HEALTH", "plan_name": "AETNA ALL OTHER PLANS", "methodology": "percent of total billed charges", "standard_charge_dollar": 101.4, "standard_charge_percentage": 52.0, "count": "0", "additional_payer_notes": "Zero final payments for the item or service in the 15 months prior to posting the file." }, { "payer_name": "BLUE SHIELD OUT OF STATE", "plan_name": "STANFORD HEALTHCARE ALLIANCE PLAN", "methodology": "percent of total billed charges", "standard_charge_dollar": 94.75, "standard_charge_percentage": 48.59, "count": "0", "additional_payer_notes": "Zero final payments for the item or service in the 15 months prior to posting the file." }, { "payer_name": "BLUE SHIELD", "plan_name": "STANFORD HEALTHCARE ALLIANCE PLAN", "methodology": "percent of total billed charges", "standard_charge_dollar": 94.75, "standard_charge_percentage": 48.59, "count": "0", "additional_payer_notes": "Zero final payments for the item or service in the 15 months prior to posting the file." }, { "payer_name": "BLUE SHIELD", "plan_name": "STANFORD HEALTHCARE ALLIANCE PLAN", "methodology": "percent of total billed charges", "standard_charge_dollar": 94.75, "standard_charge_percentage": 48.59, "count": "0", "additional_payer_notes": "Zero final payments for the item or service in the 15 months prior to posting the file." }, { "payer_name": "CIGNA", "plan_name": "CIGNA COM ALT HMO PLAN", "methodology": "percent of total billed charges", "standard_charge_dollar": 82.29, "standard_charge_percentage": 42.2, "count": "0", "additional_payer_notes": "Zero final payments for the item or service in the 15 months prior to posting the file." }, { "payer_name": "CIGNA", "plan_name": "CIGNA COM ALT HMO PLAN", "methodology": "percent of total billed charges", "standard_charge_dollar": 82.29, "standard_charge_percentage": 42.2, "count": "0", "additional_payer_notes": "Zero final payments for the item or service in the 15 months prior to posting the file." }, { "payer_name": "HEALTH NET", "plan_name": "HEALTHNET HMO, PPO, POS, EPO, CANOPY HEALTHNET HMO, OTHER-IN-NETWORK PLANS", "methodology": "per diem", "standard_charge_dollar": 8000.0, "standard_charge_algorithm": "Expected reimbursement is the lesser of Per diem ($8,000) for the length of stay and 70% of billed.", "count": "0", "additional_payer_notes": "Zero final payments for the item or service in the 15 months prior to posting the file." }, { "payer_name": "HEALTH NET", "plan_name": "HEALTHNET HMO, PPO, POS, EPO, CANOPY HEALTHNET HMO, OTHER-IN-NETWORK PLANS", "methodology": "per diem", "standard_charge_dollar": 8000.0, "standard_charge_algorithm": "Expected reimbursement is the lesser of Per diem ($8,000) for the length of stay and 70% of billed.", "count": "0", "additional_payer_notes": "Zero final payments for the item or service in the 15 months prior to posting the file." }, { "payer_name": "UNITED HEALTHCARE", "plan_name": "SUTTER SELECT & SUTTER HEALTH PLAN HMO PLANS", "methodology": "per diem", "standard_charge_dollar": 28538.0, "standard_charge_algorithm": "Per diem ($28,538).", "count": "0", "additional_payer_notes": "Zero final payments for the item or service in the 15 months prior to posting the file." }, { "payer_name": "UNITED HEALTHCARE", "plan_name": "SUTTER SELECT & SUTTER HEALTH PLAN HMO PLANS", "methodology": "per diem", "standard_charge_dollar": 28538.0, "standard_charge_algorithm": "Per diem ($28,538).", "count": "0", "additional_payer_notes": "Zero final payments for the item or service in the 15 months prior to posting the file." }, { "payer_name": "SUTTER", "plan_name": "SUTTER SELECT & SUTTER HEALTH PLAN HMO PLANS", "methodology": "per diem", "standard_charge_dollar": 28538.0, "standard_charge_algorithm": "Per diem ($28,538).", "count": "0", "additional_payer_notes": "Zero final payments for the item or service in the 15 months prior to posting the file." }, { "payer_name": "UNITED HEALTHCARE", "plan_name": "SUTTER SELECT & SUTTER HEALTH PLAN HMO PLANS", "methodology": "per diem", "standard_charge_dollar": 28538.0, "standard_charge_algorithm": "Per diem ($28,538).", "count": "0", "additional_payer_notes": "Zero final payments for the item or service in the 15 months prior to posting the file." }, { "payer_name": "UMR", "plan_name": "SUTTER SELECT & SUTTER HEALTH PLAN HMO PLANS", "methodology": "per diem", "standard_charge_dollar": 28538.0, "standard_charge_algorithm": "Per diem ($28,538).", "count": "0", "additional_payer_notes": "Zero final payments for the item or service in the 15 months prior to posting the file." } ] } ] }, { "description": "HC Bobbin No Wire Gp006", "code_information": [ { "code": "PX-2120015006", "type": "CDM" }, { "code": "99999", "type": "CPT" }, { "code": "0272", "type": "RC" } ], "standard_charges": [ { "setting": "outpatient", "gross_charge": 293.0, "discounted_cash": 146.5, "minimum": 123.65, "maximum": 152.36, "additional_generic_notes": "Zero final payments for the item or service in the 15 months prior to posting the file.", "payers_information": [ { "payer_name": "AETNA", "plan_name": "AETNA ALL OTHER PLANS", "methodology": "percent of total billed charges", "standard_charge_dollar": 152.36, "standard_charge_percentage": 52.0, "count": "0", "additional_payer_notes": "Zero final payments for the item or service in the 15 months prior to posting the file." }, { "payer_name": "AETNA", "plan_name": "AETNA ALL OTHER PLANS", "methodology": "percent of total billed charges", "standard_charge_dollar": 152.36, "standard_charge_percentage": 52.0, "count": "0", "additional_payer_notes": "Zero final payments for the item or service in the 15 months prior to posting the file." }, { "payer_name": "MERITAIN HEALTH", "plan_name": "AETNA ALL OTHER PLANS", "methodology": "percent of total billed charges", "standard_charge_dollar": 152.36, "standard_charge_percentage": 52.0, "count": "0", "additional_payer_notes": "Zero final payments for the item or service in the 15 months prior to posting the file." }, { "payer_name": "BLUE SHIELD OUT OF STATE", "plan_name": "STANFORD HEALTHCARE ALLIANCE PLAN", "methodology": "percent of total billed charges", "standard_charge_dollar": 142.37, "standard_charge_percentage": 48.59, "count": "0", "additional_payer_notes": "Zero final payments for the item or service in the 15 months prior to posting the file." }, { "payer_name": "BLUE SHIELD", "plan_name": "STANFORD HEALTHCARE ALLIANCE PLAN", "methodology": "percent of total billed charges", "standard_charge_dollar": 142.37, "standard_charge_percentage": 48.59, "count": "0", "additional_payer_notes": "Zero final payments for the item or service in the 15 months prior to posting the file." }, { "payer_name": "BLUE SHIELD", "plan_name": "STANFORD HEALTHCARE ALLIANCE PLAN", "methodology": "percent of total billed charges", "standard_charge_dollar": 142.37, "standard_charge_percentage": 48.59, "count": "0", "additional_payer_notes": "Zero final payments for the item or service in the 15 months prior to posting the file." }, { "payer_name": "CIGNA", "plan_name": "CIGNA COM ALT HMO PLAN", "methodology": "percent of total billed charges", "standard_charge_dollar": 123.65, "standard_charge_percentage": 42.2, "count": "0", "additional_payer_notes": "Zero final payments for the item or service in the 15 months prior to posting the file." }, { "payer_name": "CIGNA", "plan_name": "CIGNA COM ALT HMO PLAN", "methodology": "percent of total billed charges", "standard_charge_dollar": 123.65, "standard_charge_percentage": 42.2, "count": "0", "additional_payer_notes": "Zero final payments for the item or service in the 15 months prior to posting the file." }, { "payer_name": "HEALTH NET", "plan_name": "HEALTHNET HMO, PPO, POS, EPO, CANOPY HEALTHNET HMO, OTHER-IN-NETWORK PLANS", "methodology": "per diem", "standard_charge_dollar": 8000.0, "standard_charge_algorithm": "Expected reimbursement is the lesser of Per diem ($8,000) for the length of stay and 70% of billed.", "count": "0", "additional_payer_notes": "Zero final payments for the item or service in the 15 months prior to posting the file." }, { "payer_name": "HEALTH NET", "plan_name": "HEALTHNET HMO, PPO, POS, EPO, CANOPY HEALTHNET HMO, OTHER-IN-NETWORK PLANS", "methodology": "per diem", "standard_charge_dollar": 8000.0, "standard_charge_algorithm": "Expected reimbursement is the lesser of Per diem ($8,000) for the length of stay and 70% of billed.", "count": "0", "additional_payer_notes": "Zero final payments for the item or service in the 15 months prior to posting the file." }, { "payer_name": "UNITED HEALTHCARE", "plan_name": "SUTTER SELECT & SUTTER HEALTH PLAN HMO PLANS", "methodology": "per diem", "standard_charge_dollar": 28538.0, "standard_charge_algorithm": "Per diem ($28,538).", "count": "0", "additional_payer_notes": "Zero final payments for the item or service in the 15 months prior to posting the file." }, { "payer_name": "UNITED HEALTHCARE", "plan_name": "SUTTER SELECT & SUTTER HEALTH PLAN HMO PLANS", "methodology": "per diem", "standard_charge_dollar": 28538.0, "standard_charge_algorithm": "Per diem ($28,538).", "count": "0", "additional_payer_notes": "Zero final payments for the item or service in the 15 months prior to posting the file." }, { "payer_name": "SUTTER", "plan_name": "SUTTER SELECT & SUTTER HEALTH PLAN HMO PLANS", "methodology": "per diem", "standard_charge_dollar": 28538.0, "standard_charge_algorithm": "Per diem ($28,538).", "count": "0", "additional_payer_notes": "Zero final payments for the item or service in the 15 months prior to posting the file." }, { "payer_name": "UNITED HEALTHCARE", "plan_name": "SUTTER SELECT & SUTTER HEALTH PLAN HMO PLANS", "methodology": "per diem", "standard_charge_dollar": 28538.0, "standard_charge_algorithm": "Per diem ($28,538).", "count": "0", "additional_payer_notes": "Zero final payments for the item or service in the 15 months prior to posting the file." }, { "payer_name": "UMR", "plan_name": "SUTTER SELECT & SUTTER HEALTH PLAN HMO PLANS", "methodology": "per diem", "standard_charge_dollar": 28538.0, "standard_charge_algorithm": "Per diem ($28,538).", "count": "0", "additional_payer_notes": "Zero final payments for the item or service in the 15 months prior to posting the file." } ] } ] }, { "description": "HC Bowl Mixing Cement Gp008", "code_information": [ { "code": "PX-2120016008", "type": "CDM" }, { "code": "99999", "type": "CPT" }, { "code": "0272", "type": "RC" } ], "standard_charges": [ { "setting": "outpatient", "gross_charge": 475.0, "discounted_cash": 237.5, "minimum": 200.45, "maximum": 247.0, "additional_generic_notes": "Zero final payments for the item or service in the 15 months prior to posting the file.", "payers_information": [ { "payer_name": "AETNA", "plan_name": "AETNA ALL OTHER PLANS", "methodology": "percent of total billed charges", "standard_charge_dollar": 247.0, "standard_charge_percentage": 52.0, "count": "0", "additional_payer_notes": "Zero final payments for the item or service in the 15 months prior to posting the file." }, { "payer_name": "AETNA", "plan_name": "AETNA ALL OTHER PLANS", "methodology": "percent of total billed charges", "standard_charge_dollar": 247.0, "standard_charge_percentage": 52.0, "count": "0", "additional_payer_notes": "Zero final payments for the item or service in the 15 months prior to posting the file." }, { "payer_name": "MERITAIN HEALTH", "plan_name": "AETNA ALL OTHER PLANS", "methodology": "percent of total billed charges", "standard_charge_dollar": 247.0, "standard_charge_percentage": 52.0, "count": "0", "additional_payer_notes": "Zero final payments for the item or service in the 15 months prior to posting the file." }, { "payer_name": "BLUE SHIELD OUT OF STATE", "plan_name": "STANFORD HEALTHCARE ALLIANCE PLAN", "methodology": "percent of total billed charges", "standard_charge_dollar": 230.8, "standard_charge_percentage": 48.59, "count": "0", "additional_payer_notes": "Zero final payments for the item or service in the 15 months prior to posting the file." }, { "payer_name": "BLUE SHIELD", "plan_name": "STANFORD HEALTHCARE ALLIANCE PLAN", "methodology": "percent of total billed charges", "standard_charge_dollar": 230.8, "standard_charge_percentage": 48.59, "count": "0", "additional_payer_notes": "Zero final payments for the item or service in the 15 months prior to posting the file." }, { "payer_name": "BLUE SHIELD", "plan_name": "STANFORD HEALTHCARE ALLIANCE PLAN", "methodology": "percent of total billed charges", "standard_charge_dollar": 230.8, "standard_charge_percentage": 48.59, "count": "0", "additional_payer_notes": "Zero final payments for the item or service in the 15 months prior to posting the file." }, { "payer_name": "CIGNA", "plan_name": "CIGNA COM ALT HMO PLAN", "methodology": "percent of total billed charges", "standard_charge_dollar": 200.45, "standard_charge_percentage": 42.2, "count": "0", "additional_payer_notes": "Zero final payments for the item or service in the 15 months prior to posting the file." }, { "payer_name": "CIGNA", "plan_name": "CIGNA COM ALT HMO PLAN", "methodology": "percent of total billed charges", "standard_charge_dollar": 200.45, "standard_charge_percentage": 42.2, "count": "0", "additional_payer_notes": "Zero final payments for the item or service in the 15 months prior to posting the file." }, { "payer_name": "HEALTH NET", "plan_name": "HEALTHNET HMO, PPO, POS, EPO, CANOPY HEALTHNET HMO, OTHER-IN-NETWORK PLANS", "methodology": "per diem", "standard_charge_dollar": 8000.0, "standard_charge_algorithm": "Expected reimbursement is the lesser of Per diem ($8,000) for the length of stay and 70% of billed.", "count": "0", "additional_payer_notes": "Zero final payments for the item or service in the 15 months prior to posting the file." }, { "payer_name": "HEALTH NET", "plan_name": "HEALTHNET HMO, PPO, POS, EPO, CANOPY HEALTHNET HMO, OTHER-IN-NETWORK PLANS", "methodology": "per diem", "standard_charge_dollar": 8000.0, "standard_charge_algorithm": "Expected reimbursement is the lesser of Per diem ($8,000) for the length of stay and 70% of billed.", "count": "0", "additional_payer_notes": "Zero final payments for the item or service in the 15 months prior to posting the file." }, { "payer_name": "UNITED HEALTHCARE", "plan_name": "SUTTER SELECT & SUTTER HEALTH PLAN HMO PLANS", "methodology": "per diem", "standard_charge_dollar": 28538.0, "standard_charge_algorithm": "Per diem ($28,538).", "count": "0", "additional_payer_notes": "Zero final payments for the item or service in the 15 months prior to posting the file." }, { "payer_name": "UNITED HEALTHCARE", "plan_name": "SUTTER SELECT & SUTTER HEALTH PLAN HMO PLANS", "methodology": "per diem", "standard_charge_dollar": 28538.0, "standard_charge_algorithm": "Per diem ($28,538).", "count": "0", "additional_payer_notes": "Zero final payments for the item or service in the 15 months prior to posting the file." }, { "payer_name": "SUTTER", "plan_name": "SUTTER SELECT & SUTTER HEALTH PLAN HMO PLANS", "methodology": "per diem", "standard_charge_dollar": 28538.0, "standard_charge_algorithm": "Per diem ($28,538).", "count": "0", "additional_payer_notes": "Zero final payments for the item or service in the 15 months prior to posting the file." }, { "payer_name": "UNITED HEALTHCARE", "plan_name": "SUTTER SELECT & SUTTER HEALTH PLAN HMO PLANS", "methodology": "per diem", "standard_charge_dollar": 28538.0, "standard_charge_algorithm": "Per diem ($28,538).", "count": "0", "additional_payer_notes": "Zero final payments for the item or service in the 15 months prior to posting the file." }, { "payer_name": "UMR", "plan_name": "SUTTER SELECT & SUTTER HEALTH PLAN HMO PLANS", "methodology": "per diem", "standard_charge_dollar": 28538.0, "standard_charge_algorithm": "Per diem ($28,538).", "count": "0", "additional_payer_notes": "Zero final payments for the item or service in the 15 months prior to posting the file." } ] } ] }, { "description": "HC Bowl Cement Gp009", "code_information": [ { "code": "PX-2120016009", "type": "CDM" }, { "code": "99999", "type": "CPT" }, { "code": "0272", "type": "RC" } ], "standard_charges": [ { "setting": "outpatient", "gross_charge": 570.0, "discounted_cash": 285.0, "minimum": 240.54, "maximum": 296.4, "additional_generic_notes": "Zero final payments for the item or service in the 15 months prior to posting the file.", "payers_information": [ { "payer_name": "AETNA", "plan_name": "AETNA ALL OTHER PLANS", "methodology": "percent of total billed charges", "standard_charge_dollar": 296.4, "standard_charge_percentage": 52.0, "count": "0", "additional_payer_notes": "Zero final payments for the item or service in the 15 months prior to posting the file." }, { "payer_name": "AETNA", "plan_name": "AETNA ALL OTHER PLANS", "methodology": "percent of total billed charges", "standard_charge_dollar": 296.4, "standard_charge_percentage": 52.0, "count": "0", "additional_payer_notes": "Zero final payments for the item or service in the 15 months prior to posting the file." }, { "payer_name": "MERITAIN HEALTH", "plan_name": "AETNA ALL OTHER PLANS", "methodology": "percent of total billed charges", "standard_charge_dollar": 296.4, "standard_charge_percentage": 52.0, "count": "0", "additional_payer_notes": "Zero final payments for the item or service in the 15 months prior to posting the file." }, { "payer_name": "BLUE SHIELD OUT OF STATE", "plan_name": "STANFORD HEALTHCARE ALLIANCE PLAN", "methodology": "percent of total billed charges", "standard_charge_dollar": 276.96, "standard_charge_percentage": 48.59, "count": "0", "additional_payer_notes": "Zero final payments for the item or service in the 15 months prior to posting the file." }, { "payer_name": "BLUE SHIELD", "plan_name": "STANFORD HEALTHCARE ALLIANCE PLAN", "methodology": "percent of total billed charges", "standard_charge_dollar": 276.96, "standard_charge_percentage": 48.59, "count": "0", "additional_payer_notes": "Zero final payments for the item or service in the 15 months prior to posting the file." }, { "payer_name": "BLUE SHIELD", "plan_name": "STANFORD HEALTHCARE ALLIANCE PLAN", "methodology": "percent of total billed charges", "standard_charge_dollar": 276.96, "standard_charge_percentage": 48.59, "count": "0", "additional_payer_notes": "Zero final payments for the item or service in the 15 months prior to posting the file." }, { "payer_name": "CIGNA", "plan_name": "CIGNA COM ALT HMO PLAN", "methodology": "percent of total billed charges", "standard_charge_dollar": 240.54, "standard_charge_percentage": 42.2, "count": "0", "additional_payer_notes": "Zero final payments for the item or service in the 15 months prior to posting the file." }, { "payer_name": "CIGNA", "plan_name": "CIGNA COM ALT HMO PLAN", "methodology": "percent of total billed charges", "standard_charge_dollar": 240.54, "standard_charge_percentage": 42.2, "count": "0", "additional_payer_notes": "Zero final payments for the item or service in the 15 months prior to posting the file." }, { "payer_name": "HEALTH NET", "plan_name": "HEALTHNET HMO, PPO, POS, EPO, CANOPY HEALTHNET HMO, OTHER-IN-NETWORK PLANS", "methodology": "per diem", "standard_charge_dollar": 8000.0, "standard_charge_algorithm": "Expected reimbursement is the lesser of Per diem ($8,000) for the length of stay and 70% of billed.", "count": "0", "additional_payer_notes": "Zero final payments for the item or service in the 15 months prior to posting the file." }, { "payer_name": "HEALTH NET", "plan_name": "HEALTHNET HMO, PPO, POS, EPO, CANOPY HEALTHNET HMO, OTHER-IN-NETWORK PLANS", "methodology": "per diem", "standard_charge_dollar": 8000.0, "standard_charge_algorithm": "Expected reimbursement is the lesser of Per diem ($8,000) for the length of stay and 70% of billed.", "count": "0", "additional_payer_notes": "Zero final payments for the item or service in the 15 months prior to posting the file." }, { "payer_name": "UNITED HEALTHCARE", "plan_name": "SUTTER SELECT & SUTTER HEALTH PLAN HMO PLANS", "methodology": "per diem", "standard_charge_dollar": 28538.0, "standard_charge_algorithm": "Per diem ($28,538).", "count": "0", "additional_payer_notes": "Zero final payments for the item or service in the 15 months prior to posting the file." }, { "payer_name": "UNITED HEALTHCARE", "plan_name": "SUTTER SELECT & SUTTER HEALTH PLAN HMO PLANS", "methodology": "per diem", "standard_charge_dollar": 28538.0, "standard_charge_algorithm": "Per diem ($28,538).", "count": "0", "additional_payer_notes": "Zero final payments for the item or service in the 15 months prior to posting the file." }, { "payer_name": "SUTTER", "plan_name": "SUTTER SELECT & SUTTER HEALTH PLAN HMO PLANS", "methodology": "per diem", "standard_charge_dollar": 28538.0, "standard_charge_algorithm": "Per diem ($28,538).", "count": "0", "additional_payer_notes": "Zero final payments for the item or service in the 15 months prior to posting the file." }, { "payer_name": "UNITED HEALTHCARE", "plan_name": "SUTTER SELECT & SUTTER HEALTH PLAN HMO PLANS", "methodology": "per diem", "standard_charge_dollar": 28538.0, "standard_charge_algorithm": "Per diem ($28,538).", "count": "0", "additional_payer_notes": "Zero final payments for the item or service in the 15 months prior to posting the file." }, { "payer_name": "UMR", "plan_name": "SUTTER SELECT & SUTTER HEALTH PLAN HMO PLANS", "methodology": "per diem", "standard_charge_dollar": 28538.0, "standard_charge_algorithm": "Per diem ($28,538).", "count": "0", "additional_payer_notes": "Zero final payments for the item or service in the 15 months prior to posting the file." } ] } ] }, { "description": "HC Bowl Mixing Cement Gp010", "code_information": [ { "code": "PX-2120016010", "type": "CDM" }, { "code": "99999", "type": "CPT" }, { "code": "0272", "type": "RC" } ], "standard_charges": [ { "setting": "outpatient", "gross_charge": 665.0, "discounted_cash": 332.5, "minimum": 280.63, "maximum": 345.8, "additional_generic_notes": "Zero final payments for the item or service in the 15 months prior to posting the file.", "payers_information": [ { "payer_name": "AETNA", "plan_name": "AETNA ALL OTHER PLANS", "methodology": "percent of total billed charges", "standard_charge_dollar": 345.8, "standard_charge_percentage": 52.0, "count": "0", "additional_payer_notes": "Zero final payments for the item or service in the 15 months prior to posting the file." }, { "payer_name": "AETNA", "plan_name": "AETNA ALL OTHER PLANS", "methodology": "percent of total billed charges", "standard_charge_dollar": 345.8, "standard_charge_percentage": 52.0, "count": "0", "additional_payer_notes": "Zero final payments for the item or service in the 15 months prior to posting the file." }, { "payer_name": "MERITAIN HEALTH", "plan_name": "AETNA ALL OTHER PLANS", "methodology": "percent of total billed charges", "standard_charge_dollar": 345.8, "standard_charge_percentage": 52.0, "count": "0", "additional_payer_notes": "Zero final payments for the item or service in the 15 months prior to posting the file." }, { "payer_name": "BLUE SHIELD OUT OF STATE", "plan_name": "STANFORD HEALTHCARE ALLIANCE PLAN", "methodology": "percent of total billed charges", "standard_charge_dollar": 323.12, "standard_charge_percentage": 48.59, "count": "0", "additional_payer_notes": "Zero final payments for the item or service in the 15 months prior to posting the file." }, { "payer_name": "BLUE SHIELD", "plan_name": "STANFORD HEALTHCARE ALLIANCE PLAN", "methodology": "percent of total billed charges", "standard_charge_dollar": 323.12, "standard_charge_percentage": 48.59, "count": "0", "additional_payer_notes": "Zero final payments for the item or service in the 15 months prior to posting the file." }, { "payer_name": "BLUE SHIELD", "plan_name": "STANFORD HEALTHCARE ALLIANCE PLAN", "methodology": "percent of total billed charges", "standard_charge_dollar": 323.12, "standard_charge_percentage": 48.59, "count": "0", "additional_payer_notes": "Zero final payments for the item or service in the 15 months prior to posting the file." }, { "payer_name": "CIGNA", "plan_name": "CIGNA COM ALT HMO PLAN", "methodology": "percent of total billed charges", "standard_charge_dollar": 280.63, "standard_charge_percentage": 42.2, "count": "0", "additional_payer_notes": "Zero final payments for the item or service in the 15 months prior to posting the file." }, { "payer_name": "CIGNA", "plan_name": "CIGNA COM ALT HMO PLAN", "methodology": "percent of total billed charges", "standard_charge_dollar": 280.63, "standard_charge_percentage": 42.2, "count": "0", "additional_payer_notes": "Zero final payments for the item or service in the 15 months prior to posting the file." }, { "payer_name": "HEALTH NET", "plan_name": "HEALTHNET HMO, PPO, POS, EPO, CANOPY HEALTHNET HMO, OTHER-IN-NETWORK PLANS", "methodology": "per diem", "standard_charge_dollar": 8000.0, "standard_charge_algorithm": "Expected reimbursement is the lesser of Per diem ($8,000) for the length of stay and 70% of billed.", "count": "0", "additional_payer_notes": "Zero final payments for the item or service in the 15 months prior to posting the file." }, { "payer_name": "HEALTH NET", "plan_name": "HEALTHNET HMO, PPO, POS, EPO, CANOPY HEALTHNET HMO, OTHER-IN-NETWORK PLANS", "methodology": "per diem", "standard_charge_dollar": 8000.0, "standard_charge_algorithm": "Expected reimbursement is the lesser of Per diem ($8,000) for the length of stay and 70% of billed.", "count": "0", "additional_payer_notes": "Zero final payments for the item or service in the 15 months prior to posting the file." }, { "payer_name": "UNITED HEALTHCARE", "plan_name": "SUTTER SELECT & SUTTER HEALTH PLAN HMO PLANS", "methodology": "per diem", "standard_charge_dollar": 28538.0, "standard_charge_algorithm": "Per diem ($28,538).", "count": "0", "additional_payer_notes": "Zero final payments for the item or service in the 15 months prior to posting the file." }, { "payer_name": "UNITED HEALTHCARE", "plan_name": "SUTTER SELECT & SUTTER HEALTH PLAN HMO PLANS", "methodology": "per diem", "standard_charge_dollar": 28538.0, "standard_charge_algorithm": "Per diem ($28,538).", "count": "0", "additional_payer_notes": "Zero final payments for the item or service in the 15 months prior to posting the file." }, { "payer_name": "SUTTER", "plan_name": "SUTTER SELECT & SUTTER HEALTH PLAN HMO PLANS", "methodology": "per diem", "standard_charge_dollar": 28538.0, "standard_charge_algorithm": "Per diem ($28,538).", "count": "0", "additional_payer_notes": "Zero final payments for the item or service in the 15 months prior to posting the file." }, { "payer_name": "UNITED HEALTHCARE", "plan_name": "SUTTER SELECT & SUTTER HEALTH PLAN HMO PLANS", "methodology": "per diem", "standard_charge_dollar": 28538.0, "standard_charge_algorithm": "Per diem ($28,538).", "count": "0", "additional_payer_notes": "Zero final payments for the item or service in the 15 months prior to posting the file." }, { "payer_name": "UMR", "plan_name": "SUTTER SELECT & SUTTER HEALTH PLAN HMO PLANS", "methodology": "per diem", "standard_charge_dollar": 28538.0, "standard_charge_algorithm": "Per diem ($28,538).", "count": "0", "additional_payer_notes": "Zero final payments for the item or service in the 15 months prior to posting the file." } ] } ] }, { "description": "HC Bowl Cement Gp011", "code_information": [ { "code": "PX-2120016011", "type": "CDM" }, { "code": "99999", "type": "CPT" }, { "code": "0272", "type": "RC" } ], "standard_charges": [ { "setting": "outpatient", "gross_charge": 740.0, "discounted_cash": 370.0, "minimum": 312.28, "maximum": 384.8, "additional_generic_notes": "Zero final payments for the item or service in the 15 months prior to posting the file.", "payers_information": [ { "payer_name": "AETNA", "plan_name": "AETNA ALL OTHER PLANS", "methodology": "percent of total billed charges", "standard_charge_dollar": 384.8, "standard_charge_percentage": 52.0, "count": "0", "additional_payer_notes": "Zero final payments for the item or service in the 15 months prior to posting the file." }, { "payer_name": "AETNA", "plan_name": "AETNA ALL OTHER PLANS", "methodology": "percent of total billed charges", "standard_charge_dollar": 384.8, "standard_charge_percentage": 52.0, "count": "0", "additional_payer_notes": "Zero final payments for the item or service in the 15 months prior to posting the file." }, { "payer_name": "MERITAIN HEALTH", "plan_name": "AETNA ALL OTHER PLANS", "methodology": "percent of total billed charges", "standard_charge_dollar": 384.8, "standard_charge_percentage": 52.0, "count": "0", "additional_payer_notes": "Zero final payments for the item or service in the 15 months prior to posting the file." }, { "payer_name": "BLUE SHIELD OUT OF STATE", "plan_name": "STANFORD HEALTHCARE ALLIANCE PLAN", "methodology": "percent of total billed charges", "standard_charge_dollar": 359.57, "standard_charge_percentage": 48.59, "count": "0", "additional_payer_notes": "Zero final payments for the item or service in the 15 months prior to posting the file." }, { "payer_name": "BLUE SHIELD", "plan_name": "STANFORD HEALTHCARE ALLIANCE PLAN", "methodology": "percent of total billed charges", "standard_charge_dollar": 359.57, "standard_charge_percentage": 48.59, "count": "0", "additional_payer_notes": "Zero final payments for the item or service in the 15 months prior to posting the file." }, { "payer_name": "BLUE SHIELD", "plan_name": "STANFORD HEALTHCARE ALLIANCE PLAN", "methodology": "percent of total billed charges", "standard_charge_dollar": 359.57, "standard_charge_percentage": 48.59, "count": "0", "additional_payer_notes": "Zero final payments for the item or service in the 15 months prior to posting the file." }, { "payer_name": "CIGNA", "plan_name": "CIGNA COM ALT HMO PLAN", "methodology": "percent of total billed charges", "standard_charge_dollar": 312.28, "standard_charge_percentage": 42.2, "count": "0", "additional_payer_notes": "Zero final payments for the item or service in the 15 months prior to posting the file." }, { "payer_name": "CIGNA", "plan_name": "CIGNA COM ALT HMO PLAN", "methodology": "percent of total billed charges", "standard_charge_dollar": 312.28, "standard_charge_percentage": 42.2, "count": "0", "additional_payer_notes": "Zero final payments for the item or service in the 15 months prior to posting the file." }, { "payer_name": "HEALTH NET", "plan_name": "HEALTHNET HMO, PPO, POS, EPO, CANOPY HEALTHNET HMO, OTHER-IN-NETWORK PLANS", "methodology": "per diem", "standard_charge_dollar": 8000.0, "standard_charge_algorithm": "Expected reimbursement is the lesser of Per diem ($8,000) for the length of stay and 70% of billed.", "count": "0", "additional_payer_notes": "Zero final payments for the item or service in the 15 months prior to posting the file." }, { "payer_name": "HEALTH NET", "plan_name": "HEALTHNET HMO, PPO, POS, EPO, CANOPY HEALTHNET HMO, OTHER-IN-NETWORK PLANS", "methodology": "per diem", "standard_charge_dollar": 8000.0, "standard_charge_algorithm": "Expected reimbursement is the lesser of Per diem ($8,000) for the length of stay and 70% of billed.", "count": "0", "additional_payer_notes": "Zero final payments for the item or service in the 15 months prior to posting the file." }, { "payer_name": "UNITED HEALTHCARE", "plan_name": "SUTTER SELECT & SUTTER HEALTH PLAN HMO PLANS", "methodology": "per diem", "standard_charge_dollar": 28538.0, "standard_charge_algorithm": "Per diem ($28,538).", "count": "0", "additional_payer_notes": "Zero final payments for the item or service in the 15 months prior to posting the file." }, { "payer_name": "UNITED HEALTHCARE", "plan_name": "SUTTER SELECT & SUTTER HEALTH PLAN HMO PLANS", "methodology": "per diem", "standard_charge_dollar": 28538.0, "standard_charge_algorithm": "Per diem ($28,538).", "count": "0", "additional_payer_notes": "Zero final payments for the item or service in the 15 months prior to posting the file." }, { "payer_name": "SUTTER", "plan_name": "SUTTER SELECT & SUTTER HEALTH PLAN HMO PLANS", "methodology": "per diem", "standard_charge_dollar": 28538.0, "standard_charge_algorithm": "Per diem ($28,538).", "count": "0", "additional_payer_notes": "Zero final payments for the item or service in the 15 months prior to posting the file." }, { "payer_name": "UNITED HEALTHCARE", "plan_name": "SUTTER SELECT & SUTTER HEALTH PLAN HMO PLANS", "methodology": "per diem", "standard_charge_dollar": 28538.0, "standard_charge_algorithm": "Per diem ($28,538).", "count": "0", "additional_payer_notes": "Zero final payments for the item or service in the 15 months prior to posting the file." }, { "payer_name": "UMR", "plan_name": "SUTTER SELECT & SUTTER HEALTH PLAN HMO PLANS", "methodology": "per diem", "standard_charge_dollar": 28538.0, "standard_charge_algorithm": "Per diem ($28,538).", "count": "0", "additional_payer_notes": "Zero final payments for the item or service in the 15 months prior to posting the file." } ] } ] }, { "description": "HC Bowl Cement Gp012", "code_information": [ { "code": "PX-2120016012", "type": "CDM" }, { "code": "99999", "type": "CPT" }, { "code": "0272", "type": "RC" } ], "standard_charges": [ { "setting": "outpatient", "gross_charge": 810.0, "discounted_cash": 405.0, "minimum": 341.82, "maximum": 421.2, "additional_generic_notes": "Zero final payments for the item or service in the 15 months prior to posting the file.", "payers_information": [ { "payer_name": "AETNA", "plan_name": "AETNA ALL OTHER PLANS", "methodology": "percent of total billed charges", "standard_charge_dollar": 421.2, "standard_charge_percentage": 52.0, "count": "0", "additional_payer_notes": "Zero final payments for the item or service in the 15 months prior to posting the file." }, { "payer_name": "AETNA", "plan_name": "AETNA ALL OTHER PLANS", "methodology": "percent of total billed charges", "standard_charge_dollar": 421.2, "standard_charge_percentage": 52.0, "count": "0", "additional_payer_notes": "Zero final payments for the item or service in the 15 months prior to posting the file." }, { "payer_name": "MERITAIN HEALTH", "plan_name": "AETNA ALL OTHER PLANS", "methodology": "percent of total billed charges", "standard_charge_dollar": 421.2, "standard_charge_percentage": 52.0, "count": "0", "additional_payer_notes": "Zero final payments for the item or service in the 15 months prior to posting the file." }, { "payer_name": "BLUE SHIELD OUT OF STATE", "plan_name": "STANFORD HEALTHCARE ALLIANCE PLAN", "methodology": "percent of total billed charges", "standard_charge_dollar": 393.58, "standard_charge_percentage": 48.59, "count": "0", "additional_payer_notes": "Zero final payments for the item or service in the 15 months prior to posting the file." }, { "payer_name": "BLUE SHIELD", "plan_name": "STANFORD HEALTHCARE ALLIANCE PLAN", "methodology": "percent of total billed charges", "standard_charge_dollar": 393.58, "standard_charge_percentage": 48.59, "count": "0", "additional_payer_notes": "Zero final payments for the item or service in the 15 months prior to posting the file." }, { "payer_name": "BLUE SHIELD", "plan_name": "STANFORD HEALTHCARE ALLIANCE PLAN", "methodology": "percent of total billed charges", "standard_charge_dollar": 393.58, "standard_charge_percentage": 48.59, "count": "0", "additional_payer_notes": "Zero final payments for the item or service in the 15 months prior to posting the file." }, { "payer_name": "CIGNA", "plan_name": "CIGNA COM ALT HMO PLAN", "methodology": "percent of total billed charges", "standard_charge_dollar": 341.82, "standard_charge_percentage": 42.2, "count": "0", "additional_payer_notes": "Zero final payments for the item or service in the 15 months prior to posting the file." }, { "payer_name": "CIGNA", "plan_name": "CIGNA COM ALT HMO PLAN", "methodology": "percent of total billed charges", "standard_charge_dollar": 341.82, "standard_charge_percentage": 42.2, "count": "0", "additional_payer_notes": "Zero final payments for the item or service in the 15 months prior to posting the file." }, { "payer_name": "HEALTH NET", "plan_name": "HEALTHNET HMO, PPO, POS, EPO, CANOPY HEALTHNET HMO, OTHER-IN-NETWORK PLANS", "methodology": "per diem", "standard_charge_dollar": 8000.0, "standard_charge_algorithm": "Expected reimbursement is the lesser of Per diem ($8,000) for the length of stay and 70% of billed.", "count": "0", "additional_payer_notes": "Zero final payments for the item or service in the 15 months prior to posting the file." }, { "payer_name": "HEALTH NET", "plan_name": "HEALTHNET HMO, PPO, POS, EPO, CANOPY HEALTHNET HMO, OTHER-IN-NETWORK PLANS", "methodology": "per diem", "standard_charge_dollar": 8000.0, "standard_charge_algorithm": "Expected reimbursement is the lesser of Per diem ($8,000) for the length of stay and 70% of billed.", "count": "0", "additional_payer_notes": "Zero final payments for the item or service in the 15 months prior to posting the file." }, { "payer_name": "UNITED HEALTHCARE", "plan_name": "SUTTER SELECT & SUTTER HEALTH PLAN HMO PLANS", "methodology": "per diem", "standard_charge_dollar": 28538.0, "standard_charge_algorithm": "Per diem ($28,538).", "count": "0", "additional_payer_notes": "Zero final payments for the item or service in the 15 months prior to posting the file." }, { "payer_name": "UNITED HEALTHCARE", "plan_name": "SUTTER SELECT & SUTTER HEALTH PLAN HMO PLANS", "methodology": "per diem", "standard_charge_dollar": 28538.0, "standard_charge_algorithm": "Per diem ($28,538).", "count": "0", "additional_payer_notes": "Zero final payments for the item or service in the 15 months prior to posting the file." }, { "payer_name": "SUTTER", "plan_name": "SUTTER SELECT & SUTTER HEALTH PLAN HMO PLANS", "methodology": "per diem", "standard_charge_dollar": 28538.0, "standard_charge_algorithm": "Per diem ($28,538).", "count": "0", "additional_payer_notes": "Zero final payments for the item or service in the 15 months prior to posting the file." }, { "payer_name": "UNITED HEALTHCARE", "plan_name": "SUTTER SELECT & SUTTER HEALTH PLAN HMO PLANS", "methodology": "per diem", "standard_charge_dollar": 28538.0, "standard_charge_algorithm": "Per diem ($28,538).", "count": "0", "additional_payer_notes": "Zero final payments for the item or service in the 15 months prior to posting the file." }, { "payer_name": "UMR", "plan_name": "SUTTER SELECT & SUTTER HEALTH PLAN HMO PLANS", "methodology": "per diem", "standard_charge_dollar": 28538.0, "standard_charge_algorithm": "Per diem ($28,538).", "count": "0", "additional_payer_notes": "Zero final payments for the item or service in the 15 months prior to posting the file." } ] } ] }, { "description": "HC Bowl Mixing Cement Gp018", "code_information": [ { "code": "PX-2120016018", "type": "CDM" }, { "code": "99999", "type": "CPT" }, { "code": "0272", "type": "RC" } ], "standard_charges": [ { "setting": "outpatient", "gross_charge": 1750.0, "discounted_cash": 875.0, "minimum": 738.5, "maximum": 910.0, "additional_generic_notes": "Zero final payments for the item or service in the 15 months prior to posting the file.", "payers_information": [ { "payer_name": "AETNA", "plan_name": "AETNA ALL OTHER PLANS", "methodology": "percent of total billed charges", "standard_charge_dollar": 910.0, "standard_charge_percentage": 52.0, "count": "0", "additional_payer_notes": "Zero final payments for the item or service in the 15 months prior to posting the file." }, { "payer_name": "AETNA", "plan_name": "AETNA ALL OTHER PLANS", "methodology": "percent of total billed charges", "standard_charge_dollar": 910.0, "standard_charge_percentage": 52.0, "count": "0", "additional_payer_notes": "Zero final payments for the item or service in the 15 months prior to posting the file." }, { "payer_name": "MERITAIN HEALTH", "plan_name": "AETNA ALL OTHER PLANS", "methodology": "percent of total billed charges", "standard_charge_dollar": 910.0, "standard_charge_percentage": 52.0, "count": "0", "additional_payer_notes": "Zero final payments for the item or service in the 15 months prior to posting the file." }, { "payer_name": "BLUE SHIELD OUT OF STATE", "plan_name": "STANFORD HEALTHCARE ALLIANCE PLAN", "methodology": "percent of total billed charges", "standard_charge_dollar": 850.33, "standard_charge_percentage": 48.59, "count": "0", "additional_payer_notes": "Zero final payments for the item or service in the 15 months prior to posting the file." }, { "payer_name": "BLUE SHIELD", "plan_name": "STANFORD HEALTHCARE ALLIANCE PLAN", "methodology": "percent of total billed charges", "standard_charge_dollar": 850.33, "standard_charge_percentage": 48.59, "median_amount": 68.24, "10th_percentile": 13.6, "90th_percentile": 1043.06, "count": "30" }, { "payer_name": "BLUE SHIELD", "plan_name": "STANFORD HEALTHCARE ALLIANCE PLAN", "methodology": "percent of total billed charges", "standard_charge_dollar": 850.33, "standard_charge_percentage": 48.59, "count": "0", "additional_payer_notes": "Zero final payments for the item or service in the 15 months prior to posting the file." }, { "payer_name": "BLUE SHIELD", "plan_name": "STANFORD HEALTHCARE ALLIANCE PLAN", "methodology": "percent of total billed charges", "standard_charge_dollar": 850.33, "standard_charge_percentage": 48.59, "count": "0", "additional_payer_notes": "Zero final payments for the item or service in the 15 months prior to posting the file." }, { "payer_name": "CIGNA", "plan_name": "CIGNA COM ALT HMO PLAN", "methodology": "percent of total billed charges", "standard_charge_dollar": 738.5, "standard_charge_percentage": 42.2, "count": "0", "additional_payer_notes": "Zero final payments for the item or service in the 15 months prior to posting the file." }, { "payer_name": "CIGNA", "plan_name": "CIGNA COM ALT HMO PLAN", "methodology": "percent of total billed charges", "standard_charge_dollar": 738.5, "standard_charge_percentage": 42.2, "count": "0", "additional_payer_notes": "Zero final payments for the item or service in the 15 months prior to posting the file." }, { "payer_name": "HEALTH NET", "plan_name": "HEALTHNET HMO, PPO, POS, EPO, CANOPY HEALTHNET HMO, OTHER-IN-NETWORK PLANS", "methodology": "per diem", "standard_charge_dollar": 8000.0, "standard_charge_algorithm": "Expected reimbursement is the lesser of Per diem ($8,000) for the length of stay and 70% of billed.", "count": "0", "additional_payer_notes": "Zero final payments for the item or service in the 15 months prior to posting the file." }, { "payer_name": "HEALTH NET", "plan_name": "HEALTHNET HMO, PPO, POS, EPO, CANOPY HEALTHNET HMO, OTHER-IN-NETWORK PLANS", "methodology": "per diem", "standard_charge_dollar": 8000.0, "standard_charge_algorithm": "Expected reimbursement is the lesser of Per diem ($8,000) for the length of stay and 70% of billed.", "count": "0", "additional_payer_notes": "Zero final payments for the item or service in the 15 months prior to posting the file." }, { "payer_name": "UNITED HEALTHCARE", "plan_name": "SUTTER SELECT & SUTTER HEALTH PLAN HMO PLANS", "methodology": "per diem", "standard_charge_dollar": 28538.0, "standard_charge_algorithm": "Per diem ($28,538).", "count": "0", "additional_payer_notes": "Zero final payments for the item or service in the 15 months prior to posting the file." }, { "payer_name": "UNITED HEALTHCARE", "plan_name": "SUTTER SELECT & SUTTER HEALTH PLAN HMO PLANS", "methodology": "per diem", "standard_charge_dollar": 28538.0, "standard_charge_algorithm": "Per diem ($28,538).", "count": "0", "additional_payer_notes": "Zero final payments for the item or service in the 15 months prior to posting the file." }, { "payer_name": "SUTTER", "plan_name": "SUTTER SELECT & SUTTER HEALTH PLAN HMO PLANS", "methodology": "per diem", "standard_charge_dollar": 28538.0, "standard_charge_algorithm": "Per diem ($28,538).", "count": "0", "additional_payer_notes": "Zero final payments for the item or service in the 15 months prior to posting the file." }, { "payer_name": "UNITED HEALTHCARE", "plan_name": "SUTTER SELECT & SUTTER HEALTH PLAN HMO PLANS", "methodology": "per diem", "standard_charge_dollar": 28538.0, "standard_charge_algorithm": "Per diem ($28,538).", "count": "0", "additional_payer_notes": "Zero final payments for the item or service in the 15 months prior to posting the file." }, { "payer_name": "UMR", "plan_name": "SUTTER SELECT & SUTTER HEALTH PLAN HMO PLANS", "methodology": "per diem", "standard_charge_dollar": 28538.0, "standard_charge_algorithm": "Per diem ($28,538).", "count": "0", "additional_payer_notes": "Zero final payments for the item or service in the 15 months prior to posting the file." } ] } ] }, { "description": "HC Bur Gp002", "code_information": [ { "code": "PX-2120017002", "type": "CDM" }, { "code": "99999", "type": "CPT" }, { "code": "0272", "type": "RC" } ], "standard_charges": [ { "setting": "outpatient", "gross_charge": 50.0, "discounted_cash": 25.0, "minimum": 21.1, "maximum": 26.0, "additional_generic_notes": "Zero final payments for the item or service in the 15 months prior to posting the file.", "payers_information": [ { "payer_name": "AETNA", "plan_name": "AETNA ALL OTHER PLANS", "methodology": "percent of total billed charges", "standard_charge_dollar": 26.0, "standard_charge_percentage": 52.0, "count": "0", "additional_payer_notes": "Zero final payments for the item or service in the 15 months prior to posting the file." }, { "payer_name": "AETNA", "plan_name": "AETNA ALL OTHER PLANS", "methodology": "percent of total billed charges", "standard_charge_dollar": 26.0, "standard_charge_percentage": 52.0, "count": "0", "additional_payer_notes": "Zero final payments for the item or service in the 15 months prior to posting the file." }, { "payer_name": "MERITAIN HEALTH", "plan_name": "AETNA ALL OTHER PLANS", "methodology": "percent of total billed charges", "standard_charge_dollar": 26.0, "standard_charge_percentage": 52.0, "count": "0", "additional_payer_notes": "Zero final payments for the item or service in the 15 months prior to posting the file." }, { "payer_name": "BLUE SHIELD OUT OF STATE", "plan_name": "STANFORD HEALTHCARE ALLIANCE PLAN", "methodology": "percent of total billed charges", "standard_charge_dollar": 24.3, "standard_charge_percentage": 48.59, "count": "0", "additional_payer_notes": "Zero final payments for the item or service in the 15 months prior to posting the file." }, { "payer_name": "BLUE SHIELD", "plan_name": "STANFORD HEALTHCARE ALLIANCE PLAN", "methodology": "percent of total billed charges", "standard_charge_dollar": 24.3, "standard_charge_percentage": 48.59, "count": "0", "additional_payer_notes": "Zero final payments for the item or service in the 15 months prior to posting the file." }, { "payer_name": "BLUE SHIELD", "plan_name": "STANFORD HEALTHCARE ALLIANCE PLAN", "methodology": "percent of total billed charges", "standard_charge_dollar": 24.3, "standard_charge_percentage": 48.59, "count": "0", "additional_payer_notes": "Zero final payments for the item or service in the 15 months prior to posting the file." }, { "payer_name": "CIGNA", "plan_name": "CIGNA COM ALT HMO PLAN", "methodology": "percent of total billed charges", "standard_charge_dollar": 21.1, "standard_charge_percentage": 42.2, "count": "0", "additional_payer_notes": "Zero final payments for the item or service in the 15 months prior to posting the file." }, { "payer_name": "CIGNA", "plan_name": "CIGNA COM ALT HMO PLAN", "methodology": "percent of total billed charges", "standard_charge_dollar": 21.1, "standard_charge_percentage": 42.2, "count": "0", "additional_payer_notes": "Zero final payments for the item or service in the 15 months prior to posting the file." }, { "payer_name": "HEALTH NET", "plan_name": "HEALTHNET HMO, PPO, POS, EPO, CANOPY HEALTHNET HMO, OTHER-IN-NETWORK PLANS", "methodology": "per diem", "standard_charge_dollar": 8000.0, "standard_charge_algorithm": "Expected reimbursement is the lesser of Per diem ($8,000) for the length of stay and 70% of billed.", "count": "0", "additional_payer_notes": "Zero final payments for the item or service in the 15 months prior to posting the file." }, { "payer_name": "HEALTH NET", "plan_name": "HEALTHNET HMO, PPO, POS, EPO, CANOPY HEALTHNET HMO, OTHER-IN-NETWORK PLANS", "methodology": "per diem", "standard_charge_dollar": 8000.0, "standard_charge_algorithm": "Expected reimbursement is the lesser of Per diem ($8,000) for the length of stay and 70% of billed.", "count": "0", "additional_payer_notes": "Zero final payments for the item or service in the 15 months prior to posting the file." }, { "payer_name": "UNITED HEALTHCARE", "plan_name": "SUTTER SELECT & SUTTER HEALTH PLAN HMO PLANS", "methodology": "per diem", "standard_charge_dollar": 28538.0, "standard_charge_algorithm": "Per diem ($28,538).", "count": "0", "additional_payer_notes": "Zero final payments for the item or service in the 15 months prior to posting the file." }, { "payer_name": "UNITED HEALTHCARE", "plan_name": "SUTTER SELECT & SUTTER HEALTH PLAN HMO PLANS", "methodology": "per diem", "standard_charge_dollar": 28538.0, "standard_charge_algorithm": "Per diem ($28,538).", "count": "0", "additional_payer_notes": "Zero final payments for the item or service in the 15 months prior to posting the file." }, { "payer_name": "SUTTER", "plan_name": "SUTTER SELECT & SUTTER HEALTH PLAN HMO PLANS", "methodology": "per diem", "standard_charge_dollar": 28538.0, "standard_charge_algorithm": "Per diem ($28,538).", "count": "0", "additional_payer_notes": "Zero final payments for the item or service in the 15 months prior to posting the file." }, { "payer_name": "UNITED HEALTHCARE", "plan_name": "SUTTER SELECT & SUTTER HEALTH PLAN HMO PLANS", "methodology": "per diem", "standard_charge_dollar": 28538.0, "standard_charge_algorithm": "Per diem ($28,538).", "count": "0", "additional_payer_notes": "Zero final payments for the item or service in the 15 months prior to posting the file." }, { "payer_name": "UMR", "plan_name": "SUTTER SELECT & SUTTER HEALTH PLAN HMO PLANS", "methodology": "per diem", "standard_charge_dollar": 28538.0, "standard_charge_algorithm": "Per diem ($28,538).", "count": "0", "additional_payer_notes": "Zero final payments for the item or service in the 15 months prior to posting the file." } ] } ] }, { "description": "HC Bur Gp003", "code_information": [ { "code": "PX-2120017003", "type": "CDM" }, { "code": "99999", "type": "CPT" }, { "code": "0272", "type": "RC" } ], "standard_charges": [ { "setting": "outpatient", "gross_charge": 100.0, "discounted_cash": 50.0, "minimum": 42.2, "maximum": 52.0, "additional_generic_notes": "Zero final payments for the item or service in the 15 months prior to posting the file.", "payers_information": [ { "payer_name": "AETNA", "plan_name": "AETNA ALL OTHER PLANS", "methodology": "percent of total billed charges", "standard_charge_dollar": 52.0, "standard_charge_percentage": 52.0, "count": "0", "additional_payer_notes": "Zero final payments for the item or service in the 15 months prior to posting the file." }, { "payer_name": "AETNA", "plan_name": "AETNA ALL OTHER PLANS", "methodology": "percent of total billed charges", "standard_charge_dollar": 52.0, "standard_charge_percentage": 52.0, "count": "0", "additional_payer_notes": "Zero final payments for the item or service in the 15 months prior to posting the file." }, { "payer_name": "MERITAIN HEALTH", "plan_name": "AETNA ALL OTHER PLANS", "methodology": "percent of total billed charges", "standard_charge_dollar": 52.0, "standard_charge_percentage": 52.0, "count": "0", "additional_payer_notes": "Zero final payments for the item or service in the 15 months prior to posting the file." }, { "payer_name": "BLUE SHIELD OUT OF STATE", "plan_name": "STANFORD HEALTHCARE ALLIANCE PLAN", "methodology": "percent of total billed charges", "standard_charge_dollar": 48.59, "standard_charge_percentage": 48.59, "count": "0", "additional_payer_notes": "Zero final payments for the item or service in the 15 months prior to posting the file." }, { "payer_name": "BLUE SHIELD", "plan_name": "STANFORD HEALTHCARE ALLIANCE PLAN", "methodology": "percent of total billed charges", "standard_charge_dollar": 48.59, "standard_charge_percentage": 48.59, "count": "0", "additional_payer_notes": "Zero final payments for the item or service in the 15 months prior to posting the file." }, { "payer_name": "BLUE SHIELD", "plan_name": "STANFORD HEALTHCARE ALLIANCE PLAN", "methodology": "percent of total billed charges", "standard_charge_dollar": 48.59, "standard_charge_percentage": 48.59, "count": "0", "additional_payer_notes": "Zero final payments for the item or service in the 15 months prior to posting the file." }, { "payer_name": "CIGNA", "plan_name": "CIGNA COM ALT HMO PLAN", "methodology": "percent of total billed charges", "standard_charge_dollar": 42.2, "standard_charge_percentage": 42.2, "count": "0", "additional_payer_notes": "Zero final payments for the item or service in the 15 months prior to posting the file." }, { "payer_name": "CIGNA", "plan_name": "CIGNA COM ALT HMO PLAN", "methodology": "percent of total billed charges", "standard_charge_dollar": 42.2, "standard_charge_percentage": 42.2, "count": "0", "additional_payer_notes": "Zero final payments for the item or service in the 15 months prior to posting the file." }, { "payer_name": "HEALTH NET", "plan_name": "HEALTHNET HMO, PPO, POS, EPO, CANOPY HEALTHNET HMO, OTHER-IN-NETWORK PLANS", "methodology": "per diem", "standard_charge_dollar": 8000.0, "standard_charge_algorithm": "Expected reimbursement is the lesser of Per diem ($8,000) for the length of stay and 70% of billed.", "count": "0", "additional_payer_notes": "Zero final payments for the item or service in the 15 months prior to posting the file." }, { "payer_name": "HEALTH NET", "plan_name": "HEALTHNET HMO, PPO, POS, EPO, CANOPY HEALTHNET HMO, OTHER-IN-NETWORK PLANS", "methodology": "per diem", "standard_charge_dollar": 8000.0, "standard_charge_algorithm": "Expected reimbursement is the lesser of Per diem ($8,000) for the length of stay and 70% of billed.", "count": "0", "additional_payer_notes": "Zero final payments for the item or service in the 15 months prior to posting the file." }, { "payer_name": "UNITED HEALTHCARE", "plan_name": "SUTTER SELECT & SUTTER HEALTH PLAN HMO PLANS", "methodology": "per diem", "standard_charge_dollar": 28538.0, "standard_charge_algorithm": "Per diem ($28,538).", "count": "0", "additional_payer_notes": "Zero final payments for the item or service in the 15 months prior to posting the file." }, { "payer_name": "UNITED HEALTHCARE", "plan_name": "SUTTER SELECT & SUTTER HEALTH PLAN HMO PLANS", "methodology": "per diem", "standard_charge_dollar": 28538.0, "standard_charge_algorithm": "Per diem ($28,538).", "count": "0", "additional_payer_notes": "Zero final payments for the item or service in the 15 months prior to posting the file." }, { "payer_name": "SUTTER", "plan_name": "SUTTER SELECT & SUTTER HEALTH PLAN HMO PLANS", "methodology": "per diem", "standard_charge_dollar": 28538.0, "standard_charge_algorithm": "Per diem ($28,538).", "count": "0", "additional_payer_notes": "Zero final payments for the item or service in the 15 months prior to posting the file." }, { "payer_name": "UNITED HEALTHCARE", "plan_name": "SUTTER SELECT & SUTTER HEALTH PLAN HMO PLANS", "methodology": "per diem", "standard_charge_dollar": 28538.0, "standard_charge_algorithm": "Per diem ($28,538).", "count": "0", "additional_payer_notes": "Zero final payments for the item or service in the 15 months prior to posting the file." }, { "payer_name": "UMR", "plan_name": "SUTTER SELECT & SUTTER HEALTH PLAN HMO PLANS", "methodology": "per diem", "standard_charge_dollar": 28538.0, "standard_charge_algorithm": "Per diem ($28,538).", "count": "0", "additional_payer_notes": "Zero final payments for the item or service in the 15 months prior to posting the file." } ] } ] }, { "description": "HC Bur Gp004", "code_information": [ { "code": "PX-2120017004", "type": "CDM" }, { "code": "99999", "type": "CPT" }, { "code": "0272", "type": "RC" } ], "standard_charges": [ { "setting": "outpatient", "gross_charge": 146.0, "discounted_cash": 73.0, "minimum": 61.61, "maximum": 75.92, "additional_generic_notes": "Zero final payments for the item or service in the 15 months prior to posting the file.", "payers_information": [ { "payer_name": "AETNA", "plan_name": "AETNA ALL OTHER PLANS", "methodology": "percent of total billed charges", "standard_charge_dollar": 75.92, "standard_charge_percentage": 52.0, "count": "0", "additional_payer_notes": "Zero final payments for the item or service in the 15 months prior to posting the file." }, { "payer_name": "AETNA", "plan_name": "AETNA ALL OTHER PLANS", "methodology": "percent of total billed charges", "standard_charge_dollar": 75.92, "standard_charge_percentage": 52.0, "count": "0", "additional_payer_notes": "Zero final payments for the item or service in the 15 months prior to posting the file." }, { "payer_name": "MERITAIN HEALTH", "plan_name": "AETNA ALL OTHER PLANS", "methodology": "percent of total billed charges", "standard_charge_dollar": 75.92, "standard_charge_percentage": 52.0, "count": "0", "additional_payer_notes": "Zero final payments for the item or service in the 15 months prior to posting the file." }, { "payer_name": "BLUE SHIELD OUT OF STATE", "plan_name": "STANFORD HEALTHCARE ALLIANCE PLAN", "methodology": "percent of total billed charges", "standard_charge_dollar": 70.94, "standard_charge_percentage": 48.59, "count": "0", "additional_payer_notes": "Zero final payments for the item or service in the 15 months prior to posting the file." }, { "payer_name": "BLUE SHIELD", "plan_name": "STANFORD HEALTHCARE ALLIANCE PLAN", "methodology": "percent of total billed charges", "standard_charge_dollar": 70.94, "standard_charge_percentage": 48.59, "count": "0", "additional_payer_notes": "Zero final payments for the item or service in the 15 months prior to posting the file." }, { "payer_name": "BLUE SHIELD", "plan_name": "STANFORD HEALTHCARE ALLIANCE PLAN", "methodology": "percent of total billed charges", "standard_charge_dollar": 70.94, "standard_charge_percentage": 48.59, "count": "0", "additional_payer_notes": "Zero final payments for the item or service in the 15 months prior to posting the file." }, { "payer_name": "CIGNA", "plan_name": "CIGNA COM ALT HMO PLAN", "methodology": "percent of total billed charges", "standard_charge_dollar": 61.61, "standard_charge_percentage": 42.2, "count": "0", "additional_payer_notes": "Zero final payments for the item or service in the 15 months prior to posting the file." }, { "payer_name": "CIGNA", "plan_name": "CIGNA COM ALT HMO PLAN", "methodology": "percent of total billed charges", "standard_charge_dollar": 61.61, "standard_charge_percentage": 42.2, "count": "0", "additional_payer_notes": "Zero final payments for the item or service in the 15 months prior to posting the file." }, { "payer_name": "HEALTH NET", "plan_name": "HEALTHNET HMO, PPO, POS, EPO, CANOPY HEALTHNET HMO, OTHER-IN-NETWORK PLANS", "methodology": "per diem", "standard_charge_dollar": 8000.0, "standard_charge_algorithm": "Expected reimbursement is the lesser of Per diem ($8,000) for the length of stay and 70% of billed.", "count": "0", "additional_payer_notes": "Zero final payments for the item or service in the 15 months prior to posting the file." }, { "payer_name": "HEALTH NET", "plan_name": "HEALTHNET HMO, PPO, POS, EPO, CANOPY HEALTHNET HMO, OTHER-IN-NETWORK PLANS", "methodology": "per diem", "standard_charge_dollar": 8000.0, "standard_charge_algorithm": "Expected reimbursement is the lesser of Per diem ($8,000) for the length of stay and 70% of billed.", "count": "0", "additional_payer_notes": "Zero final payments for the item or service in the 15 months prior to posting the file." }, { "payer_name": "UNITED HEALTHCARE", "plan_name": "SUTTER SELECT & SUTTER HEALTH PLAN HMO PLANS", "methodology": "per diem", "standard_charge_dollar": 28538.0, "standard_charge_algorithm": "Per diem ($28,538).", "count": "0", "additional_payer_notes": "Zero final payments for the item or service in the 15 months prior to posting the file." }, { "payer_name": "UNITED HEALTHCARE", "plan_name": "SUTTER SELECT & SUTTER HEALTH PLAN HMO PLANS", "methodology": "per diem", "standard_charge_dollar": 28538.0, "standard_charge_algorithm": "Per diem ($28,538).", "count": "0", "additional_payer_notes": "Zero final payments for the item or service in the 15 months prior to posting the file." }, { "payer_name": "SUTTER", "plan_name": "SUTTER SELECT & SUTTER HEALTH PLAN HMO PLANS", "methodology": "per diem", "standard_charge_dollar": 28538.0, "standard_charge_algorithm": "Per diem ($28,538).", "count": "0", "additional_payer_notes": "Zero final payments for the item or service in the 15 months prior to posting the file." }, { "payer_name": "UNITED HEALTHCARE", "plan_name": "SUTTER SELECT & SUTTER HEALTH PLAN HMO PLANS", "methodology": "per diem", "standard_charge_dollar": 28538.0, "standard_charge_algorithm": "Per diem ($28,538).", "count": "0", "additional_payer_notes": "Zero final payments for the item or service in the 15 months prior to posting the file." }, { "payer_name": "UMR", "plan_name": "SUTTER SELECT & SUTTER HEALTH PLAN HMO PLANS", "methodology": "per diem", "standard_charge_dollar": 28538.0, "standard_charge_algorithm": "Per diem ($28,538).", "count": "0", "additional_payer_notes": "Zero final payments for the item or service in the 15 months prior to posting the file." } ] } ] }, { "description": "HC Bur Gp005", "code_information": [ { "code": "PX-2120017005", "type": "CDM" }, { "code": "99999", "type": "CPT" }, { "code": "0272", "type": "RC" } ], "standard_charges": [ { "setting": "outpatient", "gross_charge": 195.0, "discounted_cash": 97.5, "minimum": 82.29, "maximum": 101.4, "additional_generic_notes": "Zero final payments for the item or service in the 15 months prior to posting the file.", "payers_information": [ { "payer_name": "AETNA", "plan_name": "AETNA ALL OTHER PLANS", "methodology": "percent of total billed charges", "standard_charge_dollar": 101.4, "standard_charge_percentage": 52.0, "count": "0", "additional_payer_notes": "Zero final payments for the item or service in the 15 months prior to posting the file." }, { "payer_name": "AETNA", "plan_name": "AETNA ALL OTHER PLANS", "methodology": "percent of total billed charges", "standard_charge_dollar": 101.4, "standard_charge_percentage": 52.0, "count": "0", "additional_payer_notes": "Zero final payments for the item or service in the 15 months prior to posting the file." }, { "payer_name": "MERITAIN HEALTH", "plan_name": "AETNA ALL OTHER PLANS", "methodology": "percent of total billed charges", "standard_charge_dollar": 101.4, "standard_charge_percentage": 52.0, "count": "0", "additional_payer_notes": "Zero final payments for the item or service in the 15 months prior to posting the file." }, { "payer_name": "BLUE SHIELD OUT OF STATE", "plan_name": "STANFORD HEALTHCARE ALLIANCE PLAN", "methodology": "percent of total billed charges", "standard_charge_dollar": 94.75, "standard_charge_percentage": 48.59, "count": "0", "additional_payer_notes": "Zero final payments for the item or service in the 15 months prior to posting the file." }, { "payer_name": "BLUE SHIELD", "plan_name": "STANFORD HEALTHCARE ALLIANCE PLAN", "methodology": "percent of total billed charges", "standard_charge_dollar": 94.75, "standard_charge_percentage": 48.59, "count": "0", "additional_payer_notes": "Zero final payments for the item or service in the 15 months prior to posting the file." }, { "payer_name": "BLUE SHIELD", "plan_name": "STANFORD HEALTHCARE ALLIANCE PLAN", "methodology": "percent of total billed charges", "standard_charge_dollar": 94.75, "standard_charge_percentage": 48.59, "count": "0", "additional_payer_notes": "Zero final payments for the item or service in the 15 months prior to posting the file." }, { "payer_name": "CIGNA", "plan_name": "CIGNA COM ALT HMO PLAN", "methodology": "percent of total billed charges", "standard_charge_dollar": 82.29, "standard_charge_percentage": 42.2, "count": "0", "additional_payer_notes": "Zero final payments for the item or service in the 15 months prior to posting the file." }, { "payer_name": "CIGNA", "plan_name": "CIGNA COM ALT HMO PLAN", "methodology": "percent of total billed charges", "standard_charge_dollar": 82.29, "standard_charge_percentage": 42.2, "count": "0", "additional_payer_notes": "Zero final payments for the item or service in the 15 months prior to posting the file." }, { "payer_name": "HEALTH NET", "plan_name": "HEALTHNET HMO, PPO, POS, EPO, CANOPY HEALTHNET HMO, OTHER-IN-NETWORK PLANS", "methodology": "per diem", "standard_charge_dollar": 8000.0, "standard_charge_algorithm": "Expected reimbursement is the lesser of Per diem ($8,000) for the length of stay and 70% of billed.", "count": "0", "additional_payer_notes": "Zero final payments for the item or service in the 15 months prior to posting the file." }, { "payer_name": "HEALTH NET", "plan_name": "HEALTHNET HMO, PPO, POS, EPO, CANOPY HEALTHNET HMO, OTHER-IN-NETWORK PLANS", "methodology": "per diem", "standard_charge_dollar": 8000.0, "standard_charge_algorithm": "Expected reimbursement is the lesser of Per diem ($8,000) for the length of stay and 70% of billed.", "count": "0", "additional_payer_notes": "Zero final payments for the item or service in the 15 months prior to posting the file." }, { "payer_name": "UNITED HEALTHCARE", "plan_name": "SUTTER SELECT & SUTTER HEALTH PLAN HMO PLANS", "methodology": "per diem", "standard_charge_dollar": 28538.0, "standard_charge_algorithm": "Per diem ($28,538).", "count": "0", "additional_payer_notes": "Zero final payments for the item or service in the 15 months prior to posting the file." }, { "payer_name": "UNITED HEALTHCARE", "plan_name": "SUTTER SELECT & SUTTER HEALTH PLAN HMO PLANS", "methodology": "per diem", "standard_charge_dollar": 28538.0, "standard_charge_algorithm": "Per diem ($28,538).", "count": "0", "additional_payer_notes": "Zero final payments for the item or service in the 15 months prior to posting the file." }, { "payer_name": "SUTTER", "plan_name": "SUTTER SELECT & SUTTER HEALTH PLAN HMO PLANS", "methodology": "per diem", "standard_charge_dollar": 28538.0, "standard_charge_algorithm": "Per diem ($28,538).", "count": "0", "additional_payer_notes": "Zero final payments for the item or service in the 15 months prior to posting the file." }, { "payer_name": "UNITED HEALTHCARE", "plan_name": "SUTTER SELECT & SUTTER HEALTH PLAN HMO PLANS", "methodology": "per diem", "standard_charge_dollar": 28538.0, "standard_charge_algorithm": "Per diem ($28,538).", "count": "0", "additional_payer_notes": "Zero final payments for the item or service in the 15 months prior to posting the file." }, { "payer_name": "UMR", "plan_name": "SUTTER SELECT & SUTTER HEALTH PLAN HMO PLANS", "methodology": "per diem", "standard_charge_dollar": 28538.0, "standard_charge_algorithm": "Per diem ($28,538).", "count": "0", "additional_payer_notes": "Zero final payments for the item or service in the 15 months prior to posting the file." } ] } ] }, { "description": "HC Bur Gp006", "code_information": [ { "code": "PX-2120017006", "type": "CDM" }, { "code": "99999", "type": "CPT" }, { "code": "0272", "type": "RC" } ], "standard_charges": [ { "setting": "outpatient", "gross_charge": 293.0, "discounted_cash": 146.5, "minimum": 123.65, "maximum": 152.36, "additional_generic_notes": "Zero final payments for the item or service in the 15 months prior to posting the file.", "payers_information": [ { "payer_name": "AETNA", "plan_name": "AETNA ALL OTHER PLANS", "methodology": "percent of total billed charges", "standard_charge_dollar": 152.36, "standard_charge_percentage": 52.0, "count": "0", "additional_payer_notes": "Zero final payments for the item or service in the 15 months prior to posting the file." }, { "payer_name": "AETNA", "plan_name": "AETNA ALL OTHER PLANS", "methodology": "percent of total billed charges", "standard_charge_dollar": 152.36, "standard_charge_percentage": 52.0, "count": "0", "additional_payer_notes": "Zero final payments for the item or service in the 15 months prior to posting the file." }, { "payer_name": "MERITAIN HEALTH", "plan_name": "AETNA ALL OTHER PLANS", "methodology": "percent of total billed charges", "standard_charge_dollar": 152.36, "standard_charge_percentage": 52.0, "count": "0", "additional_payer_notes": "Zero final payments for the item or service in the 15 months prior to posting the file." }, { "payer_name": "BLUE SHIELD OUT OF STATE", "plan_name": "STANFORD HEALTHCARE ALLIANCE PLAN", "methodology": "percent of total billed charges", "standard_charge_dollar": 142.37, "standard_charge_percentage": 48.59, "count": "0", "additional_payer_notes": "Zero final payments for the item or service in the 15 months prior to posting the file." }, { "payer_name": "BLUE SHIELD", "plan_name": "STANFORD HEALTHCARE ALLIANCE PLAN", "methodology": "percent of total billed charges", "standard_charge_dollar": 142.37, "standard_charge_percentage": 48.59, "count": "0", "additional_payer_notes": "Zero final payments for the item or service in the 15 months prior to posting the file." }, { "payer_name": "BLUE SHIELD", "plan_name": "STANFORD HEALTHCARE ALLIANCE PLAN", "methodology": "percent of total billed charges", "standard_charge_dollar": 142.37, "standard_charge_percentage": 48.59, "count": "0", "additional_payer_notes": "Zero final payments for the item or service in the 15 months prior to posting the file." }, { "payer_name": "CIGNA", "plan_name": "CIGNA COM ALT HMO PLAN", "methodology": "percent of total billed charges", "standard_charge_dollar": 123.65, "standard_charge_percentage": 42.2, "count": "0", "additional_payer_notes": "Zero final payments for the item or service in the 15 months prior to posting the file." }, { "payer_name": "CIGNA", "plan_name": "CIGNA COM ALT HMO PLAN", "methodology": "percent of total billed charges", "standard_charge_dollar": 123.65, "standard_charge_percentage": 42.2, "count": "0", "additional_payer_notes": "Zero final payments for the item or service in the 15 months prior to posting the file." }, { "payer_name": "HEALTH NET", "plan_name": "HEALTHNET HMO, PPO, POS, EPO, CANOPY HEALTHNET HMO, OTHER-IN-NETWORK PLANS", "methodology": "per diem", "standard_charge_dollar": 8000.0, "standard_charge_algorithm": "Expected reimbursement is the lesser of Per diem ($8,000) for the length of stay and 70% of billed.", "count": "0", "additional_payer_notes": "Zero final payments for the item or service in the 15 months prior to posting the file." }, { "payer_name": "HEALTH NET", "plan_name": "HEALTHNET HMO, PPO, POS, EPO, CANOPY HEALTHNET HMO, OTHER-IN-NETWORK PLANS", "methodology": "per diem", "standard_charge_dollar": 8000.0, "standard_charge_algorithm": "Expected reimbursement is the lesser of Per diem ($8,000) for the length of stay and 70% of billed.", "count": "0", "additional_payer_notes": "Zero final payments for the item or service in the 15 months prior to posting the file." }, { "payer_name": "UNITED HEALTHCARE", "plan_name": "SUTTER SELECT & SUTTER HEALTH PLAN HMO PLANS", "methodology": "per diem", "standard_charge_dollar": 28538.0, "standard_charge_algorithm": "Per diem ($28,538).", "count": "0", "additional_payer_notes": "Zero final payments for the item or service in the 15 months prior to posting the file." }, { "payer_name": "UNITED HEALTHCARE", "plan_name": "SUTTER SELECT & SUTTER HEALTH PLAN HMO PLANS", "methodology": "per diem", "standard_charge_dollar": 28538.0, "standard_charge_algorithm": "Per diem ($28,538).", "count": "0", "additional_payer_notes": "Zero final payments for the item or service in the 15 months prior to posting the file." }, { "payer_name": "SUTTER", "plan_name": "SUTTER SELECT & SUTTER HEALTH PLAN HMO PLANS", "methodology": "per diem", "standard_charge_dollar": 28538.0, "standard_charge_algorithm": "Per diem ($28,538).", "count": "0", "additional_payer_notes": "Zero final payments for the item or service in the 15 months prior to posting the file." }, { "payer_name": "UNITED HEALTHCARE", "plan_name": "SUTTER SELECT & SUTTER HEALTH PLAN HMO PLANS", "methodology": "per diem", "standard_charge_dollar": 28538.0, "standard_charge_algorithm": "Per diem ($28,538).", "count": "0", "additional_payer_notes": "Zero final payments for the item or service in the 15 months prior to posting the file." }, { "payer_name": "UMR", "plan_name": "SUTTER SELECT & SUTTER HEALTH PLAN HMO PLANS", "methodology": "per diem", "standard_charge_dollar": 28538.0, "standard_charge_algorithm": "Per diem ($28,538).", "count": "0", "additional_payer_notes": "Zero final payments for the item or service in the 15 months prior to posting the file." } ] } ] }, { "description": "HC Bur Gp007", "code_information": [ { "code": "PX-2120017007", "type": "CDM" }, { "code": "99999", "type": "CPT" }, { "code": "0272", "type": "RC" } ], "standard_charges": [ { "setting": "outpatient", "gross_charge": 380.0, "discounted_cash": 190.0, "minimum": 160.36, "maximum": 197.6, "additional_generic_notes": "Zero final payments for the item or service in the 15 months prior to posting the file.", "payers_information": [ { "payer_name": "AETNA", "plan_name": "AETNA ALL OTHER PLANS", "methodology": "percent of total billed charges", "standard_charge_dollar": 197.6, "standard_charge_percentage": 52.0, "count": "0", "additional_payer_notes": "Zero final payments for the item or service in the 15 months prior to posting the file." }, { "payer_name": "AETNA", "plan_name": "AETNA ALL OTHER PLANS", "methodology": "percent of total billed charges", "standard_charge_dollar": 197.6, "standard_charge_percentage": 52.0, "count": "0", "additional_payer_notes": "Zero final payments for the item or service in the 15 months prior to posting the file." }, { "payer_name": "MERITAIN HEALTH", "plan_name": "AETNA ALL OTHER PLANS", "methodology": "percent of total billed charges", "standard_charge_dollar": 197.6, "standard_charge_percentage": 52.0, "count": "0", "additional_payer_notes": "Zero final payments for the item or service in the 15 months prior to posting the file." }, { "payer_name": "BLUE SHIELD OUT OF STATE", "plan_name": "STANFORD HEALTHCARE ALLIANCE PLAN", "methodology": "percent of total billed charges", "standard_charge_dollar": 184.64, "standard_charge_percentage": 48.59, "count": "0", "additional_payer_notes": "Zero final payments for the item or service in the 15 months prior to posting the file." }, { "payer_name": "BLUE SHIELD", "plan_name": "STANFORD HEALTHCARE ALLIANCE PLAN", "methodology": "percent of total billed charges", "standard_charge_dollar": 184.64, "standard_charge_percentage": 48.59, "count": "0", "additional_payer_notes": "Zero final payments for the item or service in the 15 months prior to posting the file." }, { "payer_name": "BLUE SHIELD", "plan_name": "STANFORD HEALTHCARE ALLIANCE PLAN", "methodology": "percent of total billed charges", "standard_charge_dollar": 184.64, "standard_charge_percentage": 48.59, "count": "0", "additional_payer_notes": "Zero final payments for the item or service in the 15 months prior to posting the file." }, { "payer_name": "CIGNA", "plan_name": "CIGNA COM ALT HMO PLAN", "methodology": "percent of total billed charges", "standard_charge_dollar": 160.36, "standard_charge_percentage": 42.2, "count": "0", "additional_payer_notes": "Zero final payments for the item or service in the 15 months prior to posting the file." }, { "payer_name": "CIGNA", "plan_name": "CIGNA COM ALT HMO PLAN", "methodology": "percent of total billed charges", "standard_charge_dollar": 160.36, "standard_charge_percentage": 42.2, "count": "0", "additional_payer_notes": "Zero final payments for the item or service in the 15 months prior to posting the file." }, { "payer_name": "HEALTH NET", "plan_name": "HEALTHNET HMO, PPO, POS, EPO, CANOPY HEALTHNET HMO, OTHER-IN-NETWORK PLANS", "methodology": "per diem", "standard_charge_dollar": 8000.0, "standard_charge_algorithm": "Expected reimbursement is the lesser of Per diem ($8,000) for the length of stay and 70% of billed.", "count": "0", "additional_payer_notes": "Zero final payments for the item or service in the 15 months prior to posting the file." }, { "payer_name": "HEALTH NET", "plan_name": "HEALTHNET HMO, PPO, POS, EPO, CANOPY HEALTHNET HMO, OTHER-IN-NETWORK PLANS", "methodology": "per diem", "standard_charge_dollar": 8000.0, "standard_charge_algorithm": "Expected reimbursement is the lesser of Per diem ($8,000) for the length of stay and 70% of billed.", "count": "0", "additional_payer_notes": "Zero final payments for the item or service in the 15 months prior to posting the file." }, { "payer_name": "UNITED HEALTHCARE", "plan_name": "SUTTER SELECT & SUTTER HEALTH PLAN HMO PLANS", "methodology": "per diem", "standard_charge_dollar": 28538.0, "standard_charge_algorithm": "Per diem ($28,538).", "count": "0", "additional_payer_notes": "Zero final payments for the item or service in the 15 months prior to posting the file." }, { "payer_name": "UNITED HEALTHCARE", "plan_name": "SUTTER SELECT & SUTTER HEALTH PLAN HMO PLANS", "methodology": "per diem", "standard_charge_dollar": 28538.0, "standard_charge_algorithm": "Per diem ($28,538).", "count": "0", "additional_payer_notes": "Zero final payments for the item or service in the 15 months prior to posting the file." }, { "payer_name": "SUTTER", "plan_name": "SUTTER SELECT & SUTTER HEALTH PLAN HMO PLANS", "methodology": "per diem", "standard_charge_dollar": 28538.0, "standard_charge_algorithm": "Per diem ($28,538).", "count": "0", "additional_payer_notes": "Zero final payments for the item or service in the 15 months prior to posting the file." }, { "payer_name": "UNITED HEALTHCARE", "plan_name": "SUTTER SELECT & SUTTER HEALTH PLAN HMO PLANS", "methodology": "per diem", "standard_charge_dollar": 28538.0, "standard_charge_algorithm": "Per diem ($28,538).", "count": "0", "additional_payer_notes": "Zero final payments for the item or service in the 15 months prior to posting the file." }, { "payer_name": "UMR", "plan_name": "SUTTER SELECT & SUTTER HEALTH PLAN HMO PLANS", "methodology": "per diem", "standard_charge_dollar": 28538.0, "standard_charge_algorithm": "Per diem ($28,538).", "count": "0", "additional_payer_notes": "Zero final payments for the item or service in the 15 months prior to posting the file." } ] } ] }, { "description": "HC Bur Gp008", "code_information": [ { "code": "PX-2120017008", "type": "CDM" }, { "code": "99999", "type": "CPT" }, { "code": "0272", "type": "RC" } ], "standard_charges": [ { "setting": "outpatient", "gross_charge": 475.0, "discounted_cash": 237.5, "minimum": 200.45, "maximum": 247.0, "additional_generic_notes": "Zero final payments for the item or service in the 15 months prior to posting the file.", "payers_information": [ { "payer_name": "AETNA", "plan_name": "AETNA ALL OTHER PLANS", "methodology": "percent of total billed charges", "standard_charge_dollar": 247.0, "standard_charge_percentage": 52.0, "count": "0", "additional_payer_notes": "Zero final payments for the item or service in the 15 months prior to posting the file." }, { "payer_name": "AETNA", "plan_name": "AETNA ALL OTHER PLANS", "methodology": "percent of total billed charges", "standard_charge_dollar": 247.0, "standard_charge_percentage": 52.0, "count": "0", "additional_payer_notes": "Zero final payments for the item or service in the 15 months prior to posting the file." }, { "payer_name": "MERITAIN HEALTH", "plan_name": "AETNA ALL OTHER PLANS", "methodology": "percent of total billed charges", "standard_charge_dollar": 247.0, "standard_charge_percentage": 52.0, "count": "0", "additional_payer_notes": "Zero final payments for the item or service in the 15 months prior to posting the file." }, { "payer_name": "BLUE SHIELD OUT OF STATE", "plan_name": "STANFORD HEALTHCARE ALLIANCE PLAN", "methodology": "percent of total billed charges", "standard_charge_dollar": 230.8, "standard_charge_percentage": 48.59, "count": "0", "additional_payer_notes": "Zero final payments for the item or service in the 15 months prior to posting the file." }, { "payer_name": "BLUE SHIELD", "plan_name": "STANFORD HEALTHCARE ALLIANCE PLAN", "methodology": "percent of total billed charges", "standard_charge_dollar": 230.8, "standard_charge_percentage": 48.59, "count": "0", "additional_payer_notes": "Zero final payments for the item or service in the 15 months prior to posting the file." }, { "payer_name": "BLUE SHIELD", "plan_name": "STANFORD HEALTHCARE ALLIANCE PLAN", "methodology": "percent of total billed charges", "standard_charge_dollar": 230.8, "standard_charge_percentage": 48.59, "count": "0", "additional_payer_notes": "Zero final payments for the item or service in the 15 months prior to posting the file." }, { "payer_name": "CIGNA", "plan_name": "CIGNA COM ALT HMO PLAN", "methodology": "percent of total billed charges", "standard_charge_dollar": 200.45, "standard_charge_percentage": 42.2, "count": "0", "additional_payer_notes": "Zero final payments for the item or service in the 15 months prior to posting the file." }, { "payer_name": "CIGNA", "plan_name": "CIGNA COM ALT HMO PLAN", "methodology": "percent of total billed charges", "standard_charge_dollar": 200.45, "standard_charge_percentage": 42.2, "count": "0", "additional_payer_notes": "Zero final payments for the item or service in the 15 months prior to posting the file." }, { "payer_name": "HEALTH NET", "plan_name": "HEALTHNET HMO, PPO, POS, EPO, CANOPY HEALTHNET HMO, OTHER-IN-NETWORK PLANS", "methodology": "per diem", "standard_charge_dollar": 8000.0, "standard_charge_algorithm": "Expected reimbursement is the lesser of Per diem ($8,000) for the length of stay and 70% of billed.", "count": "0", "additional_payer_notes": "Zero final payments for the item or service in the 15 months prior to posting the file." }, { "payer_name": "HEALTH NET", "plan_name": "HEALTHNET HMO, PPO, POS, EPO, CANOPY HEALTHNET HMO, OTHER-IN-NETWORK PLANS", "methodology": "per diem", "standard_charge_dollar": 8000.0, "standard_charge_algorithm": "Expected reimbursement is the lesser of Per diem ($8,000) for the length of stay and 70% of billed.", "count": "0", "additional_payer_notes": "Zero final payments for the item or service in the 15 months prior to posting the file." }, { "payer_name": "UNITED HEALTHCARE", "plan_name": "SUTTER SELECT & SUTTER HEALTH PLAN HMO PLANS", "methodology": "per diem", "standard_charge_dollar": 28538.0, "standard_charge_algorithm": "Per diem ($28,538).", "count": "0", "additional_payer_notes": "Zero final payments for the item or service in the 15 months prior to posting the file." }, { "payer_name": "UNITED HEALTHCARE", "plan_name": "SUTTER SELECT & SUTTER HEALTH PLAN HMO PLANS", "methodology": "per diem", "standard_charge_dollar": 28538.0, "standard_charge_algorithm": "Per diem ($28,538).", "count": "0", "additional_payer_notes": "Zero final payments for the item or service in the 15 months prior to posting the file." }, { "payer_name": "SUTTER", "plan_name": "SUTTER SELECT & SUTTER HEALTH PLAN HMO PLANS", "methodology": "per diem", "standard_charge_dollar": 28538.0, "standard_charge_algorithm": "Per diem ($28,538).", "count": "0", "additional_payer_notes": "Zero final payments for the item or service in the 15 months prior to posting the file." }, { "payer_name": "UNITED HEALTHCARE", "plan_name": "SUTTER SELECT & SUTTER HEALTH PLAN HMO PLANS", "methodology": "per diem", "standard_charge_dollar": 28538.0, "standard_charge_algorithm": "Per diem ($28,538).", "count": "0", "additional_payer_notes": "Zero final payments for the item or service in the 15 months prior to posting the file." }, { "payer_name": "UMR", "plan_name": "SUTTER SELECT & SUTTER HEALTH PLAN HMO PLANS", "methodology": "per diem", "standard_charge_dollar": 28538.0, "standard_charge_algorithm": "Per diem ($28,538).", "count": "0", "additional_payer_notes": "Zero final payments for the item or service in the 15 months prior to posting the file." } ] } ] }, { "description": "HC Bur Gp009", "code_information": [ { "code": "PX-2120017009", "type": "CDM" }, { "code": "99999", "type": "CPT" }, { "code": "0272", "type": "RC" } ], "standard_charges": [ { "setting": "outpatient", "gross_charge": 570.0, "discounted_cash": 285.0, "minimum": 240.54, "maximum": 296.4, "additional_generic_notes": "Zero final payments for the item or service in the 15 months prior to posting the file.", "payers_information": [ { "payer_name": "AETNA", "plan_name": "AETNA ALL OTHER PLANS", "methodology": "percent of total billed charges", "standard_charge_dollar": 296.4, "standard_charge_percentage": 52.0, "count": "0", "additional_payer_notes": "Zero final payments for the item or service in the 15 months prior to posting the file." }, { "payer_name": "AETNA", "plan_name": "AETNA ALL OTHER PLANS", "methodology": "percent of total billed charges", "standard_charge_dollar": 296.4, "standard_charge_percentage": 52.0, "count": "0", "additional_payer_notes": "Zero final payments for the item or service in the 15 months prior to posting the file." }, { "payer_name": "MERITAIN HEALTH", "plan_name": "AETNA ALL OTHER PLANS", "methodology": "percent of total billed charges", "standard_charge_dollar": 296.4, "standard_charge_percentage": 52.0, "count": "0", "additional_payer_notes": "Zero final payments for the item or service in the 15 months prior to posting the file." }, { "payer_name": "BLUE SHIELD OUT OF STATE", "plan_name": "STANFORD HEALTHCARE ALLIANCE PLAN", "methodology": "percent of total billed charges", "standard_charge_dollar": 276.96, "standard_charge_percentage": 48.59, "count": "0", "additional_payer_notes": "Zero final payments for the item or service in the 15 months prior to posting the file." }, { "payer_name": "BLUE SHIELD", "plan_name": "STANFORD HEALTHCARE ALLIANCE PLAN", "methodology": "percent of total billed charges", "standard_charge_dollar": 276.96, "standard_charge_percentage": 48.59, "count": "0", "additional_payer_notes": "Zero final payments for the item or service in the 15 months prior to posting the file." }, { "payer_name": "BLUE SHIELD", "plan_name": "STANFORD HEALTHCARE ALLIANCE PLAN", "methodology": "percent of total billed charges", "standard_charge_dollar": 276.96, "standard_charge_percentage": 48.59, "count": "0", "additional_payer_notes": "Zero final payments for the item or service in the 15 months prior to posting the file." }, { "payer_name": "CIGNA", "plan_name": "CIGNA COM ALT HMO PLAN", "methodology": "percent of total billed charges", "standard_charge_dollar": 240.54, "standard_charge_percentage": 42.2, "count": "0", "additional_payer_notes": "Zero final payments for the item or service in the 15 months prior to posting the file." }, { "payer_name": "CIGNA", "plan_name": "CIGNA COM ALT HMO PLAN", "methodology": "percent of total billed charges", "standard_charge_dollar": 240.54, "standard_charge_percentage": 42.2, "count": "0", "additional_payer_notes": "Zero final payments for the item or service in the 15 months prior to posting the file." }, { "payer_name": "HEALTH NET", "plan_name": "HEALTHNET HMO, PPO, POS, EPO, CANOPY HEALTHNET HMO, OTHER-IN-NETWORK PLANS", "methodology": "per diem", "standard_charge_dollar": 8000.0, "standard_charge_algorithm": "Expected reimbursement is the lesser of Per diem ($8,000) for the length of stay and 70% of billed.", "count": "0", "additional_payer_notes": "Zero final payments for the item or service in the 15 months prior to posting the file." }, { "payer_name": "HEALTH NET", "plan_name": "HEALTHNET HMO, PPO, POS, EPO, CANOPY HEALTHNET HMO, OTHER-IN-NETWORK PLANS", "methodology": "per diem", "standard_charge_dollar": 8000.0, "standard_charge_algorithm": "Expected reimbursement is the lesser of Per diem ($8,000) for the length of stay and 70% of billed.", "count": "0", "additional_payer_notes": "Zero final payments for the item or service in the 15 months prior to posting the file." }, { "payer_name": "UNITED HEALTHCARE", "plan_name": "SUTTER SELECT & SUTTER HEALTH PLAN HMO PLANS", "methodology": "per diem", "standard_charge_dollar": 28538.0, "standard_charge_algorithm": "Per diem ($28,538).", "count": "0", "additional_payer_notes": "Zero final payments for the item or service in the 15 months prior to posting the file." }, { "payer_name": "UNITED HEALTHCARE", "plan_name": "SUTTER SELECT & SUTTER HEALTH PLAN HMO PLANS", "methodology": "per diem", "standard_charge_dollar": 28538.0, "standard_charge_algorithm": "Per diem ($28,538).", "count": "0", "additional_payer_notes": "Zero final payments for the item or service in the 15 months prior to posting the file." }, { "payer_name": "SUTTER", "plan_name": "SUTTER SELECT & SUTTER HEALTH PLAN HMO PLANS", "methodology": "per diem", "standard_charge_dollar": 28538.0, "standard_charge_algorithm": "Per diem ($28,538).", "count": "0", "additional_payer_notes": "Zero final payments for the item or service in the 15 months prior to posting the file." }, { "payer_name": "UNITED HEALTHCARE", "plan_name": "SUTTER SELECT & SUTTER HEALTH PLAN HMO PLANS", "methodology": "per diem", "standard_charge_dollar": 28538.0, "standard_charge_algorithm": "Per diem ($28,538).", "count": "0", "additional_payer_notes": "Zero final payments for the item or service in the 15 months prior to posting the file." }, { "payer_name": "UMR", "plan_name": "SUTTER SELECT & SUTTER HEALTH PLAN HMO PLANS", "methodology": "per diem", "standard_charge_dollar": 28538.0, "standard_charge_algorithm": "Per diem ($28,538).", "count": "0", "additional_payer_notes": "Zero final payments for the item or service in the 15 months prior to posting the file." } ] } ] }, { "description": "HC Bur Gp010", "code_information": [ { "code": "PX-2120017010", "type": "CDM" }, { "code": "99999", "type": "CPT" }, { "code": "0272", "type": "RC" } ], "standard_charges": [ { "setting": "outpatient", "gross_charge": 665.0, "discounted_cash": 332.5, "minimum": 280.63, "maximum": 345.8, "additional_generic_notes": "Zero final payments for the item or service in the 15 months prior to posting the file.", "payers_information": [ { "payer_name": "AETNA", "plan_name": "AETNA ALL OTHER PLANS", "methodology": "percent of total billed charges", "standard_charge_dollar": 345.8, "standard_charge_percentage": 52.0, "count": "0", "additional_payer_notes": "Zero final payments for the item or service in the 15 months prior to posting the file." }, { "payer_name": "AETNA", "plan_name": "AETNA ALL OTHER PLANS", "methodology": "percent of total billed charges", "standard_charge_dollar": 345.8, "standard_charge_percentage": 52.0, "count": "0", "additional_payer_notes": "Zero final payments for the item or service in the 15 months prior to posting the file." }, { "payer_name": "MERITAIN HEALTH", "plan_name": "AETNA ALL OTHER PLANS", "methodology": "percent of total billed charges", "standard_charge_dollar": 345.8, "standard_charge_percentage": 52.0, "count": "0", "additional_payer_notes": "Zero final payments for the item or service in the 15 months prior to posting the file." }, { "payer_name": "BLUE SHIELD OUT OF STATE", "plan_name": "STANFORD HEALTHCARE ALLIANCE PLAN", "methodology": "percent of total billed charges", "standard_charge_dollar": 323.12, "standard_charge_percentage": 48.59, "count": "0", "additional_payer_notes": "Zero final payments for the item or service in the 15 months prior to posting the file." }, { "payer_name": "BLUE SHIELD", "plan_name": "STANFORD HEALTHCARE ALLIANCE PLAN", "methodology": "percent of total billed charges", "standard_charge_dollar": 323.12, "standard_charge_percentage": 48.59, "count": "0", "additional_payer_notes": "Zero final payments for the item or service in the 15 months prior to posting the file." }, { "payer_name": "BLUE SHIELD", "plan_name": "STANFORD HEALTHCARE ALLIANCE PLAN", "methodology": "percent of total billed charges", "standard_charge_dollar": 323.12, "standard_charge_percentage": 48.59, "count": "0", "additional_payer_notes": "Zero final payments for the item or service in the 15 months prior to posting the file." }, { "payer_name": "CIGNA", "plan_name": "CIGNA COM ALT HMO PLAN", "methodology": "percent of total billed charges", "standard_charge_dollar": 280.63, "standard_charge_percentage": 42.2, "count": "0", "additional_payer_notes": "Zero final payments for the item or service in the 15 months prior to posting the file." }, { "payer_name": "CIGNA", "plan_name": "CIGNA COM ALT HMO PLAN", "methodology": "percent of total billed charges", "standard_charge_dollar": 280.63, "standard_charge_percentage": 42.2, "count": "0", "additional_payer_notes": "Zero final payments for the item or service in the 15 months prior to posting the file." }, { "payer_name": "HEALTH NET", "plan_name": "HEALTHNET HMO, PPO, POS, EPO, CANOPY HEALTHNET HMO, OTHER-IN-NETWORK PLANS", "methodology": "per diem", "standard_charge_dollar": 8000.0, "standard_charge_algorithm": "Expected reimbursement is the lesser of Per diem ($8,000) for the length of stay and 70% of billed.", "count": "0", "additional_payer_notes": "Zero final payments for the item or service in the 15 months prior to posting the file." }, { "payer_name": "HEALTH NET", "plan_name": "HEALTHNET HMO, PPO, POS, EPO, CANOPY HEALTHNET HMO, OTHER-IN-NETWORK PLANS", "methodology": "per diem", "standard_charge_dollar": 8000.0, "standard_charge_algorithm": "Expected reimbursement is the lesser of Per diem ($8,000) for the length of stay and 70% of billed.", "count": "0", "additional_payer_notes": "Zero final payments for the item or service in the 15 months prior to posting the file." }, { "payer_name": "UNITED HEALTHCARE", "plan_name": "SUTTER SELECT & SUTTER HEALTH PLAN HMO PLANS", "methodology": "per diem", "standard_charge_dollar": 28538.0, "standard_charge_algorithm": "Per diem ($28,538).", "count": "0", "additional_payer_notes": "Zero final payments for the item or service in the 15 months prior to posting the file." }, { "payer_name": "UNITED HEALTHCARE", "plan_name": "SUTTER SELECT & SUTTER HEALTH PLAN HMO PLANS", "methodology": "per diem", "standard_charge_dollar": 28538.0, "standard_charge_algorithm": "Per diem ($28,538).", "count": "0", "additional_payer_notes": "Zero final payments for the item or service in the 15 months prior to posting the file." }, { "payer_name": "SUTTER", "plan_name": "SUTTER SELECT & SUTTER HEALTH PLAN HMO PLANS", "methodology": "per diem", "standard_charge_dollar": 28538.0, "standard_charge_algorithm": "Per diem ($28,538).", "count": "0", "additional_payer_notes": "Zero final payments for the item or service in the 15 months prior to posting the file." }, { "payer_name": "UNITED HEALTHCARE", "plan_name": "SUTTER SELECT & SUTTER HEALTH PLAN HMO PLANS", "methodology": "per diem", "standard_charge_dollar": 28538.0, "standard_charge_algorithm": "Per diem ($28,538).", "count": "0", "additional_payer_notes": "Zero final payments for the item or service in the 15 months prior to posting the file." }, { "payer_name": "UMR", "plan_name": "SUTTER SELECT & SUTTER HEALTH PLAN HMO PLANS", "methodology": "per diem", "standard_charge_dollar": 28538.0, "standard_charge_algorithm": "Per diem ($28,538).", "count": "0", "additional_payer_notes": "Zero final payments for the item or service in the 15 months prior to posting the file." } ] } ] }, { "description": "HC Bur Gp011", "code_information": [ { "code": "PX-2120017011", "type": "CDM" }, { "code": "99999", "type": "CPT" }, { "code": "0272", "type": "RC" } ], "standard_charges": [ { "setting": "outpatient", "gross_charge": 740.0, "discounted_cash": 370.0, "minimum": 312.28, "maximum": 384.8, "additional_generic_notes": "Zero final payments for the item or service in the 15 months prior to posting the file.", "payers_information": [ { "payer_name": "AETNA", "plan_name": "AETNA ALL OTHER PLANS", "methodology": "percent of total billed charges", "standard_charge_dollar": 384.8, "standard_charge_percentage": 52.0, "count": "0", "additional_payer_notes": "Zero final payments for the item or service in the 15 months prior to posting the file." }, { "payer_name": "AETNA", "plan_name": "AETNA ALL OTHER PLANS", "methodology": "percent of total billed charges", "standard_charge_dollar": 384.8, "standard_charge_percentage": 52.0, "count": "0", "additional_payer_notes": "Zero final payments for the item or service in the 15 months prior to posting the file." }, { "payer_name": "MERITAIN HEALTH", "plan_name": "AETNA ALL OTHER PLANS", "methodology": "percent of total billed charges", "standard_charge_dollar": 384.8, "standard_charge_percentage": 52.0, "count": "0", "additional_payer_notes": "Zero final payments for the item or service in the 15 months prior to posting the file." }, { "payer_name": "BLUE SHIELD OUT OF STATE", "plan_name": "STANFORD HEALTHCARE ALLIANCE PLAN", "methodology": "percent of total billed charges", "standard_charge_dollar": 359.57, "standard_charge_percentage": 48.59, "count": "0", "additional_payer_notes": "Zero final payments for the item or service in the 15 months prior to posting the file." }, { "payer_name": "BLUE SHIELD", "plan_name": "STANFORD HEALTHCARE ALLIANCE PLAN", "methodology": "percent of total billed charges", "standard_charge_dollar": 359.57, "standard_charge_percentage": 48.59, "count": "0", "additional_payer_notes": "Zero final payments for the item or service in the 15 months prior to posting the file." }, { "payer_name": "BLUE SHIELD", "plan_name": "STANFORD HEALTHCARE ALLIANCE PLAN", "methodology": "percent of total billed charges", "standard_charge_dollar": 359.57, "standard_charge_percentage": 48.59, "count": "0", "additional_payer_notes": "Zero final payments for the item or service in the 15 months prior to posting the file." }, { "payer_name": "CIGNA", "plan_name": "CIGNA COM ALT HMO PLAN", "methodology": "percent of total billed charges", "standard_charge_dollar": 312.28, "standard_charge_percentage": 42.2, "count": "0", "additional_payer_notes": "Zero final payments for the item or service in the 15 months prior to posting the file." }, { "payer_name": "CIGNA", "plan_name": "CIGNA COM ALT HMO PLAN", "methodology": "percent of total billed charges", "standard_charge_dollar": 312.28, "standard_charge_percentage": 42.2, "count": "0", "additional_payer_notes": "Zero final payments for the item or service in the 15 months prior to posting the file." }, { "payer_name": "HEALTH NET", "plan_name": "HEALTHNET HMO, PPO, POS, EPO, CANOPY HEALTHNET HMO, OTHER-IN-NETWORK PLANS", "methodology": "per diem", "standard_charge_dollar": 8000.0, "standard_charge_algorithm": "Expected reimbursement is the lesser of Per diem ($8,000) for the length of stay and 70% of billed.", "count": "0", "additional_payer_notes": "Zero final payments for the item or service in the 15 months prior to posting the file." }, { "payer_name": "HEALTH NET", "plan_name": "HEALTHNET HMO, PPO, POS, EPO, CANOPY HEALTHNET HMO, OTHER-IN-NETWORK PLANS", "methodology": "per diem", "standard_charge_dollar": 8000.0, "standard_charge_algorithm": "Expected reimbursement is the lesser of Per diem ($8,000) for the length of stay and 70% of billed.", "count": "0", "additional_payer_notes": "Zero final payments for the item or service in the 15 months prior to posting the file." }, { "payer_name": "UNITED HEALTHCARE", "plan_name": "SUTTER SELECT & SUTTER HEALTH PLAN HMO PLANS", "methodology": "per diem", "standard_charge_dollar": 28538.0, "standard_charge_algorithm": "Per diem ($28,538).", "count": "0", "additional_payer_notes": "Zero final payments for the item or service in the 15 months prior to posting the file." }, { "payer_name": "UNITED HEALTHCARE", "plan_name": "SUTTER SELECT & SUTTER HEALTH PLAN HMO PLANS", "methodology": "per diem", "standard_charge_dollar": 28538.0, "standard_charge_algorithm": "Per diem ($28,538).", "count": "0", "additional_payer_notes": "Zero final payments for the item or service in the 15 months prior to posting the file." }, { "payer_name": "SUTTER", "plan_name": "SUTTER SELECT & SUTTER HEALTH PLAN HMO PLANS", "methodology": "per diem", "standard_charge_dollar": 28538.0, "standard_charge_algorithm": "Per diem ($28,538).", "count": "0", "additional_payer_notes": "Zero final payments for the item or service in the 15 months prior to posting the file." }, { "payer_name": "UNITED HEALTHCARE", "plan_name": "SUTTER SELECT & SUTTER HEALTH PLAN HMO PLANS", "methodology": "per diem", "standard_charge_dollar": 28538.0, "standard_charge_algorithm": "Per diem ($28,538).", "count": "0", "additional_payer_notes": "Zero final payments for the item or service in the 15 months prior to posting the file." }, { "payer_name": "UMR", "plan_name": "SUTTER SELECT & SUTTER HEALTH PLAN HMO PLANS", "methodology": "per diem", "standard_charge_dollar": 28538.0, "standard_charge_algorithm": "Per diem ($28,538).", "count": "0", "additional_payer_notes": "Zero final payments for the item or service in the 15 months prior to posting the file." } ] } ] }, { "description": "HC Bur Gp012", "code_information": [ { "code": "PX-2120017012", "type": "CDM" }, { "code": "99999", "type": "CPT" }, { "code": "0272", "type": "RC" } ], "standard_charges": [ { "setting": "outpatient", "gross_charge": 810.0, "discounted_cash": 405.0, "minimum": 341.82, "maximum": 421.2, "additional_generic_notes": "Zero final payments for the item or service in the 15 months prior to posting the file.", "payers_information": [ { "payer_name": "AETNA", "plan_name": "AETNA ALL OTHER PLANS", "methodology": "percent of total billed charges", "standard_charge_dollar": 421.2, "standard_charge_percentage": 52.0, "count": "0", "additional_payer_notes": "Zero final payments for the item or service in the 15 months prior to posting the file." }, { "payer_name": "AETNA", "plan_name": "AETNA ALL OTHER PLANS", "methodology": "percent of total billed charges", "standard_charge_dollar": 421.2, "standard_charge_percentage": 52.0, "count": "0", "additional_payer_notes": "Zero final payments for the item or service in the 15 months prior to posting the file." }, { "payer_name": "MERITAIN HEALTH", "plan_name": "AETNA ALL OTHER PLANS", "methodology": "percent of total billed charges", "standard_charge_dollar": 421.2, "standard_charge_percentage": 52.0, "count": "0", "additional_payer_notes": "Zero final payments for the item or service in the 15 months prior to posting the file." }, { "payer_name": "BLUE SHIELD OUT OF STATE", "plan_name": "STANFORD HEALTHCARE ALLIANCE PLAN", "methodology": "percent of total billed charges", "standard_charge_dollar": 393.58, "standard_charge_percentage": 48.59, "count": "0", "additional_payer_notes": "Zero final payments for the item or service in the 15 months prior to posting the file." }, { "payer_name": "BLUE SHIELD", "plan_name": "STANFORD HEALTHCARE ALLIANCE PLAN", "methodology": "percent of total billed charges", "standard_charge_dollar": 393.58, "standard_charge_percentage": 48.59, "count": "0", "additional_payer_notes": "Zero final payments for the item or service in the 15 months prior to posting the file." }, { "payer_name": "BLUE SHIELD", "plan_name": "STANFORD HEALTHCARE ALLIANCE PLAN", "methodology": "percent of total billed charges", "standard_charge_dollar": 393.58, "standard_charge_percentage": 48.59, "count": "0", "additional_payer_notes": "Zero final payments for the item or service in the 15 months prior to posting the file." }, { "payer_name": "CIGNA", "plan_name": "CIGNA COM ALT HMO PLAN", "methodology": "percent of total billed charges", "standard_charge_dollar": 341.82, "standard_charge_percentage": 42.2, "count": "0", "additional_payer_notes": "Zero final payments for the item or service in the 15 months prior to posting the file." }, { "payer_name": "CIGNA", "plan_name": "CIGNA COM ALT HMO PLAN", "methodology": "percent of total billed charges", "standard_charge_dollar": 341.82, "standard_charge_percentage": 42.2, "count": "0", "additional_payer_notes": "Zero final payments for the item or service in the 15 months prior to posting the file." }, { "payer_name": "HEALTH NET", "plan_name": "HEALTHNET HMO, PPO, POS, EPO, CANOPY HEALTHNET HMO, OTHER-IN-NETWORK PLANS", "methodology": "per diem", "standard_charge_dollar": 8000.0, "standard_charge_algorithm": "Expected reimbursement is the lesser of Per diem ($8,000) for the length of stay and 70% of billed.", "count": "0", "additional_payer_notes": "Zero final payments for the item or service in the 15 months prior to posting the file." }, { "payer_name": "HEALTH NET", "plan_name": "HEALTHNET HMO, PPO, POS, EPO, CANOPY HEALTHNET HMO, OTHER-IN-NETWORK PLANS", "methodology": "per diem", "standard_charge_dollar": 8000.0, "standard_charge_algorithm": "Expected reimbursement is the lesser of Per diem ($8,000) for the length of stay and 70% of billed.", "count": "0", "additional_payer_notes": "Zero final payments for the item or service in the 15 months prior to posting the file." }, { "payer_name": "UNITED HEALTHCARE", "plan_name": "SUTTER SELECT & SUTTER HEALTH PLAN HMO PLANS", "methodology": "per diem", "standard_charge_dollar": 28538.0, "standard_charge_algorithm": "Per diem ($28,538).", "count": "0", "additional_payer_notes": "Zero final payments for the item or service in the 15 months prior to posting the file." }, { "payer_name": "UNITED HEALTHCARE", "plan_name": "SUTTER SELECT & SUTTER HEALTH PLAN HMO PLANS", "methodology": "per diem", "standard_charge_dollar": 28538.0, "standard_charge_algorithm": "Per diem ($28,538).", "count": "0", "additional_payer_notes": "Zero final payments for the item or service in the 15 months prior to posting the file." }, { "payer_name": "SUTTER", "plan_name": "SUTTER SELECT & SUTTER HEALTH PLAN HMO PLANS", "methodology": "per diem", "standard_charge_dollar": 28538.0, "standard_charge_algorithm": "Per diem ($28,538).", "count": "0", "additional_payer_notes": "Zero final payments for the item or service in the 15 months prior to posting the file." }, { "payer_name": "UNITED HEALTHCARE", "plan_name": "SUTTER SELECT & SUTTER HEALTH PLAN HMO PLANS", "methodology": "per diem", "standard_charge_dollar": 28538.0, "standard_charge_algorithm": "Per diem ($28,538).", "count": "0", "additional_payer_notes": "Zero final payments for the item or service in the 15 months prior to posting the file." }, { "payer_name": "UMR", "plan_name": "SUTTER SELECT & SUTTER HEALTH PLAN HMO PLANS", "methodology": "per diem", "standard_charge_dollar": 28538.0, "standard_charge_algorithm": "Per diem ($28,538).", "count": "0", "additional_payer_notes": "Zero final payments for the item or service in the 15 months prior to posting the file." } ] } ] }, { "description": "HC Bur Gp013", "code_information": [ { "code": "PX-2120017013", "type": "CDM" }, { "code": "99999", "type": "CPT" }, { "code": "0272", "type": "RC" } ], "standard_charges": [ { "setting": "outpatient", "gross_charge": 900.0, "discounted_cash": 450.0, "minimum": 379.8, "maximum": 468.0, "additional_generic_notes": "Zero final payments for the item or service in the 15 months prior to posting the file.", "payers_information": [ { "payer_name": "AETNA", "plan_name": "AETNA ALL OTHER PLANS", "methodology": "percent of total billed charges", "standard_charge_dollar": 468.0, "standard_charge_percentage": 52.0, "count": "0", "additional_payer_notes": "Zero final payments for the item or service in the 15 months prior to posting the file." }, { "payer_name": "AETNA", "plan_name": "AETNA ALL OTHER PLANS", "methodology": "percent of total billed charges", "standard_charge_dollar": 468.0, "standard_charge_percentage": 52.0, "count": "0", "additional_payer_notes": "Zero final payments for the item or service in the 15 months prior to posting the file." }, { "payer_name": "MERITAIN HEALTH", "plan_name": "AETNA ALL OTHER PLANS", "methodology": "percent of total billed charges", "standard_charge_dollar": 468.0, "standard_charge_percentage": 52.0, "count": "0", "additional_payer_notes": "Zero final payments for the item or service in the 15 months prior to posting the file." }, { "payer_name": "BLUE SHIELD OUT OF STATE", "plan_name": "STANFORD HEALTHCARE ALLIANCE PLAN", "methodology": "percent of total billed charges", "standard_charge_dollar": 437.31, "standard_charge_percentage": 48.59, "count": "0", "additional_payer_notes": "Zero final payments for the item or service in the 15 months prior to posting the file." }, { "payer_name": "BLUE SHIELD", "plan_name": "STANFORD HEALTHCARE ALLIANCE PLAN", "methodology": "percent of total billed charges", "standard_charge_dollar": 437.31, "standard_charge_percentage": 48.59, "count": "0", "additional_payer_notes": "Zero final payments for the item or service in the 15 months prior to posting the file." }, { "payer_name": "BLUE SHIELD", "plan_name": "STANFORD HEALTHCARE ALLIANCE PLAN", "methodology": "percent of total billed charges", "standard_charge_dollar": 437.31, "standard_charge_percentage": 48.59, "count": "0", "additional_payer_notes": "Zero final payments for the item or service in the 15 months prior to posting the file." }, { "payer_name": "CIGNA", "plan_name": "CIGNA COM ALT HMO PLAN", "methodology": "percent of total billed charges", "standard_charge_dollar": 379.8, "standard_charge_percentage": 42.2, "count": "0", "additional_payer_notes": "Zero final payments for the item or service in the 15 months prior to posting the file." }, { "payer_name": "CIGNA", "plan_name": "CIGNA COM ALT HMO PLAN", "methodology": "percent of total billed charges", "standard_charge_dollar": 379.8, "standard_charge_percentage": 42.2, "count": "0", "additional_payer_notes": "Zero final payments for the item or service in the 15 months prior to posting the file." }, { "payer_name": "HEALTH NET", "plan_name": "HEALTHNET HMO, PPO, POS, EPO, CANOPY HEALTHNET HMO, OTHER-IN-NETWORK PLANS", "methodology": "per diem", "standard_charge_dollar": 8000.0, "standard_charge_algorithm": "Expected reimbursement is the lesser of Per diem ($8,000) for the length of stay and 70% of billed.", "count": "0", "additional_payer_notes": "Zero final payments for the item or service in the 15 months prior to posting the file." }, { "payer_name": "HEALTH NET", "plan_name": "HEALTHNET HMO, PPO, POS, EPO, CANOPY HEALTHNET HMO, OTHER-IN-NETWORK PLANS", "methodology": "per diem", "standard_charge_dollar": 8000.0, "standard_charge_algorithm": "Expected reimbursement is the lesser of Per diem ($8,000) for the length of stay and 70% of billed.", "count": "0", "additional_payer_notes": "Zero final payments for the item or service in the 15 months prior to posting the file." }, { "payer_name": "UNITED HEALTHCARE", "plan_name": "SUTTER SELECT & SUTTER HEALTH PLAN HMO PLANS", "methodology": "per diem", "standard_charge_dollar": 28538.0, "standard_charge_algorithm": "Per diem ($28,538).", "count": "0", "additional_payer_notes": "Zero final payments for the item or service in the 15 months prior to posting the file." }, { "payer_name": "UNITED HEALTHCARE", "plan_name": "SUTTER SELECT & SUTTER HEALTH PLAN HMO PLANS", "methodology": "per diem", "standard_charge_dollar": 28538.0, "standard_charge_algorithm": "Per diem ($28,538).", "count": "0", "additional_payer_notes": "Zero final payments for the item or service in the 15 months prior to posting the file." }, { "payer_name": "SUTTER", "plan_name": "SUTTER SELECT & SUTTER HEALTH PLAN HMO PLANS", "methodology": "per diem", "standard_charge_dollar": 28538.0, "standard_charge_algorithm": "Per diem ($28,538).", "count": "0", "additional_payer_notes": "Zero final payments for the item or service in the 15 months prior to posting the file." }, { "payer_name": "UNITED HEALTHCARE", "plan_name": "SUTTER SELECT & SUTTER HEALTH PLAN HMO PLANS", "methodology": "per diem", "standard_charge_dollar": 28538.0, "standard_charge_algorithm": "Per diem ($28,538).", "count": "0", "additional_payer_notes": "Zero final payments for the item or service in the 15 months prior to posting the file." }, { "payer_name": "UMR", "plan_name": "SUTTER SELECT & SUTTER HEALTH PLAN HMO PLANS", "methodology": "per diem", "standard_charge_dollar": 28538.0, "standard_charge_algorithm": "Per diem ($28,538).", "count": "0", "additional_payer_notes": "Zero final payments for the item or service in the 15 months prior to posting the file." } ] } ] }, { "description": "HC Bur Gp014", "code_information": [ { "code": "PX-2120017014", "type": "CDM" }, { "code": "99999", "type": "CPT" }, { "code": "0272", "type": "RC" } ], "standard_charges": [ { "setting": "outpatient", "gross_charge": 1080.0, "discounted_cash": 540.0, "minimum": 455.76, "maximum": 561.6, "additional_generic_notes": "Zero final payments for the item or service in the 15 months prior to posting the file.", "payers_information": [ { "payer_name": "AETNA", "plan_name": "AETNA ALL OTHER PLANS", "methodology": "percent of total billed charges", "standard_charge_dollar": 561.6, "standard_charge_percentage": 52.0, "count": "0", "additional_payer_notes": "Zero final payments for the item or service in the 15 months prior to posting the file." }, { "payer_name": "AETNA", "plan_name": "AETNA ALL OTHER PLANS", "methodology": "percent of total billed charges", "standard_charge_dollar": 561.6, "standard_charge_percentage": 52.0, "count": "0", "additional_payer_notes": "Zero final payments for the item or service in the 15 months prior to posting the file." }, { "payer_name": "MERITAIN HEALTH", "plan_name": "AETNA ALL OTHER PLANS", "methodology": "percent of total billed charges", "standard_charge_dollar": 561.6, "standard_charge_percentage": 52.0, "count": "0", "additional_payer_notes": "Zero final payments for the item or service in the 15 months prior to posting the file." }, { "payer_name": "BLUE SHIELD OUT OF STATE", "plan_name": "STANFORD HEALTHCARE ALLIANCE PLAN", "methodology": "percent of total billed charges", "standard_charge_dollar": 524.77, "standard_charge_percentage": 48.59, "count": "0", "additional_payer_notes": "Zero final payments for the item or service in the 15 months prior to posting the file." }, { "payer_name": "BLUE SHIELD", "plan_name": "STANFORD HEALTHCARE ALLIANCE PLAN", "methodology": "percent of total billed charges", "standard_charge_dollar": 524.77, "standard_charge_percentage": 48.59, "median_amount": 68.24, "10th_percentile": 13.6, "90th_percentile": 1043.06, "count": "30" }, { "payer_name": "BLUE SHIELD", "plan_name": "STANFORD HEALTHCARE ALLIANCE PLAN", "methodology": "percent of total billed charges", "standard_charge_dollar": 524.77, "standard_charge_percentage": 48.59, "count": "0", "additional_payer_notes": "Zero final payments for the item or service in the 15 months prior to posting the file." }, { "payer_name": "BLUE SHIELD", "plan_name": "STANFORD HEALTHCARE ALLIANCE PLAN", "methodology": "percent of total billed charges", "standard_charge_dollar": 524.77, "standard_charge_percentage": 48.59, "count": "0", "additional_payer_notes": "Zero final payments for the item or service in the 15 months prior to posting the file." }, { "payer_name": "CIGNA", "plan_name": "CIGNA COM ALT HMO PLAN", "methodology": "percent of total billed charges", "standard_charge_dollar": 455.76, "standard_charge_percentage": 42.2, "count": "0", "additional_payer_notes": "Zero final payments for the item or service in the 15 months prior to posting the file." }, { "payer_name": "CIGNA", "plan_name": "CIGNA COM ALT HMO PLAN", "methodology": "percent of total billed charges", "standard_charge_dollar": 455.76, "standard_charge_percentage": 42.2, "count": "0", "additional_payer_notes": "Zero final payments for the item or service in the 15 months prior to posting the file." }, { "payer_name": "HEALTH NET", "plan_name": "HEALTHNET HMO, PPO, POS, EPO, CANOPY HEALTHNET HMO, OTHER-IN-NETWORK PLANS", "methodology": "per diem", "standard_charge_dollar": 8000.0, "standard_charge_algorithm": "Expected reimbursement is the lesser of Per diem ($8,000) for the length of stay and 70% of billed.", "count": "0", "additional_payer_notes": "Zero final payments for the item or service in the 15 months prior to posting the file." }, { "payer_name": "HEALTH NET", "plan_name": "HEALTHNET HMO, PPO, POS, EPO, CANOPY HEALTHNET HMO, OTHER-IN-NETWORK PLANS", "methodology": "per diem", "standard_charge_dollar": 8000.0, "standard_charge_algorithm": "Expected reimbursement is the lesser of Per diem ($8,000) for the length of stay and 70% of billed.", "count": "0", "additional_payer_notes": "Zero final payments for the item or service in the 15 months prior to posting the file." }, { "payer_name": "UNITED HEALTHCARE", "plan_name": "SUTTER SELECT & SUTTER HEALTH PLAN HMO PLANS", "methodology": "per diem", "standard_charge_dollar": 28538.0, "standard_charge_algorithm": "Per diem ($28,538).", "count": "0", "additional_payer_notes": "Zero final payments for the item or service in the 15 months prior to posting the file." }, { "payer_name": "UNITED HEALTHCARE", "plan_name": "SUTTER SELECT & SUTTER HEALTH PLAN HMO PLANS", "methodology": "per diem", "standard_charge_dollar": 28538.0, "standard_charge_algorithm": "Per diem ($28,538).", "count": "0", "additional_payer_notes": "Zero final payments for the item or service in the 15 months prior to posting the file." }, { "payer_name": "SUTTER", "plan_name": "SUTTER SELECT & SUTTER HEALTH PLAN HMO PLANS", "methodology": "per diem", "standard_charge_dollar": 28538.0, "standard_charge_algorithm": "Per diem ($28,538).", "count": "0", "additional_payer_notes": "Zero final payments for the item or service in the 15 months prior to posting the file." }, { "payer_name": "UNITED HEALTHCARE", "plan_name": "SUTTER SELECT & SUTTER HEALTH PLAN HMO PLANS", "methodology": "per diem", "standard_charge_dollar": 28538.0, "standard_charge_algorithm": "Per diem ($28,538).", "count": "0", "additional_payer_notes": "Zero final payments for the item or service in the 15 months prior to posting the file." }, { "payer_name": "UMR", "plan_name": "SUTTER SELECT & SUTTER HEALTH PLAN HMO PLANS", "methodology": "per diem", "standard_charge_dollar": 28538.0, "standard_charge_algorithm": "Per diem ($28,538).", "count": "0", "additional_payer_notes": "Zero final payments for the item or service in the 15 months prior to posting the file." } ] } ] }, { "description": "Hc Bur Gp015", "code_information": [ { "code": "PX-2120017015", "type": "CDM" }, { "code": "99999", "type": "CPT" }, { "code": "0272", "type": "RC" } ], "standard_charges": [ { "setting": "outpatient", "gross_charge": 1225.0, "discounted_cash": 612.5, "minimum": 516.95, "maximum": 637.0, "additional_generic_notes": "Zero final payments for the item or service in the 15 months prior to posting the file.", "payers_information": [ { "payer_name": "AETNA", "plan_name": "AETNA ALL OTHER PLANS", "methodology": "percent of total billed charges", "standard_charge_dollar": 637.0, "standard_charge_percentage": 52.0, "count": "0", "additional_payer_notes": "Zero final payments for the item or service in the 15 months prior to posting the file." }, { "payer_name": "AETNA", "plan_name": "AETNA ALL OTHER PLANS", "methodology": "percent of total billed charges", "standard_charge_dollar": 637.0, "standard_charge_percentage": 52.0, "count": "0", "additional_payer_notes": "Zero final payments for the item or service in the 15 months prior to posting the file." }, { "payer_name": "MERITAIN HEALTH", "plan_name": "AETNA ALL OTHER PLANS", "methodology": "percent of total billed charges", "standard_charge_dollar": 637.0, "standard_charge_percentage": 52.0, "count": "0", "additional_payer_notes": "Zero final payments for the item or service in the 15 months prior to posting the file." }, { "payer_name": "BLUE SHIELD OUT OF STATE", "plan_name": "STANFORD HEALTHCARE ALLIANCE PLAN", "methodology": "percent of total billed charges", "standard_charge_dollar": 595.23, "standard_charge_percentage": 48.59, "count": "0", "additional_payer_notes": "Zero final payments for the item or service in the 15 months prior to posting the file." }, { "payer_name": "BLUE SHIELD", "plan_name": "STANFORD HEALTHCARE ALLIANCE PLAN", "methodology": "percent of total billed charges", "standard_charge_dollar": 595.23, "standard_charge_percentage": 48.59, "median_amount": 68.24, "10th_percentile": 13.6, "90th_percentile": 1043.06, "count": "30" }, { "payer_name": "BLUE SHIELD", "plan_name": "STANFORD HEALTHCARE ALLIANCE PLAN", "methodology": "percent of total billed charges", "standard_charge_dollar": 595.23, "standard_charge_percentage": 48.59, "count": "0", "additional_payer_notes": "Zero final payments for the item or service in the 15 months prior to posting the file." }, { "payer_name": "BLUE SHIELD", "plan_name": "STANFORD HEALTHCARE ALLIANCE PLAN", "methodology": "percent of total billed charges", "standard_charge_dollar": 595.23, "standard_charge_percentage": 48.59, "count": "0", "additional_payer_notes": "Zero final payments for the item or service in the 15 months prior to posting the file." }, { "payer_name": "CIGNA", "plan_name": "CIGNA COM ALT HMO PLAN", "methodology": "percent of total billed charges", "standard_charge_dollar": 516.95, "standard_charge_percentage": 42.2, "count": "0", "additional_payer_notes": "Zero final payments for the item or service in the 15 months prior to posting the file." }, { "payer_name": "CIGNA", "plan_name": "CIGNA COM ALT HMO PLAN", "methodology": "percent of total billed charges", "standard_charge_dollar": 516.95, "standard_charge_percentage": 42.2, "count": "0", "additional_payer_notes": "Zero final payments for the item or service in the 15 months prior to posting the file." }, { "payer_name": "HEALTH NET", "plan_name": "HEALTHNET HMO, PPO, POS, EPO, CANOPY HEALTHNET HMO, OTHER-IN-NETWORK PLANS", "methodology": "per diem", "standard_charge_dollar": 8000.0, "standard_charge_algorithm": "Expected reimbursement is the lesser of Per diem ($8,000) for the length of stay and 70% of billed.", "count": "0", "additional_payer_notes": "Zero final payments for the item or service in the 15 months prior to posting the file." }, { "payer_name": "HEALTH NET", "plan_name": "HEALTHNET HMO, PPO, POS, EPO, CANOPY HEALTHNET HMO, OTHER-IN-NETWORK PLANS", "methodology": "per diem", "standard_charge_dollar": 8000.0, "standard_charge_algorithm": "Expected reimbursement is the lesser of Per diem ($8,000) for the length of stay and 70% of billed.", "count": "0", "additional_payer_notes": "Zero final payments for the item or service in the 15 months prior to posting the file." }, { "payer_name": "UNITED HEALTHCARE", "plan_name": "SUTTER SELECT & SUTTER HEALTH PLAN HMO PLANS", "methodology": "per diem", "standard_charge_dollar": 28538.0, "standard_charge_algorithm": "Per diem ($28,538).", "count": "0", "additional_payer_notes": "Zero final payments for the item or service in the 15 months prior to posting the file." }, { "payer_name": "UNITED HEALTHCARE", "plan_name": "SUTTER SELECT & SUTTER HEALTH PLAN HMO PLANS", "methodology": "per diem", "standard_charge_dollar": 28538.0, "standard_charge_algorithm": "Per diem ($28,538).", "count": "0", "additional_payer_notes": "Zero final payments for the item or service in the 15 months prior to posting the file." }, { "payer_name": "SUTTER", "plan_name": "SUTTER SELECT & SUTTER HEALTH PLAN HMO PLANS", "methodology": "per diem", "standard_charge_dollar": 28538.0, "standard_charge_algorithm": "Per diem ($28,538).", "count": "0", "additional_payer_notes": "Zero final payments for the item or service in the 15 months prior to posting the file." }, { "payer_name": "UNITED HEALTHCARE", "plan_name": "SUTTER SELECT & SUTTER HEALTH PLAN HMO PLANS", "methodology": "per diem", "standard_charge_dollar": 28538.0, "standard_charge_algorithm": "Per diem ($28,538).", "count": "0", "additional_payer_notes": "Zero final payments for the item or service in the 15 months prior to posting the file." }, { "payer_name": "UMR", "plan_name": "SUTTER SELECT & SUTTER HEALTH PLAN HMO PLANS", "methodology": "per diem", "standard_charge_dollar": 28538.0, "standard_charge_algorithm": "Per diem ($28,538).", "count": "0", "additional_payer_notes": "Zero final payments for the item or service in the 15 months prior to posting the file." } ] } ] }, { "description": "Hc Bur Gp016", "code_information": [ { "code": "PX-2120017016", "type": "CDM" }, { "code": "99999", "type": "CPT" }, { "code": "0272", "type": "RC" } ], "standard_charges": [ { "setting": "outpatient", "gross_charge": 1400.0, "discounted_cash": 700.0, "minimum": 590.8, "maximum": 728.0, "additional_generic_notes": "Zero final payments for the item or service in the 15 months prior to posting the file.", "payers_information": [ { "payer_name": "AETNA", "plan_name": "AETNA ALL OTHER PLANS", "methodology": "percent of total billed charges", "standard_charge_dollar": 728.0, "standard_charge_percentage": 52.0, "count": "0", "additional_payer_notes": "Zero final payments for the item or service in the 15 months prior to posting the file." }, { "payer_name": "AETNA", "plan_name": "AETNA ALL OTHER PLANS", "methodology": "percent of total billed charges", "standard_charge_dollar": 728.0, "standard_charge_percentage": 52.0, "count": "0", "additional_payer_notes": "Zero final payments for the item or service in the 15 months prior to posting the file." }, { "payer_name": "MERITAIN HEALTH", "plan_name": "AETNA ALL OTHER PLANS", "methodology": "percent of total billed charges", "standard_charge_dollar": 728.0, "standard_charge_percentage": 52.0, "count": "0", "additional_payer_notes": "Zero final payments for the item or service in the 15 months prior to posting the file." }, { "payer_name": "BLUE SHIELD OUT OF STATE", "plan_name": "STANFORD HEALTHCARE ALLIANCE PLAN", "methodology": "percent of total billed charges", "standard_charge_dollar": 680.26, "standard_charge_percentage": 48.59, "count": "0", "additional_payer_notes": "Zero final payments for the item or service in the 15 months prior to posting the file." }, { "payer_name": "BLUE SHIELD", "plan_name": "STANFORD HEALTHCARE ALLIANCE PLAN", "methodology": "percent of total billed charges", "standard_charge_dollar": 680.26, "standard_charge_percentage": 48.59, "median_amount": 68.24, "10th_percentile": 13.6, "90th_percentile": 1043.06, "count": "30" }, { "payer_name": "BLUE SHIELD", "plan_name": "STANFORD HEALTHCARE ALLIANCE PLAN", "methodology": "percent of total billed charges", "standard_charge_dollar": 680.26, "standard_charge_percentage": 48.59, "count": "0", "additional_payer_notes": "Zero final payments for the item or service in the 15 months prior to posting the file." }, { "payer_name": "BLUE SHIELD", "plan_name": "STANFORD HEALTHCARE ALLIANCE PLAN", "methodology": "percent of total billed charges", "standard_charge_dollar": 680.26, "standard_charge_percentage": 48.59, "count": "0", "additional_payer_notes": "Zero final payments for the item or service in the 15 months prior to posting the file." }, { "payer_name": "CIGNA", "plan_name": "CIGNA COM ALT HMO PLAN", "methodology": "percent of total billed charges", "standard_charge_dollar": 590.8, "standard_charge_percentage": 42.2, "count": "0", "additional_payer_notes": "Zero final payments for the item or service in the 15 months prior to posting the file." }, { "payer_name": "CIGNA", "plan_name": "CIGNA COM ALT HMO PLAN", "methodology": "percent of total billed charges", "standard_charge_dollar": 590.8, "standard_charge_percentage": 42.2, "count": "0", "additional_payer_notes": "Zero final payments for the item or service in the 15 months prior to posting the file." }, { "payer_name": "HEALTH NET", "plan_name": "HEALTHNET HMO, PPO, POS, EPO, CANOPY HEALTHNET HMO, OTHER-IN-NETWORK PLANS", "methodology": "per diem", "standard_charge_dollar": 8000.0, "standard_charge_algorithm": "Expected reimbursement is the lesser of Per diem ($8,000) for the length of stay and 70% of billed.", "count": "0", "additional_payer_notes": "Zero final payments for the item or service in the 15 months prior to posting the file." }, { "payer_name": "HEALTH NET", "plan_name": "HEALTHNET HMO, PPO, POS, EPO, CANOPY HEALTHNET HMO, OTHER-IN-NETWORK PLANS", "methodology": "per diem", "standard_charge_dollar": 8000.0, "standard_charge_algorithm": "Expected reimbursement is the lesser of Per diem ($8,000) for the length of stay and 70% of billed.", "count": "0", "additional_payer_notes": "Zero final payments for the item or service in the 15 months prior to posting the file." }, { "payer_name": "UNITED HEALTHCARE", "plan_name": "SUTTER SELECT & SUTTER HEALTH PLAN HMO PLANS", "methodology": "per diem", "standard_charge_dollar": 28538.0, "standard_charge_algorithm": "Per diem ($28,538).", "count": "0", "additional_payer_notes": "Zero final payments for the item or service in the 15 months prior to posting the file." }, { "payer_name": "UNITED HEALTHCARE", "plan_name": "SUTTER SELECT & SUTTER HEALTH PLAN HMO PLANS", "methodology": "per diem", "standard_charge_dollar": 28538.0, "standard_charge_algorithm": "Per diem ($28,538).", "count": "0", "additional_payer_notes": "Zero final payments for the item or service in the 15 months prior to posting the file." }, { "payer_name": "SUTTER", "plan_name": "SUTTER SELECT & SUTTER HEALTH PLAN HMO PLANS", "methodology": "per diem", "standard_charge_dollar": 28538.0, "standard_charge_algorithm": "Per diem ($28,538).", "count": "0", "additional_payer_notes": "Zero final payments for the item or service in the 15 months prior to posting the file." }, { "payer_name": "UNITED HEALTHCARE", "plan_name": "SUTTER SELECT & SUTTER HEALTH PLAN HMO PLANS", "methodology": "per diem", "standard_charge_dollar": 28538.0, "standard_charge_algorithm": "Per diem ($28,538).", "count": "0", "additional_payer_notes": "Zero final payments for the item or service in the 15 months prior to posting the file." }, { "payer_name": "UMR", "plan_name": "SUTTER SELECT & SUTTER HEALTH PLAN HMO PLANS", "methodology": "per diem", "standard_charge_dollar": 28538.0, "standard_charge_algorithm": "Per diem ($28,538).", "count": "0", "additional_payer_notes": "Zero final payments for the item or service in the 15 months prior to posting the file." } ] } ] }, { "description": "Hc Bur Gp017", "code_information": [ { "code": "PX-2120017017", "type": "CDM" }, { "code": "99999", "type": "CPT" }, { "code": "0272", "type": "RC" } ], "standard_charges": [ { "setting": "outpatient", "gross_charge": 1575.0, "discounted_cash": 787.5, "minimum": 664.65, "maximum": 819.0, "additional_generic_notes": "Zero final payments for the item or service in the 15 months prior to posting the file.", "payers_information": [ { "payer_name": "AETNA", "plan_name": "AETNA ALL OTHER PLANS", "methodology": "percent of total billed charges", "standard_charge_dollar": 819.0, "standard_charge_percentage": 52.0, "count": "0", "additional_payer_notes": "Zero final payments for the item or service in the 15 months prior to posting the file." }, { "payer_name": "AETNA", "plan_name": "AETNA ALL OTHER PLANS", "methodology": "percent of total billed charges", "standard_charge_dollar": 819.0, "standard_charge_percentage": 52.0, "count": "0", "additional_payer_notes": "Zero final payments for the item or service in the 15 months prior to posting the file." }, { "payer_name": "MERITAIN HEALTH", "plan_name": "AETNA ALL OTHER PLANS", "methodology": "percent of total billed charges", "standard_charge_dollar": 819.0, "standard_charge_percentage": 52.0, "count": "0", "additional_payer_notes": "Zero final payments for the item or service in the 15 months prior to posting the file." }, { "payer_name": "BLUE SHIELD OUT OF STATE", "plan_name": "STANFORD HEALTHCARE ALLIANCE PLAN", "methodology": "percent of total billed charges", "standard_charge_dollar": 765.29, "standard_charge_percentage": 48.59, "count": "0", "additional_payer_notes": "Zero final payments for the item or service in the 15 months prior to posting the file." }, { "payer_name": "BLUE SHIELD", "plan_name": "STANFORD HEALTHCARE ALLIANCE PLAN", "methodology": "percent of total billed charges", "standard_charge_dollar": 765.29, "standard_charge_percentage": 48.59, "median_amount": 68.24, "10th_percentile": 13.6, "90th_percentile": 1043.06, "count": "30" }, { "payer_name": "BLUE SHIELD", "plan_name": "STANFORD HEALTHCARE ALLIANCE PLAN", "methodology": "percent of total billed charges", "standard_charge_dollar": 765.29, "standard_charge_percentage": 48.59, "count": "0", "additional_payer_notes": "Zero final payments for the item or service in the 15 months prior to posting the file." }, { "payer_name": "BLUE SHIELD", "plan_name": "STANFORD HEALTHCARE ALLIANCE PLAN", "methodology": "percent of total billed charges", "standard_charge_dollar": 765.29, "standard_charge_percentage": 48.59, "count": "0", "additional_payer_notes": "Zero final payments for the item or service in the 15 months prior to posting the file." }, { "payer_name": "CIGNA", "plan_name": "CIGNA COM ALT HMO PLAN", "methodology": "percent of total billed charges", "standard_charge_dollar": 664.65, "standard_charge_percentage": 42.2, "count": "0", "additional_payer_notes": "Zero final payments for the item or service in the 15 months prior to posting the file." }, { "payer_name": "CIGNA", "plan_name": "CIGNA COM ALT HMO PLAN", "methodology": "percent of total billed charges", "standard_charge_dollar": 664.65, "standard_charge_percentage": 42.2, "count": "0", "additional_payer_notes": "Zero final payments for the item or service in the 15 months prior to posting the file." }, { "payer_name": "HEALTH NET", "plan_name": "HEALTHNET HMO, PPO, POS, EPO, CANOPY HEALTHNET HMO, OTHER-IN-NETWORK PLANS", "methodology": "per diem", "standard_charge_dollar": 8000.0, "standard_charge_algorithm": "Expected reimbursement is the lesser of Per diem ($8,000) for the length of stay and 70% of billed.", "count": "0", "additional_payer_notes": "Zero final payments for the item or service in the 15 months prior to posting the file." }, { "payer_name": "HEALTH NET", "plan_name": "HEALTHNET HMO, PPO, POS, EPO, CANOPY HEALTHNET HMO, OTHER-IN-NETWORK PLANS", "methodology": "per diem", "standard_charge_dollar": 8000.0, "standard_charge_algorithm": "Expected reimbursement is the lesser of Per diem ($8,000) for the length of stay and 70% of billed.", "count": "0", "additional_payer_notes": "Zero final payments for the item or service in the 15 months prior to posting the file." }, { "payer_name": "UNITED HEALTHCARE", "plan_name": "SUTTER SELECT & SUTTER HEALTH PLAN HMO PLANS", "methodology": "per diem", "standard_charge_dollar": 28538.0, "standard_charge_algorithm": "Per diem ($28,538).", "count": "0", "additional_payer_notes": "Zero final payments for the item or service in the 15 months prior to posting the file." }, { "payer_name": "UNITED HEALTHCARE", "plan_name": "SUTTER SELECT & SUTTER HEALTH PLAN HMO PLANS", "methodology": "per diem", "standard_charge_dollar": 28538.0, "standard_charge_algorithm": "Per diem ($28,538).", "count": "0", "additional_payer_notes": "Zero final payments for the item or service in the 15 months prior to posting the file." }, { "payer_name": "SUTTER", "plan_name": "SUTTER SELECT & SUTTER HEALTH PLAN HMO PLANS", "methodology": "per diem", "standard_charge_dollar": 28538.0, "standard_charge_algorithm": "Per diem ($28,538).", "count": "0", "additional_payer_notes": "Zero final payments for the item or service in the 15 months prior to posting the file." }, { "payer_name": "UNITED HEALTHCARE", "plan_name": "SUTTER SELECT & SUTTER HEALTH PLAN HMO PLANS", "methodology": "per diem", "standard_charge_dollar": 28538.0, "standard_charge_algorithm": "Per diem ($28,538).", "count": "0", "additional_payer_notes": "Zero final payments for the item or service in the 15 months prior to posting the file." }, { "payer_name": "UMR", "plan_name": "SUTTER SELECT & SUTTER HEALTH PLAN HMO PLANS", "methodology": "per diem", "standard_charge_dollar": 28538.0, "standard_charge_algorithm": "Per diem ($28,538).", "count": "0", "additional_payer_notes": "Zero final payments for the item or service in the 15 months prior to posting the file." } ] } ] }, { "description": "HC Bur Gp018", "code_information": [ { "code": "PX-2120017018", "type": "CDM" }, { "code": "99999", "type": "CPT" }, { "code": "0272", "type": "RC" } ], "standard_charges": [ { "setting": "outpatient", "gross_charge": 1750.0, "discounted_cash": 875.0, "minimum": 738.5, "maximum": 910.0, "additional_generic_notes": "Zero final payments for the item or service in the 15 months prior to posting the file.", "payers_information": [ { "payer_name": "AETNA", "plan_name": "AETNA ALL OTHER PLANS", "methodology": "percent of total billed charges", "standard_charge_dollar": 910.0, "standard_charge_percentage": 52.0, "count": "0", "additional_payer_notes": "Zero final payments for the item or service in the 15 months prior to posting the file." }, { "payer_name": "AETNA", "plan_name": "AETNA ALL OTHER PLANS", "methodology": "percent of total billed charges", "standard_charge_dollar": 910.0, "standard_charge_percentage": 52.0, "count": "0", "additional_payer_notes": "Zero final payments for the item or service in the 15 months prior to posting the file." }, { "payer_name": "MERITAIN HEALTH", "plan_name": "AETNA ALL OTHER PLANS", "methodology": "percent of total billed charges", "standard_charge_dollar": 910.0, "standard_charge_percentage": 52.0, "count": "0", "additional_payer_notes": "Zero final payments for the item or service in the 15 months prior to posting the file." }, { "payer_name": "BLUE SHIELD OUT OF STATE", "plan_name": "STANFORD HEALTHCARE ALLIANCE PLAN", "methodology": "percent of total billed charges", "standard_charge_dollar": 850.33, "standard_charge_percentage": 48.59, "count": "0", "additional_payer_notes": "Zero final payments for the item or service in the 15 months prior to posting the file." }, { "payer_name": "BLUE SHIELD", "plan_name": "STANFORD HEALTHCARE ALLIANCE PLAN", "methodology": "percent of total billed charges", "standard_charge_dollar": 850.33, "standard_charge_percentage": 48.59, "median_amount": 68.24, "10th_percentile": 13.6, "90th_percentile": 1043.06, "count": "30" }, { "payer_name": "BLUE SHIELD", "plan_name": "STANFORD HEALTHCARE ALLIANCE PLAN", "methodology": "percent of total billed charges", "standard_charge_dollar": 850.33, "standard_charge_percentage": 48.59, "count": "0", "additional_payer_notes": "Zero final payments for the item or service in the 15 months prior to posting the file." }, { "payer_name": "BLUE SHIELD", "plan_name": "STANFORD HEALTHCARE ALLIANCE PLAN", "methodology": "percent of total billed charges", "standard_charge_dollar": 850.33, "standard_charge_percentage": 48.59, "count": "0", "additional_payer_notes": "Zero final payments for the item or service in the 15 months prior to posting the file." }, { "payer_name": "CIGNA", "plan_name": "CIGNA COM ALT HMO PLAN", "methodology": "percent of total billed charges", "standard_charge_dollar": 738.5, "standard_charge_percentage": 42.2, "count": "0", "additional_payer_notes": "Zero final payments for the item or service in the 15 months prior to posting the file." }, { "payer_name": "CIGNA", "plan_name": "CIGNA COM ALT HMO PLAN", "methodology": "percent of total billed charges", "standard_charge_dollar": 738.5, "standard_charge_percentage": 42.2, "count": "0", "additional_payer_notes": "Zero final payments for the item or service in the 15 months prior to posting the file." }, { "payer_name": "HEALTH NET", "plan_name": "HEALTHNET HMO, PPO, POS, EPO, CANOPY HEALTHNET HMO, OTHER-IN-NETWORK PLANS", "methodology": "per diem", "standard_charge_dollar": 8000.0, "standard_charge_algorithm": "Expected reimbursement is the lesser of Per diem ($8,000) for the length of stay and 70% of billed.", "count": "0", "additional_payer_notes": "Zero final payments for the item or service in the 15 months prior to posting the file." }, { "payer_name": "HEALTH NET", "plan_name": "HEALTHNET HMO, PPO, POS, EPO, CANOPY HEALTHNET HMO, OTHER-IN-NETWORK PLANS", "methodology": "per diem", "standard_charge_dollar": 8000.0, "standard_charge_algorithm": "Expected reimbursement is the lesser of Per diem ($8,000) for the length of stay and 70% of billed.", "count": "0", "additional_payer_notes": "Zero final payments for the item or service in the 15 months prior to posting the file." }, { "payer_name": "UNITED HEALTHCARE", "plan_name": "SUTTER SELECT & SUTTER HEALTH PLAN HMO PLANS", "methodology": "per diem", "standard_charge_dollar": 28538.0, "standard_charge_algorithm": "Per diem ($28,538).", "count": "0", "additional_payer_notes": "Zero final payments for the item or service in the 15 months prior to posting the file." }, { "payer_name": "UNITED HEALTHCARE", "plan_name": "SUTTER SELECT & SUTTER HEALTH PLAN HMO PLANS", "methodology": "per diem", "standard_charge_dollar": 28538.0, "standard_charge_algorithm": "Per diem ($28,538).", "count": "0", "additional_payer_notes": "Zero final payments for the item or service in the 15 months prior to posting the file." }, { "payer_name": "SUTTER", "plan_name": "SUTTER SELECT & SUTTER HEALTH PLAN HMO PLANS", "methodology": "per diem", "standard_charge_dollar": 28538.0, "standard_charge_algorithm": "Per diem ($28,538).", "count": "0", "additional_payer_notes": "Zero final payments for the item or service in the 15 months prior to posting the file." }, { "payer_name": "UNITED HEALTHCARE", "plan_name": "SUTTER SELECT & SUTTER HEALTH PLAN HMO PLANS", "methodology": "per diem", "standard_charge_dollar": 28538.0, "standard_charge_algorithm": "Per diem ($28,538).", "count": "0", "additional_payer_notes": "Zero final payments for the item or service in the 15 months prior to posting the file." }, { "payer_name": "UMR", "plan_name": "SUTTER SELECT & SUTTER HEALTH PLAN HMO PLANS", "methodology": "per diem", "standard_charge_dollar": 28538.0, "standard_charge_algorithm": "Per diem ($28,538).", "count": "0", "additional_payer_notes": "Zero final payments for the item or service in the 15 months prior to posting the file." } ] } ] }, { "description": "HC Bur Gp019", "code_information": [ { "code": "PX-2120017019", "type": "CDM" }, { "code": "99999", "type": "CPT" }, { "code": "0272", "type": "RC" } ], "standard_charges": [ { "setting": "outpatient", "gross_charge": 2125.0, "discounted_cash": 1062.5, "minimum": 896.75, "maximum": 1105.0, "additional_generic_notes": "Zero final payments for the item or service in the 15 months prior to posting the file.", "payers_information": [ { "payer_name": "AETNA", "plan_name": "AETNA ALL OTHER PLANS", "methodology": "percent of total billed charges", "standard_charge_dollar": 1105.0, "standard_charge_percentage": 52.0, "count": "0", "additional_payer_notes": "Zero final payments for the item or service in the 15 months prior to posting the file." }, { "payer_name": "AETNA", "plan_name": "AETNA ALL OTHER PLANS", "methodology": "percent of total billed charges", "standard_charge_dollar": 1105.0, "standard_charge_percentage": 52.0, "count": "0", "additional_payer_notes": "Zero final payments for the item or service in the 15 months prior to posting the file." }, { "payer_name": "MERITAIN HEALTH", "plan_name": "AETNA ALL OTHER PLANS", "methodology": "percent of total billed charges", "standard_charge_dollar": 1105.0, "standard_charge_percentage": 52.0, "count": "0", "additional_payer_notes": "Zero final payments for the item or service in the 15 months prior to posting the file." }, { "payer_name": "BLUE SHIELD OUT OF STATE", "plan_name": "STANFORD HEALTHCARE ALLIANCE PLAN", "methodology": "percent of total billed charges", "standard_charge_dollar": 1032.54, "standard_charge_percentage": 48.59, "count": "0", "additional_payer_notes": "Zero final payments for the item or service in the 15 months prior to posting the file." }, { "payer_name": "BLUE SHIELD", "plan_name": "STANFORD HEALTHCARE ALLIANCE PLAN", "methodology": "percent of total billed charges", "standard_charge_dollar": 1032.54, "standard_charge_percentage": 48.59, "median_amount": 68.24, "10th_percentile": 13.6, "90th_percentile": 1043.06, "count": "30" }, { "payer_name": "BLUE SHIELD", "plan_name": "STANFORD HEALTHCARE ALLIANCE PLAN", "methodology": "percent of total billed charges", "standard_charge_dollar": 1032.54, "standard_charge_percentage": 48.59, "count": "0", "additional_payer_notes": "Zero final payments for the item or service in the 15 months prior to posting the file." }, { "payer_name": "BLUE SHIELD", "plan_name": "STANFORD HEALTHCARE ALLIANCE PLAN", "methodology": "percent of total billed charges", "standard_charge_dollar": 1032.54, "standard_charge_percentage": 48.59, "count": "0", "additional_payer_notes": "Zero final payments for the item or service in the 15 months prior to posting the file." }, { "payer_name": "CIGNA", "plan_name": "CIGNA COM ALT HMO PLAN", "methodology": "percent of total billed charges", "standard_charge_dollar": 896.75, "standard_charge_percentage": 42.2, "count": "0", "additional_payer_notes": "Zero final payments for the item or service in the 15 months prior to posting the file." }, { "payer_name": "CIGNA", "plan_name": "CIGNA COM ALT HMO PLAN", "methodology": "percent of total billed charges", "standard_charge_dollar": 896.75, "standard_charge_percentage": 42.2, "count": "0", "additional_payer_notes": "Zero final payments for the item or service in the 15 months prior to posting the file." }, { "payer_name": "HEALTH NET", "plan_name": "HEALTHNET HMO, PPO, POS, EPO, CANOPY HEALTHNET HMO, OTHER-IN-NETWORK PLANS", "methodology": "per diem", "standard_charge_dollar": 8000.0, "standard_charge_algorithm": "Expected reimbursement is the lesser of Per diem ($8,000) for the length of stay and 70% of billed.", "count": "0", "additional_payer_notes": "Zero final payments for the item or service in the 15 months prior to posting the file." }, { "payer_name": "HEALTH NET", "plan_name": "HEALTHNET HMO, PPO, POS, EPO, CANOPY HEALTHNET HMO, OTHER-IN-NETWORK PLANS", "methodology": "per diem", "standard_charge_dollar": 8000.0, "standard_charge_algorithm": "Expected reimbursement is the lesser of Per diem ($8,000) for the length of stay and 70% of billed.", "count": "0", "additional_payer_notes": "Zero final payments for the item or service in the 15 months prior to posting the file." }, { "payer_name": "UNITED HEALTHCARE", "plan_name": "SUTTER SELECT & SUTTER HEALTH PLAN HMO PLANS", "methodology": "per diem", "standard_charge_dollar": 28538.0, "standard_charge_algorithm": "Per diem ($28,538).", "count": "0", "additional_payer_notes": "Zero final payments for the item or service in the 15 months prior to posting the file." }, { "payer_name": "UNITED HEALTHCARE", "plan_name": "SUTTER SELECT & SUTTER HEALTH PLAN HMO PLANS", "methodology": "per diem", "standard_charge_dollar": 28538.0, "standard_charge_algorithm": "Per diem ($28,538).", "count": "0", "additional_payer_notes": "Zero final payments for the item or service in the 15 months prior to posting the file." }, { "payer_name": "SUTTER", "plan_name": "SUTTER SELECT & SUTTER HEALTH PLAN HMO PLANS", "methodology": "per diem", "standard_charge_dollar": 28538.0, "standard_charge_algorithm": "Per diem ($28,538).", "count": "0", "additional_payer_notes": "Zero final payments for the item or service in the 15 months prior to posting the file." }, { "payer_name": "UNITED HEALTHCARE", "plan_name": "SUTTER SELECT & SUTTER HEALTH PLAN HMO PLANS", "methodology": "per diem", "standard_charge_dollar": 28538.0, "standard_charge_algorithm": "Per diem ($28,538).", "count": "0", "additional_payer_notes": "Zero final payments for the item or service in the 15 months prior to posting the file." }, { "payer_name": "UMR", "plan_name": "SUTTER SELECT & SUTTER HEALTH PLAN HMO PLANS", "methodology": "per diem", "standard_charge_dollar": 28538.0, "standard_charge_algorithm": "Per diem ($28,538).", "count": "0", "additional_payer_notes": "Zero final payments for the item or service in the 15 months prior to posting the file." } ] } ] }, { "description": "HC Bur Gp020", "code_information": [ { "code": "PX-2120017020", "type": "CDM" }, { "code": "99999", "type": "CPT" }, { "code": "0272", "type": "RC" } ], "standard_charges": [ { "setting": "outpatient", "gross_charge": 2550.0, "discounted_cash": 1275.0, "minimum": 1076.1, "maximum": 1326.0, "additional_generic_notes": "Zero final payments for the item or service in the 15 months prior to posting the file.", "payers_information": [ { "payer_name": "AETNA", "plan_name": "AETNA ALL OTHER PLANS", "methodology": "percent of total billed charges", "standard_charge_dollar": 1326.0, "standard_charge_percentage": 52.0, "count": "0", "additional_payer_notes": "Zero final payments for the item or service in the 15 months prior to posting the file." }, { "payer_name": "AETNA", "plan_name": "AETNA ALL OTHER PLANS", "methodology": "percent of total billed charges", "standard_charge_dollar": 1326.0, "standard_charge_percentage": 52.0, "count": "0", "additional_payer_notes": "Zero final payments for the item or service in the 15 months prior to posting the file." }, { "payer_name": "MERITAIN HEALTH", "plan_name": "AETNA ALL OTHER PLANS", "methodology": "percent of total billed charges", "standard_charge_dollar": 1326.0, "standard_charge_percentage": 52.0, "count": "0", "additional_payer_notes": "Zero final payments for the item or service in the 15 months prior to posting the file." }, { "payer_name": "BLUE SHIELD OUT OF STATE", "plan_name": "STANFORD HEALTHCARE ALLIANCE PLAN", "methodology": "percent of total billed charges", "standard_charge_dollar": 1239.05, "standard_charge_percentage": 48.59, "count": "0", "additional_payer_notes": "Zero final payments for the item or service in the 15 months prior to posting the file." }, { "payer_name": "BLUE SHIELD", "plan_name": "STANFORD HEALTHCARE ALLIANCE PLAN", "methodology": "percent of total billed charges", "standard_charge_dollar": 1239.05, "standard_charge_percentage": 48.59, "median_amount": 68.24, "10th_percentile": 13.6, "90th_percentile": 1043.06, "count": "30" }, { "payer_name": "BLUE SHIELD", "plan_name": "STANFORD HEALTHCARE ALLIANCE PLAN", "methodology": "percent of total billed charges", "standard_charge_dollar": 1239.05, "standard_charge_percentage": 48.59, "count": "0", "additional_payer_notes": "Zero final payments for the item or service in the 15 months prior to posting the file." }, { "payer_name": "BLUE SHIELD", "plan_name": "STANFORD HEALTHCARE ALLIANCE PLAN", "methodology": "percent of total billed charges", "standard_charge_dollar": 1239.05, "standard_charge_percentage": 48.59, "count": "0", "additional_payer_notes": "Zero final payments for the item or service in the 15 months prior to posting the file." }, { "payer_name": "CIGNA", "plan_name": "CIGNA COM ALT HMO PLAN", "methodology": "percent of total billed charges", "standard_charge_dollar": 1076.1, "standard_charge_percentage": 42.2, "count": "0", "additional_payer_notes": "Zero final payments for the item or service in the 15 months prior to posting the file." }, { "payer_name": "CIGNA", "plan_name": "CIGNA COM ALT HMO PLAN", "methodology": "percent of total billed charges", "standard_charge_dollar": 1076.1, "standard_charge_percentage": 42.2, "count": "0", "additional_payer_notes": "Zero final payments for the item or service in the 15 months prior to posting the file." }, { "payer_name": "HEALTH NET", "plan_name": "HEALTHNET HMO, PPO, POS, EPO, CANOPY HEALTHNET HMO, OTHER-IN-NETWORK PLANS", "methodology": "per diem", "standard_charge_dollar": 8000.0, "standard_charge_algorithm": "Expected reimbursement is the lesser of Per diem ($8,000) for the length of stay and 70% of billed.", "count": "0", "additional_payer_notes": "Zero final payments for the item or service in the 15 months prior to posting the file." }, { "payer_name": "HEALTH NET", "plan_name": "HEALTHNET HMO, PPO, POS, EPO, CANOPY HEALTHNET HMO, OTHER-IN-NETWORK PLANS", "methodology": "per diem", "standard_charge_dollar": 8000.0, "standard_charge_algorithm": "Expected reimbursement is the lesser of Per diem ($8,000) for the length of stay and 70% of billed.", "count": "0", "additional_payer_notes": "Zero final payments for the item or service in the 15 months prior to posting the file." }, { "payer_name": "UNITED HEALTHCARE", "plan_name": "SUTTER SELECT & SUTTER HEALTH PLAN HMO PLANS", "methodology": "per diem", "standard_charge_dollar": 28538.0, "standard_charge_algorithm": "Per diem ($28,538).", "count": "0", "additional_payer_notes": "Zero final payments for the item or service in the 15 months prior to posting the file." }, { "payer_name": "UNITED HEALTHCARE", "plan_name": "SUTTER SELECT & SUTTER HEALTH PLAN HMO PLANS", "methodology": "per diem", "standard_charge_dollar": 28538.0, "standard_charge_algorithm": "Per diem ($28,538).", "count": "0", "additional_payer_notes": "Zero final payments for the item or service in the 15 months prior to posting the file." }, { "payer_name": "SUTTER", "plan_name": "SUTTER SELECT & SUTTER HEALTH PLAN HMO PLANS", "methodology": "per diem", "standard_charge_dollar": 28538.0, "standard_charge_algorithm": "Per diem ($28,538).", "count": "0", "additional_payer_notes": "Zero final payments for the item or service in the 15 months prior to posting the file." }, { "payer_name": "UNITED HEALTHCARE", "plan_name": "SUTTER SELECT & SUTTER HEALTH PLAN HMO PLANS", "methodology": "per diem", "standard_charge_dollar": 28538.0, "standard_charge_algorithm": "Per diem ($28,538).", "count": "0", "additional_payer_notes": "Zero final payments for the item or service in the 15 months prior to posting the file." }, { "payer_name": "UMR", "plan_name": "SUTTER SELECT & SUTTER HEALTH PLAN HMO PLANS", "methodology": "per diem", "standard_charge_dollar": 28538.0, "standard_charge_algorithm": "Per diem ($28,538).", "count": "0", "additional_payer_notes": "Zero final payments for the item or service in the 15 months prior to posting the file." } ] } ] }, { "description": "Hc Bur Gp021", "code_information": [ { "code": "PX-2120017021", "type": "CDM" }, { "code": "99999", "type": "CPT" }, { "code": "0272", "type": "RC" } ], "standard_charges": [ { "setting": "outpatient", "gross_charge": 2888.0, "discounted_cash": 1444.0, "minimum": 1218.74, "maximum": 1501.76, "additional_generic_notes": "Zero final payments for the item or service in the 15 months prior to posting the file.", "payers_information": [ { "payer_name": "AETNA", "plan_name": "AETNA ALL OTHER PLANS", "methodology": "percent of total billed charges", "standard_charge_dollar": 1501.76, "standard_charge_percentage": 52.0, "count": "0", "additional_payer_notes": "Zero final payments for the item or service in the 15 months prior to posting the file." }, { "payer_name": "AETNA", "plan_name": "AETNA ALL OTHER PLANS", "methodology": "percent of total billed charges", "standard_charge_dollar": 1501.76, "standard_charge_percentage": 52.0, "count": "0", "additional_payer_notes": "Zero final payments for the item or service in the 15 months prior to posting the file." }, { "payer_name": "MERITAIN HEALTH", "plan_name": "AETNA ALL OTHER PLANS", "methodology": "percent of total billed charges", "standard_charge_dollar": 1501.76, "standard_charge_percentage": 52.0, "count": "0", "additional_payer_notes": "Zero final payments for the item or service in the 15 months prior to posting the file." }, { "payer_name": "BLUE SHIELD OUT OF STATE", "plan_name": "STANFORD HEALTHCARE ALLIANCE PLAN", "methodology": "percent of total billed charges", "standard_charge_dollar": 1403.28, "standard_charge_percentage": 48.59, "count": "0", "additional_payer_notes": "Zero final payments for the item or service in the 15 months prior to posting the file." }, { "payer_name": "BLUE SHIELD", "plan_name": "STANFORD HEALTHCARE ALLIANCE PLAN", "methodology": "percent of total billed charges", "standard_charge_dollar": 1403.28, "standard_charge_percentage": 48.59, "median_amount": 68.24, "10th_percentile": 13.6, "90th_percentile": 1043.06, "count": "30" }, { "payer_name": "BLUE SHIELD", "plan_name": "STANFORD HEALTHCARE ALLIANCE PLAN", "methodology": "percent of total billed charges", "standard_charge_dollar": 1403.28, "standard_charge_percentage": 48.59, "count": "0", "additional_payer_notes": "Zero final payments for the item or service in the 15 months prior to posting the file." }, { "payer_name": "BLUE SHIELD", "plan_name": "STANFORD HEALTHCARE ALLIANCE PLAN", "methodology": "percent of total billed charges", "standard_charge_dollar": 1403.28, "standard_charge_percentage": 48.59, "count": "0", "additional_payer_notes": "Zero final payments for the item or service in the 15 months prior to posting the file." }, { "payer_name": "CIGNA", "plan_name": "CIGNA COM ALT HMO PLAN", "methodology": "percent of total billed charges", "standard_charge_dollar": 1218.74, "standard_charge_percentage": 42.2, "count": "0", "additional_payer_notes": "Zero final payments for the item or service in the 15 months prior to posting the file." }, { "payer_name": "CIGNA", "plan_name": "CIGNA COM ALT HMO PLAN", "methodology": "percent of total billed charges", "standard_charge_dollar": 1218.74, "standard_charge_percentage": 42.2, "count": "0", "additional_payer_notes": "Zero final payments for the item or service in the 15 months prior to posting the file." }, { "payer_name": "HEALTH NET", "plan_name": "HEALTHNET HMO, PPO, POS, EPO, CANOPY HEALTHNET HMO, OTHER-IN-NETWORK PLANS", "methodology": "per diem", "standard_charge_dollar": 8000.0, "standard_charge_algorithm": "Expected reimbursement is the lesser of Per diem ($8,000) for the length of stay and 70% of billed.", "count": "0", "additional_payer_notes": "Zero final payments for the item or service in the 15 months prior to posting the file." }, { "payer_name": "HEALTH NET", "plan_name": "HEALTHNET HMO, PPO, POS, EPO, CANOPY HEALTHNET HMO, OTHER-IN-NETWORK PLANS", "methodology": "per diem", "standard_charge_dollar": 8000.0, "standard_charge_algorithm": "Expected reimbursement is the lesser of Per diem ($8,000) for the length of stay and 70% of billed.", "count": "0", "additional_payer_notes": "Zero final payments for the item or service in the 15 months prior to posting the file." }, { "payer_name": "UNITED HEALTHCARE", "plan_name": "SUTTER SELECT & SUTTER HEALTH PLAN HMO PLANS", "methodology": "per diem", "standard_charge_dollar": 28538.0, "standard_charge_algorithm": "Per diem ($28,538).", "count": "0", "additional_payer_notes": "Zero final payments for the item or service in the 15 months prior to posting the file." }, { "payer_name": "UNITED HEALTHCARE", "plan_name": "SUTTER SELECT & SUTTER HEALTH PLAN HMO PLANS", "methodology": "per diem", "standard_charge_dollar": 28538.0, "standard_charge_algorithm": "Per diem ($28,538).", "count": "0", "additional_payer_notes": "Zero final payments for the item or service in the 15 months prior to posting the file." }, { "payer_name": "SUTTER", "plan_name": "SUTTER SELECT & SUTTER HEALTH PLAN HMO PLANS", "methodology": "per diem", "standard_charge_dollar": 28538.0, "standard_charge_algorithm": "Per diem ($28,538).", "count": "0", "additional_payer_notes": "Zero final payments for the item or service in the 15 months prior to posting the file." }, { "payer_name": "UNITED HEALTHCARE", "plan_name": "SUTTER SELECT & SUTTER HEALTH PLAN HMO PLANS", "methodology": "per diem", "standard_charge_dollar": 28538.0, "standard_charge_algorithm": "Per diem ($28,538).", "count": "0", "additional_payer_notes": "Zero final payments for the item or service in the 15 months prior to posting the file." }, { "payer_name": "UMR", "plan_name": "SUTTER SELECT & SUTTER HEALTH PLAN HMO PLANS", "methodology": "per diem", "standard_charge_dollar": 28538.0, "standard_charge_algorithm": "Per diem ($28,538).", "count": "0", "additional_payer_notes": "Zero final payments for the item or service in the 15 months prior to posting the file." } ] } ] }, { "description": "HC Bur Gp022", "code_information": [ { "code": "PX-2120017022", "type": "CDM" }, { "code": "99999", "type": "CPT" }, { "code": "0272", "type": "RC" } ], "standard_charges": [ { "setting": "outpatient", "gross_charge": 3600.0, "discounted_cash": 1800.0, "minimum": 1519.2, "maximum": 1872.0, "additional_generic_notes": "Zero final payments for the item or service in the 15 months prior to posting the file.", "payers_information": [ { "payer_name": "AETNA", "plan_name": "AETNA ALL OTHER PLANS", "methodology": "percent of total billed charges", "standard_charge_dollar": 1872.0, "standard_charge_percentage": 52.0, "count": "0", "additional_payer_notes": "Zero final payments for the item or service in the 15 months prior to posting the file." }, { "payer_name": "AETNA", "plan_name": "AETNA ALL OTHER PLANS", "methodology": "percent of total billed charges", "standard_charge_dollar": 1872.0, "standard_charge_percentage": 52.0, "count": "0", "additional_payer_notes": "Zero final payments for the item or service in the 15 months prior to posting the file." }, { "payer_name": "MERITAIN HEALTH", "plan_name": "AETNA ALL OTHER PLANS", "methodology": "percent of total billed charges", "standard_charge_dollar": 1872.0, "standard_charge_percentage": 52.0, "count": "0", "additional_payer_notes": "Zero final payments for the item or service in the 15 months prior to posting the file." }, { "payer_name": "BLUE SHIELD OUT OF STATE", "plan_name": "STANFORD HEALTHCARE ALLIANCE PLAN", "methodology": "percent of total billed charges", "standard_charge_dollar": 1749.24, "standard_charge_percentage": 48.59, "count": "0", "additional_payer_notes": "Zero final payments for the item or service in the 15 months prior to posting the file." }, { "payer_name": "BLUE SHIELD", "plan_name": "STANFORD HEALTHCARE ALLIANCE PLAN", "methodology": "percent of total billed charges", "standard_charge_dollar": 1749.24, "standard_charge_percentage": 48.59, "median_amount": 68.24, "10th_percentile": 13.6, "90th_percentile": 1043.06, "count": "30" }, { "payer_name": "BLUE SHIELD", "plan_name": "STANFORD HEALTHCARE ALLIANCE PLAN", "methodology": "percent of total billed charges", "standard_charge_dollar": 1749.24, "standard_charge_percentage": 48.59, "count": "0", "additional_payer_notes": "Zero final payments for the item or service in the 15 months prior to posting the file." }, { "payer_name": "BLUE SHIELD", "plan_name": "STANFORD HEALTHCARE ALLIANCE PLAN", "methodology": "percent of total billed charges", "standard_charge_dollar": 1749.24, "standard_charge_percentage": 48.59, "count": "0", "additional_payer_notes": "Zero final payments for the item or service in the 15 months prior to posting the file." }, { "payer_name": "CIGNA", "plan_name": "CIGNA COM ALT HMO PLAN", "methodology": "percent of total billed charges", "standard_charge_dollar": 1519.2, "standard_charge_percentage": 42.2, "count": "0", "additional_payer_notes": "Zero final payments for the item or service in the 15 months prior to posting the file." }, { "payer_name": "CIGNA", "plan_name": "CIGNA COM ALT HMO PLAN", "methodology": "percent of total billed charges", "standard_charge_dollar": 1519.2, "standard_charge_percentage": 42.2, "count": "0", "additional_payer_notes": "Zero final payments for the item or service in the 15 months prior to posting the file." }, { "payer_name": "HEALTH NET", "plan_name": "HEALTHNET HMO, PPO, POS, EPO, CANOPY HEALTHNET HMO, OTHER-IN-NETWORK PLANS", "methodology": "per diem", "standard_charge_dollar": 8000.0, "standard_charge_algorithm": "Expected reimbursement is the lesser of Per diem ($8,000) for the length of stay and 70% of billed.", "count": "0", "additional_payer_notes": "Zero final payments for the item or service in the 15 months prior to posting the file." }, { "payer_name": "HEALTH NET", "plan_name": "HEALTHNET HMO, PPO, POS, EPO, CANOPY HEALTHNET HMO, OTHER-IN-NETWORK PLANS", "methodology": "per diem", "standard_charge_dollar": 8000.0, "standard_charge_algorithm": "Expected reimbursement is the lesser of Per diem ($8,000) for the length of stay and 70% of billed.", "count": "0", "additional_payer_notes": "Zero final payments for the item or service in the 15 months prior to posting the file." }, { "payer_name": "UNITED HEALTHCARE", "plan_name": "SUTTER SELECT & SUTTER HEALTH PLAN HMO PLANS", "methodology": "per diem", "standard_charge_dollar": 28538.0, "standard_charge_algorithm": "Per diem ($28,538).", "count": "0", "additional_payer_notes": "Zero final payments for the item or service in the 15 months prior to posting the file." }, { "payer_name": "UNITED HEALTHCARE", "plan_name": "SUTTER SELECT & SUTTER HEALTH PLAN HMO PLANS", "methodology": "per diem", "standard_charge_dollar": 28538.0, "standard_charge_algorithm": "Per diem ($28,538).", "count": "0", "additional_payer_notes": "Zero final payments for the item or service in the 15 months prior to posting the file." }, { "payer_name": "SUTTER", "plan_name": "SUTTER SELECT & SUTTER HEALTH PLAN HMO PLANS", "methodology": "per diem", "standard_charge_dollar": 28538.0, "standard_charge_algorithm": "Per diem ($28,538).", "count": "0", "additional_payer_notes": "Zero final payments for the item or service in the 15 months prior to posting the file." }, { "payer_name": "UNITED HEALTHCARE", "plan_name": "SUTTER SELECT & SUTTER HEALTH PLAN HMO PLANS", "methodology": "per diem", "standard_charge_dollar": 28538.0, "standard_charge_algorithm": "Per diem ($28,538).", "count": "0", "additional_payer_notes": "Zero final payments for the item or service in the 15 months prior to posting the file." }, { "payer_name": "UMR", "plan_name": "SUTTER SELECT & SUTTER HEALTH PLAN HMO PLANS", "methodology": "per diem", "standard_charge_dollar": 28538.0, "standard_charge_algorithm": "Per diem ($28,538).", "count": "0", "additional_payer_notes": "Zero final payments for the item or service in the 15 months prior to posting the file." } ] } ] }, { "description": "HC Bur Gp024", "code_information": [ { "code": "PX-2120017024", "type": "CDM" }, { "code": "99999", "type": "CPT" }, { "code": "0272", "type": "RC" } ], "standard_charges": [ { "setting": "outpatient", "gross_charge": 7000.0, "discounted_cash": 3500.0, "minimum": 2954.0, "maximum": 3640.0, "additional_generic_notes": "Zero final payments for the item or service in the 15 months prior to posting the file.", "payers_information": [ { "payer_name": "AETNA", "plan_name": "AETNA ALL OTHER PLANS", "methodology": "percent of total billed charges", "standard_charge_dollar": 3640.0, "standard_charge_percentage": 52.0, "count": "0", "additional_payer_notes": "Zero final payments for the item or service in the 15 months prior to posting the file." }, { "payer_name": "AETNA", "plan_name": "AETNA ALL OTHER PLANS", "methodology": "percent of total billed charges", "standard_charge_dollar": 3640.0, "standard_charge_percentage": 52.0, "count": "0", "additional_payer_notes": "Zero final payments for the item or service in the 15 months prior to posting the file." }, { "payer_name": "MERITAIN HEALTH", "plan_name": "AETNA ALL OTHER PLANS", "methodology": "percent of total billed charges", "standard_charge_dollar": 3640.0, "standard_charge_percentage": 52.0, "count": "0", "additional_payer_notes": "Zero final payments for the item or service in the 15 months prior to posting the file." }, { "payer_name": "BLUE SHIELD OUT OF STATE", "plan_name": "STANFORD HEALTHCARE ALLIANCE PLAN", "methodology": "percent of total billed charges", "standard_charge_dollar": 3401.3, "standard_charge_percentage": 48.59, "count": "0", "additional_payer_notes": "Zero final payments for the item or service in the 15 months prior to posting the file." }, { "payer_name": "BLUE SHIELD", "plan_name": "STANFORD HEALTHCARE ALLIANCE PLAN", "methodology": "percent of total billed charges", "standard_charge_dollar": 3401.3, "standard_charge_percentage": 48.59, "median_amount": 68.24, "10th_percentile": 13.6, "90th_percentile": 1043.06, "count": "30" }, { "payer_name": "BLUE SHIELD", "plan_name": "STANFORD HEALTHCARE ALLIANCE PLAN", "methodology": "percent of total billed charges", "standard_charge_dollar": 3401.3, "standard_charge_percentage": 48.59, "count": "0", "additional_payer_notes": "Zero final payments for the item or service in the 15 months prior to posting the file." }, { "payer_name": "BLUE SHIELD", "plan_name": "STANFORD HEALTHCARE ALLIANCE PLAN", "methodology": "percent of total billed charges", "standard_charge_dollar": 3401.3, "standard_charge_percentage": 48.59, "count": "0", "additional_payer_notes": "Zero final payments for the item or service in the 15 months prior to posting the file." }, { "payer_name": "CIGNA", "plan_name": "CIGNA COM ALT HMO PLAN", "methodology": "percent of total billed charges", "standard_charge_dollar": 2954.0, "standard_charge_percentage": 42.2, "count": "0", "additional_payer_notes": "Zero final payments for the item or service in the 15 months prior to posting the file." }, { "payer_name": "CIGNA", "plan_name": "CIGNA COM ALT HMO PLAN", "methodology": "percent of total billed charges", "standard_charge_dollar": 2954.0, "standard_charge_percentage": 42.2, "count": "0", "additional_payer_notes": "Zero final payments for the item or service in the 15 months prior to posting the file." }, { "payer_name": "HEALTH NET", "plan_name": "HEALTHNET HMO, PPO, POS, EPO, CANOPY HEALTHNET HMO, OTHER-IN-NETWORK PLANS", "methodology": "per diem", "standard_charge_dollar": 8000.0, "standard_charge_algorithm": "Expected reimbursement is the lesser of Per diem ($8,000) for the length of stay and 70% of billed.", "count": "0", "additional_payer_notes": "Zero final payments for the item or service in the 15 months prior to posting the file." }, { "payer_name": "HEALTH NET", "plan_name": "HEALTHNET HMO, PPO, POS, EPO, CANOPY HEALTHNET HMO, OTHER-IN-NETWORK PLANS", "methodology": "per diem", "standard_charge_dollar": 8000.0, "standard_charge_algorithm": "Expected reimbursement is the lesser of Per diem ($8,000) for the length of stay and 70% of billed.", "count": "0", "additional_payer_notes": "Zero final payments for the item or service in the 15 months prior to posting the file." }, { "payer_name": "UNITED HEALTHCARE", "plan_name": "SUTTER SELECT & SUTTER HEALTH PLAN HMO PLANS", "methodology": "per diem", "standard_charge_dollar": 28538.0, "standard_charge_algorithm": "Per diem ($28,538).", "count": "0", "additional_payer_notes": "Zero final payments for the item or service in the 15 months prior to posting the file." }, { "payer_name": "UNITED HEALTHCARE", "plan_name": "SUTTER SELECT & SUTTER HEALTH PLAN HMO PLANS", "methodology": "per diem", "standard_charge_dollar": 28538.0, "standard_charge_algorithm": "Per diem ($28,538).", "count": "0", "additional_payer_notes": "Zero final payments for the item or service in the 15 months prior to posting the file." }, { "payer_name": "SUTTER", "plan_name": "SUTTER SELECT & SUTTER HEALTH PLAN HMO PLANS", "methodology": "per diem", "standard_charge_dollar": 28538.0, "standard_charge_algorithm": "Per diem ($28,538).", "count": "0", "additional_payer_notes": "Zero final payments for the item or service in the 15 months prior to posting the file." }, { "payer_name": "UNITED HEALTHCARE", "plan_name": "SUTTER SELECT & SUTTER HEALTH PLAN HMO PLANS", "methodology": "per diem", "standard_charge_dollar": 28538.0, "standard_charge_algorithm": "Per diem ($28,538).", "count": "0", "additional_payer_notes": "Zero final payments for the item or service in the 15 months prior to posting the file." }, { "payer_name": "UMR", "plan_name": "SUTTER SELECT & SUTTER HEALTH PLAN HMO PLANS", "methodology": "per diem", "standard_charge_dollar": 28538.0, "standard_charge_algorithm": "Per diem ($28,538).", "count": "0", "additional_payer_notes": "Zero final payments for the item or service in the 15 months prior to posting the file." } ] } ] }, { "description": "Hc Bur Gp030", "code_information": [ { "code": "PX-2120017030", "type": "CDM" }, { "code": "99999", "type": "CPT" }, { "code": "0272", "type": "RC" } ], "standard_charges": [ { "setting": "outpatient", "gross_charge": 5800.0, "discounted_cash": 2900.0, "minimum": 2447.6, "maximum": 3016.0, "additional_generic_notes": "Zero final payments for the item or service in the 15 months prior to posting the file.", "payers_information": [ { "payer_name": "AETNA", "plan_name": "AETNA ALL OTHER PLANS", "methodology": "percent of total billed charges", "standard_charge_dollar": 3016.0, "standard_charge_percentage": 52.0, "count": "0", "additional_payer_notes": "Zero final payments for the item or service in the 15 months prior to posting the file." }, { "payer_name": "AETNA", "plan_name": "AETNA ALL OTHER PLANS", "methodology": "percent of total billed charges", "standard_charge_dollar": 3016.0, "standard_charge_percentage": 52.0, "count": "0", "additional_payer_notes": "Zero final payments for the item or service in the 15 months prior to posting the file." }, { "payer_name": "MERITAIN HEALTH", "plan_name": "AETNA ALL OTHER PLANS", "methodology": "percent of total billed charges", "standard_charge_dollar": 3016.0, "standard_charge_percentage": 52.0, "count": "0", "additional_payer_notes": "Zero final payments for the item or service in the 15 months prior to posting the file." }, { "payer_name": "BLUE SHIELD OUT OF STATE", "plan_name": "STANFORD HEALTHCARE ALLIANCE PLAN", "methodology": "percent of total billed charges", "standard_charge_dollar": 2818.22, "standard_charge_percentage": 48.59, "count": "0", "additional_payer_notes": "Zero final payments for the item or service in the 15 months prior to posting the file." }, { "payer_name": "BLUE SHIELD", "plan_name": "STANFORD HEALTHCARE ALLIANCE PLAN", "methodology": "percent of total billed charges", "standard_charge_dollar": 2818.22, "standard_charge_percentage": 48.59, "median_amount": 68.24, "10th_percentile": 13.6, "90th_percentile": 1043.06, "count": "30" }, { "payer_name": "BLUE SHIELD", "plan_name": "STANFORD HEALTHCARE ALLIANCE PLAN", "methodology": "percent of total billed charges", "standard_charge_dollar": 2818.22, "standard_charge_percentage": 48.59, "count": "0", "additional_payer_notes": "Zero final payments for the item or service in the 15 months prior to posting the file." }, { "payer_name": "BLUE SHIELD", "plan_name": "STANFORD HEALTHCARE ALLIANCE PLAN", "methodology": "percent of total billed charges", "standard_charge_dollar": 2818.22, "standard_charge_percentage": 48.59, "count": "0", "additional_payer_notes": "Zero final payments for the item or service in the 15 months prior to posting the file." }, { "payer_name": "CIGNA", "plan_name": "CIGNA COM ALT HMO PLAN", "methodology": "percent of total billed charges", "standard_charge_dollar": 2447.6, "standard_charge_percentage": 42.2, "count": "0", "additional_payer_notes": "Zero final payments for the item or service in the 15 months prior to posting the file." }, { "payer_name": "CIGNA", "plan_name": "CIGNA COM ALT HMO PLAN", "methodology": "percent of total billed charges", "standard_charge_dollar": 2447.6, "standard_charge_percentage": 42.2, "count": "0", "additional_payer_notes": "Zero final payments for the item or service in the 15 months prior to posting the file." }, { "payer_name": "HEALTH NET", "plan_name": "HEALTHNET HMO, PPO, POS, EPO, CANOPY HEALTHNET HMO, OTHER-IN-NETWORK PLANS", "methodology": "per diem", "standard_charge_dollar": 8000.0, "standard_charge_algorithm": "Expected reimbursement is the lesser of Per diem ($8,000) for the length of stay and 70% of billed.", "count": "0", "additional_payer_notes": "Zero final payments for the item or service in the 15 months prior to posting the file." }, { "payer_name": "HEALTH NET", "plan_name": "HEALTHNET HMO, PPO, POS, EPO, CANOPY HEALTHNET HMO, OTHER-IN-NETWORK PLANS", "methodology": "per diem", "standard_charge_dollar": 8000.0, "standard_charge_algorithm": "Expected reimbursement is the lesser of Per diem ($8,000) for the length of stay and 70% of billed.", "count": "0", "additional_payer_notes": "Zero final payments for the item or service in the 15 months prior to posting the file." }, { "payer_name": "UNITED HEALTHCARE", "plan_name": "SUTTER SELECT & SUTTER HEALTH PLAN HMO PLANS", "methodology": "per diem", "standard_charge_dollar": 28538.0, "standard_charge_algorithm": "Per diem ($28,538).", "count": "0", "additional_payer_notes": "Zero final payments for the item or service in the 15 months prior to posting the file." }, { "payer_name": "UNITED HEALTHCARE", "plan_name": "SUTTER SELECT & SUTTER HEALTH PLAN HMO PLANS", "methodology": "per diem", "standard_charge_dollar": 28538.0, "standard_charge_algorithm": "Per diem ($28,538).", "count": "0", "additional_payer_notes": "Zero final payments for the item or service in the 15 months prior to posting the file." }, { "payer_name": "SUTTER", "plan_name": "SUTTER SELECT & SUTTER HEALTH PLAN HMO PLANS", "methodology": "per diem", "standard_charge_dollar": 28538.0, "standard_charge_algorithm": "Per diem ($28,538).", "count": "0", "additional_payer_notes": "Zero final payments for the item or service in the 15 months prior to posting the file." }, { "payer_name": "UNITED HEALTHCARE", "plan_name": "SUTTER SELECT & SUTTER HEALTH PLAN HMO PLANS", "methodology": "per diem", "standard_charge_dollar": 28538.0, "standard_charge_algorithm": "Per diem ($28,538).", "count": "0", "additional_payer_notes": "Zero final payments for the item or service in the 15 months prior to posting the file." }, { "payer_name": "UMR", "plan_name": "SUTTER SELECT & SUTTER HEALTH PLAN HMO PLANS", "methodology": "per diem", "standard_charge_dollar": 28538.0, "standard_charge_algorithm": "Per diem ($28,538).", "count": "0", "additional_payer_notes": "Zero final payments for the item or service in the 15 months prior to posting the file." } ] } ] }, { "description": "HC Bur Gp033", "code_information": [ { "code": "PX-2120017033", "type": "CDM" }, { "code": "99999", "type": "CPT" }, { "code": "0272", "type": "RC" } ], "standard_charges": [ { "setting": "outpatient", "gross_charge": 6413.0, "discounted_cash": 3206.5, "minimum": 2706.29, "maximum": 3334.76, "additional_generic_notes": "Zero final payments for the item or service in the 15 months prior to posting the file.", "payers_information": [ { "payer_name": "AETNA", "plan_name": "AETNA ALL OTHER PLANS", "methodology": "percent of total billed charges", "standard_charge_dollar": 3334.76, "standard_charge_percentage": 52.0, "count": "0", "additional_payer_notes": "Zero final payments for the item or service in the 15 months prior to posting the file." }, { "payer_name": "AETNA", "plan_name": "AETNA ALL OTHER PLANS", "methodology": "percent of total billed charges", "standard_charge_dollar": 3334.76, "standard_charge_percentage": 52.0, "count": "0", "additional_payer_notes": "Zero final payments for the item or service in the 15 months prior to posting the file." }, { "payer_name": "MERITAIN HEALTH", "plan_name": "AETNA ALL OTHER PLANS", "methodology": "percent of total billed charges", "standard_charge_dollar": 3334.76, "standard_charge_percentage": 52.0, "count": "0", "additional_payer_notes": "Zero final payments for the item or service in the 15 months prior to posting the file." }, { "payer_name": "BLUE SHIELD OUT OF STATE", "plan_name": "STANFORD HEALTHCARE ALLIANCE PLAN", "methodology": "percent of total billed charges", "standard_charge_dollar": 3116.08, "standard_charge_percentage": 48.59, "count": "0", "additional_payer_notes": "Zero final payments for the item or service in the 15 months prior to posting the file." }, { "payer_name": "BLUE SHIELD", "plan_name": "STANFORD HEALTHCARE ALLIANCE PLAN", "methodology": "percent of total billed charges", "standard_charge_dollar": 3116.08, "standard_charge_percentage": 48.59, "median_amount": 68.24, "10th_percentile": 13.6, "90th_percentile": 1043.06, "count": "30" }, { "payer_name": "BLUE SHIELD", "plan_name": "STANFORD HEALTHCARE ALLIANCE PLAN", "methodology": "percent of total billed charges", "standard_charge_dollar": 3116.08, "standard_charge_percentage": 48.59, "count": "0", "additional_payer_notes": "Zero final payments for the item or service in the 15 months prior to posting the file." }, { "payer_name": "BLUE SHIELD", "plan_name": "STANFORD HEALTHCARE ALLIANCE PLAN", "methodology": "percent of total billed charges", "standard_charge_dollar": 3116.08, "standard_charge_percentage": 48.59, "count": "0", "additional_payer_notes": "Zero final payments for the item or service in the 15 months prior to posting the file." }, { "payer_name": "CIGNA", "plan_name": "CIGNA COM ALT HMO PLAN", "methodology": "percent of total billed charges", "standard_charge_dollar": 2706.29, "standard_charge_percentage": 42.2, "count": "0", "additional_payer_notes": "Zero final payments for the item or service in the 15 months prior to posting the file." }, { "payer_name": "CIGNA", "plan_name": "CIGNA COM ALT HMO PLAN", "methodology": "percent of total billed charges", "standard_charge_dollar": 2706.29, "standard_charge_percentage": 42.2, "count": "0", "additional_payer_notes": "Zero final payments for the item or service in the 15 months prior to posting the file." }, { "payer_name": "HEALTH NET", "plan_name": "HEALTHNET HMO, PPO, POS, EPO, CANOPY HEALTHNET HMO, OTHER-IN-NETWORK PLANS", "methodology": "per diem", "standard_charge_dollar": 8000.0, "standard_charge_algorithm": "Expected reimbursement is the lesser of Per diem ($8,000) for the length of stay and 70% of billed.", "count": "0", "additional_payer_notes": "Zero final payments for the item or service in the 15 months prior to posting the file." }, { "payer_name": "HEALTH NET", "plan_name": "HEALTHNET HMO, PPO, POS, EPO, CANOPY HEALTHNET HMO, OTHER-IN-NETWORK PLANS", "methodology": "per diem", "standard_charge_dollar": 8000.0, "standard_charge_algorithm": "Expected reimbursement is the lesser of Per diem ($8,000) for the length of stay and 70% of billed.", "count": "0", "additional_payer_notes": "Zero final payments for the item or service in the 15 months prior to posting the file." }, { "payer_name": "UNITED HEALTHCARE", "plan_name": "SUTTER SELECT & SUTTER HEALTH PLAN HMO PLANS", "methodology": "per diem", "standard_charge_dollar": 28538.0, "standard_charge_algorithm": "Per diem ($28,538).", "count": "0", "additional_payer_notes": "Zero final payments for the item or service in the 15 months prior to posting the file." }, { "payer_name": "UNITED HEALTHCARE", "plan_name": "SUTTER SELECT & SUTTER HEALTH PLAN HMO PLANS", "methodology": "per diem", "standard_charge_dollar": 28538.0, "standard_charge_algorithm": "Per diem ($28,538).", "count": "0", "additional_payer_notes": "Zero final payments for the item or service in the 15 months prior to posting the file." }, { "payer_name": "SUTTER", "plan_name": "SUTTER SELECT & SUTTER HEALTH PLAN HMO PLANS", "methodology": "per diem", "standard_charge_dollar": 28538.0, "standard_charge_algorithm": "Per diem ($28,538).", "count": "0", "additional_payer_notes": "Zero final payments for the item or service in the 15 months prior to posting the file." }, { "payer_name": "UNITED HEALTHCARE", "plan_name": "SUTTER SELECT & SUTTER HEALTH PLAN HMO PLANS", "methodology": "per diem", "standard_charge_dollar": 28538.0, "standard_charge_algorithm": "Per diem ($28,538).", "count": "0", "additional_payer_notes": "Zero final payments for the item or service in the 15 months prior to posting the file." }, { "payer_name": "UMR", "plan_name": "SUTTER SELECT & SUTTER HEALTH PLAN HMO PLANS", "methodology": "per diem", "standard_charge_dollar": 28538.0, "standard_charge_algorithm": "Per diem ($28,538).", "count": "0", "additional_payer_notes": "Zero final payments for the item or service in the 15 months prior to posting the file." } ] } ] }, { "description": "Hc Bur Gp034", "code_information": [ { "code": "PX-2120017034", "type": "CDM" }, { "code": "99999", "type": "CPT" }, { "code": "0272", "type": "RC" } ], "standard_charges": [ { "setting": "outpatient", "gross_charge": 6750.0, "discounted_cash": 3375.0, "minimum": 2848.5, "maximum": 3510.0, "additional_generic_notes": "Zero final payments for the item or service in the 15 months prior to posting the file.", "payers_information": [ { "payer_name": "AETNA", "plan_name": "AETNA ALL OTHER PLANS", "methodology": "percent of total billed charges", "standard_charge_dollar": 3510.0, "standard_charge_percentage": 52.0, "count": "0", "additional_payer_notes": "Zero final payments for the item or service in the 15 months prior to posting the file." }, { "payer_name": "AETNA", "plan_name": "AETNA ALL OTHER PLANS", "methodology": "percent of total billed charges", "standard_charge_dollar": 3510.0, "standard_charge_percentage": 52.0, "count": "0", "additional_payer_notes": "Zero final payments for the item or service in the 15 months prior to posting the file." }, { "payer_name": "MERITAIN HEALTH", "plan_name": "AETNA ALL OTHER PLANS", "methodology": "percent of total billed charges", "standard_charge_dollar": 3510.0, "standard_charge_percentage": 52.0, "count": "0", "additional_payer_notes": "Zero final payments for the item or service in the 15 months prior to posting the file." }, { "payer_name": "BLUE SHIELD OUT OF STATE", "plan_name": "STANFORD HEALTHCARE ALLIANCE PLAN", "methodology": "percent of total billed charges", "standard_charge_dollar": 3279.83, "standard_charge_percentage": 48.59, "count": "0", "additional_payer_notes": "Zero final payments for the item or service in the 15 months prior to posting the file." }, { "payer_name": "BLUE SHIELD", "plan_name": "STANFORD HEALTHCARE ALLIANCE PLAN", "methodology": "percent of total billed charges", "standard_charge_dollar": 3279.83, "standard_charge_percentage": 48.59, "median_amount": 68.24, "10th_percentile": 13.6, "90th_percentile": 1043.06, "count": "30" }, { "payer_name": "BLUE SHIELD", "plan_name": "STANFORD HEALTHCARE ALLIANCE PLAN", "methodology": "percent of total billed charges", "standard_charge_dollar": 3279.83, "standard_charge_percentage": 48.59, "count": "0", "additional_payer_notes": "Zero final payments for the item or service in the 15 months prior to posting the file." }, { "payer_name": "BLUE SHIELD", "plan_name": "STANFORD HEALTHCARE ALLIANCE PLAN", "methodology": "percent of total billed charges", "standard_charge_dollar": 3279.83, "standard_charge_percentage": 48.59, "count": "0", "additional_payer_notes": "Zero final payments for the item or service in the 15 months prior to posting the file." }, { "payer_name": "CIGNA", "plan_name": "CIGNA COM ALT HMO PLAN", "methodology": "percent of total billed charges", "standard_charge_dollar": 2848.5, "standard_charge_percentage": 42.2, "count": "0", "additional_payer_notes": "Zero final payments for the item or service in the 15 months prior to posting the file." }, { "payer_name": "CIGNA", "plan_name": "CIGNA COM ALT HMO PLAN", "methodology": "percent of total billed charges", "standard_charge_dollar": 2848.5, "standard_charge_percentage": 42.2, "count": "0", "additional_payer_notes": "Zero final payments for the item or service in the 15 months prior to posting the file." }, { "payer_name": "HEALTH NET", "plan_name": "HEALTHNET HMO, PPO, POS, EPO, CANOPY HEALTHNET HMO, OTHER-IN-NETWORK PLANS", "methodology": "per diem", "standard_charge_dollar": 8000.0, "standard_charge_algorithm": "Expected reimbursement is the lesser of Per diem ($8,000) for the length of stay and 70% of billed.", "count": "0", "additional_payer_notes": "Zero final payments for the item or service in the 15 months prior to posting the file." }, { "payer_name": "HEALTH NET", "plan_name": "HEALTHNET HMO, PPO, POS, EPO, CANOPY HEALTHNET HMO, OTHER-IN-NETWORK PLANS", "methodology": "per diem", "standard_charge_dollar": 8000.0, "standard_charge_algorithm": "Expected reimbursement is the lesser of Per diem ($8,000) for the length of stay and 70% of billed.", "count": "0", "additional_payer_notes": "Zero final payments for the item or service in the 15 months prior to posting the file." }, { "payer_name": "UNITED HEALTHCARE", "plan_name": "SUTTER SELECT & SUTTER HEALTH PLAN HMO PLANS", "methodology": "per diem", "standard_charge_dollar": 28538.0, "standard_charge_algorithm": "Per diem ($28,538).", "count": "0", "additional_payer_notes": "Zero final payments for the item or service in the 15 months prior to posting the file." }, { "payer_name": "UNITED HEALTHCARE", "plan_name": "SUTTER SELECT & SUTTER HEALTH PLAN HMO PLANS", "methodology": "per diem", "standard_charge_dollar": 28538.0, "standard_charge_algorithm": "Per diem ($28,538).", "count": "0", "additional_payer_notes": "Zero final payments for the item or service in the 15 months prior to posting the file." }, { "payer_name": "SUTTER", "plan_name": "SUTTER SELECT & SUTTER HEALTH PLAN HMO PLANS", "methodology": "per diem", "standard_charge_dollar": 28538.0, "standard_charge_algorithm": "Per diem ($28,538).", "count": "0", "additional_payer_notes": "Zero final payments for the item or service in the 15 months prior to posting the file." }, { "payer_name": "UNITED HEALTHCARE", "plan_name": "SUTTER SELECT & SUTTER HEALTH PLAN HMO PLANS", "methodology": "per diem", "standard_charge_dollar": 28538.0, "standard_charge_algorithm": "Per diem ($28,538).", "count": "0", "additional_payer_notes": "Zero final payments for the item or service in the 15 months prior to posting the file." }, { "payer_name": "UMR", "plan_name": "SUTTER SELECT & SUTTER HEALTH PLAN HMO PLANS", "methodology": "per diem", "standard_charge_dollar": 28538.0, "standard_charge_algorithm": "Per diem ($28,538).", "count": "0", "additional_payer_notes": "Zero final payments for the item or service in the 15 months prior to posting the file." } ] } ] }, { "description": "HC Bur Gp035", "code_information": [ { "code": "PX-2120017035", "type": "CDM" }, { "code": "99999", "type": "CPT" }, { "code": "0272", "type": "RC" } ], "standard_charges": [ { "setting": "outpatient", "gross_charge": 7150.0, "discounted_cash": 3575.0, "minimum": 3017.3, "maximum": 3718.0, "additional_generic_notes": "Zero final payments for the item or service in the 15 months prior to posting the file.", "payers_information": [ { "payer_name": "AETNA", "plan_name": "AETNA ALL OTHER PLANS", "methodology": "percent of total billed charges", "standard_charge_dollar": 3718.0, "standard_charge_percentage": 52.0, "count": "0", "additional_payer_notes": "Zero final payments for the item or service in the 15 months prior to posting the file." }, { "payer_name": "AETNA", "plan_name": "AETNA ALL OTHER PLANS", "methodology": "percent of total billed charges", "standard_charge_dollar": 3718.0, "standard_charge_percentage": 52.0, "count": "0", "additional_payer_notes": "Zero final payments for the item or service in the 15 months prior to posting the file." }, { "payer_name": "MERITAIN HEALTH", "plan_name": "AETNA ALL OTHER PLANS", "methodology": "percent of total billed charges", "standard_charge_dollar": 3718.0, "standard_charge_percentage": 52.0, "count": "0", "additional_payer_notes": "Zero final payments for the item or service in the 15 months prior to posting the file." }, { "payer_name": "BLUE SHIELD OUT OF STATE", "plan_name": "STANFORD HEALTHCARE ALLIANCE PLAN", "methodology": "percent of total billed charges", "standard_charge_dollar": 3474.19, "standard_charge_percentage": 48.59, "count": "0", "additional_payer_notes": "Zero final payments for the item or service in the 15 months prior to posting the file." }, { "payer_name": "BLUE SHIELD", "plan_name": "STANFORD HEALTHCARE ALLIANCE PLAN", "methodology": "percent of total billed charges", "standard_charge_dollar": 3474.19, "standard_charge_percentage": 48.59, "median_amount": 68.24, "10th_percentile": 13.6, "90th_percentile": 1043.06, "count": "30" }, { "payer_name": "BLUE SHIELD", "plan_name": "STANFORD HEALTHCARE ALLIANCE PLAN", "methodology": "percent of total billed charges", "standard_charge_dollar": 3474.19, "standard_charge_percentage": 48.59, "count": "0", "additional_payer_notes": "Zero final payments for the item or service in the 15 months prior to posting the file." }, { "payer_name": "BLUE SHIELD", "plan_name": "STANFORD HEALTHCARE ALLIANCE PLAN", "methodology": "percent of total billed charges", "standard_charge_dollar": 3474.19, "standard_charge_percentage": 48.59, "count": "0", "additional_payer_notes": "Zero final payments for the item or service in the 15 months prior to posting the file." }, { "payer_name": "CIGNA", "plan_name": "CIGNA COM ALT HMO PLAN", "methodology": "percent of total billed charges", "standard_charge_dollar": 3017.3, "standard_charge_percentage": 42.2, "count": "0", "additional_payer_notes": "Zero final payments for the item or service in the 15 months prior to posting the file." }, { "payer_name": "CIGNA", "plan_name": "CIGNA COM ALT HMO PLAN", "methodology": "percent of total billed charges", "standard_charge_dollar": 3017.3, "standard_charge_percentage": 42.2, "count": "0", "additional_payer_notes": "Zero final payments for the item or service in the 15 months prior to posting the file." }, { "payer_name": "HEALTH NET", "plan_name": "HEALTHNET HMO, PPO, POS, EPO, CANOPY HEALTHNET HMO, OTHER-IN-NETWORK PLANS", "methodology": "per diem", "standard_charge_dollar": 8000.0, "standard_charge_algorithm": "Expected reimbursement is the lesser of Per diem ($8,000) for the length of stay and 70% of billed.", "count": "0", "additional_payer_notes": "Zero final payments for the item or service in the 15 months prior to posting the file." }, { "payer_name": "HEALTH NET", "plan_name": "HEALTHNET HMO, PPO, POS, EPO, CANOPY HEALTHNET HMO, OTHER-IN-NETWORK PLANS", "methodology": "per diem", "standard_charge_dollar": 8000.0, "standard_charge_algorithm": "Expected reimbursement is the lesser of Per diem ($8,000) for the length of stay and 70% of billed.", "count": "0", "additional_payer_notes": "Zero final payments for the item or service in the 15 months prior to posting the file." }, { "payer_name": "UNITED HEALTHCARE", "plan_name": "SUTTER SELECT & SUTTER HEALTH PLAN HMO PLANS", "methodology": "per diem", "standard_charge_dollar": 28538.0, "standard_charge_algorithm": "Per diem ($28,538).", "count": "0", "additional_payer_notes": "Zero final payments for the item or service in the 15 months prior to posting the file." }, { "payer_name": "UNITED HEALTHCARE", "plan_name": "SUTTER SELECT & SUTTER HEALTH PLAN HMO PLANS", "methodology": "per diem", "standard_charge_dollar": 28538.0, "standard_charge_algorithm": "Per diem ($28,538).", "count": "0", "additional_payer_notes": "Zero final payments for the item or service in the 15 months prior to posting the file." }, { "payer_name": "SUTTER", "plan_name": "SUTTER SELECT & SUTTER HEALTH PLAN HMO PLANS", "methodology": "per diem", "standard_charge_dollar": 28538.0, "standard_charge_algorithm": "Per diem ($28,538).", "count": "0", "additional_payer_notes": "Zero final payments for the item or service in the 15 months prior to posting the file." }, { "payer_name": "UNITED HEALTHCARE", "plan_name": "SUTTER SELECT & SUTTER HEALTH PLAN HMO PLANS", "methodology": "per diem", "standard_charge_dollar": 28538.0, "standard_charge_algorithm": "Per diem ($28,538).", "count": "0", "additional_payer_notes": "Zero final payments for the item or service in the 15 months prior to posting the file." }, { "payer_name": "UMR", "plan_name": "SUTTER SELECT & SUTTER HEALTH PLAN HMO PLANS", "methodology": "per diem", "standard_charge_dollar": 28538.0, "standard_charge_algorithm": "Per diem ($28,538).", "count": "0", "additional_payer_notes": "Zero final payments for the item or service in the 15 months prior to posting the file." } ] } ] }, { "description": "HC Bur Legend Gp009", "code_information": [ { "code": "PX-2120018009", "type": "CDM" }, { "code": "99999", "type": "CPT" }, { "code": "0272", "type": "RC" } ], "standard_charges": [ { "setting": "outpatient", "gross_charge": 570.0, "discounted_cash": 285.0, "minimum": 240.54, "maximum": 296.4, "additional_generic_notes": "Zero final payments for the item or service in the 15 months prior to posting the file.", "payers_information": [ { "payer_name": "AETNA", "plan_name": "AETNA ALL OTHER PLANS", "methodology": "percent of total billed charges", "standard_charge_dollar": 296.4, "standard_charge_percentage": 52.0, "count": "0", "additional_payer_notes": "Zero final payments for the item or service in the 15 months prior to posting the file." }, { "payer_name": "AETNA", "plan_name": "AETNA ALL OTHER PLANS", "methodology": "percent of total billed charges", "standard_charge_dollar": 296.4, "standard_charge_percentage": 52.0, "count": "0", "additional_payer_notes": "Zero final payments for the item or service in the 15 months prior to posting the file." }, { "payer_name": "MERITAIN HEALTH", "plan_name": "AETNA ALL OTHER PLANS", "methodology": "percent of total billed charges", "standard_charge_dollar": 296.4, "standard_charge_percentage": 52.0, "count": "0", "additional_payer_notes": "Zero final payments for the item or service in the 15 months prior to posting the file." }, { "payer_name": "BLUE SHIELD OUT OF STATE", "plan_name": "STANFORD HEALTHCARE ALLIANCE PLAN", "methodology": "percent of total billed charges", "standard_charge_dollar": 276.96, "standard_charge_percentage": 48.59, "count": "0", "additional_payer_notes": "Zero final payments for the item or service in the 15 months prior to posting the file." }, { "payer_name": "BLUE SHIELD", "plan_name": "STANFORD HEALTHCARE ALLIANCE PLAN", "methodology": "percent of total billed charges", "standard_charge_dollar": 276.96, "standard_charge_percentage": 48.59, "count": "0", "additional_payer_notes": "Zero final payments for the item or service in the 15 months prior to posting the file." }, { "payer_name": "BLUE SHIELD", "plan_name": "STANFORD HEALTHCARE ALLIANCE PLAN", "methodology": "percent of total billed charges", "standard_charge_dollar": 276.96, "standard_charge_percentage": 48.59, "count": "0", "additional_payer_notes": "Zero final payments for the item or service in the 15 months prior to posting the file." }, { "payer_name": "CIGNA", "plan_name": "CIGNA COM ALT HMO PLAN", "methodology": "percent of total billed charges", "standard_charge_dollar": 240.54, "standard_charge_percentage": 42.2, "count": "0", "additional_payer_notes": "Zero final payments for the item or service in the 15 months prior to posting the file." }, { "payer_name": "CIGNA", "plan_name": "CIGNA COM ALT HMO PLAN", "methodology": "percent of total billed charges", "standard_charge_dollar": 240.54, "standard_charge_percentage": 42.2, "count": "0", "additional_payer_notes": "Zero final payments for the item or service in the 15 months prior to posting the file." }, { "payer_name": "HEALTH NET", "plan_name": "HEALTHNET HMO, PPO, POS, EPO, CANOPY HEALTHNET HMO, OTHER-IN-NETWORK PLANS", "methodology": "per diem", "standard_charge_dollar": 8000.0, "standard_charge_algorithm": "Expected reimbursement is the lesser of Per diem ($8,000) for the length of stay and 70% of billed.", "count": "0", "additional_payer_notes": "Zero final payments for the item or service in the 15 months prior to posting the file." }, { "payer_name": "HEALTH NET", "plan_name": "HEALTHNET HMO, PPO, POS, EPO, CANOPY HEALTHNET HMO, OTHER-IN-NETWORK PLANS", "methodology": "per diem", "standard_charge_dollar": 8000.0, "standard_charge_algorithm": "Expected reimbursement is the lesser of Per diem ($8,000) for the length of stay and 70% of billed.", "count": "0", "additional_payer_notes": "Zero final payments for the item or service in the 15 months prior to posting the file." }, { "payer_name": "UNITED HEALTHCARE", "plan_name": "SUTTER SELECT & SUTTER HEALTH PLAN HMO PLANS", "methodology": "per diem", "standard_charge_dollar": 28538.0, "standard_charge_algorithm": "Per diem ($28,538).", "count": "0", "additional_payer_notes": "Zero final payments for the item or service in the 15 months prior to posting the file." }, { "payer_name": "UNITED HEALTHCARE", "plan_name": "SUTTER SELECT & SUTTER HEALTH PLAN HMO PLANS", "methodology": "per diem", "standard_charge_dollar": 28538.0, "standard_charge_algorithm": "Per diem ($28,538).", "count": "0", "additional_payer_notes": "Zero final payments for the item or service in the 15 months prior to posting the file." }, { "payer_name": "SUTTER", "plan_name": "SUTTER SELECT & SUTTER HEALTH PLAN HMO PLANS", "methodology": "per diem", "standard_charge_dollar": 28538.0, "standard_charge_algorithm": "Per diem ($28,538).", "count": "0", "additional_payer_notes": "Zero final payments for the item or service in the 15 months prior to posting the file." }, { "payer_name": "UNITED HEALTHCARE", "plan_name": "SUTTER SELECT & SUTTER HEALTH PLAN HMO PLANS", "methodology": "per diem", "standard_charge_dollar": 28538.0, "standard_charge_algorithm": "Per diem ($28,538).", "count": "0", "additional_payer_notes": "Zero final payments for the item or service in the 15 months prior to posting the file." }, { "payer_name": "UMR", "plan_name": "SUTTER SELECT & SUTTER HEALTH PLAN HMO PLANS", "methodology": "per diem", "standard_charge_dollar": 28538.0, "standard_charge_algorithm": "Per diem ($28,538).", "count": "0", "additional_payer_notes": "Zero final payments for the item or service in the 15 months prior to posting the file." } ] } ] }, { "description": "HC Bur Legend Gp010", "code_information": [ { "code": "PX-2120018010", "type": "CDM" }, { "code": "99999", "type": "CPT" }, { "code": "0272", "type": "RC" } ], "standard_charges": [ { "setting": "outpatient", "gross_charge": 665.0, "discounted_cash": 332.5, "minimum": 280.63, "maximum": 345.8, "additional_generic_notes": "Zero final payments for the item or service in the 15 months prior to posting the file.", "payers_information": [ { "payer_name": "AETNA", "plan_name": "AETNA ALL OTHER PLANS", "methodology": "percent of total billed charges", "standard_charge_dollar": 345.8, "standard_charge_percentage": 52.0, "count": "0", "additional_payer_notes": "Zero final payments for the item or service in the 15 months prior to posting the file." }, { "payer_name": "AETNA", "plan_name": "AETNA ALL OTHER PLANS", "methodology": "percent of total billed charges", "standard_charge_dollar": 345.8, "standard_charge_percentage": 52.0, "count": "0", "additional_payer_notes": "Zero final payments for the item or service in the 15 months prior to posting the file." }, { "payer_name": "MERITAIN HEALTH", "plan_name": "AETNA ALL OTHER PLANS", "methodology": "percent of total billed charges", "standard_charge_dollar": 345.8, "standard_charge_percentage": 52.0, "count": "0", "additional_payer_notes": "Zero final payments for the item or service in the 15 months prior to posting the file." }, { "payer_name": "BLUE SHIELD OUT OF STATE", "plan_name": "STANFORD HEALTHCARE ALLIANCE PLAN", "methodology": "percent of total billed charges", "standard_charge_dollar": 323.12, "standard_charge_percentage": 48.59, "count": "0", "additional_payer_notes": "Zero final payments for the item or service in the 15 months prior to posting the file." }, { "payer_name": "BLUE SHIELD", "plan_name": "STANFORD HEALTHCARE ALLIANCE PLAN", "methodology": "percent of total billed charges", "standard_charge_dollar": 323.12, "standard_charge_percentage": 48.59, "count": "0", "additional_payer_notes": "Zero final payments for the item or service in the 15 months prior to posting the file." }, { "payer_name": "BLUE SHIELD", "plan_name": "STANFORD HEALTHCARE ALLIANCE PLAN", "methodology": "percent of total billed charges", "standard_charge_dollar": 323.12, "standard_charge_percentage": 48.59, "count": "0", "additional_payer_notes": "Zero final payments for the item or service in the 15 months prior to posting the file." }, { "payer_name": "CIGNA", "plan_name": "CIGNA COM ALT HMO PLAN", "methodology": "percent of total billed charges", "standard_charge_dollar": 280.63, "standard_charge_percentage": 42.2, "count": "0", "additional_payer_notes": "Zero final payments for the item or service in the 15 months prior to posting the file." }, { "payer_name": "CIGNA", "plan_name": "CIGNA COM ALT HMO PLAN", "methodology": "percent of total billed charges", "standard_charge_dollar": 280.63, "standard_charge_percentage": 42.2, "count": "0", "additional_payer_notes": "Zero final payments for the item or service in the 15 months prior to posting the file." }, { "payer_name": "HEALTH NET", "plan_name": "HEALTHNET HMO, PPO, POS, EPO, CANOPY HEALTHNET HMO, OTHER-IN-NETWORK PLANS", "methodology": "per diem", "standard_charge_dollar": 8000.0, "standard_charge_algorithm": "Expected reimbursement is the lesser of Per diem ($8,000) for the length of stay and 70% of billed.", "count": "0", "additional_payer_notes": "Zero final payments for the item or service in the 15 months prior to posting the file." }, { "payer_name": "HEALTH NET", "plan_name": "HEALTHNET HMO, PPO, POS, EPO, CANOPY HEALTHNET HMO, OTHER-IN-NETWORK PLANS", "methodology": "per diem", "standard_charge_dollar": 8000.0, "standard_charge_algorithm": "Expected reimbursement is the lesser of Per diem ($8,000) for the length of stay and 70% of billed.", "count": "0", "additional_payer_notes": "Zero final payments for the item or service in the 15 months prior to posting the file." }, { "payer_name": "UNITED HEALTHCARE", "plan_name": "SUTTER SELECT & SUTTER HEALTH PLAN HMO PLANS", "methodology": "per diem", "standard_charge_dollar": 28538.0, "standard_charge_algorithm": "Per diem ($28,538).", "count": "0", "additional_payer_notes": "Zero final payments for the item or service in the 15 months prior to posting the file." }, { "payer_name": "UNITED HEALTHCARE", "plan_name": "SUTTER SELECT & SUTTER HEALTH PLAN HMO PLANS", "methodology": "per diem", "standard_charge_dollar": 28538.0, "standard_charge_algorithm": "Per diem ($28,538).", "count": "0", "additional_payer_notes": "Zero final payments for the item or service in the 15 months prior to posting the file." }, { "payer_name": "SUTTER", "plan_name": "SUTTER SELECT & SUTTER HEALTH PLAN HMO PLANS", "methodology": "per diem", "standard_charge_dollar": 28538.0, "standard_charge_algorithm": "Per diem ($28,538).", "count": "0", "additional_payer_notes": "Zero final payments for the item or service in the 15 months prior to posting the file." }, { "payer_name": "UNITED HEALTHCARE", "plan_name": "SUTTER SELECT & SUTTER HEALTH PLAN HMO PLANS", "methodology": "per diem", "standard_charge_dollar": 28538.0, "standard_charge_algorithm": "Per diem ($28,538).", "count": "0", "additional_payer_notes": "Zero final payments for the item or service in the 15 months prior to posting the file." }, { "payer_name": "UMR", "plan_name": "SUTTER SELECT & SUTTER HEALTH PLAN HMO PLANS", "methodology": "per diem", "standard_charge_dollar": 28538.0, "standard_charge_algorithm": "Per diem ($28,538).", "count": "0", "additional_payer_notes": "Zero final payments for the item or service in the 15 months prior to posting the file." } ] } ] }, { "description": "HC Bur Legend Gp011", "code_information": [ { "code": "PX-2120018011", "type": "CDM" }, { "code": "99999", "type": "CPT" }, { "code": "0272", "type": "RC" } ], "standard_charges": [ { "setting": "outpatient", "gross_charge": 740.0, "discounted_cash": 370.0, "minimum": 312.28, "maximum": 384.8, "additional_generic_notes": "Zero final payments for the item or service in the 15 months prior to posting the file.", "payers_information": [ { "payer_name": "AETNA", "plan_name": "AETNA ALL OTHER PLANS", "methodology": "percent of total billed charges", "standard_charge_dollar": 384.8, "standard_charge_percentage": 52.0, "count": "0", "additional_payer_notes": "Zero final payments for the item or service in the 15 months prior to posting the file." }, { "payer_name": "AETNA", "plan_name": "AETNA ALL OTHER PLANS", "methodology": "percent of total billed charges", "standard_charge_dollar": 384.8, "standard_charge_percentage": 52.0, "count": "0", "additional_payer_notes": "Zero final payments for the item or service in the 15 months prior to posting the file." }, { "payer_name": "MERITAIN HEALTH", "plan_name": "AETNA ALL OTHER PLANS", "methodology": "percent of total billed charges", "standard_charge_dollar": 384.8, "standard_charge_percentage": 52.0, "count": "0", "additional_payer_notes": "Zero final payments for the item or service in the 15 months prior to posting the file." }, { "payer_name": "BLUE SHIELD OUT OF STATE", "plan_name": "STANFORD HEALTHCARE ALLIANCE PLAN", "methodology": "percent of total billed charges", "standard_charge_dollar": 359.57, "standard_charge_percentage": 48.59, "count": "0", "additional_payer_notes": "Zero final payments for the item or service in the 15 months prior to posting the file." }, { "payer_name": "BLUE SHIELD", "plan_name": "STANFORD HEALTHCARE ALLIANCE PLAN", "methodology": "percent of total billed charges", "standard_charge_dollar": 359.57, "standard_charge_percentage": 48.59, "count": "0", "additional_payer_notes": "Zero final payments for the item or service in the 15 months prior to posting the file." }, { "payer_name": "BLUE SHIELD", "plan_name": "STANFORD HEALTHCARE ALLIANCE PLAN", "methodology": "percent of total billed charges", "standard_charge_dollar": 359.57, "standard_charge_percentage": 48.59, "count": "0", "additional_payer_notes": "Zero final payments for the item or service in the 15 months prior to posting the file." }, { "payer_name": "CIGNA", "plan_name": "CIGNA COM ALT HMO PLAN", "methodology": "percent of total billed charges", "standard_charge_dollar": 312.28, "standard_charge_percentage": 42.2, "count": "0", "additional_payer_notes": "Zero final payments for the item or service in the 15 months prior to posting the file." }, { "payer_name": "CIGNA", "plan_name": "CIGNA COM ALT HMO PLAN", "methodology": "percent of total billed charges", "standard_charge_dollar": 312.28, "standard_charge_percentage": 42.2, "count": "0", "additional_payer_notes": "Zero final payments for the item or service in the 15 months prior to posting the file." }, { "payer_name": "HEALTH NET", "plan_name": "HEALTHNET HMO, PPO, POS, EPO, CANOPY HEALTHNET HMO, OTHER-IN-NETWORK PLANS", "methodology": "per diem", "standard_charge_dollar": 8000.0, "standard_charge_algorithm": "Expected reimbursement is the lesser of Per diem ($8,000) for the length of stay and 70% of billed.", "count": "0", "additional_payer_notes": "Zero final payments for the item or service in the 15 months prior to posting the file." }, { "payer_name": "HEALTH NET", "plan_name": "HEALTHNET HMO, PPO, POS, EPO, CANOPY HEALTHNET HMO, OTHER-IN-NETWORK PLANS", "methodology": "per diem", "standard_charge_dollar": 8000.0, "standard_charge_algorithm": "Expected reimbursement is the lesser of Per diem ($8,000) for the length of stay and 70% of billed.", "count": "0", "additional_payer_notes": "Zero final payments for the item or service in the 15 months prior to posting the file." }, { "payer_name": "UNITED HEALTHCARE", "plan_name": "SUTTER SELECT & SUTTER HEALTH PLAN HMO PLANS", "methodology": "per diem", "standard_charge_dollar": 28538.0, "standard_charge_algorithm": "Per diem ($28,538).", "count": "0", "additional_payer_notes": "Zero final payments for the item or service in the 15 months prior to posting the file." }, { "payer_name": "UNITED HEALTHCARE", "plan_name": "SUTTER SELECT & SUTTER HEALTH PLAN HMO PLANS", "methodology": "per diem", "standard_charge_dollar": 28538.0, "standard_charge_algorithm": "Per diem ($28,538).", "count": "0", "additional_payer_notes": "Zero final payments for the item or service in the 15 months prior to posting the file." }, { "payer_name": "SUTTER", "plan_name": "SUTTER SELECT & SUTTER HEALTH PLAN HMO PLANS", "methodology": "per diem", "standard_charge_dollar": 28538.0, "standard_charge_algorithm": "Per diem ($28,538).", "count": "0", "additional_payer_notes": "Zero final payments for the item or service in the 15 months prior to posting the file." }, { "payer_name": "UNITED HEALTHCARE", "plan_name": "SUTTER SELECT & SUTTER HEALTH PLAN HMO PLANS", "methodology": "per diem", "standard_charge_dollar": 28538.0, "standard_charge_algorithm": "Per diem ($28,538).", "count": "0", "additional_payer_notes": "Zero final payments for the item or service in the 15 months prior to posting the file." }, { "payer_name": "UMR", "plan_name": "SUTTER SELECT & SUTTER HEALTH PLAN HMO PLANS", "methodology": "per diem", "standard_charge_dollar": 28538.0, "standard_charge_algorithm": "Per diem ($28,538).", "count": "0", "additional_payer_notes": "Zero final payments for the item or service in the 15 months prior to posting the file." } ] } ] }, { "description": "HC Bur Legend Gp012", "code_information": [ { "code": "PX-2120018012", "type": "CDM" }, { "code": "99999", "type": "CPT" }, { "code": "0272", "type": "RC" } ], "standard_charges": [ { "setting": "outpatient", "gross_charge": 810.0, "discounted_cash": 405.0, "minimum": 341.82, "maximum": 421.2, "additional_generic_notes": "Zero final payments for the item or service in the 15 months prior to posting the file.", "payers_information": [ { "payer_name": "AETNA", "plan_name": "AETNA ALL OTHER PLANS", "methodology": "percent of total billed charges", "standard_charge_dollar": 421.2, "standard_charge_percentage": 52.0, "count": "0", "additional_payer_notes": "Zero final payments for the item or service in the 15 months prior to posting the file." }, { "payer_name": "AETNA", "plan_name": "AETNA ALL OTHER PLANS", "methodology": "percent of total billed charges", "standard_charge_dollar": 421.2, "standard_charge_percentage": 52.0, "count": "0", "additional_payer_notes": "Zero final payments for the item or service in the 15 months prior to posting the file." }, { "payer_name": "MERITAIN HEALTH", "plan_name": "AETNA ALL OTHER PLANS", "methodology": "percent of total billed charges", "standard_charge_dollar": 421.2, "standard_charge_percentage": 52.0, "count": "0", "additional_payer_notes": "Zero final payments for the item or service in the 15 months prior to posting the file." }, { "payer_name": "BLUE SHIELD OUT OF STATE", "plan_name": "STANFORD HEALTHCARE ALLIANCE PLAN", "methodology": "percent of total billed charges", "standard_charge_dollar": 393.58, "standard_charge_percentage": 48.59, "count": "0", "additional_payer_notes": "Zero final payments for the item or service in the 15 months prior to posting the file." }, { "payer_name": "BLUE SHIELD", "plan_name": "STANFORD HEALTHCARE ALLIANCE PLAN", "methodology": "percent of total billed charges", "standard_charge_dollar": 393.58, "standard_charge_percentage": 48.59, "count": "0", "additional_payer_notes": "Zero final payments for the item or service in the 15 months prior to posting the file." }, { "payer_name": "BLUE SHIELD", "plan_name": "STANFORD HEALTHCARE ALLIANCE PLAN", "methodology": "percent of total billed charges", "standard_charge_dollar": 393.58, "standard_charge_percentage": 48.59, "count": "0", "additional_payer_notes": "Zero final payments for the item or service in the 15 months prior to posting the file." }, { "payer_name": "CIGNA", "plan_name": "CIGNA COM ALT HMO PLAN", "methodology": "percent of total billed charges", "standard_charge_dollar": 341.82, "standard_charge_percentage": 42.2, "count": "0", "additional_payer_notes": "Zero final payments for the item or service in the 15 months prior to posting the file." }, { "payer_name": "CIGNA", "plan_name": "CIGNA COM ALT HMO PLAN", "methodology": "percent of total billed charges", "standard_charge_dollar": 341.82, "standard_charge_percentage": 42.2, "count": "0", "additional_payer_notes": "Zero final payments for the item or service in the 15 months prior to posting the file." }, { "payer_name": "HEALTH NET", "plan_name": "HEALTHNET HMO, PPO, POS, EPO, CANOPY HEALTHNET HMO, OTHER-IN-NETWORK PLANS", "methodology": "per diem", "standard_charge_dollar": 8000.0, "standard_charge_algorithm": "Expected reimbursement is the lesser of Per diem ($8,000) for the length of stay and 70% of billed.", "count": "0", "additional_payer_notes": "Zero final payments for the item or service in the 15 months prior to posting the file." }, { "payer_name": "HEALTH NET", "plan_name": "HEALTHNET HMO, PPO, POS, EPO, CANOPY HEALTHNET HMO, OTHER-IN-NETWORK PLANS", "methodology": "per diem", "standard_charge_dollar": 8000.0, "standard_charge_algorithm": "Expected reimbursement is the lesser of Per diem ($8,000) for the length of stay and 70% of billed.", "count": "0", "additional_payer_notes": "Zero final payments for the item or service in the 15 months prior to posting the file." }, { "payer_name": "UNITED HEALTHCARE", "plan_name": "SUTTER SELECT & SUTTER HEALTH PLAN HMO PLANS", "methodology": "per diem", "standard_charge_dollar": 28538.0, "standard_charge_algorithm": "Per diem ($28,538).", "count": "0", "additional_payer_notes": "Zero final payments for the item or service in the 15 months prior to posting the file." }, { "payer_name": "UNITED HEALTHCARE", "plan_name": "SUTTER SELECT & SUTTER HEALTH PLAN HMO PLANS", "methodology": "per diem", "standard_charge_dollar": 28538.0, "standard_charge_algorithm": "Per diem ($28,538).", "count": "0", "additional_payer_notes": "Zero final payments for the item or service in the 15 months prior to posting the file." }, { "payer_name": "SUTTER", "plan_name": "SUTTER SELECT & SUTTER HEALTH PLAN HMO PLANS", "methodology": "per diem", "standard_charge_dollar": 28538.0, "standard_charge_algorithm": "Per diem ($28,538).", "count": "0", "additional_payer_notes": "Zero final payments for the item or service in the 15 months prior to posting the file." }, { "payer_name": "UNITED HEALTHCARE", "plan_name": "SUTTER SELECT & SUTTER HEALTH PLAN HMO PLANS", "methodology": "per diem", "standard_charge_dollar": 28538.0, "standard_charge_algorithm": "Per diem ($28,538).", "count": "0", "additional_payer_notes": "Zero final payments for the item or service in the 15 months prior to posting the file." }, { "payer_name": "UMR", "plan_name": "SUTTER SELECT & SUTTER HEALTH PLAN HMO PLANS", "methodology": "per diem", "standard_charge_dollar": 28538.0, "standard_charge_algorithm": "Per diem ($28,538).", "count": "0", "additional_payer_notes": "Zero final payments for the item or service in the 15 months prior to posting the file." } ] } ] }, { "description": "HC Bur Legend Gp013", "code_information": [ { "code": "PX-2120018013", "type": "CDM" }, { "code": "99999", "type": "CPT" }, { "code": "0272", "type": "RC" } ], "standard_charges": [ { "setting": "outpatient", "gross_charge": 900.0, "discounted_cash": 450.0, "minimum": 379.8, "maximum": 468.0, "additional_generic_notes": "Zero final payments for the item or service in the 15 months prior to posting the file.", "payers_information": [ { "payer_name": "AETNA", "plan_name": "AETNA ALL OTHER PLANS", "methodology": "percent of total billed charges", "standard_charge_dollar": 468.0, "standard_charge_percentage": 52.0, "count": "0", "additional_payer_notes": "Zero final payments for the item or service in the 15 months prior to posting the file." }, { "payer_name": "AETNA", "plan_name": "AETNA ALL OTHER PLANS", "methodology": "percent of total billed charges", "standard_charge_dollar": 468.0, "standard_charge_percentage": 52.0, "count": "0", "additional_payer_notes": "Zero final payments for the item or service in the 15 months prior to posting the file." }, { "payer_name": "MERITAIN HEALTH", "plan_name": "AETNA ALL OTHER PLANS", "methodology": "percent of total billed charges", "standard_charge_dollar": 468.0, "standard_charge_percentage": 52.0, "count": "0", "additional_payer_notes": "Zero final payments for the item or service in the 15 months prior to posting the file." }, { "payer_name": "BLUE SHIELD OUT OF STATE", "plan_name": "STANFORD HEALTHCARE ALLIANCE PLAN", "methodology": "percent of total billed charges", "standard_charge_dollar": 437.31, "standard_charge_percentage": 48.59, "count": "0", "additional_payer_notes": "Zero final payments for the item or service in the 15 months prior to posting the file." }, { "payer_name": "BLUE SHIELD", "plan_name": "STANFORD HEALTHCARE ALLIANCE PLAN", "methodology": "percent of total billed charges", "standard_charge_dollar": 437.31, "standard_charge_percentage": 48.59, "count": "0", "additional_payer_notes": "Zero final payments for the item or service in the 15 months prior to posting the file." }, { "payer_name": "BLUE SHIELD", "plan_name": "STANFORD HEALTHCARE ALLIANCE PLAN", "methodology": "percent of total billed charges", "standard_charge_dollar": 437.31, "standard_charge_percentage": 48.59, "count": "0", "additional_payer_notes": "Zero final payments for the item or service in the 15 months prior to posting the file." }, { "payer_name": "CIGNA", "plan_name": "CIGNA COM ALT HMO PLAN", "methodology": "percent of total billed charges", "standard_charge_dollar": 379.8, "standard_charge_percentage": 42.2, "count": "0", "additional_payer_notes": "Zero final payments for the item or service in the 15 months prior to posting the file." }, { "payer_name": "CIGNA", "plan_name": "CIGNA COM ALT HMO PLAN", "methodology": "percent of total billed charges", "standard_charge_dollar": 379.8, "standard_charge_percentage": 42.2, "count": "0", "additional_payer_notes": "Zero final payments for the item or service in the 15 months prior to posting the file." }, { "payer_name": "HEALTH NET", "plan_name": "HEALTHNET HMO, PPO, POS, EPO, CANOPY HEALTHNET HMO, OTHER-IN-NETWORK PLANS", "methodology": "per diem", "standard_charge_dollar": 8000.0, "standard_charge_algorithm": "Expected reimbursement is the lesser of Per diem ($8,000) for the length of stay and 70% of billed.", "count": "0", "additional_payer_notes": "Zero final payments for the item or service in the 15 months prior to posting the file." }, { "payer_name": "HEALTH NET", "plan_name": "HEALTHNET HMO, PPO, POS, EPO, CANOPY HEALTHNET HMO, OTHER-IN-NETWORK PLANS", "methodology": "per diem", "standard_charge_dollar": 8000.0, "standard_charge_algorithm": "Expected reimbursement is the lesser of Per diem ($8,000) for the length of stay and 70% of billed.", "count": "0", "additional_payer_notes": "Zero final payments for the item or service in the 15 months prior to posting the file." }, { "payer_name": "UNITED HEALTHCARE", "plan_name": "SUTTER SELECT & SUTTER HEALTH PLAN HMO PLANS", "methodology": "per diem", "standard_charge_dollar": 28538.0, "standard_charge_algorithm": "Per diem ($28,538).", "count": "0", "additional_payer_notes": "Zero final payments for the item or service in the 15 months prior to posting the file." }, { "payer_name": "UNITED HEALTHCARE", "plan_name": "SUTTER SELECT & SUTTER HEALTH PLAN HMO PLANS", "methodology": "per diem", "standard_charge_dollar": 28538.0, "standard_charge_algorithm": "Per diem ($28,538).", "count": "0", "additional_payer_notes": "Zero final payments for the item or service in the 15 months prior to posting the file." }, { "payer_name": "SUTTER", "plan_name": "SUTTER SELECT & SUTTER HEALTH PLAN HMO PLANS", "methodology": "per diem", "standard_charge_dollar": 28538.0, "standard_charge_algorithm": "Per diem ($28,538).", "count": "0", "additional_payer_notes": "Zero final payments for the item or service in the 15 months prior to posting the file." }, { "payer_name": "UNITED HEALTHCARE", "plan_name": "SUTTER SELECT & SUTTER HEALTH PLAN HMO PLANS", "methodology": "per diem", "standard_charge_dollar": 28538.0, "standard_charge_algorithm": "Per diem ($28,538).", "count": "0", "additional_payer_notes": "Zero final payments for the item or service in the 15 months prior to posting the file." }, { "payer_name": "UMR", "plan_name": "SUTTER SELECT & SUTTER HEALTH PLAN HMO PLANS", "methodology": "per diem", "standard_charge_dollar": 28538.0, "standard_charge_algorithm": "Per diem ($28,538).", "count": "0", "additional_payer_notes": "Zero final payments for the item or service in the 15 months prior to posting the file." } ] } ] }, { "description": "HC Bur Legend Gp014", "code_information": [ { "code": "PX-2120018014", "type": "CDM" }, { "code": "99999", "type": "CPT" }, { "code": "0272", "type": "RC" } ], "standard_charges": [ { "setting": "outpatient", "gross_charge": 1080.0, "discounted_cash": 540.0, "minimum": 455.76, "maximum": 561.6, "additional_generic_notes": "Zero final payments for the item or service in the 15 months prior to posting the file.", "payers_information": [ { "payer_name": "AETNA", "plan_name": "AETNA ALL OTHER PLANS", "methodology": "percent of total billed charges", "standard_charge_dollar": 561.6, "standard_charge_percentage": 52.0, "count": "0", "additional_payer_notes": "Zero final payments for the item or service in the 15 months prior to posting the file." }, { "payer_name": "AETNA", "plan_name": "AETNA ALL OTHER PLANS", "methodology": "percent of total billed charges", "standard_charge_dollar": 561.6, "standard_charge_percentage": 52.0, "count": "0", "additional_payer_notes": "Zero final payments for the item or service in the 15 months prior to posting the file." }, { "payer_name": "MERITAIN HEALTH", "plan_name": "AETNA ALL OTHER PLANS", "methodology": "percent of total billed charges", "standard_charge_dollar": 561.6, "standard_charge_percentage": 52.0, "count": "0", "additional_payer_notes": "Zero final payments for the item or service in the 15 months prior to posting the file." }, { "payer_name": "BLUE SHIELD OUT OF STATE", "plan_name": "STANFORD HEALTHCARE ALLIANCE PLAN", "methodology": "percent of total billed charges", "standard_charge_dollar": 524.77, "standard_charge_percentage": 48.59, "count": "0", "additional_payer_notes": "Zero final payments for the item or service in the 15 months prior to posting the file." }, { "payer_name": "BLUE SHIELD", "plan_name": "STANFORD HEALTHCARE ALLIANCE PLAN", "methodology": "percent of total billed charges", "standard_charge_dollar": 524.77, "standard_charge_percentage": 48.59, "median_amount": 68.24, "10th_percentile": 13.6, "90th_percentile": 1043.06, "count": "30" }, { "payer_name": "BLUE SHIELD", "plan_name": "STANFORD HEALTHCARE ALLIANCE PLAN", "methodology": "percent of total billed charges", "standard_charge_dollar": 524.77, "standard_charge_percentage": 48.59, "count": "0", "additional_payer_notes": "Zero final payments for the item or service in the 15 months prior to posting the file." }, { "payer_name": "BLUE SHIELD", "plan_name": "STANFORD HEALTHCARE ALLIANCE PLAN", "methodology": "percent of total billed charges", "standard_charge_dollar": 524.77, "standard_charge_percentage": 48.59, "count": "0", "additional_payer_notes": "Zero final payments for the item or service in the 15 months prior to posting the file." }, { "payer_name": "CIGNA", "plan_name": "CIGNA COM ALT HMO PLAN", "methodology": "percent of total billed charges", "standard_charge_dollar": 455.76, "standard_charge_percentage": 42.2, "count": "0", "additional_payer_notes": "Zero final payments for the item or service in the 15 months prior to posting the file." }, { "payer_name": "CIGNA", "plan_name": "CIGNA COM ALT HMO PLAN", "methodology": "percent of total billed charges", "standard_charge_dollar": 455.76, "standard_charge_percentage": 42.2, "count": "0", "additional_payer_notes": "Zero final payments for the item or service in the 15 months prior to posting the file." }, { "payer_name": "HEALTH NET", "plan_name": "HEALTHNET HMO, PPO, POS, EPO, CANOPY HEALTHNET HMO, OTHER-IN-NETWORK PLANS", "methodology": "per diem", "standard_charge_dollar": 8000.0, "standard_charge_algorithm": "Expected reimbursement is the lesser of Per diem ($8,000) for the length of stay and 70% of billed.", "count": "0", "additional_payer_notes": "Zero final payments for the item or service in the 15 months prior to posting the file." }, { "payer_name": "HEALTH NET", "plan_name": "HEALTHNET HMO, PPO, POS, EPO, CANOPY HEALTHNET HMO, OTHER-IN-NETWORK PLANS", "methodology": "per diem", "standard_charge_dollar": 8000.0, "standard_charge_algorithm": "Expected reimbursement is the lesser of Per diem ($8,000) for the length of stay and 70% of billed.", "count": "0", "additional_payer_notes": "Zero final payments for the item or service in the 15 months prior to posting the file." }, { "payer_name": "UNITED HEALTHCARE", "plan_name": "SUTTER SELECT & SUTTER HEALTH PLAN HMO PLANS", "methodology": "per diem", "standard_charge_dollar": 28538.0, "standard_charge_algorithm": "Per diem ($28,538).", "count": "0", "additional_payer_notes": "Zero final payments for the item or service in the 15 months prior to posting the file." }, { "payer_name": "UNITED HEALTHCARE", "plan_name": "SUTTER SELECT & SUTTER HEALTH PLAN HMO PLANS", "methodology": "per diem", "standard_charge_dollar": 28538.0, "standard_charge_algorithm": "Per diem ($28,538).", "count": "0", "additional_payer_notes": "Zero final payments for the item or service in the 15 months prior to posting the file." }, { "payer_name": "SUTTER", "plan_name": "SUTTER SELECT & SUTTER HEALTH PLAN HMO PLANS", "methodology": "per diem", "standard_charge_dollar": 28538.0, "standard_charge_algorithm": "Per diem ($28,538).", "count": "0", "additional_payer_notes": "Zero final payments for the item or service in the 15 months prior to posting the file." }, { "payer_name": "UNITED HEALTHCARE", "plan_name": "SUTTER SELECT & SUTTER HEALTH PLAN HMO PLANS", "methodology": "per diem", "standard_charge_dollar": 28538.0, "standard_charge_algorithm": "Per diem ($28,538).", "count": "0", "additional_payer_notes": "Zero final payments for the item or service in the 15 months prior to posting the file." }, { "payer_name": "UMR", "plan_name": "SUTTER SELECT & SUTTER HEALTH PLAN HMO PLANS", "methodology": "per diem", "standard_charge_dollar": 28538.0, "standard_charge_algorithm": "Per diem ($28,538).", "count": "0", "additional_payer_notes": "Zero final payments for the item or service in the 15 months prior to posting the file." } ] } ] }, { "description": "HC Bur Legend Gp015", "code_information": [ { "code": "PX-2120018015", "type": "CDM" }, { "code": "99999", "type": "CPT" }, { "code": "0272", "type": "RC" } ], "standard_charges": [ { "setting": "outpatient", "gross_charge": 1225.0, "discounted_cash": 612.5, "minimum": 516.95, "maximum": 637.0, "additional_generic_notes": "Zero final payments for the item or service in the 15 months prior to posting the file.", "payers_information": [ { "payer_name": "AETNA", "plan_name": "AETNA ALL OTHER PLANS", "methodology": "percent of total billed charges", "standard_charge_dollar": 637.0, "standard_charge_percentage": 52.0, "count": "0", "additional_payer_notes": "Zero final payments for the item or service in the 15 months prior to posting the file." }, { "payer_name": "AETNA", "plan_name": "AETNA ALL OTHER PLANS", "methodology": "percent of total billed charges", "standard_charge_dollar": 637.0, "standard_charge_percentage": 52.0, "count": "0", "additional_payer_notes": "Zero final payments for the item or service in the 15 months prior to posting the file." }, { "payer_name": "MERITAIN HEALTH", "plan_name": "AETNA ALL OTHER PLANS", "methodology": "percent of total billed charges", "standard_charge_dollar": 637.0, "standard_charge_percentage": 52.0, "count": "0", "additional_payer_notes": "Zero final payments for the item or service in the 15 months prior to posting the file." }, { "payer_name": "BLUE SHIELD OUT OF STATE", "plan_name": "STANFORD HEALTHCARE ALLIANCE PLAN", "methodology": "percent of total billed charges", "standard_charge_dollar": 595.23, "standard_charge_percentage": 48.59, "count": "0", "additional_payer_notes": "Zero final payments for the item or service in the 15 months prior to posting the file." }, { "payer_name": "BLUE SHIELD", "plan_name": "STANFORD HEALTHCARE ALLIANCE PLAN", "methodology": "percent of total billed charges", "standard_charge_dollar": 595.23, "standard_charge_percentage": 48.59, "median_amount": 68.24, "10th_percentile": 13.6, "90th_percentile": 1043.06, "count": "30" }, { "payer_name": "BLUE SHIELD", "plan_name": "STANFORD HEALTHCARE ALLIANCE PLAN", "methodology": "percent of total billed charges", "standard_charge_dollar": 595.23, "standard_charge_percentage": 48.59, "count": "0", "additional_payer_notes": "Zero final payments for the item or service in the 15 months prior to posting the file." }, { "payer_name": "BLUE SHIELD", "plan_name": "STANFORD HEALTHCARE ALLIANCE PLAN", "methodology": "percent of total billed charges", "standard_charge_dollar": 595.23, "standard_charge_percentage": 48.59, "count": "0", "additional_payer_notes": "Zero final payments for the item or service in the 15 months prior to posting the file." }, { "payer_name": "CIGNA", "plan_name": "CIGNA COM ALT HMO PLAN", "methodology": "percent of total billed charges", "standard_charge_dollar": 516.95, "standard_charge_percentage": 42.2, "count": "0", "additional_payer_notes": "Zero final payments for the item or service in the 15 months prior to posting the file." }, { "payer_name": "CIGNA", "plan_name": "CIGNA COM ALT HMO PLAN", "methodology": "percent of total billed charges", "standard_charge_dollar": 516.95, "standard_charge_percentage": 42.2, "count": "0", "additional_payer_notes": "Zero final payments for the item or service in the 15 months prior to posting the file." }, { "payer_name": "HEALTH NET", "plan_name": "HEALTHNET HMO, PPO, POS, EPO, CANOPY HEALTHNET HMO, OTHER-IN-NETWORK PLANS", "methodology": "per diem", "standard_charge_dollar": 8000.0, "standard_charge_algorithm": "Expected reimbursement is the lesser of Per diem ($8,000) for the length of stay and 70% of billed.", "count": "0", "additional_payer_notes": "Zero final payments for the item or service in the 15 months prior to posting the file." }, { "payer_name": "HEALTH NET", "plan_name": "HEALTHNET HMO, PPO, POS, EPO, CANOPY HEALTHNET HMO, OTHER-IN-NETWORK PLANS", "methodology": "per diem", "standard_charge_dollar": 8000.0, "standard_charge_algorithm": "Expected reimbursement is the lesser of Per diem ($8,000) for the length of stay and 70% of billed.", "count": "0", "additional_payer_notes": "Zero final payments for the item or service in the 15 months prior to posting the file." }, { "payer_name": "UNITED HEALTHCARE", "plan_name": "SUTTER SELECT & SUTTER HEALTH PLAN HMO PLANS", "methodology": "per diem", "standard_charge_dollar": 28538.0, "standard_charge_algorithm": "Per diem ($28,538).", "count": "0", "additional_payer_notes": "Zero final payments for the item or service in the 15 months prior to posting the file." }, { "payer_name": "UNITED HEALTHCARE", "plan_name": "SUTTER SELECT & SUTTER HEALTH PLAN HMO PLANS", "methodology": "per diem", "standard_charge_dollar": 28538.0, "standard_charge_algorithm": "Per diem ($28,538).", "count": "0", "additional_payer_notes": "Zero final payments for the item or service in the 15 months prior to posting the file." }, { "payer_name": "SUTTER", "plan_name": "SUTTER SELECT & SUTTER HEALTH PLAN HMO PLANS", "methodology": "per diem", "standard_charge_dollar": 28538.0, "standard_charge_algorithm": "Per diem ($28,538).", "count": "0", "additional_payer_notes": "Zero final payments for the item or service in the 15 months prior to posting the file." }, { "payer_name": "UNITED HEALTHCARE", "plan_name": "SUTTER SELECT & SUTTER HEALTH PLAN HMO PLANS", "methodology": "per diem", "standard_charge_dollar": 28538.0, "standard_charge_algorithm": "Per diem ($28,538).", "count": "0", "additional_payer_notes": "Zero final payments for the item or service in the 15 months prior to posting the file." }, { "payer_name": "UMR", "plan_name": "SUTTER SELECT & SUTTER HEALTH PLAN HMO PLANS", "methodology": "per diem", "standard_charge_dollar": 28538.0, "standard_charge_algorithm": "Per diem ($28,538).", "count": "0", "additional_payer_notes": "Zero final payments for the item or service in the 15 months prior to posting the file." } ] } ] }, { "description": "HC Bur Legend Gp018", "code_information": [ { "code": "PX-2120018018", "type": "CDM" }, { "code": "99999", "type": "CPT" }, { "code": "0272", "type": "RC" } ], "standard_charges": [ { "setting": "outpatient", "gross_charge": 1750.0, "discounted_cash": 875.0, "minimum": 738.5, "maximum": 910.0, "additional_generic_notes": "Zero final payments for the item or service in the 15 months prior to posting the file.", "payers_information": [ { "payer_name": "AETNA", "plan_name": "AETNA ALL OTHER PLANS", "methodology": "percent of total billed charges", "standard_charge_dollar": 910.0, "standard_charge_percentage": 52.0, "count": "0", "additional_payer_notes": "Zero final payments for the item or service in the 15 months prior to posting the file." }, { "payer_name": "AETNA", "plan_name": "AETNA ALL OTHER PLANS", "methodology": "percent of total billed charges", "standard_charge_dollar": 910.0, "standard_charge_percentage": 52.0, "count": "0", "additional_payer_notes": "Zero final payments for the item or service in the 15 months prior to posting the file." }, { "payer_name": "MERITAIN HEALTH", "plan_name": "AETNA ALL OTHER PLANS", "methodology": "percent of total billed charges", "standard_charge_dollar": 910.0, "standard_charge_percentage": 52.0, "count": "0", "additional_payer_notes": "Zero final payments for the item or service in the 15 months prior to posting the file." }, { "payer_name": "BLUE SHIELD OUT OF STATE", "plan_name": "STANFORD HEALTHCARE ALLIANCE PLAN", "methodology": "percent of total billed charges", "standard_charge_dollar": 850.33, "standard_charge_percentage": 48.59, "count": "0", "additional_payer_notes": "Zero final payments for the item or service in the 15 months prior to posting the file." }, { "payer_name": "BLUE SHIELD", "plan_name": "STANFORD HEALTHCARE ALLIANCE PLAN", "methodology": "percent of total billed charges", "standard_charge_dollar": 850.33, "standard_charge_percentage": 48.59, "median_amount": 68.24, "10th_percentile": 13.6, "90th_percentile": 1043.06, "count": "30" }, { "payer_name": "BLUE SHIELD", "plan_name": "STANFORD HEALTHCARE ALLIANCE PLAN", "methodology": "percent of total billed charges", "standard_charge_dollar": 850.33, "standard_charge_percentage": 48.59, "count": "0", "additional_payer_notes": "Zero final payments for the item or service in the 15 months prior to posting the file." }, { "payer_name": "BLUE SHIELD", "plan_name": "STANFORD HEALTHCARE ALLIANCE PLAN", "methodology": "percent of total billed charges", "standard_charge_dollar": 850.33, "standard_charge_percentage": 48.59, "count": "0", "additional_payer_notes": "Zero final payments for the item or service in the 15 months prior to posting the file." }, { "payer_name": "CIGNA", "plan_name": "CIGNA COM ALT HMO PLAN", "methodology": "percent of total billed charges", "standard_charge_dollar": 738.5, "standard_charge_percentage": 42.2, "count": "0", "additional_payer_notes": "Zero final payments for the item or service in the 15 months prior to posting the file." }, { "payer_name": "CIGNA", "plan_name": "CIGNA COM ALT HMO PLAN", "methodology": "percent of total billed charges", "standard_charge_dollar": 738.5, "standard_charge_percentage": 42.2, "count": "0", "additional_payer_notes": "Zero final payments for the item or service in the 15 months prior to posting the file." }, { "payer_name": "HEALTH NET", "plan_name": "HEALTHNET HMO, PPO, POS, EPO, CANOPY HEALTHNET HMO, OTHER-IN-NETWORK PLANS", "methodology": "per diem", "standard_charge_dollar": 8000.0, "standard_charge_algorithm": "Expected reimbursement is the lesser of Per diem ($8,000) for the length of stay and 70% of billed.", "count": "0", "additional_payer_notes": "Zero final payments for the item or service in the 15 months prior to posting the file." }, { "payer_name": "HEALTH NET", "plan_name": "HEALTHNET HMO, PPO, POS, EPO, CANOPY HEALTHNET HMO, OTHER-IN-NETWORK PLANS", "methodology": "per diem", "standard_charge_dollar": 8000.0, "standard_charge_algorithm": "Expected reimbursement is the lesser of Per diem ($8,000) for the length of stay and 70% of billed.", "count": "0", "additional_payer_notes": "Zero final payments for the item or service in the 15 months prior to posting the file." }, { "payer_name": "UNITED HEALTHCARE", "plan_name": "SUTTER SELECT & SUTTER HEALTH PLAN HMO PLANS", "methodology": "per diem", "standard_charge_dollar": 28538.0, "standard_charge_algorithm": "Per diem ($28,538).", "count": "0", "additional_payer_notes": "Zero final payments for the item or service in the 15 months prior to posting the file." }, { "payer_name": "UNITED HEALTHCARE", "plan_name": "SUTTER SELECT & SUTTER HEALTH PLAN HMO PLANS", "methodology": "per diem", "standard_charge_dollar": 28538.0, "standard_charge_algorithm": "Per diem ($28,538).", "count": "0", "additional_payer_notes": "Zero final payments for the item or service in the 15 months prior to posting the file." }, { "payer_name": "SUTTER", "plan_name": "SUTTER SELECT & SUTTER HEALTH PLAN HMO PLANS", "methodology": "per diem", "standard_charge_dollar": 28538.0, "standard_charge_algorithm": "Per diem ($28,538).", "count": "0", "additional_payer_notes": "Zero final payments for the item or service in the 15 months prior to posting the file." }, { "payer_name": "UNITED HEALTHCARE", "plan_name": "SUTTER SELECT & SUTTER HEALTH PLAN HMO PLANS", "methodology": "per diem", "standard_charge_dollar": 28538.0, "standard_charge_algorithm": "Per diem ($28,538).", "count": "0", "additional_payer_notes": "Zero final payments for the item or service in the 15 months prior to posting the file." }, { "payer_name": "UMR", "plan_name": "SUTTER SELECT & SUTTER HEALTH PLAN HMO PLANS", "methodology": "per diem", "standard_charge_dollar": 28538.0, "standard_charge_algorithm": "Per diem ($28,538).", "count": "0", "additional_payer_notes": "Zero final payments for the item or service in the 15 months prior to posting the file." } ] } ] }, { "description": "HC Bur Oval Gp002", "code_information": [ { "code": "PX-2120019002", "type": "CDM" }, { "code": "99999", "type": "CPT" }, { "code": "0272", "type": "RC" } ], "standard_charges": [ { "setting": "outpatient", "gross_charge": 50.0, "discounted_cash": 25.0, "minimum": 21.1, "maximum": 26.0, "additional_generic_notes": "Zero final payments for the item or service in the 15 months prior to posting the file.", "payers_information": [ { "payer_name": "AETNA", "plan_name": "AETNA ALL OTHER PLANS", "methodology": "percent of total billed charges", "standard_charge_dollar": 26.0, "standard_charge_percentage": 52.0, "count": "0", "additional_payer_notes": "Zero final payments for the item or service in the 15 months prior to posting the file." }, { "payer_name": "AETNA", "plan_name": "AETNA ALL OTHER PLANS", "methodology": "percent of total billed charges", "standard_charge_dollar": 26.0, "standard_charge_percentage": 52.0, "count": "0", "additional_payer_notes": "Zero final payments for the item or service in the 15 months prior to posting the file." }, { "payer_name": "MERITAIN HEALTH", "plan_name": "AETNA ALL OTHER PLANS", "methodology": "percent of total billed charges", "standard_charge_dollar": 26.0, "standard_charge_percentage": 52.0, "count": "0", "additional_payer_notes": "Zero final payments for the item or service in the 15 months prior to posting the file." }, { "payer_name": "BLUE SHIELD OUT OF STATE", "plan_name": "STANFORD HEALTHCARE ALLIANCE PLAN", "methodology": "percent of total billed charges", "standard_charge_dollar": 24.3, "standard_charge_percentage": 48.59, "count": "0", "additional_payer_notes": "Zero final payments for the item or service in the 15 months prior to posting the file." }, { "payer_name": "BLUE SHIELD", "plan_name": "STANFORD HEALTHCARE ALLIANCE PLAN", "methodology": "percent of total billed charges", "standard_charge_dollar": 24.3, "standard_charge_percentage": 48.59, "count": "0", "additional_payer_notes": "Zero final payments for the item or service in the 15 months prior to posting the file." }, { "payer_name": "BLUE SHIELD", "plan_name": "STANFORD HEALTHCARE ALLIANCE PLAN", "methodology": "percent of total billed charges", "standard_charge_dollar": 24.3, "standard_charge_percentage": 48.59, "count": "0", "additional_payer_notes": "Zero final payments for the item or service in the 15 months prior to posting the file." }, { "payer_name": "CIGNA", "plan_name": "CIGNA COM ALT HMO PLAN", "methodology": "percent of total billed charges", "standard_charge_dollar": 21.1, "standard_charge_percentage": 42.2, "count": "0", "additional_payer_notes": "Zero final payments for the item or service in the 15 months prior to posting the file." }, { "payer_name": "CIGNA", "plan_name": "CIGNA COM ALT HMO PLAN", "methodology": "percent of total billed charges", "standard_charge_dollar": 21.1, "standard_charge_percentage": 42.2, "count": "0", "additional_payer_notes": "Zero final payments for the item or service in the 15 months prior to posting the file." }, { "payer_name": "HEALTH NET", "plan_name": "HEALTHNET HMO, PPO, POS, EPO, CANOPY HEALTHNET HMO, OTHER-IN-NETWORK PLANS", "methodology": "per diem", "standard_charge_dollar": 8000.0, "standard_charge_algorithm": "Expected reimbursement is the lesser of Per diem ($8,000) for the length of stay and 70% of billed.", "count": "0", "additional_payer_notes": "Zero final payments for the item or service in the 15 months prior to posting the file." }, { "payer_name": "HEALTH NET", "plan_name": "HEALTHNET HMO, PPO, POS, EPO, CANOPY HEALTHNET HMO, OTHER-IN-NETWORK PLANS", "methodology": "per diem", "standard_charge_dollar": 8000.0, "standard_charge_algorithm": "Expected reimbursement is the lesser of Per diem ($8,000) for the length of stay and 70% of billed.", "count": "0", "additional_payer_notes": "Zero final payments for the item or service in the 15 months prior to posting the file." }, { "payer_name": "UNITED HEALTHCARE", "plan_name": "SUTTER SELECT & SUTTER HEALTH PLAN HMO PLANS", "methodology": "per diem", "standard_charge_dollar": 28538.0, "standard_charge_algorithm": "Per diem ($28,538).", "count": "0", "additional_payer_notes": "Zero final payments for the item or service in the 15 months prior to posting the file." }, { "payer_name": "UNITED HEALTHCARE", "plan_name": "SUTTER SELECT & SUTTER HEALTH PLAN HMO PLANS", "methodology": "per diem", "standard_charge_dollar": 28538.0, "standard_charge_algorithm": "Per diem ($28,538).", "count": "0", "additional_payer_notes": "Zero final payments for the item or service in the 15 months prior to posting the file." }, { "payer_name": "SUTTER", "plan_name": "SUTTER SELECT & SUTTER HEALTH PLAN HMO PLANS", "methodology": "per diem", "standard_charge_dollar": 28538.0, "standard_charge_algorithm": "Per diem ($28,538).", "count": "0", "additional_payer_notes": "Zero final payments for the item or service in the 15 months prior to posting the file." }, { "payer_name": "UNITED HEALTHCARE", "plan_name": "SUTTER SELECT & SUTTER HEALTH PLAN HMO PLANS", "methodology": "per diem", "standard_charge_dollar": 28538.0, "standard_charge_algorithm": "Per diem ($28,538).", "count": "0", "additional_payer_notes": "Zero final payments for the item or service in the 15 months prior to posting the file." }, { "payer_name": "UMR", "plan_name": "SUTTER SELECT & SUTTER HEALTH PLAN HMO PLANS", "methodology": "per diem", "standard_charge_dollar": 28538.0, "standard_charge_algorithm": "Per diem ($28,538).", "count": "0", "additional_payer_notes": "Zero final payments for the item or service in the 15 months prior to posting the file." } ] } ] }, { "description": "HC Bur Oval Gp003", "code_information": [ { "code": "PX-2120019003", "type": "CDM" }, { "code": "99999", "type": "CPT" }, { "code": "0272", "type": "RC" } ], "standard_charges": [ { "setting": "outpatient", "gross_charge": 100.0, "discounted_cash": 50.0, "minimum": 42.2, "maximum": 52.0, "additional_generic_notes": "Zero final payments for the item or service in the 15 months prior to posting the file.", "payers_information": [ { "payer_name": "AETNA", "plan_name": "AETNA ALL OTHER PLANS", "methodology": "percent of total billed charges", "standard_charge_dollar": 52.0, "standard_charge_percentage": 52.0, "count": "0", "additional_payer_notes": "Zero final payments for the item or service in the 15 months prior to posting the file." }, { "payer_name": "AETNA", "plan_name": "AETNA ALL OTHER PLANS", "methodology": "percent of total billed charges", "standard_charge_dollar": 52.0, "standard_charge_percentage": 52.0, "count": "0", "additional_payer_notes": "Zero final payments for the item or service in the 15 months prior to posting the file." }, { "payer_name": "MERITAIN HEALTH", "plan_name": "AETNA ALL OTHER PLANS", "methodology": "percent of total billed charges", "standard_charge_dollar": 52.0, "standard_charge_percentage": 52.0, "count": "0", "additional_payer_notes": "Zero final payments for the item or service in the 15 months prior to posting the file." }, { "payer_name": "BLUE SHIELD OUT OF STATE", "plan_name": "STANFORD HEALTHCARE ALLIANCE PLAN", "methodology": "percent of total billed charges", "standard_charge_dollar": 48.59, "standard_charge_percentage": 48.59, "count": "0", "additional_payer_notes": "Zero final payments for the item or service in the 15 months prior to posting the file." }, { "payer_name": "BLUE SHIELD", "plan_name": "STANFORD HEALTHCARE ALLIANCE PLAN", "methodology": "percent of total billed charges", "standard_charge_dollar": 48.59, "standard_charge_percentage": 48.59, "count": "0", "additional_payer_notes": "Zero final payments for the item or service in the 15 months prior to posting the file." }, { "payer_name": "BLUE SHIELD", "plan_name": "STANFORD HEALTHCARE ALLIANCE PLAN", "methodology": "percent of total billed charges", "standard_charge_dollar": 48.59, "standard_charge_percentage": 48.59, "count": "0", "additional_payer_notes": "Zero final payments for the item or service in the 15 months prior to posting the file." }, { "payer_name": "CIGNA", "plan_name": "CIGNA COM ALT HMO PLAN", "methodology": "percent of total billed charges", "standard_charge_dollar": 42.2, "standard_charge_percentage": 42.2, "count": "0", "additional_payer_notes": "Zero final payments for the item or service in the 15 months prior to posting the file." }, { "payer_name": "CIGNA", "plan_name": "CIGNA COM ALT HMO PLAN", "methodology": "percent of total billed charges", "standard_charge_dollar": 42.2, "standard_charge_percentage": 42.2, "count": "0", "additional_payer_notes": "Zero final payments for the item or service in the 15 months prior to posting the file." }, { "payer_name": "HEALTH NET", "plan_name": "HEALTHNET HMO, PPO, POS, EPO, CANOPY HEALTHNET HMO, OTHER-IN-NETWORK PLANS", "methodology": "per diem", "standard_charge_dollar": 8000.0, "standard_charge_algorithm": "Expected reimbursement is the lesser of Per diem ($8,000) for the length of stay and 70% of billed.", "count": "0", "additional_payer_notes": "Zero final payments for the item or service in the 15 months prior to posting the file." }, { "payer_name": "HEALTH NET", "plan_name": "HEALTHNET HMO, PPO, POS, EPO, CANOPY HEALTHNET HMO, OTHER-IN-NETWORK PLANS", "methodology": "per diem", "standard_charge_dollar": 8000.0, "standard_charge_algorithm": "Expected reimbursement is the lesser of Per diem ($8,000) for the length of stay and 70% of billed.", "count": "0", "additional_payer_notes": "Zero final payments for the item or service in the 15 months prior to posting the file." }, { "payer_name": "UNITED HEALTHCARE", "plan_name": "SUTTER SELECT & SUTTER HEALTH PLAN HMO PLANS", "methodology": "per diem", "standard_charge_dollar": 28538.0, "standard_charge_algorithm": "Per diem ($28,538).", "count": "0", "additional_payer_notes": "Zero final payments for the item or service in the 15 months prior to posting the file." }, { "payer_name": "UNITED HEALTHCARE", "plan_name": "SUTTER SELECT & SUTTER HEALTH PLAN HMO PLANS", "methodology": "per diem", "standard_charge_dollar": 28538.0, "standard_charge_algorithm": "Per diem ($28,538).", "count": "0", "additional_payer_notes": "Zero final payments for the item or service in the 15 months prior to posting the file." }, { "payer_name": "SUTTER", "plan_name": "SUTTER SELECT & SUTTER HEALTH PLAN HMO PLANS", "methodology": "per diem", "standard_charge_dollar": 28538.0, "standard_charge_algorithm": "Per diem ($28,538).", "count": "0", "additional_payer_notes": "Zero final payments for the item or service in the 15 months prior to posting the file." }, { "payer_name": "UNITED HEALTHCARE", "plan_name": "SUTTER SELECT & SUTTER HEALTH PLAN HMO PLANS", "methodology": "per diem", "standard_charge_dollar": 28538.0, "standard_charge_algorithm": "Per diem ($28,538).", "count": "0", "additional_payer_notes": "Zero final payments for the item or service in the 15 months prior to posting the file." }, { "payer_name": "UMR", "plan_name": "SUTTER SELECT & SUTTER HEALTH PLAN HMO PLANS", "methodology": "per diem", "standard_charge_dollar": 28538.0, "standard_charge_algorithm": "Per diem ($28,538).", "count": "0", "additional_payer_notes": "Zero final payments for the item or service in the 15 months prior to posting the file." } ] } ] }, { "description": "HC Bur Oval Gp004", "code_information": [ { "code": "PX-2120019004", "type": "CDM" }, { "code": "99999", "type": "CPT" }, { "code": "0272", "type": "RC" } ], "standard_charges": [ { "setting": "outpatient", "gross_charge": 146.0, "discounted_cash": 73.0, "minimum": 61.61, "maximum": 75.92, "additional_generic_notes": "Zero final payments for the item or service in the 15 months prior to posting the file.", "payers_information": [ { "payer_name": "AETNA", "plan_name": "AETNA ALL OTHER PLANS", "methodology": "percent of total billed charges", "standard_charge_dollar": 75.92, "standard_charge_percentage": 52.0, "count": "0", "additional_payer_notes": "Zero final payments for the item or service in the 15 months prior to posting the file." }, { "payer_name": "AETNA", "plan_name": "AETNA ALL OTHER PLANS", "methodology": "percent of total billed charges", "standard_charge_dollar": 75.92, "standard_charge_percentage": 52.0, "count": "0", "additional_payer_notes": "Zero final payments for the item or service in the 15 months prior to posting the file." }, { "payer_name": "MERITAIN HEALTH", "plan_name": "AETNA ALL OTHER PLANS", "methodology": "percent of total billed charges", "standard_charge_dollar": 75.92, "standard_charge_percentage": 52.0, "count": "0", "additional_payer_notes": "Zero final payments for the item or service in the 15 months prior to posting the file." }, { "payer_name": "BLUE SHIELD OUT OF STATE", "plan_name": "STANFORD HEALTHCARE ALLIANCE PLAN", "methodology": "percent of total billed charges", "standard_charge_dollar": 70.94, "standard_charge_percentage": 48.59, "count": "0", "additional_payer_notes": "Zero final payments for the item or service in the 15 months prior to posting the file." }, { "payer_name": "BLUE SHIELD", "plan_name": "STANFORD HEALTHCARE ALLIANCE PLAN", "methodology": "percent of total billed charges", "standard_charge_dollar": 70.94, "standard_charge_percentage": 48.59, "count": "0", "additional_payer_notes": "Zero final payments for the item or service in the 15 months prior to posting the file." }, { "payer_name": "BLUE SHIELD", "plan_name": "STANFORD HEALTHCARE ALLIANCE PLAN", "methodology": "percent of total billed charges", "standard_charge_dollar": 70.94, "standard_charge_percentage": 48.59, "count": "0", "additional_payer_notes": "Zero final payments for the item or service in the 15 months prior to posting the file." }, { "payer_name": "CIGNA", "plan_name": "CIGNA COM ALT HMO PLAN", "methodology": "percent of total billed charges", "standard_charge_dollar": 61.61, "standard_charge_percentage": 42.2, "count": "0", "additional_payer_notes": "Zero final payments for the item or service in the 15 months prior to posting the file." }, { "payer_name": "CIGNA", "plan_name": "CIGNA COM ALT HMO PLAN", "methodology": "percent of total billed charges", "standard_charge_dollar": 61.61, "standard_charge_percentage": 42.2, "count": "0", "additional_payer_notes": "Zero final payments for the item or service in the 15 months prior to posting the file." }, { "payer_name": "HEALTH NET", "plan_name": "HEALTHNET HMO, PPO, POS, EPO, CANOPY HEALTHNET HMO, OTHER-IN-NETWORK PLANS", "methodology": "per diem", "standard_charge_dollar": 8000.0, "standard_charge_algorithm": "Expected reimbursement is the lesser of Per diem ($8,000) for the length of stay and 70% of billed.", "count": "0", "additional_payer_notes": "Zero final payments for the item or service in the 15 months prior to posting the file." }, { "payer_name": "HEALTH NET", "plan_name": "HEALTHNET HMO, PPO, POS, EPO, CANOPY HEALTHNET HMO, OTHER-IN-NETWORK PLANS", "methodology": "per diem", "standard_charge_dollar": 8000.0, "standard_charge_algorithm": "Expected reimbursement is the lesser of Per diem ($8,000) for the length of stay and 70% of billed.", "count": "0", "additional_payer_notes": "Zero final payments for the item or service in the 15 months prior to posting the file." }, { "payer_name": "UNITED HEALTHCARE", "plan_name": "SUTTER SELECT & SUTTER HEALTH PLAN HMO PLANS", "methodology": "per diem", "standard_charge_dollar": 28538.0, "standard_charge_algorithm": "Per diem ($28,538).", "count": "0", "additional_payer_notes": "Zero final payments for the item or service in the 15 months prior to posting the file." }, { "payer_name": "UNITED HEALTHCARE", "plan_name": "SUTTER SELECT & SUTTER HEALTH PLAN HMO PLANS", "methodology": "per diem", "standard_charge_dollar": 28538.0, "standard_charge_algorithm": "Per diem ($28,538).", "count": "0", "additional_payer_notes": "Zero final payments for the item or service in the 15 months prior to posting the file." }, { "payer_name": "SUTTER", "plan_name": "SUTTER SELECT & SUTTER HEALTH PLAN HMO PLANS", "methodology": "per diem", "standard_charge_dollar": 28538.0, "standard_charge_algorithm": "Per diem ($28,538).", "count": "0", "additional_payer_notes": "Zero final payments for the item or service in the 15 months prior to posting the file." }, { "payer_name": "UNITED HEALTHCARE", "plan_name": "SUTTER SELECT & SUTTER HEALTH PLAN HMO PLANS", "methodology": "per diem", "standard_charge_dollar": 28538.0, "standard_charge_algorithm": "Per diem ($28,538).", "count": "0", "additional_payer_notes": "Zero final payments for the item or service in the 15 months prior to posting the file." }, { "payer_name": "UMR", "plan_name": "SUTTER SELECT & SUTTER HEALTH PLAN HMO PLANS", "methodology": "per diem", "standard_charge_dollar": 28538.0, "standard_charge_algorithm": "Per diem ($28,538).", "count": "0", "additional_payer_notes": "Zero final payments for the item or service in the 15 months prior to posting the file." } ] } ] }, { "description": "HC Bur Oval Gp007", "code_information": [ { "code": "PX-2120019007", "type": "CDM" }, { "code": "99999", "type": "CPT" }, { "code": "0272", "type": "RC" } ], "standard_charges": [ { "setting": "outpatient", "gross_charge": 380.0, "discounted_cash": 190.0, "minimum": 160.36, "maximum": 197.6, "additional_generic_notes": "Zero final payments for the item or service in the 15 months prior to posting the file.", "payers_information": [ { "payer_name": "AETNA", "plan_name": "AETNA ALL OTHER PLANS", "methodology": "percent of total billed charges", "standard_charge_dollar": 197.6, "standard_charge_percentage": 52.0, "count": "0", "additional_payer_notes": "Zero final payments for the item or service in the 15 months prior to posting the file." }, { "payer_name": "AETNA", "plan_name": "AETNA ALL OTHER PLANS", "methodology": "percent of total billed charges", "standard_charge_dollar": 197.6, "standard_charge_percentage": 52.0, "count": "0", "additional_payer_notes": "Zero final payments for the item or service in the 15 months prior to posting the file." }, { "payer_name": "MERITAIN HEALTH", "plan_name": "AETNA ALL OTHER PLANS", "methodology": "percent of total billed charges", "standard_charge_dollar": 197.6, "standard_charge_percentage": 52.0, "count": "0", "additional_payer_notes": "Zero final payments for the item or service in the 15 months prior to posting the file." }, { "payer_name": "BLUE SHIELD OUT OF STATE", "plan_name": "STANFORD HEALTHCARE ALLIANCE PLAN", "methodology": "percent of total billed charges", "standard_charge_dollar": 184.64, "standard_charge_percentage": 48.59, "count": "0", "additional_payer_notes": "Zero final payments for the item or service in the 15 months prior to posting the file." }, { "payer_name": "BLUE SHIELD", "plan_name": "STANFORD HEALTHCARE ALLIANCE PLAN", "methodology": "percent of total billed charges", "standard_charge_dollar": 184.64, "standard_charge_percentage": 48.59, "count": "0", "additional_payer_notes": "Zero final payments for the item or service in the 15 months prior to posting the file." }, { "payer_name": "BLUE SHIELD", "plan_name": "STANFORD HEALTHCARE ALLIANCE PLAN", "methodology": "percent of total billed charges", "standard_charge_dollar": 184.64, "standard_charge_percentage": 48.59, "count": "0", "additional_payer_notes": "Zero final payments for the item or service in the 15 months prior to posting the file." }, { "payer_name": "CIGNA", "plan_name": "CIGNA COM ALT HMO PLAN", "methodology": "percent of total billed charges", "standard_charge_dollar": 160.36, "standard_charge_percentage": 42.2, "count": "0", "additional_payer_notes": "Zero final payments for the item or service in the 15 months prior to posting the file." }, { "payer_name": "CIGNA", "plan_name": "CIGNA COM ALT HMO PLAN", "methodology": "percent of total billed charges", "standard_charge_dollar": 160.36, "standard_charge_percentage": 42.2, "count": "0", "additional_payer_notes": "Zero final payments for the item or service in the 15 months prior to posting the file." }, { "payer_name": "HEALTH NET", "plan_name": "HEALTHNET HMO, PPO, POS, EPO, CANOPY HEALTHNET HMO, OTHER-IN-NETWORK PLANS", "methodology": "per diem", "standard_charge_dollar": 8000.0, "standard_charge_algorithm": "Expected reimbursement is the lesser of Per diem ($8,000) for the length of stay and 70% of billed.", "count": "0", "additional_payer_notes": "Zero final payments for the item or service in the 15 months prior to posting the file." }, { "payer_name": "HEALTH NET", "plan_name": "HEALTHNET HMO, PPO, POS, EPO, CANOPY HEALTHNET HMO, OTHER-IN-NETWORK PLANS", "methodology": "per diem", "standard_charge_dollar": 8000.0, "standard_charge_algorithm": "Expected reimbursement is the lesser of Per diem ($8,000) for the length of stay and 70% of billed.", "count": "0", "additional_payer_notes": "Zero final payments for the item or service in the 15 months prior to posting the file." }, { "payer_name": "UNITED HEALTHCARE", "plan_name": "SUTTER SELECT & SUTTER HEALTH PLAN HMO PLANS", "methodology": "per diem", "standard_charge_dollar": 28538.0, "standard_charge_algorithm": "Per diem ($28,538).", "count": "0", "additional_payer_notes": "Zero final payments for the item or service in the 15 months prior to posting the file." }, { "payer_name": "UNITED HEALTHCARE", "plan_name": "SUTTER SELECT & SUTTER HEALTH PLAN HMO PLANS", "methodology": "per diem", "standard_charge_dollar": 28538.0, "standard_charge_algorithm": "Per diem ($28,538).", "count": "0", "additional_payer_notes": "Zero final payments for the item or service in the 15 months prior to posting the file." }, { "payer_name": "SUTTER", "plan_name": "SUTTER SELECT & SUTTER HEALTH PLAN HMO PLANS", "methodology": "per diem", "standard_charge_dollar": 28538.0, "standard_charge_algorithm": "Per diem ($28,538).", "count": "0", "additional_payer_notes": "Zero final payments for the item or service in the 15 months prior to posting the file." }, { "payer_name": "UNITED HEALTHCARE", "plan_name": "SUTTER SELECT & SUTTER HEALTH PLAN HMO PLANS", "methodology": "per diem", "standard_charge_dollar": 28538.0, "standard_charge_algorithm": "Per diem ($28,538).", "count": "0", "additional_payer_notes": "Zero final payments for the item or service in the 15 months prior to posting the file." }, { "payer_name": "UMR", "plan_name": "SUTTER SELECT & SUTTER HEALTH PLAN HMO PLANS", "methodology": "per diem", "standard_charge_dollar": 28538.0, "standard_charge_algorithm": "Per diem ($28,538).", "count": "0", "additional_payer_notes": "Zero final payments for the item or service in the 15 months prior to posting the file." } ] } ] }, { "description": "HC Bur Oval Gp008", "code_information": [ { "code": "PX-2120019008", "type": "CDM" }, { "code": "99999", "type": "CPT" }, { "code": "0272", "type": "RC" } ], "standard_charges": [ { "setting": "outpatient", "gross_charge": 475.0, "discounted_cash": 237.5, "minimum": 200.45, "maximum": 247.0, "additional_generic_notes": "Zero final payments for the item or service in the 15 months prior to posting the file.", "payers_information": [ { "payer_name": "AETNA", "plan_name": "AETNA ALL OTHER PLANS", "methodology": "percent of total billed charges", "standard_charge_dollar": 247.0, "standard_charge_percentage": 52.0, "count": "0", "additional_payer_notes": "Zero final payments for the item or service in the 15 months prior to posting the file." }, { "payer_name": "AETNA", "plan_name": "AETNA ALL OTHER PLANS", "methodology": "percent of total billed charges", "standard_charge_dollar": 247.0, "standard_charge_percentage": 52.0, "count": "0", "additional_payer_notes": "Zero final payments for the item or service in the 15 months prior to posting the file." }, { "payer_name": "MERITAIN HEALTH", "plan_name": "AETNA ALL OTHER PLANS", "methodology": "percent of total billed charges", "standard_charge_dollar": 247.0, "standard_charge_percentage": 52.0, "count": "0", "additional_payer_notes": "Zero final payments for the item or service in the 15 months prior to posting the file." }, { "payer_name": "BLUE SHIELD OUT OF STATE", "plan_name": "STANFORD HEALTHCARE ALLIANCE PLAN", "methodology": "percent of total billed charges", "standard_charge_dollar": 230.8, "standard_charge_percentage": 48.59, "count": "0", "additional_payer_notes": "Zero final payments for the item or service in the 15 months prior to posting the file." }, { "payer_name": "BLUE SHIELD", "plan_name": "STANFORD HEALTHCARE ALLIANCE PLAN", "methodology": "percent of total billed charges", "standard_charge_dollar": 230.8, "standard_charge_percentage": 48.59, "count": "0", "additional_payer_notes": "Zero final payments for the item or service in the 15 months prior to posting the file." }, { "payer_name": "BLUE SHIELD", "plan_name": "STANFORD HEALTHCARE ALLIANCE PLAN", "methodology": "percent of total billed charges", "standard_charge_dollar": 230.8, "standard_charge_percentage": 48.59, "count": "0", "additional_payer_notes": "Zero final payments for the item or service in the 15 months prior to posting the file." }, { "payer_name": "CIGNA", "plan_name": "CIGNA COM ALT HMO PLAN", "methodology": "percent of total billed charges", "standard_charge_dollar": 200.45, "standard_charge_percentage": 42.2, "count": "0", "additional_payer_notes": "Zero final payments for the item or service in the 15 months prior to posting the file." }, { "payer_name": "CIGNA", "plan_name": "CIGNA COM ALT HMO PLAN", "methodology": "percent of total billed charges", "standard_charge_dollar": 200.45, "standard_charge_percentage": 42.2, "count": "0", "additional_payer_notes": "Zero final payments for the item or service in the 15 months prior to posting the file." }, { "payer_name": "HEALTH NET", "plan_name": "HEALTHNET HMO, PPO, POS, EPO, CANOPY HEALTHNET HMO, OTHER-IN-NETWORK PLANS", "methodology": "per diem", "standard_charge_dollar": 8000.0, "standard_charge_algorithm": "Expected reimbursement is the lesser of Per diem ($8,000) for the length of stay and 70% of billed.", "count": "0", "additional_payer_notes": "Zero final payments for the item or service in the 15 months prior to posting the file." }, { "payer_name": "HEALTH NET", "plan_name": "HEALTHNET HMO, PPO, POS, EPO, CANOPY HEALTHNET HMO, OTHER-IN-NETWORK PLANS", "methodology": "per diem", "standard_charge_dollar": 8000.0, "standard_charge_algorithm": "Expected reimbursement is the lesser of Per diem ($8,000) for the length of stay and 70% of billed.", "count": "0", "additional_payer_notes": "Zero final payments for the item or service in the 15 months prior to posting the file." }, { "payer_name": "UNITED HEALTHCARE", "plan_name": "SUTTER SELECT & SUTTER HEALTH PLAN HMO PLANS", "methodology": "per diem", "standard_charge_dollar": 28538.0, "standard_charge_algorithm": "Per diem ($28,538).", "count": "0", "additional_payer_notes": "Zero final payments for the item or service in the 15 months prior to posting the file." }, { "payer_name": "UNITED HEALTHCARE", "plan_name": "SUTTER SELECT & SUTTER HEALTH PLAN HMO PLANS", "methodology": "per diem", "standard_charge_dollar": 28538.0, "standard_charge_algorithm": "Per diem ($28,538).", "count": "0", "additional_payer_notes": "Zero final payments for the item or service in the 15 months prior to posting the file." }, { "payer_name": "SUTTER", "plan_name": "SUTTER SELECT & SUTTER HEALTH PLAN HMO PLANS", "methodology": "per diem", "standard_charge_dollar": 28538.0, "standard_charge_algorithm": "Per diem ($28,538).", "count": "0", "additional_payer_notes": "Zero final payments for the item or service in the 15 months prior to posting the file." }, { "payer_name": "UNITED HEALTHCARE", "plan_name": "SUTTER SELECT & SUTTER HEALTH PLAN HMO PLANS", "methodology": "per diem", "standard_charge_dollar": 28538.0, "standard_charge_algorithm": "Per diem ($28,538).", "count": "0", "additional_payer_notes": "Zero final payments for the item or service in the 15 months prior to posting the file." }, { "payer_name": "UMR", "plan_name": "SUTTER SELECT & SUTTER HEALTH PLAN HMO PLANS", "methodology": "per diem", "standard_charge_dollar": 28538.0, "standard_charge_algorithm": "Per diem ($28,538).", "count": "0", "additional_payer_notes": "Zero final payments for the item or service in the 15 months prior to posting the file." } ] } ] }, { "description": "HC Bur Oval Gp009", "code_information": [ { "code": "PX-2120019009", "type": "CDM" }, { "code": "99999", "type": "CPT" }, { "code": "0272", "type": "RC" } ], "standard_charges": [ { "setting": "outpatient", "gross_charge": 570.0, "discounted_cash": 285.0, "minimum": 240.54, "maximum": 296.4, "additional_generic_notes": "Zero final payments for the item or service in the 15 months prior to posting the file.", "payers_information": [ { "payer_name": "AETNA", "plan_name": "AETNA ALL OTHER PLANS", "methodology": "percent of total billed charges", "standard_charge_dollar": 296.4, "standard_charge_percentage": 52.0, "count": "0", "additional_payer_notes": "Zero final payments for the item or service in the 15 months prior to posting the file." }, { "payer_name": "AETNA", "plan_name": "AETNA ALL OTHER PLANS", "methodology": "percent of total billed charges", "standard_charge_dollar": 296.4, "standard_charge_percentage": 52.0, "count": "0", "additional_payer_notes": "Zero final payments for the item or service in the 15 months prior to posting the file." }, { "payer_name": "MERITAIN HEALTH", "plan_name": "AETNA ALL OTHER PLANS", "methodology": "percent of total billed charges", "standard_charge_dollar": 296.4, "standard_charge_percentage": 52.0, "count": "0", "additional_payer_notes": "Zero final payments for the item or service in the 15 months prior to posting the file." }, { "payer_name": "BLUE SHIELD OUT OF STATE", "plan_name": "STANFORD HEALTHCARE ALLIANCE PLAN", "methodology": "percent of total billed charges", "standard_charge_dollar": 276.96, "standard_charge_percentage": 48.59, "count": "0", "additional_payer_notes": "Zero final payments for the item or service in the 15 months prior to posting the file." }, { "payer_name": "BLUE SHIELD", "plan_name": "STANFORD HEALTHCARE ALLIANCE PLAN", "methodology": "percent of total billed charges", "standard_charge_dollar": 276.96, "standard_charge_percentage": 48.59, "count": "0", "additional_payer_notes": "Zero final payments for the item or service in the 15 months prior to posting the file." }, { "payer_name": "BLUE SHIELD", "plan_name": "STANFORD HEALTHCARE ALLIANCE PLAN", "methodology": "percent of total billed charges", "standard_charge_dollar": 276.96, "standard_charge_percentage": 48.59, "count": "0", "additional_payer_notes": "Zero final payments for the item or service in the 15 months prior to posting the file." }, { "payer_name": "CIGNA", "plan_name": "CIGNA COM ALT HMO PLAN", "methodology": "percent of total billed charges", "standard_charge_dollar": 240.54, "standard_charge_percentage": 42.2, "count": "0", "additional_payer_notes": "Zero final payments for the item or service in the 15 months prior to posting the file." }, { "payer_name": "CIGNA", "plan_name": "CIGNA COM ALT HMO PLAN", "methodology": "percent of total billed charges", "standard_charge_dollar": 240.54, "standard_charge_percentage": 42.2, "count": "0", "additional_payer_notes": "Zero final payments for the item or service in the 15 months prior to posting the file." }, { "payer_name": "HEALTH NET", "plan_name": "HEALTHNET HMO, PPO, POS, EPO, CANOPY HEALTHNET HMO, OTHER-IN-NETWORK PLANS", "methodology": "per diem", "standard_charge_dollar": 8000.0, "standard_charge_algorithm": "Expected reimbursement is the lesser of Per diem ($8,000) for the length of stay and 70% of billed.", "count": "0", "additional_payer_notes": "Zero final payments for the item or service in the 15 months prior to posting the file." }, { "payer_name": "HEALTH NET", "plan_name": "HEALTHNET HMO, PPO, POS, EPO, CANOPY HEALTHNET HMO, OTHER-IN-NETWORK PLANS", "methodology": "per diem", "standard_charge_dollar": 8000.0, "standard_charge_algorithm": "Expected reimbursement is the lesser of Per diem ($8,000) for the length of stay and 70% of billed.", "count": "0", "additional_payer_notes": "Zero final payments for the item or service in the 15 months prior to posting the file." }, { "payer_name": "UNITED HEALTHCARE", "plan_name": "SUTTER SELECT & SUTTER HEALTH PLAN HMO PLANS", "methodology": "per diem", "standard_charge_dollar": 28538.0, "standard_charge_algorithm": "Per diem ($28,538).", "count": "0", "additional_payer_notes": "Zero final payments for the item or service in the 15 months prior to posting the file." }, { "payer_name": "UNITED HEALTHCARE", "plan_name": "SUTTER SELECT & SUTTER HEALTH PLAN HMO PLANS", "methodology": "per diem", "standard_charge_dollar": 28538.0, "standard_charge_algorithm": "Per diem ($28,538).", "count": "0", "additional_payer_notes": "Zero final payments for the item or service in the 15 months prior to posting the file." }, { "payer_name": "SUTTER", "plan_name": "SUTTER SELECT & SUTTER HEALTH PLAN HMO PLANS", "methodology": "per diem", "standard_charge_dollar": 28538.0, "standard_charge_algorithm": "Per diem ($28,538).", "count": "0", "additional_payer_notes": "Zero final payments for the item or service in the 15 months prior to posting the file." }, { "payer_name": "UNITED HEALTHCARE", "plan_name": "SUTTER SELECT & SUTTER HEALTH PLAN HMO PLANS", "methodology": "per diem", "standard_charge_dollar": 28538.0, "standard_charge_algorithm": "Per diem ($28,538).", "count": "0", "additional_payer_notes": "Zero final payments for the item or service in the 15 months prior to posting the file." }, { "payer_name": "UMR", "plan_name": "SUTTER SELECT & SUTTER HEALTH PLAN HMO PLANS", "methodology": "per diem", "standard_charge_dollar": 28538.0, "standard_charge_algorithm": "Per diem ($28,538).", "count": "0", "additional_payer_notes": "Zero final payments for the item or service in the 15 months prior to posting the file." } ] } ] }, { "description": "Hc Bur Oval Gp010", "code_information": [ { "code": "PX-2120019010", "type": "CDM" }, { "code": "99999", "type": "CPT" }, { "code": "0272", "type": "RC" } ], "standard_charges": [ { "setting": "outpatient", "gross_charge": 665.0, "discounted_cash": 332.5, "minimum": 280.63, "maximum": 345.8, "additional_generic_notes": "Zero final payments for the item or service in the 15 months prior to posting the file.", "payers_information": [ { "payer_name": "AETNA", "plan_name": "AETNA ALL OTHER PLANS", "methodology": "percent of total billed charges", "standard_charge_dollar": 345.8, "standard_charge_percentage": 52.0, "count": "0", "additional_payer_notes": "Zero final payments for the item or service in the 15 months prior to posting the file." }, { "payer_name": "AETNA", "plan_name": "AETNA ALL OTHER PLANS", "methodology": "percent of total billed charges", "standard_charge_dollar": 345.8, "standard_charge_percentage": 52.0, "count": "0", "additional_payer_notes": "Zero final payments for the item or service in the 15 months prior to posting the file." }, { "payer_name": "MERITAIN HEALTH", "plan_name": "AETNA ALL OTHER PLANS", "methodology": "percent of total billed charges", "standard_charge_dollar": 345.8, "standard_charge_percentage": 52.0, "count": "0", "additional_payer_notes": "Zero final payments for the item or service in the 15 months prior to posting the file." }, { "payer_name": "BLUE SHIELD OUT OF STATE", "plan_name": "STANFORD HEALTHCARE ALLIANCE PLAN", "methodology": "percent of total billed charges", "standard_charge_dollar": 323.12, "standard_charge_percentage": 48.59, "count": "0", "additional_payer_notes": "Zero final payments for the item or service in the 15 months prior to posting the file." }, { "payer_name": "BLUE SHIELD", "plan_name": "STANFORD HEALTHCARE ALLIANCE PLAN", "methodology": "percent of total billed charges", "standard_charge_dollar": 323.12, "standard_charge_percentage": 48.59, "count": "0", "additional_payer_notes": "Zero final payments for the item or service in the 15 months prior to posting the file." }, { "payer_name": "BLUE SHIELD", "plan_name": "STANFORD HEALTHCARE ALLIANCE PLAN", "methodology": "percent of total billed charges", "standard_charge_dollar": 323.12, "standard_charge_percentage": 48.59, "count": "0", "additional_payer_notes": "Zero final payments for the item or service in the 15 months prior to posting the file." }, { "payer_name": "CIGNA", "plan_name": "CIGNA COM ALT HMO PLAN", "methodology": "percent of total billed charges", "standard_charge_dollar": 280.63, "standard_charge_percentage": 42.2, "count": "0", "additional_payer_notes": "Zero final payments for the item or service in the 15 months prior to posting the file." }, { "payer_name": "CIGNA", "plan_name": "CIGNA COM ALT HMO PLAN", "methodology": "percent of total billed charges", "standard_charge_dollar": 280.63, "standard_charge_percentage": 42.2, "count": "0", "additional_payer_notes": "Zero final payments for the item or service in the 15 months prior to posting the file." }, { "payer_name": "HEALTH NET", "plan_name": "HEALTHNET HMO, PPO, POS, EPO, CANOPY HEALTHNET HMO, OTHER-IN-NETWORK PLANS", "methodology": "per diem", "standard_charge_dollar": 8000.0, "standard_charge_algorithm": "Expected reimbursement is the lesser of Per diem ($8,000) for the length of stay and 70% of billed.", "count": "0", "additional_payer_notes": "Zero final payments for the item or service in the 15 months prior to posting the file." }, { "payer_name": "HEALTH NET", "plan_name": "HEALTHNET HMO, PPO, POS, EPO, CANOPY HEALTHNET HMO, OTHER-IN-NETWORK PLANS", "methodology": "per diem", "standard_charge_dollar": 8000.0, "standard_charge_algorithm": "Expected reimbursement is the lesser of Per diem ($8,000) for the length of stay and 70% of billed.", "count": "0", "additional_payer_notes": "Zero final payments for the item or service in the 15 months prior to posting the file." }, { "payer_name": "UNITED HEALTHCARE", "plan_name": "SUTTER SELECT & SUTTER HEALTH PLAN HMO PLANS", "methodology": "per diem", "standard_charge_dollar": 28538.0, "standard_charge_algorithm": "Per diem ($28,538).", "count": "0", "additional_payer_notes": "Zero final payments for the item or service in the 15 months prior to posting the file." }, { "payer_name": "UNITED HEALTHCARE", "plan_name": "SUTTER SELECT & SUTTER HEALTH PLAN HMO PLANS", "methodology": "per diem", "standard_charge_dollar": 28538.0, "standard_charge_algorithm": "Per diem ($28,538).", "count": "0", "additional_payer_notes": "Zero final payments for the item or service in the 15 months prior to posting the file." }, { "payer_name": "SUTTER", "plan_name": "SUTTER SELECT & SUTTER HEALTH PLAN HMO PLANS", "methodology": "per diem", "standard_charge_dollar": 28538.0, "standard_charge_algorithm": "Per diem ($28,538).", "count": "0", "additional_payer_notes": "Zero final payments for the item or service in the 15 months prior to posting the file." }, { "payer_name": "UNITED HEALTHCARE", "plan_name": "SUTTER SELECT & SUTTER HEALTH PLAN HMO PLANS", "methodology": "per diem", "standard_charge_dollar": 28538.0, "standard_charge_algorithm": "Per diem ($28,538).", "count": "0", "additional_payer_notes": "Zero final payments for the item or service in the 15 months prior to posting the file." }, { "payer_name": "UMR", "plan_name": "SUTTER SELECT & SUTTER HEALTH PLAN HMO PLANS", "methodology": "per diem", "standard_charge_dollar": 28538.0, "standard_charge_algorithm": "Per diem ($28,538).", "count": "0", "additional_payer_notes": "Zero final payments for the item or service in the 15 months prior to posting the file." } ] } ] }, { "description": "HC Bur Oval Gp016", "code_information": [ { "code": "PX-2120019016", "type": "CDM" }, { "code": "99999", "type": "CPT" }, { "code": "0272", "type": "RC" } ], "standard_charges": [ { "setting": "outpatient", "gross_charge": 1400.0, "discounted_cash": 700.0, "minimum": 590.8, "maximum": 728.0, "additional_generic_notes": "Zero final payments for the item or service in the 15 months prior to posting the file.", "payers_information": [ { "payer_name": "AETNA", "plan_name": "AETNA ALL OTHER PLANS", "methodology": "percent of total billed charges", "standard_charge_dollar": 728.0, "standard_charge_percentage": 52.0, "count": "0", "additional_payer_notes": "Zero final payments for the item or service in the 15 months prior to posting the file." }, { "payer_name": "AETNA", "plan_name": "AETNA ALL OTHER PLANS", "methodology": "percent of total billed charges", "standard_charge_dollar": 728.0, "standard_charge_percentage": 52.0, "count": "0", "additional_payer_notes": "Zero final payments for the item or service in the 15 months prior to posting the file." }, { "payer_name": "MERITAIN HEALTH", "plan_name": "AETNA ALL OTHER PLANS", "methodology": "percent of total billed charges", "standard_charge_dollar": 728.0, "standard_charge_percentage": 52.0, "count": "0", "additional_payer_notes": "Zero final payments for the item or service in the 15 months prior to posting the file." }, { "payer_name": "BLUE SHIELD OUT OF STATE", "plan_name": "STANFORD HEALTHCARE ALLIANCE PLAN", "methodology": "percent of total billed charges", "standard_charge_dollar": 680.26, "standard_charge_percentage": 48.59, "count": "0", "additional_payer_notes": "Zero final payments for the item or service in the 15 months prior to posting the file." }, { "payer_name": "BLUE SHIELD", "plan_name": "STANFORD HEALTHCARE ALLIANCE PLAN", "methodology": "percent of total billed charges", "standard_charge_dollar": 680.26, "standard_charge_percentage": 48.59, "median_amount": 68.24, "10th_percentile": 13.6, "90th_percentile": 1043.06, "count": "30" }, { "payer_name": "BLUE SHIELD", "plan_name": "STANFORD HEALTHCARE ALLIANCE PLAN", "methodology": "percent of total billed charges", "standard_charge_dollar": 680.26, "standard_charge_percentage": 48.59, "count": "0", "additional_payer_notes": "Zero final payments for the item or service in the 15 months prior to posting the file." }, { "payer_name": "BLUE SHIELD", "plan_name": "STANFORD HEALTHCARE ALLIANCE PLAN", "methodology": "percent of total billed charges", "standard_charge_dollar": 680.26, "standard_charge_percentage": 48.59, "count": "0", "additional_payer_notes": "Zero final payments for the item or service in the 15 months prior to posting the file." }, { "payer_name": "CIGNA", "plan_name": "CIGNA COM ALT HMO PLAN", "methodology": "percent of total billed charges", "standard_charge_dollar": 590.8, "standard_charge_percentage": 42.2, "count": "0", "additional_payer_notes": "Zero final payments for the item or service in the 15 months prior to posting the file." }, { "payer_name": "CIGNA", "plan_name": "CIGNA COM ALT HMO PLAN", "methodology": "percent of total billed charges", "standard_charge_dollar": 590.8, "standard_charge_percentage": 42.2, "count": "0", "additional_payer_notes": "Zero final payments for the item or service in the 15 months prior to posting the file." }, { "payer_name": "HEALTH NET", "plan_name": "HEALTHNET HMO, PPO, POS, EPO, CANOPY HEALTHNET HMO, OTHER-IN-NETWORK PLANS", "methodology": "per diem", "standard_charge_dollar": 8000.0, "standard_charge_algorithm": "Expected reimbursement is the lesser of Per diem ($8,000) for the length of stay and 70% of billed.", "count": "0", "additional_payer_notes": "Zero final payments for the item or service in the 15 months prior to posting the file." }, { "payer_name": "HEALTH NET", "plan_name": "HEALTHNET HMO, PPO, POS, EPO, CANOPY HEALTHNET HMO, OTHER-IN-NETWORK PLANS", "methodology": "per diem", "standard_charge_dollar": 8000.0, "standard_charge_algorithm": "Expected reimbursement is the lesser of Per diem ($8,000) for the length of stay and 70% of billed.", "count": "0", "additional_payer_notes": "Zero final payments for the item or service in the 15 months prior to posting the file." }, { "payer_name": "UNITED HEALTHCARE", "plan_name": "SUTTER SELECT & SUTTER HEALTH PLAN HMO PLANS", "methodology": "per diem", "standard_charge_dollar": 28538.0, "standard_charge_algorithm": "Per diem ($28,538).", "count": "0", "additional_payer_notes": "Zero final payments for the item or service in the 15 months prior to posting the file." }, { "payer_name": "UNITED HEALTHCARE", "plan_name": "SUTTER SELECT & SUTTER HEALTH PLAN HMO PLANS", "methodology": "per diem", "standard_charge_dollar": 28538.0, "standard_charge_algorithm": "Per diem ($28,538).", "count": "0", "additional_payer_notes": "Zero final payments for the item or service in the 15 months prior to posting the file." }, { "payer_name": "SUTTER", "plan_name": "SUTTER SELECT & SUTTER HEALTH PLAN HMO PLANS", "methodology": "per diem", "standard_charge_dollar": 28538.0, "standard_charge_algorithm": "Per diem ($28,538).", "count": "0", "additional_payer_notes": "Zero final payments for the item or service in the 15 months prior to posting the file." }, { "payer_name": "UNITED HEALTHCARE", "plan_name": "SUTTER SELECT & SUTTER HEALTH PLAN HMO PLANS", "methodology": "per diem", "standard_charge_dollar": 28538.0, "standard_charge_algorithm": "Per diem ($28,538).", "count": "0", "additional_payer_notes": "Zero final payments for the item or service in the 15 months prior to posting the file." }, { "payer_name": "UMR", "plan_name": "SUTTER SELECT & SUTTER HEALTH PLAN HMO PLANS", "methodology": "per diem", "standard_charge_dollar": 28538.0, "standard_charge_algorithm": "Per diem ($28,538).", "count": "0", "additional_payer_notes": "Zero final payments for the item or service in the 15 months prior to posting the file." } ] } ] }, { "description": "HC Bur Oval Gp018", "code_information": [ { "code": "PX-2120019018", "type": "CDM" }, { "code": "99999", "type": "CPT" }, { "code": "0272", "type": "RC" } ], "standard_charges": [ { "setting": "outpatient", "gross_charge": 1750.0, "discounted_cash": 875.0, "minimum": 738.5, "maximum": 910.0, "additional_generic_notes": "Zero final payments for the item or service in the 15 months prior to posting the file.", "payers_information": [ { "payer_name": "AETNA", "plan_name": "AETNA ALL OTHER PLANS", "methodology": "percent of total billed charges", "standard_charge_dollar": 910.0, "standard_charge_percentage": 52.0, "count": "0", "additional_payer_notes": "Zero final payments for the item or service in the 15 months prior to posting the file." }, { "payer_name": "AETNA", "plan_name": "AETNA ALL OTHER PLANS", "methodology": "percent of total billed charges", "standard_charge_dollar": 910.0, "standard_charge_percentage": 52.0, "count": "0", "additional_payer_notes": "Zero final payments for the item or service in the 15 months prior to posting the file." }, { "payer_name": "MERITAIN HEALTH", "plan_name": "AETNA ALL OTHER PLANS", "methodology": "percent of total billed charges", "standard_charge_dollar": 910.0, "standard_charge_percentage": 52.0, "count": "0", "additional_payer_notes": "Zero final payments for the item or service in the 15 months prior to posting the file." }, { "payer_name": "BLUE SHIELD OUT OF STATE", "plan_name": "STANFORD HEALTHCARE ALLIANCE PLAN", "methodology": "percent of total billed charges", "standard_charge_dollar": 850.33, "standard_charge_percentage": 48.59, "count": "0", "additional_payer_notes": "Zero final payments for the item or service in the 15 months prior to posting the file." }, { "payer_name": "BLUE SHIELD", "plan_name": "STANFORD HEALTHCARE ALLIANCE PLAN", "methodology": "percent of total billed charges", "standard_charge_dollar": 850.33, "standard_charge_percentage": 48.59, "median_amount": 68.24, "10th_percentile": 13.6, "90th_percentile": 1043.06, "count": "30" }, { "payer_name": "BLUE SHIELD", "plan_name": "STANFORD HEALTHCARE ALLIANCE PLAN", "methodology": "percent of total billed charges", "standard_charge_dollar": 850.33, "standard_charge_percentage": 48.59, "count": "0", "additional_payer_notes": "Zero final payments for the item or service in the 15 months prior to posting the file." }, { "payer_name": "BLUE SHIELD", "plan_name": "STANFORD HEALTHCARE ALLIANCE PLAN", "methodology": "percent of total billed charges", "standard_charge_dollar": 850.33, "standard_charge_percentage": 48.59, "count": "0", "additional_payer_notes": "Zero final payments for the item or service in the 15 months prior to posting the file." }, { "payer_name": "CIGNA", "plan_name": "CIGNA COM ALT HMO PLAN", "methodology": "percent of total billed charges", "standard_charge_dollar": 738.5, "standard_charge_percentage": 42.2, "count": "0", "additional_payer_notes": "Zero final payments for the item or service in the 15 months prior to posting the file." }, { "payer_name": "CIGNA", "plan_name": "CIGNA COM ALT HMO PLAN", "methodology": "percent of total billed charges", "standard_charge_dollar": 738.5, "standard_charge_percentage": 42.2, "count": "0", "additional_payer_notes": "Zero final payments for the item or service in the 15 months prior to posting the file." }, { "payer_name": "HEALTH NET", "plan_name": "HEALTHNET HMO, PPO, POS, EPO, CANOPY HEALTHNET HMO, OTHER-IN-NETWORK PLANS", "methodology": "per diem", "standard_charge_dollar": 8000.0, "standard_charge_algorithm": "Expected reimbursement is the lesser of Per diem ($8,000) for the length of stay and 70% of billed.", "count": "0", "additional_payer_notes": "Zero final payments for the item or service in the 15 months prior to posting the file." }, { "payer_name": "HEALTH NET", "plan_name": "HEALTHNET HMO, PPO, POS, EPO, CANOPY HEALTHNET HMO, OTHER-IN-NETWORK PLANS", "methodology": "per diem", "standard_charge_dollar": 8000.0, "standard_charge_algorithm": "Expected reimbursement is the lesser of Per diem ($8,000) for the length of stay and 70% of billed.", "count": "0", "additional_payer_notes": "Zero final payments for the item or service in the 15 months prior to posting the file." }, { "payer_name": "UNITED HEALTHCARE", "plan_name": "SUTTER SELECT & SUTTER HEALTH PLAN HMO PLANS", "methodology": "per diem", "standard_charge_dollar": 28538.0, "standard_charge_algorithm": "Per diem ($28,538).", "count": "0", "additional_payer_notes": "Zero final payments for the item or service in the 15 months prior to posting the file." }, { "payer_name": "UNITED HEALTHCARE", "plan_name": "SUTTER SELECT & SUTTER HEALTH PLAN HMO PLANS", "methodology": "per diem", "standard_charge_dollar": 28538.0, "standard_charge_algorithm": "Per diem ($28,538).", "count": "0", "additional_payer_notes": "Zero final payments for the item or service in the 15 months prior to posting the file." }, { "payer_name": "SUTTER", "plan_name": "SUTTER SELECT & SUTTER HEALTH PLAN HMO PLANS", "methodology": "per diem", "standard_charge_dollar": 28538.0, "standard_charge_algorithm": "Per diem ($28,538).", "count": "0", "additional_payer_notes": "Zero final payments for the item or service in the 15 months prior to posting the file." }, { "payer_name": "UNITED HEALTHCARE", "plan_name": "SUTTER SELECT & SUTTER HEALTH PLAN HMO PLANS", "methodology": "per diem", "standard_charge_dollar": 28538.0, "standard_charge_algorithm": "Per diem ($28,538).", "count": "0", "additional_payer_notes": "Zero final payments for the item or service in the 15 months prior to posting the file." }, { "payer_name": "UMR", "plan_name": "SUTTER SELECT & SUTTER HEALTH PLAN HMO PLANS", "methodology": "per diem", "standard_charge_dollar": 28538.0, "standard_charge_algorithm": "Per diem ($28,538).", "count": "0", "additional_payer_notes": "Zero final payments for the item or service in the 15 months prior to posting the file." } ] } ] }, { "description": "HC Bur Round Gp002", "code_information": [ { "code": "PX-2120020002", "type": "CDM" }, { "code": "99999", "type": "CPT" }, { "code": "0272", "type": "RC" } ], "standard_charges": [ { "setting": "outpatient", "gross_charge": 50.0, "discounted_cash": 25.0, "minimum": 21.1, "maximum": 26.0, "additional_generic_notes": "Zero final payments for the item or service in the 15 months prior to posting the file.", "payers_information": [ { "payer_name": "AETNA", "plan_name": "AETNA ALL OTHER PLANS", "methodology": "percent of total billed charges", "standard_charge_dollar": 26.0, "standard_charge_percentage": 52.0, "count": "0", "additional_payer_notes": "Zero final payments for the item or service in the 15 months prior to posting the file." }, { "payer_name": "AETNA", "plan_name": "AETNA ALL OTHER PLANS", "methodology": "percent of total billed charges", "standard_charge_dollar": 26.0, "standard_charge_percentage": 52.0, "count": "0", "additional_payer_notes": "Zero final payments for the item or service in the 15 months prior to posting the file." }, { "payer_name": "MERITAIN HEALTH", "plan_name": "AETNA ALL OTHER PLANS", "methodology": "percent of total billed charges", "standard_charge_dollar": 26.0, "standard_charge_percentage": 52.0, "count": "0", "additional_payer_notes": "Zero final payments for the item or service in the 15 months prior to posting the file." }, { "payer_name": "BLUE SHIELD OUT OF STATE", "plan_name": "STANFORD HEALTHCARE ALLIANCE PLAN", "methodology": "percent of total billed charges", "standard_charge_dollar": 24.3, "standard_charge_percentage": 48.59, "count": "0", "additional_payer_notes": "Zero final payments for the item or service in the 15 months prior to posting the file." }, { "payer_name": "BLUE SHIELD", "plan_name": "STANFORD HEALTHCARE ALLIANCE PLAN", "methodology": "percent of total billed charges", "standard_charge_dollar": 24.3, "standard_charge_percentage": 48.59, "count": "0", "additional_payer_notes": "Zero final payments for the item or service in the 15 months prior to posting the file." }, { "payer_name": "BLUE SHIELD", "plan_name": "STANFORD HEALTHCARE ALLIANCE PLAN", "methodology": "percent of total billed charges", "standard_charge_dollar": 24.3, "standard_charge_percentage": 48.59, "count": "0", "additional_payer_notes": "Zero final payments for the item or service in the 15 months prior to posting the file." }, { "payer_name": "CIGNA", "plan_name": "CIGNA COM ALT HMO PLAN", "methodology": "percent of total billed charges", "standard_charge_dollar": 21.1, "standard_charge_percentage": 42.2, "count": "0", "additional_payer_notes": "Zero final payments for the item or service in the 15 months prior to posting the file." }, { "payer_name": "CIGNA", "plan_name": "CIGNA COM ALT HMO PLAN", "methodology": "percent of total billed charges", "standard_charge_dollar": 21.1, "standard_charge_percentage": 42.2, "count": "0", "additional_payer_notes": "Zero final payments for the item or service in the 15 months prior to posting the file." }, { "payer_name": "HEALTH NET", "plan_name": "HEALTHNET HMO, PPO, POS, EPO, CANOPY HEALTHNET HMO, OTHER-IN-NETWORK PLANS", "methodology": "per diem", "standard_charge_dollar": 8000.0, "standard_charge_algorithm": "Expected reimbursement is the lesser of Per diem ($8,000) for the length of stay and 70% of billed.", "count": "0", "additional_payer_notes": "Zero final payments for the item or service in the 15 months prior to posting the file." }, { "payer_name": "HEALTH NET", "plan_name": "HEALTHNET HMO, PPO, POS, EPO, CANOPY HEALTHNET HMO, OTHER-IN-NETWORK PLANS", "methodology": "per diem", "standard_charge_dollar": 8000.0, "standard_charge_algorithm": "Expected reimbursement is the lesser of Per diem ($8,000) for the length of stay and 70% of billed.", "count": "0", "additional_payer_notes": "Zero final payments for the item or service in the 15 months prior to posting the file." }, { "payer_name": "UNITED HEALTHCARE", "plan_name": "SUTTER SELECT & SUTTER HEALTH PLAN HMO PLANS", "methodology": "per diem", "standard_charge_dollar": 28538.0, "standard_charge_algorithm": "Per diem ($28,538).", "count": "0", "additional_payer_notes": "Zero final payments for the item or service in the 15 months prior to posting the file." }, { "payer_name": "UNITED HEALTHCARE", "plan_name": "SUTTER SELECT & SUTTER HEALTH PLAN HMO PLANS", "methodology": "per diem", "standard_charge_dollar": 28538.0, "standard_charge_algorithm": "Per diem ($28,538).", "count": "0", "additional_payer_notes": "Zero final payments for the item or service in the 15 months prior to posting the file." }, { "payer_name": "SUTTER", "plan_name": "SUTTER SELECT & SUTTER HEALTH PLAN HMO PLANS", "methodology": "per diem", "standard_charge_dollar": 28538.0, "standard_charge_algorithm": "Per diem ($28,538).", "count": "0", "additional_payer_notes": "Zero final payments for the item or service in the 15 months prior to posting the file." }, { "payer_name": "UNITED HEALTHCARE", "plan_name": "SUTTER SELECT & SUTTER HEALTH PLAN HMO PLANS", "methodology": "per diem", "standard_charge_dollar": 28538.0, "standard_charge_algorithm": "Per diem ($28,538).", "count": "0", "additional_payer_notes": "Zero final payments for the item or service in the 15 months prior to posting the file." }, { "payer_name": "UMR", "plan_name": "SUTTER SELECT & SUTTER HEALTH PLAN HMO PLANS", "methodology": "per diem", "standard_charge_dollar": 28538.0, "standard_charge_algorithm": "Per diem ($28,538).", "count": "0", "additional_payer_notes": "Zero final payments for the item or service in the 15 months prior to posting the file." } ] } ] }, { "description": "HC Bur Round Gp003", "code_information": [ { "code": "PX-2120020003", "type": "CDM" }, { "code": "99999", "type": "CPT" }, { "code": "0272", "type": "RC" } ], "standard_charges": [ { "setting": "outpatient", "gross_charge": 100.0, "discounted_cash": 50.0, "minimum": 42.2, "maximum": 52.0, "additional_generic_notes": "Zero final payments for the item or service in the 15 months prior to posting the file.", "payers_information": [ { "payer_name": "AETNA", "plan_name": "AETNA ALL OTHER PLANS", "methodology": "percent of total billed charges", "standard_charge_dollar": 52.0, "standard_charge_percentage": 52.0, "count": "0", "additional_payer_notes": "Zero final payments for the item or service in the 15 months prior to posting the file." }, { "payer_name": "AETNA", "plan_name": "AETNA ALL OTHER PLANS", "methodology": "percent of total billed charges", "standard_charge_dollar": 52.0, "standard_charge_percentage": 52.0, "count": "0", "additional_payer_notes": "Zero final payments for the item or service in the 15 months prior to posting the file." }, { "payer_name": "MERITAIN HEALTH", "plan_name": "AETNA ALL OTHER PLANS", "methodology": "percent of total billed charges", "standard_charge_dollar": 52.0, "standard_charge_percentage": 52.0, "count": "0", "additional_payer_notes": "Zero final payments for the item or service in the 15 months prior to posting the file." }, { "payer_name": "BLUE SHIELD OUT OF STATE", "plan_name": "STANFORD HEALTHCARE ALLIANCE PLAN", "methodology": "percent of total billed charges", "standard_charge_dollar": 48.59, "standard_charge_percentage": 48.59, "count": "0", "additional_payer_notes": "Zero final payments for the item or service in the 15 months prior to posting the file." }, { "payer_name": "BLUE SHIELD", "plan_name": "STANFORD HEALTHCARE ALLIANCE PLAN", "methodology": "percent of total billed charges", "standard_charge_dollar": 48.59, "standard_charge_percentage": 48.59, "count": "0", "additional_payer_notes": "Zero final payments for the item or service in the 15 months prior to posting the file." }, { "payer_name": "BLUE SHIELD", "plan_name": "STANFORD HEALTHCARE ALLIANCE PLAN", "methodology": "percent of total billed charges", "standard_charge_dollar": 48.59, "standard_charge_percentage": 48.59, "count": "0", "additional_payer_notes": "Zero final payments for the item or service in the 15 months prior to posting the file." }, { "payer_name": "CIGNA", "plan_name": "CIGNA COM ALT HMO PLAN", "methodology": "percent of total billed charges", "standard_charge_dollar": 42.2, "standard_charge_percentage": 42.2, "count": "0", "additional_payer_notes": "Zero final payments for the item or service in the 15 months prior to posting the file." }, { "payer_name": "CIGNA", "plan_name": "CIGNA COM ALT HMO PLAN", "methodology": "percent of total billed charges", "standard_charge_dollar": 42.2, "standard_charge_percentage": 42.2, "count": "0", "additional_payer_notes": "Zero final payments for the item or service in the 15 months prior to posting the file." }, { "payer_name": "HEALTH NET", "plan_name": "HEALTHNET HMO, PPO, POS, EPO, CANOPY HEALTHNET HMO, OTHER-IN-NETWORK PLANS", "methodology": "per diem", "standard_charge_dollar": 8000.0, "standard_charge_algorithm": "Expected reimbursement is the lesser of Per diem ($8,000) for the length of stay and 70% of billed.", "count": "0", "additional_payer_notes": "Zero final payments for the item or service in the 15 months prior to posting the file." }, { "payer_name": "HEALTH NET", "plan_name": "HEALTHNET HMO, PPO, POS, EPO, CANOPY HEALTHNET HMO, OTHER-IN-NETWORK PLANS", "methodology": "per diem", "standard_charge_dollar": 8000.0, "standard_charge_algorithm": "Expected reimbursement is the lesser of Per diem ($8,000) for the length of stay and 70% of billed.", "count": "0", "additional_payer_notes": "Zero final payments for the item or service in the 15 months prior to posting the file." }, { "payer_name": "UNITED HEALTHCARE", "plan_name": "SUTTER SELECT & SUTTER HEALTH PLAN HMO PLANS", "methodology": "per diem", "standard_charge_dollar": 28538.0, "standard_charge_algorithm": "Per diem ($28,538).", "count": "0", "additional_payer_notes": "Zero final payments for the item or service in the 15 months prior to posting the file." }, { "payer_name": "UNITED HEALTHCARE", "plan_name": "SUTTER SELECT & SUTTER HEALTH PLAN HMO PLANS", "methodology": "per diem", "standard_charge_dollar": 28538.0, "standard_charge_algorithm": "Per diem ($28,538).", "count": "0", "additional_payer_notes": "Zero final payments for the item or service in the 15 months prior to posting the file." }, { "payer_name": "SUTTER", "plan_name": "SUTTER SELECT & SUTTER HEALTH PLAN HMO PLANS", "methodology": "per diem", "standard_charge_dollar": 28538.0, "standard_charge_algorithm": "Per diem ($28,538).", "count": "0", "additional_payer_notes": "Zero final payments for the item or service in the 15 months prior to posting the file." }, { "payer_name": "UNITED HEALTHCARE", "plan_name": "SUTTER SELECT & SUTTER HEALTH PLAN HMO PLANS", "methodology": "per diem", "standard_charge_dollar": 28538.0, "standard_charge_algorithm": "Per diem ($28,538).", "count": "0", "additional_payer_notes": "Zero final payments for the item or service in the 15 months prior to posting the file." }, { "payer_name": "UMR", "plan_name": "SUTTER SELECT & SUTTER HEALTH PLAN HMO PLANS", "methodology": "per diem", "standard_charge_dollar": 28538.0, "standard_charge_algorithm": "Per diem ($28,538).", "count": "0", "additional_payer_notes": "Zero final payments for the item or service in the 15 months prior to posting the file." } ] } ] }, { "description": "HC Bur Round Gp004", "code_information": [ { "code": "PX-2120020004", "type": "CDM" }, { "code": "99999", "type": "CPT" }, { "code": "0272", "type": "RC" } ], "standard_charges": [ { "setting": "outpatient", "gross_charge": 146.0, "discounted_cash": 73.0, "minimum": 61.61, "maximum": 75.92, "additional_generic_notes": "Zero final payments for the item or service in the 15 months prior to posting the file.", "payers_information": [ { "payer_name": "AETNA", "plan_name": "AETNA ALL OTHER PLANS", "methodology": "percent of total billed charges", "standard_charge_dollar": 75.92, "standard_charge_percentage": 52.0, "count": "0", "additional_payer_notes": "Zero final payments for the item or service in the 15 months prior to posting the file." }, { "payer_name": "AETNA", "plan_name": "AETNA ALL OTHER PLANS", "methodology": "percent of total billed charges", "standard_charge_dollar": 75.92, "standard_charge_percentage": 52.0, "count": "0", "additional_payer_notes": "Zero final payments for the item or service in the 15 months prior to posting the file." }, { "payer_name": "MERITAIN HEALTH", "plan_name": "AETNA ALL OTHER PLANS", "methodology": "percent of total billed charges", "standard_charge_dollar": 75.92, "standard_charge_percentage": 52.0, "count": "0", "additional_payer_notes": "Zero final payments for the item or service in the 15 months prior to posting the file." }, { "payer_name": "BLUE SHIELD OUT OF STATE", "plan_name": "STANFORD HEALTHCARE ALLIANCE PLAN", "methodology": "percent of total billed charges", "standard_charge_dollar": 70.94, "standard_charge_percentage": 48.59, "count": "0", "additional_payer_notes": "Zero final payments for the item or service in the 15 months prior to posting the file." }, { "payer_name": "BLUE SHIELD", "plan_name": "STANFORD HEALTHCARE ALLIANCE PLAN", "methodology": "percent of total billed charges", "standard_charge_dollar": 70.94, "standard_charge_percentage": 48.59, "count": "0", "additional_payer_notes": "Zero final payments for the item or service in the 15 months prior to posting the file." }, { "payer_name": "BLUE SHIELD", "plan_name": "STANFORD HEALTHCARE ALLIANCE PLAN", "methodology": "percent of total billed charges", "standard_charge_dollar": 70.94, "standard_charge_percentage": 48.59, "count": "0", "additional_payer_notes": "Zero final payments for the item or service in the 15 months prior to posting the file." }, { "payer_name": "CIGNA", "plan_name": "CIGNA COM ALT HMO PLAN", "methodology": "percent of total billed charges", "standard_charge_dollar": 61.61, "standard_charge_percentage": 42.2, "count": "0", "additional_payer_notes": "Zero final payments for the item or service in the 15 months prior to posting the file." }, { "payer_name": "CIGNA", "plan_name": "CIGNA COM ALT HMO PLAN", "methodology": "percent of total billed charges", "standard_charge_dollar": 61.61, "standard_charge_percentage": 42.2, "count": "0", "additional_payer_notes": "Zero final payments for the item or service in the 15 months prior to posting the file." }, { "payer_name": "HEALTH NET", "plan_name": "HEALTHNET HMO, PPO, POS, EPO, CANOPY HEALTHNET HMO, OTHER-IN-NETWORK PLANS", "methodology": "per diem", "standard_charge_dollar": 8000.0, "standard_charge_algorithm": "Expected reimbursement is the lesser of Per diem ($8,000) for the length of stay and 70% of billed.", "count": "0", "additional_payer_notes": "Zero final payments for the item or service in the 15 months prior to posting the file." }, { "payer_name": "HEALTH NET", "plan_name": "HEALTHNET HMO, PPO, POS, EPO, CANOPY HEALTHNET HMO, OTHER-IN-NETWORK PLANS", "methodology": "per diem", "standard_charge_dollar": 8000.0, "standard_charge_algorithm": "Expected reimbursement is the lesser of Per diem ($8,000) for the length of stay and 70% of billed.", "count": "0", "additional_payer_notes": "Zero final payments for the item or service in the 15 months prior to posting the file." }, { "payer_name": "UNITED HEALTHCARE", "plan_name": "SUTTER SELECT & SUTTER HEALTH PLAN HMO PLANS", "methodology": "per diem", "standard_charge_dollar": 28538.0, "standard_charge_algorithm": "Per diem ($28,538).", "count": "0", "additional_payer_notes": "Zero final payments for the item or service in the 15 months prior to posting the file." }, { "payer_name": "UNITED HEALTHCARE", "plan_name": "SUTTER SELECT & SUTTER HEALTH PLAN HMO PLANS", "methodology": "per diem", "standard_charge_dollar": 28538.0, "standard_charge_algorithm": "Per diem ($28,538).", "count": "0", "additional_payer_notes": "Zero final payments for the item or service in the 15 months prior to posting the file." }, { "payer_name": "SUTTER", "plan_name": "SUTTER SELECT & SUTTER HEALTH PLAN HMO PLANS", "methodology": "per diem", "standard_charge_dollar": 28538.0, "standard_charge_algorithm": "Per diem ($28,538).", "count": "0", "additional_payer_notes": "Zero final payments for the item or service in the 15 months prior to posting the file." }, { "payer_name": "UNITED HEALTHCARE", "plan_name": "SUTTER SELECT & SUTTER HEALTH PLAN HMO PLANS", "methodology": "per diem", "standard_charge_dollar": 28538.0, "standard_charge_algorithm": "Per diem ($28,538).", "count": "0", "additional_payer_notes": "Zero final payments for the item or service in the 15 months prior to posting the file." }, { "payer_name": "UMR", "plan_name": "SUTTER SELECT & SUTTER HEALTH PLAN HMO PLANS", "methodology": "per diem", "standard_charge_dollar": 28538.0, "standard_charge_algorithm": "Per diem ($28,538).", "count": "0", "additional_payer_notes": "Zero final payments for the item or service in the 15 months prior to posting the file." } ] } ] }, { "description": "HC Bur Round Gp005", "code_information": [ { "code": "PX-2120020005", "type": "CDM" }, { "code": "99999", "type": "CPT" }, { "code": "0272", "type": "RC" } ], "standard_charges": [ { "setting": "outpatient", "gross_charge": 195.0, "discounted_cash": 97.5, "minimum": 82.29, "maximum": 101.4, "additional_generic_notes": "Zero final payments for the item or service in the 15 months prior to posting the file.", "payers_information": [ { "payer_name": "AETNA", "plan_name": "AETNA ALL OTHER PLANS", "methodology": "percent of total billed charges", "standard_charge_dollar": 101.4, "standard_charge_percentage": 52.0, "count": "0", "additional_payer_notes": "Zero final payments for the item or service in the 15 months prior to posting the file." }, { "payer_name": "AETNA", "plan_name": "AETNA ALL OTHER PLANS", "methodology": "percent of total billed charges", "standard_charge_dollar": 101.4, "standard_charge_percentage": 52.0, "count": "0", "additional_payer_notes": "Zero final payments for the item or service in the 15 months prior to posting the file." }, { "payer_name": "MERITAIN HEALTH", "plan_name": "AETNA ALL OTHER PLANS", "methodology": "percent of total billed charges", "standard_charge_dollar": 101.4, "standard_charge_percentage": 52.0, "count": "0", "additional_payer_notes": "Zero final payments for the item or service in the 15 months prior to posting the file." }, { "payer_name": "BLUE SHIELD OUT OF STATE", "plan_name": "STANFORD HEALTHCARE ALLIANCE PLAN", "methodology": "percent of total billed charges", "standard_charge_dollar": 94.75, "standard_charge_percentage": 48.59, "count": "0", "additional_payer_notes": "Zero final payments for the item or service in the 15 months prior to posting the file." }, { "payer_name": "BLUE SHIELD", "plan_name": "STANFORD HEALTHCARE ALLIANCE PLAN", "methodology": "percent of total billed charges", "standard_charge_dollar": 94.75, "standard_charge_percentage": 48.59, "count": "0", "additional_payer_notes": "Zero final payments for the item or service in the 15 months prior to posting the file." }, { "payer_name": "BLUE SHIELD", "plan_name": "STANFORD HEALTHCARE ALLIANCE PLAN", "methodology": "percent of total billed charges", "standard_charge_dollar": 94.75, "standard_charge_percentage": 48.59, "count": "0", "additional_payer_notes": "Zero final payments for the item or service in the 15 months prior to posting the file." }, { "payer_name": "CIGNA", "plan_name": "CIGNA COM ALT HMO PLAN", "methodology": "percent of total billed charges", "standard_charge_dollar": 82.29, "standard_charge_percentage": 42.2, "count": "0", "additional_payer_notes": "Zero final payments for the item or service in the 15 months prior to posting the file." }, { "payer_name": "CIGNA", "plan_name": "CIGNA COM ALT HMO PLAN", "methodology": "percent of total billed charges", "standard_charge_dollar": 82.29, "standard_charge_percentage": 42.2, "count": "0", "additional_payer_notes": "Zero final payments for the item or service in the 15 months prior to posting the file." }, { "payer_name": "HEALTH NET", "plan_name": "HEALTHNET HMO, PPO, POS, EPO, CANOPY HEALTHNET HMO, OTHER-IN-NETWORK PLANS", "methodology": "per diem", "standard_charge_dollar": 8000.0, "standard_charge_algorithm": "Expected reimbursement is the lesser of Per diem ($8,000) for the length of stay and 70% of billed.", "count": "0", "additional_payer_notes": "Zero final payments for the item or service in the 15 months prior to posting the file." }, { "payer_name": "HEALTH NET", "plan_name": "HEALTHNET HMO, PPO, POS, EPO, CANOPY HEALTHNET HMO, OTHER-IN-NETWORK PLANS", "methodology": "per diem", "standard_charge_dollar": 8000.0, "standard_charge_algorithm": "Expected reimbursement is the lesser of Per diem ($8,000) for the length of stay and 70% of billed.", "count": "0", "additional_payer_notes": "Zero final payments for the item or service in the 15 months prior to posting the file." }, { "payer_name": "UNITED HEALTHCARE", "plan_name": "SUTTER SELECT & SUTTER HEALTH PLAN HMO PLANS", "methodology": "per diem", "standard_charge_dollar": 28538.0, "standard_charge_algorithm": "Per diem ($28,538).", "count": "0", "additional_payer_notes": "Zero final payments for the item or service in the 15 months prior to posting the file." }, { "payer_name": "UNITED HEALTHCARE", "plan_name": "SUTTER SELECT & SUTTER HEALTH PLAN HMO PLANS", "methodology": "per diem", "standard_charge_dollar": 28538.0, "standard_charge_algorithm": "Per diem ($28,538).", "count": "0", "additional_payer_notes": "Zero final payments for the item or service in the 15 months prior to posting the file." }, { "payer_name": "SUTTER", "plan_name": "SUTTER SELECT & SUTTER HEALTH PLAN HMO PLANS", "methodology": "per diem", "standard_charge_dollar": 28538.0, "standard_charge_algorithm": "Per diem ($28,538).", "count": "0", "additional_payer_notes": "Zero final payments for the item or service in the 15 months prior to posting the file." }, { "payer_name": "UNITED HEALTHCARE", "plan_name": "SUTTER SELECT & SUTTER HEALTH PLAN HMO PLANS", "methodology": "per diem", "standard_charge_dollar": 28538.0, "standard_charge_algorithm": "Per diem ($28,538).", "count": "0", "additional_payer_notes": "Zero final payments for the item or service in the 15 months prior to posting the file." }, { "payer_name": "UMR", "plan_name": "SUTTER SELECT & SUTTER HEALTH PLAN HMO PLANS", "methodology": "per diem", "standard_charge_dollar": 28538.0, "standard_charge_algorithm": "Per diem ($28,538).", "count": "0", "additional_payer_notes": "Zero final payments for the item or service in the 15 months prior to posting the file." } ] } ] }, { "description": "HC Bur Round Gp006", "code_information": [ { "code": "PX-2120020006", "type": "CDM" }, { "code": "99999", "type": "CPT" }, { "code": "0272", "type": "RC" } ], "standard_charges": [ { "setting": "outpatient", "gross_charge": 293.0, "discounted_cash": 146.5, "minimum": 123.65, "maximum": 152.36, "additional_generic_notes": "Zero final payments for the item or service in the 15 months prior to posting the file.", "payers_information": [ { "payer_name": "AETNA", "plan_name": "AETNA ALL OTHER PLANS", "methodology": "percent of total billed charges", "standard_charge_dollar": 152.36, "standard_charge_percentage": 52.0, "count": "0", "additional_payer_notes": "Zero final payments for the item or service in the 15 months prior to posting the file." }, { "payer_name": "AETNA", "plan_name": "AETNA ALL OTHER PLANS", "methodology": "percent of total billed charges", "standard_charge_dollar": 152.36, "standard_charge_percentage": 52.0, "count": "0", "additional_payer_notes": "Zero final payments for the item or service in the 15 months prior to posting the file." }, { "payer_name": "MERITAIN HEALTH", "plan_name": "AETNA ALL OTHER PLANS", "methodology": "percent of total billed charges", "standard_charge_dollar": 152.36, "standard_charge_percentage": 52.0, "count": "0", "additional_payer_notes": "Zero final payments for the item or service in the 15 months prior to posting the file." }, { "payer_name": "BLUE SHIELD OUT OF STATE", "plan_name": "STANFORD HEALTHCARE ALLIANCE PLAN", "methodology": "percent of total billed charges", "standard_charge_dollar": 142.37, "standard_charge_percentage": 48.59, "count": "0", "additional_payer_notes": "Zero final payments for the item or service in the 15 months prior to posting the file." }, { "payer_name": "BLUE SHIELD", "plan_name": "STANFORD HEALTHCARE ALLIANCE PLAN", "methodology": "percent of total billed charges", "standard_charge_dollar": 142.37, "standard_charge_percentage": 48.59, "count": "0", "additional_payer_notes": "Zero final payments for the item or service in the 15 months prior to posting the file." }, { "payer_name": "BLUE SHIELD", "plan_name": "STANFORD HEALTHCARE ALLIANCE PLAN", "methodology": "percent of total billed charges", "standard_charge_dollar": 142.37, "standard_charge_percentage": 48.59, "count": "0", "additional_payer_notes": "Zero final payments for the item or service in the 15 months prior to posting the file." }, { "payer_name": "CIGNA", "plan_name": "CIGNA COM ALT HMO PLAN", "methodology": "percent of total billed charges", "standard_charge_dollar": 123.65, "standard_charge_percentage": 42.2, "count": "0", "additional_payer_notes": "Zero final payments for the item or service in the 15 months prior to posting the file." }, { "payer_name": "CIGNA", "plan_name": "CIGNA COM ALT HMO PLAN", "methodology": "percent of total billed charges", "standard_charge_dollar": 123.65, "standard_charge_percentage": 42.2, "count": "0", "additional_payer_notes": "Zero final payments for the item or service in the 15 months prior to posting the file." }, { "payer_name": "HEALTH NET", "plan_name": "HEALTHNET HMO, PPO, POS, EPO, CANOPY HEALTHNET HMO, OTHER-IN-NETWORK PLANS", "methodology": "per diem", "standard_charge_dollar": 8000.0, "standard_charge_algorithm": "Expected reimbursement is the lesser of Per diem ($8,000) for the length of stay and 70% of billed.", "count": "0", "additional_payer_notes": "Zero final payments for the item or service in the 15 months prior to posting the file." }, { "payer_name": "HEALTH NET", "plan_name": "HEALTHNET HMO, PPO, POS, EPO, CANOPY HEALTHNET HMO, OTHER-IN-NETWORK PLANS", "methodology": "per diem", "standard_charge_dollar": 8000.0, "standard_charge_algorithm": "Expected reimbursement is the lesser of Per diem ($8,000) for the length of stay and 70% of billed.", "count": "0", "additional_payer_notes": "Zero final payments for the item or service in the 15 months prior to posting the file." }, { "payer_name": "UNITED HEALTHCARE", "plan_name": "SUTTER SELECT & SUTTER HEALTH PLAN HMO PLANS", "methodology": "per diem", "standard_charge_dollar": 28538.0, "standard_charge_algorithm": "Per diem ($28,538).", "count": "0", "additional_payer_notes": "Zero final payments for the item or service in the 15 months prior to posting the file." }, { "payer_name": "UNITED HEALTHCARE", "plan_name": "SUTTER SELECT & SUTTER HEALTH PLAN HMO PLANS", "methodology": "per diem", "standard_charge_dollar": 28538.0, "standard_charge_algorithm": "Per diem ($28,538).", "count": "0", "additional_payer_notes": "Zero final payments for the item or service in the 15 months prior to posting the file." }, { "payer_name": "SUTTER", "plan_name": "SUTTER SELECT & SUTTER HEALTH PLAN HMO PLANS", "methodology": "per diem", "standard_charge_dollar": 28538.0, "standard_charge_algorithm": "Per diem ($28,538).", "count": "0", "additional_payer_notes": "Zero final payments for the item or service in the 15 months prior to posting the file." }, { "payer_name": "UNITED HEALTHCARE", "plan_name": "SUTTER SELECT & SUTTER HEALTH PLAN HMO PLANS", "methodology": "per diem", "standard_charge_dollar": 28538.0, "standard_charge_algorithm": "Per diem ($28,538).", "count": "0", "additional_payer_notes": "Zero final payments for the item or service in the 15 months prior to posting the file." }, { "payer_name": "UMR", "plan_name": "SUTTER SELECT & SUTTER HEALTH PLAN HMO PLANS", "methodology": "per diem", "standard_charge_dollar": 28538.0, "standard_charge_algorithm": "Per diem ($28,538).", "count": "0", "additional_payer_notes": "Zero final payments for the item or service in the 15 months prior to posting the file." } ] } ] }, { "description": "HC Bur Round Gp007", "code_information": [ { "code": "PX-2120020007", "type": "CDM" }, { "code": "99999", "type": "CPT" }, { "code": "0272", "type": "RC" } ], "standard_charges": [ { "setting": "outpatient", "gross_charge": 380.0, "discounted_cash": 190.0, "minimum": 160.36, "maximum": 197.6, "additional_generic_notes": "Zero final payments for the item or service in the 15 months prior to posting the file.", "payers_information": [ { "payer_name": "AETNA", "plan_name": "AETNA ALL OTHER PLANS", "methodology": "percent of total billed charges", "standard_charge_dollar": 197.6, "standard_charge_percentage": 52.0, "count": "0", "additional_payer_notes": "Zero final payments for the item or service in the 15 months prior to posting the file." }, { "payer_name": "AETNA", "plan_name": "AETNA ALL OTHER PLANS", "methodology": "percent of total billed charges", "standard_charge_dollar": 197.6, "standard_charge_percentage": 52.0, "count": "0", "additional_payer_notes": "Zero final payments for the item or service in the 15 months prior to posting the file." }, { "payer_name": "MERITAIN HEALTH", "plan_name": "AETNA ALL OTHER PLANS", "methodology": "percent of total billed charges", "standard_charge_dollar": 197.6, "standard_charge_percentage": 52.0, "count": "0", "additional_payer_notes": "Zero final payments for the item or service in the 15 months prior to posting the file." }, { "payer_name": "BLUE SHIELD OUT OF STATE", "plan_name": "STANFORD HEALTHCARE ALLIANCE PLAN", "methodology": "percent of total billed charges", "standard_charge_dollar": 184.64, "standard_charge_percentage": 48.59, "count": "0", "additional_payer_notes": "Zero final payments for the item or service in the 15 months prior to posting the file." }, { "payer_name": "BLUE SHIELD", "plan_name": "STANFORD HEALTHCARE ALLIANCE PLAN", "methodology": "percent of total billed charges", "standard_charge_dollar": 184.64, "standard_charge_percentage": 48.59, "count": "0", "additional_payer_notes": "Zero final payments for the item or service in the 15 months prior to posting the file." }, { "payer_name": "BLUE SHIELD", "plan_name": "STANFORD HEALTHCARE ALLIANCE PLAN", "methodology": "percent of total billed charges", "standard_charge_dollar": 184.64, "standard_charge_percentage": 48.59, "count": "0", "additional_payer_notes": "Zero final payments for the item or service in the 15 months prior to posting the file." }, { "payer_name": "CIGNA", "plan_name": "CIGNA COM ALT HMO PLAN", "methodology": "percent of total billed charges", "standard_charge_dollar": 160.36, "standard_charge_percentage": 42.2, "count": "0", "additional_payer_notes": "Zero final payments for the item or service in the 15 months prior to posting the file." }, { "payer_name": "CIGNA", "plan_name": "CIGNA COM ALT HMO PLAN", "methodology": "percent of total billed charges", "standard_charge_dollar": 160.36, "standard_charge_percentage": 42.2, "count": "0", "additional_payer_notes": "Zero final payments for the item or service in the 15 months prior to posting the file." }, { "payer_name": "HEALTH NET", "plan_name": "HEALTHNET HMO, PPO, POS, EPO, CANOPY HEALTHNET HMO, OTHER-IN-NETWORK PLANS", "methodology": "per diem", "standard_charge_dollar": 8000.0, "standard_charge_algorithm": "Expected reimbursement is the lesser of Per diem ($8,000) for the length of stay and 70% of billed.", "count": "0", "additional_payer_notes": "Zero final payments for the item or service in the 15 months prior to posting the file." }, { "payer_name": "HEALTH NET", "plan_name": "HEALTHNET HMO, PPO, POS, EPO, CANOPY HEALTHNET HMO, OTHER-IN-NETWORK PLANS", "methodology": "per diem", "standard_charge_dollar": 8000.0, "standard_charge_algorithm": "Expected reimbursement is the lesser of Per diem ($8,000) for the length of stay and 70% of billed.", "count": "0", "additional_payer_notes": "Zero final payments for the item or service in the 15 months prior to posting the file." }, { "payer_name": "UNITED HEALTHCARE", "plan_name": "SUTTER SELECT & SUTTER HEALTH PLAN HMO PLANS", "methodology": "per diem", "standard_charge_dollar": 28538.0, "standard_charge_algorithm": "Per diem ($28,538).", "count": "0", "additional_payer_notes": "Zero final payments for the item or service in the 15 months prior to posting the file." }, { "payer_name": "UNITED HEALTHCARE", "plan_name": "SUTTER SELECT & SUTTER HEALTH PLAN HMO PLANS", "methodology": "per diem", "standard_charge_dollar": 28538.0, "standard_charge_algorithm": "Per diem ($28,538).", "count": "0", "additional_payer_notes": "Zero final payments for the item or service in the 15 months prior to posting the file." }, { "payer_name": "SUTTER", "plan_name": "SUTTER SELECT & SUTTER HEALTH PLAN HMO PLANS", "methodology": "per diem", "standard_charge_dollar": 28538.0, "standard_charge_algorithm": "Per diem ($28,538).", "count": "0", "additional_payer_notes": "Zero final payments for the item or service in the 15 months prior to posting the file." }, { "payer_name": "UNITED HEALTHCARE", "plan_name": "SUTTER SELECT & SUTTER HEALTH PLAN HMO PLANS", "methodology": "per diem", "standard_charge_dollar": 28538.0, "standard_charge_algorithm": "Per diem ($28,538).", "count": "0", "additional_payer_notes": "Zero final payments for the item or service in the 15 months prior to posting the file." }, { "payer_name": "UMR", "plan_name": "SUTTER SELECT & SUTTER HEALTH PLAN HMO PLANS", "methodology": "per diem", "standard_charge_dollar": 28538.0, "standard_charge_algorithm": "Per diem ($28,538).", "count": "0", "additional_payer_notes": "Zero final payments for the item or service in the 15 months prior to posting the file." } ] } ] }, { "description": "HC Bur Round Gp008", "code_information": [ { "code": "PX-2120020008", "type": "CDM" }, { "code": "99999", "type": "CPT" }, { "code": "0272", "type": "RC" } ], "standard_charges": [ { "setting": "outpatient", "gross_charge": 475.0, "discounted_cash": 237.5, "minimum": 200.45, "maximum": 247.0, "additional_generic_notes": "Zero final payments for the item or service in the 15 months prior to posting the file.", "payers_information": [ { "payer_name": "AETNA", "plan_name": "AETNA ALL OTHER PLANS", "methodology": "percent of total billed charges", "standard_charge_dollar": 247.0, "standard_charge_percentage": 52.0, "count": "0", "additional_payer_notes": "Zero final payments for the item or service in the 15 months prior to posting the file." }, { "payer_name": "AETNA", "plan_name": "AETNA ALL OTHER PLANS", "methodology": "percent of total billed charges", "standard_charge_dollar": 247.0, "standard_charge_percentage": 52.0, "count": "0", "additional_payer_notes": "Zero final payments for the item or service in the 15 months prior to posting the file." }, { "payer_name": "MERITAIN HEALTH", "plan_name": "AETNA ALL OTHER PLANS", "methodology": "percent of total billed charges", "standard_charge_dollar": 247.0, "standard_charge_percentage": 52.0, "count": "0", "additional_payer_notes": "Zero final payments for the item or service in the 15 months prior to posting the file." }, { "payer_name": "BLUE SHIELD OUT OF STATE", "plan_name": "STANFORD HEALTHCARE ALLIANCE PLAN", "methodology": "percent of total billed charges", "standard_charge_dollar": 230.8, "standard_charge_percentage": 48.59, "count": "0", "additional_payer_notes": "Zero final payments for the item or service in the 15 months prior to posting the file." }, { "payer_name": "BLUE SHIELD", "plan_name": "STANFORD HEALTHCARE ALLIANCE PLAN", "methodology": "percent of total billed charges", "standard_charge_dollar": 230.8, "standard_charge_percentage": 48.59, "count": "0", "additional_payer_notes": "Zero final payments for the item or service in the 15 months prior to posting the file." }, { "payer_name": "BLUE SHIELD", "plan_name": "STANFORD HEALTHCARE ALLIANCE PLAN", "methodology": "percent of total billed charges", "standard_charge_dollar": 230.8, "standard_charge_percentage": 48.59, "count": "0", "additional_payer_notes": "Zero final payments for the item or service in the 15 months prior to posting the file." }, { "payer_name": "CIGNA", "plan_name": "CIGNA COM ALT HMO PLAN", "methodology": "percent of total billed charges", "standard_charge_dollar": 200.45, "standard_charge_percentage": 42.2, "count": "0", "additional_payer_notes": "Zero final payments for the item or service in the 15 months prior to posting the file." }, { "payer_name": "CIGNA", "plan_name": "CIGNA COM ALT HMO PLAN", "methodology": "percent of total billed charges", "standard_charge_dollar": 200.45, "standard_charge_percentage": 42.2, "count": "0", "additional_payer_notes": "Zero final payments for the item or service in the 15 months prior to posting the file." }, { "payer_name": "HEALTH NET", "plan_name": "HEALTHNET HMO, PPO, POS, EPO, CANOPY HEALTHNET HMO, OTHER-IN-NETWORK PLANS", "methodology": "per diem", "standard_charge_dollar": 8000.0, "standard_charge_algorithm": "Expected reimbursement is the lesser of Per diem ($8,000) for the length of stay and 70% of billed.", "count": "0", "additional_payer_notes": "Zero final payments for the item or service in the 15 months prior to posting the file." }, { "payer_name": "HEALTH NET", "plan_name": "HEALTHNET HMO, PPO, POS, EPO, CANOPY HEALTHNET HMO, OTHER-IN-NETWORK PLANS", "methodology": "per diem", "standard_charge_dollar": 8000.0, "standard_charge_algorithm": "Expected reimbursement is the lesser of Per diem ($8,000) for the length of stay and 70% of billed.", "count": "0", "additional_payer_notes": "Zero final payments for the item or service in the 15 months prior to posting the file." }, { "payer_name": "UNITED HEALTHCARE", "plan_name": "SUTTER SELECT & SUTTER HEALTH PLAN HMO PLANS", "methodology": "per diem", "standard_charge_dollar": 28538.0, "standard_charge_algorithm": "Per diem ($28,538).", "count": "0", "additional_payer_notes": "Zero final payments for the item or service in the 15 months prior to posting the file." }, { "payer_name": "UNITED HEALTHCARE", "plan_name": "SUTTER SELECT & SUTTER HEALTH PLAN HMO PLANS", "methodology": "per diem", "standard_charge_dollar": 28538.0, "standard_charge_algorithm": "Per diem ($28,538).", "count": "0", "additional_payer_notes": "Zero final payments for the item or service in the 15 months prior to posting the file." }, { "payer_name": "SUTTER", "plan_name": "SUTTER SELECT & SUTTER HEALTH PLAN HMO PLANS", "methodology": "per diem", "standard_charge_dollar": 28538.0, "standard_charge_algorithm": "Per diem ($28,538).", "count": "0", "additional_payer_notes": "Zero final payments for the item or service in the 15 months prior to posting the file." }, { "payer_name": "UNITED HEALTHCARE", "plan_name": "SUTTER SELECT & SUTTER HEALTH PLAN HMO PLANS", "methodology": "per diem", "standard_charge_dollar": 28538.0, "standard_charge_algorithm": "Per diem ($28,538).", "count": "0", "additional_payer_notes": "Zero final payments for the item or service in the 15 months prior to posting the file." }, { "payer_name": "UMR", "plan_name": "SUTTER SELECT & SUTTER HEALTH PLAN HMO PLANS", "methodology": "per diem", "standard_charge_dollar": 28538.0, "standard_charge_algorithm": "Per diem ($28,538).", "count": "0", "additional_payer_notes": "Zero final payments for the item or service in the 15 months prior to posting the file." } ] } ] }, { "description": "HC Bur Round Gp009", "code_information": [ { "code": "PX-2120020009", "type": "CDM" }, { "code": "99999", "type": "CPT" }, { "code": "0272", "type": "RC" } ], "standard_charges": [ { "setting": "outpatient", "gross_charge": 570.0, "discounted_cash": 285.0, "minimum": 240.54, "maximum": 296.4, "additional_generic_notes": "Zero final payments for the item or service in the 15 months prior to posting the file.", "payers_information": [ { "payer_name": "AETNA", "plan_name": "AETNA ALL OTHER PLANS", "methodology": "percent of total billed charges", "standard_charge_dollar": 296.4, "standard_charge_percentage": 52.0, "count": "0", "additional_payer_notes": "Zero final payments for the item or service in the 15 months prior to posting the file." }, { "payer_name": "AETNA", "plan_name": "AETNA ALL OTHER PLANS", "methodology": "percent of total billed charges", "standard_charge_dollar": 296.4, "standard_charge_percentage": 52.0, "count": "0", "additional_payer_notes": "Zero final payments for the item or service in the 15 months prior to posting the file." }, { "payer_name": "MERITAIN HEALTH", "plan_name": "AETNA ALL OTHER PLANS", "methodology": "percent of total billed charges", "standard_charge_dollar": 296.4, "standard_charge_percentage": 52.0, "count": "0", "additional_payer_notes": "Zero final payments for the item or service in the 15 months prior to posting the file." }, { "payer_name": "BLUE SHIELD OUT OF STATE", "plan_name": "STANFORD HEALTHCARE ALLIANCE PLAN", "methodology": "percent of total billed charges", "standard_charge_dollar": 276.96, "standard_charge_percentage": 48.59, "count": "0", "additional_payer_notes": "Zero final payments for the item or service in the 15 months prior to posting the file." }, { "payer_name": "BLUE SHIELD", "plan_name": "STANFORD HEALTHCARE ALLIANCE PLAN", "methodology": "percent of total billed charges", "standard_charge_dollar": 276.96, "standard_charge_percentage": 48.59, "count": "0", "additional_payer_notes": "Zero final payments for the item or service in the 15 months prior to posting the file." }, { "payer_name": "BLUE SHIELD", "plan_name": "STANFORD HEALTHCARE ALLIANCE PLAN", "methodology": "percent of total billed charges", "standard_charge_dollar": 276.96, "standard_charge_percentage": 48.59, "count": "0", "additional_payer_notes": "Zero final payments for the item or service in the 15 months prior to posting the file." }, { "payer_name": "CIGNA", "plan_name": "CIGNA COM ALT HMO PLAN", "methodology": "percent of total billed charges", "standard_charge_dollar": 240.54, "standard_charge_percentage": 42.2, "count": "0", "additional_payer_notes": "Zero final payments for the item or service in the 15 months prior to posting the file." }, { "payer_name": "CIGNA", "plan_name": "CIGNA COM ALT HMO PLAN", "methodology": "percent of total billed charges", "standard_charge_dollar": 240.54, "standard_charge_percentage": 42.2, "count": "0", "additional_payer_notes": "Zero final payments for the item or service in the 15 months prior to posting the file." }, { "payer_name": "HEALTH NET", "plan_name": "HEALTHNET HMO, PPO, POS, EPO, CANOPY HEALTHNET HMO, OTHER-IN-NETWORK PLANS", "methodology": "per diem", "standard_charge_dollar": 8000.0, "standard_charge_algorithm": "Expected reimbursement is the lesser of Per diem ($8,000) for the length of stay and 70% of billed.", "count": "0", "additional_payer_notes": "Zero final payments for the item or service in the 15 months prior to posting the file." }, { "payer_name": "HEALTH NET", "plan_name": "HEALTHNET HMO, PPO, POS, EPO, CANOPY HEALTHNET HMO, OTHER-IN-NETWORK PLANS", "methodology": "per diem", "standard_charge_dollar": 8000.0, "standard_charge_algorithm": "Expected reimbursement is the lesser of Per diem ($8,000) for the length of stay and 70% of billed.", "count": "0", "additional_payer_notes": "Zero final payments for the item or service in the 15 months prior to posting the file." }, { "payer_name": "UNITED HEALTHCARE", "plan_name": "SUTTER SELECT & SUTTER HEALTH PLAN HMO PLANS", "methodology": "per diem", "standard_charge_dollar": 28538.0, "standard_charge_algorithm": "Per diem ($28,538).", "count": "0", "additional_payer_notes": "Zero final payments for the item or service in the 15 months prior to posting the file." }, { "payer_name": "UNITED HEALTHCARE", "plan_name": "SUTTER SELECT & SUTTER HEALTH PLAN HMO PLANS", "methodology": "per diem", "standard_charge_dollar": 28538.0, "standard_charge_algorithm": "Per diem ($28,538).", "count": "0", "additional_payer_notes": "Zero final payments for the item or service in the 15 months prior to posting the file." }, { "payer_name": "SUTTER", "plan_name": "SUTTER SELECT & SUTTER HEALTH PLAN HMO PLANS", "methodology": "per diem", "standard_charge_dollar": 28538.0, "standard_charge_algorithm": "Per diem ($28,538).", "count": "0", "additional_payer_notes": "Zero final payments for the item or service in the 15 months prior to posting the file." }, { "payer_name": "UNITED HEALTHCARE", "plan_name": "SUTTER SELECT & SUTTER HEALTH PLAN HMO PLANS", "methodology": "per diem", "standard_charge_dollar": 28538.0, "standard_charge_algorithm": "Per diem ($28,538).", "count": "0", "additional_payer_notes": "Zero final payments for the item or service in the 15 months prior to posting the file." }, { "payer_name": "UMR", "plan_name": "SUTTER SELECT & SUTTER HEALTH PLAN HMO PLANS", "methodology": "per diem", "standard_charge_dollar": 28538.0, "standard_charge_algorithm": "Per diem ($28,538).", "count": "0", "additional_payer_notes": "Zero final payments for the item or service in the 15 months prior to posting the file." } ] } ] }, { "description": "HC Bur Round Gp010", "code_information": [ { "code": "PX-2120020010", "type": "CDM" }, { "code": "99999", "type": "CPT" }, { "code": "0272", "type": "RC" } ], "standard_charges": [ { "setting": "outpatient", "gross_charge": 665.0, "discounted_cash": 332.5, "minimum": 280.63, "maximum": 345.8, "additional_generic_notes": "Zero final payments for the item or service in the 15 months prior to posting the file.", "payers_information": [ { "payer_name": "AETNA", "plan_name": "AETNA ALL OTHER PLANS", "methodology": "percent of total billed charges", "standard_charge_dollar": 345.8, "standard_charge_percentage": 52.0, "count": "0", "additional_payer_notes": "Zero final payments for the item or service in the 15 months prior to posting the file." }, { "payer_name": "AETNA", "plan_name": "AETNA ALL OTHER PLANS", "methodology": "percent of total billed charges", "standard_charge_dollar": 345.8, "standard_charge_percentage": 52.0, "count": "0", "additional_payer_notes": "Zero final payments for the item or service in the 15 months prior to posting the file." }, { "payer_name": "MERITAIN HEALTH", "plan_name": "AETNA ALL OTHER PLANS", "methodology": "percent of total billed charges", "standard_charge_dollar": 345.8, "standard_charge_percentage": 52.0, "count": "0", "additional_payer_notes": "Zero final payments for the item or service in the 15 months prior to posting the file." }, { "payer_name": "BLUE SHIELD OUT OF STATE", "plan_name": "STANFORD HEALTHCARE ALLIANCE PLAN", "methodology": "percent of total billed charges", "standard_charge_dollar": 323.12, "standard_charge_percentage": 48.59, "count": "0", "additional_payer_notes": "Zero final payments for the item or service in the 15 months prior to posting the file." }, { "payer_name": "BLUE SHIELD", "plan_name": "STANFORD HEALTHCARE ALLIANCE PLAN", "methodology": "percent of total billed charges", "standard_charge_dollar": 323.12, "standard_charge_percentage": 48.59, "count": "0", "additional_payer_notes": "Zero final payments for the item or service in the 15 months prior to posting the file." }, { "payer_name": "BLUE SHIELD", "plan_name": "STANFORD HEALTHCARE ALLIANCE PLAN", "methodology": "percent of total billed charges", "standard_charge_dollar": 323.12, "standard_charge_percentage": 48.59, "count": "0", "additional_payer_notes": "Zero final payments for the item or service in the 15 months prior to posting the file." }, { "payer_name": "CIGNA", "plan_name": "CIGNA COM ALT HMO PLAN", "methodology": "percent of total billed charges", "standard_charge_dollar": 280.63, "standard_charge_percentage": 42.2, "count": "0", "additional_payer_notes": "Zero final payments for the item or service in the 15 months prior to posting the file." }, { "payer_name": "CIGNA", "plan_name": "CIGNA COM ALT HMO PLAN", "methodology": "percent of total billed charges", "standard_charge_dollar": 280.63, "standard_charge_percentage": 42.2, "count": "0", "additional_payer_notes": "Zero final payments for the item or service in the 15 months prior to posting the file." }, { "payer_name": "HEALTH NET", "plan_name": "HEALTHNET HMO, PPO, POS, EPO, CANOPY HEALTHNET HMO, OTHER-IN-NETWORK PLANS", "methodology": "per diem", "standard_charge_dollar": 8000.0, "standard_charge_algorithm": "Expected reimbursement is the lesser of Per diem ($8,000) for the length of stay and 70% of billed.", "count": "0", "additional_payer_notes": "Zero final payments for the item or service in the 15 months prior to posting the file." }, { "payer_name": "HEALTH NET", "plan_name": "HEALTHNET HMO, PPO, POS, EPO, CANOPY HEALTHNET HMO, OTHER-IN-NETWORK PLANS", "methodology": "per diem", "standard_charge_dollar": 8000.0, "standard_charge_algorithm": "Expected reimbursement is the lesser of Per diem ($8,000) for the length of stay and 70% of billed.", "count": "0", "additional_payer_notes": "Zero final payments for the item or service in the 15 months prior to posting the file." }, { "payer_name": "UNITED HEALTHCARE", "plan_name": "SUTTER SELECT & SUTTER HEALTH PLAN HMO PLANS", "methodology": "per diem", "standard_charge_dollar": 28538.0, "standard_charge_algorithm": "Per diem ($28,538).", "count": "0", "additional_payer_notes": "Zero final payments for the item or service in the 15 months prior to posting the file." }, { "payer_name": "UNITED HEALTHCARE", "plan_name": "SUTTER SELECT & SUTTER HEALTH PLAN HMO PLANS", "methodology": "per diem", "standard_charge_dollar": 28538.0, "standard_charge_algorithm": "Per diem ($28,538).", "count": "0", "additional_payer_notes": "Zero final payments for the item or service in the 15 months prior to posting the file." }, { "payer_name": "SUTTER", "plan_name": "SUTTER SELECT & SUTTER HEALTH PLAN HMO PLANS", "methodology": "per diem", "standard_charge_dollar": 28538.0, "standard_charge_algorithm": "Per diem ($28,538).", "count": "0", "additional_payer_notes": "Zero final payments for the item or service in the 15 months prior to posting the file." }, { "payer_name": "UNITED HEALTHCARE", "plan_name": "SUTTER SELECT & SUTTER HEALTH PLAN HMO PLANS", "methodology": "per diem", "standard_charge_dollar": 28538.0, "standard_charge_algorithm": "Per diem ($28,538).", "count": "0", "additional_payer_notes": "Zero final payments for the item or service in the 15 months prior to posting the file." }, { "payer_name": "UMR", "plan_name": "SUTTER SELECT & SUTTER HEALTH PLAN HMO PLANS", "methodology": "per diem", "standard_charge_dollar": 28538.0, "standard_charge_algorithm": "Per diem ($28,538).", "count": "0", "additional_payer_notes": "Zero final payments for the item or service in the 15 months prior to posting the file." } ] } ] }, { "description": "HC Bur Round Gp012", "code_information": [ { "code": "PX-2120020012", "type": "CDM" }, { "code": "99999", "type": "CPT" }, { "code": "0272", "type": "RC" } ], "standard_charges": [ { "setting": "outpatient", "gross_charge": 810.0, "discounted_cash": 405.0, "minimum": 341.82, "maximum": 421.2, "additional_generic_notes": "Zero final payments for the item or service in the 15 months prior to posting the file.", "payers_information": [ { "payer_name": "AETNA", "plan_name": "AETNA ALL OTHER PLANS", "methodology": "percent of total billed charges", "standard_charge_dollar": 421.2, "standard_charge_percentage": 52.0, "count": "0", "additional_payer_notes": "Zero final payments for the item or service in the 15 months prior to posting the file." }, { "payer_name": "AETNA", "plan_name": "AETNA ALL OTHER PLANS", "methodology": "percent of total billed charges", "standard_charge_dollar": 421.2, "standard_charge_percentage": 52.0, "count": "0", "additional_payer_notes": "Zero final payments for the item or service in the 15 months prior to posting the file." }, { "payer_name": "MERITAIN HEALTH", "plan_name": "AETNA ALL OTHER PLANS", "methodology": "percent of total billed charges", "standard_charge_dollar": 421.2, "standard_charge_percentage": 52.0, "count": "0", "additional_payer_notes": "Zero final payments for the item or service in the 15 months prior to posting the file." }, { "payer_name": "BLUE SHIELD OUT OF STATE", "plan_name": "STANFORD HEALTHCARE ALLIANCE PLAN", "methodology": "percent of total billed charges", "standard_charge_dollar": 393.58, "standard_charge_percentage": 48.59, "count": "0", "additional_payer_notes": "Zero final payments for the item or service in the 15 months prior to posting the file." }, { "payer_name": "BLUE SHIELD", "plan_name": "STANFORD HEALTHCARE ALLIANCE PLAN", "methodology": "percent of total billed charges", "standard_charge_dollar": 393.58, "standard_charge_percentage": 48.59, "count": "0", "additional_payer_notes": "Zero final payments for the item or service in the 15 months prior to posting the file." }, { "payer_name": "BLUE SHIELD", "plan_name": "STANFORD HEALTHCARE ALLIANCE PLAN", "methodology": "percent of total billed charges", "standard_charge_dollar": 393.58, "standard_charge_percentage": 48.59, "count": "0", "additional_payer_notes": "Zero final payments for the item or service in the 15 months prior to posting the file." }, { "payer_name": "CIGNA", "plan_name": "CIGNA COM ALT HMO PLAN", "methodology": "percent of total billed charges", "standard_charge_dollar": 341.82, "standard_charge_percentage": 42.2, "count": "0", "additional_payer_notes": "Zero final payments for the item or service in the 15 months prior to posting the file." }, { "payer_name": "CIGNA", "plan_name": "CIGNA COM ALT HMO PLAN", "methodology": "percent of total billed charges", "standard_charge_dollar": 341.82, "standard_charge_percentage": 42.2, "count": "0", "additional_payer_notes": "Zero final payments for the item or service in the 15 months prior to posting the file." }, { "payer_name": "HEALTH NET", "plan_name": "HEALTHNET HMO, PPO, POS, EPO, CANOPY HEALTHNET HMO, OTHER-IN-NETWORK PLANS", "methodology": "per diem", "standard_charge_dollar": 8000.0, "standard_charge_algorithm": "Expected reimbursement is the lesser of Per diem ($8,000) for the length of stay and 70% of billed.", "count": "0", "additional_payer_notes": "Zero final payments for the item or service in the 15 months prior to posting the file." }, { "payer_name": "HEALTH NET", "plan_name": "HEALTHNET HMO, PPO, POS, EPO, CANOPY HEALTHNET HMO, OTHER-IN-NETWORK PLANS", "methodology": "per diem", "standard_charge_dollar": 8000.0, "standard_charge_algorithm": "Expected reimbursement is the lesser of Per diem ($8,000) for the length of stay and 70% of billed.", "count": "0", "additional_payer_notes": "Zero final payments for the item or service in the 15 months prior to posting the file." }, { "payer_name": "UNITED HEALTHCARE", "plan_name": "SUTTER SELECT & SUTTER HEALTH PLAN HMO PLANS", "methodology": "per diem", "standard_charge_dollar": 28538.0, "standard_charge_algorithm": "Per diem ($28,538).", "count": "0", "additional_payer_notes": "Zero final payments for the item or service in the 15 months prior to posting the file." }, { "payer_name": "UNITED HEALTHCARE", "plan_name": "SUTTER SELECT & SUTTER HEALTH PLAN HMO PLANS", "methodology": "per diem", "standard_charge_dollar": 28538.0, "standard_charge_algorithm": "Per diem ($28,538).", "count": "0", "additional_payer_notes": "Zero final payments for the item or service in the 15 months prior to posting the file." }, { "payer_name": "SUTTER", "plan_name": "SUTTER SELECT & SUTTER HEALTH PLAN HMO PLANS", "methodology": "per diem", "standard_charge_dollar": 28538.0, "standard_charge_algorithm": "Per diem ($28,538).", "count": "0", "additional_payer_notes": "Zero final payments for the item or service in the 15 months prior to posting the file." }, { "payer_name": "UNITED HEALTHCARE", "plan_name": "SUTTER SELECT & SUTTER HEALTH PLAN HMO PLANS", "methodology": "per diem", "standard_charge_dollar": 28538.0, "standard_charge_algorithm": "Per diem ($28,538).", "count": "0", "additional_payer_notes": "Zero final payments for the item or service in the 15 months prior to posting the file." }, { "payer_name": "UMR", "plan_name": "SUTTER SELECT & SUTTER HEALTH PLAN HMO PLANS", "methodology": "per diem", "standard_charge_dollar": 28538.0, "standard_charge_algorithm": "Per diem ($28,538).", "count": "0", "additional_payer_notes": "Zero final payments for the item or service in the 15 months prior to posting the file." } ] } ] }, { "description": "HC Bur Round Gp013", "code_information": [ { "code": "PX-2120020013", "type": "CDM" }, { "code": "99999", "type": "CPT" }, { "code": "0272", "type": "RC" } ], "standard_charges": [ { "setting": "outpatient", "gross_charge": 900.0, "discounted_cash": 450.0, "minimum": 379.8, "maximum": 468.0, "additional_generic_notes": "Zero final payments for the item or service in the 15 months prior to posting the file.", "payers_information": [ { "payer_name": "AETNA", "plan_name": "AETNA ALL OTHER PLANS", "methodology": "percent of total billed charges", "standard_charge_dollar": 468.0, "standard_charge_percentage": 52.0, "count": "0", "additional_payer_notes": "Zero final payments for the item or service in the 15 months prior to posting the file." }, { "payer_name": "AETNA", "plan_name": "AETNA ALL OTHER PLANS", "methodology": "percent of total billed charges", "standard_charge_dollar": 468.0, "standard_charge_percentage": 52.0, "count": "0", "additional_payer_notes": "Zero final payments for the item or service in the 15 months prior to posting the file." }, { "payer_name": "MERITAIN HEALTH", "plan_name": "AETNA ALL OTHER PLANS", "methodology": "percent of total billed charges", "standard_charge_dollar": 468.0, "standard_charge_percentage": 52.0, "count": "0", "additional_payer_notes": "Zero final payments for the item or service in the 15 months prior to posting the file." }, { "payer_name": "BLUE SHIELD OUT OF STATE", "plan_name": "STANFORD HEALTHCARE ALLIANCE PLAN", "methodology": "percent of total billed charges", "standard_charge_dollar": 437.31, "standard_charge_percentage": 48.59, "count": "0", "additional_payer_notes": "Zero final payments for the item or service in the 15 months prior to posting the file." }, { "payer_name": "BLUE SHIELD", "plan_name": "STANFORD HEALTHCARE ALLIANCE PLAN", "methodology": "percent of total billed charges", "standard_charge_dollar": 437.31, "standard_charge_percentage": 48.59, "count": "0", "additional_payer_notes": "Zero final payments for the item or service in the 15 months prior to posting the file." }, { "payer_name": "BLUE SHIELD", "plan_name": "STANFORD HEALTHCARE ALLIANCE PLAN", "methodology": "percent of total billed charges", "standard_charge_dollar": 437.31, "standard_charge_percentage": 48.59, "count": "0", "additional_payer_notes": "Zero final payments for the item or service in the 15 months prior to posting the file." }, { "payer_name": "CIGNA", "plan_name": "CIGNA COM ALT HMO PLAN", "methodology": "percent of total billed charges", "standard_charge_dollar": 379.8, "standard_charge_percentage": 42.2, "count": "0", "additional_payer_notes": "Zero final payments for the item or service in the 15 months prior to posting the file." }, { "payer_name": "CIGNA", "plan_name": "CIGNA COM ALT HMO PLAN", "methodology": "percent of total billed charges", "standard_charge_dollar": 379.8, "standard_charge_percentage": 42.2, "count": "0", "additional_payer_notes": "Zero final payments for the item or service in the 15 months prior to posting the file." }, { "payer_name": "HEALTH NET", "plan_name": "HEALTHNET HMO, PPO, POS, EPO, CANOPY HEALTHNET HMO, OTHER-IN-NETWORK PLANS", "methodology": "per diem", "standard_charge_dollar": 8000.0, "standard_charge_algorithm": "Expected reimbursement is the lesser of Per diem ($8,000) for the length of stay and 70% of billed.", "count": "0", "additional_payer_notes": "Zero final payments for the item or service in the 15 months prior to posting the file." }, { "payer_name": "HEALTH NET", "plan_name": "HEALTHNET HMO, PPO, POS, EPO, CANOPY HEALTHNET HMO, OTHER-IN-NETWORK PLANS", "methodology": "per diem", "standard_charge_dollar": 8000.0, "standard_charge_algorithm": "Expected reimbursement is the lesser of Per diem ($8,000) for the length of stay and 70% of billed.", "count": "0", "additional_payer_notes": "Zero final payments for the item or service in the 15 months prior to posting the file." }, { "payer_name": "UNITED HEALTHCARE", "plan_name": "SUTTER SELECT & SUTTER HEALTH PLAN HMO PLANS", "methodology": "per diem", "standard_charge_dollar": 28538.0, "standard_charge_algorithm": "Per diem ($28,538).", "count": "0", "additional_payer_notes": "Zero final payments for the item or service in the 15 months prior to posting the file." }, { "payer_name": "UNITED HEALTHCARE", "plan_name": "SUTTER SELECT & SUTTER HEALTH PLAN HMO PLANS", "methodology": "per diem", "standard_charge_dollar": 28538.0, "standard_charge_algorithm": "Per diem ($28,538).", "count": "0", "additional_payer_notes": "Zero final payments for the item or service in the 15 months prior to posting the file." }, { "payer_name": "SUTTER", "plan_name": "SUTTER SELECT & SUTTER HEALTH PLAN HMO PLANS", "methodology": "per diem", "standard_charge_dollar": 28538.0, "standard_charge_algorithm": "Per diem ($28,538).", "count": "0", "additional_payer_notes": "Zero final payments for the item or service in the 15 months prior to posting the file." }, { "payer_name": "UNITED HEALTHCARE", "plan_name": "SUTTER SELECT & SUTTER HEALTH PLAN HMO PLANS", "methodology": "per diem", "standard_charge_dollar": 28538.0, "standard_charge_algorithm": "Per diem ($28,538).", "count": "0", "additional_payer_notes": "Zero final payments for the item or service in the 15 months prior to posting the file." }, { "payer_name": "UMR", "plan_name": "SUTTER SELECT & SUTTER HEALTH PLAN HMO PLANS", "methodology": "per diem", "standard_charge_dollar": 28538.0, "standard_charge_algorithm": "Per diem ($28,538).", "count": "0", "additional_payer_notes": "Zero final payments for the item or service in the 15 months prior to posting the file." } ] } ] }, { "description": "HC Bur Round Gp014", "code_information": [ { "code": "PX-2120020014", "type": "CDM" }, { "code": "99999", "type": "CPT" }, { "code": "0272", "type": "RC" } ], "standard_charges": [ { "setting": "outpatient", "gross_charge": 1080.0, "discounted_cash": 540.0, "minimum": 455.76, "maximum": 561.6, "additional_generic_notes": "Zero final payments for the item or service in the 15 months prior to posting the file.", "payers_information": [ { "payer_name": "AETNA", "plan_name": "AETNA ALL OTHER PLANS", "methodology": "percent of total billed charges", "standard_charge_dollar": 561.6, "standard_charge_percentage": 52.0, "count": "0", "additional_payer_notes": "Zero final payments for the item or service in the 15 months prior to posting the file." }, { "payer_name": "AETNA", "plan_name": "AETNA ALL OTHER PLANS", "methodology": "percent of total billed charges", "standard_charge_dollar": 561.6, "standard_charge_percentage": 52.0, "count": "0", "additional_payer_notes": "Zero final payments for the item or service in the 15 months prior to posting the file." }, { "payer_name": "MERITAIN HEALTH", "plan_name": "AETNA ALL OTHER PLANS", "methodology": "percent of total billed charges", "standard_charge_dollar": 561.6, "standard_charge_percentage": 52.0, "count": "0", "additional_payer_notes": "Zero final payments for the item or service in the 15 months prior to posting the file." }, { "payer_name": "BLUE SHIELD OUT OF STATE", "plan_name": "STANFORD HEALTHCARE ALLIANCE PLAN", "methodology": "percent of total billed charges", "standard_charge_dollar": 524.77, "standard_charge_percentage": 48.59, "count": "0", "additional_payer_notes": "Zero final payments for the item or service in the 15 months prior to posting the file." }, { "payer_name": "BLUE SHIELD", "plan_name": "STANFORD HEALTHCARE ALLIANCE PLAN", "methodology": "percent of total billed charges", "standard_charge_dollar": 524.77, "standard_charge_percentage": 48.59, "median_amount": 68.24, "10th_percentile": 13.6, "90th_percentile": 1043.06, "count": "30" }, { "payer_name": "BLUE SHIELD", "plan_name": "STANFORD HEALTHCARE ALLIANCE PLAN", "methodology": "percent of total billed charges", "standard_charge_dollar": 524.77, "standard_charge_percentage": 48.59, "count": "0", "additional_payer_notes": "Zero final payments for the item or service in the 15 months prior to posting the file." }, { "payer_name": "BLUE SHIELD", "plan_name": "STANFORD HEALTHCARE ALLIANCE PLAN", "methodology": "percent of total billed charges", "standard_charge_dollar": 524.77, "standard_charge_percentage": 48.59, "count": "0", "additional_payer_notes": "Zero final payments for the item or service in the 15 months prior to posting the file." }, { "payer_name": "CIGNA", "plan_name": "CIGNA COM ALT HMO PLAN", "methodology": "percent of total billed charges", "standard_charge_dollar": 455.76, "standard_charge_percentage": 42.2, "count": "0", "additional_payer_notes": "Zero final payments for the item or service in the 15 months prior to posting the file." }, { "payer_name": "CIGNA", "plan_name": "CIGNA COM ALT HMO PLAN", "methodology": "percent of total billed charges", "standard_charge_dollar": 455.76, "standard_charge_percentage": 42.2, "count": "0", "additional_payer_notes": "Zero final payments for the item or service in the 15 months prior to posting the file." }, { "payer_name": "HEALTH NET", "plan_name": "HEALTHNET HMO, PPO, POS, EPO, CANOPY HEALTHNET HMO, OTHER-IN-NETWORK PLANS", "methodology": "per diem", "standard_charge_dollar": 8000.0, "standard_charge_algorithm": "Expected reimbursement is the lesser of Per diem ($8,000) for the length of stay and 70% of billed.", "count": "0", "additional_payer_notes": "Zero final payments for the item or service in the 15 months prior to posting the file." }, { "payer_name": "HEALTH NET", "plan_name": "HEALTHNET HMO, PPO, POS, EPO, CANOPY HEALTHNET HMO, OTHER-IN-NETWORK PLANS", "methodology": "per diem", "standard_charge_dollar": 8000.0, "standard_charge_algorithm": "Expected reimbursement is the lesser of Per diem ($8,000) for the length of stay and 70% of billed.", "count": "0", "additional_payer_notes": "Zero final payments for the item or service in the 15 months prior to posting the file." }, { "payer_name": "UNITED HEALTHCARE", "plan_name": "SUTTER SELECT & SUTTER HEALTH PLAN HMO PLANS", "methodology": "per diem", "standard_charge_dollar": 28538.0, "standard_charge_algorithm": "Per diem ($28,538).", "count": "0", "additional_payer_notes": "Zero final payments for the item or service in the 15 months prior to posting the file." }, { "payer_name": "UNITED HEALTHCARE", "plan_name": "SUTTER SELECT & SUTTER HEALTH PLAN HMO PLANS", "methodology": "per diem", "standard_charge_dollar": 28538.0, "standard_charge_algorithm": "Per diem ($28,538).", "count": "0", "additional_payer_notes": "Zero final payments for the item or service in the 15 months prior to posting the file." }, { "payer_name": "SUTTER", "plan_name": "SUTTER SELECT & SUTTER HEALTH PLAN HMO PLANS", "methodology": "per diem", "standard_charge_dollar": 28538.0, "standard_charge_algorithm": "Per diem ($28,538).", "count": "0", "additional_payer_notes": "Zero final payments for the item or service in the 15 months prior to posting the file." }, { "payer_name": "UNITED HEALTHCARE", "plan_name": "SUTTER SELECT & SUTTER HEALTH PLAN HMO PLANS", "methodology": "per diem", "standard_charge_dollar": 28538.0, "standard_charge_algorithm": "Per diem ($28,538).", "count": "0", "additional_payer_notes": "Zero final payments for the item or service in the 15 months prior to posting the file." }, { "payer_name": "UMR", "plan_name": "SUTTER SELECT & SUTTER HEALTH PLAN HMO PLANS", "methodology": "per diem", "standard_charge_dollar": 28538.0, "standard_charge_algorithm": "Per diem ($28,538).", "count": "0", "additional_payer_notes": "Zero final payments for the item or service in the 15 months prior to posting the file." } ] } ] }, { "description": "HC Bur Round Gp015", "code_information": [ { "code": "PX-2120020015", "type": "CDM" }, { "code": "99999", "type": "CPT" }, { "code": "0272", "type": "RC" } ], "standard_charges": [ { "setting": "outpatient", "gross_charge": 1225.0, "discounted_cash": 612.5, "minimum": 516.95, "maximum": 637.0, "additional_generic_notes": "Zero final payments for the item or service in the 15 months prior to posting the file.", "payers_information": [ { "payer_name": "AETNA", "plan_name": "AETNA ALL OTHER PLANS", "methodology": "percent of total billed charges", "standard_charge_dollar": 637.0, "standard_charge_percentage": 52.0, "count": "0", "additional_payer_notes": "Zero final payments for the item or service in the 15 months prior to posting the file." }, { "payer_name": "AETNA", "plan_name": "AETNA ALL OTHER PLANS", "methodology": "percent of total billed charges", "standard_charge_dollar": 637.0, "standard_charge_percentage": 52.0, "count": "0", "additional_payer_notes": "Zero final payments for the item or service in the 15 months prior to posting the file." }, { "payer_name": "MERITAIN HEALTH", "plan_name": "AETNA ALL OTHER PLANS", "methodology": "percent of total billed charges", "standard_charge_dollar": 637.0, "standard_charge_percentage": 52.0, "count": "0", "additional_payer_notes": "Zero final payments for the item or service in the 15 months prior to posting the file." }, { "payer_name": "BLUE SHIELD OUT OF STATE", "plan_name": "STANFORD HEALTHCARE ALLIANCE PLAN", "methodology": "percent of total billed charges", "standard_charge_dollar": 595.23, "standard_charge_percentage": 48.59, "count": "0", "additional_payer_notes": "Zero final payments for the item or service in the 15 months prior to posting the file." }, { "payer_name": "BLUE SHIELD", "plan_name": "STANFORD HEALTHCARE ALLIANCE PLAN", "methodology": "percent of total billed charges", "standard_charge_dollar": 595.23, "standard_charge_percentage": 48.59, "median_amount": 68.24, "10th_percentile": 13.6, "90th_percentile": 1043.06, "count": "30" }, { "payer_name": "BLUE SHIELD", "plan_name": "STANFORD HEALTHCARE ALLIANCE PLAN", "methodology": "percent of total billed charges", "standard_charge_dollar": 595.23, "standard_charge_percentage": 48.59, "count": "0", "additional_payer_notes": "Zero final payments for the item or service in the 15 months prior to posting the file." }, { "payer_name": "BLUE SHIELD", "plan_name": "STANFORD HEALTHCARE ALLIANCE PLAN", "methodology": "percent of total billed charges", "standard_charge_dollar": 595.23, "standard_charge_percentage": 48.59, "count": "0", "additional_payer_notes": "Zero final payments for the item or service in the 15 months prior to posting the file." }, { "payer_name": "CIGNA", "plan_name": "CIGNA COM ALT HMO PLAN", "methodology": "percent of total billed charges", "standard_charge_dollar": 516.95, "standard_charge_percentage": 42.2, "count": "0", "additional_payer_notes": "Zero final payments for the item or service in the 15 months prior to posting the file." }, { "payer_name": "CIGNA", "plan_name": "CIGNA COM ALT HMO PLAN", "methodology": "percent of total billed charges", "standard_charge_dollar": 516.95, "standard_charge_percentage": 42.2, "count": "0", "additional_payer_notes": "Zero final payments for the item or service in the 15 months prior to posting the file." }, { "payer_name": "HEALTH NET", "plan_name": "HEALTHNET HMO, PPO, POS, EPO, CANOPY HEALTHNET HMO, OTHER-IN-NETWORK PLANS", "methodology": "per diem", "standard_charge_dollar": 8000.0, "standard_charge_algorithm": "Expected reimbursement is the lesser of Per diem ($8,000) for the length of stay and 70% of billed.", "count": "0", "additional_payer_notes": "Zero final payments for the item or service in the 15 months prior to posting the file." }, { "payer_name": "HEALTH NET", "plan_name": "HEALTHNET HMO, PPO, POS, EPO, CANOPY HEALTHNET HMO, OTHER-IN-NETWORK PLANS", "methodology": "per diem", "standard_charge_dollar": 8000.0, "standard_charge_algorithm": "Expected reimbursement is the lesser of Per diem ($8,000) for the length of stay and 70% of billed.", "count": "0", "additional_payer_notes": "Zero final payments for the item or service in the 15 months prior to posting the file." }, { "payer_name": "UNITED HEALTHCARE", "plan_name": "SUTTER SELECT & SUTTER HEALTH PLAN HMO PLANS", "methodology": "per diem", "standard_charge_dollar": 28538.0, "standard_charge_algorithm": "Per diem ($28,538).", "count": "0", "additional_payer_notes": "Zero final payments for the item or service in the 15 months prior to posting the file." }, { "payer_name": "UNITED HEALTHCARE", "plan_name": "SUTTER SELECT & SUTTER HEALTH PLAN HMO PLANS", "methodology": "per diem", "standard_charge_dollar": 28538.0, "standard_charge_algorithm": "Per diem ($28,538).", "count": "0", "additional_payer_notes": "Zero final payments for the item or service in the 15 months prior to posting the file." }, { "payer_name": "SUTTER", "plan_name": "SUTTER SELECT & SUTTER HEALTH PLAN HMO PLANS", "methodology": "per diem", "standard_charge_dollar": 28538.0, "standard_charge_algorithm": "Per diem ($28,538).", "count": "0", "additional_payer_notes": "Zero final payments for the item or service in the 15 months prior to posting the file." }, { "payer_name": "UNITED HEALTHCARE", "plan_name": "SUTTER SELECT & SUTTER HEALTH PLAN HMO PLANS", "methodology": "per diem", "standard_charge_dollar": 28538.0, "standard_charge_algorithm": "Per diem ($28,538).", "count": "0", "additional_payer_notes": "Zero final payments for the item or service in the 15 months prior to posting the file." }, { "payer_name": "UMR", "plan_name": "SUTTER SELECT & SUTTER HEALTH PLAN HMO PLANS", "methodology": "per diem", "standard_charge_dollar": 28538.0, "standard_charge_algorithm": "Per diem ($28,538).", "count": "0", "additional_payer_notes": "Zero final payments for the item or service in the 15 months prior to posting the file." } ] } ] }, { "description": "HC Bur Round Gp016", "code_information": [ { "code": "PX-2120020016", "type": "CDM" }, { "code": "99999", "type": "CPT" }, { "code": "0272", "type": "RC" } ], "standard_charges": [ { "setting": "outpatient", "gross_charge": 1400.0, "discounted_cash": 700.0, "minimum": 590.8, "maximum": 728.0, "additional_generic_notes": "Zero final payments for the item or service in the 15 months prior to posting the file.", "payers_information": [ { "payer_name": "AETNA", "plan_name": "AETNA ALL OTHER PLANS", "methodology": "percent of total billed charges", "standard_charge_dollar": 728.0, "standard_charge_percentage": 52.0, "count": "0", "additional_payer_notes": "Zero final payments for the item or service in the 15 months prior to posting the file." }, { "payer_name": "AETNA", "plan_name": "AETNA ALL OTHER PLANS", "methodology": "percent of total billed charges", "standard_charge_dollar": 728.0, "standard_charge_percentage": 52.0, "count": "0", "additional_payer_notes": "Zero final payments for the item or service in the 15 months prior to posting the file." }, { "payer_name": "MERITAIN HEALTH", "plan_name": "AETNA ALL OTHER PLANS", "methodology": "percent of total billed charges", "standard_charge_dollar": 728.0, "standard_charge_percentage": 52.0, "count": "0", "additional_payer_notes": "Zero final payments for the item or service in the 15 months prior to posting the file." }, { "payer_name": "BLUE SHIELD OUT OF STATE", "plan_name": "STANFORD HEALTHCARE ALLIANCE PLAN", "methodology": "percent of total billed charges", "standard_charge_dollar": 680.26, "standard_charge_percentage": 48.59, "count": "0", "additional_payer_notes": "Zero final payments for the item or service in the 15 months prior to posting the file." }, { "payer_name": "BLUE SHIELD", "plan_name": "STANFORD HEALTHCARE ALLIANCE PLAN", "methodology": "percent of total billed charges", "standard_charge_dollar": 680.26, "standard_charge_percentage": 48.59, "median_amount": 68.24, "10th_percentile": 13.6, "90th_percentile": 1043.06, "count": "30" }, { "payer_name": "BLUE SHIELD", "plan_name": "STANFORD HEALTHCARE ALLIANCE PLAN", "methodology": "percent of total billed charges", "standard_charge_dollar": 680.26, "standard_charge_percentage": 48.59, "count": "0", "additional_payer_notes": "Zero final payments for the item or service in the 15 months prior to posting the file." }, { "payer_name": "BLUE SHIELD", "plan_name": "STANFORD HEALTHCARE ALLIANCE PLAN", "methodology": "percent of total billed charges", "standard_charge_dollar": 680.26, "standard_charge_percentage": 48.59, "count": "0", "additional_payer_notes": "Zero final payments for the item or service in the 15 months prior to posting the file." }, { "payer_name": "CIGNA", "plan_name": "CIGNA COM ALT HMO PLAN", "methodology": "percent of total billed charges", "standard_charge_dollar": 590.8, "standard_charge_percentage": 42.2, "count": "0", "additional_payer_notes": "Zero final payments for the item or service in the 15 months prior to posting the file." }, { "payer_name": "CIGNA", "plan_name": "CIGNA COM ALT HMO PLAN", "methodology": "percent of total billed charges", "standard_charge_dollar": 590.8, "standard_charge_percentage": 42.2, "count": "0", "additional_payer_notes": "Zero final payments for the item or service in the 15 months prior to posting the file." }, { "payer_name": "HEALTH NET", "plan_name": "HEALTHNET HMO, PPO, POS, EPO, CANOPY HEALTHNET HMO, OTHER-IN-NETWORK PLANS", "methodology": "per diem", "standard_charge_dollar": 8000.0, "standard_charge_algorithm": "Expected reimbursement is the lesser of Per diem ($8,000) for the length of stay and 70% of billed.", "count": "0", "additional_payer_notes": "Zero final payments for the item or service in the 15 months prior to posting the file." }, { "payer_name": "HEALTH NET", "plan_name": "HEALTHNET HMO, PPO, POS, EPO, CANOPY HEALTHNET HMO, OTHER-IN-NETWORK PLANS", "methodology": "per diem", "standard_charge_dollar": 8000.0, "standard_charge_algorithm": "Expected reimbursement is the lesser of Per diem ($8,000) for the length of stay and 70% of billed.", "count": "0", "additional_payer_notes": "Zero final payments for the item or service in the 15 months prior to posting the file." }, { "payer_name": "UNITED HEALTHCARE", "plan_name": "SUTTER SELECT & SUTTER HEALTH PLAN HMO PLANS", "methodology": "per diem", "standard_charge_dollar": 28538.0, "standard_charge_algorithm": "Per diem ($28,538).", "count": "0", "additional_payer_notes": "Zero final payments for the item or service in the 15 months prior to posting the file." }, { "payer_name": "UNITED HEALTHCARE", "plan_name": "SUTTER SELECT & SUTTER HEALTH PLAN HMO PLANS", "methodology": "per diem", "standard_charge_dollar": 28538.0, "standard_charge_algorithm": "Per diem ($28,538).", "count": "0", "additional_payer_notes": "Zero final payments for the item or service in the 15 months prior to posting the file." }, { "payer_name": "SUTTER", "plan_name": "SUTTER SELECT & SUTTER HEALTH PLAN HMO PLANS", "methodology": "per diem", "standard_charge_dollar": 28538.0, "standard_charge_algorithm": "Per diem ($28,538).", "count": "0", "additional_payer_notes": "Zero final payments for the item or service in the 15 months prior to posting the file." }, { "payer_name": "UNITED HEALTHCARE", "plan_name": "SUTTER SELECT & SUTTER HEALTH PLAN HMO PLANS", "methodology": "per diem", "standard_charge_dollar": 28538.0, "standard_charge_algorithm": "Per diem ($28,538).", "count": "0", "additional_payer_notes": "Zero final payments for the item or service in the 15 months prior to posting the file." }, { "payer_name": "UMR", "plan_name": "SUTTER SELECT & SUTTER HEALTH PLAN HMO PLANS", "methodology": "per diem", "standard_charge_dollar": 28538.0, "standard_charge_algorithm": "Per diem ($28,538).", "count": "0", "additional_payer_notes": "Zero final payments for the item or service in the 15 months prior to posting the file." } ] } ] }, { "description": "HC Bur Round Gp017", "code_information": [ { "code": "PX-2120020017", "type": "CDM" }, { "code": "99999", "type": "CPT" }, { "code": "0272", "type": "RC" } ], "standard_charges": [ { "setting": "outpatient", "gross_charge": 1575.0, "discounted_cash": 787.5, "minimum": 664.65, "maximum": 819.0, "additional_generic_notes": "Zero final payments for the item or service in the 15 months prior to posting the file.", "payers_information": [ { "payer_name": "AETNA", "plan_name": "AETNA ALL OTHER PLANS", "methodology": "percent of total billed charges", "standard_charge_dollar": 819.0, "standard_charge_percentage": 52.0, "count": "0", "additional_payer_notes": "Zero final payments for the item or service in the 15 months prior to posting the file." }, { "payer_name": "AETNA", "plan_name": "AETNA ALL OTHER PLANS", "methodology": "percent of total billed charges", "standard_charge_dollar": 819.0, "standard_charge_percentage": 52.0, "count": "0", "additional_payer_notes": "Zero final payments for the item or service in the 15 months prior to posting the file." }, { "payer_name": "MERITAIN HEALTH", "plan_name": "AETNA ALL OTHER PLANS", "methodology": "percent of total billed charges", "standard_charge_dollar": 819.0, "standard_charge_percentage": 52.0, "count": "0", "additional_payer_notes": "Zero final payments for the item or service in the 15 months prior to posting the file." }, { "payer_name": "BLUE SHIELD OUT OF STATE", "plan_name": "STANFORD HEALTHCARE ALLIANCE PLAN", "methodology": "percent of total billed charges", "standard_charge_dollar": 765.29, "standard_charge_percentage": 48.59, "count": "0", "additional_payer_notes": "Zero final payments for the item or service in the 15 months prior to posting the file." }, { "payer_name": "BLUE SHIELD", "plan_name": "STANFORD HEALTHCARE ALLIANCE PLAN", "methodology": "percent of total billed charges", "standard_charge_dollar": 765.29, "standard_charge_percentage": 48.59, "median_amount": 68.24, "10th_percentile": 13.6, "90th_percentile": 1043.06, "count": "30" }, { "payer_name": "BLUE SHIELD", "plan_name": "STANFORD HEALTHCARE ALLIANCE PLAN", "methodology": "percent of total billed charges", "standard_charge_dollar": 765.29, "standard_charge_percentage": 48.59, "count": "0", "additional_payer_notes": "Zero final payments for the item or service in the 15 months prior to posting the file." }, { "payer_name": "BLUE SHIELD", "plan_name": "STANFORD HEALTHCARE ALLIANCE PLAN", "methodology": "percent of total billed charges", "standard_charge_dollar": 765.29, "standard_charge_percentage": 48.59, "count": "0", "additional_payer_notes": "Zero final payments for the item or service in the 15 months prior to posting the file." }, { "payer_name": "CIGNA", "plan_name": "CIGNA COM ALT HMO PLAN", "methodology": "percent of total billed charges", "standard_charge_dollar": 664.65, "standard_charge_percentage": 42.2, "count": "0", "additional_payer_notes": "Zero final payments for the item or service in the 15 months prior to posting the file." }, { "payer_name": "CIGNA", "plan_name": "CIGNA COM ALT HMO PLAN", "methodology": "percent of total billed charges", "standard_charge_dollar": 664.65, "standard_charge_percentage": 42.2, "count": "0", "additional_payer_notes": "Zero final payments for the item or service in the 15 months prior to posting the file." }, { "payer_name": "HEALTH NET", "plan_name": "HEALTHNET HMO, PPO, POS, EPO, CANOPY HEALTHNET HMO, OTHER-IN-NETWORK PLANS", "methodology": "per diem", "standard_charge_dollar": 8000.0, "standard_charge_algorithm": "Expected reimbursement is the lesser of Per diem ($8,000) for the length of stay and 70% of billed.", "count": "0", "additional_payer_notes": "Zero final payments for the item or service in the 15 months prior to posting the file." }, { "payer_name": "HEALTH NET", "plan_name": "HEALTHNET HMO, PPO, POS, EPO, CANOPY HEALTHNET HMO, OTHER-IN-NETWORK PLANS", "methodology": "per diem", "standard_charge_dollar": 8000.0, "standard_charge_algorithm": "Expected reimbursement is the lesser of Per diem ($8,000) for the length of stay and 70% of billed.", "count": "0", "additional_payer_notes": "Zero final payments for the item or service in the 15 months prior to posting the file." }, { "payer_name": "UNITED HEALTHCARE", "plan_name": "SUTTER SELECT & SUTTER HEALTH PLAN HMO PLANS", "methodology": "per diem", "standard_charge_dollar": 28538.0, "standard_charge_algorithm": "Per diem ($28,538).", "count": "0", "additional_payer_notes": "Zero final payments for the item or service in the 15 months prior to posting the file." }, { "payer_name": "UNITED HEALTHCARE", "plan_name": "SUTTER SELECT & SUTTER HEALTH PLAN HMO PLANS", "methodology": "per diem", "standard_charge_dollar": 28538.0, "standard_charge_algorithm": "Per diem ($28,538).", "count": "0", "additional_payer_notes": "Zero final payments for the item or service in the 15 months prior to posting the file." }, { "payer_name": "SUTTER", "plan_name": "SUTTER SELECT & SUTTER HEALTH PLAN HMO PLANS", "methodology": "per diem", "standard_charge_dollar": 28538.0, "standard_charge_algorithm": "Per diem ($28,538).", "count": "0", "additional_payer_notes": "Zero final payments for the item or service in the 15 months prior to posting the file." }, { "payer_name": "UNITED HEALTHCARE", "plan_name": "SUTTER SELECT & SUTTER HEALTH PLAN HMO PLANS", "methodology": "per diem", "standard_charge_dollar": 28538.0, "standard_charge_algorithm": "Per diem ($28,538).", "count": "0", "additional_payer_notes": "Zero final payments for the item or service in the 15 months prior to posting the file." }, { "payer_name": "UMR", "plan_name": "SUTTER SELECT & SUTTER HEALTH PLAN HMO PLANS", "methodology": "per diem", "standard_charge_dollar": 28538.0, "standard_charge_algorithm": "Per diem ($28,538).", "count": "0", "additional_payer_notes": "Zero final payments for the item or service in the 15 months prior to posting the file." } ] } ] }, { "description": "HC Bur Round Gp018", "code_information": [ { "code": "PX-2120020018", "type": "CDM" }, { "code": "99999", "type": "CPT" }, { "code": "0272", "type": "RC" } ], "standard_charges": [ { "setting": "outpatient", "gross_charge": 1750.0, "discounted_cash": 875.0, "minimum": 738.5, "maximum": 910.0, "additional_generic_notes": "Zero final payments for the item or service in the 15 months prior to posting the file.", "payers_information": [ { "payer_name": "AETNA", "plan_name": "AETNA ALL OTHER PLANS", "methodology": "percent of total billed charges", "standard_charge_dollar": 910.0, "standard_charge_percentage": 52.0, "count": "0", "additional_payer_notes": "Zero final payments for the item or service in the 15 months prior to posting the file." }, { "payer_name": "AETNA", "plan_name": "AETNA ALL OTHER PLANS", "methodology": "percent of total billed charges", "standard_charge_dollar": 910.0, "standard_charge_percentage": 52.0, "count": "0", "additional_payer_notes": "Zero final payments for the item or service in the 15 months prior to posting the file." }, { "payer_name": "MERITAIN HEALTH", "plan_name": "AETNA ALL OTHER PLANS", "methodology": "percent of total billed charges", "standard_charge_dollar": 910.0, "standard_charge_percentage": 52.0, "count": "0", "additional_payer_notes": "Zero final payments for the item or service in the 15 months prior to posting the file." }, { "payer_name": "BLUE SHIELD OUT OF STATE", "plan_name": "STANFORD HEALTHCARE ALLIANCE PLAN", "methodology": "percent of total billed charges", "standard_charge_dollar": 850.33, "standard_charge_percentage": 48.59, "count": "0", "additional_payer_notes": "Zero final payments for the item or service in the 15 months prior to posting the file." }, { "payer_name": "BLUE SHIELD", "plan_name": "STANFORD HEALTHCARE ALLIANCE PLAN", "methodology": "percent of total billed charges", "standard_charge_dollar": 850.33, "standard_charge_percentage": 48.59, "median_amount": 68.24, "10th_percentile": 13.6, "90th_percentile": 1043.06, "count": "30" }, { "payer_name": "BLUE SHIELD", "plan_name": "STANFORD HEALTHCARE ALLIANCE PLAN", "methodology": "percent of total billed charges", "standard_charge_dollar": 850.33, "standard_charge_percentage": 48.59, "count": "0", "additional_payer_notes": "Zero final payments for the item or service in the 15 months prior to posting the file." }, { "payer_name": "BLUE SHIELD", "plan_name": "STANFORD HEALTHCARE ALLIANCE PLAN", "methodology": "percent of total billed charges", "standard_charge_dollar": 850.33, "standard_charge_percentage": 48.59, "count": "0", "additional_payer_notes": "Zero final payments for the item or service in the 15 months prior to posting the file." }, { "payer_name": "CIGNA", "plan_name": "CIGNA COM ALT HMO PLAN", "methodology": "percent of total billed charges", "standard_charge_dollar": 738.5, "standard_charge_percentage": 42.2, "count": "0", "additional_payer_notes": "Zero final payments for the item or service in the 15 months prior to posting the file." }, { "payer_name": "CIGNA", "plan_name": "CIGNA COM ALT HMO PLAN", "methodology": "percent of total billed charges", "standard_charge_dollar": 738.5, "standard_charge_percentage": 42.2, "count": "0", "additional_payer_notes": "Zero final payments for the item or service in the 15 months prior to posting the file." }, { "payer_name": "HEALTH NET", "plan_name": "HEALTHNET HMO, PPO, POS, EPO, CANOPY HEALTHNET HMO, OTHER-IN-NETWORK PLANS", "methodology": "per diem", "standard_charge_dollar": 8000.0, "standard_charge_algorithm": "Expected reimbursement is the lesser of Per diem ($8,000) for the length of stay and 70% of billed.", "count": "0", "additional_payer_notes": "Zero final payments for the item or service in the 15 months prior to posting the file." }, { "payer_name": "HEALTH NET", "plan_name": "HEALTHNET HMO, PPO, POS, EPO, CANOPY HEALTHNET HMO, OTHER-IN-NETWORK PLANS", "methodology": "per diem", "standard_charge_dollar": 8000.0, "standard_charge_algorithm": "Expected reimbursement is the lesser of Per diem ($8,000) for the length of stay and 70% of billed.", "count": "0", "additional_payer_notes": "Zero final payments for the item or service in the 15 months prior to posting the file." }, { "payer_name": "UNITED HEALTHCARE", "plan_name": "SUTTER SELECT & SUTTER HEALTH PLAN HMO PLANS", "methodology": "per diem", "standard_charge_dollar": 28538.0, "standard_charge_algorithm": "Per diem ($28,538).", "count": "0", "additional_payer_notes": "Zero final payments for the item or service in the 15 months prior to posting the file." }, { "payer_name": "UNITED HEALTHCARE", "plan_name": "SUTTER SELECT & SUTTER HEALTH PLAN HMO PLANS", "methodology": "per diem", "standard_charge_dollar": 28538.0, "standard_charge_algorithm": "Per diem ($28,538).", "count": "0", "additional_payer_notes": "Zero final payments for the item or service in the 15 months prior to posting the file." }, { "payer_name": "SUTTER", "plan_name": "SUTTER SELECT & SUTTER HEALTH PLAN HMO PLANS", "methodology": "per diem", "standard_charge_dollar": 28538.0, "standard_charge_algorithm": "Per diem ($28,538).", "count": "0", "additional_payer_notes": "Zero final payments for the item or service in the 15 months prior to posting the file." }, { "payer_name": "UNITED HEALTHCARE", "plan_name": "SUTTER SELECT & SUTTER HEALTH PLAN HMO PLANS", "methodology": "per diem", "standard_charge_dollar": 28538.0, "standard_charge_algorithm": "Per diem ($28,538).", "count": "0", "additional_payer_notes": "Zero final payments for the item or service in the 15 months prior to posting the file." }, { "payer_name": "UMR", "plan_name": "SUTTER SELECT & SUTTER HEALTH PLAN HMO PLANS", "methodology": "per diem", "standard_charge_dollar": 28538.0, "standard_charge_algorithm": "Per diem ($28,538).", "count": "0", "additional_payer_notes": "Zero final payments for the item or service in the 15 months prior to posting the file." } ] } ] }, { "description": "Hc Bur Round Gp021", "code_information": [ { "code": "PX-2120020021", "type": "CDM" }, { "code": "99999", "type": "CPT" }, { "code": "0272", "type": "RC" } ], "standard_charges": [ { "setting": "outpatient", "gross_charge": 2888.0, "discounted_cash": 1444.0, "minimum": 1218.74, "maximum": 1501.76, "additional_generic_notes": "Zero final payments for the item or service in the 15 months prior to posting the file.", "payers_information": [ { "payer_name": "AETNA", "plan_name": "AETNA ALL OTHER PLANS", "methodology": "percent of total billed charges", "standard_charge_dollar": 1501.76, "standard_charge_percentage": 52.0, "count": "0", "additional_payer_notes": "Zero final payments for the item or service in the 15 months prior to posting the file." }, { "payer_name": "AETNA", "plan_name": "AETNA ALL OTHER PLANS", "methodology": "percent of total billed charges", "standard_charge_dollar": 1501.76, "standard_charge_percentage": 52.0, "count": "0", "additional_payer_notes": "Zero final payments for the item or service in the 15 months prior to posting the file." }, { "payer_name": "MERITAIN HEALTH", "plan_name": "AETNA ALL OTHER PLANS", "methodology": "percent of total billed charges", "standard_charge_dollar": 1501.76, "standard_charge_percentage": 52.0, "count": "0", "additional_payer_notes": "Zero final payments for the item or service in the 15 months prior to posting the file." }, { "payer_name": "BLUE SHIELD OUT OF STATE", "plan_name": "STANFORD HEALTHCARE ALLIANCE PLAN", "methodology": "percent of total billed charges", "standard_charge_dollar": 1403.28, "standard_charge_percentage": 48.59, "count": "0", "additional_payer_notes": "Zero final payments for the item or service in the 15 months prior to posting the file." }, { "payer_name": "BLUE SHIELD", "plan_name": "STANFORD HEALTHCARE ALLIANCE PLAN", "methodology": "percent of total billed charges", "standard_charge_dollar": 1403.28, "standard_charge_percentage": 48.59, "median_amount": 68.24, "10th_percentile": 13.6, "90th_percentile": 1043.06, "count": "30" }, { "payer_name": "BLUE SHIELD", "plan_name": "STANFORD HEALTHCARE ALLIANCE PLAN", "methodology": "percent of total billed charges", "standard_charge_dollar": 1403.28, "standard_charge_percentage": 48.59, "count": "0", "additional_payer_notes": "Zero final payments for the item or service in the 15 months prior to posting the file." }, { "payer_name": "BLUE SHIELD", "plan_name": "STANFORD HEALTHCARE ALLIANCE PLAN", "methodology": "percent of total billed charges", "standard_charge_dollar": 1403.28, "standard_charge_percentage": 48.59, "count": "0", "additional_payer_notes": "Zero final payments for the item or service in the 15 months prior to posting the file." }, { "payer_name": "CIGNA", "plan_name": "CIGNA COM ALT HMO PLAN", "methodology": "percent of total billed charges", "standard_charge_dollar": 1218.74, "standard_charge_percentage": 42.2, "count": "0", "additional_payer_notes": "Zero final payments for the item or service in the 15 months prior to posting the file." }, { "payer_name": "CIGNA", "plan_name": "CIGNA COM ALT HMO PLAN", "methodology": "percent of total billed charges", "standard_charge_dollar": 1218.74, "standard_charge_percentage": 42.2, "count": "0", "additional_payer_notes": "Zero final payments for the item or service in the 15 months prior to posting the file." }, { "payer_name": "HEALTH NET", "plan_name": "HEALTHNET HMO, PPO, POS, EPO, CANOPY HEALTHNET HMO, OTHER-IN-NETWORK PLANS", "methodology": "per diem", "standard_charge_dollar": 8000.0, "standard_charge_algorithm": "Expected reimbursement is the lesser of Per diem ($8,000) for the length of stay and 70% of billed.", "count": "0", "additional_payer_notes": "Zero final payments for the item or service in the 15 months prior to posting the file." }, { "payer_name": "HEALTH NET", "plan_name": "HEALTHNET HMO, PPO, POS, EPO, CANOPY HEALTHNET HMO, OTHER-IN-NETWORK PLANS", "methodology": "per diem", "standard_charge_dollar": 8000.0, "standard_charge_algorithm": "Expected reimbursement is the lesser of Per diem ($8,000) for the length of stay and 70% of billed.", "count": "0", "additional_payer_notes": "Zero final payments for the item or service in the 15 months prior to posting the file." }, { "payer_name": "UNITED HEALTHCARE", "plan_name": "SUTTER SELECT & SUTTER HEALTH PLAN HMO PLANS", "methodology": "per diem", "standard_charge_dollar": 28538.0, "standard_charge_algorithm": "Per diem ($28,538).", "count": "0", "additional_payer_notes": "Zero final payments for the item or service in the 15 months prior to posting the file." }, { "payer_name": "UNITED HEALTHCARE", "plan_name": "SUTTER SELECT & SUTTER HEALTH PLAN HMO PLANS", "methodology": "per diem", "standard_charge_dollar": 28538.0, "standard_charge_algorithm": "Per diem ($28,538).", "count": "0", "additional_payer_notes": "Zero final payments for the item or service in the 15 months prior to posting the file." }, { "payer_name": "SUTTER", "plan_name": "SUTTER SELECT & SUTTER HEALTH PLAN HMO PLANS", "methodology": "per diem", "standard_charge_dollar": 28538.0, "standard_charge_algorithm": "Per diem ($28,538).", "count": "0", "additional_payer_notes": "Zero final payments for the item or service in the 15 months prior to posting the file." }, { "payer_name": "UNITED HEALTHCARE", "plan_name": "SUTTER SELECT & SUTTER HEALTH PLAN HMO PLANS", "methodology": "per diem", "standard_charge_dollar": 28538.0, "standard_charge_algorithm": "Per diem ($28,538).", "count": "0", "additional_payer_notes": "Zero final payments for the item or service in the 15 months prior to posting the file." }, { "payer_name": "UMR", "plan_name": "SUTTER SELECT & SUTTER HEALTH PLAN HMO PLANS", "methodology": "per diem", "standard_charge_dollar": 28538.0, "standard_charge_algorithm": "Per diem ($28,538).", "count": "0", "additional_payer_notes": "Zero final payments for the item or service in the 15 months prior to posting the file." } ] } ] }, { "description": "HC Bur Wire Pass Gp002", "code_information": [ { "code": "PX-2120021002", "type": "CDM" }, { "code": "99999", "type": "CPT" }, { "code": "0272", "type": "RC" } ], "standard_charges": [ { "setting": "outpatient", "gross_charge": 50.0, "discounted_cash": 25.0, "minimum": 21.1, "maximum": 26.0, "additional_generic_notes": "Zero final payments for the item or service in the 15 months prior to posting the file.", "payers_information": [ { "payer_name": "AETNA", "plan_name": "AETNA ALL OTHER PLANS", "methodology": "percent of total billed charges", "standard_charge_dollar": 26.0, "standard_charge_percentage": 52.0, "count": "0", "additional_payer_notes": "Zero final payments for the item or service in the 15 months prior to posting the file." }, { "payer_name": "AETNA", "plan_name": "AETNA ALL OTHER PLANS", "methodology": "percent of total billed charges", "standard_charge_dollar": 26.0, "standard_charge_percentage": 52.0, "count": "0", "additional_payer_notes": "Zero final payments for the item or service in the 15 months prior to posting the file." }, { "payer_name": "MERITAIN HEALTH", "plan_name": "AETNA ALL OTHER PLANS", "methodology": "percent of total billed charges", "standard_charge_dollar": 26.0, "standard_charge_percentage": 52.0, "count": "0", "additional_payer_notes": "Zero final payments for the item or service in the 15 months prior to posting the file." }, { "payer_name": "BLUE SHIELD OUT OF STATE", "plan_name": "STANFORD HEALTHCARE ALLIANCE PLAN", "methodology": "percent of total billed charges", "standard_charge_dollar": 24.3, "standard_charge_percentage": 48.59, "count": "0", "additional_payer_notes": "Zero final payments for the item or service in the 15 months prior to posting the file." }, { "payer_name": "BLUE SHIELD", "plan_name": "STANFORD HEALTHCARE ALLIANCE PLAN", "methodology": "percent of total billed charges", "standard_charge_dollar": 24.3, "standard_charge_percentage": 48.59, "count": "0", "additional_payer_notes": "Zero final payments for the item or service in the 15 months prior to posting the file." }, { "payer_name": "BLUE SHIELD", "plan_name": "STANFORD HEALTHCARE ALLIANCE PLAN", "methodology": "percent of total billed charges", "standard_charge_dollar": 24.3, "standard_charge_percentage": 48.59, "count": "0", "additional_payer_notes": "Zero final payments for the item or service in the 15 months prior to posting the file." }, { "payer_name": "CIGNA", "plan_name": "CIGNA COM ALT HMO PLAN", "methodology": "percent of total billed charges", "standard_charge_dollar": 21.1, "standard_charge_percentage": 42.2, "count": "0", "additional_payer_notes": "Zero final payments for the item or service in the 15 months prior to posting the file." }, { "payer_name": "CIGNA", "plan_name": "CIGNA COM ALT HMO PLAN", "methodology": "percent of total billed charges", "standard_charge_dollar": 21.1, "standard_charge_percentage": 42.2, "count": "0", "additional_payer_notes": "Zero final payments for the item or service in the 15 months prior to posting the file." }, { "payer_name": "HEALTH NET", "plan_name": "HEALTHNET HMO, PPO, POS, EPO, CANOPY HEALTHNET HMO, OTHER-IN-NETWORK PLANS", "methodology": "per diem", "standard_charge_dollar": 8000.0, "standard_charge_algorithm": "Expected reimbursement is the lesser of Per diem ($8,000) for the length of stay and 70% of billed.", "count": "0", "additional_payer_notes": "Zero final payments for the item or service in the 15 months prior to posting the file." }, { "payer_name": "HEALTH NET", "plan_name": "HEALTHNET HMO, PPO, POS, EPO, CANOPY HEALTHNET HMO, OTHER-IN-NETWORK PLANS", "methodology": "per diem", "standard_charge_dollar": 8000.0, "standard_charge_algorithm": "Expected reimbursement is the lesser of Per diem ($8,000) for the length of stay and 70% of billed.", "count": "0", "additional_payer_notes": "Zero final payments for the item or service in the 15 months prior to posting the file." }, { "payer_name": "UNITED HEALTHCARE", "plan_name": "SUTTER SELECT & SUTTER HEALTH PLAN HMO PLANS", "methodology": "per diem", "standard_charge_dollar": 28538.0, "standard_charge_algorithm": "Per diem ($28,538).", "count": "0", "additional_payer_notes": "Zero final payments for the item or service in the 15 months prior to posting the file." }, { "payer_name": "UNITED HEALTHCARE", "plan_name": "SUTTER SELECT & SUTTER HEALTH PLAN HMO PLANS", "methodology": "per diem", "standard_charge_dollar": 28538.0, "standard_charge_algorithm": "Per diem ($28,538).", "count": "0", "additional_payer_notes": "Zero final payments for the item or service in the 15 months prior to posting the file." }, { "payer_name": "SUTTER", "plan_name": "SUTTER SELECT & SUTTER HEALTH PLAN HMO PLANS", "methodology": "per diem", "standard_charge_dollar": 28538.0, "standard_charge_algorithm": "Per diem ($28,538).", "count": "0", "additional_payer_notes": "Zero final payments for the item or service in the 15 months prior to posting the file." }, { "payer_name": "UNITED HEALTHCARE", "plan_name": "SUTTER SELECT & SUTTER HEALTH PLAN HMO PLANS", "methodology": "per diem", "standard_charge_dollar": 28538.0, "standard_charge_algorithm": "Per diem ($28,538).", "count": "0", "additional_payer_notes": "Zero final payments for the item or service in the 15 months prior to posting the file." }, { "payer_name": "UMR", "plan_name": "SUTTER SELECT & SUTTER HEALTH PLAN HMO PLANS", "methodology": "per diem", "standard_charge_dollar": 28538.0, "standard_charge_algorithm": "Per diem ($28,538).", "count": "0", "additional_payer_notes": "Zero final payments for the item or service in the 15 months prior to posting the file." } ] } ] }, { "description": "HC Bur Wire Pass Gp004", "code_information": [ { "code": "PX-2120021004", "type": "CDM" }, { "code": "99999", "type": "CPT" }, { "code": "0272", "type": "RC" } ], "standard_charges": [ { "setting": "outpatient", "gross_charge": 146.0, "discounted_cash": 73.0, "minimum": 61.61, "maximum": 75.92, "additional_generic_notes": "Zero final payments for the item or service in the 15 months prior to posting the file.", "payers_information": [ { "payer_name": "AETNA", "plan_name": "AETNA ALL OTHER PLANS", "methodology": "percent of total billed charges", "standard_charge_dollar": 75.92, "standard_charge_percentage": 52.0, "count": "0", "additional_payer_notes": "Zero final payments for the item or service in the 15 months prior to posting the file." }, { "payer_name": "AETNA", "plan_name": "AETNA ALL OTHER PLANS", "methodology": "percent of total billed charges", "standard_charge_dollar": 75.92, "standard_charge_percentage": 52.0, "count": "0", "additional_payer_notes": "Zero final payments for the item or service in the 15 months prior to posting the file." }, { "payer_name": "MERITAIN HEALTH", "plan_name": "AETNA ALL OTHER PLANS", "methodology": "percent of total billed charges", "standard_charge_dollar": 75.92, "standard_charge_percentage": 52.0, "count": "0", "additional_payer_notes": "Zero final payments for the item or service in the 15 months prior to posting the file." }, { "payer_name": "BLUE SHIELD OUT OF STATE", "plan_name": "STANFORD HEALTHCARE ALLIANCE PLAN", "methodology": "percent of total billed charges", "standard_charge_dollar": 70.94, "standard_charge_percentage": 48.59, "count": "0", "additional_payer_notes": "Zero final payments for the item or service in the 15 months prior to posting the file." }, { "payer_name": "BLUE SHIELD", "plan_name": "STANFORD HEALTHCARE ALLIANCE PLAN", "methodology": "percent of total billed charges", "standard_charge_dollar": 70.94, "standard_charge_percentage": 48.59, "count": "0", "additional_payer_notes": "Zero final payments for the item or service in the 15 months prior to posting the file." }, { "payer_name": "BLUE SHIELD", "plan_name": "STANFORD HEALTHCARE ALLIANCE PLAN", "methodology": "percent of total billed charges", "standard_charge_dollar": 70.94, "standard_charge_percentage": 48.59, "count": "0", "additional_payer_notes": "Zero final payments for the item or service in the 15 months prior to posting the file." }, { "payer_name": "CIGNA", "plan_name": "CIGNA COM ALT HMO PLAN", "methodology": "percent of total billed charges", "standard_charge_dollar": 61.61, "standard_charge_percentage": 42.2, "count": "0", "additional_payer_notes": "Zero final payments for the item or service in the 15 months prior to posting the file." }, { "payer_name": "CIGNA", "plan_name": "CIGNA COM ALT HMO PLAN", "methodology": "percent of total billed charges", "standard_charge_dollar": 61.61, "standard_charge_percentage": 42.2, "count": "0", "additional_payer_notes": "Zero final payments for the item or service in the 15 months prior to posting the file." }, { "payer_name": "HEALTH NET", "plan_name": "HEALTHNET HMO, PPO, POS, EPO, CANOPY HEALTHNET HMO, OTHER-IN-NETWORK PLANS", "methodology": "per diem", "standard_charge_dollar": 8000.0, "standard_charge_algorithm": "Expected reimbursement is the lesser of Per diem ($8,000) for the length of stay and 70% of billed.", "count": "0", "additional_payer_notes": "Zero final payments for the item or service in the 15 months prior to posting the file." }, { "payer_name": "HEALTH NET", "plan_name": "HEALTHNET HMO, PPO, POS, EPO, CANOPY HEALTHNET HMO, OTHER-IN-NETWORK PLANS", "methodology": "per diem", "standard_charge_dollar": 8000.0, "standard_charge_algorithm": "Expected reimbursement is the lesser of Per diem ($8,000) for the length of stay and 70% of billed.", "count": "0", "additional_payer_notes": "Zero final payments for the item or service in the 15 months prior to posting the file." }, { "payer_name": "UNITED HEALTHCARE", "plan_name": "SUTTER SELECT & SUTTER HEALTH PLAN HMO PLANS", "methodology": "per diem", "standard_charge_dollar": 28538.0, "standard_charge_algorithm": "Per diem ($28,538).", "count": "0", "additional_payer_notes": "Zero final payments for the item or service in the 15 months prior to posting the file." }, { "payer_name": "UNITED HEALTHCARE", "plan_name": "SUTTER SELECT & SUTTER HEALTH PLAN HMO PLANS", "methodology": "per diem", "standard_charge_dollar": 28538.0, "standard_charge_algorithm": "Per diem ($28,538).", "count": "0", "additional_payer_notes": "Zero final payments for the item or service in the 15 months prior to posting the file." }, { "payer_name": "SUTTER", "plan_name": "SUTTER SELECT & SUTTER HEALTH PLAN HMO PLANS", "methodology": "per diem", "standard_charge_dollar": 28538.0, "standard_charge_algorithm": "Per diem ($28,538).", "count": "0", "additional_payer_notes": "Zero final payments for the item or service in the 15 months prior to posting the file." }, { "payer_name": "UNITED HEALTHCARE", "plan_name": "SUTTER SELECT & SUTTER HEALTH PLAN HMO PLANS", "methodology": "per diem", "standard_charge_dollar": 28538.0, "standard_charge_algorithm": "Per diem ($28,538).", "count": "0", "additional_payer_notes": "Zero final payments for the item or service in the 15 months prior to posting the file." }, { "payer_name": "UMR", "plan_name": "SUTTER SELECT & SUTTER HEALTH PLAN HMO PLANS", "methodology": "per diem", "standard_charge_dollar": 28538.0, "standard_charge_algorithm": "Per diem ($28,538).", "count": "0", "additional_payer_notes": "Zero final payments for the item or service in the 15 months prior to posting the file." } ] } ] }, { "description": "HC Bur Wire Pass Gp007", "code_information": [ { "code": "PX-2120021007", "type": "CDM" }, { "code": "99999", "type": "CPT" }, { "code": "0272", "type": "RC" } ], "standard_charges": [ { "setting": "outpatient", "gross_charge": 380.0, "discounted_cash": 190.0, "minimum": 160.36, "maximum": 197.6, "additional_generic_notes": "Zero final payments for the item or service in the 15 months prior to posting the file.", "payers_information": [ { "payer_name": "AETNA", "plan_name": "AETNA ALL OTHER PLANS", "methodology": "percent of total billed charges", "standard_charge_dollar": 197.6, "standard_charge_percentage": 52.0, "count": "0", "additional_payer_notes": "Zero final payments for the item or service in the 15 months prior to posting the file." }, { "payer_name": "AETNA", "plan_name": "AETNA ALL OTHER PLANS", "methodology": "percent of total billed charges", "standard_charge_dollar": 197.6, "standard_charge_percentage": 52.0, "count": "0", "additional_payer_notes": "Zero final payments for the item or service in the 15 months prior to posting the file." }, { "payer_name": "MERITAIN HEALTH", "plan_name": "AETNA ALL OTHER PLANS", "methodology": "percent of total billed charges", "standard_charge_dollar": 197.6, "standard_charge_percentage": 52.0, "count": "0", "additional_payer_notes": "Zero final payments for the item or service in the 15 months prior to posting the file." }, { "payer_name": "BLUE SHIELD OUT OF STATE", "plan_name": "STANFORD HEALTHCARE ALLIANCE PLAN", "methodology": "percent of total billed charges", "standard_charge_dollar": 184.64, "standard_charge_percentage": 48.59, "count": "0", "additional_payer_notes": "Zero final payments for the item or service in the 15 months prior to posting the file." }, { "payer_name": "BLUE SHIELD", "plan_name": "STANFORD HEALTHCARE ALLIANCE PLAN", "methodology": "percent of total billed charges", "standard_charge_dollar": 184.64, "standard_charge_percentage": 48.59, "count": "0", "additional_payer_notes": "Zero final payments for the item or service in the 15 months prior to posting the file." }, { "payer_name": "BLUE SHIELD", "plan_name": "STANFORD HEALTHCARE ALLIANCE PLAN", "methodology": "percent of total billed charges", "standard_charge_dollar": 184.64, "standard_charge_percentage": 48.59, "count": "0", "additional_payer_notes": "Zero final payments for the item or service in the 15 months prior to posting the file." }, { "payer_name": "CIGNA", "plan_name": "CIGNA COM ALT HMO PLAN", "methodology": "percent of total billed charges", "standard_charge_dollar": 160.36, "standard_charge_percentage": 42.2, "count": "0", "additional_payer_notes": "Zero final payments for the item or service in the 15 months prior to posting the file." }, { "payer_name": "CIGNA", "plan_name": "CIGNA COM ALT HMO PLAN", "methodology": "percent of total billed charges", "standard_charge_dollar": 160.36, "standard_charge_percentage": 42.2, "count": "0", "additional_payer_notes": "Zero final payments for the item or service in the 15 months prior to posting the file." }, { "payer_name": "HEALTH NET", "plan_name": "HEALTHNET HMO, PPO, POS, EPO, CANOPY HEALTHNET HMO, OTHER-IN-NETWORK PLANS", "methodology": "per diem", "standard_charge_dollar": 8000.0, "standard_charge_algorithm": "Expected reimbursement is the lesser of Per diem ($8,000) for the length of stay and 70% of billed.", "count": "0", "additional_payer_notes": "Zero final payments for the item or service in the 15 months prior to posting the file." }, { "payer_name": "HEALTH NET", "plan_name": "HEALTHNET HMO, PPO, POS, EPO, CANOPY HEALTHNET HMO, OTHER-IN-NETWORK PLANS", "methodology": "per diem", "standard_charge_dollar": 8000.0, "standard_charge_algorithm": "Expected reimbursement is the lesser of Per diem ($8,000) for the length of stay and 70% of billed.", "count": "0", "additional_payer_notes": "Zero final payments for the item or service in the 15 months prior to posting the file." }, { "payer_name": "UNITED HEALTHCARE", "plan_name": "SUTTER SELECT & SUTTER HEALTH PLAN HMO PLANS", "methodology": "per diem", "standard_charge_dollar": 28538.0, "standard_charge_algorithm": "Per diem ($28,538).", "count": "0", "additional_payer_notes": "Zero final payments for the item or service in the 15 months prior to posting the file." }, { "payer_name": "UNITED HEALTHCARE", "plan_name": "SUTTER SELECT & SUTTER HEALTH PLAN HMO PLANS", "methodology": "per diem", "standard_charge_dollar": 28538.0, "standard_charge_algorithm": "Per diem ($28,538).", "count": "0", "additional_payer_notes": "Zero final payments for the item or service in the 15 months prior to posting the file." }, { "payer_name": "SUTTER", "plan_name": "SUTTER SELECT & SUTTER HEALTH PLAN HMO PLANS", "methodology": "per diem", "standard_charge_dollar": 28538.0, "standard_charge_algorithm": "Per diem ($28,538).", "count": "0", "additional_payer_notes": "Zero final payments for the item or service in the 15 months prior to posting the file." }, { "payer_name": "UNITED HEALTHCARE", "plan_name": "SUTTER SELECT & SUTTER HEALTH PLAN HMO PLANS", "methodology": "per diem", "standard_charge_dollar": 28538.0, "standard_charge_algorithm": "Per diem ($28,538).", "count": "0", "additional_payer_notes": "Zero final payments for the item or service in the 15 months prior to posting the file." }, { "payer_name": "UMR", "plan_name": "SUTTER SELECT & SUTTER HEALTH PLAN HMO PLANS", "methodology": "per diem", "standard_charge_dollar": 28538.0, "standard_charge_algorithm": "Per diem ($28,538).", "count": "0", "additional_payer_notes": "Zero final payments for the item or service in the 15 months prior to posting the file." } ] } ] }, { "description": "HC Bur Wire Pass Gp008", "code_information": [ { "code": "PX-2120021008", "type": "CDM" }, { "code": "99999", "type": "CPT" }, { "code": "0272", "type": "RC" } ], "standard_charges": [ { "setting": "outpatient", "gross_charge": 475.0, "discounted_cash": 237.5, "minimum": 200.45, "maximum": 247.0, "additional_generic_notes": "Zero final payments for the item or service in the 15 months prior to posting the file.", "payers_information": [ { "payer_name": "AETNA", "plan_name": "AETNA ALL OTHER PLANS", "methodology": "percent of total billed charges", "standard_charge_dollar": 247.0, "standard_charge_percentage": 52.0, "count": "0", "additional_payer_notes": "Zero final payments for the item or service in the 15 months prior to posting the file." }, { "payer_name": "AETNA", "plan_name": "AETNA ALL OTHER PLANS", "methodology": "percent of total billed charges", "standard_charge_dollar": 247.0, "standard_charge_percentage": 52.0, "count": "0", "additional_payer_notes": "Zero final payments for the item or service in the 15 months prior to posting the file." }, { "payer_name": "MERITAIN HEALTH", "plan_name": "AETNA ALL OTHER PLANS", "methodology": "percent of total billed charges", "standard_charge_dollar": 247.0, "standard_charge_percentage": 52.0, "count": "0", "additional_payer_notes": "Zero final payments for the item or service in the 15 months prior to posting the file." }, { "payer_name": "BLUE SHIELD OUT OF STATE", "plan_name": "STANFORD HEALTHCARE ALLIANCE PLAN", "methodology": "percent of total billed charges", "standard_charge_dollar": 230.8, "standard_charge_percentage": 48.59, "count": "0", "additional_payer_notes": "Zero final payments for the item or service in the 15 months prior to posting the file." }, { "payer_name": "BLUE SHIELD", "plan_name": "STANFORD HEALTHCARE ALLIANCE PLAN", "methodology": "percent of total billed charges", "standard_charge_dollar": 230.8, "standard_charge_percentage": 48.59, "count": "0", "additional_payer_notes": "Zero final payments for the item or service in the 15 months prior to posting the file." }, { "payer_name": "BLUE SHIELD", "plan_name": "STANFORD HEALTHCARE ALLIANCE PLAN", "methodology": "percent of total billed charges", "standard_charge_dollar": 230.8, "standard_charge_percentage": 48.59, "count": "0", "additional_payer_notes": "Zero final payments for the item or service in the 15 months prior to posting the file." }, { "payer_name": "CIGNA", "plan_name": "CIGNA COM ALT HMO PLAN", "methodology": "percent of total billed charges", "standard_charge_dollar": 200.45, "standard_charge_percentage": 42.2, "count": "0", "additional_payer_notes": "Zero final payments for the item or service in the 15 months prior to posting the file." }, { "payer_name": "CIGNA", "plan_name": "CIGNA COM ALT HMO PLAN", "methodology": "percent of total billed charges", "standard_charge_dollar": 200.45, "standard_charge_percentage": 42.2, "count": "0", "additional_payer_notes": "Zero final payments for the item or service in the 15 months prior to posting the file." }, { "payer_name": "HEALTH NET", "plan_name": "HEALTHNET HMO, PPO, POS, EPO, CANOPY HEALTHNET HMO, OTHER-IN-NETWORK PLANS", "methodology": "per diem", "standard_charge_dollar": 8000.0, "standard_charge_algorithm": "Expected reimbursement is the lesser of Per diem ($8,000) for the length of stay and 70% of billed.", "count": "0", "additional_payer_notes": "Zero final payments for the item or service in the 15 months prior to posting the file." }, { "payer_name": "HEALTH NET", "plan_name": "HEALTHNET HMO, PPO, POS, EPO, CANOPY HEALTHNET HMO, OTHER-IN-NETWORK PLANS", "methodology": "per diem", "standard_charge_dollar": 8000.0, "standard_charge_algorithm": "Expected reimbursement is the lesser of Per diem ($8,000) for the length of stay and 70% of billed.", "count": "0", "additional_payer_notes": "Zero final payments for the item or service in the 15 months prior to posting the file." }, { "payer_name": "UNITED HEALTHCARE", "plan_name": "SUTTER SELECT & SUTTER HEALTH PLAN HMO PLANS", "methodology": "per diem", "standard_charge_dollar": 28538.0, "standard_charge_algorithm": "Per diem ($28,538).", "count": "0", "additional_payer_notes": "Zero final payments for the item or service in the 15 months prior to posting the file." }, { "payer_name": "UNITED HEALTHCARE", "plan_name": "SUTTER SELECT & SUTTER HEALTH PLAN HMO PLANS", "methodology": "per diem", "standard_charge_dollar": 28538.0, "standard_charge_algorithm": "Per diem ($28,538).", "count": "0", "additional_payer_notes": "Zero final payments for the item or service in the 15 months prior to posting the file." }, { "payer_name": "SUTTER", "plan_name": "SUTTER SELECT & SUTTER HEALTH PLAN HMO PLANS", "methodology": "per diem", "standard_charge_dollar": 28538.0, "standard_charge_algorithm": "Per diem ($28,538).", "count": "0", "additional_payer_notes": "Zero final payments for the item or service in the 15 months prior to posting the file." }, { "payer_name": "UNITED HEALTHCARE", "plan_name": "SUTTER SELECT & SUTTER HEALTH PLAN HMO PLANS", "methodology": "per diem", "standard_charge_dollar": 28538.0, "standard_charge_algorithm": "Per diem ($28,538).", "count": "0", "additional_payer_notes": "Zero final payments for the item or service in the 15 months prior to posting the file." }, { "payer_name": "UMR", "plan_name": "SUTTER SELECT & SUTTER HEALTH PLAN HMO PLANS", "methodology": "per diem", "standard_charge_dollar": 28538.0, "standard_charge_algorithm": "Per diem ($28,538).", "count": "0", "additional_payer_notes": "Zero final payments for the item or service in the 15 months prior to posting the file." } ] } ] }, { "description": "HC Button Gp004", "code_information": [ { "code": "PX-2120022004", "type": "CDM" }, { "code": "99999", "type": "CPT" }, { "code": "0272", "type": "RC" } ], "standard_charges": [ { "setting": "outpatient", "gross_charge": 146.0, "discounted_cash": 73.0, "minimum": 61.61, "maximum": 75.92, "additional_generic_notes": "Zero final payments for the item or service in the 15 months prior to posting the file.", "payers_information": [ { "payer_name": "AETNA", "plan_name": "AETNA ALL OTHER PLANS", "methodology": "percent of total billed charges", "standard_charge_dollar": 75.92, "standard_charge_percentage": 52.0, "count": "0", "additional_payer_notes": "Zero final payments for the item or service in the 15 months prior to posting the file." }, { "payer_name": "AETNA", "plan_name": "AETNA ALL OTHER PLANS", "methodology": "percent of total billed charges", "standard_charge_dollar": 75.92, "standard_charge_percentage": 52.0, "count": "0", "additional_payer_notes": "Zero final payments for the item or service in the 15 months prior to posting the file." }, { "payer_name": "MERITAIN HEALTH", "plan_name": "AETNA ALL OTHER PLANS", "methodology": "percent of total billed charges", "standard_charge_dollar": 75.92, "standard_charge_percentage": 52.0, "count": "0", "additional_payer_notes": "Zero final payments for the item or service in the 15 months prior to posting the file." }, { "payer_name": "BLUE SHIELD OUT OF STATE", "plan_name": "STANFORD HEALTHCARE ALLIANCE PLAN", "methodology": "percent of total billed charges", "standard_charge_dollar": 70.94, "standard_charge_percentage": 48.59, "count": "0", "additional_payer_notes": "Zero final payments for the item or service in the 15 months prior to posting the file." }, { "payer_name": "BLUE SHIELD", "plan_name": "STANFORD HEALTHCARE ALLIANCE PLAN", "methodology": "percent of total billed charges", "standard_charge_dollar": 70.94, "standard_charge_percentage": 48.59, "count": "0", "additional_payer_notes": "Zero final payments for the item or service in the 15 months prior to posting the file." }, { "payer_name": "BLUE SHIELD", "plan_name": "STANFORD HEALTHCARE ALLIANCE PLAN", "methodology": "percent of total billed charges", "standard_charge_dollar": 70.94, "standard_charge_percentage": 48.59, "count": "0", "additional_payer_notes": "Zero final payments for the item or service in the 15 months prior to posting the file." }, { "payer_name": "CIGNA", "plan_name": "CIGNA COM ALT HMO PLAN", "methodology": "percent of total billed charges", "standard_charge_dollar": 61.61, "standard_charge_percentage": 42.2, "count": "0", "additional_payer_notes": "Zero final payments for the item or service in the 15 months prior to posting the file." }, { "payer_name": "CIGNA", "plan_name": "CIGNA COM ALT HMO PLAN", "methodology": "percent of total billed charges", "standard_charge_dollar": 61.61, "standard_charge_percentage": 42.2, "count": "0", "additional_payer_notes": "Zero final payments for the item or service in the 15 months prior to posting the file." }, { "payer_name": "HEALTH NET", "plan_name": "HEALTHNET HMO, PPO, POS, EPO, CANOPY HEALTHNET HMO, OTHER-IN-NETWORK PLANS", "methodology": "per diem", "standard_charge_dollar": 8000.0, "standard_charge_algorithm": "Expected reimbursement is the lesser of Per diem ($8,000) for the length of stay and 70% of billed.", "count": "0", "additional_payer_notes": "Zero final payments for the item or service in the 15 months prior to posting the file." }, { "payer_name": "HEALTH NET", "plan_name": "HEALTHNET HMO, PPO, POS, EPO, CANOPY HEALTHNET HMO, OTHER-IN-NETWORK PLANS", "methodology": "per diem", "standard_charge_dollar": 8000.0, "standard_charge_algorithm": "Expected reimbursement is the lesser of Per diem ($8,000) for the length of stay and 70% of billed.", "count": "0", "additional_payer_notes": "Zero final payments for the item or service in the 15 months prior to posting the file." }, { "payer_name": "UNITED HEALTHCARE", "plan_name": "SUTTER SELECT & SUTTER HEALTH PLAN HMO PLANS", "methodology": "per diem", "standard_charge_dollar": 28538.0, "standard_charge_algorithm": "Per diem ($28,538).", "count": "0", "additional_payer_notes": "Zero final payments for the item or service in the 15 months prior to posting the file." }, { "payer_name": "UNITED HEALTHCARE", "plan_name": "SUTTER SELECT & SUTTER HEALTH PLAN HMO PLANS", "methodology": "per diem", "standard_charge_dollar": 28538.0, "standard_charge_algorithm": "Per diem ($28,538).", "count": "0", "additional_payer_notes": "Zero final payments for the item or service in the 15 months prior to posting the file." }, { "payer_name": "SUTTER", "plan_name": "SUTTER SELECT & SUTTER HEALTH PLAN HMO PLANS", "methodology": "per diem", "standard_charge_dollar": 28538.0, "standard_charge_algorithm": "Per diem ($28,538).", "count": "0", "additional_payer_notes": "Zero final payments for the item or service in the 15 months prior to posting the file." }, { "payer_name": "UNITED HEALTHCARE", "plan_name": "SUTTER SELECT & SUTTER HEALTH PLAN HMO PLANS", "methodology": "per diem", "standard_charge_dollar": 28538.0, "standard_charge_algorithm": "Per diem ($28,538).", "count": "0", "additional_payer_notes": "Zero final payments for the item or service in the 15 months prior to posting the file." }, { "payer_name": "UMR", "plan_name": "SUTTER SELECT & SUTTER HEALTH PLAN HMO PLANS", "methodology": "per diem", "standard_charge_dollar": 28538.0, "standard_charge_algorithm": "Per diem ($28,538).", "count": "0", "additional_payer_notes": "Zero final payments for the item or service in the 15 months prior to posting the file." } ] } ] }, { "description": "HC Button Gp005", "code_information": [ { "code": "PX-2120022005", "type": "CDM" }, { "code": "99999", "type": "CPT" }, { "code": "0272", "type": "RC" } ], "standard_charges": [ { "setting": "outpatient", "gross_charge": 195.0, "discounted_cash": 97.5, "minimum": 82.29, "maximum": 101.4, "additional_generic_notes": "Zero final payments for the item or service in the 15 months prior to posting the file.", "payers_information": [ { "payer_name": "AETNA", "plan_name": "AETNA ALL OTHER PLANS", "methodology": "percent of total billed charges", "standard_charge_dollar": 101.4, "standard_charge_percentage": 52.0, "count": "0", "additional_payer_notes": "Zero final payments for the item or service in the 15 months prior to posting the file." }, { "payer_name": "AETNA", "plan_name": "AETNA ALL OTHER PLANS", "methodology": "percent of total billed charges", "standard_charge_dollar": 101.4, "standard_charge_percentage": 52.0, "count": "0", "additional_payer_notes": "Zero final payments for the item or service in the 15 months prior to posting the file." }, { "payer_name": "MERITAIN HEALTH", "plan_name": "AETNA ALL OTHER PLANS", "methodology": "percent of total billed charges", "standard_charge_dollar": 101.4, "standard_charge_percentage": 52.0, "count": "0", "additional_payer_notes": "Zero final payments for the item or service in the 15 months prior to posting the file." }, { "payer_name": "BLUE SHIELD OUT OF STATE", "plan_name": "STANFORD HEALTHCARE ALLIANCE PLAN", "methodology": "percent of total billed charges", "standard_charge_dollar": 94.75, "standard_charge_percentage": 48.59, "count": "0", "additional_payer_notes": "Zero final payments for the item or service in the 15 months prior to posting the file." }, { "payer_name": "BLUE SHIELD", "plan_name": "STANFORD HEALTHCARE ALLIANCE PLAN", "methodology": "percent of total billed charges", "standard_charge_dollar": 94.75, "standard_charge_percentage": 48.59, "count": "0", "additional_payer_notes": "Zero final payments for the item or service in the 15 months prior to posting the file." }, { "payer_name": "BLUE SHIELD", "plan_name": "STANFORD HEALTHCARE ALLIANCE PLAN", "methodology": "percent of total billed charges", "standard_charge_dollar": 94.75, "standard_charge_percentage": 48.59, "count": "0", "additional_payer_notes": "Zero final payments for the item or service in the 15 months prior to posting the file." }, { "payer_name": "CIGNA", "plan_name": "CIGNA COM ALT HMO PLAN", "methodology": "percent of total billed charges", "standard_charge_dollar": 82.29, "standard_charge_percentage": 42.2, "count": "0", "additional_payer_notes": "Zero final payments for the item or service in the 15 months prior to posting the file." }, { "payer_name": "CIGNA", "plan_name": "CIGNA COM ALT HMO PLAN", "methodology": "percent of total billed charges", "standard_charge_dollar": 82.29, "standard_charge_percentage": 42.2, "count": "0", "additional_payer_notes": "Zero final payments for the item or service in the 15 months prior to posting the file." }, { "payer_name": "HEALTH NET", "plan_name": "HEALTHNET HMO, PPO, POS, EPO, CANOPY HEALTHNET HMO, OTHER-IN-NETWORK PLANS", "methodology": "per diem", "standard_charge_dollar": 8000.0, "standard_charge_algorithm": "Expected reimbursement is the lesser of Per diem ($8,000) for the length of stay and 70% of billed.", "count": "0", "additional_payer_notes": "Zero final payments for the item or service in the 15 months prior to posting the file." }, { "payer_name": "HEALTH NET", "plan_name": "HEALTHNET HMO, PPO, POS, EPO, CANOPY HEALTHNET HMO, OTHER-IN-NETWORK PLANS", "methodology": "per diem", "standard_charge_dollar": 8000.0, "standard_charge_algorithm": "Expected reimbursement is the lesser of Per diem ($8,000) for the length of stay and 70% of billed.", "count": "0", "additional_payer_notes": "Zero final payments for the item or service in the 15 months prior to posting the file." }, { "payer_name": "UNITED HEALTHCARE", "plan_name": "SUTTER SELECT & SUTTER HEALTH PLAN HMO PLANS", "methodology": "per diem", "standard_charge_dollar": 28538.0, "standard_charge_algorithm": "Per diem ($28,538).", "count": "0", "additional_payer_notes": "Zero final payments for the item or service in the 15 months prior to posting the file." }, { "payer_name": "UNITED HEALTHCARE", "plan_name": "SUTTER SELECT & SUTTER HEALTH PLAN HMO PLANS", "methodology": "per diem", "standard_charge_dollar": 28538.0, "standard_charge_algorithm": "Per diem ($28,538).", "count": "0", "additional_payer_notes": "Zero final payments for the item or service in the 15 months prior to posting the file." }, { "payer_name": "SUTTER", "plan_name": "SUTTER SELECT & SUTTER HEALTH PLAN HMO PLANS", "methodology": "per diem", "standard_charge_dollar": 28538.0, "standard_charge_algorithm": "Per diem ($28,538).", "count": "0", "additional_payer_notes": "Zero final payments for the item or service in the 15 months prior to posting the file." }, { "payer_name": "UNITED HEALTHCARE", "plan_name": "SUTTER SELECT & SUTTER HEALTH PLAN HMO PLANS", "methodology": "per diem", "standard_charge_dollar": 28538.0, "standard_charge_algorithm": "Per diem ($28,538).", "count": "0", "additional_payer_notes": "Zero final payments for the item or service in the 15 months prior to posting the file." }, { "payer_name": "UMR", "plan_name": "SUTTER SELECT & SUTTER HEALTH PLAN HMO PLANS", "methodology": "per diem", "standard_charge_dollar": 28538.0, "standard_charge_algorithm": "Per diem ($28,538).", "count": "0", "additional_payer_notes": "Zero final payments for the item or service in the 15 months prior to posting the file." } ] } ] }, { "description": "HC Button Gp006", "code_information": [ { "code": "PX-2120022006", "type": "CDM" }, { "code": "99999", "type": "CPT" }, { "code": "0272", "type": "RC" } ], "standard_charges": [ { "setting": "outpatient", "gross_charge": 293.0, "discounted_cash": 146.5, "minimum": 123.65, "maximum": 152.36, "additional_generic_notes": "Zero final payments for the item or service in the 15 months prior to posting the file.", "payers_information": [ { "payer_name": "AETNA", "plan_name": "AETNA ALL OTHER PLANS", "methodology": "percent of total billed charges", "standard_charge_dollar": 152.36, "standard_charge_percentage": 52.0, "count": "0", "additional_payer_notes": "Zero final payments for the item or service in the 15 months prior to posting the file." }, { "payer_name": "AETNA", "plan_name": "AETNA ALL OTHER PLANS", "methodology": "percent of total billed charges", "standard_charge_dollar": 152.36, "standard_charge_percentage": 52.0, "count": "0", "additional_payer_notes": "Zero final payments for the item or service in the 15 months prior to posting the file." }, { "payer_name": "MERITAIN HEALTH", "plan_name": "AETNA ALL OTHER PLANS", "methodology": "percent of total billed charges", "standard_charge_dollar": 152.36, "standard_charge_percentage": 52.0, "count": "0", "additional_payer_notes": "Zero final payments for the item or service in the 15 months prior to posting the file." }, { "payer_name": "BLUE SHIELD OUT OF STATE", "plan_name": "STANFORD HEALTHCARE ALLIANCE PLAN", "methodology": "percent of total billed charges", "standard_charge_dollar": 142.37, "standard_charge_percentage": 48.59, "count": "0", "additional_payer_notes": "Zero final payments for the item or service in the 15 months prior to posting the file." }, { "payer_name": "BLUE SHIELD", "plan_name": "STANFORD HEALTHCARE ALLIANCE PLAN", "methodology": "percent of total billed charges", "standard_charge_dollar": 142.37, "standard_charge_percentage": 48.59, "count": "0", "additional_payer_notes": "Zero final payments for the item or service in the 15 months prior to posting the file." }, { "payer_name": "BLUE SHIELD", "plan_name": "STANFORD HEALTHCARE ALLIANCE PLAN", "methodology": "percent of total billed charges", "standard_charge_dollar": 142.37, "standard_charge_percentage": 48.59, "count": "0", "additional_payer_notes": "Zero final payments for the item or service in the 15 months prior to posting the file." }, { "payer_name": "CIGNA", "plan_name": "CIGNA COM ALT HMO PLAN", "methodology": "percent of total billed charges", "standard_charge_dollar": 123.65, "standard_charge_percentage": 42.2, "count": "0", "additional_payer_notes": "Zero final payments for the item or service in the 15 months prior to posting the file." }, { "payer_name": "CIGNA", "plan_name": "CIGNA COM ALT HMO PLAN", "methodology": "percent of total billed charges", "standard_charge_dollar": 123.65, "standard_charge_percentage": 42.2, "count": "0", "additional_payer_notes": "Zero final payments for the item or service in the 15 months prior to posting the file." }, { "payer_name": "HEALTH NET", "plan_name": "HEALTHNET HMO, PPO, POS, EPO, CANOPY HEALTHNET HMO, OTHER-IN-NETWORK PLANS", "methodology": "per diem", "standard_charge_dollar": 8000.0, "standard_charge_algorithm": "Expected reimbursement is the lesser of Per diem ($8,000) for the length of stay and 70% of billed.", "count": "0", "additional_payer_notes": "Zero final payments for the item or service in the 15 months prior to posting the file." }, { "payer_name": "HEALTH NET", "plan_name": "HEALTHNET HMO, PPO, POS, EPO, CANOPY HEALTHNET HMO, OTHER-IN-NETWORK PLANS", "methodology": "per diem", "standard_charge_dollar": 8000.0, "standard_charge_algorithm": "Expected reimbursement is the lesser of Per diem ($8,000) for the length of stay and 70% of billed.", "count": "0", "additional_payer_notes": "Zero final payments for the item or service in the 15 months prior to posting the file." }, { "payer_name": "UNITED HEALTHCARE", "plan_name": "SUTTER SELECT & SUTTER HEALTH PLAN HMO PLANS", "methodology": "per diem", "standard_charge_dollar": 28538.0, "standard_charge_algorithm": "Per diem ($28,538).", "count": "0", "additional_payer_notes": "Zero final payments for the item or service in the 15 months prior to posting the file." }, { "payer_name": "UNITED HEALTHCARE", "plan_name": "SUTTER SELECT & SUTTER HEALTH PLAN HMO PLANS", "methodology": "per diem", "standard_charge_dollar": 28538.0, "standard_charge_algorithm": "Per diem ($28,538).", "count": "0", "additional_payer_notes": "Zero final payments for the item or service in the 15 months prior to posting the file." }, { "payer_name": "SUTTER", "plan_name": "SUTTER SELECT & SUTTER HEALTH PLAN HMO PLANS", "methodology": "per diem", "standard_charge_dollar": 28538.0, "standard_charge_algorithm": "Per diem ($28,538).", "count": "0", "additional_payer_notes": "Zero final payments for the item or service in the 15 months prior to posting the file." }, { "payer_name": "UNITED HEALTHCARE", "plan_name": "SUTTER SELECT & SUTTER HEALTH PLAN HMO PLANS", "methodology": "per diem", "standard_charge_dollar": 28538.0, "standard_charge_algorithm": "Per diem ($28,538).", "count": "0", "additional_payer_notes": "Zero final payments for the item or service in the 15 months prior to posting the file." }, { "payer_name": "UMR", "plan_name": "SUTTER SELECT & SUTTER HEALTH PLAN HMO PLANS", "methodology": "per diem", "standard_charge_dollar": 28538.0, "standard_charge_algorithm": "Per diem ($28,538).", "count": "0", "additional_payer_notes": "Zero final payments for the item or service in the 15 months prior to posting the file." } ] } ] }, { "description": "HC Button Gp011", "code_information": [ { "code": "PX-2120022011", "type": "CDM" }, { "code": "99999", "type": "CPT" }, { "code": "0272", "type": "RC" } ], "standard_charges": [ { "setting": "outpatient", "gross_charge": 88.15, "discounted_cash": 44.07, "minimum": 37.2, "maximum": 45.84, "additional_generic_notes": "Zero final payments for the item or service in the 15 months prior to posting the file.", "payers_information": [ { "payer_name": "AETNA", "plan_name": "AETNA ALL OTHER PLANS", "methodology": "percent of total billed charges", "standard_charge_dollar": 45.84, "standard_charge_percentage": 52.0, "count": "0", "additional_payer_notes": "Zero final payments for the item or service in the 15 months prior to posting the file." }, { "payer_name": "AETNA", "plan_name": "AETNA ALL OTHER PLANS", "methodology": "percent of total billed charges", "standard_charge_dollar": 45.84, "standard_charge_percentage": 52.0, "count": "0", "additional_payer_notes": "Zero final payments for the item or service in the 15 months prior to posting the file." }, { "payer_name": "MERITAIN HEALTH", "plan_name": "AETNA ALL OTHER PLANS", "methodology": "percent of total billed charges", "standard_charge_dollar": 45.84, "standard_charge_percentage": 52.0, "count": "0", "additional_payer_notes": "Zero final payments for the item or service in the 15 months prior to posting the file." }, { "payer_name": "BLUE SHIELD OUT OF STATE", "plan_name": "STANFORD HEALTHCARE ALLIANCE PLAN", "methodology": "percent of total billed charges", "standard_charge_dollar": 42.83, "standard_charge_percentage": 48.59, "count": "0", "additional_payer_notes": "Zero final payments for the item or service in the 15 months prior to posting the file." }, { "payer_name": "BLUE SHIELD", "plan_name": "STANFORD HEALTHCARE ALLIANCE PLAN", "methodology": "percent of total billed charges", "standard_charge_dollar": 42.83, "standard_charge_percentage": 48.59, "count": "0", "additional_payer_notes": "Zero final payments for the item or service in the 15 months prior to posting the file." }, { "payer_name": "BLUE SHIELD", "plan_name": "STANFORD HEALTHCARE ALLIANCE PLAN", "methodology": "percent of total billed charges", "standard_charge_dollar": 42.83, "standard_charge_percentage": 48.59, "count": "0", "additional_payer_notes": "Zero final payments for the item or service in the 15 months prior to posting the file." }, { "payer_name": "CIGNA", "plan_name": "CIGNA COM ALT HMO PLAN", "methodology": "percent of total billed charges", "standard_charge_dollar": 37.2, "standard_charge_percentage": 42.2, "count": "0", "additional_payer_notes": "Zero final payments for the item or service in the 15 months prior to posting the file." }, { "payer_name": "CIGNA", "plan_name": "CIGNA COM ALT HMO PLAN", "methodology": "percent of total billed charges", "standard_charge_dollar": 37.2, "standard_charge_percentage": 42.2, "count": "0", "additional_payer_notes": "Zero final payments for the item or service in the 15 months prior to posting the file." }, { "payer_name": "HEALTH NET", "plan_name": "HEALTHNET HMO, PPO, POS, EPO, CANOPY HEALTHNET HMO, OTHER-IN-NETWORK PLANS", "methodology": "per diem", "standard_charge_dollar": 8000.0, "standard_charge_algorithm": "Expected reimbursement is the lesser of Per diem ($8,000) for the length of stay and 70% of billed.", "count": "0", "additional_payer_notes": "Zero final payments for the item or service in the 15 months prior to posting the file." }, { "payer_name": "HEALTH NET", "plan_name": "HEALTHNET HMO, PPO, POS, EPO, CANOPY HEALTHNET HMO, OTHER-IN-NETWORK PLANS", "methodology": "per diem", "standard_charge_dollar": 8000.0, "standard_charge_algorithm": "Expected reimbursement is the lesser of Per diem ($8,000) for the length of stay and 70% of billed.", "count": "0", "additional_payer_notes": "Zero final payments for the item or service in the 15 months prior to posting the file." }, { "payer_name": "UNITED HEALTHCARE", "plan_name": "SUTTER SELECT & SUTTER HEALTH PLAN HMO PLANS", "methodology": "per diem", "standard_charge_dollar": 28538.0, "standard_charge_algorithm": "Per diem ($28,538).", "count": "0", "additional_payer_notes": "Zero final payments for the item or service in the 15 months prior to posting the file." }, { "payer_name": "UNITED HEALTHCARE", "plan_name": "SUTTER SELECT & SUTTER HEALTH PLAN HMO PLANS", "methodology": "per diem", "standard_charge_dollar": 28538.0, "standard_charge_algorithm": "Per diem ($28,538).", "count": "0", "additional_payer_notes": "Zero final payments for the item or service in the 15 months prior to posting the file." }, { "payer_name": "SUTTER", "plan_name": "SUTTER SELECT & SUTTER HEALTH PLAN HMO PLANS", "methodology": "per diem", "standard_charge_dollar": 28538.0, "standard_charge_algorithm": "Per diem ($28,538).", "count": "0", "additional_payer_notes": "Zero final payments for the item or service in the 15 months prior to posting the file." }, { "payer_name": "UNITED HEALTHCARE", "plan_name": "SUTTER SELECT & SUTTER HEALTH PLAN HMO PLANS", "methodology": "per diem", "standard_charge_dollar": 28538.0, "standard_charge_algorithm": "Per diem ($28,538).", "count": "0", "additional_payer_notes": "Zero final payments for the item or service in the 15 months prior to posting the file." }, { "payer_name": "UMR", "plan_name": "SUTTER SELECT & SUTTER HEALTH PLAN HMO PLANS", "methodology": "per diem", "standard_charge_dollar": 28538.0, "standard_charge_algorithm": "Per diem ($28,538).", "count": "0", "additional_payer_notes": "Zero final payments for the item or service in the 15 months prior to posting the file." } ] } ] }, { "description": "HC Cannula Gp002", "code_information": [ { "code": "PX-2120023002", "type": "CDM" }, { "code": "99999", "type": "CPT" }, { "code": "0272", "type": "RC" } ], "standard_charges": [ { "setting": "outpatient", "gross_charge": 50.0, "discounted_cash": 25.0, "minimum": 21.1, "maximum": 26.0, "additional_generic_notes": "Zero final payments for the item or service in the 15 months prior to posting the file.", "payers_information": [ { "payer_name": "AETNA", "plan_name": "AETNA ALL OTHER PLANS", "methodology": "percent of total billed charges", "standard_charge_dollar": 26.0, "standard_charge_percentage": 52.0, "count": "0", "additional_payer_notes": "Zero final payments for the item or service in the 15 months prior to posting the file." }, { "payer_name": "AETNA", "plan_name": "AETNA ALL OTHER PLANS", "methodology": "percent of total billed charges", "standard_charge_dollar": 26.0, "standard_charge_percentage": 52.0, "count": "0", "additional_payer_notes": "Zero final payments for the item or service in the 15 months prior to posting the file." }, { "payer_name": "MERITAIN HEALTH", "plan_name": "AETNA ALL OTHER PLANS", "methodology": "percent of total billed charges", "standard_charge_dollar": 26.0, "standard_charge_percentage": 52.0, "count": "0", "additional_payer_notes": "Zero final payments for the item or service in the 15 months prior to posting the file." }, { "payer_name": "BLUE SHIELD OUT OF STATE", "plan_name": "STANFORD HEALTHCARE ALLIANCE PLAN", "methodology": "percent of total billed charges", "standard_charge_dollar": 24.3, "standard_charge_percentage": 48.59, "count": "0", "additional_payer_notes": "Zero final payments for the item or service in the 15 months prior to posting the file." }, { "payer_name": "BLUE SHIELD", "plan_name": "STANFORD HEALTHCARE ALLIANCE PLAN", "methodology": "percent of total billed charges", "standard_charge_dollar": 24.3, "standard_charge_percentage": 48.59, "count": "0", "additional_payer_notes": "Zero final payments for the item or service in the 15 months prior to posting the file." }, { "payer_name": "BLUE SHIELD", "plan_name": "STANFORD HEALTHCARE ALLIANCE PLAN", "methodology": "percent of total billed charges", "standard_charge_dollar": 24.3, "standard_charge_percentage": 48.59, "count": "0", "additional_payer_notes": "Zero final payments for the item or service in the 15 months prior to posting the file." }, { "payer_name": "CIGNA", "plan_name": "CIGNA COM ALT HMO PLAN", "methodology": "percent of total billed charges", "standard_charge_dollar": 21.1, "standard_charge_percentage": 42.2, "count": "0", "additional_payer_notes": "Zero final payments for the item or service in the 15 months prior to posting the file." }, { "payer_name": "CIGNA", "plan_name": "CIGNA COM ALT HMO PLAN", "methodology": "percent of total billed charges", "standard_charge_dollar": 21.1, "standard_charge_percentage": 42.2, "count": "0", "additional_payer_notes": "Zero final payments for the item or service in the 15 months prior to posting the file." }, { "payer_name": "HEALTH NET", "plan_name": "HEALTHNET HMO, PPO, POS, EPO, CANOPY HEALTHNET HMO, OTHER-IN-NETWORK PLANS", "methodology": "per diem", "standard_charge_dollar": 8000.0, "standard_charge_algorithm": "Expected reimbursement is the lesser of Per diem ($8,000) for the length of stay and 70% of billed.", "count": "0", "additional_payer_notes": "Zero final payments for the item or service in the 15 months prior to posting the file." }, { "payer_name": "HEALTH NET", "plan_name": "HEALTHNET HMO, PPO, POS, EPO, CANOPY HEALTHNET HMO, OTHER-IN-NETWORK PLANS", "methodology": "per diem", "standard_charge_dollar": 8000.0, "standard_charge_algorithm": "Expected reimbursement is the lesser of Per diem ($8,000) for the length of stay and 70% of billed.", "count": "0", "additional_payer_notes": "Zero final payments for the item or service in the 15 months prior to posting the file." }, { "payer_name": "UNITED HEALTHCARE", "plan_name": "SUTTER SELECT & SUTTER HEALTH PLAN HMO PLANS", "methodology": "per diem", "standard_charge_dollar": 28538.0, "standard_charge_algorithm": "Per diem ($28,538).", "count": "0", "additional_payer_notes": "Zero final payments for the item or service in the 15 months prior to posting the file." }, { "payer_name": "UNITED HEALTHCARE", "plan_name": "SUTTER SELECT & SUTTER HEALTH PLAN HMO PLANS", "methodology": "per diem", "standard_charge_dollar": 28538.0, "standard_charge_algorithm": "Per diem ($28,538).", "count": "0", "additional_payer_notes": "Zero final payments for the item or service in the 15 months prior to posting the file." }, { "payer_name": "SUTTER", "plan_name": "SUTTER SELECT & SUTTER HEALTH PLAN HMO PLANS", "methodology": "per diem", "standard_charge_dollar": 28538.0, "standard_charge_algorithm": "Per diem ($28,538).", "count": "0", "additional_payer_notes": "Zero final payments for the item or service in the 15 months prior to posting the file." }, { "payer_name": "UNITED HEALTHCARE", "plan_name": "SUTTER SELECT & SUTTER HEALTH PLAN HMO PLANS", "methodology": "per diem", "standard_charge_dollar": 28538.0, "standard_charge_algorithm": "Per diem ($28,538).", "count": "0", "additional_payer_notes": "Zero final payments for the item or service in the 15 months prior to posting the file." }, { "payer_name": "UMR", "plan_name": "SUTTER SELECT & SUTTER HEALTH PLAN HMO PLANS", "methodology": "per diem", "standard_charge_dollar": 28538.0, "standard_charge_algorithm": "Per diem ($28,538).", "count": "0", "additional_payer_notes": "Zero final payments for the item or service in the 15 months prior to posting the file." } ] } ] }, { "description": "HC Cannula Gp003", "code_information": [ { "code": "PX-2120023003", "type": "CDM" }, { "code": "99999", "type": "CPT" }, { "code": "0272", "type": "RC" } ], "standard_charges": [ { "setting": "outpatient", "gross_charge": 100.0, "discounted_cash": 50.0, "minimum": 42.2, "maximum": 52.0, "additional_generic_notes": "Zero final payments for the item or service in the 15 months prior to posting the file.", "payers_information": [ { "payer_name": "AETNA", "plan_name": "AETNA ALL OTHER PLANS", "methodology": "percent of total billed charges", "standard_charge_dollar": 52.0, "standard_charge_percentage": 52.0, "count": "0", "additional_payer_notes": "Zero final payments for the item or service in the 15 months prior to posting the file." }, { "payer_name": "AETNA", "plan_name": "AETNA ALL OTHER PLANS", "methodology": "percent of total billed charges", "standard_charge_dollar": 52.0, "standard_charge_percentage": 52.0, "count": "0", "additional_payer_notes": "Zero final payments for the item or service in the 15 months prior to posting the file." }, { "payer_name": "MERITAIN HEALTH", "plan_name": "AETNA ALL OTHER PLANS", "methodology": "percent of total billed charges", "standard_charge_dollar": 52.0, "standard_charge_percentage": 52.0, "count": "0", "additional_payer_notes": "Zero final payments for the item or service in the 15 months prior to posting the file." }, { "payer_name": "BLUE SHIELD OUT OF STATE", "plan_name": "STANFORD HEALTHCARE ALLIANCE PLAN", "methodology": "percent of total billed charges", "standard_charge_dollar": 48.59, "standard_charge_percentage": 48.59, "count": "0", "additional_payer_notes": "Zero final payments for the item or service in the 15 months prior to posting the file." }, { "payer_name": "BLUE SHIELD", "plan_name": "STANFORD HEALTHCARE ALLIANCE PLAN", "methodology": "percent of total billed charges", "standard_charge_dollar": 48.59, "standard_charge_percentage": 48.59, "count": "0", "additional_payer_notes": "Zero final payments for the item or service in the 15 months prior to posting the file." }, { "payer_name": "BLUE SHIELD", "plan_name": "STANFORD HEALTHCARE ALLIANCE PLAN", "methodology": "percent of total billed charges", "standard_charge_dollar": 48.59, "standard_charge_percentage": 48.59, "count": "0", "additional_payer_notes": "Zero final payments for the item or service in the 15 months prior to posting the file." }, { "payer_name": "CIGNA", "plan_name": "CIGNA COM ALT HMO PLAN", "methodology": "percent of total billed charges", "standard_charge_dollar": 42.2, "standard_charge_percentage": 42.2, "count": "0", "additional_payer_notes": "Zero final payments for the item or service in the 15 months prior to posting the file." }, { "payer_name": "CIGNA", "plan_name": "CIGNA COM ALT HMO PLAN", "methodology": "percent of total billed charges", "standard_charge_dollar": 42.2, "standard_charge_percentage": 42.2, "count": "0", "additional_payer_notes": "Zero final payments for the item or service in the 15 months prior to posting the file." }, { "payer_name": "HEALTH NET", "plan_name": "HEALTHNET HMO, PPO, POS, EPO, CANOPY HEALTHNET HMO, OTHER-IN-NETWORK PLANS", "methodology": "per diem", "standard_charge_dollar": 8000.0, "standard_charge_algorithm": "Expected reimbursement is the lesser of Per diem ($8,000) for the length of stay and 70% of billed.", "count": "0", "additional_payer_notes": "Zero final payments for the item or service in the 15 months prior to posting the file." }, { "payer_name": "HEALTH NET", "plan_name": "HEALTHNET HMO, PPO, POS, EPO, CANOPY HEALTHNET HMO, OTHER-IN-NETWORK PLANS", "methodology": "per diem", "standard_charge_dollar": 8000.0, "standard_charge_algorithm": "Expected reimbursement is the lesser of Per diem ($8,000) for the length of stay and 70% of billed.", "count": "0", "additional_payer_notes": "Zero final payments for the item or service in the 15 months prior to posting the file." }, { "payer_name": "UNITED HEALTHCARE", "plan_name": "SUTTER SELECT & SUTTER HEALTH PLAN HMO PLANS", "methodology": "per diem", "standard_charge_dollar": 28538.0, "standard_charge_algorithm": "Per diem ($28,538).", "count": "0", "additional_payer_notes": "Zero final payments for the item or service in the 15 months prior to posting the file." }, { "payer_name": "UNITED HEALTHCARE", "plan_name": "SUTTER SELECT & SUTTER HEALTH PLAN HMO PLANS", "methodology": "per diem", "standard_charge_dollar": 28538.0, "standard_charge_algorithm": "Per diem ($28,538).", "count": "0", "additional_payer_notes": "Zero final payments for the item or service in the 15 months prior to posting the file." }, { "payer_name": "SUTTER", "plan_name": "SUTTER SELECT & SUTTER HEALTH PLAN HMO PLANS", "methodology": "per diem", "standard_charge_dollar": 28538.0, "standard_charge_algorithm": "Per diem ($28,538).", "count": "0", "additional_payer_notes": "Zero final payments for the item or service in the 15 months prior to posting the file." }, { "payer_name": "UNITED HEALTHCARE", "plan_name": "SUTTER SELECT & SUTTER HEALTH PLAN HMO PLANS", "methodology": "per diem", "standard_charge_dollar": 28538.0, "standard_charge_algorithm": "Per diem ($28,538).", "count": "0", "additional_payer_notes": "Zero final payments for the item or service in the 15 months prior to posting the file." }, { "payer_name": "UMR", "plan_name": "SUTTER SELECT & SUTTER HEALTH PLAN HMO PLANS", "methodology": "per diem", "standard_charge_dollar": 28538.0, "standard_charge_algorithm": "Per diem ($28,538).", "count": "0", "additional_payer_notes": "Zero final payments for the item or service in the 15 months prior to posting the file." } ] } ] }, { "description": "HC Cannula Gp004", "code_information": [ { "code": "PX-2120023004", "type": "CDM" }, { "code": "99999", "type": "CPT" }, { "code": "0272", "type": "RC" } ], "standard_charges": [ { "setting": "outpatient", "gross_charge": 146.0, "discounted_cash": 73.0, "minimum": 61.61, "maximum": 75.92, "additional_generic_notes": "Zero final payments for the item or service in the 15 months prior to posting the file.", "payers_information": [ { "payer_name": "AETNA", "plan_name": "AETNA ALL OTHER PLANS", "methodology": "percent of total billed charges", "standard_charge_dollar": 75.92, "standard_charge_percentage": 52.0, "count": "0", "additional_payer_notes": "Zero final payments for the item or service in the 15 months prior to posting the file." }, { "payer_name": "AETNA", "plan_name": "AETNA ALL OTHER PLANS", "methodology": "percent of total billed charges", "standard_charge_dollar": 75.92, "standard_charge_percentage": 52.0, "count": "0", "additional_payer_notes": "Zero final payments for the item or service in the 15 months prior to posting the file." }, { "payer_name": "MERITAIN HEALTH", "plan_name": "AETNA ALL OTHER PLANS", "methodology": "percent of total billed charges", "standard_charge_dollar": 75.92, "standard_charge_percentage": 52.0, "count": "0", "additional_payer_notes": "Zero final payments for the item or service in the 15 months prior to posting the file." }, { "payer_name": "BLUE SHIELD OUT OF STATE", "plan_name": "STANFORD HEALTHCARE ALLIANCE PLAN", "methodology": "percent of total billed charges", "standard_charge_dollar": 70.94, "standard_charge_percentage": 48.59, "count": "0", "additional_payer_notes": "Zero final payments for the item or service in the 15 months prior to posting the file." }, { "payer_name": "BLUE SHIELD", "plan_name": "STANFORD HEALTHCARE ALLIANCE PLAN", "methodology": "percent of total billed charges", "standard_charge_dollar": 70.94, "standard_charge_percentage": 48.59, "count": "0", "additional_payer_notes": "Zero final payments for the item or service in the 15 months prior to posting the file." }, { "payer_name": "BLUE SHIELD", "plan_name": "STANFORD HEALTHCARE ALLIANCE PLAN", "methodology": "percent of total billed charges", "standard_charge_dollar": 70.94, "standard_charge_percentage": 48.59, "count": "0", "additional_payer_notes": "Zero final payments for the item or service in the 15 months prior to posting the file." }, { "payer_name": "CIGNA", "plan_name": "CIGNA COM ALT HMO PLAN", "methodology": "percent of total billed charges", "standard_charge_dollar": 61.61, "standard_charge_percentage": 42.2, "count": "0", "additional_payer_notes": "Zero final payments for the item or service in the 15 months prior to posting the file." }, { "payer_name": "CIGNA", "plan_name": "CIGNA COM ALT HMO PLAN", "methodology": "percent of total billed charges", "standard_charge_dollar": 61.61, "standard_charge_percentage": 42.2, "count": "0", "additional_payer_notes": "Zero final payments for the item or service in the 15 months prior to posting the file." }, { "payer_name": "HEALTH NET", "plan_name": "HEALTHNET HMO, PPO, POS, EPO, CANOPY HEALTHNET HMO, OTHER-IN-NETWORK PLANS", "methodology": "per diem", "standard_charge_dollar": 8000.0, "standard_charge_algorithm": "Expected reimbursement is the lesser of Per diem ($8,000) for the length of stay and 70% of billed.", "count": "0", "additional_payer_notes": "Zero final payments for the item or service in the 15 months prior to posting the file." }, { "payer_name": "HEALTH NET", "plan_name": "HEALTHNET HMO, PPO, POS, EPO, CANOPY HEALTHNET HMO, OTHER-IN-NETWORK PLANS", "methodology": "per diem", "standard_charge_dollar": 8000.0, "standard_charge_algorithm": "Expected reimbursement is the lesser of Per diem ($8,000) for the length of stay and 70% of billed.", "count": "0", "additional_payer_notes": "Zero final payments for the item or service in the 15 months prior to posting the file." }, { "payer_name": "UNITED HEALTHCARE", "plan_name": "SUTTER SELECT & SUTTER HEALTH PLAN HMO PLANS", "methodology": "per diem", "standard_charge_dollar": 28538.0, "standard_charge_algorithm": "Per diem ($28,538).", "count": "0", "additional_payer_notes": "Zero final payments for the item or service in the 15 months prior to posting the file." }, { "payer_name": "UNITED HEALTHCARE", "plan_name": "SUTTER SELECT & SUTTER HEALTH PLAN HMO PLANS", "methodology": "per diem", "standard_charge_dollar": 28538.0, "standard_charge_algorithm": "Per diem ($28,538).", "count": "0", "additional_payer_notes": "Zero final payments for the item or service in the 15 months prior to posting the file." }, { "payer_name": "SUTTER", "plan_name": "SUTTER SELECT & SUTTER HEALTH PLAN HMO PLANS", "methodology": "per diem", "standard_charge_dollar": 28538.0, "standard_charge_algorithm": "Per diem ($28,538).", "count": "0", "additional_payer_notes": "Zero final payments for the item or service in the 15 months prior to posting the file." }, { "payer_name": "UNITED HEALTHCARE", "plan_name": "SUTTER SELECT & SUTTER HEALTH PLAN HMO PLANS", "methodology": "per diem", "standard_charge_dollar": 28538.0, "standard_charge_algorithm": "Per diem ($28,538).", "count": "0", "additional_payer_notes": "Zero final payments for the item or service in the 15 months prior to posting the file." }, { "payer_name": "UMR", "plan_name": "SUTTER SELECT & SUTTER HEALTH PLAN HMO PLANS", "methodology": "per diem", "standard_charge_dollar": 28538.0, "standard_charge_algorithm": "Per diem ($28,538).", "count": "0", "additional_payer_notes": "Zero final payments for the item or service in the 15 months prior to posting the file." } ] } ] }, { "description": "HC Cannula Gp005", "code_information": [ { "code": "PX-2120023005", "type": "CDM" }, { "code": "99999", "type": "CPT" }, { "code": "0272", "type": "RC" } ], "standard_charges": [ { "setting": "outpatient", "gross_charge": 195.0, "discounted_cash": 97.5, "minimum": 82.29, "maximum": 101.4, "additional_generic_notes": "Zero final payments for the item or service in the 15 months prior to posting the file.", "payers_information": [ { "payer_name": "AETNA", "plan_name": "AETNA ALL OTHER PLANS", "methodology": "percent of total billed charges", "standard_charge_dollar": 101.4, "standard_charge_percentage": 52.0, "count": "0", "additional_payer_notes": "Zero final payments for the item or service in the 15 months prior to posting the file." }, { "payer_name": "AETNA", "plan_name": "AETNA ALL OTHER PLANS", "methodology": "percent of total billed charges", "standard_charge_dollar": 101.4, "standard_charge_percentage": 52.0, "count": "0", "additional_payer_notes": "Zero final payments for the item or service in the 15 months prior to posting the file." }, { "payer_name": "MERITAIN HEALTH", "plan_name": "AETNA ALL OTHER PLANS", "methodology": "percent of total billed charges", "standard_charge_dollar": 101.4, "standard_charge_percentage": 52.0, "count": "0", "additional_payer_notes": "Zero final payments for the item or service in the 15 months prior to posting the file." }, { "payer_name": "BLUE SHIELD OUT OF STATE", "plan_name": "STANFORD HEALTHCARE ALLIANCE PLAN", "methodology": "percent of total billed charges", "standard_charge_dollar": 94.75, "standard_charge_percentage": 48.59, "count": "0", "additional_payer_notes": "Zero final payments for the item or service in the 15 months prior to posting the file." }, { "payer_name": "BLUE SHIELD", "plan_name": "STANFORD HEALTHCARE ALLIANCE PLAN", "methodology": "percent of total billed charges", "standard_charge_dollar": 94.75, "standard_charge_percentage": 48.59, "count": "0", "additional_payer_notes": "Zero final payments for the item or service in the 15 months prior to posting the file." }, { "payer_name": "BLUE SHIELD", "plan_name": "STANFORD HEALTHCARE ALLIANCE PLAN", "methodology": "percent of total billed charges", "standard_charge_dollar": 94.75, "standard_charge_percentage": 48.59, "count": "0", "additional_payer_notes": "Zero final payments for the item or service in the 15 months prior to posting the file." }, { "payer_name": "CIGNA", "plan_name": "CIGNA COM ALT HMO PLAN", "methodology": "percent of total billed charges", "standard_charge_dollar": 82.29, "standard_charge_percentage": 42.2, "count": "0", "additional_payer_notes": "Zero final payments for the item or service in the 15 months prior to posting the file." }, { "payer_name": "CIGNA", "plan_name": "CIGNA COM ALT HMO PLAN", "methodology": "percent of total billed charges", "standard_charge_dollar": 82.29, "standard_charge_percentage": 42.2, "count": "0", "additional_payer_notes": "Zero final payments for the item or service in the 15 months prior to posting the file." }, { "payer_name": "HEALTH NET", "plan_name": "HEALTHNET HMO, PPO, POS, EPO, CANOPY HEALTHNET HMO, OTHER-IN-NETWORK PLANS", "methodology": "per diem", "standard_charge_dollar": 8000.0, "standard_charge_algorithm": "Expected reimbursement is the lesser of Per diem ($8,000) for the length of stay and 70% of billed.", "count": "0", "additional_payer_notes": "Zero final payments for the item or service in the 15 months prior to posting the file." }, { "payer_name": "HEALTH NET", "plan_name": "HEALTHNET HMO, PPO, POS, EPO, CANOPY HEALTHNET HMO, OTHER-IN-NETWORK PLANS", "methodology": "per diem", "standard_charge_dollar": 8000.0, "standard_charge_algorithm": "Expected reimbursement is the lesser of Per diem ($8,000) for the length of stay and 70% of billed.", "count": "0", "additional_payer_notes": "Zero final payments for the item or service in the 15 months prior to posting the file." }, { "payer_name": "UNITED HEALTHCARE", "plan_name": "SUTTER SELECT & SUTTER HEALTH PLAN HMO PLANS", "methodology": "per diem", "standard_charge_dollar": 28538.0, "standard_charge_algorithm": "Per diem ($28,538).", "count": "0", "additional_payer_notes": "Zero final payments for the item or service in the 15 months prior to posting the file." }, { "payer_name": "UNITED HEALTHCARE", "plan_name": "SUTTER SELECT & SUTTER HEALTH PLAN HMO PLANS", "methodology": "per diem", "standard_charge_dollar": 28538.0, "standard_charge_algorithm": "Per diem ($28,538).", "count": "0", "additional_payer_notes": "Zero final payments for the item or service in the 15 months prior to posting the file." }, { "payer_name": "SUTTER", "plan_name": "SUTTER SELECT & SUTTER HEALTH PLAN HMO PLANS", "methodology": "per diem", "standard_charge_dollar": 28538.0, "standard_charge_algorithm": "Per diem ($28,538).", "count": "0", "additional_payer_notes": "Zero final payments for the item or service in the 15 months prior to posting the file." }, { "payer_name": "UNITED HEALTHCARE", "plan_name": "SUTTER SELECT & SUTTER HEALTH PLAN HMO PLANS", "methodology": "per diem", "standard_charge_dollar": 28538.0, "standard_charge_algorithm": "Per diem ($28,538).", "count": "0", "additional_payer_notes": "Zero final payments for the item or service in the 15 months prior to posting the file." }, { "payer_name": "UMR", "plan_name": "SUTTER SELECT & SUTTER HEALTH PLAN HMO PLANS", "methodology": "per diem", "standard_charge_dollar": 28538.0, "standard_charge_algorithm": "Per diem ($28,538).", "count": "0", "additional_payer_notes": "Zero final payments for the item or service in the 15 months prior to posting the file." } ] } ] }, { "description": "HC Cannula Gp006", "code_information": [ { "code": "PX-2120023006", "type": "CDM" }, { "code": "99999", "type": "CPT" }, { "code": "0272", "type": "RC" } ], "standard_charges": [ { "setting": "outpatient", "gross_charge": 293.0, "discounted_cash": 146.5, "minimum": 123.65, "maximum": 152.36, "additional_generic_notes": "Zero final payments for the item or service in the 15 months prior to posting the file.", "payers_information": [ { "payer_name": "AETNA", "plan_name": "AETNA ALL OTHER PLANS", "methodology": "percent of total billed charges", "standard_charge_dollar": 152.36, "standard_charge_percentage": 52.0, "count": "0", "additional_payer_notes": "Zero final payments for the item or service in the 15 months prior to posting the file." }, { "payer_name": "AETNA", "plan_name": "AETNA ALL OTHER PLANS", "methodology": "percent of total billed charges", "standard_charge_dollar": 152.36, "standard_charge_percentage": 52.0, "count": "0", "additional_payer_notes": "Zero final payments for the item or service in the 15 months prior to posting the file." }, { "payer_name": "MERITAIN HEALTH", "plan_name": "AETNA ALL OTHER PLANS", "methodology": "percent of total billed charges", "standard_charge_dollar": 152.36, "standard_charge_percentage": 52.0, "count": "0", "additional_payer_notes": "Zero final payments for the item or service in the 15 months prior to posting the file." }, { "payer_name": "BLUE SHIELD OUT OF STATE", "plan_name": "STANFORD HEALTHCARE ALLIANCE PLAN", "methodology": "percent of total billed charges", "standard_charge_dollar": 142.37, "standard_charge_percentage": 48.59, "count": "0", "additional_payer_notes": "Zero final payments for the item or service in the 15 months prior to posting the file." }, { "payer_name": "BLUE SHIELD", "plan_name": "STANFORD HEALTHCARE ALLIANCE PLAN", "methodology": "percent of total billed charges", "standard_charge_dollar": 142.37, "standard_charge_percentage": 48.59, "count": "0", "additional_payer_notes": "Zero final payments for the item or service in the 15 months prior to posting the file." }, { "payer_name": "BLUE SHIELD", "plan_name": "STANFORD HEALTHCARE ALLIANCE PLAN", "methodology": "percent of total billed charges", "standard_charge_dollar": 142.37, "standard_charge_percentage": 48.59, "count": "0", "additional_payer_notes": "Zero final payments for the item or service in the 15 months prior to posting the file." }, { "payer_name": "CIGNA", "plan_name": "CIGNA COM ALT HMO PLAN", "methodology": "percent of total billed charges", "standard_charge_dollar": 123.65, "standard_charge_percentage": 42.2, "count": "0", "additional_payer_notes": "Zero final payments for the item or service in the 15 months prior to posting the file." }, { "payer_name": "CIGNA", "plan_name": "CIGNA COM ALT HMO PLAN", "methodology": "percent of total billed charges", "standard_charge_dollar": 123.65, "standard_charge_percentage": 42.2, "count": "0", "additional_payer_notes": "Zero final payments for the item or service in the 15 months prior to posting the file." }, { "payer_name": "HEALTH NET", "plan_name": "HEALTHNET HMO, PPO, POS, EPO, CANOPY HEALTHNET HMO, OTHER-IN-NETWORK PLANS", "methodology": "per diem", "standard_charge_dollar": 8000.0, "standard_charge_algorithm": "Expected reimbursement is the lesser of Per diem ($8,000) for the length of stay and 70% of billed.", "count": "0", "additional_payer_notes": "Zero final payments for the item or service in the 15 months prior to posting the file." }, { "payer_name": "HEALTH NET", "plan_name": "HEALTHNET HMO, PPO, POS, EPO, CANOPY HEALTHNET HMO, OTHER-IN-NETWORK PLANS", "methodology": "per diem", "standard_charge_dollar": 8000.0, "standard_charge_algorithm": "Expected reimbursement is the lesser of Per diem ($8,000) for the length of stay and 70% of billed.", "count": "0", "additional_payer_notes": "Zero final payments for the item or service in the 15 months prior to posting the file." }, { "payer_name": "UNITED HEALTHCARE", "plan_name": "SUTTER SELECT & SUTTER HEALTH PLAN HMO PLANS", "methodology": "per diem", "standard_charge_dollar": 28538.0, "standard_charge_algorithm": "Per diem ($28,538).", "count": "0", "additional_payer_notes": "Zero final payments for the item or service in the 15 months prior to posting the file." }, { "payer_name": "UNITED HEALTHCARE", "plan_name": "SUTTER SELECT & SUTTER HEALTH PLAN HMO PLANS", "methodology": "per diem", "standard_charge_dollar": 28538.0, "standard_charge_algorithm": "Per diem ($28,538).", "count": "0", "additional_payer_notes": "Zero final payments for the item or service in the 15 months prior to posting the file." }, { "payer_name": "SUTTER", "plan_name": "SUTTER SELECT & SUTTER HEALTH PLAN HMO PLANS", "methodology": "per diem", "standard_charge_dollar": 28538.0, "standard_charge_algorithm": "Per diem ($28,538).", "count": "0", "additional_payer_notes": "Zero final payments for the item or service in the 15 months prior to posting the file." }, { "payer_name": "UNITED HEALTHCARE", "plan_name": "SUTTER SELECT & SUTTER HEALTH PLAN HMO PLANS", "methodology": "per diem", "standard_charge_dollar": 28538.0, "standard_charge_algorithm": "Per diem ($28,538).", "count": "0", "additional_payer_notes": "Zero final payments for the item or service in the 15 months prior to posting the file." }, { "payer_name": "UMR", "plan_name": "SUTTER SELECT & SUTTER HEALTH PLAN HMO PLANS", "methodology": "per diem", "standard_charge_dollar": 28538.0, "standard_charge_algorithm": "Per diem ($28,538).", "count": "0", "additional_payer_notes": "Zero final payments for the item or service in the 15 months prior to posting the file." } ] } ] }, { "description": "HC Cannula Gp007", "code_information": [ { "code": "PX-2120023007", "type": "CDM" }, { "code": "99999", "type": "CPT" }, { "code": "0272", "type": "RC" } ], "standard_charges": [ { "setting": "outpatient", "gross_charge": 380.0, "discounted_cash": 190.0, "minimum": 160.36, "maximum": 197.6, "additional_generic_notes": "Zero final payments for the item or service in the 15 months prior to posting the file.", "payers_information": [ { "payer_name": "AETNA", "plan_name": "AETNA ALL OTHER PLANS", "methodology": "percent of total billed charges", "standard_charge_dollar": 197.6, "standard_charge_percentage": 52.0, "count": "0", "additional_payer_notes": "Zero final payments for the item or service in the 15 months prior to posting the file." }, { "payer_name": "AETNA", "plan_name": "AETNA ALL OTHER PLANS", "methodology": "percent of total billed charges", "standard_charge_dollar": 197.6, "standard_charge_percentage": 52.0, "count": "0", "additional_payer_notes": "Zero final payments for the item or service in the 15 months prior to posting the file." }, { "payer_name": "MERITAIN HEALTH", "plan_name": "AETNA ALL OTHER PLANS", "methodology": "percent of total billed charges", "standard_charge_dollar": 197.6, "standard_charge_percentage": 52.0, "count": "0", "additional_payer_notes": "Zero final payments for the item or service in the 15 months prior to posting the file." }, { "payer_name": "BLUE SHIELD OUT OF STATE", "plan_name": "STANFORD HEALTHCARE ALLIANCE PLAN", "methodology": "percent of total billed charges", "standard_charge_dollar": 184.64, "standard_charge_percentage": 48.59, "count": "0", "additional_payer_notes": "Zero final payments for the item or service in the 15 months prior to posting the file." }, { "payer_name": "BLUE SHIELD", "plan_name": "STANFORD HEALTHCARE ALLIANCE PLAN", "methodology": "percent of total billed charges", "standard_charge_dollar": 184.64, "standard_charge_percentage": 48.59, "count": "0", "additional_payer_notes": "Zero final payments for the item or service in the 15 months prior to posting the file." }, { "payer_name": "BLUE SHIELD", "plan_name": "STANFORD HEALTHCARE ALLIANCE PLAN", "methodology": "percent of total billed charges", "standard_charge_dollar": 184.64, "standard_charge_percentage": 48.59, "count": "0", "additional_payer_notes": "Zero final payments for the item or service in the 15 months prior to posting the file." }, { "payer_name": "CIGNA", "plan_name": "CIGNA COM ALT HMO PLAN", "methodology": "percent of total billed charges", "standard_charge_dollar": 160.36, "standard_charge_percentage": 42.2, "count": "0", "additional_payer_notes": "Zero final payments for the item or service in the 15 months prior to posting the file." }, { "payer_name": "CIGNA", "plan_name": "CIGNA COM ALT HMO PLAN", "methodology": "percent of total billed charges", "standard_charge_dollar": 160.36, "standard_charge_percentage": 42.2, "count": "0", "additional_payer_notes": "Zero final payments for the item or service in the 15 months prior to posting the file." }, { "payer_name": "HEALTH NET", "plan_name": "HEALTHNET HMO, PPO, POS, EPO, CANOPY HEALTHNET HMO, OTHER-IN-NETWORK PLANS", "methodology": "per diem", "standard_charge_dollar": 8000.0, "standard_charge_algorithm": "Expected reimbursement is the lesser of Per diem ($8,000) for the length of stay and 70% of billed.", "count": "0", "additional_payer_notes": "Zero final payments for the item or service in the 15 months prior to posting the file." }, { "payer_name": "HEALTH NET", "plan_name": "HEALTHNET HMO, PPO, POS, EPO, CANOPY HEALTHNET HMO, OTHER-IN-NETWORK PLANS", "methodology": "per diem", "standard_charge_dollar": 8000.0, "standard_charge_algorithm": "Expected reimbursement is the lesser of Per diem ($8,000) for the length of stay and 70% of billed.", "count": "0", "additional_payer_notes": "Zero final payments for the item or service in the 15 months prior to posting the file." }, { "payer_name": "UNITED HEALTHCARE", "plan_name": "SUTTER SELECT & SUTTER HEALTH PLAN HMO PLANS", "methodology": "per diem", "standard_charge_dollar": 28538.0, "standard_charge_algorithm": "Per diem ($28,538).", "count": "0", "additional_payer_notes": "Zero final payments for the item or service in the 15 months prior to posting the file." }, { "payer_name": "UNITED HEALTHCARE", "plan_name": "SUTTER SELECT & SUTTER HEALTH PLAN HMO PLANS", "methodology": "per diem", "standard_charge_dollar": 28538.0, "standard_charge_algorithm": "Per diem ($28,538).", "count": "0", "additional_payer_notes": "Zero final payments for the item or service in the 15 months prior to posting the file." }, { "payer_name": "SUTTER", "plan_name": "SUTTER SELECT & SUTTER HEALTH PLAN HMO PLANS", "methodology": "per diem", "standard_charge_dollar": 28538.0, "standard_charge_algorithm": "Per diem ($28,538).", "count": "0", "additional_payer_notes": "Zero final payments for the item or service in the 15 months prior to posting the file." }, { "payer_name": "UNITED HEALTHCARE", "plan_name": "SUTTER SELECT & SUTTER HEALTH PLAN HMO PLANS", "methodology": "per diem", "standard_charge_dollar": 28538.0, "standard_charge_algorithm": "Per diem ($28,538).", "count": "0", "additional_payer_notes": "Zero final payments for the item or service in the 15 months prior to posting the file." }, { "payer_name": "UMR", "plan_name": "SUTTER SELECT & SUTTER HEALTH PLAN HMO PLANS", "methodology": "per diem", "standard_charge_dollar": 28538.0, "standard_charge_algorithm": "Per diem ($28,538).", "count": "0", "additional_payer_notes": "Zero final payments for the item or service in the 15 months prior to posting the file." } ] } ] }, { "description": "HC Cannula Gp008", "code_information": [ { "code": "PX-2120023008", "type": "CDM" }, { "code": "99999", "type": "CPT" }, { "code": "0272", "type": "RC" } ], "standard_charges": [ { "setting": "outpatient", "gross_charge": 475.0, "discounted_cash": 237.5, "minimum": 200.45, "maximum": 247.0, "additional_generic_notes": "Zero final payments for the item or service in the 15 months prior to posting the file.", "payers_information": [ { "payer_name": "AETNA", "plan_name": "AETNA ALL OTHER PLANS", "methodology": "percent of total billed charges", "standard_charge_dollar": 247.0, "standard_charge_percentage": 52.0, "count": "0", "additional_payer_notes": "Zero final payments for the item or service in the 15 months prior to posting the file." }, { "payer_name": "AETNA", "plan_name": "AETNA ALL OTHER PLANS", "methodology": "percent of total billed charges", "standard_charge_dollar": 247.0, "standard_charge_percentage": 52.0, "count": "0", "additional_payer_notes": "Zero final payments for the item or service in the 15 months prior to posting the file." }, { "payer_name": "MERITAIN HEALTH", "plan_name": "AETNA ALL OTHER PLANS", "methodology": "percent of total billed charges", "standard_charge_dollar": 247.0, "standard_charge_percentage": 52.0, "count": "0", "additional_payer_notes": "Zero final payments for the item or service in the 15 months prior to posting the file." }, { "payer_name": "BLUE SHIELD OUT OF STATE", "plan_name": "STANFORD HEALTHCARE ALLIANCE PLAN", "methodology": "percent of total billed charges", "standard_charge_dollar": 230.8, "standard_charge_percentage": 48.59, "count": "0", "additional_payer_notes": "Zero final payments for the item or service in the 15 months prior to posting the file." }, { "payer_name": "BLUE SHIELD", "plan_name": "STANFORD HEALTHCARE ALLIANCE PLAN", "methodology": "percent of total billed charges", "standard_charge_dollar": 230.8, "standard_charge_percentage": 48.59, "count": "0", "additional_payer_notes": "Zero final payments for the item or service in the 15 months prior to posting the file." }, { "payer_name": "BLUE SHIELD", "plan_name": "STANFORD HEALTHCARE ALLIANCE PLAN", "methodology": "percent of total billed charges", "standard_charge_dollar": 230.8, "standard_charge_percentage": 48.59, "count": "0", "additional_payer_notes": "Zero final payments for the item or service in the 15 months prior to posting the file." }, { "payer_name": "CIGNA", "plan_name": "CIGNA COM ALT HMO PLAN", "methodology": "percent of total billed charges", "standard_charge_dollar": 200.45, "standard_charge_percentage": 42.2, "count": "0", "additional_payer_notes": "Zero final payments for the item or service in the 15 months prior to posting the file." }, { "payer_name": "CIGNA", "plan_name": "CIGNA COM ALT HMO PLAN", "methodology": "percent of total billed charges", "standard_charge_dollar": 200.45, "standard_charge_percentage": 42.2, "count": "0", "additional_payer_notes": "Zero final payments for the item or service in the 15 months prior to posting the file." }, { "payer_name": "HEALTH NET", "plan_name": "HEALTHNET HMO, PPO, POS, EPO, CANOPY HEALTHNET HMO, OTHER-IN-NETWORK PLANS", "methodology": "per diem", "standard_charge_dollar": 8000.0, "standard_charge_algorithm": "Expected reimbursement is the lesser of Per diem ($8,000) for the length of stay and 70% of billed.", "count": "0", "additional_payer_notes": "Zero final payments for the item or service in the 15 months prior to posting the file." }, { "payer_name": "HEALTH NET", "plan_name": "HEALTHNET HMO, PPO, POS, EPO, CANOPY HEALTHNET HMO, OTHER-IN-NETWORK PLANS", "methodology": "per diem", "standard_charge_dollar": 8000.0, "standard_charge_algorithm": "Expected reimbursement is the lesser of Per diem ($8,000) for the length of stay and 70% of billed.", "count": "0", "additional_payer_notes": "Zero final payments for the item or service in the 15 months prior to posting the file." }, { "payer_name": "UNITED HEALTHCARE", "plan_name": "SUTTER SELECT & SUTTER HEALTH PLAN HMO PLANS", "methodology": "per diem", "standard_charge_dollar": 28538.0, "standard_charge_algorithm": "Per diem ($28,538).", "count": "0", "additional_payer_notes": "Zero final payments for the item or service in the 15 months prior to posting the file." }, { "payer_name": "UNITED HEALTHCARE", "plan_name": "SUTTER SELECT & SUTTER HEALTH PLAN HMO PLANS", "methodology": "per diem", "standard_charge_dollar": 28538.0, "standard_charge_algorithm": "Per diem ($28,538).", "count": "0", "additional_payer_notes": "Zero final payments for the item or service in the 15 months prior to posting the file." }, { "payer_name": "SUTTER", "plan_name": "SUTTER SELECT & SUTTER HEALTH PLAN HMO PLANS", "methodology": "per diem", "standard_charge_dollar": 28538.0, "standard_charge_algorithm": "Per diem ($28,538).", "count": "0", "additional_payer_notes": "Zero final payments for the item or service in the 15 months prior to posting the file." }, { "payer_name": "UNITED HEALTHCARE", "plan_name": "SUTTER SELECT & SUTTER HEALTH PLAN HMO PLANS", "methodology": "per diem", "standard_charge_dollar": 28538.0, "standard_charge_algorithm": "Per diem ($28,538).", "count": "0", "additional_payer_notes": "Zero final payments for the item or service in the 15 months prior to posting the file." }, { "payer_name": "UMR", "plan_name": "SUTTER SELECT & SUTTER HEALTH PLAN HMO PLANS", "methodology": "per diem", "standard_charge_dollar": 28538.0, "standard_charge_algorithm": "Per diem ($28,538).", "count": "0", "additional_payer_notes": "Zero final payments for the item or service in the 15 months prior to posting the file." } ] } ] }, { "description": "HC Cannula Gp009", "code_information": [ { "code": "PX-2120023009", "type": "CDM" }, { "code": "99999", "type": "CPT" }, { "code": "0272", "type": "RC" } ], "standard_charges": [ { "setting": "outpatient", "gross_charge": 570.0, "discounted_cash": 285.0, "minimum": 240.54, "maximum": 296.4, "additional_generic_notes": "Zero final payments for the item or service in the 15 months prior to posting the file.", "payers_information": [ { "payer_name": "AETNA", "plan_name": "AETNA ALL OTHER PLANS", "methodology": "percent of total billed charges", "standard_charge_dollar": 296.4, "standard_charge_percentage": 52.0, "count": "0", "additional_payer_notes": "Zero final payments for the item or service in the 15 months prior to posting the file." }, { "payer_name": "AETNA", "plan_name": "AETNA ALL OTHER PLANS", "methodology": "percent of total billed charges", "standard_charge_dollar": 296.4, "standard_charge_percentage": 52.0, "count": "0", "additional_payer_notes": "Zero final payments for the item or service in the 15 months prior to posting the file." }, { "payer_name": "MERITAIN HEALTH", "plan_name": "AETNA ALL OTHER PLANS", "methodology": "percent of total billed charges", "standard_charge_dollar": 296.4, "standard_charge_percentage": 52.0, "count": "0", "additional_payer_notes": "Zero final payments for the item or service in the 15 months prior to posting the file." }, { "payer_name": "BLUE SHIELD OUT OF STATE", "plan_name": "STANFORD HEALTHCARE ALLIANCE PLAN", "methodology": "percent of total billed charges", "standard_charge_dollar": 276.96, "standard_charge_percentage": 48.59, "count": "0", "additional_payer_notes": "Zero final payments for the item or service in the 15 months prior to posting the file." }, { "payer_name": "BLUE SHIELD", "plan_name": "STANFORD HEALTHCARE ALLIANCE PLAN", "methodology": "percent of total billed charges", "standard_charge_dollar": 276.96, "standard_charge_percentage": 48.59, "count": "0", "additional_payer_notes": "Zero final payments for the item or service in the 15 months prior to posting the file." }, { "payer_name": "BLUE SHIELD", "plan_name": "STANFORD HEALTHCARE ALLIANCE PLAN", "methodology": "percent of total billed charges", "standard_charge_dollar": 276.96, "standard_charge_percentage": 48.59, "count": "0", "additional_payer_notes": "Zero final payments for the item or service in the 15 months prior to posting the file." }, { "payer_name": "CIGNA", "plan_name": "CIGNA COM ALT HMO PLAN", "methodology": "percent of total billed charges", "standard_charge_dollar": 240.54, "standard_charge_percentage": 42.2, "count": "0", "additional_payer_notes": "Zero final payments for the item or service in the 15 months prior to posting the file." }, { "payer_name": "CIGNA", "plan_name": "CIGNA COM ALT HMO PLAN", "methodology": "percent of total billed charges", "standard_charge_dollar": 240.54, "standard_charge_percentage": 42.2, "count": "0", "additional_payer_notes": "Zero final payments for the item or service in the 15 months prior to posting the file." }, { "payer_name": "HEALTH NET", "plan_name": "HEALTHNET HMO, PPO, POS, EPO, CANOPY HEALTHNET HMO, OTHER-IN-NETWORK PLANS", "methodology": "per diem", "standard_charge_dollar": 8000.0, "standard_charge_algorithm": "Expected reimbursement is the lesser of Per diem ($8,000) for the length of stay and 70% of billed.", "count": "0", "additional_payer_notes": "Zero final payments for the item or service in the 15 months prior to posting the file." }, { "payer_name": "HEALTH NET", "plan_name": "HEALTHNET HMO, PPO, POS, EPO, CANOPY HEALTHNET HMO, OTHER-IN-NETWORK PLANS", "methodology": "per diem", "standard_charge_dollar": 8000.0, "standard_charge_algorithm": "Expected reimbursement is the lesser of Per diem ($8,000) for the length of stay and 70% of billed.", "count": "0", "additional_payer_notes": "Zero final payments for the item or service in the 15 months prior to posting the file." }, { "payer_name": "UNITED HEALTHCARE", "plan_name": "SUTTER SELECT & SUTTER HEALTH PLAN HMO PLANS", "methodology": "per diem", "standard_charge_dollar": 28538.0, "standard_charge_algorithm": "Per diem ($28,538).", "count": "0", "additional_payer_notes": "Zero final payments for the item or service in the 15 months prior to posting the file." }, { "payer_name": "UNITED HEALTHCARE", "plan_name": "SUTTER SELECT & SUTTER HEALTH PLAN HMO PLANS", "methodology": "per diem", "standard_charge_dollar": 28538.0, "standard_charge_algorithm": "Per diem ($28,538).", "count": "0", "additional_payer_notes": "Zero final payments for the item or service in the 15 months prior to posting the file." }, { "payer_name": "SUTTER", "plan_name": "SUTTER SELECT & SUTTER HEALTH PLAN HMO PLANS", "methodology": "per diem", "standard_charge_dollar": 28538.0, "standard_charge_algorithm": "Per diem ($28,538).", "count": "0", "additional_payer_notes": "Zero final payments for the item or service in the 15 months prior to posting the file." }, { "payer_name": "UNITED HEALTHCARE", "plan_name": "SUTTER SELECT & SUTTER HEALTH PLAN HMO PLANS", "methodology": "per diem", "standard_charge_dollar": 28538.0, "standard_charge_algorithm": "Per diem ($28,538).", "count": "0", "additional_payer_notes": "Zero final payments for the item or service in the 15 months prior to posting the file." }, { "payer_name": "UMR", "plan_name": "SUTTER SELECT & SUTTER HEALTH PLAN HMO PLANS", "methodology": "per diem", "standard_charge_dollar": 28538.0, "standard_charge_algorithm": "Per diem ($28,538).", "count": "0", "additional_payer_notes": "Zero final payments for the item or service in the 15 months prior to posting the file." } ] } ] }, { "description": "HC Cannula Gp010", "code_information": [ { "code": "PX-2120023010", "type": "CDM" }, { "code": "99999", "type": "CPT" }, { "code": "0272", "type": "RC" } ], "standard_charges": [ { "setting": "outpatient", "gross_charge": 665.0, "discounted_cash": 332.5, "minimum": 280.63, "maximum": 345.8, "additional_generic_notes": "Zero final payments for the item or service in the 15 months prior to posting the file.", "payers_information": [ { "payer_name": "AETNA", "plan_name": "AETNA ALL OTHER PLANS", "methodology": "percent of total billed charges", "standard_charge_dollar": 345.8, "standard_charge_percentage": 52.0, "count": "0", "additional_payer_notes": "Zero final payments for the item or service in the 15 months prior to posting the file." }, { "payer_name": "AETNA", "plan_name": "AETNA ALL OTHER PLANS", "methodology": "percent of total billed charges", "standard_charge_dollar": 345.8, "standard_charge_percentage": 52.0, "count": "0", "additional_payer_notes": "Zero final payments for the item or service in the 15 months prior to posting the file." }, { "payer_name": "MERITAIN HEALTH", "plan_name": "AETNA ALL OTHER PLANS", "methodology": "percent of total billed charges", "standard_charge_dollar": 345.8, "standard_charge_percentage": 52.0, "count": "0", "additional_payer_notes": "Zero final payments for the item or service in the 15 months prior to posting the file." }, { "payer_name": "BLUE SHIELD OUT OF STATE", "plan_name": "STANFORD HEALTHCARE ALLIANCE PLAN", "methodology": "percent of total billed charges", "standard_charge_dollar": 323.12, "standard_charge_percentage": 48.59, "count": "0", "additional_payer_notes": "Zero final payments for the item or service in the 15 months prior to posting the file." }, { "payer_name": "BLUE SHIELD", "plan_name": "STANFORD HEALTHCARE ALLIANCE PLAN", "methodology": "percent of total billed charges", "standard_charge_dollar": 323.12, "standard_charge_percentage": 48.59, "count": "0", "additional_payer_notes": "Zero final payments for the item or service in the 15 months prior to posting the file." }, { "payer_name": "BLUE SHIELD", "plan_name": "STANFORD HEALTHCARE ALLIANCE PLAN", "methodology": "percent of total billed charges", "standard_charge_dollar": 323.12, "standard_charge_percentage": 48.59, "count": "0", "additional_payer_notes": "Zero final payments for the item or service in the 15 months prior to posting the file." }, { "payer_name": "CIGNA", "plan_name": "CIGNA COM ALT HMO PLAN", "methodology": "percent of total billed charges", "standard_charge_dollar": 280.63, "standard_charge_percentage": 42.2, "count": "0", "additional_payer_notes": "Zero final payments for the item or service in the 15 months prior to posting the file." }, { "payer_name": "CIGNA", "plan_name": "CIGNA COM ALT HMO PLAN", "methodology": "percent of total billed charges", "standard_charge_dollar": 280.63, "standard_charge_percentage": 42.2, "count": "0", "additional_payer_notes": "Zero final payments for the item or service in the 15 months prior to posting the file." }, { "payer_name": "HEALTH NET", "plan_name": "HEALTHNET HMO, PPO, POS, EPO, CANOPY HEALTHNET HMO, OTHER-IN-NETWORK PLANS", "methodology": "per diem", "standard_charge_dollar": 8000.0, "standard_charge_algorithm": "Expected reimbursement is the lesser of Per diem ($8,000) for the length of stay and 70% of billed.", "count": "0", "additional_payer_notes": "Zero final payments for the item or service in the 15 months prior to posting the file." }, { "payer_name": "HEALTH NET", "plan_name": "HEALTHNET HMO, PPO, POS, EPO, CANOPY HEALTHNET HMO, OTHER-IN-NETWORK PLANS", "methodology": "per diem", "standard_charge_dollar": 8000.0, "standard_charge_algorithm": "Expected reimbursement is the lesser of Per diem ($8,000) for the length of stay and 70% of billed.", "count": "0", "additional_payer_notes": "Zero final payments for the item or service in the 15 months prior to posting the file." }, { "payer_name": "UNITED HEALTHCARE", "plan_name": "SUTTER SELECT & SUTTER HEALTH PLAN HMO PLANS", "methodology": "per diem", "standard_charge_dollar": 28538.0, "standard_charge_algorithm": "Per diem ($28,538).", "count": "0", "additional_payer_notes": "Zero final payments for the item or service in the 15 months prior to posting the file." }, { "payer_name": "UNITED HEALTHCARE", "plan_name": "SUTTER SELECT & SUTTER HEALTH PLAN HMO PLANS", "methodology": "per diem", "standard_charge_dollar": 28538.0, "standard_charge_algorithm": "Per diem ($28,538).", "count": "0", "additional_payer_notes": "Zero final payments for the item or service in the 15 months prior to posting the file." }, { "payer_name": "SUTTER", "plan_name": "SUTTER SELECT & SUTTER HEALTH PLAN HMO PLANS", "methodology": "per diem", "standard_charge_dollar": 28538.0, "standard_charge_algorithm": "Per diem ($28,538).", "count": "0", "additional_payer_notes": "Zero final payments for the item or service in the 15 months prior to posting the file." }, { "payer_name": "UNITED HEALTHCARE", "plan_name": "SUTTER SELECT & SUTTER HEALTH PLAN HMO PLANS", "methodology": "per diem", "standard_charge_dollar": 28538.0, "standard_charge_algorithm": "Per diem ($28,538).", "count": "0", "additional_payer_notes": "Zero final payments for the item or service in the 15 months prior to posting the file." }, { "payer_name": "UMR", "plan_name": "SUTTER SELECT & SUTTER HEALTH PLAN HMO PLANS", "methodology": "per diem", "standard_charge_dollar": 28538.0, "standard_charge_algorithm": "Per diem ($28,538).", "count": "0", "additional_payer_notes": "Zero final payments for the item or service in the 15 months prior to posting the file." } ] } ] }, { "description": "HC Cannula Gp011", "code_information": [ { "code": "PX-2120023011", "type": "CDM" }, { "code": "99999", "type": "CPT" }, { "code": "0272", "type": "RC" } ], "standard_charges": [ { "setting": "outpatient", "gross_charge": 740.0, "discounted_cash": 370.0, "minimum": 312.28, "maximum": 384.8, "additional_generic_notes": "Zero final payments for the item or service in the 15 months prior to posting the file.", "payers_information": [ { "payer_name": "AETNA", "plan_name": "AETNA ALL OTHER PLANS", "methodology": "percent of total billed charges", "standard_charge_dollar": 384.8, "standard_charge_percentage": 52.0, "count": "0", "additional_payer_notes": "Zero final payments for the item or service in the 15 months prior to posting the file." }, { "payer_name": "AETNA", "plan_name": "AETNA ALL OTHER PLANS", "methodology": "percent of total billed charges", "standard_charge_dollar": 384.8, "standard_charge_percentage": 52.0, "count": "0", "additional_payer_notes": "Zero final payments for the item or service in the 15 months prior to posting the file." }, { "payer_name": "MERITAIN HEALTH", "plan_name": "AETNA ALL OTHER PLANS", "methodology": "percent of total billed charges", "standard_charge_dollar": 384.8, "standard_charge_percentage": 52.0, "count": "0", "additional_payer_notes": "Zero final payments for the item or service in the 15 months prior to posting the file." }, { "payer_name": "BLUE SHIELD OUT OF STATE", "plan_name": "STANFORD HEALTHCARE ALLIANCE PLAN", "methodology": "percent of total billed charges", "standard_charge_dollar": 359.57, "standard_charge_percentage": 48.59, "count": "0", "additional_payer_notes": "Zero final payments for the item or service in the 15 months prior to posting the file." }, { "payer_name": "BLUE SHIELD", "plan_name": "STANFORD HEALTHCARE ALLIANCE PLAN", "methodology": "percent of total billed charges", "standard_charge_dollar": 359.57, "standard_charge_percentage": 48.59, "count": "0", "additional_payer_notes": "Zero final payments for the item or service in the 15 months prior to posting the file." }, { "payer_name": "BLUE SHIELD", "plan_name": "STANFORD HEALTHCARE ALLIANCE PLAN", "methodology": "percent of total billed charges", "standard_charge_dollar": 359.57, "standard_charge_percentage": 48.59, "count": "0", "additional_payer_notes": "Zero final payments for the item or service in the 15 months prior to posting the file." }, { "payer_name": "CIGNA", "plan_name": "CIGNA COM ALT HMO PLAN", "methodology": "percent of total billed charges", "standard_charge_dollar": 312.28, "standard_charge_percentage": 42.2, "count": "0", "additional_payer_notes": "Zero final payments for the item or service in the 15 months prior to posting the file." }, { "payer_name": "CIGNA", "plan_name": "CIGNA COM ALT HMO PLAN", "methodology": "percent of total billed charges", "standard_charge_dollar": 312.28, "standard_charge_percentage": 42.2, "count": "0", "additional_payer_notes": "Zero final payments for the item or service in the 15 months prior to posting the file." }, { "payer_name": "HEALTH NET", "plan_name": "HEALTHNET HMO, PPO, POS, EPO, CANOPY HEALTHNET HMO, OTHER-IN-NETWORK PLANS", "methodology": "per diem", "standard_charge_dollar": 8000.0, "standard_charge_algorithm": "Expected reimbursement is the lesser of Per diem ($8,000) for the length of stay and 70% of billed.", "count": "0", "additional_payer_notes": "Zero final payments for the item or service in the 15 months prior to posting the file." }, { "payer_name": "HEALTH NET", "plan_name": "HEALTHNET HMO, PPO, POS, EPO, CANOPY HEALTHNET HMO, OTHER-IN-NETWORK PLANS", "methodology": "per diem", "standard_charge_dollar": 8000.0, "standard_charge_algorithm": "Expected reimbursement is the lesser of Per diem ($8,000) for the length of stay and 70% of billed.", "count": "0", "additional_payer_notes": "Zero final payments for the item or service in the 15 months prior to posting the file." }, { "payer_name": "UNITED HEALTHCARE", "plan_name": "SUTTER SELECT & SUTTER HEALTH PLAN HMO PLANS", "methodology": "per diem", "standard_charge_dollar": 28538.0, "standard_charge_algorithm": "Per diem ($28,538).", "count": "0", "additional_payer_notes": "Zero final payments for the item or service in the 15 months prior to posting the file." }, { "payer_name": "UNITED HEALTHCARE", "plan_name": "SUTTER SELECT & SUTTER HEALTH PLAN HMO PLANS", "methodology": "per diem", "standard_charge_dollar": 28538.0, "standard_charge_algorithm": "Per diem ($28,538).", "count": "0", "additional_payer_notes": "Zero final payments for the item or service in the 15 months prior to posting the file." }, { "payer_name": "SUTTER", "plan_name": "SUTTER SELECT & SUTTER HEALTH PLAN HMO PLANS", "methodology": "per diem", "standard_charge_dollar": 28538.0, "standard_charge_algorithm": "Per diem ($28,538).", "count": "0", "additional_payer_notes": "Zero final payments for the item or service in the 15 months prior to posting the file." }, { "payer_name": "UNITED HEALTHCARE", "plan_name": "SUTTER SELECT & SUTTER HEALTH PLAN HMO PLANS", "methodology": "per diem", "standard_charge_dollar": 28538.0, "standard_charge_algorithm": "Per diem ($28,538).", "count": "0", "additional_payer_notes": "Zero final payments for the item or service in the 15 months prior to posting the file." }, { "payer_name": "UMR", "plan_name": "SUTTER SELECT & SUTTER HEALTH PLAN HMO PLANS", "methodology": "per diem", "standard_charge_dollar": 28538.0, "standard_charge_algorithm": "Per diem ($28,538).", "count": "0", "additional_payer_notes": "Zero final payments for the item or service in the 15 months prior to posting the file." } ] } ] }, { "description": "HC Cannula Gp012", "code_information": [ { "code": "PX-2120023012", "type": "CDM" }, { "code": "99999", "type": "CPT" }, { "code": "0272", "type": "RC" } ], "standard_charges": [ { "setting": "outpatient", "gross_charge": 810.0, "discounted_cash": 405.0, "minimum": 341.82, "maximum": 421.2, "additional_generic_notes": "Zero final payments for the item or service in the 15 months prior to posting the file.", "payers_information": [ { "payer_name": "AETNA", "plan_name": "AETNA ALL OTHER PLANS", "methodology": "percent of total billed charges", "standard_charge_dollar": 421.2, "standard_charge_percentage": 52.0, "count": "0", "additional_payer_notes": "Zero final payments for the item or service in the 15 months prior to posting the file." }, { "payer_name": "AETNA", "plan_name": "AETNA ALL OTHER PLANS", "methodology": "percent of total billed charges", "standard_charge_dollar": 421.2, "standard_charge_percentage": 52.0, "count": "0", "additional_payer_notes": "Zero final payments for the item or service in the 15 months prior to posting the file." }, { "payer_name": "MERITAIN HEALTH", "plan_name": "AETNA ALL OTHER PLANS", "methodology": "percent of total billed charges", "standard_charge_dollar": 421.2, "standard_charge_percentage": 52.0, "count": "0", "additional_payer_notes": "Zero final payments for the item or service in the 15 months prior to posting the file." }, { "payer_name": "BLUE SHIELD OUT OF STATE", "plan_name": "STANFORD HEALTHCARE ALLIANCE PLAN", "methodology": "percent of total billed charges", "standard_charge_dollar": 393.58, "standard_charge_percentage": 48.59, "count": "0", "additional_payer_notes": "Zero final payments for the item or service in the 15 months prior to posting the file." }, { "payer_name": "BLUE SHIELD", "plan_name": "STANFORD HEALTHCARE ALLIANCE PLAN", "methodology": "percent of total billed charges", "standard_charge_dollar": 393.58, "standard_charge_percentage": 48.59, "count": "0", "additional_payer_notes": "Zero final payments for the item or service in the 15 months prior to posting the file." }, { "payer_name": "BLUE SHIELD", "plan_name": "STANFORD HEALTHCARE ALLIANCE PLAN", "methodology": "percent of total billed charges", "standard_charge_dollar": 393.58, "standard_charge_percentage": 48.59, "count": "0", "additional_payer_notes": "Zero final payments for the item or service in the 15 months prior to posting the file." }, { "payer_name": "CIGNA", "plan_name": "CIGNA COM ALT HMO PLAN", "methodology": "percent of total billed charges", "standard_charge_dollar": 341.82, "standard_charge_percentage": 42.2, "count": "0", "additional_payer_notes": "Zero final payments for the item or service in the 15 months prior to posting the file." }, { "payer_name": "CIGNA", "plan_name": "CIGNA COM ALT HMO PLAN", "methodology": "percent of total billed charges", "standard_charge_dollar": 341.82, "standard_charge_percentage": 42.2, "count": "0", "additional_payer_notes": "Zero final payments for the item or service in the 15 months prior to posting the file." }, { "payer_name": "HEALTH NET", "plan_name": "HEALTHNET HMO, PPO, POS, EPO, CANOPY HEALTHNET HMO, OTHER-IN-NETWORK PLANS", "methodology": "per diem", "standard_charge_dollar": 8000.0, "standard_charge_algorithm": "Expected reimbursement is the lesser of Per diem ($8,000) for the length of stay and 70% of billed.", "count": "0", "additional_payer_notes": "Zero final payments for the item or service in the 15 months prior to posting the file." }, { "payer_name": "HEALTH NET", "plan_name": "HEALTHNET HMO, PPO, POS, EPO, CANOPY HEALTHNET HMO, OTHER-IN-NETWORK PLANS", "methodology": "per diem", "standard_charge_dollar": 8000.0, "standard_charge_algorithm": "Expected reimbursement is the lesser of Per diem ($8,000) for the length of stay and 70% of billed.", "count": "0", "additional_payer_notes": "Zero final payments for the item or service in the 15 months prior to posting the file." }, { "payer_name": "UNITED HEALTHCARE", "plan_name": "SUTTER SELECT & SUTTER HEALTH PLAN HMO PLANS", "methodology": "per diem", "standard_charge_dollar": 28538.0, "standard_charge_algorithm": "Per diem ($28,538).", "count": "0", "additional_payer_notes": "Zero final payments for the item or service in the 15 months prior to posting the file." }, { "payer_name": "UNITED HEALTHCARE", "plan_name": "SUTTER SELECT & SUTTER HEALTH PLAN HMO PLANS", "methodology": "per diem", "standard_charge_dollar": 28538.0, "standard_charge_algorithm": "Per diem ($28,538).", "count": "0", "additional_payer_notes": "Zero final payments for the item or service in the 15 months prior to posting the file." }, { "payer_name": "SUTTER", "plan_name": "SUTTER SELECT & SUTTER HEALTH PLAN HMO PLANS", "methodology": "per diem", "standard_charge_dollar": 28538.0, "standard_charge_algorithm": "Per diem ($28,538).", "count": "0", "additional_payer_notes": "Zero final payments for the item or service in the 15 months prior to posting the file." }, { "payer_name": "UNITED HEALTHCARE", "plan_name": "SUTTER SELECT & SUTTER HEALTH PLAN HMO PLANS", "methodology": "per diem", "standard_charge_dollar": 28538.0, "standard_charge_algorithm": "Per diem ($28,538).", "count": "0", "additional_payer_notes": "Zero final payments for the item or service in the 15 months prior to posting the file." }, { "payer_name": "UMR", "plan_name": "SUTTER SELECT & SUTTER HEALTH PLAN HMO PLANS", "methodology": "per diem", "standard_charge_dollar": 28538.0, "standard_charge_algorithm": "Per diem ($28,538).", "count": "0", "additional_payer_notes": "Zero final payments for the item or service in the 15 months prior to posting the file." } ] } ] }, { "description": "HC Cannula Gp013", "code_information": [ { "code": "PX-2120023013", "type": "CDM" }, { "code": "99999", "type": "CPT" }, { "code": "0272", "type": "RC" } ], "standard_charges": [ { "setting": "outpatient", "gross_charge": 900.0, "discounted_cash": 450.0, "minimum": 379.8, "maximum": 468.0, "additional_generic_notes": "Zero final payments for the item or service in the 15 months prior to posting the file.", "payers_information": [ { "payer_name": "AETNA", "plan_name": "AETNA ALL OTHER PLANS", "methodology": "percent of total billed charges", "standard_charge_dollar": 468.0, "standard_charge_percentage": 52.0, "count": "0", "additional_payer_notes": "Zero final payments for the item or service in the 15 months prior to posting the file." }, { "payer_name": "AETNA", "plan_name": "AETNA ALL OTHER PLANS", "methodology": "percent of total billed charges", "standard_charge_dollar": 468.0, "standard_charge_percentage": 52.0, "count": "0", "additional_payer_notes": "Zero final payments for the item or service in the 15 months prior to posting the file." }, { "payer_name": "MERITAIN HEALTH", "plan_name": "AETNA ALL OTHER PLANS", "methodology": "percent of total billed charges", "standard_charge_dollar": 468.0, "standard_charge_percentage": 52.0, "count": "0", "additional_payer_notes": "Zero final payments for the item or service in the 15 months prior to posting the file." }, { "payer_name": "BLUE SHIELD OUT OF STATE", "plan_name": "STANFORD HEALTHCARE ALLIANCE PLAN", "methodology": "percent of total billed charges", "standard_charge_dollar": 437.31, "standard_charge_percentage": 48.59, "count": "0", "additional_payer_notes": "Zero final payments for the item or service in the 15 months prior to posting the file." }, { "payer_name": "BLUE SHIELD", "plan_name": "STANFORD HEALTHCARE ALLIANCE PLAN", "methodology": "percent of total billed charges", "standard_charge_dollar": 437.31, "standard_charge_percentage": 48.59, "count": "0", "additional_payer_notes": "Zero final payments for the item or service in the 15 months prior to posting the file." }, { "payer_name": "BLUE SHIELD", "plan_name": "STANFORD HEALTHCARE ALLIANCE PLAN", "methodology": "percent of total billed charges", "standard_charge_dollar": 437.31, "standard_charge_percentage": 48.59, "count": "0", "additional_payer_notes": "Zero final payments for the item or service in the 15 months prior to posting the file." }, { "payer_name": "CIGNA", "plan_name": "CIGNA COM ALT HMO PLAN", "methodology": "percent of total billed charges", "standard_charge_dollar": 379.8, "standard_charge_percentage": 42.2, "count": "0", "additional_payer_notes": "Zero final payments for the item or service in the 15 months prior to posting the file." }, { "payer_name": "CIGNA", "plan_name": "CIGNA COM ALT HMO PLAN", "methodology": "percent of total billed charges", "standard_charge_dollar": 379.8, "standard_charge_percentage": 42.2, "count": "0", "additional_payer_notes": "Zero final payments for the item or service in the 15 months prior to posting the file." }, { "payer_name": "HEALTH NET", "plan_name": "HEALTHNET HMO, PPO, POS, EPO, CANOPY HEALTHNET HMO, OTHER-IN-NETWORK PLANS", "methodology": "per diem", "standard_charge_dollar": 8000.0, "standard_charge_algorithm": "Expected reimbursement is the lesser of Per diem ($8,000) for the length of stay and 70% of billed.", "count": "0", "additional_payer_notes": "Zero final payments for the item or service in the 15 months prior to posting the file." }, { "payer_name": "HEALTH NET", "plan_name": "HEALTHNET HMO, PPO, POS, EPO, CANOPY HEALTHNET HMO, OTHER-IN-NETWORK PLANS", "methodology": "per diem", "standard_charge_dollar": 8000.0, "standard_charge_algorithm": "Expected reimbursement is the lesser of Per diem ($8,000) for the length of stay and 70% of billed.", "count": "0", "additional_payer_notes": "Zero final payments for the item or service in the 15 months prior to posting the file." }, { "payer_name": "UNITED HEALTHCARE", "plan_name": "SUTTER SELECT & SUTTER HEALTH PLAN HMO PLANS", "methodology": "per diem", "standard_charge_dollar": 28538.0, "standard_charge_algorithm": "Per diem ($28,538).", "count": "0", "additional_payer_notes": "Zero final payments for the item or service in the 15 months prior to posting the file." }, { "payer_name": "UNITED HEALTHCARE", "plan_name": "SUTTER SELECT & SUTTER HEALTH PLAN HMO PLANS", "methodology": "per diem", "standard_charge_dollar": 28538.0, "standard_charge_algorithm": "Per diem ($28,538).", "count": "0", "additional_payer_notes": "Zero final payments for the item or service in the 15 months prior to posting the file." }, { "payer_name": "SUTTER", "plan_name": "SUTTER SELECT & SUTTER HEALTH PLAN HMO PLANS", "methodology": "per diem", "standard_charge_dollar": 28538.0, "standard_charge_algorithm": "Per diem ($28,538).", "count": "0", "additional_payer_notes": "Zero final payments for the item or service in the 15 months prior to posting the file." }, { "payer_name": "UNITED HEALTHCARE", "plan_name": "SUTTER SELECT & SUTTER HEALTH PLAN HMO PLANS", "methodology": "per diem", "standard_charge_dollar": 28538.0, "standard_charge_algorithm": "Per diem ($28,538).", "count": "0", "additional_payer_notes": "Zero final payments for the item or service in the 15 months prior to posting the file." }, { "payer_name": "UMR", "plan_name": "SUTTER SELECT & SUTTER HEALTH PLAN HMO PLANS", "methodology": "per diem", "standard_charge_dollar": 28538.0, "standard_charge_algorithm": "Per diem ($28,538).", "count": "0", "additional_payer_notes": "Zero final payments for the item or service in the 15 months prior to posting the file." } ] } ] }, { "description": "HC Cannula Gp014", "code_information": [ { "code": "PX-2120023014", "type": "CDM" }, { "code": "99999", "type": "CPT" }, { "code": "0272", "type": "RC" } ], "standard_charges": [ { "setting": "outpatient", "gross_charge": 1080.0, "discounted_cash": 540.0, "minimum": 455.76, "maximum": 561.6, "additional_generic_notes": "Zero final payments for the item or service in the 15 months prior to posting the file.", "payers_information": [ { "payer_name": "AETNA", "plan_name": "AETNA ALL OTHER PLANS", "methodology": "percent of total billed charges", "standard_charge_dollar": 561.6, "standard_charge_percentage": 52.0, "count": "0", "additional_payer_notes": "Zero final payments for the item or service in the 15 months prior to posting the file." }, { "payer_name": "AETNA", "plan_name": "AETNA ALL OTHER PLANS", "methodology": "percent of total billed charges", "standard_charge_dollar": 561.6, "standard_charge_percentage": 52.0, "count": "0", "additional_payer_notes": "Zero final payments for the item or service in the 15 months prior to posting the file." }, { "payer_name": "MERITAIN HEALTH", "plan_name": "AETNA ALL OTHER PLANS", "methodology": "percent of total billed charges", "standard_charge_dollar": 561.6, "standard_charge_percentage": 52.0, "count": "0", "additional_payer_notes": "Zero final payments for the item or service in the 15 months prior to posting the file." }, { "payer_name": "BLUE SHIELD OUT OF STATE", "plan_name": "STANFORD HEALTHCARE ALLIANCE PLAN", "methodology": "percent of total billed charges", "standard_charge_dollar": 524.77, "standard_charge_percentage": 48.59, "count": "0", "additional_payer_notes": "Zero final payments for the item or service in the 15 months prior to posting the file." }, { "payer_name": "BLUE SHIELD", "plan_name": "STANFORD HEALTHCARE ALLIANCE PLAN", "methodology": "percent of total billed charges", "standard_charge_dollar": 524.77, "standard_charge_percentage": 48.59, "median_amount": 68.24, "10th_percentile": 13.6, "90th_percentile": 1043.06, "count": "30" }, { "payer_name": "BLUE SHIELD", "plan_name": "STANFORD HEALTHCARE ALLIANCE PLAN", "methodology": "percent of total billed charges", "standard_charge_dollar": 524.77, "standard_charge_percentage": 48.59, "count": "0", "additional_payer_notes": "Zero final payments for the item or service in the 15 months prior to posting the file." }, { "payer_name": "BLUE SHIELD", "plan_name": "STANFORD HEALTHCARE ALLIANCE PLAN", "methodology": "percent of total billed charges", "standard_charge_dollar": 524.77, "standard_charge_percentage": 48.59, "count": "0", "additional_payer_notes": "Zero final payments for the item or service in the 15 months prior to posting the file." }, { "payer_name": "CIGNA", "plan_name": "CIGNA COM ALT HMO PLAN", "methodology": "percent of total billed charges", "standard_charge_dollar": 455.76, "standard_charge_percentage": 42.2, "count": "0", "additional_payer_notes": "Zero final payments for the item or service in the 15 months prior to posting the file." }, { "payer_name": "CIGNA", "plan_name": "CIGNA COM ALT HMO PLAN", "methodology": "percent of total billed charges", "standard_charge_dollar": 455.76, "standard_charge_percentage": 42.2, "count": "0", "additional_payer_notes": "Zero final payments for the item or service in the 15 months prior to posting the file." }, { "payer_name": "HEALTH NET", "plan_name": "HEALTHNET HMO, PPO, POS, EPO, CANOPY HEALTHNET HMO, OTHER-IN-NETWORK PLANS", "methodology": "per diem", "standard_charge_dollar": 8000.0, "standard_charge_algorithm": "Expected reimbursement is the lesser of Per diem ($8,000) for the length of stay and 70% of billed.", "count": "0", "additional_payer_notes": "Zero final payments for the item or service in the 15 months prior to posting the file." }, { "payer_name": "HEALTH NET", "plan_name": "HEALTHNET HMO, PPO, POS, EPO, CANOPY HEALTHNET HMO, OTHER-IN-NETWORK PLANS", "methodology": "per diem", "standard_charge_dollar": 8000.0, "standard_charge_algorithm": "Expected reimbursement is the lesser of Per diem ($8,000) for the length of stay and 70% of billed.", "count": "0", "additional_payer_notes": "Zero final payments for the item or service in the 15 months prior to posting the file." }, { "payer_name": "UNITED HEALTHCARE", "plan_name": "SUTTER SELECT & SUTTER HEALTH PLAN HMO PLANS", "methodology": "per diem", "standard_charge_dollar": 28538.0, "standard_charge_algorithm": "Per diem ($28,538).", "count": "0", "additional_payer_notes": "Zero final payments for the item or service in the 15 months prior to posting the file." }, { "payer_name": "UNITED HEALTHCARE", "plan_name": "SUTTER SELECT & SUTTER HEALTH PLAN HMO PLANS", "methodology": "per diem", "standard_charge_dollar": 28538.0, "standard_charge_algorithm": "Per diem ($28,538).", "count": "0", "additional_payer_notes": "Zero final payments for the item or service in the 15 months prior to posting the file." }, { "payer_name": "SUTTER", "plan_name": "SUTTER SELECT & SUTTER HEALTH PLAN HMO PLANS", "methodology": "per diem", "standard_charge_dollar": 28538.0, "standard_charge_algorithm": "Per diem ($28,538).", "count": "0", "additional_payer_notes": "Zero final payments for the item or service in the 15 months prior to posting the file." }, { "payer_name": "UNITED HEALTHCARE", "plan_name": "SUTTER SELECT & SUTTER HEALTH PLAN HMO PLANS", "methodology": "per diem", "standard_charge_dollar": 28538.0, "standard_charge_algorithm": "Per diem ($28,538).", "count": "0", "additional_payer_notes": "Zero final payments for the item or service in the 15 months prior to posting the file." }, { "payer_name": "UMR", "plan_name": "SUTTER SELECT & SUTTER HEALTH PLAN HMO PLANS", "methodology": "per diem", "standard_charge_dollar": 28538.0, "standard_charge_algorithm": "Per diem ($28,538).", "count": "0", "additional_payer_notes": "Zero final payments for the item or service in the 15 months prior to posting the file." } ] } ] }, { "description": "HC Cannula Gp015", "code_information": [ { "code": "PX-2120023015", "type": "CDM" }, { "code": "99999", "type": "CPT" }, { "code": "0272", "type": "RC" } ], "standard_charges": [ { "setting": "outpatient", "gross_charge": 1225.0, "discounted_cash": 612.5, "minimum": 516.95, "maximum": 637.0, "additional_generic_notes": "Zero final payments for the item or service in the 15 months prior to posting the file.", "payers_information": [ { "payer_name": "AETNA", "plan_name": "AETNA ALL OTHER PLANS", "methodology": "percent of total billed charges", "standard_charge_dollar": 637.0, "standard_charge_percentage": 52.0, "count": "0", "additional_payer_notes": "Zero final payments for the item or service in the 15 months prior to posting the file." }, { "payer_name": "AETNA", "plan_name": "AETNA ALL OTHER PLANS", "methodology": "percent of total billed charges", "standard_charge_dollar": 637.0, "standard_charge_percentage": 52.0, "count": "0", "additional_payer_notes": "Zero final payments for the item or service in the 15 months prior to posting the file." }, { "payer_name": "MERITAIN HEALTH", "plan_name": "AETNA ALL OTHER PLANS", "methodology": "percent of total billed charges", "standard_charge_dollar": 637.0, "standard_charge_percentage": 52.0, "count": "0", "additional_payer_notes": "Zero final payments for the item or service in the 15 months prior to posting the file." }, { "payer_name": "BLUE SHIELD OUT OF STATE", "plan_name": "STANFORD HEALTHCARE ALLIANCE PLAN", "methodology": "percent of total billed charges", "standard_charge_dollar": 595.23, "standard_charge_percentage": 48.59, "count": "0", "additional_payer_notes": "Zero final payments for the item or service in the 15 months prior to posting the file." }, { "payer_name": "BLUE SHIELD", "plan_name": "STANFORD HEALTHCARE ALLIANCE PLAN", "methodology": "percent of total billed charges", "standard_charge_dollar": 595.23, "standard_charge_percentage": 48.59, "median_amount": 68.24, "10th_percentile": 13.6, "90th_percentile": 1043.06, "count": "30" }, { "payer_name": "BLUE SHIELD", "plan_name": "STANFORD HEALTHCARE ALLIANCE PLAN", "methodology": "percent of total billed charges", "standard_charge_dollar": 595.23, "standard_charge_percentage": 48.59, "count": "0", "additional_payer_notes": "Zero final payments for the item or service in the 15 months prior to posting the file." }, { "payer_name": "BLUE SHIELD", "plan_name": "STANFORD HEALTHCARE ALLIANCE PLAN", "methodology": "percent of total billed charges", "standard_charge_dollar": 595.23, "standard_charge_percentage": 48.59, "count": "0", "additional_payer_notes": "Zero final payments for the item or service in the 15 months prior to posting the file." }, { "payer_name": "CIGNA", "plan_name": "CIGNA COM ALT HMO PLAN", "methodology": "percent of total billed charges", "standard_charge_dollar": 516.95, "standard_charge_percentage": 42.2, "count": "0", "additional_payer_notes": "Zero final payments for the item or service in the 15 months prior to posting the file." }, { "payer_name": "CIGNA", "plan_name": "CIGNA COM ALT HMO PLAN", "methodology": "percent of total billed charges", "standard_charge_dollar": 516.95, "standard_charge_percentage": 42.2, "count": "0", "additional_payer_notes": "Zero final payments for the item or service in the 15 months prior to posting the file." }, { "payer_name": "HEALTH NET", "plan_name": "HEALTHNET HMO, PPO, POS, EPO, CANOPY HEALTHNET HMO, OTHER-IN-NETWORK PLANS", "methodology": "per diem", "standard_charge_dollar": 8000.0, "standard_charge_algorithm": "Expected reimbursement is the lesser of Per diem ($8,000) for the length of stay and 70% of billed.", "count": "0", "additional_payer_notes": "Zero final payments for the item or service in the 15 months prior to posting the file." }, { "payer_name": "HEALTH NET", "plan_name": "HEALTHNET HMO, PPO, POS, EPO, CANOPY HEALTHNET HMO, OTHER-IN-NETWORK PLANS", "methodology": "per diem", "standard_charge_dollar": 8000.0, "standard_charge_algorithm": "Expected reimbursement is the lesser of Per diem ($8,000) for the length of stay and 70% of billed.", "count": "0", "additional_payer_notes": "Zero final payments for the item or service in the 15 months prior to posting the file." }, { "payer_name": "UNITED HEALTHCARE", "plan_name": "SUTTER SELECT & SUTTER HEALTH PLAN HMO PLANS", "methodology": "per diem", "standard_charge_dollar": 28538.0, "standard_charge_algorithm": "Per diem ($28,538).", "count": "0", "additional_payer_notes": "Zero final payments for the item or service in the 15 months prior to posting the file." }, { "payer_name": "UNITED HEALTHCARE", "plan_name": "SUTTER SELECT & SUTTER HEALTH PLAN HMO PLANS", "methodology": "per diem", "standard_charge_dollar": 28538.0, "standard_charge_algorithm": "Per diem ($28,538).", "count": "0", "additional_payer_notes": "Zero final payments for the item or service in the 15 months prior to posting the file." }, { "payer_name": "SUTTER", "plan_name": "SUTTER SELECT & SUTTER HEALTH PLAN HMO PLANS", "methodology": "per diem", "standard_charge_dollar": 28538.0, "standard_charge_algorithm": "Per diem ($28,538).", "count": "0", "additional_payer_notes": "Zero final payments for the item or service in the 15 months prior to posting the file." }, { "payer_name": "UNITED HEALTHCARE", "plan_name": "SUTTER SELECT & SUTTER HEALTH PLAN HMO PLANS", "methodology": "per diem", "standard_charge_dollar": 28538.0, "standard_charge_algorithm": "Per diem ($28,538).", "count": "0", "additional_payer_notes": "Zero final payments for the item or service in the 15 months prior to posting the file." }, { "payer_name": "UMR", "plan_name": "SUTTER SELECT & SUTTER HEALTH PLAN HMO PLANS", "methodology": "per diem", "standard_charge_dollar": 28538.0, "standard_charge_algorithm": "Per diem ($28,538).", "count": "0", "additional_payer_notes": "Zero final payments for the item or service in the 15 months prior to posting the file." } ] } ] }, { "description": "HC Cannula Gp016", "code_information": [ { "code": "PX-2120023016", "type": "CDM" }, { "code": "99999", "type": "CPT" }, { "code": "0272", "type": "RC" } ], "standard_charges": [ { "setting": "outpatient", "gross_charge": 1400.0, "discounted_cash": 700.0, "minimum": 590.8, "maximum": 728.0, "additional_generic_notes": "Zero final payments for the item or service in the 15 months prior to posting the file.", "payers_information": [ { "payer_name": "AETNA", "plan_name": "AETNA ALL OTHER PLANS", "methodology": "percent of total billed charges", "standard_charge_dollar": 728.0, "standard_charge_percentage": 52.0, "count": "0", "additional_payer_notes": "Zero final payments for the item or service in the 15 months prior to posting the file." }, { "payer_name": "AETNA", "plan_name": "AETNA ALL OTHER PLANS", "methodology": "percent of total billed charges", "standard_charge_dollar": 728.0, "standard_charge_percentage": 52.0, "count": "0", "additional_payer_notes": "Zero final payments for the item or service in the 15 months prior to posting the file." }, { "payer_name": "MERITAIN HEALTH", "plan_name": "AETNA ALL OTHER PLANS", "methodology": "percent of total billed charges", "standard_charge_dollar": 728.0, "standard_charge_percentage": 52.0, "count": "0", "additional_payer_notes": "Zero final payments for the item or service in the 15 months prior to posting the file." }, { "payer_name": "BLUE SHIELD OUT OF STATE", "plan_name": "STANFORD HEALTHCARE ALLIANCE PLAN", "methodology": "percent of total billed charges", "standard_charge_dollar": 680.26, "standard_charge_percentage": 48.59, "count": "0", "additional_payer_notes": "Zero final payments for the item or service in the 15 months prior to posting the file." }, { "payer_name": "BLUE SHIELD", "plan_name": "STANFORD HEALTHCARE ALLIANCE PLAN", "methodology": "percent of total billed charges", "standard_charge_dollar": 680.26, "standard_charge_percentage": 48.59, "median_amount": 68.24, "10th_percentile": 13.6, "90th_percentile": 1043.06, "count": "30" }, { "payer_name": "BLUE SHIELD", "plan_name": "STANFORD HEALTHCARE ALLIANCE PLAN", "methodology": "percent of total billed charges", "standard_charge_dollar": 680.26, "standard_charge_percentage": 48.59, "count": "0", "additional_payer_notes": "Zero final payments for the item or service in the 15 months prior to posting the file." }, { "payer_name": "BLUE SHIELD", "plan_name": "STANFORD HEALTHCARE ALLIANCE PLAN", "methodology": "percent of total billed charges", "standard_charge_dollar": 680.26, "standard_charge_percentage": 48.59, "count": "0", "additional_payer_notes": "Zero final payments for the item or service in the 15 months prior to posting the file." }, { "payer_name": "CIGNA", "plan_name": "CIGNA COM ALT HMO PLAN", "methodology": "percent of total billed charges", "standard_charge_dollar": 590.8, "standard_charge_percentage": 42.2, "count": "0", "additional_payer_notes": "Zero final payments for the item or service in the 15 months prior to posting the file." }, { "payer_name": "CIGNA", "plan_name": "CIGNA COM ALT HMO PLAN", "methodology": "percent of total billed charges", "standard_charge_dollar": 590.8, "standard_charge_percentage": 42.2, "count": "0", "additional_payer_notes": "Zero final payments for the item or service in the 15 months prior to posting the file." }, { "payer_name": "HEALTH NET", "plan_name": "HEALTHNET HMO, PPO, POS, EPO, CANOPY HEALTHNET HMO, OTHER-IN-NETWORK PLANS", "methodology": "per diem", "standard_charge_dollar": 8000.0, "standard_charge_algorithm": "Expected reimbursement is the lesser of Per diem ($8,000) for the length of stay and 70% of billed.", "count": "0", "additional_payer_notes": "Zero final payments for the item or service in the 15 months prior to posting the file." }, { "payer_name": "HEALTH NET", "plan_name": "HEALTHNET HMO, PPO, POS, EPO, CANOPY HEALTHNET HMO, OTHER-IN-NETWORK PLANS", "methodology": "per diem", "standard_charge_dollar": 8000.0, "standard_charge_algorithm": "Expected reimbursement is the lesser of Per diem ($8,000) for the length of stay and 70% of billed.", "count": "0", "additional_payer_notes": "Zero final payments for the item or service in the 15 months prior to posting the file." }, { "payer_name": "UNITED HEALTHCARE", "plan_name": "SUTTER SELECT & SUTTER HEALTH PLAN HMO PLANS", "methodology": "per diem", "standard_charge_dollar": 28538.0, "standard_charge_algorithm": "Per diem ($28,538).", "count": "0", "additional_payer_notes": "Zero final payments for the item or service in the 15 months prior to posting the file." }, { "payer_name": "UNITED HEALTHCARE", "plan_name": "SUTTER SELECT & SUTTER HEALTH PLAN HMO PLANS", "methodology": "per diem", "standard_charge_dollar": 28538.0, "standard_charge_algorithm": "Per diem ($28,538).", "count": "0", "additional_payer_notes": "Zero final payments for the item or service in the 15 months prior to posting the file." }, { "payer_name": "SUTTER", "plan_name": "SUTTER SELECT & SUTTER HEALTH PLAN HMO PLANS", "methodology": "per diem", "standard_charge_dollar": 28538.0, "standard_charge_algorithm": "Per diem ($28,538).", "count": "0", "additional_payer_notes": "Zero final payments for the item or service in the 15 months prior to posting the file." }, { "payer_name": "UNITED HEALTHCARE", "plan_name": "SUTTER SELECT & SUTTER HEALTH PLAN HMO PLANS", "methodology": "per diem", "standard_charge_dollar": 28538.0, "standard_charge_algorithm": "Per diem ($28,538).", "count": "0", "additional_payer_notes": "Zero final payments for the item or service in the 15 months prior to posting the file." }, { "payer_name": "UMR", "plan_name": "SUTTER SELECT & SUTTER HEALTH PLAN HMO PLANS", "methodology": "per diem", "standard_charge_dollar": 28538.0, "standard_charge_algorithm": "Per diem ($28,538).", "count": "0", "additional_payer_notes": "Zero final payments for the item or service in the 15 months prior to posting the file." } ] } ] }, { "description": "HC Cannula Gp017", "code_information": [ { "code": "PX-2120023017", "type": "CDM" }, { "code": "99999", "type": "CPT" }, { "code": "0272", "type": "RC" } ], "standard_charges": [ { "setting": "outpatient", "gross_charge": 1575.0, "discounted_cash": 787.5, "minimum": 664.65, "maximum": 819.0, "additional_generic_notes": "Zero final payments for the item or service in the 15 months prior to posting the file.", "payers_information": [ { "payer_name": "AETNA", "plan_name": "AETNA ALL OTHER PLANS", "methodology": "percent of total billed charges", "standard_charge_dollar": 819.0, "standard_charge_percentage": 52.0, "count": "0", "additional_payer_notes": "Zero final payments for the item or service in the 15 months prior to posting the file." }, { "payer_name": "AETNA", "plan_name": "AETNA ALL OTHER PLANS", "methodology": "percent of total billed charges", "standard_charge_dollar": 819.0, "standard_charge_percentage": 52.0, "count": "0", "additional_payer_notes": "Zero final payments for the item or service in the 15 months prior to posting the file." }, { "payer_name": "MERITAIN HEALTH", "plan_name": "AETNA ALL OTHER PLANS", "methodology": "percent of total billed charges", "standard_charge_dollar": 819.0, "standard_charge_percentage": 52.0, "count": "0", "additional_payer_notes": "Zero final payments for the item or service in the 15 months prior to posting the file." }, { "payer_name": "BLUE SHIELD OUT OF STATE", "plan_name": "STANFORD HEALTHCARE ALLIANCE PLAN", "methodology": "percent of total billed charges", "standard_charge_dollar": 765.29, "standard_charge_percentage": 48.59, "count": "0", "additional_payer_notes": "Zero final payments for the item or service in the 15 months prior to posting the file." }, { "payer_name": "BLUE SHIELD", "plan_name": "STANFORD HEALTHCARE ALLIANCE PLAN", "methodology": "percent of total billed charges", "standard_charge_dollar": 765.29, "standard_charge_percentage": 48.59, "median_amount": 68.24, "10th_percentile": 13.6, "90th_percentile": 1043.06, "count": "30" }, { "payer_name": "BLUE SHIELD", "plan_name": "STANFORD HEALTHCARE ALLIANCE PLAN", "methodology": "percent of total billed charges", "standard_charge_dollar": 765.29, "standard_charge_percentage": 48.59, "count": "0", "additional_payer_notes": "Zero final payments for the item or service in the 15 months prior to posting the file." }, { "payer_name": "BLUE SHIELD", "plan_name": "STANFORD HEALTHCARE ALLIANCE PLAN", "methodology": "percent of total billed charges", "standard_charge_dollar": 765.29, "standard_charge_percentage": 48.59, "count": "0", "additional_payer_notes": "Zero final payments for the item or service in the 15 months prior to posting the file." }, { "payer_name": "CIGNA", "plan_name": "CIGNA COM ALT HMO PLAN", "methodology": "percent of total billed charges", "standard_charge_dollar": 664.65, "standard_charge_percentage": 42.2, "count": "0", "additional_payer_notes": "Zero final payments for the item or service in the 15 months prior to posting the file." }, { "payer_name": "CIGNA", "plan_name": "CIGNA COM ALT HMO PLAN", "methodology": "percent of total billed charges", "standard_charge_dollar": 664.65, "standard_charge_percentage": 42.2, "count": "0", "additional_payer_notes": "Zero final payments for the item or service in the 15 months prior to posting the file." }, { "payer_name": "HEALTH NET", "plan_name": "HEALTHNET HMO, PPO, POS, EPO, CANOPY HEALTHNET HMO, OTHER-IN-NETWORK PLANS", "methodology": "per diem", "standard_charge_dollar": 8000.0, "standard_charge_algorithm": "Expected reimbursement is the lesser of Per diem ($8,000) for the length of stay and 70% of billed.", "count": "0", "additional_payer_notes": "Zero final payments for the item or service in the 15 months prior to posting the file." }, { "payer_name": "HEALTH NET", "plan_name": "HEALTHNET HMO, PPO, POS, EPO, CANOPY HEALTHNET HMO, OTHER-IN-NETWORK PLANS", "methodology": "per diem", "standard_charge_dollar": 8000.0, "standard_charge_algorithm": "Expected reimbursement is the lesser of Per diem ($8,000) for the length of stay and 70% of billed.", "count": "0", "additional_payer_notes": "Zero final payments for the item or service in the 15 months prior to posting the file." }, { "payer_name": "UNITED HEALTHCARE", "plan_name": "SUTTER SELECT & SUTTER HEALTH PLAN HMO PLANS", "methodology": "per diem", "standard_charge_dollar": 28538.0, "standard_charge_algorithm": "Per diem ($28,538).", "count": "0", "additional_payer_notes": "Zero final payments for the item or service in the 15 months prior to posting the file." }, { "payer_name": "UNITED HEALTHCARE", "plan_name": "SUTTER SELECT & SUTTER HEALTH PLAN HMO PLANS", "methodology": "per diem", "standard_charge_dollar": 28538.0, "standard_charge_algorithm": "Per diem ($28,538).", "count": "0", "additional_payer_notes": "Zero final payments for the item or service in the 15 months prior to posting the file." }, { "payer_name": "SUTTER", "plan_name": "SUTTER SELECT & SUTTER HEALTH PLAN HMO PLANS", "methodology": "per diem", "standard_charge_dollar": 28538.0, "standard_charge_algorithm": "Per diem ($28,538).", "count": "0", "additional_payer_notes": "Zero final payments for the item or service in the 15 months prior to posting the file." }, { "payer_name": "UNITED HEALTHCARE", "plan_name": "SUTTER SELECT & SUTTER HEALTH PLAN HMO PLANS", "methodology": "per diem", "standard_charge_dollar": 28538.0, "standard_charge_algorithm": "Per diem ($28,538).", "count": "0", "additional_payer_notes": "Zero final payments for the item or service in the 15 months prior to posting the file." }, { "payer_name": "UMR", "plan_name": "SUTTER SELECT & SUTTER HEALTH PLAN HMO PLANS", "methodology": "per diem", "standard_charge_dollar": 28538.0, "standard_charge_algorithm": "Per diem ($28,538).", "count": "0", "additional_payer_notes": "Zero final payments for the item or service in the 15 months prior to posting the file." } ] } ] }, { "description": "HC Cannula Gp018", "code_information": [ { "code": "PX-2120023018", "type": "CDM" }, { "code": "99999", "type": "CPT" }, { "code": "0272", "type": "RC" } ], "standard_charges": [ { "setting": "outpatient", "gross_charge": 1750.0, "discounted_cash": 875.0, "minimum": 738.5, "maximum": 910.0, "additional_generic_notes": "Zero final payments for the item or service in the 15 months prior to posting the file.", "payers_information": [ { "payer_name": "AETNA", "plan_name": "AETNA ALL OTHER PLANS", "methodology": "percent of total billed charges", "standard_charge_dollar": 910.0, "standard_charge_percentage": 52.0, "count": "0", "additional_payer_notes": "Zero final payments for the item or service in the 15 months prior to posting the file." }, { "payer_name": "AETNA", "plan_name": "AETNA ALL OTHER PLANS", "methodology": "percent of total billed charges", "standard_charge_dollar": 910.0, "standard_charge_percentage": 52.0, "count": "0", "additional_payer_notes": "Zero final payments for the item or service in the 15 months prior to posting the file." }, { "payer_name": "MERITAIN HEALTH", "plan_name": "AETNA ALL OTHER PLANS", "methodology": "percent of total billed charges", "standard_charge_dollar": 910.0, "standard_charge_percentage": 52.0, "count": "0", "additional_payer_notes": "Zero final payments for the item or service in the 15 months prior to posting the file." }, { "payer_name": "BLUE SHIELD OUT OF STATE", "plan_name": "STANFORD HEALTHCARE ALLIANCE PLAN", "methodology": "percent of total billed charges", "standard_charge_dollar": 850.33, "standard_charge_percentage": 48.59, "count": "0", "additional_payer_notes": "Zero final payments for the item or service in the 15 months prior to posting the file." }, { "payer_name": "BLUE SHIELD", "plan_name": "STANFORD HEALTHCARE ALLIANCE PLAN", "methodology": "percent of total billed charges", "standard_charge_dollar": 850.33, "standard_charge_percentage": 48.59, "median_amount": 68.24, "10th_percentile": 13.6, "90th_percentile": 1043.06, "count": "30" }, { "payer_name": "BLUE SHIELD", "plan_name": "STANFORD HEALTHCARE ALLIANCE PLAN", "methodology": "percent of total billed charges", "standard_charge_dollar": 850.33, "standard_charge_percentage": 48.59, "count": "0", "additional_payer_notes": "Zero final payments for the item or service in the 15 months prior to posting the file." }, { "payer_name": "BLUE SHIELD", "plan_name": "STANFORD HEALTHCARE ALLIANCE PLAN", "methodology": "percent of total billed charges", "standard_charge_dollar": 850.33, "standard_charge_percentage": 48.59, "count": "0", "additional_payer_notes": "Zero final payments for the item or service in the 15 months prior to posting the file." }, { "payer_name": "CIGNA", "plan_name": "CIGNA COM ALT HMO PLAN", "methodology": "percent of total billed charges", "standard_charge_dollar": 738.5, "standard_charge_percentage": 42.2, "count": "0", "additional_payer_notes": "Zero final payments for the item or service in the 15 months prior to posting the file." }, { "payer_name": "CIGNA", "plan_name": "CIGNA COM ALT HMO PLAN", "methodology": "percent of total billed charges", "standard_charge_dollar": 738.5, "standard_charge_percentage": 42.2, "count": "0", "additional_payer_notes": "Zero final payments for the item or service in the 15 months prior to posting the file." }, { "payer_name": "HEALTH NET", "plan_name": "HEALTHNET HMO, PPO, POS, EPO, CANOPY HEALTHNET HMO, OTHER-IN-NETWORK PLANS", "methodology": "per diem", "standard_charge_dollar": 8000.0, "standard_charge_algorithm": "Expected reimbursement is the lesser of Per diem ($8,000) for the length of stay and 70% of billed.", "count": "0", "additional_payer_notes": "Zero final payments for the item or service in the 15 months prior to posting the file." }, { "payer_name": "HEALTH NET", "plan_name": "HEALTHNET HMO, PPO, POS, EPO, CANOPY HEALTHNET HMO, OTHER-IN-NETWORK PLANS", "methodology": "per diem", "standard_charge_dollar": 8000.0, "standard_charge_algorithm": "Expected reimbursement is the lesser of Per diem ($8,000) for the length of stay and 70% of billed.", "count": "0", "additional_payer_notes": "Zero final payments for the item or service in the 15 months prior to posting the file." }, { "payer_name": "UNITED HEALTHCARE", "plan_name": "SUTTER SELECT & SUTTER HEALTH PLAN HMO PLANS", "methodology": "per diem", "standard_charge_dollar": 28538.0, "standard_charge_algorithm": "Per diem ($28,538).", "count": "0", "additional_payer_notes": "Zero final payments for the item or service in the 15 months prior to posting the file." }, { "payer_name": "UNITED HEALTHCARE", "plan_name": "SUTTER SELECT & SUTTER HEALTH PLAN HMO PLANS", "methodology": "per diem", "standard_charge_dollar": 28538.0, "standard_charge_algorithm": "Per diem ($28,538).", "count": "0", "additional_payer_notes": "Zero final payments for the item or service in the 15 months prior to posting the file." }, { "payer_name": "SUTTER", "plan_name": "SUTTER SELECT & SUTTER HEALTH PLAN HMO PLANS", "methodology": "per diem", "standard_charge_dollar": 28538.0, "standard_charge_algorithm": "Per diem ($28,538).", "count": "0", "additional_payer_notes": "Zero final payments for the item or service in the 15 months prior to posting the file." }, { "payer_name": "UNITED HEALTHCARE", "plan_name": "SUTTER SELECT & SUTTER HEALTH PLAN HMO PLANS", "methodology": "per diem", "standard_charge_dollar": 28538.0, "standard_charge_algorithm": "Per diem ($28,538).", "count": "0", "additional_payer_notes": "Zero final payments for the item or service in the 15 months prior to posting the file." }, { "payer_name": "UMR", "plan_name": "SUTTER SELECT & SUTTER HEALTH PLAN HMO PLANS", "methodology": "per diem", "standard_charge_dollar": 28538.0, "standard_charge_algorithm": "Per diem ($28,538).", "count": "0", "additional_payer_notes": "Zero final payments for the item or service in the 15 months prior to posting the file." } ] } ] }, { "description": "HC Cannula Gp019", "code_information": [ { "code": "PX-2120023019", "type": "CDM" }, { "code": "99999", "type": "CPT" }, { "code": "0272", "type": "RC" } ], "standard_charges": [ { "setting": "outpatient", "gross_charge": 2125.0, "discounted_cash": 1062.5, "minimum": 896.75, "maximum": 1105.0, "additional_generic_notes": "Zero final payments for the item or service in the 15 months prior to posting the file.", "payers_information": [ { "payer_name": "AETNA", "plan_name": "AETNA ALL OTHER PLANS", "methodology": "percent of total billed charges", "standard_charge_dollar": 1105.0, "standard_charge_percentage": 52.0, "count": "0", "additional_payer_notes": "Zero final payments for the item or service in the 15 months prior to posting the file." }, { "payer_name": "AETNA", "plan_name": "AETNA ALL OTHER PLANS", "methodology": "percent of total billed charges", "standard_charge_dollar": 1105.0, "standard_charge_percentage": 52.0, "count": "0", "additional_payer_notes": "Zero final payments for the item or service in the 15 months prior to posting the file." }, { "payer_name": "MERITAIN HEALTH", "plan_name": "AETNA ALL OTHER PLANS", "methodology": "percent of total billed charges", "standard_charge_dollar": 1105.0, "standard_charge_percentage": 52.0, "count": "0", "additional_payer_notes": "Zero final payments for the item or service in the 15 months prior to posting the file." }, { "payer_name": "BLUE SHIELD OUT OF STATE", "plan_name": "STANFORD HEALTHCARE ALLIANCE PLAN", "methodology": "percent of total billed charges", "standard_charge_dollar": 1032.54, "standard_charge_percentage": 48.59, "count": "0", "additional_payer_notes": "Zero final payments for the item or service in the 15 months prior to posting the file." }, { "payer_name": "BLUE SHIELD", "plan_name": "STANFORD HEALTHCARE ALLIANCE PLAN", "methodology": "percent of total billed charges", "standard_charge_dollar": 1032.54, "standard_charge_percentage": 48.59, "median_amount": 68.24, "10th_percentile": 13.6, "90th_percentile": 1043.06, "count": "30" }, { "payer_name": "BLUE SHIELD", "plan_name": "STANFORD HEALTHCARE ALLIANCE PLAN", "methodology": "percent of total billed charges", "standard_charge_dollar": 1032.54, "standard_charge_percentage": 48.59, "count": "0", "additional_payer_notes": "Zero final payments for the item or service in the 15 months prior to posting the file." }, { "payer_name": "BLUE SHIELD", "plan_name": "STANFORD HEALTHCARE ALLIANCE PLAN", "methodology": "percent of total billed charges", "standard_charge_dollar": 1032.54, "standard_charge_percentage": 48.59, "count": "0", "additional_payer_notes": "Zero final payments for the item or service in the 15 months prior to posting the file." }, { "payer_name": "CIGNA", "plan_name": "CIGNA COM ALT HMO PLAN", "methodology": "percent of total billed charges", "standard_charge_dollar": 896.75, "standard_charge_percentage": 42.2, "count": "0", "additional_payer_notes": "Zero final payments for the item or service in the 15 months prior to posting the file." }, { "payer_name": "CIGNA", "plan_name": "CIGNA COM ALT HMO PLAN", "methodology": "percent of total billed charges", "standard_charge_dollar": 896.75, "standard_charge_percentage": 42.2, "count": "0", "additional_payer_notes": "Zero final payments for the item or service in the 15 months prior to posting the file." }, { "payer_name": "HEALTH NET", "plan_name": "HEALTHNET HMO, PPO, POS, EPO, CANOPY HEALTHNET HMO, OTHER-IN-NETWORK PLANS", "methodology": "per diem", "standard_charge_dollar": 8000.0, "standard_charge_algorithm": "Expected reimbursement is the lesser of Per diem ($8,000) for the length of stay and 70% of billed.", "count": "0", "additional_payer_notes": "Zero final payments for the item or service in the 15 months prior to posting the file." }, { "payer_name": "HEALTH NET", "plan_name": "HEALTHNET HMO, PPO, POS, EPO, CANOPY HEALTHNET HMO, OTHER-IN-NETWORK PLANS", "methodology": "per diem", "standard_charge_dollar": 8000.0, "standard_charge_algorithm": "Expected reimbursement is the lesser of Per diem ($8,000) for the length of stay and 70% of billed.", "count": "0", "additional_payer_notes": "Zero final payments for the item or service in the 15 months prior to posting the file." }, { "payer_name": "UNITED HEALTHCARE", "plan_name": "SUTTER SELECT & SUTTER HEALTH PLAN HMO PLANS", "methodology": "per diem", "standard_charge_dollar": 28538.0, "standard_charge_algorithm": "Per diem ($28,538).", "count": "0", "additional_payer_notes": "Zero final payments for the item or service in the 15 months prior to posting the file." }, { "payer_name": "UNITED HEALTHCARE", "plan_name": "SUTTER SELECT & SUTTER HEALTH PLAN HMO PLANS", "methodology": "per diem", "standard_charge_dollar": 28538.0, "standard_charge_algorithm": "Per diem ($28,538).", "count": "0", "additional_payer_notes": "Zero final payments for the item or service in the 15 months prior to posting the file." }, { "payer_name": "SUTTER", "plan_name": "SUTTER SELECT & SUTTER HEALTH PLAN HMO PLANS", "methodology": "per diem", "standard_charge_dollar": 28538.0, "standard_charge_algorithm": "Per diem ($28,538).", "count": "0", "additional_payer_notes": "Zero final payments for the item or service in the 15 months prior to posting the file." }, { "payer_name": "UNITED HEALTHCARE", "plan_name": "SUTTER SELECT & SUTTER HEALTH PLAN HMO PLANS", "methodology": "per diem", "standard_charge_dollar": 28538.0, "standard_charge_algorithm": "Per diem ($28,538).", "count": "0", "additional_payer_notes": "Zero final payments for the item or service in the 15 months prior to posting the file." }, { "payer_name": "UMR", "plan_name": "SUTTER SELECT & SUTTER HEALTH PLAN HMO PLANS", "methodology": "per diem", "standard_charge_dollar": 28538.0, "standard_charge_algorithm": "Per diem ($28,538).", "count": "0", "additional_payer_notes": "Zero final payments for the item or service in the 15 months prior to posting the file." } ] } ] }, { "description": "HC Cannula Gp020", "code_information": [ { "code": "PX-2120023020", "type": "CDM" }, { "code": "99999", "type": "CPT" }, { "code": "0272", "type": "RC" } ], "standard_charges": [ { "setting": "outpatient", "gross_charge": 2550.0, "discounted_cash": 1275.0, "minimum": 1076.1, "maximum": 1326.0, "additional_generic_notes": "Zero final payments for the item or service in the 15 months prior to posting the file.", "payers_information": [ { "payer_name": "AETNA", "plan_name": "AETNA ALL OTHER PLANS", "methodology": "percent of total billed charges", "standard_charge_dollar": 1326.0, "standard_charge_percentage": 52.0, "count": "0", "additional_payer_notes": "Zero final payments for the item or service in the 15 months prior to posting the file." }, { "payer_name": "AETNA", "plan_name": "AETNA ALL OTHER PLANS", "methodology": "percent of total billed charges", "standard_charge_dollar": 1326.0, "standard_charge_percentage": 52.0, "count": "0", "additional_payer_notes": "Zero final payments for the item or service in the 15 months prior to posting the file." }, { "payer_name": "MERITAIN HEALTH", "plan_name": "AETNA ALL OTHER PLANS", "methodology": "percent of total billed charges", "standard_charge_dollar": 1326.0, "standard_charge_percentage": 52.0, "count": "0", "additional_payer_notes": "Zero final payments for the item or service in the 15 months prior to posting the file." }, { "payer_name": "BLUE SHIELD OUT OF STATE", "plan_name": "STANFORD HEALTHCARE ALLIANCE PLAN", "methodology": "percent of total billed charges", "standard_charge_dollar": 1239.05, "standard_charge_percentage": 48.59, "count": "0", "additional_payer_notes": "Zero final payments for the item or service in the 15 months prior to posting the file." }, { "payer_name": "BLUE SHIELD", "plan_name": "STANFORD HEALTHCARE ALLIANCE PLAN", "methodology": "percent of total billed charges", "standard_charge_dollar": 1239.05, "standard_charge_percentage": 48.59, "median_amount": 68.24, "10th_percentile": 13.6, "90th_percentile": 1043.06, "count": "30" }, { "payer_name": "BLUE SHIELD", "plan_name": "STANFORD HEALTHCARE ALLIANCE PLAN", "methodology": "percent of total billed charges", "standard_charge_dollar": 1239.05, "standard_charge_percentage": 48.59, "count": "0", "additional_payer_notes": "Zero final payments for the item or service in the 15 months prior to posting the file." }, { "payer_name": "BLUE SHIELD", "plan_name": "STANFORD HEALTHCARE ALLIANCE PLAN", "methodology": "percent of total billed charges", "standard_charge_dollar": 1239.05, "standard_charge_percentage": 48.59, "count": "0", "additional_payer_notes": "Zero final payments for the item or service in the 15 months prior to posting the file." }, { "payer_name": "CIGNA", "plan_name": "CIGNA COM ALT HMO PLAN", "methodology": "percent of total billed charges", "standard_charge_dollar": 1076.1, "standard_charge_percentage": 42.2, "count": "0", "additional_payer_notes": "Zero final payments for the item or service in the 15 months prior to posting the file." }, { "payer_name": "CIGNA", "plan_name": "CIGNA COM ALT HMO PLAN", "methodology": "percent of total billed charges", "standard_charge_dollar": 1076.1, "standard_charge_percentage": 42.2, "count": "0", "additional_payer_notes": "Zero final payments for the item or service in the 15 months prior to posting the file." }, { "payer_name": "HEALTH NET", "plan_name": "HEALTHNET HMO, PPO, POS, EPO, CANOPY HEALTHNET HMO, OTHER-IN-NETWORK PLANS", "methodology": "per diem", "standard_charge_dollar": 8000.0, "standard_charge_algorithm": "Expected reimbursement is the lesser of Per diem ($8,000) for the length of stay and 70% of billed.", "count": "0", "additional_payer_notes": "Zero final payments for the item or service in the 15 months prior to posting the file." }, { "payer_name": "HEALTH NET", "plan_name": "HEALTHNET HMO, PPO, POS, EPO, CANOPY HEALTHNET HMO, OTHER-IN-NETWORK PLANS", "methodology": "per diem", "standard_charge_dollar": 8000.0, "standard_charge_algorithm": "Expected reimbursement is the lesser of Per diem ($8,000) for the length of stay and 70% of billed.", "count": "0", "additional_payer_notes": "Zero final payments for the item or service in the 15 months prior to posting the file." }, { "payer_name": "UNITED HEALTHCARE", "plan_name": "SUTTER SELECT & SUTTER HEALTH PLAN HMO PLANS", "methodology": "per diem", "standard_charge_dollar": 28538.0, "standard_charge_algorithm": "Per diem ($28,538).", "count": "0", "additional_payer_notes": "Zero final payments for the item or service in the 15 months prior to posting the file." }, { "payer_name": "UNITED HEALTHCARE", "plan_name": "SUTTER SELECT & SUTTER HEALTH PLAN HMO PLANS", "methodology": "per diem", "standard_charge_dollar": 28538.0, "standard_charge_algorithm": "Per diem ($28,538).", "count": "0", "additional_payer_notes": "Zero final payments for the item or service in the 15 months prior to posting the file." }, { "payer_name": "SUTTER", "plan_name": "SUTTER SELECT & SUTTER HEALTH PLAN HMO PLANS", "methodology": "per diem", "standard_charge_dollar": 28538.0, "standard_charge_algorithm": "Per diem ($28,538).", "count": "0", "additional_payer_notes": "Zero final payments for the item or service in the 15 months prior to posting the file." }, { "payer_name": "UNITED HEALTHCARE", "plan_name": "SUTTER SELECT & SUTTER HEALTH PLAN HMO PLANS", "methodology": "per diem", "standard_charge_dollar": 28538.0, "standard_charge_algorithm": "Per diem ($28,538).", "count": "0", "additional_payer_notes": "Zero final payments for the item or service in the 15 months prior to posting the file." }, { "payer_name": "UMR", "plan_name": "SUTTER SELECT & SUTTER HEALTH PLAN HMO PLANS", "methodology": "per diem", "standard_charge_dollar": 28538.0, "standard_charge_algorithm": "Per diem ($28,538).", "count": "0", "additional_payer_notes": "Zero final payments for the item or service in the 15 months prior to posting the file." } ] } ] }, { "description": "HC Cannula Gp021", "code_information": [ { "code": "PX-2120023021", "type": "CDM" }, { "code": "99999", "type": "CPT" }, { "code": "0272", "type": "RC" } ], "standard_charges": [ { "setting": "outpatient", "gross_charge": 2888.0, "discounted_cash": 1444.0, "minimum": 1218.74, "maximum": 1501.76, "additional_generic_notes": "Zero final payments for the item or service in the 15 months prior to posting the file.", "payers_information": [ { "payer_name": "AETNA", "plan_name": "AETNA ALL OTHER PLANS", "methodology": "percent of total billed charges", "standard_charge_dollar": 1501.76, "standard_charge_percentage": 52.0, "count": "0", "additional_payer_notes": "Zero final payments for the item or service in the 15 months prior to posting the file." }, { "payer_name": "AETNA", "plan_name": "AETNA ALL OTHER PLANS", "methodology": "percent of total billed charges", "standard_charge_dollar": 1501.76, "standard_charge_percentage": 52.0, "count": "0", "additional_payer_notes": "Zero final payments for the item or service in the 15 months prior to posting the file." }, { "payer_name": "MERITAIN HEALTH", "plan_name": "AETNA ALL OTHER PLANS", "methodology": "percent of total billed charges", "standard_charge_dollar": 1501.76, "standard_charge_percentage": 52.0, "count": "0", "additional_payer_notes": "Zero final payments for the item or service in the 15 months prior to posting the file." }, { "payer_name": "BLUE SHIELD OUT OF STATE", "plan_name": "STANFORD HEALTHCARE ALLIANCE PLAN", "methodology": "percent of total billed charges", "standard_charge_dollar": 1403.28, "standard_charge_percentage": 48.59, "count": "0", "additional_payer_notes": "Zero final payments for the item or service in the 15 months prior to posting the file." }, { "payer_name": "BLUE SHIELD", "plan_name": "STANFORD HEALTHCARE ALLIANCE PLAN", "methodology": "percent of total billed charges", "standard_charge_dollar": 1403.28, "standard_charge_percentage": 48.59, "median_amount": 68.24, "10th_percentile": 13.6, "90th_percentile": 1043.06, "count": "30" }, { "payer_name": "BLUE SHIELD", "plan_name": "STANFORD HEALTHCARE ALLIANCE PLAN", "methodology": "percent of total billed charges", "standard_charge_dollar": 1403.28, "standard_charge_percentage": 48.59, "count": "0", "additional_payer_notes": "Zero final payments for the item or service in the 15 months prior to posting the file." }, { "payer_name": "BLUE SHIELD", "plan_name": "STANFORD HEALTHCARE ALLIANCE PLAN", "methodology": "percent of total billed charges", "standard_charge_dollar": 1403.28, "standard_charge_percentage": 48.59, "count": "0", "additional_payer_notes": "Zero final payments for the item or service in the 15 months prior to posting the file." }, { "payer_name": "CIGNA", "plan_name": "CIGNA COM ALT HMO PLAN", "methodology": "percent of total billed charges", "standard_charge_dollar": 1218.74, "standard_charge_percentage": 42.2, "count": "0", "additional_payer_notes": "Zero final payments for the item or service in the 15 months prior to posting the file." }, { "payer_name": "CIGNA", "plan_name": "CIGNA COM ALT HMO PLAN", "methodology": "percent of total billed charges", "standard_charge_dollar": 1218.74, "standard_charge_percentage": 42.2, "count": "0", "additional_payer_notes": "Zero final payments for the item or service in the 15 months prior to posting the file." }, { "payer_name": "HEALTH NET", "plan_name": "HEALTHNET HMO, PPO, POS, EPO, CANOPY HEALTHNET HMO, OTHER-IN-NETWORK PLANS", "methodology": "per diem", "standard_charge_dollar": 8000.0, "standard_charge_algorithm": "Expected reimbursement is the lesser of Per diem ($8,000) for the length of stay and 70% of billed.", "count": "0", "additional_payer_notes": "Zero final payments for the item or service in the 15 months prior to posting the file." }, { "payer_name": "HEALTH NET", "plan_name": "HEALTHNET HMO, PPO, POS, EPO, CANOPY HEALTHNET HMO, OTHER-IN-NETWORK PLANS", "methodology": "per diem", "standard_charge_dollar": 8000.0, "standard_charge_algorithm": "Expected reimbursement is the lesser of Per diem ($8,000) for the length of stay and 70% of billed.", "count": "0", "additional_payer_notes": "Zero final payments for the item or service in the 15 months prior to posting the file." }, { "payer_name": "UNITED HEALTHCARE", "plan_name": "SUTTER SELECT & SUTTER HEALTH PLAN HMO PLANS", "methodology": "per diem", "standard_charge_dollar": 28538.0, "standard_charge_algorithm": "Per diem ($28,538).", "count": "0", "additional_payer_notes": "Zero final payments for the item or service in the 15 months prior to posting the file." }, { "payer_name": "UNITED HEALTHCARE", "plan_name": "SUTTER SELECT & SUTTER HEALTH PLAN HMO PLANS", "methodology": "per diem", "standard_charge_dollar": 28538.0, "standard_charge_algorithm": "Per diem ($28,538).", "count": "0", "additional_payer_notes": "Zero final payments for the item or service in the 15 months prior to posting the file." }, { "payer_name": "SUTTER", "plan_name": "SUTTER SELECT & SUTTER HEALTH PLAN HMO PLANS", "methodology": "per diem", "standard_charge_dollar": 28538.0, "standard_charge_algorithm": "Per diem ($28,538).", "count": "0", "additional_payer_notes": "Zero final payments for the item or service in the 15 months prior to posting the file." }, { "payer_name": "UNITED HEALTHCARE", "plan_name": "SUTTER SELECT & SUTTER HEALTH PLAN HMO PLANS", "methodology": "per diem", "standard_charge_dollar": 28538.0, "standard_charge_algorithm": "Per diem ($28,538).", "count": "0", "additional_payer_notes": "Zero final payments for the item or service in the 15 months prior to posting the file." }, { "payer_name": "UMR", "plan_name": "SUTTER SELECT & SUTTER HEALTH PLAN HMO PLANS", "methodology": "per diem", "standard_charge_dollar": 28538.0, "standard_charge_algorithm": "Per diem ($28,538).", "count": "0", "additional_payer_notes": "Zero final payments for the item or service in the 15 months prior to posting the file." } ] } ] }, { "description": "HC Cannula Gp022", "code_information": [ { "code": "PX-2120023022", "type": "CDM" }, { "code": "99999", "type": "CPT" }, { "code": "0272", "type": "RC" } ], "standard_charges": [ { "setting": "outpatient", "gross_charge": 3300.0, "discounted_cash": 1650.0, "minimum": 1392.6, "maximum": 1716.0, "additional_generic_notes": "Zero final payments for the item or service in the 15 months prior to posting the file.", "payers_information": [ { "payer_name": "AETNA", "plan_name": "AETNA ALL OTHER PLANS", "methodology": "percent of total billed charges", "standard_charge_dollar": 1716.0, "standard_charge_percentage": 52.0, "count": "0", "additional_payer_notes": "Zero final payments for the item or service in the 15 months prior to posting the file." }, { "payer_name": "AETNA", "plan_name": "AETNA ALL OTHER PLANS", "methodology": "percent of total billed charges", "standard_charge_dollar": 1716.0, "standard_charge_percentage": 52.0, "count": "0", "additional_payer_notes": "Zero final payments for the item or service in the 15 months prior to posting the file." }, { "payer_name": "MERITAIN HEALTH", "plan_name": "AETNA ALL OTHER PLANS", "methodology": "percent of total billed charges", "standard_charge_dollar": 1716.0, "standard_charge_percentage": 52.0, "count": "0", "additional_payer_notes": "Zero final payments for the item or service in the 15 months prior to posting the file." }, { "payer_name": "BLUE SHIELD OUT OF STATE", "plan_name": "STANFORD HEALTHCARE ALLIANCE PLAN", "methodology": "percent of total billed charges", "standard_charge_dollar": 1603.47, "standard_charge_percentage": 48.59, "count": "0", "additional_payer_notes": "Zero final payments for the item or service in the 15 months prior to posting the file." }, { "payer_name": "BLUE SHIELD", "plan_name": "STANFORD HEALTHCARE ALLIANCE PLAN", "methodology": "percent of total billed charges", "standard_charge_dollar": 1603.47, "standard_charge_percentage": 48.59, "median_amount": 68.24, "10th_percentile": 13.6, "90th_percentile": 1043.06, "count": "30" }, { "payer_name": "BLUE SHIELD", "plan_name": "STANFORD HEALTHCARE ALLIANCE PLAN", "methodology": "percent of total billed charges", "standard_charge_dollar": 1603.47, "standard_charge_percentage": 48.59, "count": "0", "additional_payer_notes": "Zero final payments for the item or service in the 15 months prior to posting the file." }, { "payer_name": "BLUE SHIELD", "plan_name": "STANFORD HEALTHCARE ALLIANCE PLAN", "methodology": "percent of total billed charges", "standard_charge_dollar": 1603.47, "standard_charge_percentage": 48.59, "count": "0", "additional_payer_notes": "Zero final payments for the item or service in the 15 months prior to posting the file." }, { "payer_name": "CIGNA", "plan_name": "CIGNA COM ALT HMO PLAN", "methodology": "percent of total billed charges", "standard_charge_dollar": 1392.6, "standard_charge_percentage": 42.2, "count": "0", "additional_payer_notes": "Zero final payments for the item or service in the 15 months prior to posting the file." }, { "payer_name": "CIGNA", "plan_name": "CIGNA COM ALT HMO PLAN", "methodology": "percent of total billed charges", "standard_charge_dollar": 1392.6, "standard_charge_percentage": 42.2, "count": "0", "additional_payer_notes": "Zero final payments for the item or service in the 15 months prior to posting the file." }, { "payer_name": "HEALTH NET", "plan_name": "HEALTHNET HMO, PPO, POS, EPO, CANOPY HEALTHNET HMO, OTHER-IN-NETWORK PLANS", "methodology": "per diem", "standard_charge_dollar": 8000.0, "standard_charge_algorithm": "Expected reimbursement is the lesser of Per diem ($8,000) for the length of stay and 70% of billed.", "count": "0", "additional_payer_notes": "Zero final payments for the item or service in the 15 months prior to posting the file." }, { "payer_name": "HEALTH NET", "plan_name": "HEALTHNET HMO, PPO, POS, EPO, CANOPY HEALTHNET HMO, OTHER-IN-NETWORK PLANS", "methodology": "per diem", "standard_charge_dollar": 8000.0, "standard_charge_algorithm": "Expected reimbursement is the lesser of Per diem ($8,000) for the length of stay and 70% of billed.", "count": "0", "additional_payer_notes": "Zero final payments for the item or service in the 15 months prior to posting the file." }, { "payer_name": "UNITED HEALTHCARE", "plan_name": "SUTTER SELECT & SUTTER HEALTH PLAN HMO PLANS", "methodology": "per diem", "standard_charge_dollar": 28538.0, "standard_charge_algorithm": "Per diem ($28,538).", "count": "0", "additional_payer_notes": "Zero final payments for the item or service in the 15 months prior to posting the file." }, { "payer_name": "UNITED HEALTHCARE", "plan_name": "SUTTER SELECT & SUTTER HEALTH PLAN HMO PLANS", "methodology": "per diem", "standard_charge_dollar": 28538.0, "standard_charge_algorithm": "Per diem ($28,538).", "count": "0", "additional_payer_notes": "Zero final payments for the item or service in the 15 months prior to posting the file." }, { "payer_name": "SUTTER", "plan_name": "SUTTER SELECT & SUTTER HEALTH PLAN HMO PLANS", "methodology": "per diem", "standard_charge_dollar": 28538.0, "standard_charge_algorithm": "Per diem ($28,538).", "count": "0", "additional_payer_notes": "Zero final payments for the item or service in the 15 months prior to posting the file." }, { "payer_name": "UNITED HEALTHCARE", "plan_name": "SUTTER SELECT & SUTTER HEALTH PLAN HMO PLANS", "methodology": "per diem", "standard_charge_dollar": 28538.0, "standard_charge_algorithm": "Per diem ($28,538).", "count": "0", "additional_payer_notes": "Zero final payments for the item or service in the 15 months prior to posting the file." }, { "payer_name": "UMR", "plan_name": "SUTTER SELECT & SUTTER HEALTH PLAN HMO PLANS", "methodology": "per diem", "standard_charge_dollar": 28538.0, "standard_charge_algorithm": "Per diem ($28,538).", "count": "0", "additional_payer_notes": "Zero final payments for the item or service in the 15 months prior to posting the file." } ] } ] }, { "description": "HC Cannula Gp027", "code_information": [ { "code": "PX-2120023027", "type": "CDM" }, { "code": "99999", "type": "CPT" }, { "code": "0272", "type": "RC" } ], "standard_charges": [ { "setting": "outpatient", "gross_charge": 4875.0, "discounted_cash": 2437.5, "minimum": 2057.25, "maximum": 2535.0, "additional_generic_notes": "Zero final payments for the item or service in the 15 months prior to posting the file.", "payers_information": [ { "payer_name": "AETNA", "plan_name": "AETNA ALL OTHER PLANS", "methodology": "percent of total billed charges", "standard_charge_dollar": 2535.0, "standard_charge_percentage": 52.0, "count": "0", "additional_payer_notes": "Zero final payments for the item or service in the 15 months prior to posting the file." }, { "payer_name": "AETNA", "plan_name": "AETNA ALL OTHER PLANS", "methodology": "percent of total billed charges", "standard_charge_dollar": 2535.0, "standard_charge_percentage": 52.0, "count": "0", "additional_payer_notes": "Zero final payments for the item or service in the 15 months prior to posting the file." }, { "payer_name": "MERITAIN HEALTH", "plan_name": "AETNA ALL OTHER PLANS", "methodology": "percent of total billed charges", "standard_charge_dollar": 2535.0, "standard_charge_percentage": 52.0, "count": "0", "additional_payer_notes": "Zero final payments for the item or service in the 15 months prior to posting the file." }, { "payer_name": "BLUE SHIELD OUT OF STATE", "plan_name": "STANFORD HEALTHCARE ALLIANCE PLAN", "methodology": "percent of total billed charges", "standard_charge_dollar": 2368.76, "standard_charge_percentage": 48.59, "count": "0", "additional_payer_notes": "Zero final payments for the item or service in the 15 months prior to posting the file." }, { "payer_name": "BLUE SHIELD", "plan_name": "STANFORD HEALTHCARE ALLIANCE PLAN", "methodology": "percent of total billed charges", "standard_charge_dollar": 2368.76, "standard_charge_percentage": 48.59, "median_amount": 68.24, "10th_percentile": 13.6, "90th_percentile": 1043.06, "count": "30" }, { "payer_name": "BLUE SHIELD", "plan_name": "STANFORD HEALTHCARE ALLIANCE PLAN", "methodology": "percent of total billed charges", "standard_charge_dollar": 2368.76, "standard_charge_percentage": 48.59, "count": "0", "additional_payer_notes": "Zero final payments for the item or service in the 15 months prior to posting the file." }, { "payer_name": "BLUE SHIELD", "plan_name": "STANFORD HEALTHCARE ALLIANCE PLAN", "methodology": "percent of total billed charges", "standard_charge_dollar": 2368.76, "standard_charge_percentage": 48.59, "count": "0", "additional_payer_notes": "Zero final payments for the item or service in the 15 months prior to posting the file." }, { "payer_name": "CIGNA", "plan_name": "CIGNA COM ALT HMO PLAN", "methodology": "percent of total billed charges", "standard_charge_dollar": 2057.25, "standard_charge_percentage": 42.2, "count": "0", "additional_payer_notes": "Zero final payments for the item or service in the 15 months prior to posting the file." }, { "payer_name": "CIGNA", "plan_name": "CIGNA COM ALT HMO PLAN", "methodology": "percent of total billed charges", "standard_charge_dollar": 2057.25, "standard_charge_percentage": 42.2, "count": "0", "additional_payer_notes": "Zero final payments for the item or service in the 15 months prior to posting the file." }, { "payer_name": "HEALTH NET", "plan_name": "HEALTHNET HMO, PPO, POS, EPO, CANOPY HEALTHNET HMO, OTHER-IN-NETWORK PLANS", "methodology": "per diem", "standard_charge_dollar": 8000.0, "standard_charge_algorithm": "Expected reimbursement is the lesser of Per diem ($8,000) for the length of stay and 70% of billed.", "count": "0", "additional_payer_notes": "Zero final payments for the item or service in the 15 months prior to posting the file." }, { "payer_name": "HEALTH NET", "plan_name": "HEALTHNET HMO, PPO, POS, EPO, CANOPY HEALTHNET HMO, OTHER-IN-NETWORK PLANS", "methodology": "per diem", "standard_charge_dollar": 8000.0, "standard_charge_algorithm": "Expected reimbursement is the lesser of Per diem ($8,000) for the length of stay and 70% of billed.", "count": "0", "additional_payer_notes": "Zero final payments for the item or service in the 15 months prior to posting the file." }, { "payer_name": "UNITED HEALTHCARE", "plan_name": "SUTTER SELECT & SUTTER HEALTH PLAN HMO PLANS", "methodology": "per diem", "standard_charge_dollar": 28538.0, "standard_charge_algorithm": "Per diem ($28,538).", "count": "0", "additional_payer_notes": "Zero final payments for the item or service in the 15 months prior to posting the file." }, { "payer_name": "UNITED HEALTHCARE", "plan_name": "SUTTER SELECT & SUTTER HEALTH PLAN HMO PLANS", "methodology": "per diem", "standard_charge_dollar": 28538.0, "standard_charge_algorithm": "Per diem ($28,538).", "count": "0", "additional_payer_notes": "Zero final payments for the item or service in the 15 months prior to posting the file." }, { "payer_name": "SUTTER", "plan_name": "SUTTER SELECT & SUTTER HEALTH PLAN HMO PLANS", "methodology": "per diem", "standard_charge_dollar": 28538.0, "standard_charge_algorithm": "Per diem ($28,538).", "count": "0", "additional_payer_notes": "Zero final payments for the item or service in the 15 months prior to posting the file." }, { "payer_name": "UNITED HEALTHCARE", "plan_name": "SUTTER SELECT & SUTTER HEALTH PLAN HMO PLANS", "methodology": "per diem", "standard_charge_dollar": 28538.0, "standard_charge_algorithm": "Per diem ($28,538).", "count": "0", "additional_payer_notes": "Zero final payments for the item or service in the 15 months prior to posting the file." }, { "payer_name": "UMR", "plan_name": "SUTTER SELECT & SUTTER HEALTH PLAN HMO PLANS", "methodology": "per diem", "standard_charge_dollar": 28538.0, "standard_charge_algorithm": "Per diem ($28,538).", "count": "0", "additional_payer_notes": "Zero final payments for the item or service in the 15 months prior to posting the file." } ] } ] }, { "description": "HC Cannula Gp028", "code_information": [ { "code": "PX-2120023028", "type": "CDM" }, { "code": "99999", "type": "CPT" }, { "code": "0272", "type": "RC" } ], "standard_charges": [ { "setting": "outpatient", "gross_charge": 5250.0, "discounted_cash": 2625.0, "minimum": 2215.5, "maximum": 2730.0, "additional_generic_notes": "Zero final payments for the item or service in the 15 months prior to posting the file.", "payers_information": [ { "payer_name": "AETNA", "plan_name": "AETNA ALL OTHER PLANS", "methodology": "percent of total billed charges", "standard_charge_dollar": 2730.0, "standard_charge_percentage": 52.0, "count": "0", "additional_payer_notes": "Zero final payments for the item or service in the 15 months prior to posting the file." }, { "payer_name": "AETNA", "plan_name": "AETNA ALL OTHER PLANS", "methodology": "percent of total billed charges", "standard_charge_dollar": 2730.0, "standard_charge_percentage": 52.0, "count": "0", "additional_payer_notes": "Zero final payments for the item or service in the 15 months prior to posting the file." }, { "payer_name": "MERITAIN HEALTH", "plan_name": "AETNA ALL OTHER PLANS", "methodology": "percent of total billed charges", "standard_charge_dollar": 2730.0, "standard_charge_percentage": 52.0, "count": "0", "additional_payer_notes": "Zero final payments for the item or service in the 15 months prior to posting the file." }, { "payer_name": "BLUE SHIELD OUT OF STATE", "plan_name": "STANFORD HEALTHCARE ALLIANCE PLAN", "methodology": "percent of total billed charges", "standard_charge_dollar": 2550.98, "standard_charge_percentage": 48.59, "count": "0", "additional_payer_notes": "Zero final payments for the item or service in the 15 months prior to posting the file." }, { "payer_name": "BLUE SHIELD", "plan_name": "STANFORD HEALTHCARE ALLIANCE PLAN", "methodology": "percent of total billed charges", "standard_charge_dollar": 2550.98, "standard_charge_percentage": 48.59, "median_amount": 68.24, "10th_percentile": 13.6, "90th_percentile": 1043.06, "count": "30" }, { "payer_name": "BLUE SHIELD", "plan_name": "STANFORD HEALTHCARE ALLIANCE PLAN", "methodology": "percent of total billed charges", "standard_charge_dollar": 2550.98, "standard_charge_percentage": 48.59, "count": "0", "additional_payer_notes": "Zero final payments for the item or service in the 15 months prior to posting the file." }, { "payer_name": "BLUE SHIELD", "plan_name": "STANFORD HEALTHCARE ALLIANCE PLAN", "methodology": "percent of total billed charges", "standard_charge_dollar": 2550.98, "standard_charge_percentage": 48.59, "count": "0", "additional_payer_notes": "Zero final payments for the item or service in the 15 months prior to posting the file." }, { "payer_name": "CIGNA", "plan_name": "CIGNA COM ALT HMO PLAN", "methodology": "percent of total billed charges", "standard_charge_dollar": 2215.5, "standard_charge_percentage": 42.2, "count": "0", "additional_payer_notes": "Zero final payments for the item or service in the 15 months prior to posting the file." }, { "payer_name": "CIGNA", "plan_name": "CIGNA COM ALT HMO PLAN", "methodology": "percent of total billed charges", "standard_charge_dollar": 2215.5, "standard_charge_percentage": 42.2, "count": "0", "additional_payer_notes": "Zero final payments for the item or service in the 15 months prior to posting the file." }, { "payer_name": "HEALTH NET", "plan_name": "HEALTHNET HMO, PPO, POS, EPO, CANOPY HEALTHNET HMO, OTHER-IN-NETWORK PLANS", "methodology": "per diem", "standard_charge_dollar": 8000.0, "standard_charge_algorithm": "Expected reimbursement is the lesser of Per diem ($8,000) for the length of stay and 70% of billed.", "count": "0", "additional_payer_notes": "Zero final payments for the item or service in the 15 months prior to posting the file." }, { "payer_name": "HEALTH NET", "plan_name": "HEALTHNET HMO, PPO, POS, EPO, CANOPY HEALTHNET HMO, OTHER-IN-NETWORK PLANS", "methodology": "per diem", "standard_charge_dollar": 8000.0, "standard_charge_algorithm": "Expected reimbursement is the lesser of Per diem ($8,000) for the length of stay and 70% of billed.", "count": "0", "additional_payer_notes": "Zero final payments for the item or service in the 15 months prior to posting the file." }, { "payer_name": "UNITED HEALTHCARE", "plan_name": "SUTTER SELECT & SUTTER HEALTH PLAN HMO PLANS", "methodology": "per diem", "standard_charge_dollar": 28538.0, "standard_charge_algorithm": "Per diem ($28,538).", "count": "0", "additional_payer_notes": "Zero final payments for the item or service in the 15 months prior to posting the file." }, { "payer_name": "UNITED HEALTHCARE", "plan_name": "SUTTER SELECT & SUTTER HEALTH PLAN HMO PLANS", "methodology": "per diem", "standard_charge_dollar": 28538.0, "standard_charge_algorithm": "Per diem ($28,538).", "count": "0", "additional_payer_notes": "Zero final payments for the item or service in the 15 months prior to posting the file." }, { "payer_name": "SUTTER", "plan_name": "SUTTER SELECT & SUTTER HEALTH PLAN HMO PLANS", "methodology": "per diem", "standard_charge_dollar": 28538.0, "standard_charge_algorithm": "Per diem ($28,538).", "count": "0", "additional_payer_notes": "Zero final payments for the item or service in the 15 months prior to posting the file." }, { "payer_name": "UNITED HEALTHCARE", "plan_name": "SUTTER SELECT & SUTTER HEALTH PLAN HMO PLANS", "methodology": "per diem", "standard_charge_dollar": 28538.0, "standard_charge_algorithm": "Per diem ($28,538).", "count": "0", "additional_payer_notes": "Zero final payments for the item or service in the 15 months prior to posting the file." }, { "payer_name": "UMR", "plan_name": "SUTTER SELECT & SUTTER HEALTH PLAN HMO PLANS", "methodology": "per diem", "standard_charge_dollar": 28538.0, "standard_charge_algorithm": "Per diem ($28,538).", "count": "0", "additional_payer_notes": "Zero final payments for the item or service in the 15 months prior to posting the file." } ] } ] }, { "description": "HC Cannula Gp038", "code_information": [ { "code": "PX-2120023038", "type": "CDM" }, { "code": "99999", "type": "CPT" }, { "code": "0272", "type": "RC" } ], "standard_charges": [ { "setting": "outpatient", "gross_charge": 8750.0, "discounted_cash": 4375.0, "minimum": 3692.5, "maximum": 4550.0, "additional_generic_notes": "Zero final payments for the item or service in the 15 months prior to posting the file.", "payers_information": [ { "payer_name": "AETNA", "plan_name": "AETNA ALL OTHER PLANS", "methodology": "percent of total billed charges", "standard_charge_dollar": 4550.0, "standard_charge_percentage": 52.0, "count": "0", "additional_payer_notes": "Zero final payments for the item or service in the 15 months prior to posting the file." }, { "payer_name": "AETNA", "plan_name": "AETNA ALL OTHER PLANS", "methodology": "percent of total billed charges", "standard_charge_dollar": 4550.0, "standard_charge_percentage": 52.0, "count": "0", "additional_payer_notes": "Zero final payments for the item or service in the 15 months prior to posting the file." }, { "payer_name": "MERITAIN HEALTH", "plan_name": "AETNA ALL OTHER PLANS", "methodology": "percent of total billed charges", "standard_charge_dollar": 4550.0, "standard_charge_percentage": 52.0, "count": "0", "additional_payer_notes": "Zero final payments for the item or service in the 15 months prior to posting the file." }, { "payer_name": "BLUE SHIELD OUT OF STATE", "plan_name": "STANFORD HEALTHCARE ALLIANCE PLAN", "methodology": "percent of total billed charges", "standard_charge_dollar": 4251.63, "standard_charge_percentage": 48.59, "count": "0", "additional_payer_notes": "Zero final payments for the item or service in the 15 months prior to posting the file." }, { "payer_name": "BLUE SHIELD", "plan_name": "STANFORD HEALTHCARE ALLIANCE PLAN", "methodology": "percent of total billed charges", "standard_charge_dollar": 4251.63, "standard_charge_percentage": 48.59, "median_amount": 68.24, "10th_percentile": 13.6, "90th_percentile": 1043.06, "count": "30" }, { "payer_name": "BLUE SHIELD", "plan_name": "STANFORD HEALTHCARE ALLIANCE PLAN", "methodology": "percent of total billed charges", "standard_charge_dollar": 4251.63, "standard_charge_percentage": 48.59, "count": "0", "additional_payer_notes": "Zero final payments for the item or service in the 15 months prior to posting the file." }, { "payer_name": "BLUE SHIELD", "plan_name": "STANFORD HEALTHCARE ALLIANCE PLAN", "methodology": "percent of total billed charges", "standard_charge_dollar": 4251.63, "standard_charge_percentage": 48.59, "count": "0", "additional_payer_notes": "Zero final payments for the item or service in the 15 months prior to posting the file." }, { "payer_name": "CIGNA", "plan_name": "CIGNA COM ALT HMO PLAN", "methodology": "percent of total billed charges", "standard_charge_dollar": 3692.5, "standard_charge_percentage": 42.2, "count": "0", "additional_payer_notes": "Zero final payments for the item or service in the 15 months prior to posting the file." }, { "payer_name": "CIGNA", "plan_name": "CIGNA COM ALT HMO PLAN", "methodology": "percent of total billed charges", "standard_charge_dollar": 3692.5, "standard_charge_percentage": 42.2, "count": "0", "additional_payer_notes": "Zero final payments for the item or service in the 15 months prior to posting the file." }, { "payer_name": "HEALTH NET", "plan_name": "HEALTHNET HMO, PPO, POS, EPO, CANOPY HEALTHNET HMO, OTHER-IN-NETWORK PLANS", "methodology": "per diem", "standard_charge_dollar": 8000.0, "standard_charge_algorithm": "Expected reimbursement is the lesser of Per diem ($8,000) for the length of stay and 70% of billed.", "count": "0", "additional_payer_notes": "Zero final payments for the item or service in the 15 months prior to posting the file." }, { "payer_name": "HEALTH NET", "plan_name": "HEALTHNET HMO, PPO, POS, EPO, CANOPY HEALTHNET HMO, OTHER-IN-NETWORK PLANS", "methodology": "per diem", "standard_charge_dollar": 8000.0, "standard_charge_algorithm": "Expected reimbursement is the lesser of Per diem ($8,000) for the length of stay and 70% of billed.", "count": "0", "additional_payer_notes": "Zero final payments for the item or service in the 15 months prior to posting the file." }, { "payer_name": "UNITED HEALTHCARE", "plan_name": "SUTTER SELECT & SUTTER HEALTH PLAN HMO PLANS", "methodology": "per diem", "standard_charge_dollar": 28538.0, "standard_charge_algorithm": "Per diem ($28,538).", "count": "0", "additional_payer_notes": "Zero final payments for the item or service in the 15 months prior to posting the file." }, { "payer_name": "UNITED HEALTHCARE", "plan_name": "SUTTER SELECT & SUTTER HEALTH PLAN HMO PLANS", "methodology": "per diem", "standard_charge_dollar": 28538.0, "standard_charge_algorithm": "Per diem ($28,538).", "count": "0", "additional_payer_notes": "Zero final payments for the item or service in the 15 months prior to posting the file." }, { "payer_name": "SUTTER", "plan_name": "SUTTER SELECT & SUTTER HEALTH PLAN HMO PLANS", "methodology": "per diem", "standard_charge_dollar": 28538.0, "standard_charge_algorithm": "Per diem ($28,538).", "count": "0", "additional_payer_notes": "Zero final payments for the item or service in the 15 months prior to posting the file." }, { "payer_name": "UNITED HEALTHCARE", "plan_name": "SUTTER SELECT & SUTTER HEALTH PLAN HMO PLANS", "methodology": "per diem", "standard_charge_dollar": 28538.0, "standard_charge_algorithm": "Per diem ($28,538).", "count": "0", "additional_payer_notes": "Zero final payments for the item or service in the 15 months prior to posting the file." }, { "payer_name": "UMR", "plan_name": "SUTTER SELECT & SUTTER HEALTH PLAN HMO PLANS", "methodology": "per diem", "standard_charge_dollar": 28538.0, "standard_charge_algorithm": "Per diem ($28,538).", "count": "0", "additional_payer_notes": "Zero final payments for the item or service in the 15 months prior to posting the file." } ] } ] }, { "description": "HC Cannula Gp040", "code_information": [ { "code": "PX-2120023040", "type": "CDM" }, { "code": "99999", "type": "CPT" }, { "code": "0272", "type": "RC" } ], "standard_charges": [ { "setting": "outpatient", "gross_charge": 1620.0, "discounted_cash": 810.0, "minimum": 683.64, "maximum": 842.4, "additional_generic_notes": "Zero final payments for the item or service in the 15 months prior to posting the file.", "payers_information": [ { "payer_name": "AETNA", "plan_name": "AETNA ALL OTHER PLANS", "methodology": "percent of total billed charges", "standard_charge_dollar": 842.4, "standard_charge_percentage": 52.0, "count": "0", "additional_payer_notes": "Zero final payments for the item or service in the 15 months prior to posting the file." }, { "payer_name": "AETNA", "plan_name": "AETNA ALL OTHER PLANS", "methodology": "percent of total billed charges", "standard_charge_dollar": 842.4, "standard_charge_percentage": 52.0, "count": "0", "additional_payer_notes": "Zero final payments for the item or service in the 15 months prior to posting the file." }, { "payer_name": "MERITAIN HEALTH", "plan_name": "AETNA ALL OTHER PLANS", "methodology": "percent of total billed charges", "standard_charge_dollar": 842.4, "standard_charge_percentage": 52.0, "count": "0", "additional_payer_notes": "Zero final payments for the item or service in the 15 months prior to posting the file." }, { "payer_name": "BLUE SHIELD OUT OF STATE", "plan_name": "STANFORD HEALTHCARE ALLIANCE PLAN", "methodology": "percent of total billed charges", "standard_charge_dollar": 787.16, "standard_charge_percentage": 48.59, "count": "0", "additional_payer_notes": "Zero final payments for the item or service in the 15 months prior to posting the file." }, { "payer_name": "BLUE SHIELD", "plan_name": "STANFORD HEALTHCARE ALLIANCE PLAN", "methodology": "percent of total billed charges", "standard_charge_dollar": 787.16, "standard_charge_percentage": 48.59, "median_amount": 68.24, "10th_percentile": 13.6, "90th_percentile": 1043.06, "count": "30" }, { "payer_name": "BLUE SHIELD", "plan_name": "STANFORD HEALTHCARE ALLIANCE PLAN", "methodology": "percent of total billed charges", "standard_charge_dollar": 787.16, "standard_charge_percentage": 48.59, "count": "0", "additional_payer_notes": "Zero final payments for the item or service in the 15 months prior to posting the file." }, { "payer_name": "BLUE SHIELD", "plan_name": "STANFORD HEALTHCARE ALLIANCE PLAN", "methodology": "percent of total billed charges", "standard_charge_dollar": 787.16, "standard_charge_percentage": 48.59, "count": "0", "additional_payer_notes": "Zero final payments for the item or service in the 15 months prior to posting the file." }, { "payer_name": "CIGNA", "plan_name": "CIGNA COM ALT HMO PLAN", "methodology": "percent of total billed charges", "standard_charge_dollar": 683.64, "standard_charge_percentage": 42.2, "count": "0", "additional_payer_notes": "Zero final payments for the item or service in the 15 months prior to posting the file." }, { "payer_name": "CIGNA", "plan_name": "CIGNA COM ALT HMO PLAN", "methodology": "percent of total billed charges", "standard_charge_dollar": 683.64, "standard_charge_percentage": 42.2, "count": "0", "additional_payer_notes": "Zero final payments for the item or service in the 15 months prior to posting the file." }, { "payer_name": "HEALTH NET", "plan_name": "HEALTHNET HMO, PPO, POS, EPO, CANOPY HEALTHNET HMO, OTHER-IN-NETWORK PLANS", "methodology": "per diem", "standard_charge_dollar": 8000.0, "standard_charge_algorithm": "Expected reimbursement is the lesser of Per diem ($8,000) for the length of stay and 70% of billed.", "count": "0", "additional_payer_notes": "Zero final payments for the item or service in the 15 months prior to posting the file." }, { "payer_name": "HEALTH NET", "plan_name": "HEALTHNET HMO, PPO, POS, EPO, CANOPY HEALTHNET HMO, OTHER-IN-NETWORK PLANS", "methodology": "per diem", "standard_charge_dollar": 8000.0, "standard_charge_algorithm": "Expected reimbursement is the lesser of Per diem ($8,000) for the length of stay and 70% of billed.", "count": "0", "additional_payer_notes": "Zero final payments for the item or service in the 15 months prior to posting the file." }, { "payer_name": "UNITED HEALTHCARE", "plan_name": "SUTTER SELECT & SUTTER HEALTH PLAN HMO PLANS", "methodology": "per diem", "standard_charge_dollar": 28538.0, "standard_charge_algorithm": "Per diem ($28,538).", "count": "0", "additional_payer_notes": "Zero final payments for the item or service in the 15 months prior to posting the file." }, { "payer_name": "UNITED HEALTHCARE", "plan_name": "SUTTER SELECT & SUTTER HEALTH PLAN HMO PLANS", "methodology": "per diem", "standard_charge_dollar": 28538.0, "standard_charge_algorithm": "Per diem ($28,538).", "count": "0", "additional_payer_notes": "Zero final payments for the item or service in the 15 months prior to posting the file." }, { "payer_name": "SUTTER", "plan_name": "SUTTER SELECT & SUTTER HEALTH PLAN HMO PLANS", "methodology": "per diem", "standard_charge_dollar": 28538.0, "standard_charge_algorithm": "Per diem ($28,538).", "count": "0", "additional_payer_notes": "Zero final payments for the item or service in the 15 months prior to posting the file." }, { "payer_name": "UNITED HEALTHCARE", "plan_name": "SUTTER SELECT & SUTTER HEALTH PLAN HMO PLANS", "methodology": "per diem", "standard_charge_dollar": 28538.0, "standard_charge_algorithm": "Per diem ($28,538).", "count": "0", "additional_payer_notes": "Zero final payments for the item or service in the 15 months prior to posting the file." }, { "payer_name": "UMR", "plan_name": "SUTTER SELECT & SUTTER HEALTH PLAN HMO PLANS", "methodology": "per diem", "standard_charge_dollar": 28538.0, "standard_charge_algorithm": "Per diem ($28,538).", "count": "0", "additional_payer_notes": "Zero final payments for the item or service in the 15 months prior to posting the file." } ] } ] }, { "description": "HC Cannula Gp044", "code_information": [ { "code": "PX-2120023044", "type": "CDM" }, { "code": "99999", "type": "CPT" }, { "code": "0272", "type": "RC" } ], "standard_charges": [ { "setting": "outpatient", "gross_charge": 11000.0, "discounted_cash": 5500.0, "minimum": 4642.0, "maximum": 5720.0, "additional_generic_notes": "Zero final payments for the item or service in the 15 months prior to posting the file.", "payers_information": [ { "payer_name": "AETNA", "plan_name": "AETNA ALL OTHER PLANS", "methodology": "percent of total billed charges", "standard_charge_dollar": 5720.0, "standard_charge_percentage": 52.0, "count": "0", "additional_payer_notes": "Zero final payments for the item or service in the 15 months prior to posting the file." }, { "payer_name": "AETNA", "plan_name": "AETNA ALL OTHER PLANS", "methodology": "percent of total billed charges", "standard_charge_dollar": 5720.0, "standard_charge_percentage": 52.0, "count": "0", "additional_payer_notes": "Zero final payments for the item or service in the 15 months prior to posting the file." }, { "payer_name": "MERITAIN HEALTH", "plan_name": "AETNA ALL OTHER PLANS", "methodology": "percent of total billed charges", "standard_charge_dollar": 5720.0, "standard_charge_percentage": 52.0, "count": "0", "additional_payer_notes": "Zero final payments for the item or service in the 15 months prior to posting the file." }, { "payer_name": "BLUE SHIELD OUT OF STATE", "plan_name": "STANFORD HEALTHCARE ALLIANCE PLAN", "methodology": "percent of total billed charges", "standard_charge_dollar": 5344.9, "standard_charge_percentage": 48.59, "count": "0", "additional_payer_notes": "Zero final payments for the item or service in the 15 months prior to posting the file." }, { "payer_name": "BLUE SHIELD", "plan_name": "STANFORD HEALTHCARE ALLIANCE PLAN", "methodology": "percent of total billed charges", "standard_charge_dollar": 5344.9, "standard_charge_percentage": 48.59, "median_amount": 68.24, "10th_percentile": 13.6, "90th_percentile": 1043.06, "count": "30" }, { "payer_name": "BLUE SHIELD", "plan_name": "STANFORD HEALTHCARE ALLIANCE PLAN", "methodology": "percent of total billed charges", "standard_charge_dollar": 5344.9, "standard_charge_percentage": 48.59, "count": "0", "additional_payer_notes": "Zero final payments for the item or service in the 15 months prior to posting the file." }, { "payer_name": "BLUE SHIELD", "plan_name": "STANFORD HEALTHCARE ALLIANCE PLAN", "methodology": "percent of total billed charges", "standard_charge_dollar": 5344.9, "standard_charge_percentage": 48.59, "count": "0", "additional_payer_notes": "Zero final payments for the item or service in the 15 months prior to posting the file." }, { "payer_name": "CIGNA", "plan_name": "CIGNA COM ALT HMO PLAN", "methodology": "percent of total billed charges", "standard_charge_dollar": 4642.0, "standard_charge_percentage": 42.2, "count": "0", "additional_payer_notes": "Zero final payments for the item or service in the 15 months prior to posting the file." }, { "payer_name": "CIGNA", "plan_name": "CIGNA COM ALT HMO PLAN", "methodology": "percent of total billed charges", "standard_charge_dollar": 4642.0, "standard_charge_percentage": 42.2, "count": "0", "additional_payer_notes": "Zero final payments for the item or service in the 15 months prior to posting the file." }, { "payer_name": "HEALTH NET", "plan_name": "HEALTHNET HMO, PPO, POS, EPO, CANOPY HEALTHNET HMO, OTHER-IN-NETWORK PLANS", "methodology": "per diem", "standard_charge_dollar": 8000.0, "standard_charge_algorithm": "Expected reimbursement is the lesser of Per diem ($8,000) for the length of stay and 70% of billed.", "count": "0", "additional_payer_notes": "Zero final payments for the item or service in the 15 months prior to posting the file." }, { "payer_name": "HEALTH NET", "plan_name": "HEALTHNET HMO, PPO, POS, EPO, CANOPY HEALTHNET HMO, OTHER-IN-NETWORK PLANS", "methodology": "per diem", "standard_charge_dollar": 8000.0, "standard_charge_algorithm": "Expected reimbursement is the lesser of Per diem ($8,000) for the length of stay and 70% of billed.", "count": "0", "additional_payer_notes": "Zero final payments for the item or service in the 15 months prior to posting the file." }, { "payer_name": "UNITED HEALTHCARE", "plan_name": "SUTTER SELECT & SUTTER HEALTH PLAN HMO PLANS", "methodology": "per diem", "standard_charge_dollar": 28538.0, "standard_charge_algorithm": "Per diem ($28,538).", "count": "0", "additional_payer_notes": "Zero final payments for the item or service in the 15 months prior to posting the file." }, { "payer_name": "UNITED HEALTHCARE", "plan_name": "SUTTER SELECT & SUTTER HEALTH PLAN HMO PLANS", "methodology": "per diem", "standard_charge_dollar": 28538.0, "standard_charge_algorithm": "Per diem ($28,538).", "count": "0", "additional_payer_notes": "Zero final payments for the item or service in the 15 months prior to posting the file." }, { "payer_name": "SUTTER", "plan_name": "SUTTER SELECT & SUTTER HEALTH PLAN HMO PLANS", "methodology": "per diem", "standard_charge_dollar": 28538.0, "standard_charge_algorithm": "Per diem ($28,538).", "count": "0", "additional_payer_notes": "Zero final payments for the item or service in the 15 months prior to posting the file." }, { "payer_name": "UNITED HEALTHCARE", "plan_name": "SUTTER SELECT & SUTTER HEALTH PLAN HMO PLANS", "methodology": "per diem", "standard_charge_dollar": 28538.0, "standard_charge_algorithm": "Per diem ($28,538).", "count": "0", "additional_payer_notes": "Zero final payments for the item or service in the 15 months prior to posting the file." }, { "payer_name": "UMR", "plan_name": "SUTTER SELECT & SUTTER HEALTH PLAN HMO PLANS", "methodology": "per diem", "standard_charge_dollar": 28538.0, "standard_charge_algorithm": "Per diem ($28,538).", "count": "0", "additional_payer_notes": "Zero final payments for the item or service in the 15 months prior to posting the file." } ] } ] }, { "description": "Hc Cannula Gp045", "code_information": [ { "code": "PX-2120023045", "type": "CDM" }, { "code": "99999", "type": "CPT" }, { "code": "0272", "type": "RC" } ], "standard_charges": [ { "setting": "outpatient", "gross_charge": 11550.0, "discounted_cash": 5775.0, "minimum": 4874.1, "maximum": 6006.0, "additional_generic_notes": "Zero final payments for the item or service in the 15 months prior to posting the file.", "payers_information": [ { "payer_name": "AETNA", "plan_name": "AETNA ALL OTHER PLANS", "methodology": "percent of total billed charges", "standard_charge_dollar": 6006.0, "standard_charge_percentage": 52.0, "count": "0", "additional_payer_notes": "Zero final payments for the item or service in the 15 months prior to posting the file." }, { "payer_name": "AETNA", "plan_name": "AETNA ALL OTHER PLANS", "methodology": "percent of total billed charges", "standard_charge_dollar": 6006.0, "standard_charge_percentage": 52.0, "count": "0", "additional_payer_notes": "Zero final payments for the item or service in the 15 months prior to posting the file." }, { "payer_name": "MERITAIN HEALTH", "plan_name": "AETNA ALL OTHER PLANS", "methodology": "percent of total billed charges", "standard_charge_dollar": 6006.0, "standard_charge_percentage": 52.0, "count": "0", "additional_payer_notes": "Zero final payments for the item or service in the 15 months prior to posting the file." }, { "payer_name": "BLUE SHIELD OUT OF STATE", "plan_name": "STANFORD HEALTHCARE ALLIANCE PLAN", "methodology": "percent of total billed charges", "standard_charge_dollar": 5612.15, "standard_charge_percentage": 48.59, "count": "0", "additional_payer_notes": "Zero final payments for the item or service in the 15 months prior to posting the file." }, { "payer_name": "BLUE SHIELD", "plan_name": "STANFORD HEALTHCARE ALLIANCE PLAN", "methodology": "percent of total billed charges", "standard_charge_dollar": 5612.15, "standard_charge_percentage": 48.59, "median_amount": 68.24, "10th_percentile": 13.6, "90th_percentile": 1043.06, "count": "30" }, { "payer_name": "BLUE SHIELD", "plan_name": "STANFORD HEALTHCARE ALLIANCE PLAN", "methodology": "percent of total billed charges", "standard_charge_dollar": 5612.15, "standard_charge_percentage": 48.59, "count": "0", "additional_payer_notes": "Zero final payments for the item or service in the 15 months prior to posting the file." }, { "payer_name": "BLUE SHIELD", "plan_name": "STANFORD HEALTHCARE ALLIANCE PLAN", "methodology": "percent of total billed charges", "standard_charge_dollar": 5612.15, "standard_charge_percentage": 48.59, "count": "0", "additional_payer_notes": "Zero final payments for the item or service in the 15 months prior to posting the file." }, { "payer_name": "CIGNA", "plan_name": "CIGNA COM ALT HMO PLAN", "methodology": "percent of total billed charges", "standard_charge_dollar": 4874.1, "standard_charge_percentage": 42.2, "count": "0", "additional_payer_notes": "Zero final payments for the item or service in the 15 months prior to posting the file." }, { "payer_name": "CIGNA", "plan_name": "CIGNA COM ALT HMO PLAN", "methodology": "percent of total billed charges", "standard_charge_dollar": 4874.1, "standard_charge_percentage": 42.2, "count": "0", "additional_payer_notes": "Zero final payments for the item or service in the 15 months prior to posting the file." }, { "payer_name": "HEALTH NET", "plan_name": "HEALTHNET HMO, PPO, POS, EPO, CANOPY HEALTHNET HMO, OTHER-IN-NETWORK PLANS", "methodology": "per diem", "standard_charge_dollar": 8000.0, "standard_charge_algorithm": "Expected reimbursement is the lesser of Per diem ($8,000) for the length of stay and 70% of billed.", "count": "0", "additional_payer_notes": "Zero final payments for the item or service in the 15 months prior to posting the file." }, { "payer_name": "HEALTH NET", "plan_name": "HEALTHNET HMO, PPO, POS, EPO, CANOPY HEALTHNET HMO, OTHER-IN-NETWORK PLANS", "methodology": "per diem", "standard_charge_dollar": 8000.0, "standard_charge_algorithm": "Expected reimbursement is the lesser of Per diem ($8,000) for the length of stay and 70% of billed.", "count": "0", "additional_payer_notes": "Zero final payments for the item or service in the 15 months prior to posting the file." }, { "payer_name": "UNITED HEALTHCARE", "plan_name": "SUTTER SELECT & SUTTER HEALTH PLAN HMO PLANS", "methodology": "per diem", "standard_charge_dollar": 28538.0, "standard_charge_algorithm": "Per diem ($28,538).", "count": "0", "additional_payer_notes": "Zero final payments for the item or service in the 15 months prior to posting the file." }, { "payer_name": "UNITED HEALTHCARE", "plan_name": "SUTTER SELECT & SUTTER HEALTH PLAN HMO PLANS", "methodology": "per diem", "standard_charge_dollar": 28538.0, "standard_charge_algorithm": "Per diem ($28,538).", "count": "0", "additional_payer_notes": "Zero final payments for the item or service in the 15 months prior to posting the file." }, { "payer_name": "SUTTER", "plan_name": "SUTTER SELECT & SUTTER HEALTH PLAN HMO PLANS", "methodology": "per diem", "standard_charge_dollar": 28538.0, "standard_charge_algorithm": "Per diem ($28,538).", "count": "0", "additional_payer_notes": "Zero final payments for the item or service in the 15 months prior to posting the file." }, { "payer_name": "UNITED HEALTHCARE", "plan_name": "SUTTER SELECT & SUTTER HEALTH PLAN HMO PLANS", "methodology": "per diem", "standard_charge_dollar": 28538.0, "standard_charge_algorithm": "Per diem ($28,538).", "count": "0", "additional_payer_notes": "Zero final payments for the item or service in the 15 months prior to posting the file." }, { "payer_name": "UMR", "plan_name": "SUTTER SELECT & SUTTER HEALTH PLAN HMO PLANS", "methodology": "per diem", "standard_charge_dollar": 28538.0, "standard_charge_algorithm": "Per diem ($28,538).", "count": "0", "additional_payer_notes": "Zero final payments for the item or service in the 15 months prior to posting the file." } ] } ] }, { "description": "HC Cannula Arterial Gp002", "code_information": [ { "code": "PX-2120024002", "type": "CDM" }, { "code": "99999", "type": "CPT" }, { "code": "0272", "type": "RC" } ], "standard_charges": [ { "setting": "outpatient", "gross_charge": 50.0, "discounted_cash": 25.0, "minimum": 21.1, "maximum": 26.0, "additional_generic_notes": "Zero final payments for the item or service in the 15 months prior to posting the file.", "payers_information": [ { "payer_name": "AETNA", "plan_name": "AETNA ALL OTHER PLANS", "methodology": "percent of total billed charges", "standard_charge_dollar": 26.0, "standard_charge_percentage": 52.0, "count": "0", "additional_payer_notes": "Zero final payments for the item or service in the 15 months prior to posting the file." }, { "payer_name": "AETNA", "plan_name": "AETNA ALL OTHER PLANS", "methodology": "percent of total billed charges", "standard_charge_dollar": 26.0, "standard_charge_percentage": 52.0, "count": "0", "additional_payer_notes": "Zero final payments for the item or service in the 15 months prior to posting the file." }, { "payer_name": "MERITAIN HEALTH", "plan_name": "AETNA ALL OTHER PLANS", "methodology": "percent of total billed charges", "standard_charge_dollar": 26.0, "standard_charge_percentage": 52.0, "count": "0", "additional_payer_notes": "Zero final payments for the item or service in the 15 months prior to posting the file." }, { "payer_name": "BLUE SHIELD OUT OF STATE", "plan_name": "STANFORD HEALTHCARE ALLIANCE PLAN", "methodology": "percent of total billed charges", "standard_charge_dollar": 24.3, "standard_charge_percentage": 48.59, "count": "0", "additional_payer_notes": "Zero final payments for the item or service in the 15 months prior to posting the file." }, { "payer_name": "BLUE SHIELD", "plan_name": "STANFORD HEALTHCARE ALLIANCE PLAN", "methodology": "percent of total billed charges", "standard_charge_dollar": 24.3, "standard_charge_percentage": 48.59, "count": "0", "additional_payer_notes": "Zero final payments for the item or service in the 15 months prior to posting the file." }, { "payer_name": "BLUE SHIELD", "plan_name": "STANFORD HEALTHCARE ALLIANCE PLAN", "methodology": "percent of total billed charges", "standard_charge_dollar": 24.3, "standard_charge_percentage": 48.59, "count": "0", "additional_payer_notes": "Zero final payments for the item or service in the 15 months prior to posting the file." }, { "payer_name": "CIGNA", "plan_name": "CIGNA COM ALT HMO PLAN", "methodology": "percent of total billed charges", "standard_charge_dollar": 21.1, "standard_charge_percentage": 42.2, "count": "0", "additional_payer_notes": "Zero final payments for the item or service in the 15 months prior to posting the file." }, { "payer_name": "CIGNA", "plan_name": "CIGNA COM ALT HMO PLAN", "methodology": "percent of total billed charges", "standard_charge_dollar": 21.1, "standard_charge_percentage": 42.2, "count": "0", "additional_payer_notes": "Zero final payments for the item or service in the 15 months prior to posting the file." }, { "payer_name": "HEALTH NET", "plan_name": "HEALTHNET HMO, PPO, POS, EPO, CANOPY HEALTHNET HMO, OTHER-IN-NETWORK PLANS", "methodology": "per diem", "standard_charge_dollar": 8000.0, "standard_charge_algorithm": "Expected reimbursement is the lesser of Per diem ($8,000) for the length of stay and 70% of billed.", "count": "0", "additional_payer_notes": "Zero final payments for the item or service in the 15 months prior to posting the file." }, { "payer_name": "HEALTH NET", "plan_name": "HEALTHNET HMO, PPO, POS, EPO, CANOPY HEALTHNET HMO, OTHER-IN-NETWORK PLANS", "methodology": "per diem", "standard_charge_dollar": 8000.0, "standard_charge_algorithm": "Expected reimbursement is the lesser of Per diem ($8,000) for the length of stay and 70% of billed.", "count": "0", "additional_payer_notes": "Zero final payments for the item or service in the 15 months prior to posting the file." }, { "payer_name": "UNITED HEALTHCARE", "plan_name": "SUTTER SELECT & SUTTER HEALTH PLAN HMO PLANS", "methodology": "per diem", "standard_charge_dollar": 28538.0, "standard_charge_algorithm": "Per diem ($28,538).", "count": "0", "additional_payer_notes": "Zero final payments for the item or service in the 15 months prior to posting the file." }, { "payer_name": "UNITED HEALTHCARE", "plan_name": "SUTTER SELECT & SUTTER HEALTH PLAN HMO PLANS", "methodology": "per diem", "standard_charge_dollar": 28538.0, "standard_charge_algorithm": "Per diem ($28,538).", "count": "0", "additional_payer_notes": "Zero final payments for the item or service in the 15 months prior to posting the file." }, { "payer_name": "SUTTER", "plan_name": "SUTTER SELECT & SUTTER HEALTH PLAN HMO PLANS", "methodology": "per diem", "standard_charge_dollar": 28538.0, "standard_charge_algorithm": "Per diem ($28,538).", "count": "0", "additional_payer_notes": "Zero final payments for the item or service in the 15 months prior to posting the file." }, { "payer_name": "UNITED HEALTHCARE", "plan_name": "SUTTER SELECT & SUTTER HEALTH PLAN HMO PLANS", "methodology": "per diem", "standard_charge_dollar": 28538.0, "standard_charge_algorithm": "Per diem ($28,538).", "count": "0", "additional_payer_notes": "Zero final payments for the item or service in the 15 months prior to posting the file." }, { "payer_name": "UMR", "plan_name": "SUTTER SELECT & SUTTER HEALTH PLAN HMO PLANS", "methodology": "per diem", "standard_charge_dollar": 28538.0, "standard_charge_algorithm": "Per diem ($28,538).", "count": "0", "additional_payer_notes": "Zero final payments for the item or service in the 15 months prior to posting the file." } ] } ] }, { "description": "HC Cannula Arterial Gp003", "code_information": [ { "code": "PX-2120024003", "type": "CDM" }, { "code": "99999", "type": "CPT" }, { "code": "0272", "type": "RC" } ], "standard_charges": [ { "setting": "outpatient", "gross_charge": 100.0, "discounted_cash": 50.0, "minimum": 42.2, "maximum": 52.0, "additional_generic_notes": "Zero final payments for the item or service in the 15 months prior to posting the file.", "payers_information": [ { "payer_name": "AETNA", "plan_name": "AETNA ALL OTHER PLANS", "methodology": "percent of total billed charges", "standard_charge_dollar": 52.0, "standard_charge_percentage": 52.0, "count": "0", "additional_payer_notes": "Zero final payments for the item or service in the 15 months prior to posting the file." }, { "payer_name": "AETNA", "plan_name": "AETNA ALL OTHER PLANS", "methodology": "percent of total billed charges", "standard_charge_dollar": 52.0, "standard_charge_percentage": 52.0, "count": "0", "additional_payer_notes": "Zero final payments for the item or service in the 15 months prior to posting the file." }, { "payer_name": "MERITAIN HEALTH", "plan_name": "AETNA ALL OTHER PLANS", "methodology": "percent of total billed charges", "standard_charge_dollar": 52.0, "standard_charge_percentage": 52.0, "count": "0", "additional_payer_notes": "Zero final payments for the item or service in the 15 months prior to posting the file." }, { "payer_name": "BLUE SHIELD OUT OF STATE", "plan_name": "STANFORD HEALTHCARE ALLIANCE PLAN", "methodology": "percent of total billed charges", "standard_charge_dollar": 48.59, "standard_charge_percentage": 48.59, "count": "0", "additional_payer_notes": "Zero final payments for the item or service in the 15 months prior to posting the file." }, { "payer_name": "BLUE SHIELD", "plan_name": "STANFORD HEALTHCARE ALLIANCE PLAN", "methodology": "percent of total billed charges", "standard_charge_dollar": 48.59, "standard_charge_percentage": 48.59, "count": "0", "additional_payer_notes": "Zero final payments for the item or service in the 15 months prior to posting the file." }, { "payer_name": "BLUE SHIELD", "plan_name": "STANFORD HEALTHCARE ALLIANCE PLAN", "methodology": "percent of total billed charges", "standard_charge_dollar": 48.59, "standard_charge_percentage": 48.59, "count": "0", "additional_payer_notes": "Zero final payments for the item or service in the 15 months prior to posting the file." }, { "payer_name": "CIGNA", "plan_name": "CIGNA COM ALT HMO PLAN", "methodology": "percent of total billed charges", "standard_charge_dollar": 42.2, "standard_charge_percentage": 42.2, "count": "0", "additional_payer_notes": "Zero final payments for the item or service in the 15 months prior to posting the file." }, { "payer_name": "CIGNA", "plan_name": "CIGNA COM ALT HMO PLAN", "methodology": "percent of total billed charges", "standard_charge_dollar": 42.2, "standard_charge_percentage": 42.2, "count": "0", "additional_payer_notes": "Zero final payments for the item or service in the 15 months prior to posting the file." }, { "payer_name": "HEALTH NET", "plan_name": "HEALTHNET HMO, PPO, POS, EPO, CANOPY HEALTHNET HMO, OTHER-IN-NETWORK PLANS", "methodology": "per diem", "standard_charge_dollar": 8000.0, "standard_charge_algorithm": "Expected reimbursement is the lesser of Per diem ($8,000) for the length of stay and 70% of billed.", "count": "0", "additional_payer_notes": "Zero final payments for the item or service in the 15 months prior to posting the file." }, { "payer_name": "HEALTH NET", "plan_name": "HEALTHNET HMO, PPO, POS, EPO, CANOPY HEALTHNET HMO, OTHER-IN-NETWORK PLANS", "methodology": "per diem", "standard_charge_dollar": 8000.0, "standard_charge_algorithm": "Expected reimbursement is the lesser of Per diem ($8,000) for the length of stay and 70% of billed.", "count": "0", "additional_payer_notes": "Zero final payments for the item or service in the 15 months prior to posting the file." }, { "payer_name": "UNITED HEALTHCARE", "plan_name": "SUTTER SELECT & SUTTER HEALTH PLAN HMO PLANS", "methodology": "per diem", "standard_charge_dollar": 28538.0, "standard_charge_algorithm": "Per diem ($28,538).", "count": "0", "additional_payer_notes": "Zero final payments for the item or service in the 15 months prior to posting the file." }, { "payer_name": "UNITED HEALTHCARE", "plan_name": "SUTTER SELECT & SUTTER HEALTH PLAN HMO PLANS", "methodology": "per diem", "standard_charge_dollar": 28538.0, "standard_charge_algorithm": "Per diem ($28,538).", "count": "0", "additional_payer_notes": "Zero final payments for the item or service in the 15 months prior to posting the file." }, { "payer_name": "SUTTER", "plan_name": "SUTTER SELECT & SUTTER HEALTH PLAN HMO PLANS", "methodology": "per diem", "standard_charge_dollar": 28538.0, "standard_charge_algorithm": "Per diem ($28,538).", "count": "0", "additional_payer_notes": "Zero final payments for the item or service in the 15 months prior to posting the file." }, { "payer_name": "UNITED HEALTHCARE", "plan_name": "SUTTER SELECT & SUTTER HEALTH PLAN HMO PLANS", "methodology": "per diem", "standard_charge_dollar": 28538.0, "standard_charge_algorithm": "Per diem ($28,538).", "count": "0", "additional_payer_notes": "Zero final payments for the item or service in the 15 months prior to posting the file." }, { "payer_name": "UMR", "plan_name": "SUTTER SELECT & SUTTER HEALTH PLAN HMO PLANS", "methodology": "per diem", "standard_charge_dollar": 28538.0, "standard_charge_algorithm": "Per diem ($28,538).", "count": "0", "additional_payer_notes": "Zero final payments for the item or service in the 15 months prior to posting the file." } ] } ] }, { "description": "HC Cannula Arterial Gp004", "code_information": [ { "code": "PX-2120024004", "type": "CDM" }, { "code": "99999", "type": "CPT" }, { "code": "0272", "type": "RC" } ], "standard_charges": [ { "setting": "outpatient", "gross_charge": 146.0, "discounted_cash": 73.0, "minimum": 61.61, "maximum": 75.92, "additional_generic_notes": "Zero final payments for the item or service in the 15 months prior to posting the file.", "payers_information": [ { "payer_name": "AETNA", "plan_name": "AETNA ALL OTHER PLANS", "methodology": "percent of total billed charges", "standard_charge_dollar": 75.92, "standard_charge_percentage": 52.0, "count": "0", "additional_payer_notes": "Zero final payments for the item or service in the 15 months prior to posting the file." }, { "payer_name": "AETNA", "plan_name": "AETNA ALL OTHER PLANS", "methodology": "percent of total billed charges", "standard_charge_dollar": 75.92, "standard_charge_percentage": 52.0, "count": "0", "additional_payer_notes": "Zero final payments for the item or service in the 15 months prior to posting the file." }, { "payer_name": "MERITAIN HEALTH", "plan_name": "AETNA ALL OTHER PLANS", "methodology": "percent of total billed charges", "standard_charge_dollar": 75.92, "standard_charge_percentage": 52.0, "count": "0", "additional_payer_notes": "Zero final payments for the item or service in the 15 months prior to posting the file." }, { "payer_name": "BLUE SHIELD OUT OF STATE", "plan_name": "STANFORD HEALTHCARE ALLIANCE PLAN", "methodology": "percent of total billed charges", "standard_charge_dollar": 70.94, "standard_charge_percentage": 48.59, "count": "0", "additional_payer_notes": "Zero final payments for the item or service in the 15 months prior to posting the file." }, { "payer_name": "BLUE SHIELD", "plan_name": "STANFORD HEALTHCARE ALLIANCE PLAN", "methodology": "percent of total billed charges", "standard_charge_dollar": 70.94, "standard_charge_percentage": 48.59, "count": "0", "additional_payer_notes": "Zero final payments for the item or service in the 15 months prior to posting the file." }, { "payer_name": "BLUE SHIELD", "plan_name": "STANFORD HEALTHCARE ALLIANCE PLAN", "methodology": "percent of total billed charges", "standard_charge_dollar": 70.94, "standard_charge_percentage": 48.59, "count": "0", "additional_payer_notes": "Zero final payments for the item or service in the 15 months prior to posting the file." }, { "payer_name": "CIGNA", "plan_name": "CIGNA COM ALT HMO PLAN", "methodology": "percent of total billed charges", "standard_charge_dollar": 61.61, "standard_charge_percentage": 42.2, "count": "0", "additional_payer_notes": "Zero final payments for the item or service in the 15 months prior to posting the file." }, { "payer_name": "CIGNA", "plan_name": "CIGNA COM ALT HMO PLAN", "methodology": "percent of total billed charges", "standard_charge_dollar": 61.61, "standard_charge_percentage": 42.2, "count": "0", "additional_payer_notes": "Zero final payments for the item or service in the 15 months prior to posting the file." }, { "payer_name": "HEALTH NET", "plan_name": "HEALTHNET HMO, PPO, POS, EPO, CANOPY HEALTHNET HMO, OTHER-IN-NETWORK PLANS", "methodology": "per diem", "standard_charge_dollar": 8000.0, "standard_charge_algorithm": "Expected reimbursement is the lesser of Per diem ($8,000) for the length of stay and 70% of billed.", "count": "0", "additional_payer_notes": "Zero final payments for the item or service in the 15 months prior to posting the file." }, { "payer_name": "HEALTH NET", "plan_name": "HEALTHNET HMO, PPO, POS, EPO, CANOPY HEALTHNET HMO, OTHER-IN-NETWORK PLANS", "methodology": "per diem", "standard_charge_dollar": 8000.0, "standard_charge_algorithm": "Expected reimbursement is the lesser of Per diem ($8,000) for the length of stay and 70% of billed.", "count": "0", "additional_payer_notes": "Zero final payments for the item or service in the 15 months prior to posting the file." }, { "payer_name": "UNITED HEALTHCARE", "plan_name": "SUTTER SELECT & SUTTER HEALTH PLAN HMO PLANS", "methodology": "per diem", "standard_charge_dollar": 28538.0, "standard_charge_algorithm": "Per diem ($28,538).", "count": "0", "additional_payer_notes": "Zero final payments for the item or service in the 15 months prior to posting the file." }, { "payer_name": "UNITED HEALTHCARE", "plan_name": "SUTTER SELECT & SUTTER HEALTH PLAN HMO PLANS", "methodology": "per diem", "standard_charge_dollar": 28538.0, "standard_charge_algorithm": "Per diem ($28,538).", "count": "0", "additional_payer_notes": "Zero final payments for the item or service in the 15 months prior to posting the file." }, { "payer_name": "SUTTER", "plan_name": "SUTTER SELECT & SUTTER HEALTH PLAN HMO PLANS", "methodology": "per diem", "standard_charge_dollar": 28538.0, "standard_charge_algorithm": "Per diem ($28,538).", "count": "0", "additional_payer_notes": "Zero final payments for the item or service in the 15 months prior to posting the file." }, { "payer_name": "UNITED HEALTHCARE", "plan_name": "SUTTER SELECT & SUTTER HEALTH PLAN HMO PLANS", "methodology": "per diem", "standard_charge_dollar": 28538.0, "standard_charge_algorithm": "Per diem ($28,538).", "count": "0", "additional_payer_notes": "Zero final payments for the item or service in the 15 months prior to posting the file." }, { "payer_name": "UMR", "plan_name": "SUTTER SELECT & SUTTER HEALTH PLAN HMO PLANS", "methodology": "per diem", "standard_charge_dollar": 28538.0, "standard_charge_algorithm": "Per diem ($28,538).", "count": "0", "additional_payer_notes": "Zero final payments for the item or service in the 15 months prior to posting the file." } ] } ] }, { "description": "HC Cannula Arterial Gp005", "code_information": [ { "code": "PX-2120024005", "type": "CDM" }, { "code": "99999", "type": "CPT" }, { "code": "0272", "type": "RC" } ], "standard_charges": [ { "setting": "outpatient", "gross_charge": 195.0, "discounted_cash": 97.5, "minimum": 82.29, "maximum": 101.4, "additional_generic_notes": "Zero final payments for the item or service in the 15 months prior to posting the file.", "payers_information": [ { "payer_name": "AETNA", "plan_name": "AETNA ALL OTHER PLANS", "methodology": "percent of total billed charges", "standard_charge_dollar": 101.4, "standard_charge_percentage": 52.0, "count": "0", "additional_payer_notes": "Zero final payments for the item or service in the 15 months prior to posting the file." }, { "payer_name": "AETNA", "plan_name": "AETNA ALL OTHER PLANS", "methodology": "percent of total billed charges", "standard_charge_dollar": 101.4, "standard_charge_percentage": 52.0, "count": "0", "additional_payer_notes": "Zero final payments for the item or service in the 15 months prior to posting the file." }, { "payer_name": "MERITAIN HEALTH", "plan_name": "AETNA ALL OTHER PLANS", "methodology": "percent of total billed charges", "standard_charge_dollar": 101.4, "standard_charge_percentage": 52.0, "count": "0", "additional_payer_notes": "Zero final payments for the item or service in the 15 months prior to posting the file." }, { "payer_name": "BLUE SHIELD OUT OF STATE", "plan_name": "STANFORD HEALTHCARE ALLIANCE PLAN", "methodology": "percent of total billed charges", "standard_charge_dollar": 94.75, "standard_charge_percentage": 48.59, "count": "0", "additional_payer_notes": "Zero final payments for the item or service in the 15 months prior to posting the file." }, { "payer_name": "BLUE SHIELD", "plan_name": "STANFORD HEALTHCARE ALLIANCE PLAN", "methodology": "percent of total billed charges", "standard_charge_dollar": 94.75, "standard_charge_percentage": 48.59, "count": "0", "additional_payer_notes": "Zero final payments for the item or service in the 15 months prior to posting the file." }, { "payer_name": "BLUE SHIELD", "plan_name": "STANFORD HEALTHCARE ALLIANCE PLAN", "methodology": "percent of total billed charges", "standard_charge_dollar": 94.75, "standard_charge_percentage": 48.59, "count": "0", "additional_payer_notes": "Zero final payments for the item or service in the 15 months prior to posting the file." }, { "payer_name": "CIGNA", "plan_name": "CIGNA COM ALT HMO PLAN", "methodology": "percent of total billed charges", "standard_charge_dollar": 82.29, "standard_charge_percentage": 42.2, "count": "0", "additional_payer_notes": "Zero final payments for the item or service in the 15 months prior to posting the file." }, { "payer_name": "CIGNA", "plan_name": "CIGNA COM ALT HMO PLAN", "methodology": "percent of total billed charges", "standard_charge_dollar": 82.29, "standard_charge_percentage": 42.2, "count": "0", "additional_payer_notes": "Zero final payments for the item or service in the 15 months prior to posting the file." }, { "payer_name": "HEALTH NET", "plan_name": "HEALTHNET HMO, PPO, POS, EPO, CANOPY HEALTHNET HMO, OTHER-IN-NETWORK PLANS", "methodology": "per diem", "standard_charge_dollar": 8000.0, "standard_charge_algorithm": "Expected reimbursement is the lesser of Per diem ($8,000) for the length of stay and 70% of billed.", "count": "0", "additional_payer_notes": "Zero final payments for the item or service in the 15 months prior to posting the file." }, { "payer_name": "HEALTH NET", "plan_name": "HEALTHNET HMO, PPO, POS, EPO, CANOPY HEALTHNET HMO, OTHER-IN-NETWORK PLANS", "methodology": "per diem", "standard_charge_dollar": 8000.0, "standard_charge_algorithm": "Expected reimbursement is the lesser of Per diem ($8,000) for the length of stay and 70% of billed.", "count": "0", "additional_payer_notes": "Zero final payments for the item or service in the 15 months prior to posting the file." }, { "payer_name": "UNITED HEALTHCARE", "plan_name": "SUTTER SELECT & SUTTER HEALTH PLAN HMO PLANS", "methodology": "per diem", "standard_charge_dollar": 28538.0, "standard_charge_algorithm": "Per diem ($28,538).", "count": "0", "additional_payer_notes": "Zero final payments for the item or service in the 15 months prior to posting the file." }, { "payer_name": "UNITED HEALTHCARE", "plan_name": "SUTTER SELECT & SUTTER HEALTH PLAN HMO PLANS", "methodology": "per diem", "standard_charge_dollar": 28538.0, "standard_charge_algorithm": "Per diem ($28,538).", "count": "0", "additional_payer_notes": "Zero final payments for the item or service in the 15 months prior to posting the file." }, { "payer_name": "SUTTER", "plan_name": "SUTTER SELECT & SUTTER HEALTH PLAN HMO PLANS", "methodology": "per diem", "standard_charge_dollar": 28538.0, "standard_charge_algorithm": "Per diem ($28,538).", "count": "0", "additional_payer_notes": "Zero final payments for the item or service in the 15 months prior to posting the file." }, { "payer_name": "UNITED HEALTHCARE", "plan_name": "SUTTER SELECT & SUTTER HEALTH PLAN HMO PLANS", "methodology": "per diem", "standard_charge_dollar": 28538.0, "standard_charge_algorithm": "Per diem ($28,538).", "count": "0", "additional_payer_notes": "Zero final payments for the item or service in the 15 months prior to posting the file." }, { "payer_name": "UMR", "plan_name": "SUTTER SELECT & SUTTER HEALTH PLAN HMO PLANS", "methodology": "per diem", "standard_charge_dollar": 28538.0, "standard_charge_algorithm": "Per diem ($28,538).", "count": "0", "additional_payer_notes": "Zero final payments for the item or service in the 15 months prior to posting the file." } ] } ] }, { "description": "HC Cannula Arterial Gp006", "code_information": [ { "code": "PX-2120024006", "type": "CDM" }, { "code": "99999", "type": "CPT" }, { "code": "0272", "type": "RC" } ], "standard_charges": [ { "setting": "outpatient", "gross_charge": 293.0, "discounted_cash": 146.5, "minimum": 123.65, "maximum": 152.36, "additional_generic_notes": "Zero final payments for the item or service in the 15 months prior to posting the file.", "payers_information": [ { "payer_name": "AETNA", "plan_name": "AETNA ALL OTHER PLANS", "methodology": "percent of total billed charges", "standard_charge_dollar": 152.36, "standard_charge_percentage": 52.0, "count": "0", "additional_payer_notes": "Zero final payments for the item or service in the 15 months prior to posting the file." }, { "payer_name": "AETNA", "plan_name": "AETNA ALL OTHER PLANS", "methodology": "percent of total billed charges", "standard_charge_dollar": 152.36, "standard_charge_percentage": 52.0, "count": "0", "additional_payer_notes": "Zero final payments for the item or service in the 15 months prior to posting the file." }, { "payer_name": "MERITAIN HEALTH", "plan_name": "AETNA ALL OTHER PLANS", "methodology": "percent of total billed charges", "standard_charge_dollar": 152.36, "standard_charge_percentage": 52.0, "count": "0", "additional_payer_notes": "Zero final payments for the item or service in the 15 months prior to posting the file." }, { "payer_name": "BLUE SHIELD OUT OF STATE", "plan_name": "STANFORD HEALTHCARE ALLIANCE PLAN", "methodology": "percent of total billed charges", "standard_charge_dollar": 142.37, "standard_charge_percentage": 48.59, "count": "0", "additional_payer_notes": "Zero final payments for the item or service in the 15 months prior to posting the file." }, { "payer_name": "BLUE SHIELD", "plan_name": "STANFORD HEALTHCARE ALLIANCE PLAN", "methodology": "percent of total billed charges", "standard_charge_dollar": 142.37, "standard_charge_percentage": 48.59, "count": "0", "additional_payer_notes": "Zero final payments for the item or service in the 15 months prior to posting the file." }, { "payer_name": "BLUE SHIELD", "plan_name": "STANFORD HEALTHCARE ALLIANCE PLAN", "methodology": "percent of total billed charges", "standard_charge_dollar": 142.37, "standard_charge_percentage": 48.59, "count": "0", "additional_payer_notes": "Zero final payments for the item or service in the 15 months prior to posting the file." }, { "payer_name": "CIGNA", "plan_name": "CIGNA COM ALT HMO PLAN", "methodology": "percent of total billed charges", "standard_charge_dollar": 123.65, "standard_charge_percentage": 42.2, "count": "0", "additional_payer_notes": "Zero final payments for the item or service in the 15 months prior to posting the file." }, { "payer_name": "CIGNA", "plan_name": "CIGNA COM ALT HMO PLAN", "methodology": "percent of total billed charges", "standard_charge_dollar": 123.65, "standard_charge_percentage": 42.2, "count": "0", "additional_payer_notes": "Zero final payments for the item or service in the 15 months prior to posting the file." }, { "payer_name": "HEALTH NET", "plan_name": "HEALTHNET HMO, PPO, POS, EPO, CANOPY HEALTHNET HMO, OTHER-IN-NETWORK PLANS", "methodology": "per diem", "standard_charge_dollar": 8000.0, "standard_charge_algorithm": "Expected reimbursement is the lesser of Per diem ($8,000) for the length of stay and 70% of billed.", "count": "0", "additional_payer_notes": "Zero final payments for the item or service in the 15 months prior to posting the file." }, { "payer_name": "HEALTH NET", "plan_name": "HEALTHNET HMO, PPO, POS, EPO, CANOPY HEALTHNET HMO, OTHER-IN-NETWORK PLANS", "methodology": "per diem", "standard_charge_dollar": 8000.0, "standard_charge_algorithm": "Expected reimbursement is the lesser of Per diem ($8,000) for the length of stay and 70% of billed.", "count": "0", "additional_payer_notes": "Zero final payments for the item or service in the 15 months prior to posting the file." }, { "payer_name": "UNITED HEALTHCARE", "plan_name": "SUTTER SELECT & SUTTER HEALTH PLAN HMO PLANS", "methodology": "per diem", "standard_charge_dollar": 28538.0, "standard_charge_algorithm": "Per diem ($28,538).", "count": "0", "additional_payer_notes": "Zero final payments for the item or service in the 15 months prior to posting the file." }, { "payer_name": "UNITED HEALTHCARE", "plan_name": "SUTTER SELECT & SUTTER HEALTH PLAN HMO PLANS", "methodology": "per diem", "standard_charge_dollar": 28538.0, "standard_charge_algorithm": "Per diem ($28,538).", "count": "0", "additional_payer_notes": "Zero final payments for the item or service in the 15 months prior to posting the file." }, { "payer_name": "SUTTER", "plan_name": "SUTTER SELECT & SUTTER HEALTH PLAN HMO PLANS", "methodology": "per diem", "standard_charge_dollar": 28538.0, "standard_charge_algorithm": "Per diem ($28,538).", "count": "0", "additional_payer_notes": "Zero final payments for the item or service in the 15 months prior to posting the file." }, { "payer_name": "UNITED HEALTHCARE", "plan_name": "SUTTER SELECT & SUTTER HEALTH PLAN HMO PLANS", "methodology": "per diem", "standard_charge_dollar": 28538.0, "standard_charge_algorithm": "Per diem ($28,538).", "count": "0", "additional_payer_notes": "Zero final payments for the item or service in the 15 months prior to posting the file." }, { "payer_name": "UMR", "plan_name": "SUTTER SELECT & SUTTER HEALTH PLAN HMO PLANS", "methodology": "per diem", "standard_charge_dollar": 28538.0, "standard_charge_algorithm": "Per diem ($28,538).", "count": "0", "additional_payer_notes": "Zero final payments for the item or service in the 15 months prior to posting the file." } ] } ] }, { "description": "HC Cannula Arterial Gp007", "code_information": [ { "code": "PX-2120024007", "type": "CDM" }, { "code": "99999", "type": "CPT" }, { "code": "0272", "type": "RC" } ], "standard_charges": [ { "setting": "outpatient", "gross_charge": 380.0, "discounted_cash": 190.0, "minimum": 160.36, "maximum": 197.6, "additional_generic_notes": "Zero final payments for the item or service in the 15 months prior to posting the file.", "payers_information": [ { "payer_name": "AETNA", "plan_name": "AETNA ALL OTHER PLANS", "methodology": "percent of total billed charges", "standard_charge_dollar": 197.6, "standard_charge_percentage": 52.0, "count": "0", "additional_payer_notes": "Zero final payments for the item or service in the 15 months prior to posting the file." }, { "payer_name": "AETNA", "plan_name": "AETNA ALL OTHER PLANS", "methodology": "percent of total billed charges", "standard_charge_dollar": 197.6, "standard_charge_percentage": 52.0, "count": "0", "additional_payer_notes": "Zero final payments for the item or service in the 15 months prior to posting the file." }, { "payer_name": "MERITAIN HEALTH", "plan_name": "AETNA ALL OTHER PLANS", "methodology": "percent of total billed charges", "standard_charge_dollar": 197.6, "standard_charge_percentage": 52.0, "count": "0", "additional_payer_notes": "Zero final payments for the item or service in the 15 months prior to posting the file." }, { "payer_name": "BLUE SHIELD OUT OF STATE", "plan_name": "STANFORD HEALTHCARE ALLIANCE PLAN", "methodology": "percent of total billed charges", "standard_charge_dollar": 184.64, "standard_charge_percentage": 48.59, "count": "0", "additional_payer_notes": "Zero final payments for the item or service in the 15 months prior to posting the file." }, { "payer_name": "BLUE SHIELD", "plan_name": "STANFORD HEALTHCARE ALLIANCE PLAN", "methodology": "percent of total billed charges", "standard_charge_dollar": 184.64, "standard_charge_percentage": 48.59, "count": "0", "additional_payer_notes": "Zero final payments for the item or service in the 15 months prior to posting the file." }, { "payer_name": "BLUE SHIELD", "plan_name": "STANFORD HEALTHCARE ALLIANCE PLAN", "methodology": "percent of total billed charges", "standard_charge_dollar": 184.64, "standard_charge_percentage": 48.59, "count": "0", "additional_payer_notes": "Zero final payments for the item or service in the 15 months prior to posting the file." }, { "payer_name": "CIGNA", "plan_name": "CIGNA COM ALT HMO PLAN", "methodology": "percent of total billed charges", "standard_charge_dollar": 160.36, "standard_charge_percentage": 42.2, "count": "0", "additional_payer_notes": "Zero final payments for the item or service in the 15 months prior to posting the file." }, { "payer_name": "CIGNA", "plan_name": "CIGNA COM ALT HMO PLAN", "methodology": "percent of total billed charges", "standard_charge_dollar": 160.36, "standard_charge_percentage": 42.2, "count": "0", "additional_payer_notes": "Zero final payments for the item or service in the 15 months prior to posting the file." }, { "payer_name": "HEALTH NET", "plan_name": "HEALTHNET HMO, PPO, POS, EPO, CANOPY HEALTHNET HMO, OTHER-IN-NETWORK PLANS", "methodology": "per diem", "standard_charge_dollar": 8000.0, "standard_charge_algorithm": "Expected reimbursement is the lesser of Per diem ($8,000) for the length of stay and 70% of billed.", "count": "0", "additional_payer_notes": "Zero final payments for the item or service in the 15 months prior to posting the file." }, { "payer_name": "HEALTH NET", "plan_name": "HEALTHNET HMO, PPO, POS, EPO, CANOPY HEALTHNET HMO, OTHER-IN-NETWORK PLANS", "methodology": "per diem", "standard_charge_dollar": 8000.0, "standard_charge_algorithm": "Expected reimbursement is the lesser of Per diem ($8,000) for the length of stay and 70% of billed.", "count": "0", "additional_payer_notes": "Zero final payments for the item or service in the 15 months prior to posting the file." }, { "payer_name": "UNITED HEALTHCARE", "plan_name": "SUTTER SELECT & SUTTER HEALTH PLAN HMO PLANS", "methodology": "per diem", "standard_charge_dollar": 28538.0, "standard_charge_algorithm": "Per diem ($28,538).", "count": "0", "additional_payer_notes": "Zero final payments for the item or service in the 15 months prior to posting the file." }, { "payer_name": "UNITED HEALTHCARE", "plan_name": "SUTTER SELECT & SUTTER HEALTH PLAN HMO PLANS", "methodology": "per diem", "standard_charge_dollar": 28538.0, "standard_charge_algorithm": "Per diem ($28,538).", "count": "0", "additional_payer_notes": "Zero final payments for the item or service in the 15 months prior to posting the file." }, { "payer_name": "SUTTER", "plan_name": "SUTTER SELECT & SUTTER HEALTH PLAN HMO PLANS", "methodology": "per diem", "standard_charge_dollar": 28538.0, "standard_charge_algorithm": "Per diem ($28,538).", "count": "0", "additional_payer_notes": "Zero final payments for the item or service in the 15 months prior to posting the file." }, { "payer_name": "UNITED HEALTHCARE", "plan_name": "SUTTER SELECT & SUTTER HEALTH PLAN HMO PLANS", "methodology": "per diem", "standard_charge_dollar": 28538.0, "standard_charge_algorithm": "Per diem ($28,538).", "count": "0", "additional_payer_notes": "Zero final payments for the item or service in the 15 months prior to posting the file." }, { "payer_name": "UMR", "plan_name": "SUTTER SELECT & SUTTER HEALTH PLAN HMO PLANS", "methodology": "per diem", "standard_charge_dollar": 28538.0, "standard_charge_algorithm": "Per diem ($28,538).", "count": "0", "additional_payer_notes": "Zero final payments for the item or service in the 15 months prior to posting the file." } ] } ] }, { "description": "HC Cannula Arterial Gp009", "code_information": [ { "code": "PX-2120024009", "type": "CDM" }, { "code": "99999", "type": "CPT" }, { "code": "0272", "type": "RC" } ], "standard_charges": [ { "setting": "outpatient", "gross_charge": 570.0, "discounted_cash": 285.0, "minimum": 240.54, "maximum": 296.4, "additional_generic_notes": "Zero final payments for the item or service in the 15 months prior to posting the file.", "payers_information": [ { "payer_name": "AETNA", "plan_name": "AETNA ALL OTHER PLANS", "methodology": "percent of total billed charges", "standard_charge_dollar": 296.4, "standard_charge_percentage": 52.0, "count": "0", "additional_payer_notes": "Zero final payments for the item or service in the 15 months prior to posting the file." }, { "payer_name": "AETNA", "plan_name": "AETNA ALL OTHER PLANS", "methodology": "percent of total billed charges", "standard_charge_dollar": 296.4, "standard_charge_percentage": 52.0, "count": "0", "additional_payer_notes": "Zero final payments for the item or service in the 15 months prior to posting the file." }, { "payer_name": "MERITAIN HEALTH", "plan_name": "AETNA ALL OTHER PLANS", "methodology": "percent of total billed charges", "standard_charge_dollar": 296.4, "standard_charge_percentage": 52.0, "count": "0", "additional_payer_notes": "Zero final payments for the item or service in the 15 months prior to posting the file." }, { "payer_name": "BLUE SHIELD OUT OF STATE", "plan_name": "STANFORD HEALTHCARE ALLIANCE PLAN", "methodology": "percent of total billed charges", "standard_charge_dollar": 276.96, "standard_charge_percentage": 48.59, "count": "0", "additional_payer_notes": "Zero final payments for the item or service in the 15 months prior to posting the file." }, { "payer_name": "BLUE SHIELD", "plan_name": "STANFORD HEALTHCARE ALLIANCE PLAN", "methodology": "percent of total billed charges", "standard_charge_dollar": 276.96, "standard_charge_percentage": 48.59, "count": "0", "additional_payer_notes": "Zero final payments for the item or service in the 15 months prior to posting the file." }, { "payer_name": "BLUE SHIELD", "plan_name": "STANFORD HEALTHCARE ALLIANCE PLAN", "methodology": "percent of total billed charges", "standard_charge_dollar": 276.96, "standard_charge_percentage": 48.59, "count": "0", "additional_payer_notes": "Zero final payments for the item or service in the 15 months prior to posting the file." }, { "payer_name": "CIGNA", "plan_name": "CIGNA COM ALT HMO PLAN", "methodology": "percent of total billed charges", "standard_charge_dollar": 240.54, "standard_charge_percentage": 42.2, "count": "0", "additional_payer_notes": "Zero final payments for the item or service in the 15 months prior to posting the file." }, { "payer_name": "CIGNA", "plan_name": "CIGNA COM ALT HMO PLAN", "methodology": "percent of total billed charges", "standard_charge_dollar": 240.54, "standard_charge_percentage": 42.2, "count": "0", "additional_payer_notes": "Zero final payments for the item or service in the 15 months prior to posting the file." }, { "payer_name": "HEALTH NET", "plan_name": "HEALTHNET HMO, PPO, POS, EPO, CANOPY HEALTHNET HMO, OTHER-IN-NETWORK PLANS", "methodology": "per diem", "standard_charge_dollar": 8000.0, "standard_charge_algorithm": "Expected reimbursement is the lesser of Per diem ($8,000) for the length of stay and 70% of billed.", "count": "0", "additional_payer_notes": "Zero final payments for the item or service in the 15 months prior to posting the file." }, { "payer_name": "HEALTH NET", "plan_name": "HEALTHNET HMO, PPO, POS, EPO, CANOPY HEALTHNET HMO, OTHER-IN-NETWORK PLANS", "methodology": "per diem", "standard_charge_dollar": 8000.0, "standard_charge_algorithm": "Expected reimbursement is the lesser of Per diem ($8,000) for the length of stay and 70% of billed.", "count": "0", "additional_payer_notes": "Zero final payments for the item or service in the 15 months prior to posting the file." }, { "payer_name": "UNITED HEALTHCARE", "plan_name": "SUTTER SELECT & SUTTER HEALTH PLAN HMO PLANS", "methodology": "per diem", "standard_charge_dollar": 28538.0, "standard_charge_algorithm": "Per diem ($28,538).", "count": "0", "additional_payer_notes": "Zero final payments for the item or service in the 15 months prior to posting the file." }, { "payer_name": "UNITED HEALTHCARE", "plan_name": "SUTTER SELECT & SUTTER HEALTH PLAN HMO PLANS", "methodology": "per diem", "standard_charge_dollar": 28538.0, "standard_charge_algorithm": "Per diem ($28,538).", "count": "0", "additional_payer_notes": "Zero final payments for the item or service in the 15 months prior to posting the file." }, { "payer_name": "SUTTER", "plan_name": "SUTTER SELECT & SUTTER HEALTH PLAN HMO PLANS", "methodology": "per diem", "standard_charge_dollar": 28538.0, "standard_charge_algorithm": "Per diem ($28,538).", "count": "0", "additional_payer_notes": "Zero final payments for the item or service in the 15 months prior to posting the file." }, { "payer_name": "UNITED HEALTHCARE", "plan_name": "SUTTER SELECT & SUTTER HEALTH PLAN HMO PLANS", "methodology": "per diem", "standard_charge_dollar": 28538.0, "standard_charge_algorithm": "Per diem ($28,538).", "count": "0", "additional_payer_notes": "Zero final payments for the item or service in the 15 months prior to posting the file." }, { "payer_name": "UMR", "plan_name": "SUTTER SELECT & SUTTER HEALTH PLAN HMO PLANS", "methodology": "per diem", "standard_charge_dollar": 28538.0, "standard_charge_algorithm": "Per diem ($28,538).", "count": "0", "additional_payer_notes": "Zero final payments for the item or service in the 15 months prior to posting the file." } ] } ] }, { "description": "HC Cannula Arterial Gp010", "code_information": [ { "code": "PX-2120024010", "type": "CDM" }, { "code": "99999", "type": "CPT" }, { "code": "0272", "type": "RC" } ], "standard_charges": [ { "setting": "outpatient", "gross_charge": 665.0, "discounted_cash": 332.5, "minimum": 280.63, "maximum": 345.8, "additional_generic_notes": "Zero final payments for the item or service in the 15 months prior to posting the file.", "payers_information": [ { "payer_name": "AETNA", "plan_name": "AETNA ALL OTHER PLANS", "methodology": "percent of total billed charges", "standard_charge_dollar": 345.8, "standard_charge_percentage": 52.0, "count": "0", "additional_payer_notes": "Zero final payments for the item or service in the 15 months prior to posting the file." }, { "payer_name": "AETNA", "plan_name": "AETNA ALL OTHER PLANS", "methodology": "percent of total billed charges", "standard_charge_dollar": 345.8, "standard_charge_percentage": 52.0, "count": "0", "additional_payer_notes": "Zero final payments for the item or service in the 15 months prior to posting the file." }, { "payer_name": "MERITAIN HEALTH", "plan_name": "AETNA ALL OTHER PLANS", "methodology": "percent of total billed charges", "standard_charge_dollar": 345.8, "standard_charge_percentage": 52.0, "count": "0", "additional_payer_notes": "Zero final payments for the item or service in the 15 months prior to posting the file." }, { "payer_name": "BLUE SHIELD OUT OF STATE", "plan_name": "STANFORD HEALTHCARE ALLIANCE PLAN", "methodology": "percent of total billed charges", "standard_charge_dollar": 323.12, "standard_charge_percentage": 48.59, "count": "0", "additional_payer_notes": "Zero final payments for the item or service in the 15 months prior to posting the file." }, { "payer_name": "BLUE SHIELD", "plan_name": "STANFORD HEALTHCARE ALLIANCE PLAN", "methodology": "percent of total billed charges", "standard_charge_dollar": 323.12, "standard_charge_percentage": 48.59, "count": "0", "additional_payer_notes": "Zero final payments for the item or service in the 15 months prior to posting the file." }, { "payer_name": "BLUE SHIELD", "plan_name": "STANFORD HEALTHCARE ALLIANCE PLAN", "methodology": "percent of total billed charges", "standard_charge_dollar": 323.12, "standard_charge_percentage": 48.59, "count": "0", "additional_payer_notes": "Zero final payments for the item or service in the 15 months prior to posting the file." }, { "payer_name": "CIGNA", "plan_name": "CIGNA COM ALT HMO PLAN", "methodology": "percent of total billed charges", "standard_charge_dollar": 280.63, "standard_charge_percentage": 42.2, "count": "0", "additional_payer_notes": "Zero final payments for the item or service in the 15 months prior to posting the file." }, { "payer_name": "CIGNA", "plan_name": "CIGNA COM ALT HMO PLAN", "methodology": "percent of total billed charges", "standard_charge_dollar": 280.63, "standard_charge_percentage": 42.2, "count": "0", "additional_payer_notes": "Zero final payments for the item or service in the 15 months prior to posting the file." }, { "payer_name": "HEALTH NET", "plan_name": "HEALTHNET HMO, PPO, POS, EPO, CANOPY HEALTHNET HMO, OTHER-IN-NETWORK PLANS", "methodology": "per diem", "standard_charge_dollar": 8000.0, "standard_charge_algorithm": "Expected reimbursement is the lesser of Per diem ($8,000) for the length of stay and 70% of billed.", "count": "0", "additional_payer_notes": "Zero final payments for the item or service in the 15 months prior to posting the file." }, { "payer_name": "HEALTH NET", "plan_name": "HEALTHNET HMO, PPO, POS, EPO, CANOPY HEALTHNET HMO, OTHER-IN-NETWORK PLANS", "methodology": "per diem", "standard_charge_dollar": 8000.0, "standard_charge_algorithm": "Expected reimbursement is the lesser of Per diem ($8,000) for the length of stay and 70% of billed.", "count": "0", "additional_payer_notes": "Zero final payments for the item or service in the 15 months prior to posting the file." }, { "payer_name": "UNITED HEALTHCARE", "plan_name": "SUTTER SELECT & SUTTER HEALTH PLAN HMO PLANS", "methodology": "per diem", "standard_charge_dollar": 28538.0, "standard_charge_algorithm": "Per diem ($28,538).", "count": "0", "additional_payer_notes": "Zero final payments for the item or service in the 15 months prior to posting the file." }, { "payer_name": "UNITED HEALTHCARE", "plan_name": "SUTTER SELECT & SUTTER HEALTH PLAN HMO PLANS", "methodology": "per diem", "standard_charge_dollar": 28538.0, "standard_charge_algorithm": "Per diem ($28,538).", "count": "0", "additional_payer_notes": "Zero final payments for the item or service in the 15 months prior to posting the file." }, { "payer_name": "SUTTER", "plan_name": "SUTTER SELECT & SUTTER HEALTH PLAN HMO PLANS", "methodology": "per diem", "standard_charge_dollar": 28538.0, "standard_charge_algorithm": "Per diem ($28,538).", "count": "0", "additional_payer_notes": "Zero final payments for the item or service in the 15 months prior to posting the file." }, { "payer_name": "UNITED HEALTHCARE", "plan_name": "SUTTER SELECT & SUTTER HEALTH PLAN HMO PLANS", "methodology": "per diem", "standard_charge_dollar": 28538.0, "standard_charge_algorithm": "Per diem ($28,538).", "count": "0", "additional_payer_notes": "Zero final payments for the item or service in the 15 months prior to posting the file." }, { "payer_name": "UMR", "plan_name": "SUTTER SELECT & SUTTER HEALTH PLAN HMO PLANS", "methodology": "per diem", "standard_charge_dollar": 28538.0, "standard_charge_algorithm": "Per diem ($28,538).", "count": "0", "additional_payer_notes": "Zero final payments for the item or service in the 15 months prior to posting the file." } ] } ] }, { "description": "HC Cannula Arterial Gp017", "code_information": [ { "code": "PX-2120024017", "type": "CDM" }, { "code": "99999", "type": "CPT" }, { "code": "0272", "type": "RC" } ], "standard_charges": [ { "setting": "outpatient", "gross_charge": 1575.0, "discounted_cash": 787.5, "minimum": 664.65, "maximum": 819.0, "additional_generic_notes": "Zero final payments for the item or service in the 15 months prior to posting the file.", "payers_information": [ { "payer_name": "AETNA", "plan_name": "AETNA ALL OTHER PLANS", "methodology": "percent of total billed charges", "standard_charge_dollar": 819.0, "standard_charge_percentage": 52.0, "count": "0", "additional_payer_notes": "Zero final payments for the item or service in the 15 months prior to posting the file." }, { "payer_name": "AETNA", "plan_name": "AETNA ALL OTHER PLANS", "methodology": "percent of total billed charges", "standard_charge_dollar": 819.0, "standard_charge_percentage": 52.0, "count": "0", "additional_payer_notes": "Zero final payments for the item or service in the 15 months prior to posting the file." }, { "payer_name": "MERITAIN HEALTH", "plan_name": "AETNA ALL OTHER PLANS", "methodology": "percent of total billed charges", "standard_charge_dollar": 819.0, "standard_charge_percentage": 52.0, "count": "0", "additional_payer_notes": "Zero final payments for the item or service in the 15 months prior to posting the file." }, { "payer_name": "BLUE SHIELD OUT OF STATE", "plan_name": "STANFORD HEALTHCARE ALLIANCE PLAN", "methodology": "percent of total billed charges", "standard_charge_dollar": 765.29, "standard_charge_percentage": 48.59, "count": "0", "additional_payer_notes": "Zero final payments for the item or service in the 15 months prior to posting the file." }, { "payer_name": "BLUE SHIELD", "plan_name": "STANFORD HEALTHCARE ALLIANCE PLAN", "methodology": "percent of total billed charges", "standard_charge_dollar": 765.29, "standard_charge_percentage": 48.59, "median_amount": 68.24, "10th_percentile": 13.6, "90th_percentile": 1043.06, "count": "30" }, { "payer_name": "BLUE SHIELD", "plan_name": "STANFORD HEALTHCARE ALLIANCE PLAN", "methodology": "percent of total billed charges", "standard_charge_dollar": 765.29, "standard_charge_percentage": 48.59, "count": "0", "additional_payer_notes": "Zero final payments for the item or service in the 15 months prior to posting the file." }, { "payer_name": "BLUE SHIELD", "plan_name": "STANFORD HEALTHCARE ALLIANCE PLAN", "methodology": "percent of total billed charges", "standard_charge_dollar": 765.29, "standard_charge_percentage": 48.59, "count": "0", "additional_payer_notes": "Zero final payments for the item or service in the 15 months prior to posting the file." }, { "payer_name": "CIGNA", "plan_name": "CIGNA COM ALT HMO PLAN", "methodology": "percent of total billed charges", "standard_charge_dollar": 664.65, "standard_charge_percentage": 42.2, "count": "0", "additional_payer_notes": "Zero final payments for the item or service in the 15 months prior to posting the file." }, { "payer_name": "CIGNA", "plan_name": "CIGNA COM ALT HMO PLAN", "methodology": "percent of total billed charges", "standard_charge_dollar": 664.65, "standard_charge_percentage": 42.2, "count": "0", "additional_payer_notes": "Zero final payments for the item or service in the 15 months prior to posting the file." }, { "payer_name": "HEALTH NET", "plan_name": "HEALTHNET HMO, PPO, POS, EPO, CANOPY HEALTHNET HMO, OTHER-IN-NETWORK PLANS", "methodology": "per diem", "standard_charge_dollar": 8000.0, "standard_charge_algorithm": "Expected reimbursement is the lesser of Per diem ($8,000) for the length of stay and 70% of billed.", "count": "0", "additional_payer_notes": "Zero final payments for the item or service in the 15 months prior to posting the file." }, { "payer_name": "HEALTH NET", "plan_name": "HEALTHNET HMO, PPO, POS, EPO, CANOPY HEALTHNET HMO, OTHER-IN-NETWORK PLANS", "methodology": "per diem", "standard_charge_dollar": 8000.0, "standard_charge_algorithm": "Expected reimbursement is the lesser of Per diem ($8,000) for the length of stay and 70% of billed.", "count": "0", "additional_payer_notes": "Zero final payments for the item or service in the 15 months prior to posting the file." }, { "payer_name": "UNITED HEALTHCARE", "plan_name": "SUTTER SELECT & SUTTER HEALTH PLAN HMO PLANS", "methodology": "per diem", "standard_charge_dollar": 28538.0, "standard_charge_algorithm": "Per diem ($28,538).", "count": "0", "additional_payer_notes": "Zero final payments for the item or service in the 15 months prior to posting the file." }, { "payer_name": "UNITED HEALTHCARE", "plan_name": "SUTTER SELECT & SUTTER HEALTH PLAN HMO PLANS", "methodology": "per diem", "standard_charge_dollar": 28538.0, "standard_charge_algorithm": "Per diem ($28,538).", "count": "0", "additional_payer_notes": "Zero final payments for the item or service in the 15 months prior to posting the file." }, { "payer_name": "SUTTER", "plan_name": "SUTTER SELECT & SUTTER HEALTH PLAN HMO PLANS", "methodology": "per diem", "standard_charge_dollar": 28538.0, "standard_charge_algorithm": "Per diem ($28,538).", "count": "0", "additional_payer_notes": "Zero final payments for the item or service in the 15 months prior to posting the file." }, { "payer_name": "UNITED HEALTHCARE", "plan_name": "SUTTER SELECT & SUTTER HEALTH PLAN HMO PLANS", "methodology": "per diem", "standard_charge_dollar": 28538.0, "standard_charge_algorithm": "Per diem ($28,538).", "count": "0", "additional_payer_notes": "Zero final payments for the item or service in the 15 months prior to posting the file." }, { "payer_name": "UMR", "plan_name": "SUTTER SELECT & SUTTER HEALTH PLAN HMO PLANS", "methodology": "per diem", "standard_charge_dollar": 28538.0, "standard_charge_algorithm": "Per diem ($28,538).", "count": "0", "additional_payer_notes": "Zero final payments for the item or service in the 15 months prior to posting the file." } ] } ] }, { "description": "HC Cannula Arterial Gp018", "code_information": [ { "code": "PX-2120024018", "type": "CDM" }, { "code": "99999", "type": "CPT" }, { "code": "0272", "type": "RC" } ], "standard_charges": [ { "setting": "outpatient", "gross_charge": 1750.0, "discounted_cash": 875.0, "minimum": 738.5, "maximum": 910.0, "additional_generic_notes": "Zero final payments for the item or service in the 15 months prior to posting the file.", "payers_information": [ { "payer_name": "AETNA", "plan_name": "AETNA ALL OTHER PLANS", "methodology": "percent of total billed charges", "standard_charge_dollar": 910.0, "standard_charge_percentage": 52.0, "count": "0", "additional_payer_notes": "Zero final payments for the item or service in the 15 months prior to posting the file." }, { "payer_name": "AETNA", "plan_name": "AETNA ALL OTHER PLANS", "methodology": "percent of total billed charges", "standard_charge_dollar": 910.0, "standard_charge_percentage": 52.0, "count": "0", "additional_payer_notes": "Zero final payments for the item or service in the 15 months prior to posting the file." }, { "payer_name": "MERITAIN HEALTH", "plan_name": "AETNA ALL OTHER PLANS", "methodology": "percent of total billed charges", "standard_charge_dollar": 910.0, "standard_charge_percentage": 52.0, "count": "0", "additional_payer_notes": "Zero final payments for the item or service in the 15 months prior to posting the file." }, { "payer_name": "BLUE SHIELD OUT OF STATE", "plan_name": "STANFORD HEALTHCARE ALLIANCE PLAN", "methodology": "percent of total billed charges", "standard_charge_dollar": 850.33, "standard_charge_percentage": 48.59, "count": "0", "additional_payer_notes": "Zero final payments for the item or service in the 15 months prior to posting the file." }, { "payer_name": "BLUE SHIELD", "plan_name": "STANFORD HEALTHCARE ALLIANCE PLAN", "methodology": "percent of total billed charges", "standard_charge_dollar": 850.33, "standard_charge_percentage": 48.59, "median_amount": 68.24, "10th_percentile": 13.6, "90th_percentile": 1043.06, "count": "30" }, { "payer_name": "BLUE SHIELD", "plan_name": "STANFORD HEALTHCARE ALLIANCE PLAN", "methodology": "percent of total billed charges", "standard_charge_dollar": 850.33, "standard_charge_percentage": 48.59, "count": "0", "additional_payer_notes": "Zero final payments for the item or service in the 15 months prior to posting the file." }, { "payer_name": "BLUE SHIELD", "plan_name": "STANFORD HEALTHCARE ALLIANCE PLAN", "methodology": "percent of total billed charges", "standard_charge_dollar": 850.33, "standard_charge_percentage": 48.59, "count": "0", "additional_payer_notes": "Zero final payments for the item or service in the 15 months prior to posting the file." }, { "payer_name": "CIGNA", "plan_name": "CIGNA COM ALT HMO PLAN", "methodology": "percent of total billed charges", "standard_charge_dollar": 738.5, "standard_charge_percentage": 42.2, "count": "0", "additional_payer_notes": "Zero final payments for the item or service in the 15 months prior to posting the file." }, { "payer_name": "CIGNA", "plan_name": "CIGNA COM ALT HMO PLAN", "methodology": "percent of total billed charges", "standard_charge_dollar": 738.5, "standard_charge_percentage": 42.2, "count": "0", "additional_payer_notes": "Zero final payments for the item or service in the 15 months prior to posting the file." }, { "payer_name": "HEALTH NET", "plan_name": "HEALTHNET HMO, PPO, POS, EPO, CANOPY HEALTHNET HMO, OTHER-IN-NETWORK PLANS", "methodology": "per diem", "standard_charge_dollar": 8000.0, "standard_charge_algorithm": "Expected reimbursement is the lesser of Per diem ($8,000) for the length of stay and 70% of billed.", "count": "0", "additional_payer_notes": "Zero final payments for the item or service in the 15 months prior to posting the file." }, { "payer_name": "HEALTH NET", "plan_name": "HEALTHNET HMO, PPO, POS, EPO, CANOPY HEALTHNET HMO, OTHER-IN-NETWORK PLANS", "methodology": "per diem", "standard_charge_dollar": 8000.0, "standard_charge_algorithm": "Expected reimbursement is the lesser of Per diem ($8,000) for the length of stay and 70% of billed.", "count": "0", "additional_payer_notes": "Zero final payments for the item or service in the 15 months prior to posting the file." }, { "payer_name": "UNITED HEALTHCARE", "plan_name": "SUTTER SELECT & SUTTER HEALTH PLAN HMO PLANS", "methodology": "per diem", "standard_charge_dollar": 28538.0, "standard_charge_algorithm": "Per diem ($28,538).", "count": "0", "additional_payer_notes": "Zero final payments for the item or service in the 15 months prior to posting the file." }, { "payer_name": "UNITED HEALTHCARE", "plan_name": "SUTTER SELECT & SUTTER HEALTH PLAN HMO PLANS", "methodology": "per diem", "standard_charge_dollar": 28538.0, "standard_charge_algorithm": "Per diem ($28,538).", "count": "0", "additional_payer_notes": "Zero final payments for the item or service in the 15 months prior to posting the file." }, { "payer_name": "SUTTER", "plan_name": "SUTTER SELECT & SUTTER HEALTH PLAN HMO PLANS", "methodology": "per diem", "standard_charge_dollar": 28538.0, "standard_charge_algorithm": "Per diem ($28,538).", "count": "0", "additional_payer_notes": "Zero final payments for the item or service in the 15 months prior to posting the file." }, { "payer_name": "UNITED HEALTHCARE", "plan_name": "SUTTER SELECT & SUTTER HEALTH PLAN HMO PLANS", "methodology": "per diem", "standard_charge_dollar": 28538.0, "standard_charge_algorithm": "Per diem ($28,538).", "count": "0", "additional_payer_notes": "Zero final payments for the item or service in the 15 months prior to posting the file." }, { "payer_name": "UMR", "plan_name": "SUTTER SELECT & SUTTER HEALTH PLAN HMO PLANS", "methodology": "per diem", "standard_charge_dollar": 28538.0, "standard_charge_algorithm": "Per diem ($28,538).", "count": "0", "additional_payer_notes": "Zero final payments for the item or service in the 15 months prior to posting the file." } ] } ] }, { "description": "HC Cannula Arterial Gp019", "code_information": [ { "code": "PX-2120024019", "type": "CDM" }, { "code": "99999", "type": "CPT" }, { "code": "0272", "type": "RC" } ], "standard_charges": [ { "setting": "outpatient", "gross_charge": 2125.0, "discounted_cash": 1062.5, "minimum": 896.75, "maximum": 1105.0, "additional_generic_notes": "Zero final payments for the item or service in the 15 months prior to posting the file.", "payers_information": [ { "payer_name": "AETNA", "plan_name": "AETNA ALL OTHER PLANS", "methodology": "percent of total billed charges", "standard_charge_dollar": 1105.0, "standard_charge_percentage": 52.0, "count": "0", "additional_payer_notes": "Zero final payments for the item or service in the 15 months prior to posting the file." }, { "payer_name": "AETNA", "plan_name": "AETNA ALL OTHER PLANS", "methodology": "percent of total billed charges", "standard_charge_dollar": 1105.0, "standard_charge_percentage": 52.0, "count": "0", "additional_payer_notes": "Zero final payments for the item or service in the 15 months prior to posting the file." }, { "payer_name": "MERITAIN HEALTH", "plan_name": "AETNA ALL OTHER PLANS", "methodology": "percent of total billed charges", "standard_charge_dollar": 1105.0, "standard_charge_percentage": 52.0, "count": "0", "additional_payer_notes": "Zero final payments for the item or service in the 15 months prior to posting the file." }, { "payer_name": "BLUE SHIELD OUT OF STATE", "plan_name": "STANFORD HEALTHCARE ALLIANCE PLAN", "methodology": "percent of total billed charges", "standard_charge_dollar": 1032.54, "standard_charge_percentage": 48.59, "count": "0", "additional_payer_notes": "Zero final payments for the item or service in the 15 months prior to posting the file." }, { "payer_name": "BLUE SHIELD", "plan_name": "STANFORD HEALTHCARE ALLIANCE PLAN", "methodology": "percent of total billed charges", "standard_charge_dollar": 1032.54, "standard_charge_percentage": 48.59, "median_amount": 68.24, "10th_percentile": 13.6, "90th_percentile": 1043.06, "count": "30" }, { "payer_name": "BLUE SHIELD", "plan_name": "STANFORD HEALTHCARE ALLIANCE PLAN", "methodology": "percent of total billed charges", "standard_charge_dollar": 1032.54, "standard_charge_percentage": 48.59, "count": "0", "additional_payer_notes": "Zero final payments for the item or service in the 15 months prior to posting the file." }, { "payer_name": "BLUE SHIELD", "plan_name": "STANFORD HEALTHCARE ALLIANCE PLAN", "methodology": "percent of total billed charges", "standard_charge_dollar": 1032.54, "standard_charge_percentage": 48.59, "count": "0", "additional_payer_notes": "Zero final payments for the item or service in the 15 months prior to posting the file." }, { "payer_name": "CIGNA", "plan_name": "CIGNA COM ALT HMO PLAN", "methodology": "percent of total billed charges", "standard_charge_dollar": 896.75, "standard_charge_percentage": 42.2, "count": "0", "additional_payer_notes": "Zero final payments for the item or service in the 15 months prior to posting the file." }, { "payer_name": "CIGNA", "plan_name": "CIGNA COM ALT HMO PLAN", "methodology": "percent of total billed charges", "standard_charge_dollar": 896.75, "standard_charge_percentage": 42.2, "count": "0", "additional_payer_notes": "Zero final payments for the item or service in the 15 months prior to posting the file." }, { "payer_name": "HEALTH NET", "plan_name": "HEALTHNET HMO, PPO, POS, EPO, CANOPY HEALTHNET HMO, OTHER-IN-NETWORK PLANS", "methodology": "per diem", "standard_charge_dollar": 8000.0, "standard_charge_algorithm": "Expected reimbursement is the lesser of Per diem ($8,000) for the length of stay and 70% of billed.", "count": "0", "additional_payer_notes": "Zero final payments for the item or service in the 15 months prior to posting the file." }, { "payer_name": "HEALTH NET", "plan_name": "HEALTHNET HMO, PPO, POS, EPO, CANOPY HEALTHNET HMO, OTHER-IN-NETWORK PLANS", "methodology": "per diem", "standard_charge_dollar": 8000.0, "standard_charge_algorithm": "Expected reimbursement is the lesser of Per diem ($8,000) for the length of stay and 70% of billed.", "count": "0", "additional_payer_notes": "Zero final payments for the item or service in the 15 months prior to posting the file." }, { "payer_name": "UNITED HEALTHCARE", "plan_name": "SUTTER SELECT & SUTTER HEALTH PLAN HMO PLANS", "methodology": "per diem", "standard_charge_dollar": 28538.0, "standard_charge_algorithm": "Per diem ($28,538).", "count": "0", "additional_payer_notes": "Zero final payments for the item or service in the 15 months prior to posting the file." }, { "payer_name": "UNITED HEALTHCARE", "plan_name": "SUTTER SELECT & SUTTER HEALTH PLAN HMO PLANS", "methodology": "per diem", "standard_charge_dollar": 28538.0, "standard_charge_algorithm": "Per diem ($28,538).", "count": "0", "additional_payer_notes": "Zero final payments for the item or service in the 15 months prior to posting the file." }, { "payer_name": "SUTTER", "plan_name": "SUTTER SELECT & SUTTER HEALTH PLAN HMO PLANS", "methodology": "per diem", "standard_charge_dollar": 28538.0, "standard_charge_algorithm": "Per diem ($28,538).", "count": "0", "additional_payer_notes": "Zero final payments for the item or service in the 15 months prior to posting the file." }, { "payer_name": "UNITED HEALTHCARE", "plan_name": "SUTTER SELECT & SUTTER HEALTH PLAN HMO PLANS", "methodology": "per diem", "standard_charge_dollar": 28538.0, "standard_charge_algorithm": "Per diem ($28,538).", "count": "0", "additional_payer_notes": "Zero final payments for the item or service in the 15 months prior to posting the file." }, { "payer_name": "UMR", "plan_name": "SUTTER SELECT & SUTTER HEALTH PLAN HMO PLANS", "methodology": "per diem", "standard_charge_dollar": 28538.0, "standard_charge_algorithm": "Per diem ($28,538).", "count": "0", "additional_payer_notes": "Zero final payments for the item or service in the 15 months prior to posting the file." } ] } ] }, { "description": "HC Cannula Arterial Gp021", "code_information": [ { "code": "PX-2120024021", "type": "CDM" }, { "code": "99999", "type": "CPT" }, { "code": "0272", "type": "RC" } ], "standard_charges": [ { "setting": "outpatient", "gross_charge": 2888.0, "discounted_cash": 1444.0, "minimum": 1218.74, "maximum": 1501.76, "additional_generic_notes": "Zero final payments for the item or service in the 15 months prior to posting the file.", "payers_information": [ { "payer_name": "AETNA", "plan_name": "AETNA ALL OTHER PLANS", "methodology": "percent of total billed charges", "standard_charge_dollar": 1501.76, "standard_charge_percentage": 52.0, "count": "0", "additional_payer_notes": "Zero final payments for the item or service in the 15 months prior to posting the file." }, { "payer_name": "AETNA", "plan_name": "AETNA ALL OTHER PLANS", "methodology": "percent of total billed charges", "standard_charge_dollar": 1501.76, "standard_charge_percentage": 52.0, "count": "0", "additional_payer_notes": "Zero final payments for the item or service in the 15 months prior to posting the file." }, { "payer_name": "MERITAIN HEALTH", "plan_name": "AETNA ALL OTHER PLANS", "methodology": "percent of total billed charges", "standard_charge_dollar": 1501.76, "standard_charge_percentage": 52.0, "count": "0", "additional_payer_notes": "Zero final payments for the item or service in the 15 months prior to posting the file." }, { "payer_name": "BLUE SHIELD OUT OF STATE", "plan_name": "STANFORD HEALTHCARE ALLIANCE PLAN", "methodology": "percent of total billed charges", "standard_charge_dollar": 1403.28, "standard_charge_percentage": 48.59, "count": "0", "additional_payer_notes": "Zero final payments for the item or service in the 15 months prior to posting the file." }, { "payer_name": "BLUE SHIELD", "plan_name": "STANFORD HEALTHCARE ALLIANCE PLAN", "methodology": "percent of total billed charges", "standard_charge_dollar": 1403.28, "standard_charge_percentage": 48.59, "median_amount": 68.24, "10th_percentile": 13.6, "90th_percentile": 1043.06, "count": "30" }, { "payer_name": "BLUE SHIELD", "plan_name": "STANFORD HEALTHCARE ALLIANCE PLAN", "methodology": "percent of total billed charges", "standard_charge_dollar": 1403.28, "standard_charge_percentage": 48.59, "count": "0", "additional_payer_notes": "Zero final payments for the item or service in the 15 months prior to posting the file." }, { "payer_name": "BLUE SHIELD", "plan_name": "STANFORD HEALTHCARE ALLIANCE PLAN", "methodology": "percent of total billed charges", "standard_charge_dollar": 1403.28, "standard_charge_percentage": 48.59, "count": "0", "additional_payer_notes": "Zero final payments for the item or service in the 15 months prior to posting the file." }, { "payer_name": "CIGNA", "plan_name": "CIGNA COM ALT HMO PLAN", "methodology": "percent of total billed charges", "standard_charge_dollar": 1218.74, "standard_charge_percentage": 42.2, "count": "0", "additional_payer_notes": "Zero final payments for the item or service in the 15 months prior to posting the file." }, { "payer_name": "CIGNA", "plan_name": "CIGNA COM ALT HMO PLAN", "methodology": "percent of total billed charges", "standard_charge_dollar": 1218.74, "standard_charge_percentage": 42.2, "count": "0", "additional_payer_notes": "Zero final payments for the item or service in the 15 months prior to posting the file." }, { "payer_name": "HEALTH NET", "plan_name": "HEALTHNET HMO, PPO, POS, EPO, CANOPY HEALTHNET HMO, OTHER-IN-NETWORK PLANS", "methodology": "per diem", "standard_charge_dollar": 8000.0, "standard_charge_algorithm": "Expected reimbursement is the lesser of Per diem ($8,000) for the length of stay and 70% of billed.", "count": "0", "additional_payer_notes": "Zero final payments for the item or service in the 15 months prior to posting the file." }, { "payer_name": "HEALTH NET", "plan_name": "HEALTHNET HMO, PPO, POS, EPO, CANOPY HEALTHNET HMO, OTHER-IN-NETWORK PLANS", "methodology": "per diem", "standard_charge_dollar": 8000.0, "standard_charge_algorithm": "Expected reimbursement is the lesser of Per diem ($8,000) for the length of stay and 70% of billed.", "count": "0", "additional_payer_notes": "Zero final payments for the item or service in the 15 months prior to posting the file." }, { "payer_name": "UNITED HEALTHCARE", "plan_name": "SUTTER SELECT & SUTTER HEALTH PLAN HMO PLANS", "methodology": "per diem", "standard_charge_dollar": 28538.0, "standard_charge_algorithm": "Per diem ($28,538).", "count": "0", "additional_payer_notes": "Zero final payments for the item or service in the 15 months prior to posting the file." }, { "payer_name": "UNITED HEALTHCARE", "plan_name": "SUTTER SELECT & SUTTER HEALTH PLAN HMO PLANS", "methodology": "per diem", "standard_charge_dollar": 28538.0, "standard_charge_algorithm": "Per diem ($28,538).", "count": "0", "additional_payer_notes": "Zero final payments for the item or service in the 15 months prior to posting the file." }, { "payer_name": "SUTTER", "plan_name": "SUTTER SELECT & SUTTER HEALTH PLAN HMO PLANS", "methodology": "per diem", "standard_charge_dollar": 28538.0, "standard_charge_algorithm": "Per diem ($28,538).", "count": "0", "additional_payer_notes": "Zero final payments for the item or service in the 15 months prior to posting the file." }, { "payer_name": "UNITED HEALTHCARE", "plan_name": "SUTTER SELECT & SUTTER HEALTH PLAN HMO PLANS", "methodology": "per diem", "standard_charge_dollar": 28538.0, "standard_charge_algorithm": "Per diem ($28,538).", "count": "0", "additional_payer_notes": "Zero final payments for the item or service in the 15 months prior to posting the file." }, { "payer_name": "UMR", "plan_name": "SUTTER SELECT & SUTTER HEALTH PLAN HMO PLANS", "methodology": "per diem", "standard_charge_dollar": 28538.0, "standard_charge_algorithm": "Per diem ($28,538).", "count": "0", "additional_payer_notes": "Zero final payments for the item or service in the 15 months prior to posting the file." } ] } ] }, { "description": "HC Cannula Arterial Gp047", "code_information": [ { "code": "PX-2120024047", "type": "CDM" }, { "code": "99999", "type": "CPT" }, { "code": "0272", "type": "RC" } ], "standard_charges": [ { "setting": "outpatient", "gross_charge": 13000.0, "discounted_cash": 6500.0, "minimum": 5486.0, "maximum": 6760.0, "additional_generic_notes": "Zero final payments for the item or service in the 15 months prior to posting the file.", "payers_information": [ { "payer_name": "AETNA", "plan_name": "AETNA ALL OTHER PLANS", "methodology": "percent of total billed charges", "standard_charge_dollar": 6760.0, "standard_charge_percentage": 52.0, "count": "0", "additional_payer_notes": "Zero final payments for the item or service in the 15 months prior to posting the file." }, { "payer_name": "AETNA", "plan_name": "AETNA ALL OTHER PLANS", "methodology": "percent of total billed charges", "standard_charge_dollar": 6760.0, "standard_charge_percentage": 52.0, "count": "0", "additional_payer_notes": "Zero final payments for the item or service in the 15 months prior to posting the file." }, { "payer_name": "MERITAIN HEALTH", "plan_name": "AETNA ALL OTHER PLANS", "methodology": "percent of total billed charges", "standard_charge_dollar": 6760.0, "standard_charge_percentage": 52.0, "count": "0", "additional_payer_notes": "Zero final payments for the item or service in the 15 months prior to posting the file." }, { "payer_name": "BLUE SHIELD OUT OF STATE", "plan_name": "STANFORD HEALTHCARE ALLIANCE PLAN", "methodology": "percent of total billed charges", "standard_charge_dollar": 6316.7, "standard_charge_percentage": 48.59, "count": "0", "additional_payer_notes": "Zero final payments for the item or service in the 15 months prior to posting the file." }, { "payer_name": "BLUE SHIELD", "plan_name": "STANFORD HEALTHCARE ALLIANCE PLAN", "methodology": "percent of total billed charges", "standard_charge_dollar": 6316.7, "standard_charge_percentage": 48.59, "median_amount": 68.24, "10th_percentile": 13.6, "90th_percentile": 1043.06, "count": "30" }, { "payer_name": "BLUE SHIELD", "plan_name": "STANFORD HEALTHCARE ALLIANCE PLAN", "methodology": "percent of total billed charges", "standard_charge_dollar": 6316.7, "standard_charge_percentage": 48.59, "count": "0", "additional_payer_notes": "Zero final payments for the item or service in the 15 months prior to posting the file." }, { "payer_name": "BLUE SHIELD", "plan_name": "STANFORD HEALTHCARE ALLIANCE PLAN", "methodology": "percent of total billed charges", "standard_charge_dollar": 6316.7, "standard_charge_percentage": 48.59, "count": "0", "additional_payer_notes": "Zero final payments for the item or service in the 15 months prior to posting the file." }, { "payer_name": "CIGNA", "plan_name": "CIGNA COM ALT HMO PLAN", "methodology": "percent of total billed charges", "standard_charge_dollar": 5486.0, "standard_charge_percentage": 42.2, "count": "0", "additional_payer_notes": "Zero final payments for the item or service in the 15 months prior to posting the file." }, { "payer_name": "CIGNA", "plan_name": "CIGNA COM ALT HMO PLAN", "methodology": "percent of total billed charges", "standard_charge_dollar": 5486.0, "standard_charge_percentage": 42.2, "count": "0", "additional_payer_notes": "Zero final payments for the item or service in the 15 months prior to posting the file." }, { "payer_name": "HEALTH NET", "plan_name": "HEALTHNET HMO, PPO, POS, EPO, CANOPY HEALTHNET HMO, OTHER-IN-NETWORK PLANS", "methodology": "per diem", "standard_charge_dollar": 8000.0, "standard_charge_algorithm": "Expected reimbursement is the lesser of Per diem ($8,000) for the length of stay and 70% of billed.", "count": "0", "additional_payer_notes": "Zero final payments for the item or service in the 15 months prior to posting the file." }, { "payer_name": "HEALTH NET", "plan_name": "HEALTHNET HMO, PPO, POS, EPO, CANOPY HEALTHNET HMO, OTHER-IN-NETWORK PLANS", "methodology": "per diem", "standard_charge_dollar": 8000.0, "standard_charge_algorithm": "Expected reimbursement is the lesser of Per diem ($8,000) for the length of stay and 70% of billed.", "count": "0", "additional_payer_notes": "Zero final payments for the item or service in the 15 months prior to posting the file." }, { "payer_name": "UNITED HEALTHCARE", "plan_name": "SUTTER SELECT & SUTTER HEALTH PLAN HMO PLANS", "methodology": "per diem", "standard_charge_dollar": 28538.0, "standard_charge_algorithm": "Per diem ($28,538).", "count": "0", "additional_payer_notes": "Zero final payments for the item or service in the 15 months prior to posting the file." }, { "payer_name": "UNITED HEALTHCARE", "plan_name": "SUTTER SELECT & SUTTER HEALTH PLAN HMO PLANS", "methodology": "per diem", "standard_charge_dollar": 28538.0, "standard_charge_algorithm": "Per diem ($28,538).", "count": "0", "additional_payer_notes": "Zero final payments for the item or service in the 15 months prior to posting the file." }, { "payer_name": "SUTTER", "plan_name": "SUTTER SELECT & SUTTER HEALTH PLAN HMO PLANS", "methodology": "per diem", "standard_charge_dollar": 28538.0, "standard_charge_algorithm": "Per diem ($28,538).", "count": "0", "additional_payer_notes": "Zero final payments for the item or service in the 15 months prior to posting the file." }, { "payer_name": "UNITED HEALTHCARE", "plan_name": "SUTTER SELECT & SUTTER HEALTH PLAN HMO PLANS", "methodology": "per diem", "standard_charge_dollar": 28538.0, "standard_charge_algorithm": "Per diem ($28,538).", "count": "0", "additional_payer_notes": "Zero final payments for the item or service in the 15 months prior to posting the file." }, { "payer_name": "UMR", "plan_name": "SUTTER SELECT & SUTTER HEALTH PLAN HMO PLANS", "methodology": "per diem", "standard_charge_dollar": 28538.0, "standard_charge_algorithm": "Per diem ($28,538).", "count": "0", "additional_payer_notes": "Zero final payments for the item or service in the 15 months prior to posting the file." } ] } ] }, { "description": "HC Cannula Arterial Gp049", "code_information": [ { "code": "PX-2120024049", "type": "CDM" }, { "code": "99999", "type": "CPT" }, { "code": "0272", "type": "RC" } ], "standard_charges": [ { "setting": "outpatient", "gross_charge": 14250.0, "discounted_cash": 7125.0, "minimum": 6013.5, "maximum": 7410.0, "additional_generic_notes": "Zero final payments for the item or service in the 15 months prior to posting the file.", "payers_information": [ { "payer_name": "AETNA", "plan_name": "AETNA ALL OTHER PLANS", "methodology": "percent of total billed charges", "standard_charge_dollar": 7410.0, "standard_charge_percentage": 52.0, "count": "0", "additional_payer_notes": "Zero final payments for the item or service in the 15 months prior to posting the file." }, { "payer_name": "AETNA", "plan_name": "AETNA ALL OTHER PLANS", "methodology": "percent of total billed charges", "standard_charge_dollar": 7410.0, "standard_charge_percentage": 52.0, "count": "0", "additional_payer_notes": "Zero final payments for the item or service in the 15 months prior to posting the file." }, { "payer_name": "MERITAIN HEALTH", "plan_name": "AETNA ALL OTHER PLANS", "methodology": "percent of total billed charges", "standard_charge_dollar": 7410.0, "standard_charge_percentage": 52.0, "count": "0", "additional_payer_notes": "Zero final payments for the item or service in the 15 months prior to posting the file." }, { "payer_name": "BLUE SHIELD OUT OF STATE", "plan_name": "STANFORD HEALTHCARE ALLIANCE PLAN", "methodology": "percent of total billed charges", "standard_charge_dollar": 6924.08, "standard_charge_percentage": 48.59, "count": "0", "additional_payer_notes": "Zero final payments for the item or service in the 15 months prior to posting the file." }, { "payer_name": "BLUE SHIELD", "plan_name": "STANFORD HEALTHCARE ALLIANCE PLAN", "methodology": "percent of total billed charges", "standard_charge_dollar": 6924.08, "standard_charge_percentage": 48.59, "median_amount": 68.24, "10th_percentile": 13.6, "90th_percentile": 1043.06, "count": "30" }, { "payer_name": "BLUE SHIELD", "plan_name": "STANFORD HEALTHCARE ALLIANCE PLAN", "methodology": "percent of total billed charges", "standard_charge_dollar": 6924.08, "standard_charge_percentage": 48.59, "count": "0", "additional_payer_notes": "Zero final payments for the item or service in the 15 months prior to posting the file." }, { "payer_name": "BLUE SHIELD", "plan_name": "STANFORD HEALTHCARE ALLIANCE PLAN", "methodology": "percent of total billed charges", "standard_charge_dollar": 6924.08, "standard_charge_percentage": 48.59, "count": "0", "additional_payer_notes": "Zero final payments for the item or service in the 15 months prior to posting the file." }, { "payer_name": "CIGNA", "plan_name": "CIGNA COM ALT HMO PLAN", "methodology": "percent of total billed charges", "standard_charge_dollar": 6013.5, "standard_charge_percentage": 42.2, "count": "0", "additional_payer_notes": "Zero final payments for the item or service in the 15 months prior to posting the file." }, { "payer_name": "CIGNA", "plan_name": "CIGNA COM ALT HMO PLAN", "methodology": "percent of total billed charges", "standard_charge_dollar": 6013.5, "standard_charge_percentage": 42.2, "count": "0", "additional_payer_notes": "Zero final payments for the item or service in the 15 months prior to posting the file." }, { "payer_name": "HEALTH NET", "plan_name": "HEALTHNET HMO, PPO, POS, EPO, CANOPY HEALTHNET HMO, OTHER-IN-NETWORK PLANS", "methodology": "per diem", "standard_charge_dollar": 8000.0, "standard_charge_algorithm": "Expected reimbursement is the lesser of Per diem ($8,000) for the length of stay and 70% of billed.", "count": "0", "additional_payer_notes": "Zero final payments for the item or service in the 15 months prior to posting the file." }, { "payer_name": "HEALTH NET", "plan_name": "HEALTHNET HMO, PPO, POS, EPO, CANOPY HEALTHNET HMO, OTHER-IN-NETWORK PLANS", "methodology": "per diem", "standard_charge_dollar": 8000.0, "standard_charge_algorithm": "Expected reimbursement is the lesser of Per diem ($8,000) for the length of stay and 70% of billed.", "count": "0", "additional_payer_notes": "Zero final payments for the item or service in the 15 months prior to posting the file." }, { "payer_name": "UNITED HEALTHCARE", "plan_name": "SUTTER SELECT & SUTTER HEALTH PLAN HMO PLANS", "methodology": "per diem", "standard_charge_dollar": 28538.0, "standard_charge_algorithm": "Per diem ($28,538).", "count": "0", "additional_payer_notes": "Zero final payments for the item or service in the 15 months prior to posting the file." }, { "payer_name": "UNITED HEALTHCARE", "plan_name": "SUTTER SELECT & SUTTER HEALTH PLAN HMO PLANS", "methodology": "per diem", "standard_charge_dollar": 28538.0, "standard_charge_algorithm": "Per diem ($28,538).", "count": "0", "additional_payer_notes": "Zero final payments for the item or service in the 15 months prior to posting the file." }, { "payer_name": "SUTTER", "plan_name": "SUTTER SELECT & SUTTER HEALTH PLAN HMO PLANS", "methodology": "per diem", "standard_charge_dollar": 28538.0, "standard_charge_algorithm": "Per diem ($28,538).", "count": "0", "additional_payer_notes": "Zero final payments for the item or service in the 15 months prior to posting the file." }, { "payer_name": "UNITED HEALTHCARE", "plan_name": "SUTTER SELECT & SUTTER HEALTH PLAN HMO PLANS", "methodology": "per diem", "standard_charge_dollar": 28538.0, "standard_charge_algorithm": "Per diem ($28,538).", "count": "0", "additional_payer_notes": "Zero final payments for the item or service in the 15 months prior to posting the file." }, { "payer_name": "UMR", "plan_name": "SUTTER SELECT & SUTTER HEALTH PLAN HMO PLANS", "methodology": "per diem", "standard_charge_dollar": 28538.0, "standard_charge_algorithm": "Per diem ($28,538).", "count": "0", "additional_payer_notes": "Zero final payments for the item or service in the 15 months prior to posting the file." } ] } ] }, { "description": "HC Cannula Arterial Gp051", "code_information": [ { "code": "PX-2120024051", "type": "CDM" }, { "code": "99999", "type": "CPT" }, { "code": "0272", "type": "RC" } ], "standard_charges": [ { "setting": "outpatient", "gross_charge": 15300.0, "discounted_cash": 7650.0, "minimum": 6456.6, "maximum": 7956.0, "additional_generic_notes": "Zero final payments for the item or service in the 15 months prior to posting the file.", "payers_information": [ { "payer_name": "AETNA", "plan_name": "AETNA ALL OTHER PLANS", "methodology": "percent of total billed charges", "standard_charge_dollar": 7956.0, "standard_charge_percentage": 52.0, "count": "0", "additional_payer_notes": "Zero final payments for the item or service in the 15 months prior to posting the file." }, { "payer_name": "AETNA", "plan_name": "AETNA ALL OTHER PLANS", "methodology": "percent of total billed charges", "standard_charge_dollar": 7956.0, "standard_charge_percentage": 52.0, "count": "0", "additional_payer_notes": "Zero final payments for the item or service in the 15 months prior to posting the file." }, { "payer_name": "MERITAIN HEALTH", "plan_name": "AETNA ALL OTHER PLANS", "methodology": "percent of total billed charges", "standard_charge_dollar": 7956.0, "standard_charge_percentage": 52.0, "count": "0", "additional_payer_notes": "Zero final payments for the item or service in the 15 months prior to posting the file." }, { "payer_name": "BLUE SHIELD OUT OF STATE", "plan_name": "STANFORD HEALTHCARE ALLIANCE PLAN", "methodology": "percent of total billed charges", "standard_charge_dollar": 7434.27, "standard_charge_percentage": 48.59, "count": "0", "additional_payer_notes": "Zero final payments for the item or service in the 15 months prior to posting the file." }, { "payer_name": "BLUE SHIELD", "plan_name": "STANFORD HEALTHCARE ALLIANCE PLAN", "methodology": "percent of total billed charges", "standard_charge_dollar": 7434.27, "standard_charge_percentage": 48.59, "median_amount": 68.24, "10th_percentile": 13.6, "90th_percentile": 1043.06, "count": "30" }, { "payer_name": "BLUE SHIELD", "plan_name": "STANFORD HEALTHCARE ALLIANCE PLAN", "methodology": "percent of total billed charges", "standard_charge_dollar": 7434.27, "standard_charge_percentage": 48.59, "count": "0", "additional_payer_notes": "Zero final payments for the item or service in the 15 months prior to posting the file." }, { "payer_name": "BLUE SHIELD", "plan_name": "STANFORD HEALTHCARE ALLIANCE PLAN", "methodology": "percent of total billed charges", "standard_charge_dollar": 7434.27, "standard_charge_percentage": 48.59, "count": "0", "additional_payer_notes": "Zero final payments for the item or service in the 15 months prior to posting the file." }, { "payer_name": "CIGNA", "plan_name": "CIGNA COM ALT HMO PLAN", "methodology": "percent of total billed charges", "standard_charge_dollar": 6456.6, "standard_charge_percentage": 42.2, "count": "0", "additional_payer_notes": "Zero final payments for the item or service in the 15 months prior to posting the file." }, { "payer_name": "CIGNA", "plan_name": "CIGNA COM ALT HMO PLAN", "methodology": "percent of total billed charges", "standard_charge_dollar": 6456.6, "standard_charge_percentage": 42.2, "count": "0", "additional_payer_notes": "Zero final payments for the item or service in the 15 months prior to posting the file." }, { "payer_name": "HEALTH NET", "plan_name": "HEALTHNET HMO, PPO, POS, EPO, CANOPY HEALTHNET HMO, OTHER-IN-NETWORK PLANS", "methodology": "per diem", "standard_charge_dollar": 8000.0, "standard_charge_algorithm": "Expected reimbursement is the lesser of Per diem ($8,000) for the length of stay and 70% of billed.", "count": "0", "additional_payer_notes": "Zero final payments for the item or service in the 15 months prior to posting the file." }, { "payer_name": "HEALTH NET", "plan_name": "HEALTHNET HMO, PPO, POS, EPO, CANOPY HEALTHNET HMO, OTHER-IN-NETWORK PLANS", "methodology": "per diem", "standard_charge_dollar": 8000.0, "standard_charge_algorithm": "Expected reimbursement is the lesser of Per diem ($8,000) for the length of stay and 70% of billed.", "count": "0", "additional_payer_notes": "Zero final payments for the item or service in the 15 months prior to posting the file." }, { "payer_name": "UNITED HEALTHCARE", "plan_name": "SUTTER SELECT & SUTTER HEALTH PLAN HMO PLANS", "methodology": "per diem", "standard_charge_dollar": 28538.0, "standard_charge_algorithm": "Per diem ($28,538).", "count": "0", "additional_payer_notes": "Zero final payments for the item or service in the 15 months prior to posting the file." }, { "payer_name": "UNITED HEALTHCARE", "plan_name": "SUTTER SELECT & SUTTER HEALTH PLAN HMO PLANS", "methodology": "per diem", "standard_charge_dollar": 28538.0, "standard_charge_algorithm": "Per diem ($28,538).", "count": "0", "additional_payer_notes": "Zero final payments for the item or service in the 15 months prior to posting the file." }, { "payer_name": "SUTTER", "plan_name": "SUTTER SELECT & SUTTER HEALTH PLAN HMO PLANS", "methodology": "per diem", "standard_charge_dollar": 28538.0, "standard_charge_algorithm": "Per diem ($28,538).", "count": "0", "additional_payer_notes": "Zero final payments for the item or service in the 15 months prior to posting the file." }, { "payer_name": "UNITED HEALTHCARE", "plan_name": "SUTTER SELECT & SUTTER HEALTH PLAN HMO PLANS", "methodology": "per diem", "standard_charge_dollar": 28538.0, "standard_charge_algorithm": "Per diem ($28,538).", "count": "0", "additional_payer_notes": "Zero final payments for the item or service in the 15 months prior to posting the file." }, { "payer_name": "UMR", "plan_name": "SUTTER SELECT & SUTTER HEALTH PLAN HMO PLANS", "methodology": "per diem", "standard_charge_dollar": 28538.0, "standard_charge_algorithm": "Per diem ($28,538).", "count": "0", "additional_payer_notes": "Zero final payments for the item or service in the 15 months prior to posting the file." } ] } ] }, { "description": "HC Cannula Arterial Gp053", "code_information": [ { "code": "PX-2120024053", "type": "CDM" }, { "code": "99999", "type": "CPT" }, { "code": "0272", "type": "RC" } ], "standard_charges": [ { "setting": "outpatient", "gross_charge": 16300.0, "discounted_cash": 8150.0, "minimum": 6878.6, "maximum": 8476.0, "additional_generic_notes": "Zero final payments for the item or service in the 15 months prior to posting the file.", "payers_information": [ { "payer_name": "AETNA", "plan_name": "AETNA ALL OTHER PLANS", "methodology": "percent of total billed charges", "standard_charge_dollar": 8476.0, "standard_charge_percentage": 52.0, "count": "0", "additional_payer_notes": "Zero final payments for the item or service in the 15 months prior to posting the file." }, { "payer_name": "AETNA", "plan_name": "AETNA ALL OTHER PLANS", "methodology": "percent of total billed charges", "standard_charge_dollar": 8476.0, "standard_charge_percentage": 52.0, "count": "0", "additional_payer_notes": "Zero final payments for the item or service in the 15 months prior to posting the file." }, { "payer_name": "MERITAIN HEALTH", "plan_name": "AETNA ALL OTHER PLANS", "methodology": "percent of total billed charges", "standard_charge_dollar": 8476.0, "standard_charge_percentage": 52.0, "count": "0", "additional_payer_notes": "Zero final payments for the item or service in the 15 months prior to posting the file." }, { "payer_name": "BLUE SHIELD OUT OF STATE", "plan_name": "STANFORD HEALTHCARE ALLIANCE PLAN", "methodology": "percent of total billed charges", "standard_charge_dollar": 7920.17, "standard_charge_percentage": 48.59, "count": "0", "additional_payer_notes": "Zero final payments for the item or service in the 15 months prior to posting the file." }, { "payer_name": "BLUE SHIELD", "plan_name": "STANFORD HEALTHCARE ALLIANCE PLAN", "methodology": "percent of total billed charges", "standard_charge_dollar": 7920.17, "standard_charge_percentage": 48.59, "median_amount": 68.24, "10th_percentile": 13.6, "90th_percentile": 1043.06, "count": "30" }, { "payer_name": "BLUE SHIELD", "plan_name": "STANFORD HEALTHCARE ALLIANCE PLAN", "methodology": "percent of total billed charges", "standard_charge_dollar": 7920.17, "standard_charge_percentage": 48.59, "count": "0", "additional_payer_notes": "Zero final payments for the item or service in the 15 months prior to posting the file." }, { "payer_name": "BLUE SHIELD", "plan_name": "STANFORD HEALTHCARE ALLIANCE PLAN", "methodology": "percent of total billed charges", "standard_charge_dollar": 7920.17, "standard_charge_percentage": 48.59, "count": "0", "additional_payer_notes": "Zero final payments for the item or service in the 15 months prior to posting the file." }, { "payer_name": "CIGNA", "plan_name": "CIGNA COM ALT HMO PLAN", "methodology": "percent of total billed charges", "standard_charge_dollar": 6878.6, "standard_charge_percentage": 42.2, "count": "0", "additional_payer_notes": "Zero final payments for the item or service in the 15 months prior to posting the file." }, { "payer_name": "CIGNA", "plan_name": "CIGNA COM ALT HMO PLAN", "methodology": "percent of total billed charges", "standard_charge_dollar": 6878.6, "standard_charge_percentage": 42.2, "count": "0", "additional_payer_notes": "Zero final payments for the item or service in the 15 months prior to posting the file." }, { "payer_name": "HEALTH NET", "plan_name": "HEALTHNET HMO, PPO, POS, EPO, CANOPY HEALTHNET HMO, OTHER-IN-NETWORK PLANS", "methodology": "per diem", "standard_charge_dollar": 8000.0, "standard_charge_algorithm": "Expected reimbursement is the lesser of Per diem ($8,000) for the length of stay and 70% of billed.", "count": "0", "additional_payer_notes": "Zero final payments for the item or service in the 15 months prior to posting the file." }, { "payer_name": "HEALTH NET", "plan_name": "HEALTHNET HMO, PPO, POS, EPO, CANOPY HEALTHNET HMO, OTHER-IN-NETWORK PLANS", "methodology": "per diem", "standard_charge_dollar": 8000.0, "standard_charge_algorithm": "Expected reimbursement is the lesser of Per diem ($8,000) for the length of stay and 70% of billed.", "count": "0", "additional_payer_notes": "Zero final payments for the item or service in the 15 months prior to posting the file." }, { "payer_name": "UNITED HEALTHCARE", "plan_name": "SUTTER SELECT & SUTTER HEALTH PLAN HMO PLANS", "methodology": "per diem", "standard_charge_dollar": 28538.0, "standard_charge_algorithm": "Per diem ($28,538).", "count": "0", "additional_payer_notes": "Zero final payments for the item or service in the 15 months prior to posting the file." }, { "payer_name": "UNITED HEALTHCARE", "plan_name": "SUTTER SELECT & SUTTER HEALTH PLAN HMO PLANS", "methodology": "per diem", "standard_charge_dollar": 28538.0, "standard_charge_algorithm": "Per diem ($28,538).", "count": "0", "additional_payer_notes": "Zero final payments for the item or service in the 15 months prior to posting the file." }, { "payer_name": "SUTTER", "plan_name": "SUTTER SELECT & SUTTER HEALTH PLAN HMO PLANS", "methodology": "per diem", "standard_charge_dollar": 28538.0, "standard_charge_algorithm": "Per diem ($28,538).", "count": "0", "additional_payer_notes": "Zero final payments for the item or service in the 15 months prior to posting the file." }, { "payer_name": "UNITED HEALTHCARE", "plan_name": "SUTTER SELECT & SUTTER HEALTH PLAN HMO PLANS", "methodology": "per diem", "standard_charge_dollar": 28538.0, "standard_charge_algorithm": "Per diem ($28,538).", "count": "0", "additional_payer_notes": "Zero final payments for the item or service in the 15 months prior to posting the file." }, { "payer_name": "UMR", "plan_name": "SUTTER SELECT & SUTTER HEALTH PLAN HMO PLANS", "methodology": "per diem", "standard_charge_dollar": 28538.0, "standard_charge_algorithm": "Per diem ($28,538).", "count": "0", "additional_payer_notes": "Zero final payments for the item or service in the 15 months prior to posting the file." } ] } ] }, { "description": "HC Cap Gp004", "code_information": [ { "code": "PX-2120026004", "type": "CDM" }, { "code": "99999", "type": "CPT" }, { "code": "0272", "type": "RC" } ], "standard_charges": [ { "setting": "outpatient", "gross_charge": 146.0, "discounted_cash": 73.0, "minimum": 61.61, "maximum": 75.92, "additional_generic_notes": "Zero final payments for the item or service in the 15 months prior to posting the file.", "payers_information": [ { "payer_name": "AETNA", "plan_name": "AETNA ALL OTHER PLANS", "methodology": "percent of total billed charges", "standard_charge_dollar": 75.92, "standard_charge_percentage": 52.0, "count": "0", "additional_payer_notes": "Zero final payments for the item or service in the 15 months prior to posting the file." }, { "payer_name": "AETNA", "plan_name": "AETNA ALL OTHER PLANS", "methodology": "percent of total billed charges", "standard_charge_dollar": 75.92, "standard_charge_percentage": 52.0, "count": "0", "additional_payer_notes": "Zero final payments for the item or service in the 15 months prior to posting the file." }, { "payer_name": "MERITAIN HEALTH", "plan_name": "AETNA ALL OTHER PLANS", "methodology": "percent of total billed charges", "standard_charge_dollar": 75.92, "standard_charge_percentage": 52.0, "count": "0", "additional_payer_notes": "Zero final payments for the item or service in the 15 months prior to posting the file." }, { "payer_name": "BLUE SHIELD OUT OF STATE", "plan_name": "STANFORD HEALTHCARE ALLIANCE PLAN", "methodology": "percent of total billed charges", "standard_charge_dollar": 70.94, "standard_charge_percentage": 48.59, "count": "0", "additional_payer_notes": "Zero final payments for the item or service in the 15 months prior to posting the file." }, { "payer_name": "BLUE SHIELD", "plan_name": "STANFORD HEALTHCARE ALLIANCE PLAN", "methodology": "percent of total billed charges", "standard_charge_dollar": 70.94, "standard_charge_percentage": 48.59, "count": "0", "additional_payer_notes": "Zero final payments for the item or service in the 15 months prior to posting the file." }, { "payer_name": "BLUE SHIELD", "plan_name": "STANFORD HEALTHCARE ALLIANCE PLAN", "methodology": "percent of total billed charges", "standard_charge_dollar": 70.94, "standard_charge_percentage": 48.59, "count": "0", "additional_payer_notes": "Zero final payments for the item or service in the 15 months prior to posting the file." }, { "payer_name": "CIGNA", "plan_name": "CIGNA COM ALT HMO PLAN", "methodology": "percent of total billed charges", "standard_charge_dollar": 61.61, "standard_charge_percentage": 42.2, "count": "0", "additional_payer_notes": "Zero final payments for the item or service in the 15 months prior to posting the file." }, { "payer_name": "CIGNA", "plan_name": "CIGNA COM ALT HMO PLAN", "methodology": "percent of total billed charges", "standard_charge_dollar": 61.61, "standard_charge_percentage": 42.2, "count": "0", "additional_payer_notes": "Zero final payments for the item or service in the 15 months prior to posting the file." }, { "payer_name": "HEALTH NET", "plan_name": "HEALTHNET HMO, PPO, POS, EPO, CANOPY HEALTHNET HMO, OTHER-IN-NETWORK PLANS", "methodology": "per diem", "standard_charge_dollar": 8000.0, "standard_charge_algorithm": "Expected reimbursement is the lesser of Per diem ($8,000) for the length of stay and 70% of billed.", "count": "0", "additional_payer_notes": "Zero final payments for the item or service in the 15 months prior to posting the file." }, { "payer_name": "HEALTH NET", "plan_name": "HEALTHNET HMO, PPO, POS, EPO, CANOPY HEALTHNET HMO, OTHER-IN-NETWORK PLANS", "methodology": "per diem", "standard_charge_dollar": 8000.0, "standard_charge_algorithm": "Expected reimbursement is the lesser of Per diem ($8,000) for the length of stay and 70% of billed.", "count": "0", "additional_payer_notes": "Zero final payments for the item or service in the 15 months prior to posting the file." }, { "payer_name": "UNITED HEALTHCARE", "plan_name": "SUTTER SELECT & SUTTER HEALTH PLAN HMO PLANS", "methodology": "per diem", "standard_charge_dollar": 28538.0, "standard_charge_algorithm": "Per diem ($28,538).", "count": "0", "additional_payer_notes": "Zero final payments for the item or service in the 15 months prior to posting the file." }, { "payer_name": "UNITED HEALTHCARE", "plan_name": "SUTTER SELECT & SUTTER HEALTH PLAN HMO PLANS", "methodology": "per diem", "standard_charge_dollar": 28538.0, "standard_charge_algorithm": "Per diem ($28,538).", "count": "0", "additional_payer_notes": "Zero final payments for the item or service in the 15 months prior to posting the file." }, { "payer_name": "SUTTER", "plan_name": "SUTTER SELECT & SUTTER HEALTH PLAN HMO PLANS", "methodology": "per diem", "standard_charge_dollar": 28538.0, "standard_charge_algorithm": "Per diem ($28,538).", "count": "0", "additional_payer_notes": "Zero final payments for the item or service in the 15 months prior to posting the file." }, { "payer_name": "UNITED HEALTHCARE", "plan_name": "SUTTER SELECT & SUTTER HEALTH PLAN HMO PLANS", "methodology": "per diem", "standard_charge_dollar": 28538.0, "standard_charge_algorithm": "Per diem ($28,538).", "count": "0", "additional_payer_notes": "Zero final payments for the item or service in the 15 months prior to posting the file." }, { "payer_name": "UMR", "plan_name": "SUTTER SELECT & SUTTER HEALTH PLAN HMO PLANS", "methodology": "per diem", "standard_charge_dollar": 28538.0, "standard_charge_algorithm": "Per diem ($28,538).", "count": "0", "additional_payer_notes": "Zero final payments for the item or service in the 15 months prior to posting the file." } ] } ] }, { "description": "HC Cap Gp005", "code_information": [ { "code": "PX-2120026005", "type": "CDM" }, { "code": "99999", "type": "CPT" }, { "code": "0272", "type": "RC" } ], "standard_charges": [ { "setting": "outpatient", "gross_charge": 195.0, "discounted_cash": 97.5, "minimum": 82.29, "maximum": 101.4, "additional_generic_notes": "Zero final payments for the item or service in the 15 months prior to posting the file.", "payers_information": [ { "payer_name": "AETNA", "plan_name": "AETNA ALL OTHER PLANS", "methodology": "percent of total billed charges", "standard_charge_dollar": 101.4, "standard_charge_percentage": 52.0, "count": "0", "additional_payer_notes": "Zero final payments for the item or service in the 15 months prior to posting the file." }, { "payer_name": "AETNA", "plan_name": "AETNA ALL OTHER PLANS", "methodology": "percent of total billed charges", "standard_charge_dollar": 101.4, "standard_charge_percentage": 52.0, "count": "0", "additional_payer_notes": "Zero final payments for the item or service in the 15 months prior to posting the file." }, { "payer_name": "MERITAIN HEALTH", "plan_name": "AETNA ALL OTHER PLANS", "methodology": "percent of total billed charges", "standard_charge_dollar": 101.4, "standard_charge_percentage": 52.0, "count": "0", "additional_payer_notes": "Zero final payments for the item or service in the 15 months prior to posting the file." }, { "payer_name": "BLUE SHIELD OUT OF STATE", "plan_name": "STANFORD HEALTHCARE ALLIANCE PLAN", "methodology": "percent of total billed charges", "standard_charge_dollar": 94.75, "standard_charge_percentage": 48.59, "count": "0", "additional_payer_notes": "Zero final payments for the item or service in the 15 months prior to posting the file." }, { "payer_name": "BLUE SHIELD", "plan_name": "STANFORD HEALTHCARE ALLIANCE PLAN", "methodology": "percent of total billed charges", "standard_charge_dollar": 94.75, "standard_charge_percentage": 48.59, "count": "0", "additional_payer_notes": "Zero final payments for the item or service in the 15 months prior to posting the file." }, { "payer_name": "BLUE SHIELD", "plan_name": "STANFORD HEALTHCARE ALLIANCE PLAN", "methodology": "percent of total billed charges", "standard_charge_dollar": 94.75, "standard_charge_percentage": 48.59, "count": "0", "additional_payer_notes": "Zero final payments for the item or service in the 15 months prior to posting the file." }, { "payer_name": "CIGNA", "plan_name": "CIGNA COM ALT HMO PLAN", "methodology": "percent of total billed charges", "standard_charge_dollar": 82.29, "standard_charge_percentage": 42.2, "count": "0", "additional_payer_notes": "Zero final payments for the item or service in the 15 months prior to posting the file." }, { "payer_name": "CIGNA", "plan_name": "CIGNA COM ALT HMO PLAN", "methodology": "percent of total billed charges", "standard_charge_dollar": 82.29, "standard_charge_percentage": 42.2, "count": "0", "additional_payer_notes": "Zero final payments for the item or service in the 15 months prior to posting the file." }, { "payer_name": "HEALTH NET", "plan_name": "HEALTHNET HMO, PPO, POS, EPO, CANOPY HEALTHNET HMO, OTHER-IN-NETWORK PLANS", "methodology": "per diem", "standard_charge_dollar": 8000.0, "standard_charge_algorithm": "Expected reimbursement is the lesser of Per diem ($8,000) for the length of stay and 70% of billed.", "count": "0", "additional_payer_notes": "Zero final payments for the item or service in the 15 months prior to posting the file." }, { "payer_name": "HEALTH NET", "plan_name": "HEALTHNET HMO, PPO, POS, EPO, CANOPY HEALTHNET HMO, OTHER-IN-NETWORK PLANS", "methodology": "per diem", "standard_charge_dollar": 8000.0, "standard_charge_algorithm": "Expected reimbursement is the lesser of Per diem ($8,000) for the length of stay and 70% of billed.", "count": "0", "additional_payer_notes": "Zero final payments for the item or service in the 15 months prior to posting the file." }, { "payer_name": "UNITED HEALTHCARE", "plan_name": "SUTTER SELECT & SUTTER HEALTH PLAN HMO PLANS", "methodology": "per diem", "standard_charge_dollar": 28538.0, "standard_charge_algorithm": "Per diem ($28,538).", "count": "0", "additional_payer_notes": "Zero final payments for the item or service in the 15 months prior to posting the file." }, { "payer_name": "UNITED HEALTHCARE", "plan_name": "SUTTER SELECT & SUTTER HEALTH PLAN HMO PLANS", "methodology": "per diem", "standard_charge_dollar": 28538.0, "standard_charge_algorithm": "Per diem ($28,538).", "count": "0", "additional_payer_notes": "Zero final payments for the item or service in the 15 months prior to posting the file." }, { "payer_name": "SUTTER", "plan_name": "SUTTER SELECT & SUTTER HEALTH PLAN HMO PLANS", "methodology": "per diem", "standard_charge_dollar": 28538.0, "standard_charge_algorithm": "Per diem ($28,538).", "count": "0", "additional_payer_notes": "Zero final payments for the item or service in the 15 months prior to posting the file." }, { "payer_name": "UNITED HEALTHCARE", "plan_name": "SUTTER SELECT & SUTTER HEALTH PLAN HMO PLANS", "methodology": "per diem", "standard_charge_dollar": 28538.0, "standard_charge_algorithm": "Per diem ($28,538).", "count": "0", "additional_payer_notes": "Zero final payments for the item or service in the 15 months prior to posting the file." }, { "payer_name": "UMR", "plan_name": "SUTTER SELECT & SUTTER HEALTH PLAN HMO PLANS", "methodology": "per diem", "standard_charge_dollar": 28538.0, "standard_charge_algorithm": "Per diem ($28,538).", "count": "0", "additional_payer_notes": "Zero final payments for the item or service in the 15 months prior to posting the file." } ] } ] }, { "description": "HC Cap Gp006", "code_information": [ { "code": "PX-2120026006", "type": "CDM" }, { "code": "99999", "type": "CPT" }, { "code": "0272", "type": "RC" } ], "standard_charges": [ { "setting": "outpatient", "gross_charge": 293.0, "discounted_cash": 146.5, "minimum": 123.65, "maximum": 152.36, "additional_generic_notes": "Zero final payments for the item or service in the 15 months prior to posting the file.", "payers_information": [ { "payer_name": "AETNA", "plan_name": "AETNA ALL OTHER PLANS", "methodology": "percent of total billed charges", "standard_charge_dollar": 152.36, "standard_charge_percentage": 52.0, "count": "0", "additional_payer_notes": "Zero final payments for the item or service in the 15 months prior to posting the file." }, { "payer_name": "AETNA", "plan_name": "AETNA ALL OTHER PLANS", "methodology": "percent of total billed charges", "standard_charge_dollar": 152.36, "standard_charge_percentage": 52.0, "count": "0", "additional_payer_notes": "Zero final payments for the item or service in the 15 months prior to posting the file." }, { "payer_name": "MERITAIN HEALTH", "plan_name": "AETNA ALL OTHER PLANS", "methodology": "percent of total billed charges", "standard_charge_dollar": 152.36, "standard_charge_percentage": 52.0, "count": "0", "additional_payer_notes": "Zero final payments for the item or service in the 15 months prior to posting the file." }, { "payer_name": "BLUE SHIELD OUT OF STATE", "plan_name": "STANFORD HEALTHCARE ALLIANCE PLAN", "methodology": "percent of total billed charges", "standard_charge_dollar": 142.37, "standard_charge_percentage": 48.59, "count": "0", "additional_payer_notes": "Zero final payments for the item or service in the 15 months prior to posting the file." }, { "payer_name": "BLUE SHIELD", "plan_name": "STANFORD HEALTHCARE ALLIANCE PLAN", "methodology": "percent of total billed charges", "standard_charge_dollar": 142.37, "standard_charge_percentage": 48.59, "count": "0", "additional_payer_notes": "Zero final payments for the item or service in the 15 months prior to posting the file." }, { "payer_name": "BLUE SHIELD", "plan_name": "STANFORD HEALTHCARE ALLIANCE PLAN", "methodology": "percent of total billed charges", "standard_charge_dollar": 142.37, "standard_charge_percentage": 48.59, "count": "0", "additional_payer_notes": "Zero final payments for the item or service in the 15 months prior to posting the file." }, { "payer_name": "CIGNA", "plan_name": "CIGNA COM ALT HMO PLAN", "methodology": "percent of total billed charges", "standard_charge_dollar": 123.65, "standard_charge_percentage": 42.2, "count": "0", "additional_payer_notes": "Zero final payments for the item or service in the 15 months prior to posting the file." }, { "payer_name": "CIGNA", "plan_name": "CIGNA COM ALT HMO PLAN", "methodology": "percent of total billed charges", "standard_charge_dollar": 123.65, "standard_charge_percentage": 42.2, "count": "0", "additional_payer_notes": "Zero final payments for the item or service in the 15 months prior to posting the file." }, { "payer_name": "HEALTH NET", "plan_name": "HEALTHNET HMO, PPO, POS, EPO, CANOPY HEALTHNET HMO, OTHER-IN-NETWORK PLANS", "methodology": "per diem", "standard_charge_dollar": 8000.0, "standard_charge_algorithm": "Expected reimbursement is the lesser of Per diem ($8,000) for the length of stay and 70% of billed.", "count": "0", "additional_payer_notes": "Zero final payments for the item or service in the 15 months prior to posting the file." }, { "payer_name": "HEALTH NET", "plan_name": "HEALTHNET HMO, PPO, POS, EPO, CANOPY HEALTHNET HMO, OTHER-IN-NETWORK PLANS", "methodology": "per diem", "standard_charge_dollar": 8000.0, "standard_charge_algorithm": "Expected reimbursement is the lesser of Per diem ($8,000) for the length of stay and 70% of billed.", "count": "0", "additional_payer_notes": "Zero final payments for the item or service in the 15 months prior to posting the file." }, { "payer_name": "UNITED HEALTHCARE", "plan_name": "SUTTER SELECT & SUTTER HEALTH PLAN HMO PLANS", "methodology": "per diem", "standard_charge_dollar": 28538.0, "standard_charge_algorithm": "Per diem ($28,538).", "count": "0", "additional_payer_notes": "Zero final payments for the item or service in the 15 months prior to posting the file." }, { "payer_name": "UNITED HEALTHCARE", "plan_name": "SUTTER SELECT & SUTTER HEALTH PLAN HMO PLANS", "methodology": "per diem", "standard_charge_dollar": 28538.0, "standard_charge_algorithm": "Per diem ($28,538).", "count": "0", "additional_payer_notes": "Zero final payments for the item or service in the 15 months prior to posting the file." }, { "payer_name": "SUTTER", "plan_name": "SUTTER SELECT & SUTTER HEALTH PLAN HMO PLANS", "methodology": "per diem", "standard_charge_dollar": 28538.0, "standard_charge_algorithm": "Per diem ($28,538).", "count": "0", "additional_payer_notes": "Zero final payments for the item or service in the 15 months prior to posting the file." }, { "payer_name": "UNITED HEALTHCARE", "plan_name": "SUTTER SELECT & SUTTER HEALTH PLAN HMO PLANS", "methodology": "per diem", "standard_charge_dollar": 28538.0, "standard_charge_algorithm": "Per diem ($28,538).", "count": "0", "additional_payer_notes": "Zero final payments for the item or service in the 15 months prior to posting the file." }, { "payer_name": "UMR", "plan_name": "SUTTER SELECT & SUTTER HEALTH PLAN HMO PLANS", "methodology": "per diem", "standard_charge_dollar": 28538.0, "standard_charge_algorithm": "Per diem ($28,538).", "count": "0", "additional_payer_notes": "Zero final payments for the item or service in the 15 months prior to posting the file." } ] } ] }, { "description": "HC Cap Gp007", "code_information": [ { "code": "PX-2120026007", "type": "CDM" }, { "code": "99999", "type": "CPT" }, { "code": "0272", "type": "RC" } ], "standard_charges": [ { "setting": "outpatient", "gross_charge": 380.0, "discounted_cash": 190.0, "minimum": 160.36, "maximum": 197.6, "additional_generic_notes": "Zero final payments for the item or service in the 15 months prior to posting the file.", "payers_information": [ { "payer_name": "AETNA", "plan_name": "AETNA ALL OTHER PLANS", "methodology": "percent of total billed charges", "standard_charge_dollar": 197.6, "standard_charge_percentage": 52.0, "count": "0", "additional_payer_notes": "Zero final payments for the item or service in the 15 months prior to posting the file." }, { "payer_name": "AETNA", "plan_name": "AETNA ALL OTHER PLANS", "methodology": "percent of total billed charges", "standard_charge_dollar": 197.6, "standard_charge_percentage": 52.0, "count": "0", "additional_payer_notes": "Zero final payments for the item or service in the 15 months prior to posting the file." }, { "payer_name": "MERITAIN HEALTH", "plan_name": "AETNA ALL OTHER PLANS", "methodology": "percent of total billed charges", "standard_charge_dollar": 197.6, "standard_charge_percentage": 52.0, "count": "0", "additional_payer_notes": "Zero final payments for the item or service in the 15 months prior to posting the file." }, { "payer_name": "BLUE SHIELD OUT OF STATE", "plan_name": "STANFORD HEALTHCARE ALLIANCE PLAN", "methodology": "percent of total billed charges", "standard_charge_dollar": 184.64, "standard_charge_percentage": 48.59, "count": "0", "additional_payer_notes": "Zero final payments for the item or service in the 15 months prior to posting the file." }, { "payer_name": "BLUE SHIELD", "plan_name": "STANFORD HEALTHCARE ALLIANCE PLAN", "methodology": "percent of total billed charges", "standard_charge_dollar": 184.64, "standard_charge_percentage": 48.59, "count": "0", "additional_payer_notes": "Zero final payments for the item or service in the 15 months prior to posting the file." }, { "payer_name": "BLUE SHIELD", "plan_name": "STANFORD HEALTHCARE ALLIANCE PLAN", "methodology": "percent of total billed charges", "standard_charge_dollar": 184.64, "standard_charge_percentage": 48.59, "count": "0", "additional_payer_notes": "Zero final payments for the item or service in the 15 months prior to posting the file." }, { "payer_name": "CIGNA", "plan_name": "CIGNA COM ALT HMO PLAN", "methodology": "percent of total billed charges", "standard_charge_dollar": 160.36, "standard_charge_percentage": 42.2, "count": "0", "additional_payer_notes": "Zero final payments for the item or service in the 15 months prior to posting the file." }, { "payer_name": "CIGNA", "plan_name": "CIGNA COM ALT HMO PLAN", "methodology": "percent of total billed charges", "standard_charge_dollar": 160.36, "standard_charge_percentage": 42.2, "count": "0", "additional_payer_notes": "Zero final payments for the item or service in the 15 months prior to posting the file." }, { "payer_name": "HEALTH NET", "plan_name": "HEALTHNET HMO, PPO, POS, EPO, CANOPY HEALTHNET HMO, OTHER-IN-NETWORK PLANS", "methodology": "per diem", "standard_charge_dollar": 8000.0, "standard_charge_algorithm": "Expected reimbursement is the lesser of Per diem ($8,000) for the length of stay and 70% of billed.", "count": "0", "additional_payer_notes": "Zero final payments for the item or service in the 15 months prior to posting the file." }, { "payer_name": "HEALTH NET", "plan_name": "HEALTHNET HMO, PPO, POS, EPO, CANOPY HEALTHNET HMO, OTHER-IN-NETWORK PLANS", "methodology": "per diem", "standard_charge_dollar": 8000.0, "standard_charge_algorithm": "Expected reimbursement is the lesser of Per diem ($8,000) for the length of stay and 70% of billed.", "count": "0", "additional_payer_notes": "Zero final payments for the item or service in the 15 months prior to posting the file." }, { "payer_name": "UNITED HEALTHCARE", "plan_name": "SUTTER SELECT & SUTTER HEALTH PLAN HMO PLANS", "methodology": "per diem", "standard_charge_dollar": 28538.0, "standard_charge_algorithm": "Per diem ($28,538).", "count": "0", "additional_payer_notes": "Zero final payments for the item or service in the 15 months prior to posting the file." }, { "payer_name": "UNITED HEALTHCARE", "plan_name": "SUTTER SELECT & SUTTER HEALTH PLAN HMO PLANS", "methodology": "per diem", "standard_charge_dollar": 28538.0, "standard_charge_algorithm": "Per diem ($28,538).", "count": "0", "additional_payer_notes": "Zero final payments for the item or service in the 15 months prior to posting the file." }, { "payer_name": "SUTTER", "plan_name": "SUTTER SELECT & SUTTER HEALTH PLAN HMO PLANS", "methodology": "per diem", "standard_charge_dollar": 28538.0, "standard_charge_algorithm": "Per diem ($28,538).", "count": "0", "additional_payer_notes": "Zero final payments for the item or service in the 15 months prior to posting the file." }, { "payer_name": "UNITED HEALTHCARE", "plan_name": "SUTTER SELECT & SUTTER HEALTH PLAN HMO PLANS", "methodology": "per diem", "standard_charge_dollar": 28538.0, "standard_charge_algorithm": "Per diem ($28,538).", "count": "0", "additional_payer_notes": "Zero final payments for the item or service in the 15 months prior to posting the file." }, { "payer_name": "UMR", "plan_name": "SUTTER SELECT & SUTTER HEALTH PLAN HMO PLANS", "methodology": "per diem", "standard_charge_dollar": 28538.0, "standard_charge_algorithm": "Per diem ($28,538).", "count": "0", "additional_payer_notes": "Zero final payments for the item or service in the 15 months prior to posting the file." } ] } ] }, { "description": "HC Cap Gp009", "code_information": [ { "code": "PX-2120026009", "type": "CDM" }, { "code": "99999", "type": "CPT" }, { "code": "0272", "type": "RC" } ], "standard_charges": [ { "setting": "outpatient", "gross_charge": 570.0, "discounted_cash": 285.0, "minimum": 240.54, "maximum": 296.4, "additional_generic_notes": "Zero final payments for the item or service in the 15 months prior to posting the file.", "payers_information": [ { "payer_name": "AETNA", "plan_name": "AETNA ALL OTHER PLANS", "methodology": "percent of total billed charges", "standard_charge_dollar": 296.4, "standard_charge_percentage": 52.0, "count": "0", "additional_payer_notes": "Zero final payments for the item or service in the 15 months prior to posting the file." }, { "payer_name": "AETNA", "plan_name": "AETNA ALL OTHER PLANS", "methodology": "percent of total billed charges", "standard_charge_dollar": 296.4, "standard_charge_percentage": 52.0, "count": "0", "additional_payer_notes": "Zero final payments for the item or service in the 15 months prior to posting the file." }, { "payer_name": "MERITAIN HEALTH", "plan_name": "AETNA ALL OTHER PLANS", "methodology": "percent of total billed charges", "standard_charge_dollar": 296.4, "standard_charge_percentage": 52.0, "count": "0", "additional_payer_notes": "Zero final payments for the item or service in the 15 months prior to posting the file." }, { "payer_name": "BLUE SHIELD OUT OF STATE", "plan_name": "STANFORD HEALTHCARE ALLIANCE PLAN", "methodology": "percent of total billed charges", "standard_charge_dollar": 276.96, "standard_charge_percentage": 48.59, "count": "0", "additional_payer_notes": "Zero final payments for the item or service in the 15 months prior to posting the file." }, { "payer_name": "BLUE SHIELD", "plan_name": "STANFORD HEALTHCARE ALLIANCE PLAN", "methodology": "percent of total billed charges", "standard_charge_dollar": 276.96, "standard_charge_percentage": 48.59, "count": "0", "additional_payer_notes": "Zero final payments for the item or service in the 15 months prior to posting the file." }, { "payer_name": "BLUE SHIELD", "plan_name": "STANFORD HEALTHCARE ALLIANCE PLAN", "methodology": "percent of total billed charges", "standard_charge_dollar": 276.96, "standard_charge_percentage": 48.59, "count": "0", "additional_payer_notes": "Zero final payments for the item or service in the 15 months prior to posting the file." }, { "payer_name": "CIGNA", "plan_name": "CIGNA COM ALT HMO PLAN", "methodology": "percent of total billed charges", "standard_charge_dollar": 240.54, "standard_charge_percentage": 42.2, "count": "0", "additional_payer_notes": "Zero final payments for the item or service in the 15 months prior to posting the file." }, { "payer_name": "CIGNA", "plan_name": "CIGNA COM ALT HMO PLAN", "methodology": "percent of total billed charges", "standard_charge_dollar": 240.54, "standard_charge_percentage": 42.2, "count": "0", "additional_payer_notes": "Zero final payments for the item or service in the 15 months prior to posting the file." }, { "payer_name": "HEALTH NET", "plan_name": "HEALTHNET HMO, PPO, POS, EPO, CANOPY HEALTHNET HMO, OTHER-IN-NETWORK PLANS", "methodology": "per diem", "standard_charge_dollar": 8000.0, "standard_charge_algorithm": "Expected reimbursement is the lesser of Per diem ($8,000) for the length of stay and 70% of billed.", "count": "0", "additional_payer_notes": "Zero final payments for the item or service in the 15 months prior to posting the file." }, { "payer_name": "HEALTH NET", "plan_name": "HEALTHNET HMO, PPO, POS, EPO, CANOPY HEALTHNET HMO, OTHER-IN-NETWORK PLANS", "methodology": "per diem", "standard_charge_dollar": 8000.0, "standard_charge_algorithm": "Expected reimbursement is the lesser of Per diem ($8,000) for the length of stay and 70% of billed.", "count": "0", "additional_payer_notes": "Zero final payments for the item or service in the 15 months prior to posting the file." }, { "payer_name": "UNITED HEALTHCARE", "plan_name": "SUTTER SELECT & SUTTER HEALTH PLAN HMO PLANS", "methodology": "per diem", "standard_charge_dollar": 28538.0, "standard_charge_algorithm": "Per diem ($28,538).", "count": "0", "additional_payer_notes": "Zero final payments for the item or service in the 15 months prior to posting the file." }, { "payer_name": "UNITED HEALTHCARE", "plan_name": "SUTTER SELECT & SUTTER HEALTH PLAN HMO PLANS", "methodology": "per diem", "standard_charge_dollar": 28538.0, "standard_charge_algorithm": "Per diem ($28,538).", "count": "0", "additional_payer_notes": "Zero final payments for the item or service in the 15 months prior to posting the file." }, { "payer_name": "SUTTER", "plan_name": "SUTTER SELECT & SUTTER HEALTH PLAN HMO PLANS", "methodology": "per diem", "standard_charge_dollar": 28538.0, "standard_charge_algorithm": "Per diem ($28,538).", "count": "0", "additional_payer_notes": "Zero final payments for the item or service in the 15 months prior to posting the file." }, { "payer_name": "UNITED HEALTHCARE", "plan_name": "SUTTER SELECT & SUTTER HEALTH PLAN HMO PLANS", "methodology": "per diem", "standard_charge_dollar": 28538.0, "standard_charge_algorithm": "Per diem ($28,538).", "count": "0", "additional_payer_notes": "Zero final payments for the item or service in the 15 months prior to posting the file." }, { "payer_name": "UMR", "plan_name": "SUTTER SELECT & SUTTER HEALTH PLAN HMO PLANS", "methodology": "per diem", "standard_charge_dollar": 28538.0, "standard_charge_algorithm": "Per diem ($28,538).", "count": "0", "additional_payer_notes": "Zero final payments for the item or service in the 15 months prior to posting the file." } ] } ] }, { "description": "HC Cap Gp014", "code_information": [ { "code": "PX-2120026014", "type": "CDM" }, { "code": "99999", "type": "CPT" }, { "code": "0272", "type": "RC" } ], "standard_charges": [ { "setting": "outpatient", "gross_charge": 1080.0, "discounted_cash": 540.0, "minimum": 455.76, "maximum": 561.6, "additional_generic_notes": "Zero final payments for the item or service in the 15 months prior to posting the file.", "payers_information": [ { "payer_name": "AETNA", "plan_name": "AETNA ALL OTHER PLANS", "methodology": "percent of total billed charges", "standard_charge_dollar": 561.6, "standard_charge_percentage": 52.0, "count": "0", "additional_payer_notes": "Zero final payments for the item or service in the 15 months prior to posting the file." }, { "payer_name": "AETNA", "plan_name": "AETNA ALL OTHER PLANS", "methodology": "percent of total billed charges", "standard_charge_dollar": 561.6, "standard_charge_percentage": 52.0, "count": "0", "additional_payer_notes": "Zero final payments for the item or service in the 15 months prior to posting the file." }, { "payer_name": "MERITAIN HEALTH", "plan_name": "AETNA ALL OTHER PLANS", "methodology": "percent of total billed charges", "standard_charge_dollar": 561.6, "standard_charge_percentage": 52.0, "count": "0", "additional_payer_notes": "Zero final payments for the item or service in the 15 months prior to posting the file." }, { "payer_name": "BLUE SHIELD OUT OF STATE", "plan_name": "STANFORD HEALTHCARE ALLIANCE PLAN", "methodology": "percent of total billed charges", "standard_charge_dollar": 524.77, "standard_charge_percentage": 48.59, "count": "0", "additional_payer_notes": "Zero final payments for the item or service in the 15 months prior to posting the file." }, { "payer_name": "BLUE SHIELD", "plan_name": "STANFORD HEALTHCARE ALLIANCE PLAN", "methodology": "percent of total billed charges", "standard_charge_dollar": 524.77, "standard_charge_percentage": 48.59, "median_amount": 68.24, "10th_percentile": 13.6, "90th_percentile": 1043.06, "count": "30" }, { "payer_name": "BLUE SHIELD", "plan_name": "STANFORD HEALTHCARE ALLIANCE PLAN", "methodology": "percent of total billed charges", "standard_charge_dollar": 524.77, "standard_charge_percentage": 48.59, "count": "0", "additional_payer_notes": "Zero final payments for the item or service in the 15 months prior to posting the file." }, { "payer_name": "BLUE SHIELD", "plan_name": "STANFORD HEALTHCARE ALLIANCE PLAN", "methodology": "percent of total billed charges", "standard_charge_dollar": 524.77, "standard_charge_percentage": 48.59, "count": "0", "additional_payer_notes": "Zero final payments for the item or service in the 15 months prior to posting the file." }, { "payer_name": "CIGNA", "plan_name": "CIGNA COM ALT HMO PLAN", "methodology": "percent of total billed charges", "standard_charge_dollar": 455.76, "standard_charge_percentage": 42.2, "count": "0", "additional_payer_notes": "Zero final payments for the item or service in the 15 months prior to posting the file." }, { "payer_name": "CIGNA", "plan_name": "CIGNA COM ALT HMO PLAN", "methodology": "percent of total billed charges", "standard_charge_dollar": 455.76, "standard_charge_percentage": 42.2, "count": "0", "additional_payer_notes": "Zero final payments for the item or service in the 15 months prior to posting the file." }, { "payer_name": "HEALTH NET", "plan_name": "HEALTHNET HMO, PPO, POS, EPO, CANOPY HEALTHNET HMO, OTHER-IN-NETWORK PLANS", "methodology": "per diem", "standard_charge_dollar": 8000.0, "standard_charge_algorithm": "Expected reimbursement is the lesser of Per diem ($8,000) for the length of stay and 70% of billed.", "count": "0", "additional_payer_notes": "Zero final payments for the item or service in the 15 months prior to posting the file." }, { "payer_name": "HEALTH NET", "plan_name": "HEALTHNET HMO, PPO, POS, EPO, CANOPY HEALTHNET HMO, OTHER-IN-NETWORK PLANS", "methodology": "per diem", "standard_charge_dollar": 8000.0, "standard_charge_algorithm": "Expected reimbursement is the lesser of Per diem ($8,000) for the length of stay and 70% of billed.", "count": "0", "additional_payer_notes": "Zero final payments for the item or service in the 15 months prior to posting the file." }, { "payer_name": "UNITED HEALTHCARE", "plan_name": "SUTTER SELECT & SUTTER HEALTH PLAN HMO PLANS", "methodology": "per diem", "standard_charge_dollar": 28538.0, "standard_charge_algorithm": "Per diem ($28,538).", "count": "0", "additional_payer_notes": "Zero final payments for the item or service in the 15 months prior to posting the file." }, { "payer_name": "UNITED HEALTHCARE", "plan_name": "SUTTER SELECT & SUTTER HEALTH PLAN HMO PLANS", "methodology": "per diem", "standard_charge_dollar": 28538.0, "standard_charge_algorithm": "Per diem ($28,538).", "count": "0", "additional_payer_notes": "Zero final payments for the item or service in the 15 months prior to posting the file." }, { "payer_name": "SUTTER", "plan_name": "SUTTER SELECT & SUTTER HEALTH PLAN HMO PLANS", "methodology": "per diem", "standard_charge_dollar": 28538.0, "standard_charge_algorithm": "Per diem ($28,538).", "count": "0", "additional_payer_notes": "Zero final payments for the item or service in the 15 months prior to posting the file." }, { "payer_name": "UNITED HEALTHCARE", "plan_name": "SUTTER SELECT & SUTTER HEALTH PLAN HMO PLANS", "methodology": "per diem", "standard_charge_dollar": 28538.0, "standard_charge_algorithm": "Per diem ($28,538).", "count": "0", "additional_payer_notes": "Zero final payments for the item or service in the 15 months prior to posting the file." }, { "payer_name": "UMR", "plan_name": "SUTTER SELECT & SUTTER HEALTH PLAN HMO PLANS", "methodology": "per diem", "standard_charge_dollar": 28538.0, "standard_charge_algorithm": "Per diem ($28,538).", "count": "0", "additional_payer_notes": "Zero final payments for the item or service in the 15 months prior to posting the file." } ] } ] }, { "description": "HC Cap Gp018", "code_information": [ { "code": "PX-2120026018", "type": "CDM" }, { "code": "99999", "type": "CPT" }, { "code": "0272", "type": "RC" } ], "standard_charges": [ { "setting": "outpatient", "gross_charge": 1750.0, "discounted_cash": 875.0, "minimum": 738.5, "maximum": 910.0, "additional_generic_notes": "Zero final payments for the item or service in the 15 months prior to posting the file.", "payers_information": [ { "payer_name": "AETNA", "plan_name": "AETNA ALL OTHER PLANS", "methodology": "percent of total billed charges", "standard_charge_dollar": 910.0, "standard_charge_percentage": 52.0, "count": "0", "additional_payer_notes": "Zero final payments for the item or service in the 15 months prior to posting the file." }, { "payer_name": "AETNA", "plan_name": "AETNA ALL OTHER PLANS", "methodology": "percent of total billed charges", "standard_charge_dollar": 910.0, "standard_charge_percentage": 52.0, "count": "0", "additional_payer_notes": "Zero final payments for the item or service in the 15 months prior to posting the file." }, { "payer_name": "MERITAIN HEALTH", "plan_name": "AETNA ALL OTHER PLANS", "methodology": "percent of total billed charges", "standard_charge_dollar": 910.0, "standard_charge_percentage": 52.0, "count": "0", "additional_payer_notes": "Zero final payments for the item or service in the 15 months prior to posting the file." }, { "payer_name": "BLUE SHIELD OUT OF STATE", "plan_name": "STANFORD HEALTHCARE ALLIANCE PLAN", "methodology": "percent of total billed charges", "standard_charge_dollar": 850.33, "standard_charge_percentage": 48.59, "count": "0", "additional_payer_notes": "Zero final payments for the item or service in the 15 months prior to posting the file." }, { "payer_name": "BLUE SHIELD", "plan_name": "STANFORD HEALTHCARE ALLIANCE PLAN", "methodology": "percent of total billed charges", "standard_charge_dollar": 850.33, "standard_charge_percentage": 48.59, "median_amount": 68.24, "10th_percentile": 13.6, "90th_percentile": 1043.06, "count": "30" }, { "payer_name": "BLUE SHIELD", "plan_name": "STANFORD HEALTHCARE ALLIANCE PLAN", "methodology": "percent of total billed charges", "standard_charge_dollar": 850.33, "standard_charge_percentage": 48.59, "count": "0", "additional_payer_notes": "Zero final payments for the item or service in the 15 months prior to posting the file." }, { "payer_name": "BLUE SHIELD", "plan_name": "STANFORD HEALTHCARE ALLIANCE PLAN", "methodology": "percent of total billed charges", "standard_charge_dollar": 850.33, "standard_charge_percentage": 48.59, "count": "0", "additional_payer_notes": "Zero final payments for the item or service in the 15 months prior to posting the file." }, { "payer_name": "CIGNA", "plan_name": "CIGNA COM ALT HMO PLAN", "methodology": "percent of total billed charges", "standard_charge_dollar": 738.5, "standard_charge_percentage": 42.2, "count": "0", "additional_payer_notes": "Zero final payments for the item or service in the 15 months prior to posting the file." }, { "payer_name": "CIGNA", "plan_name": "CIGNA COM ALT HMO PLAN", "methodology": "percent of total billed charges", "standard_charge_dollar": 738.5, "standard_charge_percentage": 42.2, "count": "0", "additional_payer_notes": "Zero final payments for the item or service in the 15 months prior to posting the file." }, { "payer_name": "HEALTH NET", "plan_name": "HEALTHNET HMO, PPO, POS, EPO, CANOPY HEALTHNET HMO, OTHER-IN-NETWORK PLANS", "methodology": "per diem", "standard_charge_dollar": 8000.0, "standard_charge_algorithm": "Expected reimbursement is the lesser of Per diem ($8,000) for the length of stay and 70% of billed.", "count": "0", "additional_payer_notes": "Zero final payments for the item or service in the 15 months prior to posting the file." }, { "payer_name": "HEALTH NET", "plan_name": "HEALTHNET HMO, PPO, POS, EPO, CANOPY HEALTHNET HMO, OTHER-IN-NETWORK PLANS", "methodology": "per diem", "standard_charge_dollar": 8000.0, "standard_charge_algorithm": "Expected reimbursement is the lesser of Per diem ($8,000) for the length of stay and 70% of billed.", "count": "0", "additional_payer_notes": "Zero final payments for the item or service in the 15 months prior to posting the file." }, { "payer_name": "UNITED HEALTHCARE", "plan_name": "SUTTER SELECT & SUTTER HEALTH PLAN HMO PLANS", "methodology": "per diem", "standard_charge_dollar": 28538.0, "standard_charge_algorithm": "Per diem ($28,538).", "count": "0", "additional_payer_notes": "Zero final payments for the item or service in the 15 months prior to posting the file." }, { "payer_name": "UNITED HEALTHCARE", "plan_name": "SUTTER SELECT & SUTTER HEALTH PLAN HMO PLANS", "methodology": "per diem", "standard_charge_dollar": 28538.0, "standard_charge_algorithm": "Per diem ($28,538).", "count": "0", "additional_payer_notes": "Zero final payments for the item or service in the 15 months prior to posting the file." }, { "payer_name": "SUTTER", "plan_name": "SUTTER SELECT & SUTTER HEALTH PLAN HMO PLANS", "methodology": "per diem", "standard_charge_dollar": 28538.0, "standard_charge_algorithm": "Per diem ($28,538).", "count": "0", "additional_payer_notes": "Zero final payments for the item or service in the 15 months prior to posting the file." }, { "payer_name": "UNITED HEALTHCARE", "plan_name": "SUTTER SELECT & SUTTER HEALTH PLAN HMO PLANS", "methodology": "per diem", "standard_charge_dollar": 28538.0, "standard_charge_algorithm": "Per diem ($28,538).", "count": "0", "additional_payer_notes": "Zero final payments for the item or service in the 15 months prior to posting the file." }, { "payer_name": "UMR", "plan_name": "SUTTER SELECT & SUTTER HEALTH PLAN HMO PLANS", "methodology": "per diem", "standard_charge_dollar": 28538.0, "standard_charge_algorithm": "Per diem ($28,538).", "count": "0", "additional_payer_notes": "Zero final payments for the item or service in the 15 months prior to posting the file." } ] } ] }, { "description": "HC Cap Gp019", "code_information": [ { "code": "PX-2120026019", "type": "CDM" }, { "code": "99999", "type": "CPT" }, { "code": "0272", "type": "RC" } ], "standard_charges": [ { "setting": "outpatient", "gross_charge": 2125.0, "discounted_cash": 1062.5, "minimum": 896.75, "maximum": 1105.0, "additional_generic_notes": "Zero final payments for the item or service in the 15 months prior to posting the file.", "payers_information": [ { "payer_name": "AETNA", "plan_name": "AETNA ALL OTHER PLANS", "methodology": "percent of total billed charges", "standard_charge_dollar": 1105.0, "standard_charge_percentage": 52.0, "count": "0", "additional_payer_notes": "Zero final payments for the item or service in the 15 months prior to posting the file." }, { "payer_name": "AETNA", "plan_name": "AETNA ALL OTHER PLANS", "methodology": "percent of total billed charges", "standard_charge_dollar": 1105.0, "standard_charge_percentage": 52.0, "count": "0", "additional_payer_notes": "Zero final payments for the item or service in the 15 months prior to posting the file." }, { "payer_name": "MERITAIN HEALTH", "plan_name": "AETNA ALL OTHER PLANS", "methodology": "percent of total billed charges", "standard_charge_dollar": 1105.0, "standard_charge_percentage": 52.0, "count": "0", "additional_payer_notes": "Zero final payments for the item or service in the 15 months prior to posting the file." }, { "payer_name": "BLUE SHIELD OUT OF STATE", "plan_name": "STANFORD HEALTHCARE ALLIANCE PLAN", "methodology": "percent of total billed charges", "standard_charge_dollar": 1032.54, "standard_charge_percentage": 48.59, "count": "0", "additional_payer_notes": "Zero final payments for the item or service in the 15 months prior to posting the file." }, { "payer_name": "BLUE SHIELD", "plan_name": "STANFORD HEALTHCARE ALLIANCE PLAN", "methodology": "percent of total billed charges", "standard_charge_dollar": 1032.54, "standard_charge_percentage": 48.59, "median_amount": 68.24, "10th_percentile": 13.6, "90th_percentile": 1043.06, "count": "30" }, { "payer_name": "BLUE SHIELD", "plan_name": "STANFORD HEALTHCARE ALLIANCE PLAN", "methodology": "percent of total billed charges", "standard_charge_dollar": 1032.54, "standard_charge_percentage": 48.59, "count": "0", "additional_payer_notes": "Zero final payments for the item or service in the 15 months prior to posting the file." }, { "payer_name": "BLUE SHIELD", "plan_name": "STANFORD HEALTHCARE ALLIANCE PLAN", "methodology": "percent of total billed charges", "standard_charge_dollar": 1032.54, "standard_charge_percentage": 48.59, "count": "0", "additional_payer_notes": "Zero final payments for the item or service in the 15 months prior to posting the file." }, { "payer_name": "CIGNA", "plan_name": "CIGNA COM ALT HMO PLAN", "methodology": "percent of total billed charges", "standard_charge_dollar": 896.75, "standard_charge_percentage": 42.2, "count": "0", "additional_payer_notes": "Zero final payments for the item or service in the 15 months prior to posting the file." }, { "payer_name": "CIGNA", "plan_name": "CIGNA COM ALT HMO PLAN", "methodology": "percent of total billed charges", "standard_charge_dollar": 896.75, "standard_charge_percentage": 42.2, "count": "0", "additional_payer_notes": "Zero final payments for the item or service in the 15 months prior to posting the file." }, { "payer_name": "HEALTH NET", "plan_name": "HEALTHNET HMO, PPO, POS, EPO, CANOPY HEALTHNET HMO, OTHER-IN-NETWORK PLANS", "methodology": "per diem", "standard_charge_dollar": 8000.0, "standard_charge_algorithm": "Expected reimbursement is the lesser of Per diem ($8,000) for the length of stay and 70% of billed.", "count": "0", "additional_payer_notes": "Zero final payments for the item or service in the 15 months prior to posting the file." }, { "payer_name": "HEALTH NET", "plan_name": "HEALTHNET HMO, PPO, POS, EPO, CANOPY HEALTHNET HMO, OTHER-IN-NETWORK PLANS", "methodology": "per diem", "standard_charge_dollar": 8000.0, "standard_charge_algorithm": "Expected reimbursement is the lesser of Per diem ($8,000) for the length of stay and 70% of billed.", "count": "0", "additional_payer_notes": "Zero final payments for the item or service in the 15 months prior to posting the file." }, { "payer_name": "UNITED HEALTHCARE", "plan_name": "SUTTER SELECT & SUTTER HEALTH PLAN HMO PLANS", "methodology": "per diem", "standard_charge_dollar": 28538.0, "standard_charge_algorithm": "Per diem ($28,538).", "count": "0", "additional_payer_notes": "Zero final payments for the item or service in the 15 months prior to posting the file." }, { "payer_name": "UNITED HEALTHCARE", "plan_name": "SUTTER SELECT & SUTTER HEALTH PLAN HMO PLANS", "methodology": "per diem", "standard_charge_dollar": 28538.0, "standard_charge_algorithm": "Per diem ($28,538).", "count": "0", "additional_payer_notes": "Zero final payments for the item or service in the 15 months prior to posting the file." }, { "payer_name": "SUTTER", "plan_name": "SUTTER SELECT & SUTTER HEALTH PLAN HMO PLANS", "methodology": "per diem", "standard_charge_dollar": 28538.0, "standard_charge_algorithm": "Per diem ($28,538).", "count": "0", "additional_payer_notes": "Zero final payments for the item or service in the 15 months prior to posting the file." }, { "payer_name": "UNITED HEALTHCARE", "plan_name": "SUTTER SELECT & SUTTER HEALTH PLAN HMO PLANS", "methodology": "per diem", "standard_charge_dollar": 28538.0, "standard_charge_algorithm": "Per diem ($28,538).", "count": "0", "additional_payer_notes": "Zero final payments for the item or service in the 15 months prior to posting the file." }, { "payer_name": "UMR", "plan_name": "SUTTER SELECT & SUTTER HEALTH PLAN HMO PLANS", "methodology": "per diem", "standard_charge_dollar": 28538.0, "standard_charge_algorithm": "Per diem ($28,538).", "count": "0", "additional_payer_notes": "Zero final payments for the item or service in the 15 months prior to posting the file." } ] } ] }, { "description": "HC Cap Gp020", "code_information": [ { "code": "PX-2120026020", "type": "CDM" }, { "code": "99999", "type": "CPT" }, { "code": "0272", "type": "RC" } ], "standard_charges": [ { "setting": "outpatient", "gross_charge": 2550.0, "discounted_cash": 1275.0, "minimum": 1076.1, "maximum": 1326.0, "additional_generic_notes": "Zero final payments for the item or service in the 15 months prior to posting the file.", "payers_information": [ { "payer_name": "AETNA", "plan_name": "AETNA ALL OTHER PLANS", "methodology": "percent of total billed charges", "standard_charge_dollar": 1326.0, "standard_charge_percentage": 52.0, "count": "0", "additional_payer_notes": "Zero final payments for the item or service in the 15 months prior to posting the file." }, { "payer_name": "AETNA", "plan_name": "AETNA ALL OTHER PLANS", "methodology": "percent of total billed charges", "standard_charge_dollar": 1326.0, "standard_charge_percentage": 52.0, "count": "0", "additional_payer_notes": "Zero final payments for the item or service in the 15 months prior to posting the file." }, { "payer_name": "MERITAIN HEALTH", "plan_name": "AETNA ALL OTHER PLANS", "methodology": "percent of total billed charges", "standard_charge_dollar": 1326.0, "standard_charge_percentage": 52.0, "count": "0", "additional_payer_notes": "Zero final payments for the item or service in the 15 months prior to posting the file." }, { "payer_name": "BLUE SHIELD OUT OF STATE", "plan_name": "STANFORD HEALTHCARE ALLIANCE PLAN", "methodology": "percent of total billed charges", "standard_charge_dollar": 1239.05, "standard_charge_percentage": 48.59, "count": "0", "additional_payer_notes": "Zero final payments for the item or service in the 15 months prior to posting the file." }, { "payer_name": "BLUE SHIELD", "plan_name": "STANFORD HEALTHCARE ALLIANCE PLAN", "methodology": "percent of total billed charges", "standard_charge_dollar": 1239.05, "standard_charge_percentage": 48.59, "median_amount": 68.24, "10th_percentile": 13.6, "90th_percentile": 1043.06, "count": "30" }, { "payer_name": "BLUE SHIELD", "plan_name": "STANFORD HEALTHCARE ALLIANCE PLAN", "methodology": "percent of total billed charges", "standard_charge_dollar": 1239.05, "standard_charge_percentage": 48.59, "count": "0", "additional_payer_notes": "Zero final payments for the item or service in the 15 months prior to posting the file." }, { "payer_name": "BLUE SHIELD", "plan_name": "STANFORD HEALTHCARE ALLIANCE PLAN", "methodology": "percent of total billed charges", "standard_charge_dollar": 1239.05, "standard_charge_percentage": 48.59, "count": "0", "additional_payer_notes": "Zero final payments for the item or service in the 15 months prior to posting the file." }, { "payer_name": "CIGNA", "plan_name": "CIGNA COM ALT HMO PLAN", "methodology": "percent of total billed charges", "standard_charge_dollar": 1076.1, "standard_charge_percentage": 42.2, "count": "0", "additional_payer_notes": "Zero final payments for the item or service in the 15 months prior to posting the file." }, { "payer_name": "CIGNA", "plan_name": "CIGNA COM ALT HMO PLAN", "methodology": "percent of total billed charges", "standard_charge_dollar": 1076.1, "standard_charge_percentage": 42.2, "count": "0", "additional_payer_notes": "Zero final payments for the item or service in the 15 months prior to posting the file." }, { "payer_name": "HEALTH NET", "plan_name": "HEALTHNET HMO, PPO, POS, EPO, CANOPY HEALTHNET HMO, OTHER-IN-NETWORK PLANS", "methodology": "per diem", "standard_charge_dollar": 8000.0, "standard_charge_algorithm": "Expected reimbursement is the lesser of Per diem ($8,000) for the length of stay and 70% of billed.", "count": "0", "additional_payer_notes": "Zero final payments for the item or service in the 15 months prior to posting the file." }, { "payer_name": "HEALTH NET", "plan_name": "HEALTHNET HMO, PPO, POS, EPO, CANOPY HEALTHNET HMO, OTHER-IN-NETWORK PLANS", "methodology": "per diem", "standard_charge_dollar": 8000.0, "standard_charge_algorithm": "Expected reimbursement is the lesser of Per diem ($8,000) for the length of stay and 70% of billed.", "count": "0", "additional_payer_notes": "Zero final payments for the item or service in the 15 months prior to posting the file." }, { "payer_name": "UNITED HEALTHCARE", "plan_name": "SUTTER SELECT & SUTTER HEALTH PLAN HMO PLANS", "methodology": "per diem", "standard_charge_dollar": 28538.0, "standard_charge_algorithm": "Per diem ($28,538).", "count": "0", "additional_payer_notes": "Zero final payments for the item or service in the 15 months prior to posting the file." }, { "payer_name": "UNITED HEALTHCARE", "plan_name": "SUTTER SELECT & SUTTER HEALTH PLAN HMO PLANS", "methodology": "per diem", "standard_charge_dollar": 28538.0, "standard_charge_algorithm": "Per diem ($28,538).", "count": "0", "additional_payer_notes": "Zero final payments for the item or service in the 15 months prior to posting the file." }, { "payer_name": "SUTTER", "plan_name": "SUTTER SELECT & SUTTER HEALTH PLAN HMO PLANS", "methodology": "per diem", "standard_charge_dollar": 28538.0, "standard_charge_algorithm": "Per diem ($28,538).", "count": "0", "additional_payer_notes": "Zero final payments for the item or service in the 15 months prior to posting the file." }, { "payer_name": "UNITED HEALTHCARE", "plan_name": "SUTTER SELECT & SUTTER HEALTH PLAN HMO PLANS", "methodology": "per diem", "standard_charge_dollar": 28538.0, "standard_charge_algorithm": "Per diem ($28,538).", "count": "0", "additional_payer_notes": "Zero final payments for the item or service in the 15 months prior to posting the file." }, { "payer_name": "UMR", "plan_name": "SUTTER SELECT & SUTTER HEALTH PLAN HMO PLANS", "methodology": "per diem", "standard_charge_dollar": 28538.0, "standard_charge_algorithm": "Per diem ($28,538).", "count": "0", "additional_payer_notes": "Zero final payments for the item or service in the 15 months prior to posting the file." } ] } ] }, { "description": "Hc Cap Gp038", "code_information": [ { "code": "PX-2120026038", "type": "CDM" }, { "code": "99999", "type": "CPT" }, { "code": "0272", "type": "RC" } ], "standard_charges": [ { "setting": "outpatient", "gross_charge": 8750.0, "discounted_cash": 4375.0, "minimum": 3692.5, "maximum": 4550.0, "additional_generic_notes": "Zero final payments for the item or service in the 15 months prior to posting the file.", "payers_information": [ { "payer_name": "AETNA", "plan_name": "AETNA ALL OTHER PLANS", "methodology": "percent of total billed charges", "standard_charge_dollar": 4550.0, "standard_charge_percentage": 52.0, "count": "0", "additional_payer_notes": "Zero final payments for the item or service in the 15 months prior to posting the file." }, { "payer_name": "AETNA", "plan_name": "AETNA ALL OTHER PLANS", "methodology": "percent of total billed charges", "standard_charge_dollar": 4550.0, "standard_charge_percentage": 52.0, "count": "0", "additional_payer_notes": "Zero final payments for the item or service in the 15 months prior to posting the file." }, { "payer_name": "MERITAIN HEALTH", "plan_name": "AETNA ALL OTHER PLANS", "methodology": "percent of total billed charges", "standard_charge_dollar": 4550.0, "standard_charge_percentage": 52.0, "count": "0", "additional_payer_notes": "Zero final payments for the item or service in the 15 months prior to posting the file." }, { "payer_name": "BLUE SHIELD OUT OF STATE", "plan_name": "STANFORD HEALTHCARE ALLIANCE PLAN", "methodology": "percent of total billed charges", "standard_charge_dollar": 4251.63, "standard_charge_percentage": 48.59, "count": "0", "additional_payer_notes": "Zero final payments for the item or service in the 15 months prior to posting the file." }, { "payer_name": "BLUE SHIELD", "plan_name": "STANFORD HEALTHCARE ALLIANCE PLAN", "methodology": "percent of total billed charges", "standard_charge_dollar": 4251.63, "standard_charge_percentage": 48.59, "median_amount": 68.24, "10th_percentile": 13.6, "90th_percentile": 1043.06, "count": "30" }, { "payer_name": "BLUE SHIELD", "plan_name": "STANFORD HEALTHCARE ALLIANCE PLAN", "methodology": "percent of total billed charges", "standard_charge_dollar": 4251.63, "standard_charge_percentage": 48.59, "count": "0", "additional_payer_notes": "Zero final payments for the item or service in the 15 months prior to posting the file." }, { "payer_name": "BLUE SHIELD", "plan_name": "STANFORD HEALTHCARE ALLIANCE PLAN", "methodology": "percent of total billed charges", "standard_charge_dollar": 4251.63, "standard_charge_percentage": 48.59, "count": "0", "additional_payer_notes": "Zero final payments for the item or service in the 15 months prior to posting the file." }, { "payer_name": "CIGNA", "plan_name": "CIGNA COM ALT HMO PLAN", "methodology": "percent of total billed charges", "standard_charge_dollar": 3692.5, "standard_charge_percentage": 42.2, "count": "0", "additional_payer_notes": "Zero final payments for the item or service in the 15 months prior to posting the file." }, { "payer_name": "CIGNA", "plan_name": "CIGNA COM ALT HMO PLAN", "methodology": "percent of total billed charges", "standard_charge_dollar": 3692.5, "standard_charge_percentage": 42.2, "count": "0", "additional_payer_notes": "Zero final payments for the item or service in the 15 months prior to posting the file." }, { "payer_name": "HEALTH NET", "plan_name": "HEALTHNET HMO, PPO, POS, EPO, CANOPY HEALTHNET HMO, OTHER-IN-NETWORK PLANS", "methodology": "per diem", "standard_charge_dollar": 8000.0, "standard_charge_algorithm": "Expected reimbursement is the lesser of Per diem ($8,000) for the length of stay and 70% of billed.", "count": "0", "additional_payer_notes": "Zero final payments for the item or service in the 15 months prior to posting the file." }, { "payer_name": "HEALTH NET", "plan_name": "HEALTHNET HMO, PPO, POS, EPO, CANOPY HEALTHNET HMO, OTHER-IN-NETWORK PLANS", "methodology": "per diem", "standard_charge_dollar": 8000.0, "standard_charge_algorithm": "Expected reimbursement is the lesser of Per diem ($8,000) for the length of stay and 70% of billed.", "count": "0", "additional_payer_notes": "Zero final payments for the item or service in the 15 months prior to posting the file." }, { "payer_name": "UNITED HEALTHCARE", "plan_name": "SUTTER SELECT & SUTTER HEALTH PLAN HMO PLANS", "methodology": "per diem", "standard_charge_dollar": 28538.0, "standard_charge_algorithm": "Per diem ($28,538).", "count": "0", "additional_payer_notes": "Zero final payments for the item or service in the 15 months prior to posting the file." }, { "payer_name": "UNITED HEALTHCARE", "plan_name": "SUTTER SELECT & SUTTER HEALTH PLAN HMO PLANS", "methodology": "per diem", "standard_charge_dollar": 28538.0, "standard_charge_algorithm": "Per diem ($28,538).", "count": "0", "additional_payer_notes": "Zero final payments for the item or service in the 15 months prior to posting the file." }, { "payer_name": "SUTTER", "plan_name": "SUTTER SELECT & SUTTER HEALTH PLAN HMO PLANS", "methodology": "per diem", "standard_charge_dollar": 28538.0, "standard_charge_algorithm": "Per diem ($28,538).", "count": "0", "additional_payer_notes": "Zero final payments for the item or service in the 15 months prior to posting the file." }, { "payer_name": "UNITED HEALTHCARE", "plan_name": "SUTTER SELECT & SUTTER HEALTH PLAN HMO PLANS", "methodology": "per diem", "standard_charge_dollar": 28538.0, "standard_charge_algorithm": "Per diem ($28,538).", "count": "0", "additional_payer_notes": "Zero final payments for the item or service in the 15 months prior to posting the file." }, { "payer_name": "UMR", "plan_name": "SUTTER SELECT & SUTTER HEALTH PLAN HMO PLANS", "methodology": "per diem", "standard_charge_dollar": 28538.0, "standard_charge_algorithm": "Per diem ($28,538).", "count": "0", "additional_payer_notes": "Zero final payments for the item or service in the 15 months prior to posting the file." } ] } ] }, { "description": "HC Cap End Gp009", "code_information": [ { "code": "PX-2120027009", "type": "CDM" }, { "code": "99999", "type": "CPT" }, { "code": "0272", "type": "RC" } ], "standard_charges": [ { "setting": "outpatient", "gross_charge": 570.0, "discounted_cash": 285.0, "minimum": 240.54, "maximum": 296.4, "additional_generic_notes": "Zero final payments for the item or service in the 15 months prior to posting the file.", "payers_information": [ { "payer_name": "AETNA", "plan_name": "AETNA ALL OTHER PLANS", "methodology": "percent of total billed charges", "standard_charge_dollar": 296.4, "standard_charge_percentage": 52.0, "count": "0", "additional_payer_notes": "Zero final payments for the item or service in the 15 months prior to posting the file." }, { "payer_name": "AETNA", "plan_name": "AETNA ALL OTHER PLANS", "methodology": "percent of total billed charges", "standard_charge_dollar": 296.4, "standard_charge_percentage": 52.0, "count": "0", "additional_payer_notes": "Zero final payments for the item or service in the 15 months prior to posting the file." }, { "payer_name": "MERITAIN HEALTH", "plan_name": "AETNA ALL OTHER PLANS", "methodology": "percent of total billed charges", "standard_charge_dollar": 296.4, "standard_charge_percentage": 52.0, "count": "0", "additional_payer_notes": "Zero final payments for the item or service in the 15 months prior to posting the file." }, { "payer_name": "BLUE SHIELD OUT OF STATE", "plan_name": "STANFORD HEALTHCARE ALLIANCE PLAN", "methodology": "percent of total billed charges", "standard_charge_dollar": 276.96, "standard_charge_percentage": 48.59, "count": "0", "additional_payer_notes": "Zero final payments for the item or service in the 15 months prior to posting the file." }, { "payer_name": "BLUE SHIELD", "plan_name": "STANFORD HEALTHCARE ALLIANCE PLAN", "methodology": "percent of total billed charges", "standard_charge_dollar": 276.96, "standard_charge_percentage": 48.59, "count": "0", "additional_payer_notes": "Zero final payments for the item or service in the 15 months prior to posting the file." }, { "payer_name": "BLUE SHIELD", "plan_name": "STANFORD HEALTHCARE ALLIANCE PLAN", "methodology": "percent of total billed charges", "standard_charge_dollar": 276.96, "standard_charge_percentage": 48.59, "count": "0", "additional_payer_notes": "Zero final payments for the item or service in the 15 months prior to posting the file." }, { "payer_name": "CIGNA", "plan_name": "CIGNA COM ALT HMO PLAN", "methodology": "percent of total billed charges", "standard_charge_dollar": 240.54, "standard_charge_percentage": 42.2, "count": "0", "additional_payer_notes": "Zero final payments for the item or service in the 15 months prior to posting the file." }, { "payer_name": "CIGNA", "plan_name": "CIGNA COM ALT HMO PLAN", "methodology": "percent of total billed charges", "standard_charge_dollar": 240.54, "standard_charge_percentage": 42.2, "count": "0", "additional_payer_notes": "Zero final payments for the item or service in the 15 months prior to posting the file." }, { "payer_name": "HEALTH NET", "plan_name": "HEALTHNET HMO, PPO, POS, EPO, CANOPY HEALTHNET HMO, OTHER-IN-NETWORK PLANS", "methodology": "per diem", "standard_charge_dollar": 8000.0, "standard_charge_algorithm": "Expected reimbursement is the lesser of Per diem ($8,000) for the length of stay and 70% of billed.", "count": "0", "additional_payer_notes": "Zero final payments for the item or service in the 15 months prior to posting the file." }, { "payer_name": "HEALTH NET", "plan_name": "HEALTHNET HMO, PPO, POS, EPO, CANOPY HEALTHNET HMO, OTHER-IN-NETWORK PLANS", "methodology": "per diem", "standard_charge_dollar": 8000.0, "standard_charge_algorithm": "Expected reimbursement is the lesser of Per diem ($8,000) for the length of stay and 70% of billed.", "count": "0", "additional_payer_notes": "Zero final payments for the item or service in the 15 months prior to posting the file." }, { "payer_name": "UNITED HEALTHCARE", "plan_name": "SUTTER SELECT & SUTTER HEALTH PLAN HMO PLANS", "methodology": "per diem", "standard_charge_dollar": 28538.0, "standard_charge_algorithm": "Per diem ($28,538).", "count": "0", "additional_payer_notes": "Zero final payments for the item or service in the 15 months prior to posting the file." }, { "payer_name": "UNITED HEALTHCARE", "plan_name": "SUTTER SELECT & SUTTER HEALTH PLAN HMO PLANS", "methodology": "per diem", "standard_charge_dollar": 28538.0, "standard_charge_algorithm": "Per diem ($28,538).", "count": "0", "additional_payer_notes": "Zero final payments for the item or service in the 15 months prior to posting the file." }, { "payer_name": "SUTTER", "plan_name": "SUTTER SELECT & SUTTER HEALTH PLAN HMO PLANS", "methodology": "per diem", "standard_charge_dollar": 28538.0, "standard_charge_algorithm": "Per diem ($28,538).", "count": "0", "additional_payer_notes": "Zero final payments for the item or service in the 15 months prior to posting the file." }, { "payer_name": "UNITED HEALTHCARE", "plan_name": "SUTTER SELECT & SUTTER HEALTH PLAN HMO PLANS", "methodology": "per diem", "standard_charge_dollar": 28538.0, "standard_charge_algorithm": "Per diem ($28,538).", "count": "0", "additional_payer_notes": "Zero final payments for the item or service in the 15 months prior to posting the file." }, { "payer_name": "UMR", "plan_name": "SUTTER SELECT & SUTTER HEALTH PLAN HMO PLANS", "methodology": "per diem", "standard_charge_dollar": 28538.0, "standard_charge_algorithm": "Per diem ($28,538).", "count": "0", "additional_payer_notes": "Zero final payments for the item or service in the 15 months prior to posting the file." } ] } ] }, { "description": "HC Cap End Gp010", "code_information": [ { "code": "PX-2120027010", "type": "CDM" }, { "code": "99999", "type": "CPT" }, { "code": "0272", "type": "RC" } ], "standard_charges": [ { "setting": "outpatient", "gross_charge": 665.0, "discounted_cash": 332.5, "minimum": 280.63, "maximum": 345.8, "additional_generic_notes": "Zero final payments for the item or service in the 15 months prior to posting the file.", "payers_information": [ { "payer_name": "AETNA", "plan_name": "AETNA ALL OTHER PLANS", "methodology": "percent of total billed charges", "standard_charge_dollar": 345.8, "standard_charge_percentage": 52.0, "count": "0", "additional_payer_notes": "Zero final payments for the item or service in the 15 months prior to posting the file." }, { "payer_name": "AETNA", "plan_name": "AETNA ALL OTHER PLANS", "methodology": "percent of total billed charges", "standard_charge_dollar": 345.8, "standard_charge_percentage": 52.0, "count": "0", "additional_payer_notes": "Zero final payments for the item or service in the 15 months prior to posting the file." }, { "payer_name": "MERITAIN HEALTH", "plan_name": "AETNA ALL OTHER PLANS", "methodology": "percent of total billed charges", "standard_charge_dollar": 345.8, "standard_charge_percentage": 52.0, "count": "0", "additional_payer_notes": "Zero final payments for the item or service in the 15 months prior to posting the file." }, { "payer_name": "BLUE SHIELD OUT OF STATE", "plan_name": "STANFORD HEALTHCARE ALLIANCE PLAN", "methodology": "percent of total billed charges", "standard_charge_dollar": 323.12, "standard_charge_percentage": 48.59, "count": "0", "additional_payer_notes": "Zero final payments for the item or service in the 15 months prior to posting the file." }, { "payer_name": "BLUE SHIELD", "plan_name": "STANFORD HEALTHCARE ALLIANCE PLAN", "methodology": "percent of total billed charges", "standard_charge_dollar": 323.12, "standard_charge_percentage": 48.59, "count": "0", "additional_payer_notes": "Zero final payments for the item or service in the 15 months prior to posting the file." }, { "payer_name": "BLUE SHIELD", "plan_name": "STANFORD HEALTHCARE ALLIANCE PLAN", "methodology": "percent of total billed charges", "standard_charge_dollar": 323.12, "standard_charge_percentage": 48.59, "count": "0", "additional_payer_notes": "Zero final payments for the item or service in the 15 months prior to posting the file." }, { "payer_name": "CIGNA", "plan_name": "CIGNA COM ALT HMO PLAN", "methodology": "percent of total billed charges", "standard_charge_dollar": 280.63, "standard_charge_percentage": 42.2, "count": "0", "additional_payer_notes": "Zero final payments for the item or service in the 15 months prior to posting the file." }, { "payer_name": "CIGNA", "plan_name": "CIGNA COM ALT HMO PLAN", "methodology": "percent of total billed charges", "standard_charge_dollar": 280.63, "standard_charge_percentage": 42.2, "count": "0", "additional_payer_notes": "Zero final payments for the item or service in the 15 months prior to posting the file." }, { "payer_name": "HEALTH NET", "plan_name": "HEALTHNET HMO, PPO, POS, EPO, CANOPY HEALTHNET HMO, OTHER-IN-NETWORK PLANS", "methodology": "per diem", "standard_charge_dollar": 8000.0, "standard_charge_algorithm": "Expected reimbursement is the lesser of Per diem ($8,000) for the length of stay and 70% of billed.", "count": "0", "additional_payer_notes": "Zero final payments for the item or service in the 15 months prior to posting the file." }, { "payer_name": "HEALTH NET", "plan_name": "HEALTHNET HMO, PPO, POS, EPO, CANOPY HEALTHNET HMO, OTHER-IN-NETWORK PLANS", "methodology": "per diem", "standard_charge_dollar": 8000.0, "standard_charge_algorithm": "Expected reimbursement is the lesser of Per diem ($8,000) for the length of stay and 70% of billed.", "count": "0", "additional_payer_notes": "Zero final payments for the item or service in the 15 months prior to posting the file." }, { "payer_name": "UNITED HEALTHCARE", "plan_name": "SUTTER SELECT & SUTTER HEALTH PLAN HMO PLANS", "methodology": "per diem", "standard_charge_dollar": 28538.0, "standard_charge_algorithm": "Per diem ($28,538).", "count": "0", "additional_payer_notes": "Zero final payments for the item or service in the 15 months prior to posting the file." }, { "payer_name": "UNITED HEALTHCARE", "plan_name": "SUTTER SELECT & SUTTER HEALTH PLAN HMO PLANS", "methodology": "per diem", "standard_charge_dollar": 28538.0, "standard_charge_algorithm": "Per diem ($28,538).", "count": "0", "additional_payer_notes": "Zero final payments for the item or service in the 15 months prior to posting the file." }, { "payer_name": "SUTTER", "plan_name": "SUTTER SELECT & SUTTER HEALTH PLAN HMO PLANS", "methodology": "per diem", "standard_charge_dollar": 28538.0, "standard_charge_algorithm": "Per diem ($28,538).", "count": "0", "additional_payer_notes": "Zero final payments for the item or service in the 15 months prior to posting the file." }, { "payer_name": "UNITED HEALTHCARE", "plan_name": "SUTTER SELECT & SUTTER HEALTH PLAN HMO PLANS", "methodology": "per diem", "standard_charge_dollar": 28538.0, "standard_charge_algorithm": "Per diem ($28,538).", "count": "0", "additional_payer_notes": "Zero final payments for the item or service in the 15 months prior to posting the file." }, { "payer_name": "UMR", "plan_name": "SUTTER SELECT & SUTTER HEALTH PLAN HMO PLANS", "methodology": "per diem", "standard_charge_dollar": 28538.0, "standard_charge_algorithm": "Per diem ($28,538).", "count": "0", "additional_payer_notes": "Zero final payments for the item or service in the 15 months prior to posting the file." } ] } ] }, { "description": "HC Cath Gp002", "code_information": [ { "code": "PX-2120029002", "type": "CDM" }, { "code": "99999", "type": "CPT" }, { "code": "0272", "type": "RC" } ], "standard_charges": [ { "setting": "outpatient", "gross_charge": 50.0, "discounted_cash": 25.0, "minimum": 21.1, "maximum": 26.0, "additional_generic_notes": "Zero final payments for the item or service in the 15 months prior to posting the file.", "payers_information": [ { "payer_name": "AETNA", "plan_name": "AETNA ALL OTHER PLANS", "methodology": "percent of total billed charges", "standard_charge_dollar": 26.0, "standard_charge_percentage": 52.0, "count": "0", "additional_payer_notes": "Zero final payments for the item or service in the 15 months prior to posting the file." }, { "payer_name": "AETNA", "plan_name": "AETNA ALL OTHER PLANS", "methodology": "percent of total billed charges", "standard_charge_dollar": 26.0, "standard_charge_percentage": 52.0, "count": "0", "additional_payer_notes": "Zero final payments for the item or service in the 15 months prior to posting the file." }, { "payer_name": "MERITAIN HEALTH", "plan_name": "AETNA ALL OTHER PLANS", "methodology": "percent of total billed charges", "standard_charge_dollar": 26.0, "standard_charge_percentage": 52.0, "count": "0", "additional_payer_notes": "Zero final payments for the item or service in the 15 months prior to posting the file." }, { "payer_name": "BLUE SHIELD OUT OF STATE", "plan_name": "STANFORD HEALTHCARE ALLIANCE PLAN", "methodology": "percent of total billed charges", "standard_charge_dollar": 24.3, "standard_charge_percentage": 48.59, "count": "0", "additional_payer_notes": "Zero final payments for the item or service in the 15 months prior to posting the file." }, { "payer_name": "BLUE SHIELD", "plan_name": "STANFORD HEALTHCARE ALLIANCE PLAN", "methodology": "percent of total billed charges", "standard_charge_dollar": 24.3, "standard_charge_percentage": 48.59, "count": "0", "additional_payer_notes": "Zero final payments for the item or service in the 15 months prior to posting the file." }, { "payer_name": "BLUE SHIELD", "plan_name": "STANFORD HEALTHCARE ALLIANCE PLAN", "methodology": "percent of total billed charges", "standard_charge_dollar": 24.3, "standard_charge_percentage": 48.59, "count": "0", "additional_payer_notes": "Zero final payments for the item or service in the 15 months prior to posting the file." }, { "payer_name": "CIGNA", "plan_name": "CIGNA COM ALT HMO PLAN", "methodology": "percent of total billed charges", "standard_charge_dollar": 21.1, "standard_charge_percentage": 42.2, "count": "0", "additional_payer_notes": "Zero final payments for the item or service in the 15 months prior to posting the file." }, { "payer_name": "CIGNA", "plan_name": "CIGNA COM ALT HMO PLAN", "methodology": "percent of total billed charges", "standard_charge_dollar": 21.1, "standard_charge_percentage": 42.2, "count": "0", "additional_payer_notes": "Zero final payments for the item or service in the 15 months prior to posting the file." }, { "payer_name": "HEALTH NET", "plan_name": "HEALTHNET HMO, PPO, POS, EPO, CANOPY HEALTHNET HMO, OTHER-IN-NETWORK PLANS", "methodology": "per diem", "standard_charge_dollar": 8000.0, "standard_charge_algorithm": "Expected reimbursement is the lesser of Per diem ($8,000) for the length of stay and 70% of billed.", "count": "0", "additional_payer_notes": "Zero final payments for the item or service in the 15 months prior to posting the file." }, { "payer_name": "HEALTH NET", "plan_name": "HEALTHNET HMO, PPO, POS, EPO, CANOPY HEALTHNET HMO, OTHER-IN-NETWORK PLANS", "methodology": "per diem", "standard_charge_dollar": 8000.0, "standard_charge_algorithm": "Expected reimbursement is the lesser of Per diem ($8,000) for the length of stay and 70% of billed.", "count": "0", "additional_payer_notes": "Zero final payments for the item or service in the 15 months prior to posting the file." }, { "payer_name": "UNITED HEALTHCARE", "plan_name": "SUTTER SELECT & SUTTER HEALTH PLAN HMO PLANS", "methodology": "per diem", "standard_charge_dollar": 28538.0, "standard_charge_algorithm": "Per diem ($28,538).", "count": "0", "additional_payer_notes": "Zero final payments for the item or service in the 15 months prior to posting the file." }, { "payer_name": "UNITED HEALTHCARE", "plan_name": "SUTTER SELECT & SUTTER HEALTH PLAN HMO PLANS", "methodology": "per diem", "standard_charge_dollar": 28538.0, "standard_charge_algorithm": "Per diem ($28,538).", "count": "0", "additional_payer_notes": "Zero final payments for the item or service in the 15 months prior to posting the file." }, { "payer_name": "SUTTER", "plan_name": "SUTTER SELECT & SUTTER HEALTH PLAN HMO PLANS", "methodology": "per diem", "standard_charge_dollar": 28538.0, "standard_charge_algorithm": "Per diem ($28,538).", "count": "0", "additional_payer_notes": "Zero final payments for the item or service in the 15 months prior to posting the file." }, { "payer_name": "UNITED HEALTHCARE", "plan_name": "SUTTER SELECT & SUTTER HEALTH PLAN HMO PLANS", "methodology": "per diem", "standard_charge_dollar": 28538.0, "standard_charge_algorithm": "Per diem ($28,538).", "count": "0", "additional_payer_notes": "Zero final payments for the item or service in the 15 months prior to posting the file." }, { "payer_name": "UMR", "plan_name": "SUTTER SELECT & SUTTER HEALTH PLAN HMO PLANS", "methodology": "per diem", "standard_charge_dollar": 28538.0, "standard_charge_algorithm": "Per diem ($28,538).", "count": "0", "additional_payer_notes": "Zero final payments for the item or service in the 15 months prior to posting the file." } ] } ] }, { "description": "HC Cath Gp003", "code_information": [ { "code": "PX-2120029003", "type": "CDM" }, { "code": "99999", "type": "CPT" }, { "code": "0272", "type": "RC" } ], "standard_charges": [ { "setting": "outpatient", "gross_charge": 100.0, "discounted_cash": 50.0, "minimum": 42.2, "maximum": 52.0, "additional_generic_notes": "Zero final payments for the item or service in the 15 months prior to posting the file.", "payers_information": [ { "payer_name": "AETNA", "plan_name": "AETNA ALL OTHER PLANS", "methodology": "percent of total billed charges", "standard_charge_dollar": 52.0, "standard_charge_percentage": 52.0, "count": "0", "additional_payer_notes": "Zero final payments for the item or service in the 15 months prior to posting the file." }, { "payer_name": "AETNA", "plan_name": "AETNA ALL OTHER PLANS", "methodology": "percent of total billed charges", "standard_charge_dollar": 52.0, "standard_charge_percentage": 52.0, "count": "0", "additional_payer_notes": "Zero final payments for the item or service in the 15 months prior to posting the file." }, { "payer_name": "MERITAIN HEALTH", "plan_name": "AETNA ALL OTHER PLANS", "methodology": "percent of total billed charges", "standard_charge_dollar": 52.0, "standard_charge_percentage": 52.0, "count": "0", "additional_payer_notes": "Zero final payments for the item or service in the 15 months prior to posting the file." }, { "payer_name": "BLUE SHIELD OUT OF STATE", "plan_name": "STANFORD HEALTHCARE ALLIANCE PLAN", "methodology": "percent of total billed charges", "standard_charge_dollar": 48.59, "standard_charge_percentage": 48.59, "count": "0", "additional_payer_notes": "Zero final payments for the item or service in the 15 months prior to posting the file." }, { "payer_name": "BLUE SHIELD", "plan_name": "STANFORD HEALTHCARE ALLIANCE PLAN", "methodology": "percent of total billed charges", "standard_charge_dollar": 48.59, "standard_charge_percentage": 48.59, "count": "0", "additional_payer_notes": "Zero final payments for the item or service in the 15 months prior to posting the file." }, { "payer_name": "BLUE SHIELD", "plan_name": "STANFORD HEALTHCARE ALLIANCE PLAN", "methodology": "percent of total billed charges", "standard_charge_dollar": 48.59, "standard_charge_percentage": 48.59, "count": "0", "additional_payer_notes": "Zero final payments for the item or service in the 15 months prior to posting the file." }, { "payer_name": "CIGNA", "plan_name": "CIGNA COM ALT HMO PLAN", "methodology": "percent of total billed charges", "standard_charge_dollar": 42.2, "standard_charge_percentage": 42.2, "count": "0", "additional_payer_notes": "Zero final payments for the item or service in the 15 months prior to posting the file." }, { "payer_name": "CIGNA", "plan_name": "CIGNA COM ALT HMO PLAN", "methodology": "percent of total billed charges", "standard_charge_dollar": 42.2, "standard_charge_percentage": 42.2, "count": "0", "additional_payer_notes": "Zero final payments for the item or service in the 15 months prior to posting the file." }, { "payer_name": "HEALTH NET", "plan_name": "HEALTHNET HMO, PPO, POS, EPO, CANOPY HEALTHNET HMO, OTHER-IN-NETWORK PLANS", "methodology": "per diem", "standard_charge_dollar": 8000.0, "standard_charge_algorithm": "Expected reimbursement is the lesser of Per diem ($8,000) for the length of stay and 70% of billed.", "count": "0", "additional_payer_notes": "Zero final payments for the item or service in the 15 months prior to posting the file." }, { "payer_name": "HEALTH NET", "plan_name": "HEALTHNET HMO, PPO, POS, EPO, CANOPY HEALTHNET HMO, OTHER-IN-NETWORK PLANS", "methodology": "per diem", "standard_charge_dollar": 8000.0, "standard_charge_algorithm": "Expected reimbursement is the lesser of Per diem ($8,000) for the length of stay and 70% of billed.", "count": "0", "additional_payer_notes": "Zero final payments for the item or service in the 15 months prior to posting the file." }, { "payer_name": "UNITED HEALTHCARE", "plan_name": "SUTTER SELECT & SUTTER HEALTH PLAN HMO PLANS", "methodology": "per diem", "standard_charge_dollar": 28538.0, "standard_charge_algorithm": "Per diem ($28,538).", "count": "0", "additional_payer_notes": "Zero final payments for the item or service in the 15 months prior to posting the file." }, { "payer_name": "UNITED HEALTHCARE", "plan_name": "SUTTER SELECT & SUTTER HEALTH PLAN HMO PLANS", "methodology": "per diem", "standard_charge_dollar": 28538.0, "standard_charge_algorithm": "Per diem ($28,538).", "count": "0", "additional_payer_notes": "Zero final payments for the item or service in the 15 months prior to posting the file." }, { "payer_name": "SUTTER", "plan_name": "SUTTER SELECT & SUTTER HEALTH PLAN HMO PLANS", "methodology": "per diem", "standard_charge_dollar": 28538.0, "standard_charge_algorithm": "Per diem ($28,538).", "count": "0", "additional_payer_notes": "Zero final payments for the item or service in the 15 months prior to posting the file." }, { "payer_name": "UNITED HEALTHCARE", "plan_name": "SUTTER SELECT & SUTTER HEALTH PLAN HMO PLANS", "methodology": "per diem", "standard_charge_dollar": 28538.0, "standard_charge_algorithm": "Per diem ($28,538).", "count": "0", "additional_payer_notes": "Zero final payments for the item or service in the 15 months prior to posting the file." }, { "payer_name": "UMR", "plan_name": "SUTTER SELECT & SUTTER HEALTH PLAN HMO PLANS", "methodology": "per diem", "standard_charge_dollar": 28538.0, "standard_charge_algorithm": "Per diem ($28,538).", "count": "0", "additional_payer_notes": "Zero final payments for the item or service in the 15 months prior to posting the file." } ] } ] }, { "description": "HC Cath Gp004", "code_information": [ { "code": "PX-2120029004", "type": "CDM" }, { "code": "99999", "type": "CPT" }, { "code": "0272", "type": "RC" } ], "standard_charges": [ { "setting": "outpatient", "gross_charge": 146.0, "discounted_cash": 73.0, "minimum": 61.61, "maximum": 75.92, "additional_generic_notes": "Zero final payments for the item or service in the 15 months prior to posting the file.", "payers_information": [ { "payer_name": "AETNA", "plan_name": "AETNA ALL OTHER PLANS", "methodology": "percent of total billed charges", "standard_charge_dollar": 75.92, "standard_charge_percentage": 52.0, "count": "0", "additional_payer_notes": "Zero final payments for the item or service in the 15 months prior to posting the file." }, { "payer_name": "AETNA", "plan_name": "AETNA ALL OTHER PLANS", "methodology": "percent of total billed charges", "standard_charge_dollar": 75.92, "standard_charge_percentage": 52.0, "count": "0", "additional_payer_notes": "Zero final payments for the item or service in the 15 months prior to posting the file." }, { "payer_name": "MERITAIN HEALTH", "plan_name": "AETNA ALL OTHER PLANS", "methodology": "percent of total billed charges", "standard_charge_dollar": 75.92, "standard_charge_percentage": 52.0, "count": "0", "additional_payer_notes": "Zero final payments for the item or service in the 15 months prior to posting the file." }, { "payer_name": "BLUE SHIELD OUT OF STATE", "plan_name": "STANFORD HEALTHCARE ALLIANCE PLAN", "methodology": "percent of total billed charges", "standard_charge_dollar": 70.94, "standard_charge_percentage": 48.59, "count": "0", "additional_payer_notes": "Zero final payments for the item or service in the 15 months prior to posting the file." }, { "payer_name": "BLUE SHIELD", "plan_name": "STANFORD HEALTHCARE ALLIANCE PLAN", "methodology": "percent of total billed charges", "standard_charge_dollar": 70.94, "standard_charge_percentage": 48.59, "count": "0", "additional_payer_notes": "Zero final payments for the item or service in the 15 months prior to posting the file." }, { "payer_name": "BLUE SHIELD", "plan_name": "STANFORD HEALTHCARE ALLIANCE PLAN", "methodology": "percent of total billed charges", "standard_charge_dollar": 70.94, "standard_charge_percentage": 48.59, "count": "0", "additional_payer_notes": "Zero final payments for the item or service in the 15 months prior to posting the file." }, { "payer_name": "CIGNA", "plan_name": "CIGNA COM ALT HMO PLAN", "methodology": "percent of total billed charges", "standard_charge_dollar": 61.61, "standard_charge_percentage": 42.2, "count": "0", "additional_payer_notes": "Zero final payments for the item or service in the 15 months prior to posting the file." }, { "payer_name": "CIGNA", "plan_name": "CIGNA COM ALT HMO PLAN", "methodology": "percent of total billed charges", "standard_charge_dollar": 61.61, "standard_charge_percentage": 42.2, "count": "0", "additional_payer_notes": "Zero final payments for the item or service in the 15 months prior to posting the file." }, { "payer_name": "HEALTH NET", "plan_name": "HEALTHNET HMO, PPO, POS, EPO, CANOPY HEALTHNET HMO, OTHER-IN-NETWORK PLANS", "methodology": "per diem", "standard_charge_dollar": 8000.0, "standard_charge_algorithm": "Expected reimbursement is the lesser of Per diem ($8,000) for the length of stay and 70% of billed.", "count": "0", "additional_payer_notes": "Zero final payments for the item or service in the 15 months prior to posting the file." }, { "payer_name": "HEALTH NET", "plan_name": "HEALTHNET HMO, PPO, POS, EPO, CANOPY HEALTHNET HMO, OTHER-IN-NETWORK PLANS", "methodology": "per diem", "standard_charge_dollar": 8000.0, "standard_charge_algorithm": "Expected reimbursement is the lesser of Per diem ($8,000) for the length of stay and 70% of billed.", "count": "0", "additional_payer_notes": "Zero final payments for the item or service in the 15 months prior to posting the file." }, { "payer_name": "UNITED HEALTHCARE", "plan_name": "SUTTER SELECT & SUTTER HEALTH PLAN HMO PLANS", "methodology": "per diem", "standard_charge_dollar": 28538.0, "standard_charge_algorithm": "Per diem ($28,538).", "count": "0", "additional_payer_notes": "Zero final payments for the item or service in the 15 months prior to posting the file." }, { "payer_name": "UNITED HEALTHCARE", "plan_name": "SUTTER SELECT & SUTTER HEALTH PLAN HMO PLANS", "methodology": "per diem", "standard_charge_dollar": 28538.0, "standard_charge_algorithm": "Per diem ($28,538).", "count": "0", "additional_payer_notes": "Zero final payments for the item or service in the 15 months prior to posting the file." }, { "payer_name": "SUTTER", "plan_name": "SUTTER SELECT & SUTTER HEALTH PLAN HMO PLANS", "methodology": "per diem", "standard_charge_dollar": 28538.0, "standard_charge_algorithm": "Per diem ($28,538).", "count": "0", "additional_payer_notes": "Zero final payments for the item or service in the 15 months prior to posting the file." }, { "payer_name": "UNITED HEALTHCARE", "plan_name": "SUTTER SELECT & SUTTER HEALTH PLAN HMO PLANS", "methodology": "per diem", "standard_charge_dollar": 28538.0, "standard_charge_algorithm": "Per diem ($28,538).", "count": "0", "additional_payer_notes": "Zero final payments for the item or service in the 15 months prior to posting the file." }, { "payer_name": "UMR", "plan_name": "SUTTER SELECT & SUTTER HEALTH PLAN HMO PLANS", "methodology": "per diem", "standard_charge_dollar": 28538.0, "standard_charge_algorithm": "Per diem ($28,538).", "count": "0", "additional_payer_notes": "Zero final payments for the item or service in the 15 months prior to posting the file." } ] } ] }, { "description": "HC Cath Gp005", "code_information": [ { "code": "PX-2120029005", "type": "CDM" }, { "code": "99999", "type": "CPT" }, { "code": "0272", "type": "RC" } ], "standard_charges": [ { "setting": "outpatient", "gross_charge": 195.0, "discounted_cash": 97.5, "minimum": 82.29, "maximum": 101.4, "additional_generic_notes": "Zero final payments for the item or service in the 15 months prior to posting the file.", "payers_information": [ { "payer_name": "AETNA", "plan_name": "AETNA ALL OTHER PLANS", "methodology": "percent of total billed charges", "standard_charge_dollar": 101.4, "standard_charge_percentage": 52.0, "count": "0", "additional_payer_notes": "Zero final payments for the item or service in the 15 months prior to posting the file." }, { "payer_name": "AETNA", "plan_name": "AETNA ALL OTHER PLANS", "methodology": "percent of total billed charges", "standard_charge_dollar": 101.4, "standard_charge_percentage": 52.0, "count": "0", "additional_payer_notes": "Zero final payments for the item or service in the 15 months prior to posting the file." }, { "payer_name": "MERITAIN HEALTH", "plan_name": "AETNA ALL OTHER PLANS", "methodology": "percent of total billed charges", "standard_charge_dollar": 101.4, "standard_charge_percentage": 52.0, "count": "0", "additional_payer_notes": "Zero final payments for the item or service in the 15 months prior to posting the file." }, { "payer_name": "BLUE SHIELD OUT OF STATE", "plan_name": "STANFORD HEALTHCARE ALLIANCE PLAN", "methodology": "percent of total billed charges", "standard_charge_dollar": 94.75, "standard_charge_percentage": 48.59, "count": "0", "additional_payer_notes": "Zero final payments for the item or service in the 15 months prior to posting the file." }, { "payer_name": "BLUE SHIELD", "plan_name": "STANFORD HEALTHCARE ALLIANCE PLAN", "methodology": "percent of total billed charges", "standard_charge_dollar": 94.75, "standard_charge_percentage": 48.59, "count": "0", "additional_payer_notes": "Zero final payments for the item or service in the 15 months prior to posting the file." }, { "payer_name": "BLUE SHIELD", "plan_name": "STANFORD HEALTHCARE ALLIANCE PLAN", "methodology": "percent of total billed charges", "standard_charge_dollar": 94.75, "standard_charge_percentage": 48.59, "count": "0", "additional_payer_notes": "Zero final payments for the item or service in the 15 months prior to posting the file." }, { "payer_name": "CIGNA", "plan_name": "CIGNA COM ALT HMO PLAN", "methodology": "percent of total billed charges", "standard_charge_dollar": 82.29, "standard_charge_percentage": 42.2, "count": "0", "additional_payer_notes": "Zero final payments for the item or service in the 15 months prior to posting the file." }, { "payer_name": "CIGNA", "plan_name": "CIGNA COM ALT HMO PLAN", "methodology": "percent of total billed charges", "standard_charge_dollar": 82.29, "standard_charge_percentage": 42.2, "count": "0", "additional_payer_notes": "Zero final payments for the item or service in the 15 months prior to posting the file." }, { "payer_name": "HEALTH NET", "plan_name": "HEALTHNET HMO, PPO, POS, EPO, CANOPY HEALTHNET HMO, OTHER-IN-NETWORK PLANS", "methodology": "per diem", "standard_charge_dollar": 8000.0, "standard_charge_algorithm": "Expected reimbursement is the lesser of Per diem ($8,000) for the length of stay and 70% of billed.", "count": "0", "additional_payer_notes": "Zero final payments for the item or service in the 15 months prior to posting the file." }, { "payer_name": "HEALTH NET", "plan_name": "HEALTHNET HMO, PPO, POS, EPO, CANOPY HEALTHNET HMO, OTHER-IN-NETWORK PLANS", "methodology": "per diem", "standard_charge_dollar": 8000.0, "standard_charge_algorithm": "Expected reimbursement is the lesser of Per diem ($8,000) for the length of stay and 70% of billed.", "count": "0", "additional_payer_notes": "Zero final payments for the item or service in the 15 months prior to posting the file." }, { "payer_name": "UNITED HEALTHCARE", "plan_name": "SUTTER SELECT & SUTTER HEALTH PLAN HMO PLANS", "methodology": "per diem", "standard_charge_dollar": 28538.0, "standard_charge_algorithm": "Per diem ($28,538).", "count": "0", "additional_payer_notes": "Zero final payments for the item or service in the 15 months prior to posting the file." }, { "payer_name": "UNITED HEALTHCARE", "plan_name": "SUTTER SELECT & SUTTER HEALTH PLAN HMO PLANS", "methodology": "per diem", "standard_charge_dollar": 28538.0, "standard_charge_algorithm": "Per diem ($28,538).", "count": "0", "additional_payer_notes": "Zero final payments for the item or service in the 15 months prior to posting the file." }, { "payer_name": "SUTTER", "plan_name": "SUTTER SELECT & SUTTER HEALTH PLAN HMO PLANS", "methodology": "per diem", "standard_charge_dollar": 28538.0, "standard_charge_algorithm": "Per diem ($28,538).", "count": "0", "additional_payer_notes": "Zero final payments for the item or service in the 15 months prior to posting the file." }, { "payer_name": "UNITED HEALTHCARE", "plan_name": "SUTTER SELECT & SUTTER HEALTH PLAN HMO PLANS", "methodology": "per diem", "standard_charge_dollar": 28538.0, "standard_charge_algorithm": "Per diem ($28,538).", "count": "0", "additional_payer_notes": "Zero final payments for the item or service in the 15 months prior to posting the file." }, { "payer_name": "UMR", "plan_name": "SUTTER SELECT & SUTTER HEALTH PLAN HMO PLANS", "methodology": "per diem", "standard_charge_dollar": 28538.0, "standard_charge_algorithm": "Per diem ($28,538).", "count": "0", "additional_payer_notes": "Zero final payments for the item or service in the 15 months prior to posting the file." } ] } ] }, { "description": "HC Cath Gp006", "code_information": [ { "code": "PX-2120029006", "type": "CDM" }, { "code": "99999", "type": "CPT" }, { "code": "0272", "type": "RC" } ], "standard_charges": [ { "setting": "outpatient", "gross_charge": 293.0, "discounted_cash": 146.5, "minimum": 123.65, "maximum": 152.36, "additional_generic_notes": "Zero final payments for the item or service in the 15 months prior to posting the file.", "payers_information": [ { "payer_name": "AETNA", "plan_name": "AETNA ALL OTHER PLANS", "methodology": "percent of total billed charges", "standard_charge_dollar": 152.36, "standard_charge_percentage": 52.0, "count": "0", "additional_payer_notes": "Zero final payments for the item or service in the 15 months prior to posting the file." }, { "payer_name": "AETNA", "plan_name": "AETNA ALL OTHER PLANS", "methodology": "percent of total billed charges", "standard_charge_dollar": 152.36, "standard_charge_percentage": 52.0, "count": "0", "additional_payer_notes": "Zero final payments for the item or service in the 15 months prior to posting the file." }, { "payer_name": "MERITAIN HEALTH", "plan_name": "AETNA ALL OTHER PLANS", "methodology": "percent of total billed charges", "standard_charge_dollar": 152.36, "standard_charge_percentage": 52.0, "count": "0", "additional_payer_notes": "Zero final payments for the item or service in the 15 months prior to posting the file." }, { "payer_name": "BLUE SHIELD OUT OF STATE", "plan_name": "STANFORD HEALTHCARE ALLIANCE PLAN", "methodology": "percent of total billed charges", "standard_charge_dollar": 142.37, "standard_charge_percentage": 48.59, "count": "0", "additional_payer_notes": "Zero final payments for the item or service in the 15 months prior to posting the file." }, { "payer_name": "BLUE SHIELD", "plan_name": "STANFORD HEALTHCARE ALLIANCE PLAN", "methodology": "percent of total billed charges", "standard_charge_dollar": 142.37, "standard_charge_percentage": 48.59, "count": "0", "additional_payer_notes": "Zero final payments for the item or service in the 15 months prior to posting the file." }, { "payer_name": "BLUE SHIELD", "plan_name": "STANFORD HEALTHCARE ALLIANCE PLAN", "methodology": "percent of total billed charges", "standard_charge_dollar": 142.37, "standard_charge_percentage": 48.59, "count": "0", "additional_payer_notes": "Zero final payments for the item or service in the 15 months prior to posting the file." }, { "payer_name": "CIGNA", "plan_name": "CIGNA COM ALT HMO PLAN", "methodology": "percent of total billed charges", "standard_charge_dollar": 123.65, "standard_charge_percentage": 42.2, "count": "0", "additional_payer_notes": "Zero final payments for the item or service in the 15 months prior to posting the file." }, { "payer_name": "CIGNA", "plan_name": "CIGNA COM ALT HMO PLAN", "methodology": "percent of total billed charges", "standard_charge_dollar": 123.65, "standard_charge_percentage": 42.2, "count": "0", "additional_payer_notes": "Zero final payments for the item or service in the 15 months prior to posting the file." }, { "payer_name": "HEALTH NET", "plan_name": "HEALTHNET HMO, PPO, POS, EPO, CANOPY HEALTHNET HMO, OTHER-IN-NETWORK PLANS", "methodology": "per diem", "standard_charge_dollar": 8000.0, "standard_charge_algorithm": "Expected reimbursement is the lesser of Per diem ($8,000) for the length of stay and 70% of billed.", "count": "0", "additional_payer_notes": "Zero final payments for the item or service in the 15 months prior to posting the file." }, { "payer_name": "HEALTH NET", "plan_name": "HEALTHNET HMO, PPO, POS, EPO, CANOPY HEALTHNET HMO, OTHER-IN-NETWORK PLANS", "methodology": "per diem", "standard_charge_dollar": 8000.0, "standard_charge_algorithm": "Expected reimbursement is the lesser of Per diem ($8,000) for the length of stay and 70% of billed.", "count": "0", "additional_payer_notes": "Zero final payments for the item or service in the 15 months prior to posting the file." }, { "payer_name": "UNITED HEALTHCARE", "plan_name": "SUTTER SELECT & SUTTER HEALTH PLAN HMO PLANS", "methodology": "per diem", "standard_charge_dollar": 28538.0, "standard_charge_algorithm": "Per diem ($28,538).", "count": "0", "additional_payer_notes": "Zero final payments for the item or service in the 15 months prior to posting the file." }, { "payer_name": "UNITED HEALTHCARE", "plan_name": "SUTTER SELECT & SUTTER HEALTH PLAN HMO PLANS", "methodology": "per diem", "standard_charge_dollar": 28538.0, "standard_charge_algorithm": "Per diem ($28,538).", "count": "0", "additional_payer_notes": "Zero final payments for the item or service in the 15 months prior to posting the file." }, { "payer_name": "SUTTER", "plan_name": "SUTTER SELECT & SUTTER HEALTH PLAN HMO PLANS", "methodology": "per diem", "standard_charge_dollar": 28538.0, "standard_charge_algorithm": "Per diem ($28,538).", "count": "0", "additional_payer_notes": "Zero final payments for the item or service in the 15 months prior to posting the file." }, { "payer_name": "UNITED HEALTHCARE", "plan_name": "SUTTER SELECT & SUTTER HEALTH PLAN HMO PLANS", "methodology": "per diem", "standard_charge_dollar": 28538.0, "standard_charge_algorithm": "Per diem ($28,538).", "count": "0", "additional_payer_notes": "Zero final payments for the item or service in the 15 months prior to posting the file." }, { "payer_name": "UMR", "plan_name": "SUTTER SELECT & SUTTER HEALTH PLAN HMO PLANS", "methodology": "per diem", "standard_charge_dollar": 28538.0, "standard_charge_algorithm": "Per diem ($28,538).", "count": "0", "additional_payer_notes": "Zero final payments for the item or service in the 15 months prior to posting the file." } ] } ] }, { "description": "HC Cath Gp007", "code_information": [ { "code": "PX-2120029007", "type": "CDM" }, { "code": "99999", "type": "CPT" }, { "code": "0272", "type": "RC" } ], "standard_charges": [ { "setting": "outpatient", "gross_charge": 380.0, "discounted_cash": 190.0, "minimum": 160.36, "maximum": 197.6, "additional_generic_notes": "Zero final payments for the item or service in the 15 months prior to posting the file.", "payers_information": [ { "payer_name": "AETNA", "plan_name": "AETNA ALL OTHER PLANS", "methodology": "percent of total billed charges", "standard_charge_dollar": 197.6, "standard_charge_percentage": 52.0, "count": "0", "additional_payer_notes": "Zero final payments for the item or service in the 15 months prior to posting the file." }, { "payer_name": "AETNA", "plan_name": "AETNA ALL OTHER PLANS", "methodology": "percent of total billed charges", "standard_charge_dollar": 197.6, "standard_charge_percentage": 52.0, "count": "0", "additional_payer_notes": "Zero final payments for the item or service in the 15 months prior to posting the file." }, { "payer_name": "MERITAIN HEALTH", "plan_name": "AETNA ALL OTHER PLANS", "methodology": "percent of total billed charges", "standard_charge_dollar": 197.6, "standard_charge_percentage": 52.0, "count": "0", "additional_payer_notes": "Zero final payments for the item or service in the 15 months prior to posting the file." }, { "payer_name": "BLUE SHIELD OUT OF STATE", "plan_name": "STANFORD HEALTHCARE ALLIANCE PLAN", "methodology": "percent of total billed charges", "standard_charge_dollar": 184.64, "standard_charge_percentage": 48.59, "count": "0", "additional_payer_notes": "Zero final payments for the item or service in the 15 months prior to posting the file." }, { "payer_name": "BLUE SHIELD", "plan_name": "STANFORD HEALTHCARE ALLIANCE PLAN", "methodology": "percent of total billed charges", "standard_charge_dollar": 184.64, "standard_charge_percentage": 48.59, "count": "0", "additional_payer_notes": "Zero final payments for the item or service in the 15 months prior to posting the file." }, { "payer_name": "BLUE SHIELD", "plan_name": "STANFORD HEALTHCARE ALLIANCE PLAN", "methodology": "percent of total billed charges", "standard_charge_dollar": 184.64, "standard_charge_percentage": 48.59, "count": "0", "additional_payer_notes": "Zero final payments for the item or service in the 15 months prior to posting the file." }, { "payer_name": "CIGNA", "plan_name": "CIGNA COM ALT HMO PLAN", "methodology": "percent of total billed charges", "standard_charge_dollar": 160.36, "standard_charge_percentage": 42.2, "count": "0", "additional_payer_notes": "Zero final payments for the item or service in the 15 months prior to posting the file." }, { "payer_name": "CIGNA", "plan_name": "CIGNA COM ALT HMO PLAN", "methodology": "percent of total billed charges", "standard_charge_dollar": 160.36, "standard_charge_percentage": 42.2, "count": "0", "additional_payer_notes": "Zero final payments for the item or service in the 15 months prior to posting the file." }, { "payer_name": "HEALTH NET", "plan_name": "HEALTHNET HMO, PPO, POS, EPO, CANOPY HEALTHNET HMO, OTHER-IN-NETWORK PLANS", "methodology": "per diem", "standard_charge_dollar": 8000.0, "standard_charge_algorithm": "Expected reimbursement is the lesser of Per diem ($8,000) for the length of stay and 70% of billed.", "count": "0", "additional_payer_notes": "Zero final payments for the item or service in the 15 months prior to posting the file." }, { "payer_name": "HEALTH NET", "plan_name": "HEALTHNET HMO, PPO, POS, EPO, CANOPY HEALTHNET HMO, OTHER-IN-NETWORK PLANS", "methodology": "per diem", "standard_charge_dollar": 8000.0, "standard_charge_algorithm": "Expected reimbursement is the lesser of Per diem ($8,000) for the length of stay and 70% of billed.", "count": "0", "additional_payer_notes": "Zero final payments for the item or service in the 15 months prior to posting the file." }, { "payer_name": "UNITED HEALTHCARE", "plan_name": "SUTTER SELECT & SUTTER HEALTH PLAN HMO PLANS", "methodology": "per diem", "standard_charge_dollar": 28538.0, "standard_charge_algorithm": "Per diem ($28,538).", "count": "0", "additional_payer_notes": "Zero final payments for the item or service in the 15 months prior to posting the file." }, { "payer_name": "UNITED HEALTHCARE", "plan_name": "SUTTER SELECT & SUTTER HEALTH PLAN HMO PLANS", "methodology": "per diem", "standard_charge_dollar": 28538.0, "standard_charge_algorithm": "Per diem ($28,538).", "count": "0", "additional_payer_notes": "Zero final payments for the item or service in the 15 months prior to posting the file." }, { "payer_name": "SUTTER", "plan_name": "SUTTER SELECT & SUTTER HEALTH PLAN HMO PLANS", "methodology": "per diem", "standard_charge_dollar": 28538.0, "standard_charge_algorithm": "Per diem ($28,538).", "count": "0", "additional_payer_notes": "Zero final payments for the item or service in the 15 months prior to posting the file." }, { "payer_name": "UNITED HEALTHCARE", "plan_name": "SUTTER SELECT & SUTTER HEALTH PLAN HMO PLANS", "methodology": "per diem", "standard_charge_dollar": 28538.0, "standard_charge_algorithm": "Per diem ($28,538).", "count": "0", "additional_payer_notes": "Zero final payments for the item or service in the 15 months prior to posting the file." }, { "payer_name": "UMR", "plan_name": "SUTTER SELECT & SUTTER HEALTH PLAN HMO PLANS", "methodology": "per diem", "standard_charge_dollar": 28538.0, "standard_charge_algorithm": "Per diem ($28,538).", "count": "0", "additional_payer_notes": "Zero final payments for the item or service in the 15 months prior to posting the file." } ] } ] }, { "description": "HC Cath Gp008", "code_information": [ { "code": "PX-2120029008", "type": "CDM" }, { "code": "99999", "type": "CPT" }, { "code": "0272", "type": "RC" } ], "standard_charges": [ { "setting": "outpatient", "gross_charge": 475.0, "discounted_cash": 237.5, "minimum": 200.45, "maximum": 247.0, "additional_generic_notes": "Zero final payments for the item or service in the 15 months prior to posting the file.", "payers_information": [ { "payer_name": "AETNA", "plan_name": "AETNA ALL OTHER PLANS", "methodology": "percent of total billed charges", "standard_charge_dollar": 247.0, "standard_charge_percentage": 52.0, "count": "0", "additional_payer_notes": "Zero final payments for the item or service in the 15 months prior to posting the file." }, { "payer_name": "AETNA", "plan_name": "AETNA ALL OTHER PLANS", "methodology": "percent of total billed charges", "standard_charge_dollar": 247.0, "standard_charge_percentage": 52.0, "count": "0", "additional_payer_notes": "Zero final payments for the item or service in the 15 months prior to posting the file." }, { "payer_name": "MERITAIN HEALTH", "plan_name": "AETNA ALL OTHER PLANS", "methodology": "percent of total billed charges", "standard_charge_dollar": 247.0, "standard_charge_percentage": 52.0, "count": "0", "additional_payer_notes": "Zero final payments for the item or service in the 15 months prior to posting the file." }, { "payer_name": "BLUE SHIELD OUT OF STATE", "plan_name": "STANFORD HEALTHCARE ALLIANCE PLAN", "methodology": "percent of total billed charges", "standard_charge_dollar": 230.8, "standard_charge_percentage": 48.59, "count": "0", "additional_payer_notes": "Zero final payments for the item or service in the 15 months prior to posting the file." }, { "payer_name": "BLUE SHIELD", "plan_name": "STANFORD HEALTHCARE ALLIANCE PLAN", "methodology": "percent of total billed charges", "standard_charge_dollar": 230.8, "standard_charge_percentage": 48.59, "count": "0", "additional_payer_notes": "Zero final payments for the item or service in the 15 months prior to posting the file." }, { "payer_name": "BLUE SHIELD", "plan_name": "STANFORD HEALTHCARE ALLIANCE PLAN", "methodology": "percent of total billed charges", "standard_charge_dollar": 230.8, "standard_charge_percentage": 48.59, "count": "0", "additional_payer_notes": "Zero final payments for the item or service in the 15 months prior to posting the file." }, { "payer_name": "CIGNA", "plan_name": "CIGNA COM ALT HMO PLAN", "methodology": "percent of total billed charges", "standard_charge_dollar": 200.45, "standard_charge_percentage": 42.2, "count": "0", "additional_payer_notes": "Zero final payments for the item or service in the 15 months prior to posting the file." }, { "payer_name": "CIGNA", "plan_name": "CIGNA COM ALT HMO PLAN", "methodology": "percent of total billed charges", "standard_charge_dollar": 200.45, "standard_charge_percentage": 42.2, "count": "0", "additional_payer_notes": "Zero final payments for the item or service in the 15 months prior to posting the file." }, { "payer_name": "HEALTH NET", "plan_name": "HEALTHNET HMO, PPO, POS, EPO, CANOPY HEALTHNET HMO, OTHER-IN-NETWORK PLANS", "methodology": "per diem", "standard_charge_dollar": 8000.0, "standard_charge_algorithm": "Expected reimbursement is the lesser of Per diem ($8,000) for the length of stay and 70% of billed.", "count": "0", "additional_payer_notes": "Zero final payments for the item or service in the 15 months prior to posting the file." }, { "payer_name": "HEALTH NET", "plan_name": "HEALTHNET HMO, PPO, POS, EPO, CANOPY HEALTHNET HMO, OTHER-IN-NETWORK PLANS", "methodology": "per diem", "standard_charge_dollar": 8000.0, "standard_charge_algorithm": "Expected reimbursement is the lesser of Per diem ($8,000) for the length of stay and 70% of billed.", "count": "0", "additional_payer_notes": "Zero final payments for the item or service in the 15 months prior to posting the file." }, { "payer_name": "UNITED HEALTHCARE", "plan_name": "SUTTER SELECT & SUTTER HEALTH PLAN HMO PLANS", "methodology": "per diem", "standard_charge_dollar": 28538.0, "standard_charge_algorithm": "Per diem ($28,538).", "count": "0", "additional_payer_notes": "Zero final payments for the item or service in the 15 months prior to posting the file." }, { "payer_name": "UNITED HEALTHCARE", "plan_name": "SUTTER SELECT & SUTTER HEALTH PLAN HMO PLANS", "methodology": "per diem", "standard_charge_dollar": 28538.0, "standard_charge_algorithm": "Per diem ($28,538).", "count": "0", "additional_payer_notes": "Zero final payments for the item or service in the 15 months prior to posting the file." }, { "payer_name": "SUTTER", "plan_name": "SUTTER SELECT & SUTTER HEALTH PLAN HMO PLANS", "methodology": "per diem", "standard_charge_dollar": 28538.0, "standard_charge_algorithm": "Per diem ($28,538).", "count": "0", "additional_payer_notes": "Zero final payments for the item or service in the 15 months prior to posting the file." }, { "payer_name": "UNITED HEALTHCARE", "plan_name": "SUTTER SELECT & SUTTER HEALTH PLAN HMO PLANS", "methodology": "per diem", "standard_charge_dollar": 28538.0, "standard_charge_algorithm": "Per diem ($28,538).", "count": "0", "additional_payer_notes": "Zero final payments for the item or service in the 15 months prior to posting the file." }, { "payer_name": "UMR", "plan_name": "SUTTER SELECT & SUTTER HEALTH PLAN HMO PLANS", "methodology": "per diem", "standard_charge_dollar": 28538.0, "standard_charge_algorithm": "Per diem ($28,538).", "count": "0", "additional_payer_notes": "Zero final payments for the item or service in the 15 months prior to posting the file." } ] } ] }, { "description": "HC Cath Gp009", "code_information": [ { "code": "PX-2120029009", "type": "CDM" }, { "code": "99999", "type": "CPT" }, { "code": "0272", "type": "RC" } ], "standard_charges": [ { "setting": "outpatient", "gross_charge": 570.0, "discounted_cash": 285.0, "minimum": 240.54, "maximum": 296.4, "additional_generic_notes": "Zero final payments for the item or service in the 15 months prior to posting the file.", "payers_information": [ { "payer_name": "AETNA", "plan_name": "AETNA ALL OTHER PLANS", "methodology": "percent of total billed charges", "standard_charge_dollar": 296.4, "standard_charge_percentage": 52.0, "count": "0", "additional_payer_notes": "Zero final payments for the item or service in the 15 months prior to posting the file." }, { "payer_name": "AETNA", "plan_name": "AETNA ALL OTHER PLANS", "methodology": "percent of total billed charges", "standard_charge_dollar": 296.4, "standard_charge_percentage": 52.0, "count": "0", "additional_payer_notes": "Zero final payments for the item or service in the 15 months prior to posting the file." }, { "payer_name": "MERITAIN HEALTH", "plan_name": "AETNA ALL OTHER PLANS", "methodology": "percent of total billed charges", "standard_charge_dollar": 296.4, "standard_charge_percentage": 52.0, "count": "0", "additional_payer_notes": "Zero final payments for the item or service in the 15 months prior to posting the file." }, { "payer_name": "BLUE SHIELD OUT OF STATE", "plan_name": "STANFORD HEALTHCARE ALLIANCE PLAN", "methodology": "percent of total billed charges", "standard_charge_dollar": 276.96, "standard_charge_percentage": 48.59, "count": "0", "additional_payer_notes": "Zero final payments for the item or service in the 15 months prior to posting the file." }, { "payer_name": "BLUE SHIELD", "plan_name": "STANFORD HEALTHCARE ALLIANCE PLAN", "methodology": "percent of total billed charges", "standard_charge_dollar": 276.96, "standard_charge_percentage": 48.59, "count": "0", "additional_payer_notes": "Zero final payments for the item or service in the 15 months prior to posting the file." }, { "payer_name": "BLUE SHIELD", "plan_name": "STANFORD HEALTHCARE ALLIANCE PLAN", "methodology": "percent of total billed charges", "standard_charge_dollar": 276.96, "standard_charge_percentage": 48.59, "count": "0", "additional_payer_notes": "Zero final payments for the item or service in the 15 months prior to posting the file." }, { "payer_name": "CIGNA", "plan_name": "CIGNA COM ALT HMO PLAN", "methodology": "percent of total billed charges", "standard_charge_dollar": 240.54, "standard_charge_percentage": 42.2, "count": "0", "additional_payer_notes": "Zero final payments for the item or service in the 15 months prior to posting the file." }, { "payer_name": "CIGNA", "plan_name": "CIGNA COM ALT HMO PLAN", "methodology": "percent of total billed charges", "standard_charge_dollar": 240.54, "standard_charge_percentage": 42.2, "count": "0", "additional_payer_notes": "Zero final payments for the item or service in the 15 months prior to posting the file." }, { "payer_name": "HEALTH NET", "plan_name": "HEALTHNET HMO, PPO, POS, EPO, CANOPY HEALTHNET HMO, OTHER-IN-NETWORK PLANS", "methodology": "per diem", "standard_charge_dollar": 8000.0, "standard_charge_algorithm": "Expected reimbursement is the lesser of Per diem ($8,000) for the length of stay and 70% of billed.", "count": "0", "additional_payer_notes": "Zero final payments for the item or service in the 15 months prior to posting the file." }, { "payer_name": "HEALTH NET", "plan_name": "HEALTHNET HMO, PPO, POS, EPO, CANOPY HEALTHNET HMO, OTHER-IN-NETWORK PLANS", "methodology": "per diem", "standard_charge_dollar": 8000.0, "standard_charge_algorithm": "Expected reimbursement is the lesser of Per diem ($8,000) for the length of stay and 70% of billed.", "count": "0", "additional_payer_notes": "Zero final payments for the item or service in the 15 months prior to posting the file." }, { "payer_name": "UNITED HEALTHCARE", "plan_name": "SUTTER SELECT & SUTTER HEALTH PLAN HMO PLANS", "methodology": "per diem", "standard_charge_dollar": 28538.0, "standard_charge_algorithm": "Per diem ($28,538).", "count": "0", "additional_payer_notes": "Zero final payments for the item or service in the 15 months prior to posting the file." }, { "payer_name": "UNITED HEALTHCARE", "plan_name": "SUTTER SELECT & SUTTER HEALTH PLAN HMO PLANS", "methodology": "per diem", "standard_charge_dollar": 28538.0, "standard_charge_algorithm": "Per diem ($28,538).", "count": "0", "additional_payer_notes": "Zero final payments for the item or service in the 15 months prior to posting the file." }, { "payer_name": "SUTTER", "plan_name": "SUTTER SELECT & SUTTER HEALTH PLAN HMO PLANS", "methodology": "per diem", "standard_charge_dollar": 28538.0, "standard_charge_algorithm": "Per diem ($28,538).", "count": "0", "additional_payer_notes": "Zero final payments for the item or service in the 15 months prior to posting the file." }, { "payer_name": "UNITED HEALTHCARE", "plan_name": "SUTTER SELECT & SUTTER HEALTH PLAN HMO PLANS", "methodology": "per diem", "standard_charge_dollar": 28538.0, "standard_charge_algorithm": "Per diem ($28,538).", "count": "0", "additional_payer_notes": "Zero final payments for the item or service in the 15 months prior to posting the file." }, { "payer_name": "UMR", "plan_name": "SUTTER SELECT & SUTTER HEALTH PLAN HMO PLANS", "methodology": "per diem", "standard_charge_dollar": 28538.0, "standard_charge_algorithm": "Per diem ($28,538).", "count": "0", "additional_payer_notes": "Zero final payments for the item or service in the 15 months prior to posting the file." } ] } ] }, { "description": "HC Cath Gp010", "code_information": [ { "code": "PX-2120029010", "type": "CDM" }, { "code": "99999", "type": "CPT" }, { "code": "0272", "type": "RC" } ], "standard_charges": [ { "setting": "outpatient", "gross_charge": 665.0, "discounted_cash": 332.5, "minimum": 280.63, "maximum": 345.8, "additional_generic_notes": "Zero final payments for the item or service in the 15 months prior to posting the file.", "payers_information": [ { "payer_name": "AETNA", "plan_name": "AETNA ALL OTHER PLANS", "methodology": "percent of total billed charges", "standard_charge_dollar": 345.8, "standard_charge_percentage": 52.0, "count": "0", "additional_payer_notes": "Zero final payments for the item or service in the 15 months prior to posting the file." }, { "payer_name": "AETNA", "plan_name": "AETNA ALL OTHER PLANS", "methodology": "percent of total billed charges", "standard_charge_dollar": 345.8, "standard_charge_percentage": 52.0, "count": "0", "additional_payer_notes": "Zero final payments for the item or service in the 15 months prior to posting the file." }, { "payer_name": "MERITAIN HEALTH", "plan_name": "AETNA ALL OTHER PLANS", "methodology": "percent of total billed charges", "standard_charge_dollar": 345.8, "standard_charge_percentage": 52.0, "count": "0", "additional_payer_notes": "Zero final payments for the item or service in the 15 months prior to posting the file." }, { "payer_name": "BLUE SHIELD OUT OF STATE", "plan_name": "STANFORD HEALTHCARE ALLIANCE PLAN", "methodology": "percent of total billed charges", "standard_charge_dollar": 323.12, "standard_charge_percentage": 48.59, "count": "0", "additional_payer_notes": "Zero final payments for the item or service in the 15 months prior to posting the file." }, { "payer_name": "BLUE SHIELD", "plan_name": "STANFORD HEALTHCARE ALLIANCE PLAN", "methodology": "percent of total billed charges", "standard_charge_dollar": 323.12, "standard_charge_percentage": 48.59, "count": "0", "additional_payer_notes": "Zero final payments for the item or service in the 15 months prior to posting the file." }, { "payer_name": "BLUE SHIELD", "plan_name": "STANFORD HEALTHCARE ALLIANCE PLAN", "methodology": "percent of total billed charges", "standard_charge_dollar": 323.12, "standard_charge_percentage": 48.59, "count": "0", "additional_payer_notes": "Zero final payments for the item or service in the 15 months prior to posting the file." }, { "payer_name": "CIGNA", "plan_name": "CIGNA COM ALT HMO PLAN", "methodology": "percent of total billed charges", "standard_charge_dollar": 280.63, "standard_charge_percentage": 42.2, "count": "0", "additional_payer_notes": "Zero final payments for the item or service in the 15 months prior to posting the file." }, { "payer_name": "CIGNA", "plan_name": "CIGNA COM ALT HMO PLAN", "methodology": "percent of total billed charges", "standard_charge_dollar": 280.63, "standard_charge_percentage": 42.2, "count": "0", "additional_payer_notes": "Zero final payments for the item or service in the 15 months prior to posting the file." }, { "payer_name": "HEALTH NET", "plan_name": "HEALTHNET HMO, PPO, POS, EPO, CANOPY HEALTHNET HMO, OTHER-IN-NETWORK PLANS", "methodology": "per diem", "standard_charge_dollar": 8000.0, "standard_charge_algorithm": "Expected reimbursement is the lesser of Per diem ($8,000) for the length of stay and 70% of billed.", "count": "0", "additional_payer_notes": "Zero final payments for the item or service in the 15 months prior to posting the file." }, { "payer_name": "HEALTH NET", "plan_name": "HEALTHNET HMO, PPO, POS, EPO, CANOPY HEALTHNET HMO, OTHER-IN-NETWORK PLANS", "methodology": "per diem", "standard_charge_dollar": 8000.0, "standard_charge_algorithm": "Expected reimbursement is the lesser of Per diem ($8,000) for the length of stay and 70% of billed.", "count": "0", "additional_payer_notes": "Zero final payments for the item or service in the 15 months prior to posting the file." }, { "payer_name": "UNITED HEALTHCARE", "plan_name": "SUTTER SELECT & SUTTER HEALTH PLAN HMO PLANS", "methodology": "per diem", "standard_charge_dollar": 28538.0, "standard_charge_algorithm": "Per diem ($28,538).", "count": "0", "additional_payer_notes": "Zero final payments for the item or service in the 15 months prior to posting the file." }, { "payer_name": "UNITED HEALTHCARE", "plan_name": "SUTTER SELECT & SUTTER HEALTH PLAN HMO PLANS", "methodology": "per diem", "standard_charge_dollar": 28538.0, "standard_charge_algorithm": "Per diem ($28,538).", "count": "0", "additional_payer_notes": "Zero final payments for the item or service in the 15 months prior to posting the file." }, { "payer_name": "SUTTER", "plan_name": "SUTTER SELECT & SUTTER HEALTH PLAN HMO PLANS", "methodology": "per diem", "standard_charge_dollar": 28538.0, "standard_charge_algorithm": "Per diem ($28,538).", "count": "0", "additional_payer_notes": "Zero final payments for the item or service in the 15 months prior to posting the file." }, { "payer_name": "UNITED HEALTHCARE", "plan_name": "SUTTER SELECT & SUTTER HEALTH PLAN HMO PLANS", "methodology": "per diem", "standard_charge_dollar": 28538.0, "standard_charge_algorithm": "Per diem ($28,538).", "count": "0", "additional_payer_notes": "Zero final payments for the item or service in the 15 months prior to posting the file." }, { "payer_name": "UMR", "plan_name": "SUTTER SELECT & SUTTER HEALTH PLAN HMO PLANS", "methodology": "per diem", "standard_charge_dollar": 28538.0, "standard_charge_algorithm": "Per diem ($28,538).", "count": "0", "additional_payer_notes": "Zero final payments for the item or service in the 15 months prior to posting the file." } ] } ] }, { "description": "HC Cath Gp011", "code_information": [ { "code": "PX-2120029011", "type": "CDM" }, { "code": "99999", "type": "CPT" }, { "code": "0272", "type": "RC" } ], "standard_charges": [ { "setting": "outpatient", "gross_charge": 740.0, "discounted_cash": 370.0, "minimum": 312.28, "maximum": 384.8, "additional_generic_notes": "Zero final payments for the item or service in the 15 months prior to posting the file.", "payers_information": [ { "payer_name": "AETNA", "plan_name": "AETNA ALL OTHER PLANS", "methodology": "percent of total billed charges", "standard_charge_dollar": 384.8, "standard_charge_percentage": 52.0, "count": "0", "additional_payer_notes": "Zero final payments for the item or service in the 15 months prior to posting the file." }, { "payer_name": "AETNA", "plan_name": "AETNA ALL OTHER PLANS", "methodology": "percent of total billed charges", "standard_charge_dollar": 384.8, "standard_charge_percentage": 52.0, "count": "0", "additional_payer_notes": "Zero final payments for the item or service in the 15 months prior to posting the file." }, { "payer_name": "MERITAIN HEALTH", "plan_name": "AETNA ALL OTHER PLANS", "methodology": "percent of total billed charges", "standard_charge_dollar": 384.8, "standard_charge_percentage": 52.0, "count": "0", "additional_payer_notes": "Zero final payments for the item or service in the 15 months prior to posting the file." }, { "payer_name": "BLUE SHIELD OUT OF STATE", "plan_name": "STANFORD HEALTHCARE ALLIANCE PLAN", "methodology": "percent of total billed charges", "standard_charge_dollar": 359.57, "standard_charge_percentage": 48.59, "count": "0", "additional_payer_notes": "Zero final payments for the item or service in the 15 months prior to posting the file." }, { "payer_name": "BLUE SHIELD", "plan_name": "STANFORD HEALTHCARE ALLIANCE PLAN", "methodology": "percent of total billed charges", "standard_charge_dollar": 359.57, "standard_charge_percentage": 48.59, "count": "0", "additional_payer_notes": "Zero final payments for the item or service in the 15 months prior to posting the file." }, { "payer_name": "BLUE SHIELD", "plan_name": "STANFORD HEALTHCARE ALLIANCE PLAN", "methodology": "percent of total billed charges", "standard_charge_dollar": 359.57, "standard_charge_percentage": 48.59, "count": "0", "additional_payer_notes": "Zero final payments for the item or service in the 15 months prior to posting the file." }, { "payer_name": "CIGNA", "plan_name": "CIGNA COM ALT HMO PLAN", "methodology": "percent of total billed charges", "standard_charge_dollar": 312.28, "standard_charge_percentage": 42.2, "count": "0", "additional_payer_notes": "Zero final payments for the item or service in the 15 months prior to posting the file." }, { "payer_name": "CIGNA", "plan_name": "CIGNA COM ALT HMO PLAN", "methodology": "percent of total billed charges", "standard_charge_dollar": 312.28, "standard_charge_percentage": 42.2, "count": "0", "additional_payer_notes": "Zero final payments for the item or service in the 15 months prior to posting the file." }, { "payer_name": "HEALTH NET", "plan_name": "HEALTHNET HMO, PPO, POS, EPO, CANOPY HEALTHNET HMO, OTHER-IN-NETWORK PLANS", "methodology": "per diem", "standard_charge_dollar": 8000.0, "standard_charge_algorithm": "Expected reimbursement is the lesser of Per diem ($8,000) for the length of stay and 70% of billed.", "count": "0", "additional_payer_notes": "Zero final payments for the item or service in the 15 months prior to posting the file." }, { "payer_name": "HEALTH NET", "plan_name": "HEALTHNET HMO, PPO, POS, EPO, CANOPY HEALTHNET HMO, OTHER-IN-NETWORK PLANS", "methodology": "per diem", "standard_charge_dollar": 8000.0, "standard_charge_algorithm": "Expected reimbursement is the lesser of Per diem ($8,000) for the length of stay and 70% of billed.", "count": "0", "additional_payer_notes": "Zero final payments for the item or service in the 15 months prior to posting the file." }, { "payer_name": "UNITED HEALTHCARE", "plan_name": "SUTTER SELECT & SUTTER HEALTH PLAN HMO PLANS", "methodology": "per diem", "standard_charge_dollar": 28538.0, "standard_charge_algorithm": "Per diem ($28,538).", "count": "0", "additional_payer_notes": "Zero final payments for the item or service in the 15 months prior to posting the file." }, { "payer_name": "UNITED HEALTHCARE", "plan_name": "SUTTER SELECT & SUTTER HEALTH PLAN HMO PLANS", "methodology": "per diem", "standard_charge_dollar": 28538.0, "standard_charge_algorithm": "Per diem ($28,538).", "count": "0", "additional_payer_notes": "Zero final payments for the item or service in the 15 months prior to posting the file." }, { "payer_name": "SUTTER", "plan_name": "SUTTER SELECT & SUTTER HEALTH PLAN HMO PLANS", "methodology": "per diem", "standard_charge_dollar": 28538.0, "standard_charge_algorithm": "Per diem ($28,538).", "count": "0", "additional_payer_notes": "Zero final payments for the item or service in the 15 months prior to posting the file." }, { "payer_name": "UNITED HEALTHCARE", "plan_name": "SUTTER SELECT & SUTTER HEALTH PLAN HMO PLANS", "methodology": "per diem", "standard_charge_dollar": 28538.0, "standard_charge_algorithm": "Per diem ($28,538).", "count": "0", "additional_payer_notes": "Zero final payments for the item or service in the 15 months prior to posting the file." }, { "payer_name": "UMR", "plan_name": "SUTTER SELECT & SUTTER HEALTH PLAN HMO PLANS", "methodology": "per diem", "standard_charge_dollar": 28538.0, "standard_charge_algorithm": "Per diem ($28,538).", "count": "0", "additional_payer_notes": "Zero final payments for the item or service in the 15 months prior to posting the file." } ] } ] }, { "description": "HC Cath Gp012", "code_information": [ { "code": "PX-2120029012", "type": "CDM" }, { "code": "99999", "type": "CPT" }, { "code": "0272", "type": "RC" } ], "standard_charges": [ { "setting": "outpatient", "gross_charge": 810.0, "discounted_cash": 405.0, "minimum": 341.82, "maximum": 421.2, "additional_generic_notes": "Zero final payments for the item or service in the 15 months prior to posting the file.", "payers_information": [ { "payer_name": "AETNA", "plan_name": "AETNA ALL OTHER PLANS", "methodology": "percent of total billed charges", "standard_charge_dollar": 421.2, "standard_charge_percentage": 52.0, "count": "0", "additional_payer_notes": "Zero final payments for the item or service in the 15 months prior to posting the file." }, { "payer_name": "AETNA", "plan_name": "AETNA ALL OTHER PLANS", "methodology": "percent of total billed charges", "standard_charge_dollar": 421.2, "standard_charge_percentage": 52.0, "count": "0", "additional_payer_notes": "Zero final payments for the item or service in the 15 months prior to posting the file." }, { "payer_name": "MERITAIN HEALTH", "plan_name": "AETNA ALL OTHER PLANS", "methodology": "percent of total billed charges", "standard_charge_dollar": 421.2, "standard_charge_percentage": 52.0, "count": "0", "additional_payer_notes": "Zero final payments for the item or service in the 15 months prior to posting the file." }, { "payer_name": "BLUE SHIELD OUT OF STATE", "plan_name": "STANFORD HEALTHCARE ALLIANCE PLAN", "methodology": "percent of total billed charges", "standard_charge_dollar": 393.58, "standard_charge_percentage": 48.59, "count": "0", "additional_payer_notes": "Zero final payments for the item or service in the 15 months prior to posting the file." }, { "payer_name": "BLUE SHIELD", "plan_name": "STANFORD HEALTHCARE ALLIANCE PLAN", "methodology": "percent of total billed charges", "standard_charge_dollar": 393.58, "standard_charge_percentage": 48.59, "count": "0", "additional_payer_notes": "Zero final payments for the item or service in the 15 months prior to posting the file." }, { "payer_name": "BLUE SHIELD", "plan_name": "STANFORD HEALTHCARE ALLIANCE PLAN", "methodology": "percent of total billed charges", "standard_charge_dollar": 393.58, "standard_charge_percentage": 48.59, "count": "0", "additional_payer_notes": "Zero final payments for the item or service in the 15 months prior to posting the file." }, { "payer_name": "CIGNA", "plan_name": "CIGNA COM ALT HMO PLAN", "methodology": "percent of total billed charges", "standard_charge_dollar": 341.82, "standard_charge_percentage": 42.2, "count": "0", "additional_payer_notes": "Zero final payments for the item or service in the 15 months prior to posting the file." }, { "payer_name": "CIGNA", "plan_name": "CIGNA COM ALT HMO PLAN", "methodology": "percent of total billed charges", "standard_charge_dollar": 341.82, "standard_charge_percentage": 42.2, "count": "0", "additional_payer_notes": "Zero final payments for the item or service in the 15 months prior to posting the file." }, { "payer_name": "HEALTH NET", "plan_name": "HEALTHNET HMO, PPO, POS, EPO, CANOPY HEALTHNET HMO, OTHER-IN-NETWORK PLANS", "methodology": "per diem", "standard_charge_dollar": 8000.0, "standard_charge_algorithm": "Expected reimbursement is the lesser of Per diem ($8,000) for the length of stay and 70% of billed.", "count": "0", "additional_payer_notes": "Zero final payments for the item or service in the 15 months prior to posting the file." }, { "payer_name": "HEALTH NET", "plan_name": "HEALTHNET HMO, PPO, POS, EPO, CANOPY HEALTHNET HMO, OTHER-IN-NETWORK PLANS", "methodology": "per diem", "standard_charge_dollar": 8000.0, "standard_charge_algorithm": "Expected reimbursement is the lesser of Per diem ($8,000) for the length of stay and 70% of billed.", "count": "0", "additional_payer_notes": "Zero final payments for the item or service in the 15 months prior to posting the file." }, { "payer_name": "UNITED HEALTHCARE", "plan_name": "SUTTER SELECT & SUTTER HEALTH PLAN HMO PLANS", "methodology": "per diem", "standard_charge_dollar": 28538.0, "standard_charge_algorithm": "Per diem ($28,538).", "count": "0", "additional_payer_notes": "Zero final payments for the item or service in the 15 months prior to posting the file." }, { "payer_name": "UNITED HEALTHCARE", "plan_name": "SUTTER SELECT & SUTTER HEALTH PLAN HMO PLANS", "methodology": "per diem", "standard_charge_dollar": 28538.0, "standard_charge_algorithm": "Per diem ($28,538).", "count": "0", "additional_payer_notes": "Zero final payments for the item or service in the 15 months prior to posting the file." }, { "payer_name": "SUTTER", "plan_name": "SUTTER SELECT & SUTTER HEALTH PLAN HMO PLANS", "methodology": "per diem", "standard_charge_dollar": 28538.0, "standard_charge_algorithm": "Per diem ($28,538).", "count": "0", "additional_payer_notes": "Zero final payments for the item or service in the 15 months prior to posting the file." }, { "payer_name": "UNITED HEALTHCARE", "plan_name": "SUTTER SELECT & SUTTER HEALTH PLAN HMO PLANS", "methodology": "per diem", "standard_charge_dollar": 28538.0, "standard_charge_algorithm": "Per diem ($28,538).", "count": "0", "additional_payer_notes": "Zero final payments for the item or service in the 15 months prior to posting the file." }, { "payer_name": "UMR", "plan_name": "SUTTER SELECT & SUTTER HEALTH PLAN HMO PLANS", "methodology": "per diem", "standard_charge_dollar": 28538.0, "standard_charge_algorithm": "Per diem ($28,538).", "count": "0", "additional_payer_notes": "Zero final payments for the item or service in the 15 months prior to posting the file." } ] } ] }, { "description": "HC Cath Gp013", "code_information": [ { "code": "PX-2120029013", "type": "CDM" }, { "code": "99999", "type": "CPT" }, { "code": "0272", "type": "RC" } ], "standard_charges": [ { "setting": "outpatient", "gross_charge": 900.0, "discounted_cash": 450.0, "minimum": 379.8, "maximum": 468.0, "additional_generic_notes": "Zero final payments for the item or service in the 15 months prior to posting the file.", "payers_information": [ { "payer_name": "AETNA", "plan_name": "AETNA ALL OTHER PLANS", "methodology": "percent of total billed charges", "standard_charge_dollar": 468.0, "standard_charge_percentage": 52.0, "count": "0", "additional_payer_notes": "Zero final payments for the item or service in the 15 months prior to posting the file." }, { "payer_name": "AETNA", "plan_name": "AETNA ALL OTHER PLANS", "methodology": "percent of total billed charges", "standard_charge_dollar": 468.0, "standard_charge_percentage": 52.0, "count": "0", "additional_payer_notes": "Zero final payments for the item or service in the 15 months prior to posting the file." }, { "payer_name": "MERITAIN HEALTH", "plan_name": "AETNA ALL OTHER PLANS", "methodology": "percent of total billed charges", "standard_charge_dollar": 468.0, "standard_charge_percentage": 52.0, "count": "0", "additional_payer_notes": "Zero final payments for the item or service in the 15 months prior to posting the file." }, { "payer_name": "BLUE SHIELD OUT OF STATE", "plan_name": "STANFORD HEALTHCARE ALLIANCE PLAN", "methodology": "percent of total billed charges", "standard_charge_dollar": 437.31, "standard_charge_percentage": 48.59, "count": "0", "additional_payer_notes": "Zero final payments for the item or service in the 15 months prior to posting the file." }, { "payer_name": "BLUE SHIELD", "plan_name": "STANFORD HEALTHCARE ALLIANCE PLAN", "methodology": "percent of total billed charges", "standard_charge_dollar": 437.31, "standard_charge_percentage": 48.59, "count": "0", "additional_payer_notes": "Zero final payments for the item or service in the 15 months prior to posting the file." }, { "payer_name": "BLUE SHIELD", "plan_name": "STANFORD HEALTHCARE ALLIANCE PLAN", "methodology": "percent of total billed charges", "standard_charge_dollar": 437.31, "standard_charge_percentage": 48.59, "count": "0", "additional_payer_notes": "Zero final payments for the item or service in the 15 months prior to posting the file." }, { "payer_name": "CIGNA", "plan_name": "CIGNA COM ALT HMO PLAN", "methodology": "percent of total billed charges", "standard_charge_dollar": 379.8, "standard_charge_percentage": 42.2, "count": "0", "additional_payer_notes": "Zero final payments for the item or service in the 15 months prior to posting the file." }, { "payer_name": "CIGNA", "plan_name": "CIGNA COM ALT HMO PLAN", "methodology": "percent of total billed charges", "standard_charge_dollar": 379.8, "standard_charge_percentage": 42.2, "count": "0", "additional_payer_notes": "Zero final payments for the item or service in the 15 months prior to posting the file." }, { "payer_name": "HEALTH NET", "plan_name": "HEALTHNET HMO, PPO, POS, EPO, CANOPY HEALTHNET HMO, OTHER-IN-NETWORK PLANS", "methodology": "per diem", "standard_charge_dollar": 8000.0, "standard_charge_algorithm": "Expected reimbursement is the lesser of Per diem ($8,000) for the length of stay and 70% of billed.", "count": "0", "additional_payer_notes": "Zero final payments for the item or service in the 15 months prior to posting the file." }, { "payer_name": "HEALTH NET", "plan_name": "HEALTHNET HMO, PPO, POS, EPO, CANOPY HEALTHNET HMO, OTHER-IN-NETWORK PLANS", "methodology": "per diem", "standard_charge_dollar": 8000.0, "standard_charge_algorithm": "Expected reimbursement is the lesser of Per diem ($8,000) for the length of stay and 70% of billed.", "count": "0", "additional_payer_notes": "Zero final payments for the item or service in the 15 months prior to posting the file." }, { "payer_name": "UNITED HEALTHCARE", "plan_name": "SUTTER SELECT & SUTTER HEALTH PLAN HMO PLANS", "methodology": "per diem", "standard_charge_dollar": 28538.0, "standard_charge_algorithm": "Per diem ($28,538).", "count": "0", "additional_payer_notes": "Zero final payments for the item or service in the 15 months prior to posting the file." }, { "payer_name": "UNITED HEALTHCARE", "plan_name": "SUTTER SELECT & SUTTER HEALTH PLAN HMO PLANS", "methodology": "per diem", "standard_charge_dollar": 28538.0, "standard_charge_algorithm": "Per diem ($28,538).", "count": "0", "additional_payer_notes": "Zero final payments for the item or service in the 15 months prior to posting the file." }, { "payer_name": "SUTTER", "plan_name": "SUTTER SELECT & SUTTER HEALTH PLAN HMO PLANS", "methodology": "per diem", "standard_charge_dollar": 28538.0, "standard_charge_algorithm": "Per diem ($28,538).", "count": "0", "additional_payer_notes": "Zero final payments for the item or service in the 15 months prior to posting the file." }, { "payer_name": "UNITED HEALTHCARE", "plan_name": "SUTTER SELECT & SUTTER HEALTH PLAN HMO PLANS", "methodology": "per diem", "standard_charge_dollar": 28538.0, "standard_charge_algorithm": "Per diem ($28,538).", "count": "0", "additional_payer_notes": "Zero final payments for the item or service in the 15 months prior to posting the file." }, { "payer_name": "UMR", "plan_name": "SUTTER SELECT & SUTTER HEALTH PLAN HMO PLANS", "methodology": "per diem", "standard_charge_dollar": 28538.0, "standard_charge_algorithm": "Per diem ($28,538).", "count": "0", "additional_payer_notes": "Zero final payments for the item or service in the 15 months prior to posting the file." } ] } ] }, { "description": "HC Cath Gp014", "code_information": [ { "code": "PX-2120029014", "type": "CDM" }, { "code": "99999", "type": "CPT" }, { "code": "0272", "type": "RC" } ], "standard_charges": [ { "setting": "outpatient", "gross_charge": 1080.0, "discounted_cash": 540.0, "minimum": 455.76, "maximum": 561.6, "additional_generic_notes": "Zero final payments for the item or service in the 15 months prior to posting the file.", "payers_information": [ { "payer_name": "AETNA", "plan_name": "AETNA ALL OTHER PLANS", "methodology": "percent of total billed charges", "standard_charge_dollar": 561.6, "standard_charge_percentage": 52.0, "count": "0", "additional_payer_notes": "Zero final payments for the item or service in the 15 months prior to posting the file." }, { "payer_name": "AETNA", "plan_name": "AETNA ALL OTHER PLANS", "methodology": "percent of total billed charges", "standard_charge_dollar": 561.6, "standard_charge_percentage": 52.0, "count": "0", "additional_payer_notes": "Zero final payments for the item or service in the 15 months prior to posting the file." }, { "payer_name": "MERITAIN HEALTH", "plan_name": "AETNA ALL OTHER PLANS", "methodology": "percent of total billed charges", "standard_charge_dollar": 561.6, "standard_charge_percentage": 52.0, "count": "0", "additional_payer_notes": "Zero final payments for the item or service in the 15 months prior to posting the file." }, { "payer_name": "BLUE SHIELD OUT OF STATE", "plan_name": "STANFORD HEALTHCARE ALLIANCE PLAN", "methodology": "percent of total billed charges", "standard_charge_dollar": 524.77, "standard_charge_percentage": 48.59, "count": "0", "additional_payer_notes": "Zero final payments for the item or service in the 15 months prior to posting the file." }, { "payer_name": "BLUE SHIELD", "plan_name": "STANFORD HEALTHCARE ALLIANCE PLAN", "methodology": "percent of total billed charges", "standard_charge_dollar": 524.77, "standard_charge_percentage": 48.59, "median_amount": 68.24, "10th_percentile": 13.6, "90th_percentile": 1043.06, "count": "30" }, { "payer_name": "BLUE SHIELD", "plan_name": "STANFORD HEALTHCARE ALLIANCE PLAN", "methodology": "percent of total billed charges", "standard_charge_dollar": 524.77, "standard_charge_percentage": 48.59, "count": "0", "additional_payer_notes": "Zero final payments for the item or service in the 15 months prior to posting the file." }, { "payer_name": "BLUE SHIELD", "plan_name": "STANFORD HEALTHCARE ALLIANCE PLAN", "methodology": "percent of total billed charges", "standard_charge_dollar": 524.77, "standard_charge_percentage": 48.59, "count": "0", "additional_payer_notes": "Zero final payments for the item or service in the 15 months prior to posting the file." }, { "payer_name": "CIGNA", "plan_name": "CIGNA COM ALT HMO PLAN", "methodology": "percent of total billed charges", "standard_charge_dollar": 455.76, "standard_charge_percentage": 42.2, "count": "0", "additional_payer_notes": "Zero final payments for the item or service in the 15 months prior to posting the file." }, { "payer_name": "CIGNA", "plan_name": "CIGNA COM ALT HMO PLAN", "methodology": "percent of total billed charges", "standard_charge_dollar": 455.76, "standard_charge_percentage": 42.2, "count": "0", "additional_payer_notes": "Zero final payments for the item or service in the 15 months prior to posting the file." }, { "payer_name": "HEALTH NET", "plan_name": "HEALTHNET HMO, PPO, POS, EPO, CANOPY HEALTHNET HMO, OTHER-IN-NETWORK PLANS", "methodology": "per diem", "standard_charge_dollar": 8000.0, "standard_charge_algorithm": "Expected reimbursement is the lesser of Per diem ($8,000) for the length of stay and 70% of billed.", "count": "0", "additional_payer_notes": "Zero final payments for the item or service in the 15 months prior to posting the file." }, { "payer_name": "HEALTH NET", "plan_name": "HEALTHNET HMO, PPO, POS, EPO, CANOPY HEALTHNET HMO, OTHER-IN-NETWORK PLANS", "methodology": "per diem", "standard_charge_dollar": 8000.0, "standard_charge_algorithm": "Expected reimbursement is the lesser of Per diem ($8,000) for the length of stay and 70% of billed.", "count": "0", "additional_payer_notes": "Zero final payments for the item or service in the 15 months prior to posting the file." }, { "payer_name": "UNITED HEALTHCARE", "plan_name": "SUTTER SELECT & SUTTER HEALTH PLAN HMO PLANS", "methodology": "per diem", "standard_charge_dollar": 28538.0, "standard_charge_algorithm": "Per diem ($28,538).", "count": "0", "additional_payer_notes": "Zero final payments for the item or service in the 15 months prior to posting the file." }, { "payer_name": "UNITED HEALTHCARE", "plan_name": "SUTTER SELECT & SUTTER HEALTH PLAN HMO PLANS", "methodology": "per diem", "standard_charge_dollar": 28538.0, "standard_charge_algorithm": "Per diem ($28,538).", "count": "0", "additional_payer_notes": "Zero final payments for the item or service in the 15 months prior to posting the file." }, { "payer_name": "SUTTER", "plan_name": "SUTTER SELECT & SUTTER HEALTH PLAN HMO PLANS", "methodology": "per diem", "standard_charge_dollar": 28538.0, "standard_charge_algorithm": "Per diem ($28,538).", "count": "0", "additional_payer_notes": "Zero final payments for the item or service in the 15 months prior to posting the file." }, { "payer_name": "UNITED HEALTHCARE", "plan_name": "SUTTER SELECT & SUTTER HEALTH PLAN HMO PLANS", "methodology": "per diem", "standard_charge_dollar": 28538.0, "standard_charge_algorithm": "Per diem ($28,538).", "count": "0", "additional_payer_notes": "Zero final payments for the item or service in the 15 months prior to posting the file." }, { "payer_name": "UMR", "plan_name": "SUTTER SELECT & SUTTER HEALTH PLAN HMO PLANS", "methodology": "per diem", "standard_charge_dollar": 28538.0, "standard_charge_algorithm": "Per diem ($28,538).", "count": "0", "additional_payer_notes": "Zero final payments for the item or service in the 15 months prior to posting the file." } ] } ] }, { "description": "HC Cath Gp015", "code_information": [ { "code": "PX-2120029015", "type": "CDM" }, { "code": "99999", "type": "CPT" }, { "code": "0272", "type": "RC" } ], "standard_charges": [ { "setting": "outpatient", "gross_charge": 1225.0, "discounted_cash": 612.5, "minimum": 516.95, "maximum": 637.0, "additional_generic_notes": "Zero final payments for the item or service in the 15 months prior to posting the file.", "payers_information": [ { "payer_name": "AETNA", "plan_name": "AETNA ALL OTHER PLANS", "methodology": "percent of total billed charges", "standard_charge_dollar": 637.0, "standard_charge_percentage": 52.0, "count": "0", "additional_payer_notes": "Zero final payments for the item or service in the 15 months prior to posting the file." }, { "payer_name": "AETNA", "plan_name": "AETNA ALL OTHER PLANS", "methodology": "percent of total billed charges", "standard_charge_dollar": 637.0, "standard_charge_percentage": 52.0, "count": "0", "additional_payer_notes": "Zero final payments for the item or service in the 15 months prior to posting the file." }, { "payer_name": "MERITAIN HEALTH", "plan_name": "AETNA ALL OTHER PLANS", "methodology": "percent of total billed charges", "standard_charge_dollar": 637.0, "standard_charge_percentage": 52.0, "count": "0", "additional_payer_notes": "Zero final payments for the item or service in the 15 months prior to posting the file." }, { "payer_name": "BLUE SHIELD OUT OF STATE", "plan_name": "STANFORD HEALTHCARE ALLIANCE PLAN", "methodology": "percent of total billed charges", "standard_charge_dollar": 595.23, "standard_charge_percentage": 48.59, "count": "0", "additional_payer_notes": "Zero final payments for the item or service in the 15 months prior to posting the file." }, { "payer_name": "BLUE SHIELD", "plan_name": "STANFORD HEALTHCARE ALLIANCE PLAN", "methodology": "percent of total billed charges", "standard_charge_dollar": 595.23, "standard_charge_percentage": 48.59, "median_amount": 68.24, "10th_percentile": 13.6, "90th_percentile": 1043.06, "count": "30" }, { "payer_name": "BLUE SHIELD", "plan_name": "STANFORD HEALTHCARE ALLIANCE PLAN", "methodology": "percent of total billed charges", "standard_charge_dollar": 595.23, "standard_charge_percentage": 48.59, "count": "0", "additional_payer_notes": "Zero final payments for the item or service in the 15 months prior to posting the file." }, { "payer_name": "BLUE SHIELD", "plan_name": "STANFORD HEALTHCARE ALLIANCE PLAN", "methodology": "percent of total billed charges", "standard_charge_dollar": 595.23, "standard_charge_percentage": 48.59, "count": "0", "additional_payer_notes": "Zero final payments for the item or service in the 15 months prior to posting the file." }, { "payer_name": "CIGNA", "plan_name": "CIGNA COM ALT HMO PLAN", "methodology": "percent of total billed charges", "standard_charge_dollar": 516.95, "standard_charge_percentage": 42.2, "count": "0", "additional_payer_notes": "Zero final payments for the item or service in the 15 months prior to posting the file." }, { "payer_name": "CIGNA", "plan_name": "CIGNA COM ALT HMO PLAN", "methodology": "percent of total billed charges", "standard_charge_dollar": 516.95, "standard_charge_percentage": 42.2, "count": "0", "additional_payer_notes": "Zero final payments for the item or service in the 15 months prior to posting the file." }, { "payer_name": "HEALTH NET", "plan_name": "HEALTHNET HMO, PPO, POS, EPO, CANOPY HEALTHNET HMO, OTHER-IN-NETWORK PLANS", "methodology": "per diem", "standard_charge_dollar": 8000.0, "standard_charge_algorithm": "Expected reimbursement is the lesser of Per diem ($8,000) for the length of stay and 70% of billed.", "count": "0", "additional_payer_notes": "Zero final payments for the item or service in the 15 months prior to posting the file." }, { "payer_name": "HEALTH NET", "plan_name": "HEALTHNET HMO, PPO, POS, EPO, CANOPY HEALTHNET HMO, OTHER-IN-NETWORK PLANS", "methodology": "per diem", "standard_charge_dollar": 8000.0, "standard_charge_algorithm": "Expected reimbursement is the lesser of Per diem ($8,000) for the length of stay and 70% of billed.", "count": "0", "additional_payer_notes": "Zero final payments for the item or service in the 15 months prior to posting the file." }, { "payer_name": "UNITED HEALTHCARE", "plan_name": "SUTTER SELECT & SUTTER HEALTH PLAN HMO PLANS", "methodology": "per diem", "standard_charge_dollar": 28538.0, "standard_charge_algorithm": "Per diem ($28,538).", "count": "0", "additional_payer_notes": "Zero final payments for the item or service in the 15 months prior to posting the file." }, { "payer_name": "UNITED HEALTHCARE", "plan_name": "SUTTER SELECT & SUTTER HEALTH PLAN HMO PLANS", "methodology": "per diem", "standard_charge_dollar": 28538.0, "standard_charge_algorithm": "Per diem ($28,538).", "count": "0", "additional_payer_notes": "Zero final payments for the item or service in the 15 months prior to posting the file." }, { "payer_name": "SUTTER", "plan_name": "SUTTER SELECT & SUTTER HEALTH PLAN HMO PLANS", "methodology": "per diem", "standard_charge_dollar": 28538.0, "standard_charge_algorithm": "Per diem ($28,538).", "count": "0", "additional_payer_notes": "Zero final payments for the item or service in the 15 months prior to posting the file." }, { "payer_name": "UNITED HEALTHCARE", "plan_name": "SUTTER SELECT & SUTTER HEALTH PLAN HMO PLANS", "methodology": "per diem", "standard_charge_dollar": 28538.0, "standard_charge_algorithm": "Per diem ($28,538).", "count": "0", "additional_payer_notes": "Zero final payments for the item or service in the 15 months prior to posting the file." }, { "payer_name": "UMR", "plan_name": "SUTTER SELECT & SUTTER HEALTH PLAN HMO PLANS", "methodology": "per diem", "standard_charge_dollar": 28538.0, "standard_charge_algorithm": "Per diem ($28,538).", "count": "0", "additional_payer_notes": "Zero final payments for the item or service in the 15 months prior to posting the file." } ] } ] }, { "description": "HC Cath Gp016", "code_information": [ { "code": "PX-2120029016", "type": "CDM" }, { "code": "99999", "type": "CPT" }, { "code": "0272", "type": "RC" } ], "standard_charges": [ { "setting": "outpatient", "gross_charge": 1400.0, "discounted_cash": 700.0, "minimum": 590.8, "maximum": 728.0, "additional_generic_notes": "Zero final payments for the item or service in the 15 months prior to posting the file.", "payers_information": [ { "payer_name": "AETNA", "plan_name": "AETNA ALL OTHER PLANS", "methodology": "percent of total billed charges", "standard_charge_dollar": 728.0, "standard_charge_percentage": 52.0, "count": "0", "additional_payer_notes": "Zero final payments for the item or service in the 15 months prior to posting the file." }, { "payer_name": "AETNA", "plan_name": "AETNA ALL OTHER PLANS", "methodology": "percent of total billed charges", "standard_charge_dollar": 728.0, "standard_charge_percentage": 52.0, "count": "0", "additional_payer_notes": "Zero final payments for the item or service in the 15 months prior to posting the file." }, { "payer_name": "MERITAIN HEALTH", "plan_name": "AETNA ALL OTHER PLANS", "methodology": "percent of total billed charges", "standard_charge_dollar": 728.0, "standard_charge_percentage": 52.0, "count": "0", "additional_payer_notes": "Zero final payments for the item or service in the 15 months prior to posting the file." }, { "payer_name": "BLUE SHIELD OUT OF STATE", "plan_name": "STANFORD HEALTHCARE ALLIANCE PLAN", "methodology": "percent of total billed charges", "standard_charge_dollar": 680.26, "standard_charge_percentage": 48.59, "count": "0", "additional_payer_notes": "Zero final payments for the item or service in the 15 months prior to posting the file." }, { "payer_name": "BLUE SHIELD", "plan_name": "STANFORD HEALTHCARE ALLIANCE PLAN", "methodology": "percent of total billed charges", "standard_charge_dollar": 680.26, "standard_charge_percentage": 48.59, "median_amount": 68.24, "10th_percentile": 13.6, "90th_percentile": 1043.06, "count": "30" }, { "payer_name": "BLUE SHIELD", "plan_name": "STANFORD HEALTHCARE ALLIANCE PLAN", "methodology": "percent of total billed charges", "standard_charge_dollar": 680.26, "standard_charge_percentage": 48.59, "count": "0", "additional_payer_notes": "Zero final payments for the item or service in the 15 months prior to posting the file." }, { "payer_name": "BLUE SHIELD", "plan_name": "STANFORD HEALTHCARE ALLIANCE PLAN", "methodology": "percent of total billed charges", "standard_charge_dollar": 680.26, "standard_charge_percentage": 48.59, "count": "0", "additional_payer_notes": "Zero final payments for the item or service in the 15 months prior to posting the file." }, { "payer_name": "CIGNA", "plan_name": "CIGNA COM ALT HMO PLAN", "methodology": "percent of total billed charges", "standard_charge_dollar": 590.8, "standard_charge_percentage": 42.2, "count": "0", "additional_payer_notes": "Zero final payments for the item or service in the 15 months prior to posting the file." }, { "payer_name": "CIGNA", "plan_name": "CIGNA COM ALT HMO PLAN", "methodology": "percent of total billed charges", "standard_charge_dollar": 590.8, "standard_charge_percentage": 42.2, "count": "0", "additional_payer_notes": "Zero final payments for the item or service in the 15 months prior to posting the file." }, { "payer_name": "HEALTH NET", "plan_name": "HEALTHNET HMO, PPO, POS, EPO, CANOPY HEALTHNET HMO, OTHER-IN-NETWORK PLANS", "methodology": "per diem", "standard_charge_dollar": 8000.0, "standard_charge_algorithm": "Expected reimbursement is the lesser of Per diem ($8,000) for the length of stay and 70% of billed.", "count": "0", "additional_payer_notes": "Zero final payments for the item or service in the 15 months prior to posting the file." }, { "payer_name": "HEALTH NET", "plan_name": "HEALTHNET HMO, PPO, POS, EPO, CANOPY HEALTHNET HMO, OTHER-IN-NETWORK PLANS", "methodology": "per diem", "standard_charge_dollar": 8000.0, "standard_charge_algorithm": "Expected reimbursement is the lesser of Per diem ($8,000) for the length of stay and 70% of billed.", "count": "0", "additional_payer_notes": "Zero final payments for the item or service in the 15 months prior to posting the file." }, { "payer_name": "UNITED HEALTHCARE", "plan_name": "SUTTER SELECT & SUTTER HEALTH PLAN HMO PLANS", "methodology": "per diem", "standard_charge_dollar": 28538.0, "standard_charge_algorithm": "Per diem ($28,538).", "count": "0", "additional_payer_notes": "Zero final payments for the item or service in the 15 months prior to posting the file." }, { "payer_name": "UNITED HEALTHCARE", "plan_name": "SUTTER SELECT & SUTTER HEALTH PLAN HMO PLANS", "methodology": "per diem", "standard_charge_dollar": 28538.0, "standard_charge_algorithm": "Per diem ($28,538).", "count": "0", "additional_payer_notes": "Zero final payments for the item or service in the 15 months prior to posting the file." }, { "payer_name": "SUTTER", "plan_name": "SUTTER SELECT & SUTTER HEALTH PLAN HMO PLANS", "methodology": "per diem", "standard_charge_dollar": 28538.0, "standard_charge_algorithm": "Per diem ($28,538).", "count": "0", "additional_payer_notes": "Zero final payments for the item or service in the 15 months prior to posting the file." }, { "payer_name": "UNITED HEALTHCARE", "plan_name": "SUTTER SELECT & SUTTER HEALTH PLAN HMO PLANS", "methodology": "per diem", "standard_charge_dollar": 28538.0, "standard_charge_algorithm": "Per diem ($28,538).", "count": "0", "additional_payer_notes": "Zero final payments for the item or service in the 15 months prior to posting the file." }, { "payer_name": "UMR", "plan_name": "SUTTER SELECT & SUTTER HEALTH PLAN HMO PLANS", "methodology": "per diem", "standard_charge_dollar": 28538.0, "standard_charge_algorithm": "Per diem ($28,538).", "count": "0", "additional_payer_notes": "Zero final payments for the item or service in the 15 months prior to posting the file." } ] } ] }, { "description": "HC Cath Gp017", "code_information": [ { "code": "PX-2120029017", "type": "CDM" }, { "code": "99999", "type": "CPT" }, { "code": "0272", "type": "RC" } ], "standard_charges": [ { "setting": "outpatient", "gross_charge": 1575.0, "discounted_cash": 787.5, "minimum": 664.65, "maximum": 819.0, "additional_generic_notes": "Zero final payments for the item or service in the 15 months prior to posting the file.", "payers_information": [ { "payer_name": "AETNA", "plan_name": "AETNA ALL OTHER PLANS", "methodology": "percent of total billed charges", "standard_charge_dollar": 819.0, "standard_charge_percentage": 52.0, "count": "0", "additional_payer_notes": "Zero final payments for the item or service in the 15 months prior to posting the file." }, { "payer_name": "AETNA", "plan_name": "AETNA ALL OTHER PLANS", "methodology": "percent of total billed charges", "standard_charge_dollar": 819.0, "standard_charge_percentage": 52.0, "count": "0", "additional_payer_notes": "Zero final payments for the item or service in the 15 months prior to posting the file." }, { "payer_name": "MERITAIN HEALTH", "plan_name": "AETNA ALL OTHER PLANS", "methodology": "percent of total billed charges", "standard_charge_dollar": 819.0, "standard_charge_percentage": 52.0, "count": "0", "additional_payer_notes": "Zero final payments for the item or service in the 15 months prior to posting the file." }, { "payer_name": "BLUE SHIELD OUT OF STATE", "plan_name": "STANFORD HEALTHCARE ALLIANCE PLAN", "methodology": "percent of total billed charges", "standard_charge_dollar": 765.29, "standard_charge_percentage": 48.59, "count": "0", "additional_payer_notes": "Zero final payments for the item or service in the 15 months prior to posting the file." }, { "payer_name": "BLUE SHIELD", "plan_name": "STANFORD HEALTHCARE ALLIANCE PLAN", "methodology": "percent of total billed charges", "standard_charge_dollar": 765.29, "standard_charge_percentage": 48.59, "median_amount": 68.24, "10th_percentile": 13.6, "90th_percentile": 1043.06, "count": "30" }, { "payer_name": "BLUE SHIELD", "plan_name": "STANFORD HEALTHCARE ALLIANCE PLAN", "methodology": "percent of total billed charges", "standard_charge_dollar": 765.29, "standard_charge_percentage": 48.59, "count": "0", "additional_payer_notes": "Zero final payments for the item or service in the 15 months prior to posting the file." }, { "payer_name": "BLUE SHIELD", "plan_name": "STANFORD HEALTHCARE ALLIANCE PLAN", "methodology": "percent of total billed charges", "standard_charge_dollar": 765.29, "standard_charge_percentage": 48.59, "count": "0", "additional_payer_notes": "Zero final payments for the item or service in the 15 months prior to posting the file." }, { "payer_name": "CIGNA", "plan_name": "CIGNA COM ALT HMO PLAN", "methodology": "percent of total billed charges", "standard_charge_dollar": 664.65, "standard_charge_percentage": 42.2, "count": "0", "additional_payer_notes": "Zero final payments for the item or service in the 15 months prior to posting the file." }, { "payer_name": "CIGNA", "plan_name": "CIGNA COM ALT HMO PLAN", "methodology": "percent of total billed charges", "standard_charge_dollar": 664.65, "standard_charge_percentage": 42.2, "count": "0", "additional_payer_notes": "Zero final payments for the item or service in the 15 months prior to posting the file." }, { "payer_name": "HEALTH NET", "plan_name": "HEALTHNET HMO, PPO, POS, EPO, CANOPY HEALTHNET HMO, OTHER-IN-NETWORK PLANS", "methodology": "per diem", "standard_charge_dollar": 8000.0, "standard_charge_algorithm": "Expected reimbursement is the lesser of Per diem ($8,000) for the length of stay and 70% of billed.", "count": "0", "additional_payer_notes": "Zero final payments for the item or service in the 15 months prior to posting the file." }, { "payer_name": "HEALTH NET", "plan_name": "HEALTHNET HMO, PPO, POS, EPO, CANOPY HEALTHNET HMO, OTHER-IN-NETWORK PLANS", "methodology": "per diem", "standard_charge_dollar": 8000.0, "standard_charge_algorithm": "Expected reimbursement is the lesser of Per diem ($8,000) for the length of stay and 70% of billed.", "count": "0", "additional_payer_notes": "Zero final payments for the item or service in the 15 months prior to posting the file." }, { "payer_name": "UNITED HEALTHCARE", "plan_name": "SUTTER SELECT & SUTTER HEALTH PLAN HMO PLANS", "methodology": "per diem", "standard_charge_dollar": 28538.0, "standard_charge_algorithm": "Per diem ($28,538).", "count": "0", "additional_payer_notes": "Zero final payments for the item or service in the 15 months prior to posting the file." }, { "payer_name": "UNITED HEALTHCARE", "plan_name": "SUTTER SELECT & SUTTER HEALTH PLAN HMO PLANS", "methodology": "per diem", "standard_charge_dollar": 28538.0, "standard_charge_algorithm": "Per diem ($28,538).", "count": "0", "additional_payer_notes": "Zero final payments for the item or service in the 15 months prior to posting the file." }, { "payer_name": "SUTTER", "plan_name": "SUTTER SELECT & SUTTER HEALTH PLAN HMO PLANS", "methodology": "per diem", "standard_charge_dollar": 28538.0, "standard_charge_algorithm": "Per diem ($28,538).", "count": "0", "additional_payer_notes": "Zero final payments for the item or service in the 15 months prior to posting the file." }, { "payer_name": "UNITED HEALTHCARE", "plan_name": "SUTTER SELECT & SUTTER HEALTH PLAN HMO PLANS", "methodology": "per diem", "standard_charge_dollar": 28538.0, "standard_charge_algorithm": "Per diem ($28,538).", "count": "0", "additional_payer_notes": "Zero final payments for the item or service in the 15 months prior to posting the file." }, { "payer_name": "UMR", "plan_name": "SUTTER SELECT & SUTTER HEALTH PLAN HMO PLANS", "methodology": "per diem", "standard_charge_dollar": 28538.0, "standard_charge_algorithm": "Per diem ($28,538).", "count": "0", "additional_payer_notes": "Zero final payments for the item or service in the 15 months prior to posting the file." } ] } ] }, { "description": "HC Cath Gp018", "code_information": [ { "code": "PX-2120029018", "type": "CDM" }, { "code": "99999", "type": "CPT" }, { "code": "0272", "type": "RC" } ], "standard_charges": [ { "setting": "outpatient", "gross_charge": 1750.0, "discounted_cash": 875.0, "minimum": 738.5, "maximum": 910.0, "additional_generic_notes": "Zero final payments for the item or service in the 15 months prior to posting the file.", "payers_information": [ { "payer_name": "AETNA", "plan_name": "AETNA ALL OTHER PLANS", "methodology": "percent of total billed charges", "standard_charge_dollar": 910.0, "standard_charge_percentage": 52.0, "count": "0", "additional_payer_notes": "Zero final payments for the item or service in the 15 months prior to posting the file." }, { "payer_name": "AETNA", "plan_name": "AETNA ALL OTHER PLANS", "methodology": "percent of total billed charges", "standard_charge_dollar": 910.0, "standard_charge_percentage": 52.0, "count": "0", "additional_payer_notes": "Zero final payments for the item or service in the 15 months prior to posting the file." }, { "payer_name": "MERITAIN HEALTH", "plan_name": "AETNA ALL OTHER PLANS", "methodology": "percent of total billed charges", "standard_charge_dollar": 910.0, "standard_charge_percentage": 52.0, "count": "0", "additional_payer_notes": "Zero final payments for the item or service in the 15 months prior to posting the file." }, { "payer_name": "BLUE SHIELD OUT OF STATE", "plan_name": "STANFORD HEALTHCARE ALLIANCE PLAN", "methodology": "percent of total billed charges", "standard_charge_dollar": 850.33, "standard_charge_percentage": 48.59, "count": "0", "additional_payer_notes": "Zero final payments for the item or service in the 15 months prior to posting the file." }, { "payer_name": "BLUE SHIELD", "plan_name": "STANFORD HEALTHCARE ALLIANCE PLAN", "methodology": "percent of total billed charges", "standard_charge_dollar": 850.33, "standard_charge_percentage": 48.59, "median_amount": 68.24, "10th_percentile": 13.6, "90th_percentile": 1043.06, "count": "30" }, { "payer_name": "BLUE SHIELD", "plan_name": "STANFORD HEALTHCARE ALLIANCE PLAN", "methodology": "percent of total billed charges", "standard_charge_dollar": 850.33, "standard_charge_percentage": 48.59, "count": "0", "additional_payer_notes": "Zero final payments for the item or service in the 15 months prior to posting the file." }, { "payer_name": "BLUE SHIELD", "plan_name": "STANFORD HEALTHCARE ALLIANCE PLAN", "methodology": "percent of total billed charges", "standard_charge_dollar": 850.33, "standard_charge_percentage": 48.59, "count": "0", "additional_payer_notes": "Zero final payments for the item or service in the 15 months prior to posting the file." }, { "payer_name": "CIGNA", "plan_name": "CIGNA COM ALT HMO PLAN", "methodology": "percent of total billed charges", "standard_charge_dollar": 738.5, "standard_charge_percentage": 42.2, "count": "0", "additional_payer_notes": "Zero final payments for the item or service in the 15 months prior to posting the file." }, { "payer_name": "CIGNA", "plan_name": "CIGNA COM ALT HMO PLAN", "methodology": "percent of total billed charges", "standard_charge_dollar": 738.5, "standard_charge_percentage": 42.2, "count": "0", "additional_payer_notes": "Zero final payments for the item or service in the 15 months prior to posting the file." }, { "payer_name": "HEALTH NET", "plan_name": "HEALTHNET HMO, PPO, POS, EPO, CANOPY HEALTHNET HMO, OTHER-IN-NETWORK PLANS", "methodology": "per diem", "standard_charge_dollar": 8000.0, "standard_charge_algorithm": "Expected reimbursement is the lesser of Per diem ($8,000) for the length of stay and 70% of billed.", "count": "0", "additional_payer_notes": "Zero final payments for the item or service in the 15 months prior to posting the file." }, { "payer_name": "HEALTH NET", "plan_name": "HEALTHNET HMO, PPO, POS, EPO, CANOPY HEALTHNET HMO, OTHER-IN-NETWORK PLANS", "methodology": "per diem", "standard_charge_dollar": 8000.0, "standard_charge_algorithm": "Expected reimbursement is the lesser of Per diem ($8,000) for the length of stay and 70% of billed.", "count": "0", "additional_payer_notes": "Zero final payments for the item or service in the 15 months prior to posting the file." }, { "payer_name": "UNITED HEALTHCARE", "plan_name": "SUTTER SELECT & SUTTER HEALTH PLAN HMO PLANS", "methodology": "per diem", "standard_charge_dollar": 28538.0, "standard_charge_algorithm": "Per diem ($28,538).", "count": "0", "additional_payer_notes": "Zero final payments for the item or service in the 15 months prior to posting the file." }, { "payer_name": "UNITED HEALTHCARE", "plan_name": "SUTTER SELECT & SUTTER HEALTH PLAN HMO PLANS", "methodology": "per diem", "standard_charge_dollar": 28538.0, "standard_charge_algorithm": "Per diem ($28,538).", "count": "0", "additional_payer_notes": "Zero final payments for the item or service in the 15 months prior to posting the file." }, { "payer_name": "SUTTER", "plan_name": "SUTTER SELECT & SUTTER HEALTH PLAN HMO PLANS", "methodology": "per diem", "standard_charge_dollar": 28538.0, "standard_charge_algorithm": "Per diem ($28,538).", "count": "0", "additional_payer_notes": "Zero final payments for the item or service in the 15 months prior to posting the file." }, { "payer_name": "UNITED HEALTHCARE", "plan_name": "SUTTER SELECT & SUTTER HEALTH PLAN HMO PLANS", "methodology": "per diem", "standard_charge_dollar": 28538.0, "standard_charge_algorithm": "Per diem ($28,538).", "count": "0", "additional_payer_notes": "Zero final payments for the item or service in the 15 months prior to posting the file." }, { "payer_name": "UMR", "plan_name": "SUTTER SELECT & SUTTER HEALTH PLAN HMO PLANS", "methodology": "per diem", "standard_charge_dollar": 28538.0, "standard_charge_algorithm": "Per diem ($28,538).", "count": "0", "additional_payer_notes": "Zero final payments for the item or service in the 15 months prior to posting the file." } ] } ] }, { "description": "HC Cath Gp019", "code_information": [ { "code": "PX-2120029019", "type": "CDM" }, { "code": "99999", "type": "CPT" }, { "code": "0272", "type": "RC" } ], "standard_charges": [ { "setting": "outpatient", "gross_charge": 2125.0, "discounted_cash": 1062.5, "minimum": 896.75, "maximum": 1105.0, "additional_generic_notes": "Zero final payments for the item or service in the 15 months prior to posting the file.", "payers_information": [ { "payer_name": "AETNA", "plan_name": "AETNA ALL OTHER PLANS", "methodology": "percent of total billed charges", "standard_charge_dollar": 1105.0, "standard_charge_percentage": 52.0, "count": "0", "additional_payer_notes": "Zero final payments for the item or service in the 15 months prior to posting the file." }, { "payer_name": "AETNA", "plan_name": "AETNA ALL OTHER PLANS", "methodology": "percent of total billed charges", "standard_charge_dollar": 1105.0, "standard_charge_percentage": 52.0, "count": "0", "additional_payer_notes": "Zero final payments for the item or service in the 15 months prior to posting the file." }, { "payer_name": "MERITAIN HEALTH", "plan_name": "AETNA ALL OTHER PLANS", "methodology": "percent of total billed charges", "standard_charge_dollar": 1105.0, "standard_charge_percentage": 52.0, "count": "0", "additional_payer_notes": "Zero final payments for the item or service in the 15 months prior to posting the file." }, { "payer_name": "BLUE SHIELD OUT OF STATE", "plan_name": "STANFORD HEALTHCARE ALLIANCE PLAN", "methodology": "percent of total billed charges", "standard_charge_dollar": 1032.54, "standard_charge_percentage": 48.59, "count": "0", "additional_payer_notes": "Zero final payments for the item or service in the 15 months prior to posting the file." }, { "payer_name": "BLUE SHIELD", "plan_name": "STANFORD HEALTHCARE ALLIANCE PLAN", "methodology": "percent of total billed charges", "standard_charge_dollar": 1032.54, "standard_charge_percentage": 48.59, "median_amount": 68.24, "10th_percentile": 13.6, "90th_percentile": 1043.06, "count": "30" }, { "payer_name": "BLUE SHIELD", "plan_name": "STANFORD HEALTHCARE ALLIANCE PLAN", "methodology": "percent of total billed charges", "standard_charge_dollar": 1032.54, "standard_charge_percentage": 48.59, "count": "0", "additional_payer_notes": "Zero final payments for the item or service in the 15 months prior to posting the file." }, { "payer_name": "BLUE SHIELD", "plan_name": "STANFORD HEALTHCARE ALLIANCE PLAN", "methodology": "percent of total billed charges", "standard_charge_dollar": 1032.54, "standard_charge_percentage": 48.59, "count": "0", "additional_payer_notes": "Zero final payments for the item or service in the 15 months prior to posting the file." }, { "payer_name": "CIGNA", "plan_name": "CIGNA COM ALT HMO PLAN", "methodology": "percent of total billed charges", "standard_charge_dollar": 896.75, "standard_charge_percentage": 42.2, "count": "0", "additional_payer_notes": "Zero final payments for the item or service in the 15 months prior to posting the file." }, { "payer_name": "CIGNA", "plan_name": "CIGNA COM ALT HMO PLAN", "methodology": "percent of total billed charges", "standard_charge_dollar": 896.75, "standard_charge_percentage": 42.2, "count": "0", "additional_payer_notes": "Zero final payments for the item or service in the 15 months prior to posting the file." }, { "payer_name": "HEALTH NET", "plan_name": "HEALTHNET HMO, PPO, POS, EPO, CANOPY HEALTHNET HMO, OTHER-IN-NETWORK PLANS", "methodology": "per diem", "standard_charge_dollar": 8000.0, "standard_charge_algorithm": "Expected reimbursement is the lesser of Per diem ($8,000) for the length of stay and 70% of billed.", "count": "0", "additional_payer_notes": "Zero final payments for the item or service in the 15 months prior to posting the file." }, { "payer_name": "HEALTH NET", "plan_name": "HEALTHNET HMO, PPO, POS, EPO, CANOPY HEALTHNET HMO, OTHER-IN-NETWORK PLANS", "methodology": "per diem", "standard_charge_dollar": 8000.0, "standard_charge_algorithm": "Expected reimbursement is the lesser of Per diem ($8,000) for the length of stay and 70% of billed.", "count": "0", "additional_payer_notes": "Zero final payments for the item or service in the 15 months prior to posting the file." }, { "payer_name": "UNITED HEALTHCARE", "plan_name": "SUTTER SELECT & SUTTER HEALTH PLAN HMO PLANS", "methodology": "per diem", "standard_charge_dollar": 28538.0, "standard_charge_algorithm": "Per diem ($28,538).", "count": "0", "additional_payer_notes": "Zero final payments for the item or service in the 15 months prior to posting the file." }, { "payer_name": "UNITED HEALTHCARE", "plan_name": "SUTTER SELECT & SUTTER HEALTH PLAN HMO PLANS", "methodology": "per diem", "standard_charge_dollar": 28538.0, "standard_charge_algorithm": "Per diem ($28,538).", "count": "0", "additional_payer_notes": "Zero final payments for the item or service in the 15 months prior to posting the file." }, { "payer_name": "SUTTER", "plan_name": "SUTTER SELECT & SUTTER HEALTH PLAN HMO PLANS", "methodology": "per diem", "standard_charge_dollar": 28538.0, "standard_charge_algorithm": "Per diem ($28,538).", "count": "0", "additional_payer_notes": "Zero final payments for the item or service in the 15 months prior to posting the file." }, { "payer_name": "UNITED HEALTHCARE", "plan_name": "SUTTER SELECT & SUTTER HEALTH PLAN HMO PLANS", "methodology": "per diem", "standard_charge_dollar": 28538.0, "standard_charge_algorithm": "Per diem ($28,538).", "count": "0", "additional_payer_notes": "Zero final payments for the item or service in the 15 months prior to posting the file." }, { "payer_name": "UMR", "plan_name": "SUTTER SELECT & SUTTER HEALTH PLAN HMO PLANS", "methodology": "per diem", "standard_charge_dollar": 28538.0, "standard_charge_algorithm": "Per diem ($28,538).", "count": "0", "additional_payer_notes": "Zero final payments for the item or service in the 15 months prior to posting the file." } ] } ] }, { "description": "HC Cath Gp024", "code_information": [ { "code": "PX-2120029024", "type": "CDM" }, { "code": "99999", "type": "CPT" }, { "code": "0272", "type": "RC" } ], "standard_charges": [ { "setting": "outpatient", "gross_charge": 4000.0, "discounted_cash": 2000.0, "minimum": 1688.0, "maximum": 2080.0, "additional_generic_notes": "Zero final payments for the item or service in the 15 months prior to posting the file.", "payers_information": [ { "payer_name": "AETNA", "plan_name": "AETNA ALL OTHER PLANS", "methodology": "percent of total billed charges", "standard_charge_dollar": 2080.0, "standard_charge_percentage": 52.0, "count": "0", "additional_payer_notes": "Zero final payments for the item or service in the 15 months prior to posting the file." }, { "payer_name": "AETNA", "plan_name": "AETNA ALL OTHER PLANS", "methodology": "percent of total billed charges", "standard_charge_dollar": 2080.0, "standard_charge_percentage": 52.0, "count": "0", "additional_payer_notes": "Zero final payments for the item or service in the 15 months prior to posting the file." }, { "payer_name": "MERITAIN HEALTH", "plan_name": "AETNA ALL OTHER PLANS", "methodology": "percent of total billed charges", "standard_charge_dollar": 2080.0, "standard_charge_percentage": 52.0, "count": "0", "additional_payer_notes": "Zero final payments for the item or service in the 15 months prior to posting the file." }, { "payer_name": "BLUE SHIELD OUT OF STATE", "plan_name": "STANFORD HEALTHCARE ALLIANCE PLAN", "methodology": "percent of total billed charges", "standard_charge_dollar": 1943.6, "standard_charge_percentage": 48.59, "count": "0", "additional_payer_notes": "Zero final payments for the item or service in the 15 months prior to posting the file." }, { "payer_name": "BLUE SHIELD", "plan_name": "STANFORD HEALTHCARE ALLIANCE PLAN", "methodology": "percent of total billed charges", "standard_charge_dollar": 1943.6, "standard_charge_percentage": 48.59, "median_amount": 68.24, "10th_percentile": 13.6, "90th_percentile": 1043.06, "count": "30" }, { "payer_name": "BLUE SHIELD", "plan_name": "STANFORD HEALTHCARE ALLIANCE PLAN", "methodology": "percent of total billed charges", "standard_charge_dollar": 1943.6, "standard_charge_percentage": 48.59, "count": "0", "additional_payer_notes": "Zero final payments for the item or service in the 15 months prior to posting the file." }, { "payer_name": "BLUE SHIELD", "plan_name": "STANFORD HEALTHCARE ALLIANCE PLAN", "methodology": "percent of total billed charges", "standard_charge_dollar": 1943.6, "standard_charge_percentage": 48.59, "count": "0", "additional_payer_notes": "Zero final payments for the item or service in the 15 months prior to posting the file." }, { "payer_name": "CIGNA", "plan_name": "CIGNA COM ALT HMO PLAN", "methodology": "percent of total billed charges", "standard_charge_dollar": 1688.0, "standard_charge_percentage": 42.2, "count": "0", "additional_payer_notes": "Zero final payments for the item or service in the 15 months prior to posting the file." }, { "payer_name": "CIGNA", "plan_name": "CIGNA COM ALT HMO PLAN", "methodology": "percent of total billed charges", "standard_charge_dollar": 1688.0, "standard_charge_percentage": 42.2, "count": "0", "additional_payer_notes": "Zero final payments for the item or service in the 15 months prior to posting the file." }, { "payer_name": "HEALTH NET", "plan_name": "HEALTHNET HMO, PPO, POS, EPO, CANOPY HEALTHNET HMO, OTHER-IN-NETWORK PLANS", "methodology": "per diem", "standard_charge_dollar": 8000.0, "standard_charge_algorithm": "Expected reimbursement is the lesser of Per diem ($8,000) for the length of stay and 70% of billed.", "count": "0", "additional_payer_notes": "Zero final payments for the item or service in the 15 months prior to posting the file." }, { "payer_name": "HEALTH NET", "plan_name": "HEALTHNET HMO, PPO, POS, EPO, CANOPY HEALTHNET HMO, OTHER-IN-NETWORK PLANS", "methodology": "per diem", "standard_charge_dollar": 8000.0, "standard_charge_algorithm": "Expected reimbursement is the lesser of Per diem ($8,000) for the length of stay and 70% of billed.", "count": "0", "additional_payer_notes": "Zero final payments for the item or service in the 15 months prior to posting the file." }, { "payer_name": "UNITED HEALTHCARE", "plan_name": "SUTTER SELECT & SUTTER HEALTH PLAN HMO PLANS", "methodology": "per diem", "standard_charge_dollar": 28538.0, "standard_charge_algorithm": "Per diem ($28,538).", "count": "0", "additional_payer_notes": "Zero final payments for the item or service in the 15 months prior to posting the file." }, { "payer_name": "UNITED HEALTHCARE", "plan_name": "SUTTER SELECT & SUTTER HEALTH PLAN HMO PLANS", "methodology": "per diem", "standard_charge_dollar": 28538.0, "standard_charge_algorithm": "Per diem ($28,538).", "count": "0", "additional_payer_notes": "Zero final payments for the item or service in the 15 months prior to posting the file." }, { "payer_name": "SUTTER", "plan_name": "SUTTER SELECT & SUTTER HEALTH PLAN HMO PLANS", "methodology": "per diem", "standard_charge_dollar": 28538.0, "standard_charge_algorithm": "Per diem ($28,538).", "count": "0", "additional_payer_notes": "Zero final payments for the item or service in the 15 months prior to posting the file." }, { "payer_name": "UNITED HEALTHCARE", "plan_name": "SUTTER SELECT & SUTTER HEALTH PLAN HMO PLANS", "methodology": "per diem", "standard_charge_dollar": 28538.0, "standard_charge_algorithm": "Per diem ($28,538).", "count": "0", "additional_payer_notes": "Zero final payments for the item or service in the 15 months prior to posting the file." }, { "payer_name": "UMR", "plan_name": "SUTTER SELECT & SUTTER HEALTH PLAN HMO PLANS", "methodology": "per diem", "standard_charge_dollar": 28538.0, "standard_charge_algorithm": "Per diem ($28,538).", "count": "0", "additional_payer_notes": "Zero final payments for the item or service in the 15 months prior to posting the file." } ] } ] }, { "description": "HC Cath Gp029", "code_information": [ { "code": "PX-2120029029", "type": "CDM" }, { "code": "99999", "type": "CPT" }, { "code": "0272", "type": "RC" } ], "standard_charges": [ { "setting": "outpatient", "gross_charge": 5438.0, "discounted_cash": 2719.0, "minimum": 2294.84, "maximum": 2827.76, "additional_generic_notes": "Zero final payments for the item or service in the 15 months prior to posting the file.", "payers_information": [ { "payer_name": "AETNA", "plan_name": "AETNA ALL OTHER PLANS", "methodology": "percent of total billed charges", "standard_charge_dollar": 2827.76, "standard_charge_percentage": 52.0, "count": "0", "additional_payer_notes": "Zero final payments for the item or service in the 15 months prior to posting the file." }, { "payer_name": "AETNA", "plan_name": "AETNA ALL OTHER PLANS", "methodology": "percent of total billed charges", "standard_charge_dollar": 2827.76, "standard_charge_percentage": 52.0, "count": "0", "additional_payer_notes": "Zero final payments for the item or service in the 15 months prior to posting the file." }, { "payer_name": "MERITAIN HEALTH", "plan_name": "AETNA ALL OTHER PLANS", "methodology": "percent of total billed charges", "standard_charge_dollar": 2827.76, "standard_charge_percentage": 52.0, "count": "0", "additional_payer_notes": "Zero final payments for the item or service in the 15 months prior to posting the file." }, { "payer_name": "BLUE SHIELD OUT OF STATE", "plan_name": "STANFORD HEALTHCARE ALLIANCE PLAN", "methodology": "percent of total billed charges", "standard_charge_dollar": 2642.32, "standard_charge_percentage": 48.59, "count": "0", "additional_payer_notes": "Zero final payments for the item or service in the 15 months prior to posting the file." }, { "payer_name": "BLUE SHIELD", "plan_name": "STANFORD HEALTHCARE ALLIANCE PLAN", "methodology": "percent of total billed charges", "standard_charge_dollar": 2642.32, "standard_charge_percentage": 48.59, "median_amount": 68.24, "10th_percentile": 13.6, "90th_percentile": 1043.06, "count": "30" }, { "payer_name": "BLUE SHIELD", "plan_name": "STANFORD HEALTHCARE ALLIANCE PLAN", "methodology": "percent of total billed charges", "standard_charge_dollar": 2642.32, "standard_charge_percentage": 48.59, "count": "0", "additional_payer_notes": "Zero final payments for the item or service in the 15 months prior to posting the file." }, { "payer_name": "BLUE SHIELD", "plan_name": "STANFORD HEALTHCARE ALLIANCE PLAN", "methodology": "percent of total billed charges", "standard_charge_dollar": 2642.32, "standard_charge_percentage": 48.59, "count": "0", "additional_payer_notes": "Zero final payments for the item or service in the 15 months prior to posting the file." }, { "payer_name": "CIGNA", "plan_name": "CIGNA COM ALT HMO PLAN", "methodology": "percent of total billed charges", "standard_charge_dollar": 2294.84, "standard_charge_percentage": 42.2, "count": "0", "additional_payer_notes": "Zero final payments for the item or service in the 15 months prior to posting the file." }, { "payer_name": "CIGNA", "plan_name": "CIGNA COM ALT HMO PLAN", "methodology": "percent of total billed charges", "standard_charge_dollar": 2294.84, "standard_charge_percentage": 42.2, "count": "0", "additional_payer_notes": "Zero final payments for the item or service in the 15 months prior to posting the file." }, { "payer_name": "HEALTH NET", "plan_name": "HEALTHNET HMO, PPO, POS, EPO, CANOPY HEALTHNET HMO, OTHER-IN-NETWORK PLANS", "methodology": "per diem", "standard_charge_dollar": 8000.0, "standard_charge_algorithm": "Expected reimbursement is the lesser of Per diem ($8,000) for the length of stay and 70% of billed.", "count": "0", "additional_payer_notes": "Zero final payments for the item or service in the 15 months prior to posting the file." }, { "payer_name": "HEALTH NET", "plan_name": "HEALTHNET HMO, PPO, POS, EPO, CANOPY HEALTHNET HMO, OTHER-IN-NETWORK PLANS", "methodology": "per diem", "standard_charge_dollar": 8000.0, "standard_charge_algorithm": "Expected reimbursement is the lesser of Per diem ($8,000) for the length of stay and 70% of billed.", "count": "0", "additional_payer_notes": "Zero final payments for the item or service in the 15 months prior to posting the file." }, { "payer_name": "UNITED HEALTHCARE", "plan_name": "SUTTER SELECT & SUTTER HEALTH PLAN HMO PLANS", "methodology": "per diem", "standard_charge_dollar": 28538.0, "standard_charge_algorithm": "Per diem ($28,538).", "count": "0", "additional_payer_notes": "Zero final payments for the item or service in the 15 months prior to posting the file." }, { "payer_name": "UNITED HEALTHCARE", "plan_name": "SUTTER SELECT & SUTTER HEALTH PLAN HMO PLANS", "methodology": "per diem", "standard_charge_dollar": 28538.0, "standard_charge_algorithm": "Per diem ($28,538).", "count": "0", "additional_payer_notes": "Zero final payments for the item or service in the 15 months prior to posting the file." }, { "payer_name": "SUTTER", "plan_name": "SUTTER SELECT & SUTTER HEALTH PLAN HMO PLANS", "methodology": "per diem", "standard_charge_dollar": 28538.0, "standard_charge_algorithm": "Per diem ($28,538).", "count": "0", "additional_payer_notes": "Zero final payments for the item or service in the 15 months prior to posting the file." }, { "payer_name": "UNITED HEALTHCARE", "plan_name": "SUTTER SELECT & SUTTER HEALTH PLAN HMO PLANS", "methodology": "per diem", "standard_charge_dollar": 28538.0, "standard_charge_algorithm": "Per diem ($28,538).", "count": "0", "additional_payer_notes": "Zero final payments for the item or service in the 15 months prior to posting the file." }, { "payer_name": "UMR", "plan_name": "SUTTER SELECT & SUTTER HEALTH PLAN HMO PLANS", "methodology": "per diem", "standard_charge_dollar": 28538.0, "standard_charge_algorithm": "Per diem ($28,538).", "count": "0", "additional_payer_notes": "Zero final payments for the item or service in the 15 months prior to posting the file." } ] } ] }, { "description": "HC Cath Gp038", "code_information": [ { "code": "PX-2120029038", "type": "CDM" }, { "code": "99999", "type": "CPT" }, { "code": "0272", "type": "RC" } ], "standard_charges": [ { "setting": "outpatient", "gross_charge": 8750.0, "discounted_cash": 4375.0, "minimum": 3692.5, "maximum": 4550.0, "additional_generic_notes": "Zero final payments for the item or service in the 15 months prior to posting the file.", "payers_information": [ { "payer_name": "AETNA", "plan_name": "AETNA ALL OTHER PLANS", "methodology": "percent of total billed charges", "standard_charge_dollar": 4550.0, "standard_charge_percentage": 52.0, "count": "0", "additional_payer_notes": "Zero final payments for the item or service in the 15 months prior to posting the file." }, { "payer_name": "AETNA", "plan_name": "AETNA ALL OTHER PLANS", "methodology": "percent of total billed charges", "standard_charge_dollar": 4550.0, "standard_charge_percentage": 52.0, "count": "0", "additional_payer_notes": "Zero final payments for the item or service in the 15 months prior to posting the file." }, { "payer_name": "MERITAIN HEALTH", "plan_name": "AETNA ALL OTHER PLANS", "methodology": "percent of total billed charges", "standard_charge_dollar": 4550.0, "standard_charge_percentage": 52.0, "count": "0", "additional_payer_notes": "Zero final payments for the item or service in the 15 months prior to posting the file." }, { "payer_name": "BLUE SHIELD OUT OF STATE", "plan_name": "STANFORD HEALTHCARE ALLIANCE PLAN", "methodology": "percent of total billed charges", "standard_charge_dollar": 4251.63, "standard_charge_percentage": 48.59, "count": "0", "additional_payer_notes": "Zero final payments for the item or service in the 15 months prior to posting the file." }, { "payer_name": "BLUE SHIELD", "plan_name": "STANFORD HEALTHCARE ALLIANCE PLAN", "methodology": "percent of total billed charges", "standard_charge_dollar": 4251.63, "standard_charge_percentage": 48.59, "median_amount": 68.24, "10th_percentile": 13.6, "90th_percentile": 1043.06, "count": "30" }, { "payer_name": "BLUE SHIELD", "plan_name": "STANFORD HEALTHCARE ALLIANCE PLAN", "methodology": "percent of total billed charges", "standard_charge_dollar": 4251.63, "standard_charge_percentage": 48.59, "count": "0", "additional_payer_notes": "Zero final payments for the item or service in the 15 months prior to posting the file." }, { "payer_name": "BLUE SHIELD", "plan_name": "STANFORD HEALTHCARE ALLIANCE PLAN", "methodology": "percent of total billed charges", "standard_charge_dollar": 4251.63, "standard_charge_percentage": 48.59, "count": "0", "additional_payer_notes": "Zero final payments for the item or service in the 15 months prior to posting the file." }, { "payer_name": "CIGNA", "plan_name": "CIGNA COM ALT HMO PLAN", "methodology": "percent of total billed charges", "standard_charge_dollar": 3692.5, "standard_charge_percentage": 42.2, "count": "0", "additional_payer_notes": "Zero final payments for the item or service in the 15 months prior to posting the file." }, { "payer_name": "CIGNA", "plan_name": "CIGNA COM ALT HMO PLAN", "methodology": "percent of total billed charges", "standard_charge_dollar": 3692.5, "standard_charge_percentage": 42.2, "count": "0", "additional_payer_notes": "Zero final payments for the item or service in the 15 months prior to posting the file." }, { "payer_name": "HEALTH NET", "plan_name": "HEALTHNET HMO, PPO, POS, EPO, CANOPY HEALTHNET HMO, OTHER-IN-NETWORK PLANS", "methodology": "per diem", "standard_charge_dollar": 8000.0, "standard_charge_algorithm": "Expected reimbursement is the lesser of Per diem ($8,000) for the length of stay and 70% of billed.", "count": "0", "additional_payer_notes": "Zero final payments for the item or service in the 15 months prior to posting the file." }, { "payer_name": "HEALTH NET", "plan_name": "HEALTHNET HMO, PPO, POS, EPO, CANOPY HEALTHNET HMO, OTHER-IN-NETWORK PLANS", "methodology": "per diem", "standard_charge_dollar": 8000.0, "standard_charge_algorithm": "Expected reimbursement is the lesser of Per diem ($8,000) for the length of stay and 70% of billed.", "count": "0", "additional_payer_notes": "Zero final payments for the item or service in the 15 months prior to posting the file." }, { "payer_name": "UNITED HEALTHCARE", "plan_name": "SUTTER SELECT & SUTTER HEALTH PLAN HMO PLANS", "methodology": "per diem", "standard_charge_dollar": 28538.0, "standard_charge_algorithm": "Per diem ($28,538).", "count": "0", "additional_payer_notes": "Zero final payments for the item or service in the 15 months prior to posting the file." }, { "payer_name": "UNITED HEALTHCARE", "plan_name": "SUTTER SELECT & SUTTER HEALTH PLAN HMO PLANS", "methodology": "per diem", "standard_charge_dollar": 28538.0, "standard_charge_algorithm": "Per diem ($28,538).", "count": "0", "additional_payer_notes": "Zero final payments for the item or service in the 15 months prior to posting the file." }, { "payer_name": "SUTTER", "plan_name": "SUTTER SELECT & SUTTER HEALTH PLAN HMO PLANS", "methodology": "per diem", "standard_charge_dollar": 28538.0, "standard_charge_algorithm": "Per diem ($28,538).", "count": "0", "additional_payer_notes": "Zero final payments for the item or service in the 15 months prior to posting the file." }, { "payer_name": "UNITED HEALTHCARE", "plan_name": "SUTTER SELECT & SUTTER HEALTH PLAN HMO PLANS", "methodology": "per diem", "standard_charge_dollar": 28538.0, "standard_charge_algorithm": "Per diem ($28,538).", "count": "0", "additional_payer_notes": "Zero final payments for the item or service in the 15 months prior to posting the file." }, { "payer_name": "UMR", "plan_name": "SUTTER SELECT & SUTTER HEALTH PLAN HMO PLANS", "methodology": "per diem", "standard_charge_dollar": 28538.0, "standard_charge_algorithm": "Per diem ($28,538).", "count": "0", "additional_payer_notes": "Zero final payments for the item or service in the 15 months prior to posting the file." } ] } ] }, { "description": "HC Cath Gp047", "code_information": [ { "code": "PX-2120029047", "type": "CDM" }, { "code": "99999", "type": "CPT" }, { "code": "0272", "type": "RC" } ], "standard_charges": [ { "setting": "outpatient", "gross_charge": 13000.0, "discounted_cash": 6500.0, "minimum": 5486.0, "maximum": 6760.0, "additional_generic_notes": "Zero final payments for the item or service in the 15 months prior to posting the file.", "payers_information": [ { "payer_name": "AETNA", "plan_name": "AETNA ALL OTHER PLANS", "methodology": "percent of total billed charges", "standard_charge_dollar": 6760.0, "standard_charge_percentage": 52.0, "count": "0", "additional_payer_notes": "Zero final payments for the item or service in the 15 months prior to posting the file." }, { "payer_name": "AETNA", "plan_name": "AETNA ALL OTHER PLANS", "methodology": "percent of total billed charges", "standard_charge_dollar": 6760.0, "standard_charge_percentage": 52.0, "count": "0", "additional_payer_notes": "Zero final payments for the item or service in the 15 months prior to posting the file." }, { "payer_name": "MERITAIN HEALTH", "plan_name": "AETNA ALL OTHER PLANS", "methodology": "percent of total billed charges", "standard_charge_dollar": 6760.0, "standard_charge_percentage": 52.0, "count": "0", "additional_payer_notes": "Zero final payments for the item or service in the 15 months prior to posting the file." }, { "payer_name": "BLUE SHIELD OUT OF STATE", "plan_name": "STANFORD HEALTHCARE ALLIANCE PLAN", "methodology": "percent of total billed charges", "standard_charge_dollar": 6316.7, "standard_charge_percentage": 48.59, "count": "0", "additional_payer_notes": "Zero final payments for the item or service in the 15 months prior to posting the file." }, { "payer_name": "BLUE SHIELD", "plan_name": "STANFORD HEALTHCARE ALLIANCE PLAN", "methodology": "percent of total billed charges", "standard_charge_dollar": 6316.7, "standard_charge_percentage": 48.59, "median_amount": 68.24, "10th_percentile": 13.6, "90th_percentile": 1043.06, "count": "30" }, { "payer_name": "BLUE SHIELD", "plan_name": "STANFORD HEALTHCARE ALLIANCE PLAN", "methodology": "percent of total billed charges", "standard_charge_dollar": 6316.7, "standard_charge_percentage": 48.59, "count": "0", "additional_payer_notes": "Zero final payments for the item or service in the 15 months prior to posting the file." }, { "payer_name": "BLUE SHIELD", "plan_name": "STANFORD HEALTHCARE ALLIANCE PLAN", "methodology": "percent of total billed charges", "standard_charge_dollar": 6316.7, "standard_charge_percentage": 48.59, "count": "0", "additional_payer_notes": "Zero final payments for the item or service in the 15 months prior to posting the file." }, { "payer_name": "CIGNA", "plan_name": "CIGNA COM ALT HMO PLAN", "methodology": "percent of total billed charges", "standard_charge_dollar": 5486.0, "standard_charge_percentage": 42.2, "count": "0", "additional_payer_notes": "Zero final payments for the item or service in the 15 months prior to posting the file." }, { "payer_name": "CIGNA", "plan_name": "CIGNA COM ALT HMO PLAN", "methodology": "percent of total billed charges", "standard_charge_dollar": 5486.0, "standard_charge_percentage": 42.2, "count": "0", "additional_payer_notes": "Zero final payments for the item or service in the 15 months prior to posting the file." }, { "payer_name": "HEALTH NET", "plan_name": "HEALTHNET HMO, PPO, POS, EPO, CANOPY HEALTHNET HMO, OTHER-IN-NETWORK PLANS", "methodology": "per diem", "standard_charge_dollar": 8000.0, "standard_charge_algorithm": "Expected reimbursement is the lesser of Per diem ($8,000) for the length of stay and 70% of billed.", "count": "0", "additional_payer_notes": "Zero final payments for the item or service in the 15 months prior to posting the file." }, { "payer_name": "HEALTH NET", "plan_name": "HEALTHNET HMO, PPO, POS, EPO, CANOPY HEALTHNET HMO, OTHER-IN-NETWORK PLANS", "methodology": "per diem", "standard_charge_dollar": 8000.0, "standard_charge_algorithm": "Expected reimbursement is the lesser of Per diem ($8,000) for the length of stay and 70% of billed.", "count": "0", "additional_payer_notes": "Zero final payments for the item or service in the 15 months prior to posting the file." }, { "payer_name": "UNITED HEALTHCARE", "plan_name": "SUTTER SELECT & SUTTER HEALTH PLAN HMO PLANS", "methodology": "per diem", "standard_charge_dollar": 28538.0, "standard_charge_algorithm": "Per diem ($28,538).", "count": "0", "additional_payer_notes": "Zero final payments for the item or service in the 15 months prior to posting the file." }, { "payer_name": "UNITED HEALTHCARE", "plan_name": "SUTTER SELECT & SUTTER HEALTH PLAN HMO PLANS", "methodology": "per diem", "standard_charge_dollar": 28538.0, "standard_charge_algorithm": "Per diem ($28,538).", "count": "0", "additional_payer_notes": "Zero final payments for the item or service in the 15 months prior to posting the file." }, { "payer_name": "SUTTER", "plan_name": "SUTTER SELECT & SUTTER HEALTH PLAN HMO PLANS", "methodology": "per diem", "standard_charge_dollar": 28538.0, "standard_charge_algorithm": "Per diem ($28,538).", "count": "0", "additional_payer_notes": "Zero final payments for the item or service in the 15 months prior to posting the file." }, { "payer_name": "UNITED HEALTHCARE", "plan_name": "SUTTER SELECT & SUTTER HEALTH PLAN HMO PLANS", "methodology": "per diem", "standard_charge_dollar": 28538.0, "standard_charge_algorithm": "Per diem ($28,538).", "count": "0", "additional_payer_notes": "Zero final payments for the item or service in the 15 months prior to posting the file." }, { "payer_name": "UMR", "plan_name": "SUTTER SELECT & SUTTER HEALTH PLAN HMO PLANS", "methodology": "per diem", "standard_charge_dollar": 28538.0, "standard_charge_algorithm": "Per diem ($28,538).", "count": "0", "additional_payer_notes": "Zero final payments for the item or service in the 15 months prior to posting the file." } ] } ] }, { "description": "HC Cath Blln Occl Gp017", "code_information": [ { "code": "PX-2120030017", "type": "CDM" }, { "code": "C2628", "type": "HCPCS" }, { "code": "0272", "type": "RC" } ], "standard_charges": [ { "setting": "outpatient", "gross_charge": 1575.0, "discounted_cash": 787.5, "minimum": 664.65, "maximum": 819.0, "additional_generic_notes": "Zero final payments for the item or service in the 15 months prior to posting the file.", "payers_information": [ { "payer_name": "AETNA", "plan_name": "AETNA ALL OTHER PLANS", "methodology": "percent of total billed charges", "standard_charge_dollar": 819.0, "standard_charge_percentage": 52.0, "count": "0", "additional_payer_notes": "Zero final payments for the item or service in the 15 months prior to posting the file." }, { "payer_name": "AETNA", "plan_name": "AETNA ALL OTHER PLANS", "methodology": "percent of total billed charges", "standard_charge_dollar": 819.0, "standard_charge_percentage": 52.0, "count": "0", "additional_payer_notes": "Zero final payments for the item or service in the 15 months prior to posting the file." }, { "payer_name": "MERITAIN HEALTH", "plan_name": "AETNA ALL OTHER PLANS", "methodology": "percent of total billed charges", "standard_charge_dollar": 819.0, "standard_charge_percentage": 52.0, "count": "0", "additional_payer_notes": "Zero final payments for the item or service in the 15 months prior to posting the file." }, { "payer_name": "BLUE SHIELD OUT OF STATE", "plan_name": "STANFORD HEALTHCARE ALLIANCE PLAN", "methodology": "percent of total billed charges", "standard_charge_dollar": 765.29, "standard_charge_percentage": 48.59, "count": "0", "additional_payer_notes": "Zero final payments for the item or service in the 15 months prior to posting the file." }, { "payer_name": "BLUE SHIELD", "plan_name": "STANFORD HEALTHCARE ALLIANCE PLAN", "methodology": "percent of total billed charges", "standard_charge_dollar": 765.29, "standard_charge_percentage": 48.59, "count": "0", "additional_payer_notes": "Zero final payments for the item or service in the 15 months prior to posting the file." }, { "payer_name": "BLUE SHIELD", "plan_name": "STANFORD HEALTHCARE ALLIANCE PLAN", "methodology": "percent of total billed charges", "standard_charge_dollar": 765.29, "standard_charge_percentage": 48.59, "count": "0", "additional_payer_notes": "Zero final payments for the item or service in the 15 months prior to posting the file." }, { "payer_name": "BLUE SHIELD", "plan_name": "STANFORD HEALTHCARE ALLIANCE PLAN", "methodology": "percent of total billed charges", "standard_charge_dollar": 765.29, "standard_charge_percentage": 48.59, "count": "0", "additional_payer_notes": "Zero final payments for the item or service in the 15 months prior to posting the file." }, { "payer_name": "CIGNA", "plan_name": "CIGNA COM ALT HMO PLAN", "methodology": "percent of total billed charges", "standard_charge_dollar": 664.65, "standard_charge_percentage": 42.2, "count": "0", "additional_payer_notes": "Zero final payments for the item or service in the 15 months prior to posting the file." }, { "payer_name": "CIGNA", "plan_name": "CIGNA COM ALT HMO PLAN", "methodology": "percent of total billed charges", "standard_charge_dollar": 664.65, "standard_charge_percentage": 42.2, "count": "0", "additional_payer_notes": "Zero final payments for the item or service in the 15 months prior to posting the file." }, { "payer_name": "HEALTH NET", "plan_name": "HEALTHNET HMO, PPO, POS, EPO, CANOPY HEALTHNET HMO, OTHER-IN-NETWORK PLANS", "methodology": "per diem", "standard_charge_dollar": 8000.0, "standard_charge_algorithm": "Expected reimbursement is the lesser of Per diem ($8,000) for the length of stay and 70% of billed.", "count": "0", "additional_payer_notes": "Zero final payments for the item or service in the 15 months prior to posting the file." }, { "payer_name": "HEALTH NET", "plan_name": "HEALTHNET HMO, PPO, POS, EPO, CANOPY HEALTHNET HMO, OTHER-IN-NETWORK PLANS", "methodology": "per diem", "standard_charge_dollar": 8000.0, "standard_charge_algorithm": "Expected reimbursement is the lesser of Per diem ($8,000) for the length of stay and 70% of billed.", "count": "0", "additional_payer_notes": "Zero final payments for the item or service in the 15 months prior to posting the file." }, { "payer_name": "UNITED HEALTHCARE", "plan_name": "SUTTER SELECT & SUTTER HEALTH PLAN HMO PLANS", "methodology": "per diem", "standard_charge_dollar": 28538.0, "standard_charge_algorithm": "Per diem ($28,538).", "count": "0", "additional_payer_notes": "Zero final payments for the item or service in the 15 months prior to posting the file." }, { "payer_name": "UNITED HEALTHCARE", "plan_name": "SUTTER SELECT & SUTTER HEALTH PLAN HMO PLANS", "methodology": "per diem", "standard_charge_dollar": 28538.0, "standard_charge_algorithm": "Per diem ($28,538).", "count": "0", "additional_payer_notes": "Zero final payments for the item or service in the 15 months prior to posting the file." }, { "payer_name": "SUTTER", "plan_name": "SUTTER SELECT & SUTTER HEALTH PLAN HMO PLANS", "methodology": "per diem", "standard_charge_dollar": 28538.0, "standard_charge_algorithm": "Per diem ($28,538).", "count": "0", "additional_payer_notes": "Zero final payments for the item or service in the 15 months prior to posting the file." }, { "payer_name": "UNITED HEALTHCARE", "plan_name": "SUTTER SELECT & SUTTER HEALTH PLAN HMO PLANS", "methodology": "per diem", "standard_charge_dollar": 28538.0, "standard_charge_algorithm": "Per diem ($28,538).", "count": "0", "additional_payer_notes": "Zero final payments for the item or service in the 15 months prior to posting the file." }, { "payer_name": "UMR", "plan_name": "SUTTER SELECT & SUTTER HEALTH PLAN HMO PLANS", "methodology": "per diem", "standard_charge_dollar": 28538.0, "standard_charge_algorithm": "Per diem ($28,538).", "count": "0", "additional_payer_notes": "Zero final payments for the item or service in the 15 months prior to posting the file." }, { "payer_name": "UNITED HEALTHCARE", "plan_name": "SUTTER SELECT & SUTTER HEALTH PLAN HMO PLANS", "methodology": "per diem", "standard_charge_dollar": 28538.0, "standard_charge_algorithm": "Per diem ($28,538).", "count": "0", "additional_payer_notes": "Zero final payments for the item or service in the 15 months prior to posting the file." } ] } ] }, { "description": "HC Cath Blln Occl Gp022", "code_information": [ { "code": "PX-2120030022", "type": "CDM" }, { "code": "C2628", "type": "HCPCS" }, { "code": "0272", "type": "RC" } ], "standard_charges": [ { "setting": "outpatient", "gross_charge": 3300.0, "discounted_cash": 1650.0, "minimum": 1392.6, "maximum": 1716.0, "additional_generic_notes": "Zero final payments for the item or service in the 15 months prior to posting the file.", "payers_information": [ { "payer_name": "AETNA", "plan_name": "AETNA ALL OTHER PLANS", "methodology": "percent of total billed charges", "standard_charge_dollar": 1716.0, "standard_charge_percentage": 52.0, "count": "0", "additional_payer_notes": "Zero final payments for the item or service in the 15 months prior to posting the file." }, { "payer_name": "AETNA", "plan_name": "AETNA ALL OTHER PLANS", "methodology": "percent of total billed charges", "standard_charge_dollar": 1716.0, "standard_charge_percentage": 52.0, "count": "0", "additional_payer_notes": "Zero final payments for the item or service in the 15 months prior to posting the file." }, { "payer_name": "MERITAIN HEALTH", "plan_name": "AETNA ALL OTHER PLANS", "methodology": "percent of total billed charges", "standard_charge_dollar": 1716.0, "standard_charge_percentage": 52.0, "count": "0", "additional_payer_notes": "Zero final payments for the item or service in the 15 months prior to posting the file." }, { "payer_name": "BLUE SHIELD OUT OF STATE", "plan_name": "STANFORD HEALTHCARE ALLIANCE PLAN", "methodology": "percent of total billed charges", "standard_charge_dollar": 1603.47, "standard_charge_percentage": 48.59, "count": "0", "additional_payer_notes": "Zero final payments for the item or service in the 15 months prior to posting the file." }, { "payer_name": "BLUE SHIELD", "plan_name": "STANFORD HEALTHCARE ALLIANCE PLAN", "methodology": "percent of total billed charges", "standard_charge_dollar": 1603.47, "standard_charge_percentage": 48.59, "count": "0", "additional_payer_notes": "Zero final payments for the item or service in the 15 months prior to posting the file." }, { "payer_name": "BLUE SHIELD", "plan_name": "STANFORD HEALTHCARE ALLIANCE PLAN", "methodology": "percent of total billed charges", "standard_charge_dollar": 1603.47, "standard_charge_percentage": 48.59, "count": "0", "additional_payer_notes": "Zero final payments for the item or service in the 15 months prior to posting the file." }, { "payer_name": "BLUE SHIELD", "plan_name": "STANFORD HEALTHCARE ALLIANCE PLAN", "methodology": "percent of total billed charges", "standard_charge_dollar": 1603.47, "standard_charge_percentage": 48.59, "count": "0", "additional_payer_notes": "Zero final payments for the item or service in the 15 months prior to posting the file." }, { "payer_name": "CIGNA", "plan_name": "CIGNA COM ALT HMO PLAN", "methodology": "percent of total billed charges", "standard_charge_dollar": 1392.6, "standard_charge_percentage": 42.2, "count": "0", "additional_payer_notes": "Zero final payments for the item or service in the 15 months prior to posting the file." }, { "payer_name": "CIGNA", "plan_name": "CIGNA COM ALT HMO PLAN", "methodology": "percent of total billed charges", "standard_charge_dollar": 1392.6, "standard_charge_percentage": 42.2, "count": "0", "additional_payer_notes": "Zero final payments for the item or service in the 15 months prior to posting the file." }, { "payer_name": "HEALTH NET", "plan_name": "HEALTHNET HMO, PPO, POS, EPO, CANOPY HEALTHNET HMO, OTHER-IN-NETWORK PLANS", "methodology": "per diem", "standard_charge_dollar": 8000.0, "standard_charge_algorithm": "Expected reimbursement is the lesser of Per diem ($8,000) for the length of stay and 70% of billed.", "count": "0", "additional_payer_notes": "Zero final payments for the item or service in the 15 months prior to posting the file." }, { "payer_name": "HEALTH NET", "plan_name": "HEALTHNET HMO, PPO, POS, EPO, CANOPY HEALTHNET HMO, OTHER-IN-NETWORK PLANS", "methodology": "per diem", "standard_charge_dollar": 8000.0, "standard_charge_algorithm": "Expected reimbursement is the lesser of Per diem ($8,000) for the length of stay and 70% of billed.", "count": "0", "additional_payer_notes": "Zero final payments for the item or service in the 15 months prior to posting the file." }, { "payer_name": "UNITED HEALTHCARE", "plan_name": "SUTTER SELECT & SUTTER HEALTH PLAN HMO PLANS", "methodology": "per diem", "standard_charge_dollar": 28538.0, "standard_charge_algorithm": "Per diem ($28,538).", "count": "0", "additional_payer_notes": "Zero final payments for the item or service in the 15 months prior to posting the file." }, { "payer_name": "UNITED HEALTHCARE", "plan_name": "SUTTER SELECT & SUTTER HEALTH PLAN HMO PLANS", "methodology": "per diem", "standard_charge_dollar": 28538.0, "standard_charge_algorithm": "Per diem ($28,538).", "count": "0", "additional_payer_notes": "Zero final payments for the item or service in the 15 months prior to posting the file." }, { "payer_name": "SUTTER", "plan_name": "SUTTER SELECT & SUTTER HEALTH PLAN HMO PLANS", "methodology": "per diem", "standard_charge_dollar": 28538.0, "standard_charge_algorithm": "Per diem ($28,538).", "count": "0", "additional_payer_notes": "Zero final payments for the item or service in the 15 months prior to posting the file." }, { "payer_name": "UNITED HEALTHCARE", "plan_name": "SUTTER SELECT & SUTTER HEALTH PLAN HMO PLANS", "methodology": "per diem", "standard_charge_dollar": 28538.0, "standard_charge_algorithm": "Per diem ($28,538).", "count": "0", "additional_payer_notes": "Zero final payments for the item or service in the 15 months prior to posting the file." }, { "payer_name": "UMR", "plan_name": "SUTTER SELECT & SUTTER HEALTH PLAN HMO PLANS", "methodology": "per diem", "standard_charge_dollar": 28538.0, "standard_charge_algorithm": "Per diem ($28,538).", "count": "0", "additional_payer_notes": "Zero final payments for the item or service in the 15 months prior to posting the file." }, { "payer_name": "UNITED HEALTHCARE", "plan_name": "SUTTER SELECT & SUTTER HEALTH PLAN HMO PLANS", "methodology": "per diem", "standard_charge_dollar": 28538.0, "standard_charge_algorithm": "Per diem ($28,538).", "count": "0", "additional_payer_notes": "Zero final payments for the item or service in the 15 months prior to posting the file." } ] } ] }, { "description": "HC Cath Blln Occl Gp023", "code_information": [ { "code": "PX-2120030023", "type": "CDM" }, { "code": "C2628", "type": "HCPCS" }, { "code": "0272", "type": "RC" } ], "standard_charges": [ { "setting": "outpatient", "gross_charge": 3600.0, "discounted_cash": 1800.0, "minimum": 1519.2, "maximum": 1872.0, "additional_generic_notes": "Zero final payments for the item or service in the 15 months prior to posting the file.", "payers_information": [ { "payer_name": "AETNA", "plan_name": "AETNA ALL OTHER PLANS", "methodology": "percent of total billed charges", "standard_charge_dollar": 1872.0, "standard_charge_percentage": 52.0, "count": "0", "additional_payer_notes": "Zero final payments for the item or service in the 15 months prior to posting the file." }, { "payer_name": "AETNA", "plan_name": "AETNA ALL OTHER PLANS", "methodology": "percent of total billed charges", "standard_charge_dollar": 1872.0, "standard_charge_percentage": 52.0, "count": "0", "additional_payer_notes": "Zero final payments for the item or service in the 15 months prior to posting the file." }, { "payer_name": "MERITAIN HEALTH", "plan_name": "AETNA ALL OTHER PLANS", "methodology": "percent of total billed charges", "standard_charge_dollar": 1872.0, "standard_charge_percentage": 52.0, "count": "0", "additional_payer_notes": "Zero final payments for the item or service in the 15 months prior to posting the file." }, { "payer_name": "BLUE SHIELD OUT OF STATE", "plan_name": "STANFORD HEALTHCARE ALLIANCE PLAN", "methodology": "percent of total billed charges", "standard_charge_dollar": 1749.24, "standard_charge_percentage": 48.59, "count": "0", "additional_payer_notes": "Zero final payments for the item or service in the 15 months prior to posting the file." }, { "payer_name": "BLUE SHIELD", "plan_name": "STANFORD HEALTHCARE ALLIANCE PLAN", "methodology": "percent of total billed charges", "standard_charge_dollar": 1749.24, "standard_charge_percentage": 48.59, "count": "0", "additional_payer_notes": "Zero final payments for the item or service in the 15 months prior to posting the file." }, { "payer_name": "BLUE SHIELD", "plan_name": "STANFORD HEALTHCARE ALLIANCE PLAN", "methodology": "percent of total billed charges", "standard_charge_dollar": 1749.24, "standard_charge_percentage": 48.59, "count": "0", "additional_payer_notes": "Zero final payments for the item or service in the 15 months prior to posting the file." }, { "payer_name": "BLUE SHIELD", "plan_name": "STANFORD HEALTHCARE ALLIANCE PLAN", "methodology": "percent of total billed charges", "standard_charge_dollar": 1749.24, "standard_charge_percentage": 48.59, "count": "0", "additional_payer_notes": "Zero final payments for the item or service in the 15 months prior to posting the file." }, { "payer_name": "CIGNA", "plan_name": "CIGNA COM ALT HMO PLAN", "methodology": "percent of total billed charges", "standard_charge_dollar": 1519.2, "standard_charge_percentage": 42.2, "count": "0", "additional_payer_notes": "Zero final payments for the item or service in the 15 months prior to posting the file." }, { "payer_name": "CIGNA", "plan_name": "CIGNA COM ALT HMO PLAN", "methodology": "percent of total billed charges", "standard_charge_dollar": 1519.2, "standard_charge_percentage": 42.2, "count": "0", "additional_payer_notes": "Zero final payments for the item or service in the 15 months prior to posting the file." }, { "payer_name": "HEALTH NET", "plan_name": "HEALTHNET HMO, PPO, POS, EPO, CANOPY HEALTHNET HMO, OTHER-IN-NETWORK PLANS", "methodology": "per diem", "standard_charge_dollar": 8000.0, "standard_charge_algorithm": "Expected reimbursement is the lesser of Per diem ($8,000) for the length of stay and 70% of billed.", "count": "0", "additional_payer_notes": "Zero final payments for the item or service in the 15 months prior to posting the file." }, { "payer_name": "HEALTH NET", "plan_name": "HEALTHNET HMO, PPO, POS, EPO, CANOPY HEALTHNET HMO, OTHER-IN-NETWORK PLANS", "methodology": "per diem", "standard_charge_dollar": 8000.0, "standard_charge_algorithm": "Expected reimbursement is the lesser of Per diem ($8,000) for the length of stay and 70% of billed.", "count": "0", "additional_payer_notes": "Zero final payments for the item or service in the 15 months prior to posting the file." }, { "payer_name": "UNITED HEALTHCARE", "plan_name": "SUTTER SELECT & SUTTER HEALTH PLAN HMO PLANS", "methodology": "per diem", "standard_charge_dollar": 28538.0, "standard_charge_algorithm": "Per diem ($28,538).", "count": "0", "additional_payer_notes": "Zero final payments for the item or service in the 15 months prior to posting the file." }, { "payer_name": "UNITED HEALTHCARE", "plan_name": "SUTTER SELECT & SUTTER HEALTH PLAN HMO PLANS", "methodology": "per diem", "standard_charge_dollar": 28538.0, "standard_charge_algorithm": "Per diem ($28,538).", "count": "0", "additional_payer_notes": "Zero final payments for the item or service in the 15 months prior to posting the file." }, { "payer_name": "SUTTER", "plan_name": "SUTTER SELECT & SUTTER HEALTH PLAN HMO PLANS", "methodology": "per diem", "standard_charge_dollar": 28538.0, "standard_charge_algorithm": "Per diem ($28,538).", "count": "0", "additional_payer_notes": "Zero final payments for the item or service in the 15 months prior to posting the file." }, { "payer_name": "UNITED HEALTHCARE", "plan_name": "SUTTER SELECT & SUTTER HEALTH PLAN HMO PLANS", "methodology": "per diem", "standard_charge_dollar": 28538.0, "standard_charge_algorithm": "Per diem ($28,538).", "count": "0", "additional_payer_notes": "Zero final payments for the item or service in the 15 months prior to posting the file." }, { "payer_name": "UMR", "plan_name": "SUTTER SELECT & SUTTER HEALTH PLAN HMO PLANS", "methodology": "per diem", "standard_charge_dollar": 28538.0, "standard_charge_algorithm": "Per diem ($28,538).", "count": "0", "additional_payer_notes": "Zero final payments for the item or service in the 15 months prior to posting the file." }, { "payer_name": "UNITED HEALTHCARE", "plan_name": "SUTTER SELECT & SUTTER HEALTH PLAN HMO PLANS", "methodology": "per diem", "standard_charge_dollar": 28538.0, "standard_charge_algorithm": "Per diem ($28,538).", "count": "0", "additional_payer_notes": "Zero final payments for the item or service in the 15 months prior to posting the file." } ] } ] }, { "description": "HC Cath Blln Occl Gp034", "code_information": [ { "code": "PX-2120030034", "type": "CDM" }, { "code": "C2628", "type": "HCPCS" }, { "code": "0272", "type": "RC" } ], "standard_charges": [ { "setting": "outpatient", "gross_charge": 6750.0, "discounted_cash": 3375.0, "minimum": 2848.5, "maximum": 3510.0, "additional_generic_notes": "Zero final payments for the item or service in the 15 months prior to posting the file.", "payers_information": [ { "payer_name": "AETNA", "plan_name": "AETNA ALL OTHER PLANS", "methodology": "percent of total billed charges", "standard_charge_dollar": 3510.0, "standard_charge_percentage": 52.0, "count": "0", "additional_payer_notes": "Zero final payments for the item or service in the 15 months prior to posting the file." }, { "payer_name": "AETNA", "plan_name": "AETNA ALL OTHER PLANS", "methodology": "percent of total billed charges", "standard_charge_dollar": 3510.0, "standard_charge_percentage": 52.0, "count": "0", "additional_payer_notes": "Zero final payments for the item or service in the 15 months prior to posting the file." }, { "payer_name": "MERITAIN HEALTH", "plan_name": "AETNA ALL OTHER PLANS", "methodology": "percent of total billed charges", "standard_charge_dollar": 3510.0, "standard_charge_percentage": 52.0, "count": "0", "additional_payer_notes": "Zero final payments for the item or service in the 15 months prior to posting the file." }, { "payer_name": "BLUE SHIELD OUT OF STATE", "plan_name": "STANFORD HEALTHCARE ALLIANCE PLAN", "methodology": "percent of total billed charges", "standard_charge_dollar": 3279.83, "standard_charge_percentage": 48.59, "count": "0", "additional_payer_notes": "Zero final payments for the item or service in the 15 months prior to posting the file." }, { "payer_name": "BLUE SHIELD", "plan_name": "STANFORD HEALTHCARE ALLIANCE PLAN", "methodology": "percent of total billed charges", "standard_charge_dollar": 3279.83, "standard_charge_percentage": 48.59, "count": "0", "additional_payer_notes": "Zero final payments for the item or service in the 15 months prior to posting the file." }, { "payer_name": "BLUE SHIELD", "plan_name": "STANFORD HEALTHCARE ALLIANCE PLAN", "methodology": "percent of total billed charges", "standard_charge_dollar": 3279.83, "standard_charge_percentage": 48.59, "count": "0", "additional_payer_notes": "Zero final payments for the item or service in the 15 months prior to posting the file." }, { "payer_name": "BLUE SHIELD", "plan_name": "STANFORD HEALTHCARE ALLIANCE PLAN", "methodology": "percent of total billed charges", "standard_charge_dollar": 3279.83, "standard_charge_percentage": 48.59, "count": "0", "additional_payer_notes": "Zero final payments for the item or service in the 15 months prior to posting the file." }, { "payer_name": "CIGNA", "plan_name": "CIGNA COM ALT HMO PLAN", "methodology": "percent of total billed charges", "standard_charge_dollar": 2848.5, "standard_charge_percentage": 42.2, "count": "0", "additional_payer_notes": "Zero final payments for the item or service in the 15 months prior to posting the file." }, { "payer_name": "CIGNA", "plan_name": "CIGNA COM ALT HMO PLAN", "methodology": "percent of total billed charges", "standard_charge_dollar": 2848.5, "standard_charge_percentage": 42.2, "count": "0", "additional_payer_notes": "Zero final payments for the item or service in the 15 months prior to posting the file." }, { "payer_name": "HEALTH NET", "plan_name": "HEALTHNET HMO, PPO, POS, EPO, CANOPY HEALTHNET HMO, OTHER-IN-NETWORK PLANS", "methodology": "per diem", "standard_charge_dollar": 8000.0, "standard_charge_algorithm": "Expected reimbursement is the lesser of Per diem ($8,000) for the length of stay and 70% of billed.", "count": "0", "additional_payer_notes": "Zero final payments for the item or service in the 15 months prior to posting the file." }, { "payer_name": "HEALTH NET", "plan_name": "HEALTHNET HMO, PPO, POS, EPO, CANOPY HEALTHNET HMO, OTHER-IN-NETWORK PLANS", "methodology": "per diem", "standard_charge_dollar": 8000.0, "standard_charge_algorithm": "Expected reimbursement is the lesser of Per diem ($8,000) for the length of stay and 70% of billed.", "count": "0", "additional_payer_notes": "Zero final payments for the item or service in the 15 months prior to posting the file." }, { "payer_name": "UNITED HEALTHCARE", "plan_name": "SUTTER SELECT & SUTTER HEALTH PLAN HMO PLANS", "methodology": "per diem", "standard_charge_dollar": 28538.0, "standard_charge_algorithm": "Per diem ($28,538).", "count": "0", "additional_payer_notes": "Zero final payments for the item or service in the 15 months prior to posting the file." }, { "payer_name": "UNITED HEALTHCARE", "plan_name": "SUTTER SELECT & SUTTER HEALTH PLAN HMO PLANS", "methodology": "per diem", "standard_charge_dollar": 28538.0, "standard_charge_algorithm": "Per diem ($28,538).", "count": "0", "additional_payer_notes": "Zero final payments for the item or service in the 15 months prior to posting the file." }, { "payer_name": "SUTTER", "plan_name": "SUTTER SELECT & SUTTER HEALTH PLAN HMO PLANS", "methodology": "per diem", "standard_charge_dollar": 28538.0, "standard_charge_algorithm": "Per diem ($28,538).", "count": "0", "additional_payer_notes": "Zero final payments for the item or service in the 15 months prior to posting the file." }, { "payer_name": "UNITED HEALTHCARE", "plan_name": "SUTTER SELECT & SUTTER HEALTH PLAN HMO PLANS", "methodology": "per diem", "standard_charge_dollar": 28538.0, "standard_charge_algorithm": "Per diem ($28,538).", "count": "0", "additional_payer_notes": "Zero final payments for the item or service in the 15 months prior to posting the file." }, { "payer_name": "UMR", "plan_name": "SUTTER SELECT & SUTTER HEALTH PLAN HMO PLANS", "methodology": "per diem", "standard_charge_dollar": 28538.0, "standard_charge_algorithm": "Per diem ($28,538).", "count": "0", "additional_payer_notes": "Zero final payments for the item or service in the 15 months prior to posting the file." }, { "payer_name": "UNITED HEALTHCARE", "plan_name": "SUTTER SELECT & SUTTER HEALTH PLAN HMO PLANS", "methodology": "per diem", "standard_charge_dollar": 28538.0, "standard_charge_algorithm": "Per diem ($28,538).", "count": "0", "additional_payer_notes": "Zero final payments for the item or service in the 15 months prior to posting the file." } ] } ] }, { "description": "HC Cath Blln Occl Gp035", "code_information": [ { "code": "PX-2120030035", "type": "CDM" }, { "code": "C2628", "type": "HCPCS" }, { "code": "0272", "type": "RC" } ], "standard_charges": [ { "setting": "outpatient", "gross_charge": 7150.0, "discounted_cash": 3575.0, "minimum": 3017.3, "maximum": 3718.0, "additional_generic_notes": "Zero final payments for the item or service in the 15 months prior to posting the file.", "payers_information": [ { "payer_name": "AETNA", "plan_name": "AETNA ALL OTHER PLANS", "methodology": "percent of total billed charges", "standard_charge_dollar": 3718.0, "standard_charge_percentage": 52.0, "count": "0", "additional_payer_notes": "Zero final payments for the item or service in the 15 months prior to posting the file." }, { "payer_name": "AETNA", "plan_name": "AETNA ALL OTHER PLANS", "methodology": "percent of total billed charges", "standard_charge_dollar": 3718.0, "standard_charge_percentage": 52.0, "count": "0", "additional_payer_notes": "Zero final payments for the item or service in the 15 months prior to posting the file." }, { "payer_name": "MERITAIN HEALTH", "plan_name": "AETNA ALL OTHER PLANS", "methodology": "percent of total billed charges", "standard_charge_dollar": 3718.0, "standard_charge_percentage": 52.0, "count": "0", "additional_payer_notes": "Zero final payments for the item or service in the 15 months prior to posting the file." }, { "payer_name": "BLUE SHIELD OUT OF STATE", "plan_name": "STANFORD HEALTHCARE ALLIANCE PLAN", "methodology": "percent of total billed charges", "standard_charge_dollar": 3474.19, "standard_charge_percentage": 48.59, "count": "0", "additional_payer_notes": "Zero final payments for the item or service in the 15 months prior to posting the file." }, { "payer_name": "BLUE SHIELD", "plan_name": "STANFORD HEALTHCARE ALLIANCE PLAN", "methodology": "percent of total billed charges", "standard_charge_dollar": 3474.19, "standard_charge_percentage": 48.59, "count": "0", "additional_payer_notes": "Zero final payments for the item or service in the 15 months prior to posting the file." }, { "payer_name": "BLUE SHIELD", "plan_name": "STANFORD HEALTHCARE ALLIANCE PLAN", "methodology": "percent of total billed charges", "standard_charge_dollar": 3474.19, "standard_charge_percentage": 48.59, "count": "0", "additional_payer_notes": "Zero final payments for the item or service in the 15 months prior to posting the file." }, { "payer_name": "BLUE SHIELD", "plan_name": "STANFORD HEALTHCARE ALLIANCE PLAN", "methodology": "percent of total billed charges", "standard_charge_dollar": 3474.19, "standard_charge_percentage": 48.59, "count": "0", "additional_payer_notes": "Zero final payments for the item or service in the 15 months prior to posting the file." }, { "payer_name": "CIGNA", "plan_name": "CIGNA COM ALT HMO PLAN", "methodology": "percent of total billed charges", "standard_charge_dollar": 3017.3, "standard_charge_percentage": 42.2, "count": "0", "additional_payer_notes": "Zero final payments for the item or service in the 15 months prior to posting the file." }, { "payer_name": "CIGNA", "plan_name": "CIGNA COM ALT HMO PLAN", "methodology": "percent of total billed charges", "standard_charge_dollar": 3017.3, "standard_charge_percentage": 42.2, "count": "0", "additional_payer_notes": "Zero final payments for the item or service in the 15 months prior to posting the file." }, { "payer_name": "HEALTH NET", "plan_name": "HEALTHNET HMO, PPO, POS, EPO, CANOPY HEALTHNET HMO, OTHER-IN-NETWORK PLANS", "methodology": "per diem", "standard_charge_dollar": 8000.0, "standard_charge_algorithm": "Expected reimbursement is the lesser of Per diem ($8,000) for the length of stay and 70% of billed.", "count": "0", "additional_payer_notes": "Zero final payments for the item or service in the 15 months prior to posting the file." }, { "payer_name": "HEALTH NET", "plan_name": "HEALTHNET HMO, PPO, POS, EPO, CANOPY HEALTHNET HMO, OTHER-IN-NETWORK PLANS", "methodology": "per diem", "standard_charge_dollar": 8000.0, "standard_charge_algorithm": "Expected reimbursement is the lesser of Per diem ($8,000) for the length of stay and 70% of billed.", "count": "0", "additional_payer_notes": "Zero final payments for the item or service in the 15 months prior to posting the file." }, { "payer_name": "UNITED HEALTHCARE", "plan_name": "SUTTER SELECT & SUTTER HEALTH PLAN HMO PLANS", "methodology": "per diem", "standard_charge_dollar": 28538.0, "standard_charge_algorithm": "Per diem ($28,538).", "count": "0", "additional_payer_notes": "Zero final payments for the item or service in the 15 months prior to posting the file." }, { "payer_name": "UNITED HEALTHCARE", "plan_name": "SUTTER SELECT & SUTTER HEALTH PLAN HMO PLANS", "methodology": "per diem", "standard_charge_dollar": 28538.0, "standard_charge_algorithm": "Per diem ($28,538).", "count": "0", "additional_payer_notes": "Zero final payments for the item or service in the 15 months prior to posting the file." }, { "payer_name": "SUTTER", "plan_name": "SUTTER SELECT & SUTTER HEALTH PLAN HMO PLANS", "methodology": "per diem", "standard_charge_dollar": 28538.0, "standard_charge_algorithm": "Per diem ($28,538).", "count": "0", "additional_payer_notes": "Zero final payments for the item or service in the 15 months prior to posting the file." }, { "payer_name": "UNITED HEALTHCARE", "plan_name": "SUTTER SELECT & SUTTER HEALTH PLAN HMO PLANS", "methodology": "per diem", "standard_charge_dollar": 28538.0, "standard_charge_algorithm": "Per diem ($28,538).", "count": "0", "additional_payer_notes": "Zero final payments for the item or service in the 15 months prior to posting the file." }, { "payer_name": "UMR", "plan_name": "SUTTER SELECT & SUTTER HEALTH PLAN HMO PLANS", "methodology": "per diem", "standard_charge_dollar": 28538.0, "standard_charge_algorithm": "Per diem ($28,538).", "count": "0", "additional_payer_notes": "Zero final payments for the item or service in the 15 months prior to posting the file." }, { "payer_name": "UNITED HEALTHCARE", "plan_name": "SUTTER SELECT & SUTTER HEALTH PLAN HMO PLANS", "methodology": "per diem", "standard_charge_dollar": 28538.0, "standard_charge_algorithm": "Per diem ($28,538).", "count": "0", "additional_payer_notes": "Zero final payments for the item or service in the 15 months prior to posting the file." } ] } ] }, { "description": "HC Cath Blln Occl Gp038", "code_information": [ { "code": "PX-2120030038", "type": "CDM" }, { "code": "C2628", "type": "HCPCS" }, { "code": "0272", "type": "RC" } ], "standard_charges": [ { "setting": "outpatient", "gross_charge": 8750.0, "discounted_cash": 4375.0, "minimum": 3692.5, "maximum": 4550.0, "additional_generic_notes": "Zero final payments for the item or service in the 15 months prior to posting the file.", "payers_information": [ { "payer_name": "AETNA", "plan_name": "AETNA ALL OTHER PLANS", "methodology": "percent of total billed charges", "standard_charge_dollar": 4550.0, "standard_charge_percentage": 52.0, "count": "0", "additional_payer_notes": "Zero final payments for the item or service in the 15 months prior to posting the file." }, { "payer_name": "AETNA", "plan_name": "AETNA ALL OTHER PLANS", "methodology": "percent of total billed charges", "standard_charge_dollar": 4550.0, "standard_charge_percentage": 52.0, "count": "0", "additional_payer_notes": "Zero final payments for the item or service in the 15 months prior to posting the file." }, { "payer_name": "MERITAIN HEALTH", "plan_name": "AETNA ALL OTHER PLANS", "methodology": "percent of total billed charges", "standard_charge_dollar": 4550.0, "standard_charge_percentage": 52.0, "count": "0", "additional_payer_notes": "Zero final payments for the item or service in the 15 months prior to posting the file." }, { "payer_name": "BLUE SHIELD OUT OF STATE", "plan_name": "STANFORD HEALTHCARE ALLIANCE PLAN", "methodology": "percent of total billed charges", "standard_charge_dollar": 4251.63, "standard_charge_percentage": 48.59, "count": "0", "additional_payer_notes": "Zero final payments for the item or service in the 15 months prior to posting the file." }, { "payer_name": "BLUE SHIELD", "plan_name": "STANFORD HEALTHCARE ALLIANCE PLAN", "methodology": "percent of total billed charges", "standard_charge_dollar": 4251.63, "standard_charge_percentage": 48.59, "count": "0", "additional_payer_notes": "Zero final payments for the item or service in the 15 months prior to posting the file." }, { "payer_name": "BLUE SHIELD", "plan_name": "STANFORD HEALTHCARE ALLIANCE PLAN", "methodology": "percent of total billed charges", "standard_charge_dollar": 4251.63, "standard_charge_percentage": 48.59, "count": "0", "additional_payer_notes": "Zero final payments for the item or service in the 15 months prior to posting the file." }, { "payer_name": "BLUE SHIELD", "plan_name": "STANFORD HEALTHCARE ALLIANCE PLAN", "methodology": "percent of total billed charges", "standard_charge_dollar": 4251.63, "standard_charge_percentage": 48.59, "count": "0", "additional_payer_notes": "Zero final payments for the item or service in the 15 months prior to posting the file." }, { "payer_name": "CIGNA", "plan_name": "CIGNA COM ALT HMO PLAN", "methodology": "percent of total billed charges", "standard_charge_dollar": 3692.5, "standard_charge_percentage": 42.2, "count": "0", "additional_payer_notes": "Zero final payments for the item or service in the 15 months prior to posting the file." }, { "payer_name": "CIGNA", "plan_name": "CIGNA COM ALT HMO PLAN", "methodology": "percent of total billed charges", "standard_charge_dollar": 3692.5, "standard_charge_percentage": 42.2, "count": "0", "additional_payer_notes": "Zero final payments for the item or service in the 15 months prior to posting the file." }, { "payer_name": "HEALTH NET", "plan_name": "HEALTHNET HMO, PPO, POS, EPO, CANOPY HEALTHNET HMO, OTHER-IN-NETWORK PLANS", "methodology": "per diem", "standard_charge_dollar": 8000.0, "standard_charge_algorithm": "Expected reimbursement is the lesser of Per diem ($8,000) for the length of stay and 70% of billed.", "count": "0", "additional_payer_notes": "Zero final payments for the item or service in the 15 months prior to posting the file." }, { "payer_name": "HEALTH NET", "plan_name": "HEALTHNET HMO, PPO, POS, EPO, CANOPY HEALTHNET HMO, OTHER-IN-NETWORK PLANS", "methodology": "per diem", "standard_charge_dollar": 8000.0, "standard_charge_algorithm": "Expected reimbursement is the lesser of Per diem ($8,000) for the length of stay and 70% of billed.", "count": "0", "additional_payer_notes": "Zero final payments for the item or service in the 15 months prior to posting the file." }, { "payer_name": "UNITED HEALTHCARE", "plan_name": "SUTTER SELECT & SUTTER HEALTH PLAN HMO PLANS", "methodology": "per diem", "standard_charge_dollar": 28538.0, "standard_charge_algorithm": "Per diem ($28,538).", "count": "0", "additional_payer_notes": "Zero final payments for the item or service in the 15 months prior to posting the file." }, { "payer_name": "UNITED HEALTHCARE", "plan_name": "SUTTER SELECT & SUTTER HEALTH PLAN HMO PLANS", "methodology": "per diem", "standard_charge_dollar": 28538.0, "standard_charge_algorithm": "Per diem ($28,538).", "count": "0", "additional_payer_notes": "Zero final payments for the item or service in the 15 months prior to posting the file." }, { "payer_name": "SUTTER", "plan_name": "SUTTER SELECT & SUTTER HEALTH PLAN HMO PLANS", "methodology": "per diem", "standard_charge_dollar": 28538.0, "standard_charge_algorithm": "Per diem ($28,538).", "count": "0", "additional_payer_notes": "Zero final payments for the item or service in the 15 months prior to posting the file." }, { "payer_name": "UNITED HEALTHCARE", "plan_name": "SUTTER SELECT & SUTTER HEALTH PLAN HMO PLANS", "methodology": "per diem", "standard_charge_dollar": 28538.0, "standard_charge_algorithm": "Per diem ($28,538).", "count": "0", "additional_payer_notes": "Zero final payments for the item or service in the 15 months prior to posting the file." }, { "payer_name": "UMR", "plan_name": "SUTTER SELECT & SUTTER HEALTH PLAN HMO PLANS", "methodology": "per diem", "standard_charge_dollar": 28538.0, "standard_charge_algorithm": "Per diem ($28,538).", "count": "0", "additional_payer_notes": "Zero final payments for the item or service in the 15 months prior to posting the file." }, { "payer_name": "UNITED HEALTHCARE", "plan_name": "SUTTER SELECT & SUTTER HEALTH PLAN HMO PLANS", "methodology": "per diem", "standard_charge_dollar": 28538.0, "standard_charge_algorithm": "Per diem ($28,538).", "count": "0", "additional_payer_notes": "Zero final payments for the item or service in the 15 months prior to posting the file." } ] } ] }, { "description": "HC Cath Blln Occl Gp039", "code_information": [ { "code": "PX-2120030039", "type": "CDM" }, { "code": "C2628", "type": "HCPCS" }, { "code": "0272", "type": "RC" } ], "standard_charges": [ { "setting": "outpatient", "gross_charge": 9000.0, "discounted_cash": 4500.0, "minimum": 3798.0, "maximum": 4680.0, "additional_generic_notes": "Zero final payments for the item or service in the 15 months prior to posting the file.", "payers_information": [ { "payer_name": "AETNA", "plan_name": "AETNA ALL OTHER PLANS", "methodology": "percent of total billed charges", "standard_charge_dollar": 4680.0, "standard_charge_percentage": 52.0, "count": "0", "additional_payer_notes": "Zero final payments for the item or service in the 15 months prior to posting the file." }, { "payer_name": "AETNA", "plan_name": "AETNA ALL OTHER PLANS", "methodology": "percent of total billed charges", "standard_charge_dollar": 4680.0, "standard_charge_percentage": 52.0, "count": "0", "additional_payer_notes": "Zero final payments for the item or service in the 15 months prior to posting the file." }, { "payer_name": "MERITAIN HEALTH", "plan_name": "AETNA ALL OTHER PLANS", "methodology": "percent of total billed charges", "standard_charge_dollar": 4680.0, "standard_charge_percentage": 52.0, "count": "0", "additional_payer_notes": "Zero final payments for the item or service in the 15 months prior to posting the file." }, { "payer_name": "BLUE SHIELD OUT OF STATE", "plan_name": "STANFORD HEALTHCARE ALLIANCE PLAN", "methodology": "percent of total billed charges", "standard_charge_dollar": 4373.1, "standard_charge_percentage": 48.59, "count": "0", "additional_payer_notes": "Zero final payments for the item or service in the 15 months prior to posting the file." }, { "payer_name": "BLUE SHIELD", "plan_name": "STANFORD HEALTHCARE ALLIANCE PLAN", "methodology": "percent of total billed charges", "standard_charge_dollar": 4373.1, "standard_charge_percentage": 48.59, "count": "0", "additional_payer_notes": "Zero final payments for the item or service in the 15 months prior to posting the file." }, { "payer_name": "BLUE SHIELD", "plan_name": "STANFORD HEALTHCARE ALLIANCE PLAN", "methodology": "percent of total billed charges", "standard_charge_dollar": 4373.1, "standard_charge_percentage": 48.59, "count": "0", "additional_payer_notes": "Zero final payments for the item or service in the 15 months prior to posting the file." }, { "payer_name": "BLUE SHIELD", "plan_name": "STANFORD HEALTHCARE ALLIANCE PLAN", "methodology": "percent of total billed charges", "standard_charge_dollar": 4373.1, "standard_charge_percentage": 48.59, "count": "0", "additional_payer_notes": "Zero final payments for the item or service in the 15 months prior to posting the file." }, { "payer_name": "CIGNA", "plan_name": "CIGNA COM ALT HMO PLAN", "methodology": "percent of total billed charges", "standard_charge_dollar": 3798.0, "standard_charge_percentage": 42.2, "count": "0", "additional_payer_notes": "Zero final payments for the item or service in the 15 months prior to posting the file." }, { "payer_name": "CIGNA", "plan_name": "CIGNA COM ALT HMO PLAN", "methodology": "percent of total billed charges", "standard_charge_dollar": 3798.0, "standard_charge_percentage": 42.2, "count": "0", "additional_payer_notes": "Zero final payments for the item or service in the 15 months prior to posting the file." }, { "payer_name": "HEALTH NET", "plan_name": "HEALTHNET HMO, PPO, POS, EPO, CANOPY HEALTHNET HMO, OTHER-IN-NETWORK PLANS", "methodology": "per diem", "standard_charge_dollar": 8000.0, "standard_charge_algorithm": "Expected reimbursement is the lesser of Per diem ($8,000) for the length of stay and 70% of billed.", "count": "0", "additional_payer_notes": "Zero final payments for the item or service in the 15 months prior to posting the file." }, { "payer_name": "HEALTH NET", "plan_name": "HEALTHNET HMO, PPO, POS, EPO, CANOPY HEALTHNET HMO, OTHER-IN-NETWORK PLANS", "methodology": "per diem", "standard_charge_dollar": 8000.0, "standard_charge_algorithm": "Expected reimbursement is the lesser of Per diem ($8,000) for the length of stay and 70% of billed.", "count": "0", "additional_payer_notes": "Zero final payments for the item or service in the 15 months prior to posting the file." }, { "payer_name": "UNITED HEALTHCARE", "plan_name": "SUTTER SELECT & SUTTER HEALTH PLAN HMO PLANS", "methodology": "per diem", "standard_charge_dollar": 28538.0, "standard_charge_algorithm": "Per diem ($28,538).", "count": "0", "additional_payer_notes": "Zero final payments for the item or service in the 15 months prior to posting the file." }, { "payer_name": "UNITED HEALTHCARE", "plan_name": "SUTTER SELECT & SUTTER HEALTH PLAN HMO PLANS", "methodology": "per diem", "standard_charge_dollar": 28538.0, "standard_charge_algorithm": "Per diem ($28,538).", "count": "0", "additional_payer_notes": "Zero final payments for the item or service in the 15 months prior to posting the file." }, { "payer_name": "SUTTER", "plan_name": "SUTTER SELECT & SUTTER HEALTH PLAN HMO PLANS", "methodology": "per diem", "standard_charge_dollar": 28538.0, "standard_charge_algorithm": "Per diem ($28,538).", "count": "0", "additional_payer_notes": "Zero final payments for the item or service in the 15 months prior to posting the file." }, { "payer_name": "UNITED HEALTHCARE", "plan_name": "SUTTER SELECT & SUTTER HEALTH PLAN HMO PLANS", "methodology": "per diem", "standard_charge_dollar": 28538.0, "standard_charge_algorithm": "Per diem ($28,538).", "count": "0", "additional_payer_notes": "Zero final payments for the item or service in the 15 months prior to posting the file." }, { "payer_name": "UMR", "plan_name": "SUTTER SELECT & SUTTER HEALTH PLAN HMO PLANS", "methodology": "per diem", "standard_charge_dollar": 28538.0, "standard_charge_algorithm": "Per diem ($28,538).", "count": "0", "additional_payer_notes": "Zero final payments for the item or service in the 15 months prior to posting the file." }, { "payer_name": "UNITED HEALTHCARE", "plan_name": "SUTTER SELECT & SUTTER HEALTH PLAN HMO PLANS", "methodology": "per diem", "standard_charge_dollar": 28538.0, "standard_charge_algorithm": "Per diem ($28,538).", "count": "0", "additional_payer_notes": "Zero final payments for the item or service in the 15 months prior to posting the file." } ] } ] }, { "description": "HC Cath Fogarty Gp005", "code_information": [ { "code": "PX-2120031005", "type": "CDM" }, { "code": "C1757", "type": "HCPCS" }, { "code": "0272", "type": "RC" } ], "standard_charges": [ { "setting": "outpatient", "gross_charge": 195.0, "discounted_cash": 97.5, "minimum": 82.29, "maximum": 101.4, "additional_generic_notes": "Zero final payments for the item or service in the 15 months prior to posting the file.", "payers_information": [ { "payer_name": "AETNA", "plan_name": "AETNA ALL OTHER PLANS", "methodology": "percent of total billed charges", "standard_charge_dollar": 101.4, "standard_charge_percentage": 52.0, "count": "0", "additional_payer_notes": "Zero final payments for the item or service in the 15 months prior to posting the file." }, { "payer_name": "AETNA", "plan_name": "AETNA ALL OTHER PLANS", "methodology": "percent of total billed charges", "standard_charge_dollar": 101.4, "standard_charge_percentage": 52.0, "count": "0", "additional_payer_notes": "Zero final payments for the item or service in the 15 months prior to posting the file." }, { "payer_name": "MERITAIN HEALTH", "plan_name": "AETNA ALL OTHER PLANS", "methodology": "percent of total billed charges", "standard_charge_dollar": 101.4, "standard_charge_percentage": 52.0, "count": "0", "additional_payer_notes": "Zero final payments for the item or service in the 15 months prior to posting the file." }, { "payer_name": "BLUE SHIELD OUT OF STATE", "plan_name": "STANFORD HEALTHCARE ALLIANCE PLAN", "methodology": "percent of total billed charges", "standard_charge_dollar": 94.75, "standard_charge_percentage": 48.59, "count": "0", "additional_payer_notes": "Zero final payments for the item or service in the 15 months prior to posting the file." }, { "payer_name": "BLUE SHIELD", "plan_name": "STANFORD HEALTHCARE ALLIANCE PLAN", "methodology": "percent of total billed charges", "standard_charge_dollar": 94.75, "standard_charge_percentage": 48.59, "count": "0", "additional_payer_notes": "Zero final payments for the item or service in the 15 months prior to posting the file." }, { "payer_name": "BLUE SHIELD", "plan_name": "STANFORD HEALTHCARE ALLIANCE PLAN", "methodology": "percent of total billed charges", "standard_charge_dollar": 94.75, "standard_charge_percentage": 48.59, "count": "0", "additional_payer_notes": "Zero final payments for the item or service in the 15 months prior to posting the file." }, { "payer_name": "BLUE SHIELD", "plan_name": "STANFORD HEALTHCARE ALLIANCE PLAN", "methodology": "percent of total billed charges", "standard_charge_dollar": 94.75, "standard_charge_percentage": 48.59, "count": "0", "additional_payer_notes": "Zero final payments for the item or service in the 15 months prior to posting the file." }, { "payer_name": "CIGNA", "plan_name": "CIGNA COM ALT HMO PLAN", "methodology": "percent of total billed charges", "standard_charge_dollar": 82.29, "standard_charge_percentage": 42.2, "count": "0", "additional_payer_notes": "Zero final payments for the item or service in the 15 months prior to posting the file." }, { "payer_name": "CIGNA", "plan_name": "CIGNA COM ALT HMO PLAN", "methodology": "percent of total billed charges", "standard_charge_dollar": 82.29, "standard_charge_percentage": 42.2, "count": "0", "additional_payer_notes": "Zero final payments for the item or service in the 15 months prior to posting the file." }, { "payer_name": "HEALTH NET", "plan_name": "HEALTHNET HMO, PPO, POS, EPO, CANOPY HEALTHNET HMO, OTHER-IN-NETWORK PLANS", "methodology": "per diem", "standard_charge_dollar": 8000.0, "standard_charge_algorithm": "Expected reimbursement is the lesser of Per diem ($8,000) for the length of stay and 70% of billed.", "count": "0", "additional_payer_notes": "Zero final payments for the item or service in the 15 months prior to posting the file." }, { "payer_name": "HEALTH NET", "plan_name": "HEALTHNET HMO, PPO, POS, EPO, CANOPY HEALTHNET HMO, OTHER-IN-NETWORK PLANS", "methodology": "per diem", "standard_charge_dollar": 8000.0, "standard_charge_algorithm": "Expected reimbursement is the lesser of Per diem ($8,000) for the length of stay and 70% of billed.", "count": "0", "additional_payer_notes": "Zero final payments for the item or service in the 15 months prior to posting the file." }, { "payer_name": "UNITED HEALTHCARE", "plan_name": "SUTTER SELECT & SUTTER HEALTH PLAN HMO PLANS", "methodology": "per diem", "standard_charge_dollar": 28538.0, "standard_charge_algorithm": "Per diem ($28,538).", "count": "0", "additional_payer_notes": "Zero final payments for the item or service in the 15 months prior to posting the file." }, { "payer_name": "UNITED HEALTHCARE", "plan_name": "SUTTER SELECT & SUTTER HEALTH PLAN HMO PLANS", "methodology": "per diem", "standard_charge_dollar": 28538.0, "standard_charge_algorithm": "Per diem ($28,538).", "count": "0", "additional_payer_notes": "Zero final payments for the item or service in the 15 months prior to posting the file." }, { "payer_name": "SUTTER", "plan_name": "SUTTER SELECT & SUTTER HEALTH PLAN HMO PLANS", "methodology": "per diem", "standard_charge_dollar": 28538.0, "standard_charge_algorithm": "Per diem ($28,538).", "count": "0", "additional_payer_notes": "Zero final payments for the item or service in the 15 months prior to posting the file." }, { "payer_name": "UNITED HEALTHCARE", "plan_name": "SUTTER SELECT & SUTTER HEALTH PLAN HMO PLANS", "methodology": "per diem", "standard_charge_dollar": 28538.0, "standard_charge_algorithm": "Per diem ($28,538).", "count": "0", "additional_payer_notes": "Zero final payments for the item or service in the 15 months prior to posting the file." }, { "payer_name": "UMR", "plan_name": "SUTTER SELECT & SUTTER HEALTH PLAN HMO PLANS", "methodology": "per diem", "standard_charge_dollar": 28538.0, "standard_charge_algorithm": "Per diem ($28,538).", "count": "0", "additional_payer_notes": "Zero final payments for the item or service in the 15 months prior to posting the file." }, { "payer_name": "UNITED HEALTHCARE", "plan_name": "SUTTER SELECT & SUTTER HEALTH PLAN HMO PLANS", "methodology": "per diem", "standard_charge_dollar": 28538.0, "standard_charge_algorithm": "Per diem ($28,538).", "count": "0", "additional_payer_notes": "Zero final payments for the item or service in the 15 months prior to posting the file." } ] } ] }, { "description": "HC Cath Fogarty Gp007", "code_information": [ { "code": "PX-2120031007", "type": "CDM" }, { "code": "C1757", "type": "HCPCS" }, { "code": "0272", "type": "RC" } ], "standard_charges": [ { "setting": "outpatient", "gross_charge": 380.0, "discounted_cash": 190.0, "minimum": 160.36, "maximum": 197.6, "additional_generic_notes": "Zero final payments for the item or service in the 15 months prior to posting the file.", "payers_information": [ { "payer_name": "AETNA", "plan_name": "AETNA ALL OTHER PLANS", "methodology": "percent of total billed charges", "standard_charge_dollar": 197.6, "standard_charge_percentage": 52.0, "count": "0", "additional_payer_notes": "Zero final payments for the item or service in the 15 months prior to posting the file." }, { "payer_name": "AETNA", "plan_name": "AETNA ALL OTHER PLANS", "methodology": "percent of total billed charges", "standard_charge_dollar": 197.6, "standard_charge_percentage": 52.0, "count": "0", "additional_payer_notes": "Zero final payments for the item or service in the 15 months prior to posting the file." }, { "payer_name": "MERITAIN HEALTH", "plan_name": "AETNA ALL OTHER PLANS", "methodology": "percent of total billed charges", "standard_charge_dollar": 197.6, "standard_charge_percentage": 52.0, "count": "0", "additional_payer_notes": "Zero final payments for the item or service in the 15 months prior to posting the file." }, { "payer_name": "BLUE SHIELD OUT OF STATE", "plan_name": "STANFORD HEALTHCARE ALLIANCE PLAN", "methodology": "percent of total billed charges", "standard_charge_dollar": 184.64, "standard_charge_percentage": 48.59, "count": "0", "additional_payer_notes": "Zero final payments for the item or service in the 15 months prior to posting the file." }, { "payer_name": "BLUE SHIELD", "plan_name": "STANFORD HEALTHCARE ALLIANCE PLAN", "methodology": "percent of total billed charges", "standard_charge_dollar": 184.64, "standard_charge_percentage": 48.59, "count": "0", "additional_payer_notes": "Zero final payments for the item or service in the 15 months prior to posting the file." }, { "payer_name": "BLUE SHIELD", "plan_name": "STANFORD HEALTHCARE ALLIANCE PLAN", "methodology": "percent of total billed charges", "standard_charge_dollar": 184.64, "standard_charge_percentage": 48.59, "count": "0", "additional_payer_notes": "Zero final payments for the item or service in the 15 months prior to posting the file." }, { "payer_name": "BLUE SHIELD", "plan_name": "STANFORD HEALTHCARE ALLIANCE PLAN", "methodology": "percent of total billed charges", "standard_charge_dollar": 184.64, "standard_charge_percentage": 48.59, "count": "0", "additional_payer_notes": "Zero final payments for the item or service in the 15 months prior to posting the file." }, { "payer_name": "CIGNA", "plan_name": "CIGNA COM ALT HMO PLAN", "methodology": "percent of total billed charges", "standard_charge_dollar": 160.36, "standard_charge_percentage": 42.2, "count": "0", "additional_payer_notes": "Zero final payments for the item or service in the 15 months prior to posting the file." }, { "payer_name": "CIGNA", "plan_name": "CIGNA COM ALT HMO PLAN", "methodology": "percent of total billed charges", "standard_charge_dollar": 160.36, "standard_charge_percentage": 42.2, "count": "0", "additional_payer_notes": "Zero final payments for the item or service in the 15 months prior to posting the file." }, { "payer_name": "HEALTH NET", "plan_name": "HEALTHNET HMO, PPO, POS, EPO, CANOPY HEALTHNET HMO, OTHER-IN-NETWORK PLANS", "methodology": "per diem", "standard_charge_dollar": 8000.0, "standard_charge_algorithm": "Expected reimbursement is the lesser of Per diem ($8,000) for the length of stay and 70% of billed.", "count": "0", "additional_payer_notes": "Zero final payments for the item or service in the 15 months prior to posting the file." }, { "payer_name": "HEALTH NET", "plan_name": "HEALTHNET HMO, PPO, POS, EPO, CANOPY HEALTHNET HMO, OTHER-IN-NETWORK PLANS", "methodology": "per diem", "standard_charge_dollar": 8000.0, "standard_charge_algorithm": "Expected reimbursement is the lesser of Per diem ($8,000) for the length of stay and 70% of billed.", "count": "0", "additional_payer_notes": "Zero final payments for the item or service in the 15 months prior to posting the file." }, { "payer_name": "UNITED HEALTHCARE", "plan_name": "SUTTER SELECT & SUTTER HEALTH PLAN HMO PLANS", "methodology": "per diem", "standard_charge_dollar": 28538.0, "standard_charge_algorithm": "Per diem ($28,538).", "count": "0", "additional_payer_notes": "Zero final payments for the item or service in the 15 months prior to posting the file." }, { "payer_name": "UNITED HEALTHCARE", "plan_name": "SUTTER SELECT & SUTTER HEALTH PLAN HMO PLANS", "methodology": "per diem", "standard_charge_dollar": 28538.0, "standard_charge_algorithm": "Per diem ($28,538).", "count": "0", "additional_payer_notes": "Zero final payments for the item or service in the 15 months prior to posting the file." }, { "payer_name": "SUTTER", "plan_name": "SUTTER SELECT & SUTTER HEALTH PLAN HMO PLANS", "methodology": "per diem", "standard_charge_dollar": 28538.0, "standard_charge_algorithm": "Per diem ($28,538).", "count": "0", "additional_payer_notes": "Zero final payments for the item or service in the 15 months prior to posting the file." }, { "payer_name": "UNITED HEALTHCARE", "plan_name": "SUTTER SELECT & SUTTER HEALTH PLAN HMO PLANS", "methodology": "per diem", "standard_charge_dollar": 28538.0, "standard_charge_algorithm": "Per diem ($28,538).", "count": "0", "additional_payer_notes": "Zero final payments for the item or service in the 15 months prior to posting the file." }, { "payer_name": "UMR", "plan_name": "SUTTER SELECT & SUTTER HEALTH PLAN HMO PLANS", "methodology": "per diem", "standard_charge_dollar": 28538.0, "standard_charge_algorithm": "Per diem ($28,538).", "count": "0", "additional_payer_notes": "Zero final payments for the item or service in the 15 months prior to posting the file." }, { "payer_name": "UNITED HEALTHCARE", "plan_name": "SUTTER SELECT & SUTTER HEALTH PLAN HMO PLANS", "methodology": "per diem", "standard_charge_dollar": 28538.0, "standard_charge_algorithm": "Per diem ($28,538).", "count": "0", "additional_payer_notes": "Zero final payments for the item or service in the 15 months prior to posting the file." } ] } ] }, { "description": "HC Cath Fogarty Gp009", "code_information": [ { "code": "PX-2120031009", "type": "CDM" }, { "code": "C1757", "type": "HCPCS" }, { "code": "0272", "type": "RC" } ], "standard_charges": [ { "setting": "outpatient", "gross_charge": 570.0, "discounted_cash": 285.0, "minimum": 240.54, "maximum": 296.4, "additional_generic_notes": "Zero final payments for the item or service in the 15 months prior to posting the file.", "payers_information": [ { "payer_name": "AETNA", "plan_name": "AETNA ALL OTHER PLANS", "methodology": "percent of total billed charges", "standard_charge_dollar": 296.4, "standard_charge_percentage": 52.0, "count": "0", "additional_payer_notes": "Zero final payments for the item or service in the 15 months prior to posting the file." }, { "payer_name": "AETNA", "plan_name": "AETNA ALL OTHER PLANS", "methodology": "percent of total billed charges", "standard_charge_dollar": 296.4, "standard_charge_percentage": 52.0, "count": "0", "additional_payer_notes": "Zero final payments for the item or service in the 15 months prior to posting the file." }, { "payer_name": "MERITAIN HEALTH", "plan_name": "AETNA ALL OTHER PLANS", "methodology": "percent of total billed charges", "standard_charge_dollar": 296.4, "standard_charge_percentage": 52.0, "count": "0", "additional_payer_notes": "Zero final payments for the item or service in the 15 months prior to posting the file." }, { "payer_name": "BLUE SHIELD OUT OF STATE", "plan_name": "STANFORD HEALTHCARE ALLIANCE PLAN", "methodology": "percent of total billed charges", "standard_charge_dollar": 276.96, "standard_charge_percentage": 48.59, "count": "0", "additional_payer_notes": "Zero final payments for the item or service in the 15 months prior to posting the file." }, { "payer_name": "BLUE SHIELD", "plan_name": "STANFORD HEALTHCARE ALLIANCE PLAN", "methodology": "percent of total billed charges", "standard_charge_dollar": 276.96, "standard_charge_percentage": 48.59, "count": "0", "additional_payer_notes": "Zero final payments for the item or service in the 15 months prior to posting the file." }, { "payer_name": "BLUE SHIELD", "plan_name": "STANFORD HEALTHCARE ALLIANCE PLAN", "methodology": "percent of total billed charges", "standard_charge_dollar": 276.96, "standard_charge_percentage": 48.59, "count": "0", "additional_payer_notes": "Zero final payments for the item or service in the 15 months prior to posting the file." }, { "payer_name": "BLUE SHIELD", "plan_name": "STANFORD HEALTHCARE ALLIANCE PLAN", "methodology": "percent of total billed charges", "standard_charge_dollar": 276.96, "standard_charge_percentage": 48.59, "count": "0", "additional_payer_notes": "Zero final payments for the item or service in the 15 months prior to posting the file." }, { "payer_name": "CIGNA", "plan_name": "CIGNA COM ALT HMO PLAN", "methodology": "percent of total billed charges", "standard_charge_dollar": 240.54, "standard_charge_percentage": 42.2, "count": "0", "additional_payer_notes": "Zero final payments for the item or service in the 15 months prior to posting the file." }, { "payer_name": "CIGNA", "plan_name": "CIGNA COM ALT HMO PLAN", "methodology": "percent of total billed charges", "standard_charge_dollar": 240.54, "standard_charge_percentage": 42.2, "count": "0", "additional_payer_notes": "Zero final payments for the item or service in the 15 months prior to posting the file." }, { "payer_name": "HEALTH NET", "plan_name": "HEALTHNET HMO, PPO, POS, EPO, CANOPY HEALTHNET HMO, OTHER-IN-NETWORK PLANS", "methodology": "per diem", "standard_charge_dollar": 8000.0, "standard_charge_algorithm": "Expected reimbursement is the lesser of Per diem ($8,000) for the length of stay and 70% of billed.", "count": "0", "additional_payer_notes": "Zero final payments for the item or service in the 15 months prior to posting the file." }, { "payer_name": "HEALTH NET", "plan_name": "HEALTHNET HMO, PPO, POS, EPO, CANOPY HEALTHNET HMO, OTHER-IN-NETWORK PLANS", "methodology": "per diem", "standard_charge_dollar": 8000.0, "standard_charge_algorithm": "Expected reimbursement is the lesser of Per diem ($8,000) for the length of stay and 70% of billed.", "count": "0", "additional_payer_notes": "Zero final payments for the item or service in the 15 months prior to posting the file." }, { "payer_name": "UNITED HEALTHCARE", "plan_name": "SUTTER SELECT & SUTTER HEALTH PLAN HMO PLANS", "methodology": "per diem", "standard_charge_dollar": 28538.0, "standard_charge_algorithm": "Per diem ($28,538).", "count": "0", "additional_payer_notes": "Zero final payments for the item or service in the 15 months prior to posting the file." }, { "payer_name": "UNITED HEALTHCARE", "plan_name": "SUTTER SELECT & SUTTER HEALTH PLAN HMO PLANS", "methodology": "per diem", "standard_charge_dollar": 28538.0, "standard_charge_algorithm": "Per diem ($28,538).", "count": "0", "additional_payer_notes": "Zero final payments for the item or service in the 15 months prior to posting the file." }, { "payer_name": "SUTTER", "plan_name": "SUTTER SELECT & SUTTER HEALTH PLAN HMO PLANS", "methodology": "per diem", "standard_charge_dollar": 28538.0, "standard_charge_algorithm": "Per diem ($28,538).", "count": "0", "additional_payer_notes": "Zero final payments for the item or service in the 15 months prior to posting the file." }, { "payer_name": "UNITED HEALTHCARE", "plan_name": "SUTTER SELECT & SUTTER HEALTH PLAN HMO PLANS", "methodology": "per diem", "standard_charge_dollar": 28538.0, "standard_charge_algorithm": "Per diem ($28,538).", "count": "0", "additional_payer_notes": "Zero final payments for the item or service in the 15 months prior to posting the file." }, { "payer_name": "UMR", "plan_name": "SUTTER SELECT & SUTTER HEALTH PLAN HMO PLANS", "methodology": "per diem", "standard_charge_dollar": 28538.0, "standard_charge_algorithm": "Per diem ($28,538).", "count": "0", "additional_payer_notes": "Zero final payments for the item or service in the 15 months prior to posting the file." }, { "payer_name": "UNITED HEALTHCARE", "plan_name": "SUTTER SELECT & SUTTER HEALTH PLAN HMO PLANS", "methodology": "per diem", "standard_charge_dollar": 28538.0, "standard_charge_algorithm": "Per diem ($28,538).", "count": "0", "additional_payer_notes": "Zero final payments for the item or service in the 15 months prior to posting the file." } ] } ] }, { "description": "HC Cath Fogarty Gp010", "code_information": [ { "code": "PX-2120031010", "type": "CDM" }, { "code": "C1757", "type": "HCPCS" }, { "code": "0272", "type": "RC" } ], "standard_charges": [ { "setting": "outpatient", "gross_charge": 665.0, "discounted_cash": 332.5, "minimum": 280.63, "maximum": 345.8, "additional_generic_notes": "Zero final payments for the item or service in the 15 months prior to posting the file.", "payers_information": [ { "payer_name": "AETNA", "plan_name": "AETNA ALL OTHER PLANS", "methodology": "percent of total billed charges", "standard_charge_dollar": 345.8, "standard_charge_percentage": 52.0, "count": "0", "additional_payer_notes": "Zero final payments for the item or service in the 15 months prior to posting the file." }, { "payer_name": "AETNA", "plan_name": "AETNA ALL OTHER PLANS", "methodology": "percent of total billed charges", "standard_charge_dollar": 345.8, "standard_charge_percentage": 52.0, "count": "0", "additional_payer_notes": "Zero final payments for the item or service in the 15 months prior to posting the file." }, { "payer_name": "MERITAIN HEALTH", "plan_name": "AETNA ALL OTHER PLANS", "methodology": "percent of total billed charges", "standard_charge_dollar": 345.8, "standard_charge_percentage": 52.0, "count": "0", "additional_payer_notes": "Zero final payments for the item or service in the 15 months prior to posting the file." }, { "payer_name": "BLUE SHIELD OUT OF STATE", "plan_name": "STANFORD HEALTHCARE ALLIANCE PLAN", "methodology": "percent of total billed charges", "standard_charge_dollar": 323.12, "standard_charge_percentage": 48.59, "count": "0", "additional_payer_notes": "Zero final payments for the item or service in the 15 months prior to posting the file." }, { "payer_name": "BLUE SHIELD", "plan_name": "STANFORD HEALTHCARE ALLIANCE PLAN", "methodology": "percent of total billed charges", "standard_charge_dollar": 323.12, "standard_charge_percentage": 48.59, "count": "0", "additional_payer_notes": "Zero final payments for the item or service in the 15 months prior to posting the file." }, { "payer_name": "BLUE SHIELD", "plan_name": "STANFORD HEALTHCARE ALLIANCE PLAN", "methodology": "percent of total billed charges", "standard_charge_dollar": 323.12, "standard_charge_percentage": 48.59, "count": "0", "additional_payer_notes": "Zero final payments for the item or service in the 15 months prior to posting the file." }, { "payer_name": "BLUE SHIELD", "plan_name": "STANFORD HEALTHCARE ALLIANCE PLAN", "methodology": "percent of total billed charges", "standard_charge_dollar": 323.12, "standard_charge_percentage": 48.59, "count": "0", "additional_payer_notes": "Zero final payments for the item or service in the 15 months prior to posting the file." }, { "payer_name": "CIGNA", "plan_name": "CIGNA COM ALT HMO PLAN", "methodology": "percent of total billed charges", "standard_charge_dollar": 280.63, "standard_charge_percentage": 42.2, "count": "0", "additional_payer_notes": "Zero final payments for the item or service in the 15 months prior to posting the file." }, { "payer_name": "CIGNA", "plan_name": "CIGNA COM ALT HMO PLAN", "methodology": "percent of total billed charges", "standard_charge_dollar": 280.63, "standard_charge_percentage": 42.2, "count": "0", "additional_payer_notes": "Zero final payments for the item or service in the 15 months prior to posting the file." }, { "payer_name": "HEALTH NET", "plan_name": "HEALTHNET HMO, PPO, POS, EPO, CANOPY HEALTHNET HMO, OTHER-IN-NETWORK PLANS", "methodology": "per diem", "standard_charge_dollar": 8000.0, "standard_charge_algorithm": "Expected reimbursement is the lesser of Per diem ($8,000) for the length of stay and 70% of billed.", "count": "0", "additional_payer_notes": "Zero final payments for the item or service in the 15 months prior to posting the file." }, { "payer_name": "HEALTH NET", "plan_name": "HEALTHNET HMO, PPO, POS, EPO, CANOPY HEALTHNET HMO, OTHER-IN-NETWORK PLANS", "methodology": "per diem", "standard_charge_dollar": 8000.0, "standard_charge_algorithm": "Expected reimbursement is the lesser of Per diem ($8,000) for the length of stay and 70% of billed.", "count": "0", "additional_payer_notes": "Zero final payments for the item or service in the 15 months prior to posting the file." }, { "payer_name": "UNITED HEALTHCARE", "plan_name": "SUTTER SELECT & SUTTER HEALTH PLAN HMO PLANS", "methodology": "per diem", "standard_charge_dollar": 28538.0, "standard_charge_algorithm": "Per diem ($28,538).", "count": "0", "additional_payer_notes": "Zero final payments for the item or service in the 15 months prior to posting the file." }, { "payer_name": "UNITED HEALTHCARE", "plan_name": "SUTTER SELECT & SUTTER HEALTH PLAN HMO PLANS", "methodology": "per diem", "standard_charge_dollar": 28538.0, "standard_charge_algorithm": "Per diem ($28,538).", "count": "0", "additional_payer_notes": "Zero final payments for the item or service in the 15 months prior to posting the file." }, { "payer_name": "SUTTER", "plan_name": "SUTTER SELECT & SUTTER HEALTH PLAN HMO PLANS", "methodology": "per diem", "standard_charge_dollar": 28538.0, "standard_charge_algorithm": "Per diem ($28,538).", "count": "0", "additional_payer_notes": "Zero final payments for the item or service in the 15 months prior to posting the file." }, { "payer_name": "UNITED HEALTHCARE", "plan_name": "SUTTER SELECT & SUTTER HEALTH PLAN HMO PLANS", "methodology": "per diem", "standard_charge_dollar": 28538.0, "standard_charge_algorithm": "Per diem ($28,538).", "count": "0", "additional_payer_notes": "Zero final payments for the item or service in the 15 months prior to posting the file." }, { "payer_name": "UMR", "plan_name": "SUTTER SELECT & SUTTER HEALTH PLAN HMO PLANS", "methodology": "per diem", "standard_charge_dollar": 28538.0, "standard_charge_algorithm": "Per diem ($28,538).", "count": "0", "additional_payer_notes": "Zero final payments for the item or service in the 15 months prior to posting the file." }, { "payer_name": "UNITED HEALTHCARE", "plan_name": "SUTTER SELECT & SUTTER HEALTH PLAN HMO PLANS", "methodology": "per diem", "standard_charge_dollar": 28538.0, "standard_charge_algorithm": "Per diem ($28,538).", "count": "0", "additional_payer_notes": "Zero final payments for the item or service in the 15 months prior to posting the file." } ] } ] }, { "description": "HC Cath Fogarty Gp011", "code_information": [ { "code": "PX-2120031011", "type": "CDM" }, { "code": "C1757", "type": "HCPCS" }, { "code": "0272", "type": "RC" } ], "standard_charges": [ { "setting": "outpatient", "gross_charge": 740.0, "discounted_cash": 370.0, "minimum": 312.28, "maximum": 384.8, "additional_generic_notes": "Zero final payments for the item or service in the 15 months prior to posting the file.", "payers_information": [ { "payer_name": "AETNA", "plan_name": "AETNA ALL OTHER PLANS", "methodology": "percent of total billed charges", "standard_charge_dollar": 384.8, "standard_charge_percentage": 52.0, "count": "0", "additional_payer_notes": "Zero final payments for the item or service in the 15 months prior to posting the file." }, { "payer_name": "AETNA", "plan_name": "AETNA ALL OTHER PLANS", "methodology": "percent of total billed charges", "standard_charge_dollar": 384.8, "standard_charge_percentage": 52.0, "count": "0", "additional_payer_notes": "Zero final payments for the item or service in the 15 months prior to posting the file." }, { "payer_name": "MERITAIN HEALTH", "plan_name": "AETNA ALL OTHER PLANS", "methodology": "percent of total billed charges", "standard_charge_dollar": 384.8, "standard_charge_percentage": 52.0, "count": "0", "additional_payer_notes": "Zero final payments for the item or service in the 15 months prior to posting the file." }, { "payer_name": "BLUE SHIELD OUT OF STATE", "plan_name": "STANFORD HEALTHCARE ALLIANCE PLAN", "methodology": "percent of total billed charges", "standard_charge_dollar": 359.57, "standard_charge_percentage": 48.59, "count": "0", "additional_payer_notes": "Zero final payments for the item or service in the 15 months prior to posting the file." }, { "payer_name": "BLUE SHIELD", "plan_name": "STANFORD HEALTHCARE ALLIANCE PLAN", "methodology": "percent of total billed charges", "standard_charge_dollar": 359.57, "standard_charge_percentage": 48.59, "count": "0", "additional_payer_notes": "Zero final payments for the item or service in the 15 months prior to posting the file." }, { "payer_name": "BLUE SHIELD", "plan_name": "STANFORD HEALTHCARE ALLIANCE PLAN", "methodology": "percent of total billed charges", "standard_charge_dollar": 359.57, "standard_charge_percentage": 48.59, "count": "0", "additional_payer_notes": "Zero final payments for the item or service in the 15 months prior to posting the file." }, { "payer_name": "BLUE SHIELD", "plan_name": "STANFORD HEALTHCARE ALLIANCE PLAN", "methodology": "percent of total billed charges", "standard_charge_dollar": 359.57, "standard_charge_percentage": 48.59, "count": "0", "additional_payer_notes": "Zero final payments for the item or service in the 15 months prior to posting the file." }, { "payer_name": "CIGNA", "plan_name": "CIGNA COM ALT HMO PLAN", "methodology": "percent of total billed charges", "standard_charge_dollar": 312.28, "standard_charge_percentage": 42.2, "count": "0", "additional_payer_notes": "Zero final payments for the item or service in the 15 months prior to posting the file." }, { "payer_name": "CIGNA", "plan_name": "CIGNA COM ALT HMO PLAN", "methodology": "percent of total billed charges", "standard_charge_dollar": 312.28, "standard_charge_percentage": 42.2, "count": "0", "additional_payer_notes": "Zero final payments for the item or service in the 15 months prior to posting the file." }, { "payer_name": "HEALTH NET", "plan_name": "HEALTHNET HMO, PPO, POS, EPO, CANOPY HEALTHNET HMO, OTHER-IN-NETWORK PLANS", "methodology": "per diem", "standard_charge_dollar": 8000.0, "standard_charge_algorithm": "Expected reimbursement is the lesser of Per diem ($8,000) for the length of stay and 70% of billed.", "count": "0", "additional_payer_notes": "Zero final payments for the item or service in the 15 months prior to posting the file." }, { "payer_name": "HEALTH NET", "plan_name": "HEALTHNET HMO, PPO, POS, EPO, CANOPY HEALTHNET HMO, OTHER-IN-NETWORK PLANS", "methodology": "per diem", "standard_charge_dollar": 8000.0, "standard_charge_algorithm": "Expected reimbursement is the lesser of Per diem ($8,000) for the length of stay and 70% of billed.", "count": "0", "additional_payer_notes": "Zero final payments for the item or service in the 15 months prior to posting the file." }, { "payer_name": "UNITED HEALTHCARE", "plan_name": "SUTTER SELECT & SUTTER HEALTH PLAN HMO PLANS", "methodology": "per diem", "standard_charge_dollar": 28538.0, "standard_charge_algorithm": "Per diem ($28,538).", "count": "0", "additional_payer_notes": "Zero final payments for the item or service in the 15 months prior to posting the file." }, { "payer_name": "UNITED HEALTHCARE", "plan_name": "SUTTER SELECT & SUTTER HEALTH PLAN HMO PLANS", "methodology": "per diem", "standard_charge_dollar": 28538.0, "standard_charge_algorithm": "Per diem ($28,538).", "count": "0", "additional_payer_notes": "Zero final payments for the item or service in the 15 months prior to posting the file." }, { "payer_name": "SUTTER", "plan_name": "SUTTER SELECT & SUTTER HEALTH PLAN HMO PLANS", "methodology": "per diem", "standard_charge_dollar": 28538.0, "standard_charge_algorithm": "Per diem ($28,538).", "count": "0", "additional_payer_notes": "Zero final payments for the item or service in the 15 months prior to posting the file." }, { "payer_name": "UNITED HEALTHCARE", "plan_name": "SUTTER SELECT & SUTTER HEALTH PLAN HMO PLANS", "methodology": "per diem", "standard_charge_dollar": 28538.0, "standard_charge_algorithm": "Per diem ($28,538).", "count": "0", "additional_payer_notes": "Zero final payments for the item or service in the 15 months prior to posting the file." }, { "payer_name": "UMR", "plan_name": "SUTTER SELECT & SUTTER HEALTH PLAN HMO PLANS", "methodology": "per diem", "standard_charge_dollar": 28538.0, "standard_charge_algorithm": "Per diem ($28,538).", "count": "0", "additional_payer_notes": "Zero final payments for the item or service in the 15 months prior to posting the file." }, { "payer_name": "UNITED HEALTHCARE", "plan_name": "SUTTER SELECT & SUTTER HEALTH PLAN HMO PLANS", "methodology": "per diem", "standard_charge_dollar": 28538.0, "standard_charge_algorithm": "Per diem ($28,538).", "count": "0", "additional_payer_notes": "Zero final payments for the item or service in the 15 months prior to posting the file." } ] } ] }, { "description": "HC Cath Fogarty Gp012", "code_information": [ { "code": "PX-2120031012", "type": "CDM" }, { "code": "C1757", "type": "HCPCS" }, { "code": "0272", "type": "RC" } ], "standard_charges": [ { "setting": "outpatient", "gross_charge": 810.0, "discounted_cash": 405.0, "minimum": 341.82, "maximum": 421.2, "additional_generic_notes": "Zero final payments for the item or service in the 15 months prior to posting the file.", "payers_information": [ { "payer_name": "AETNA", "plan_name": "AETNA ALL OTHER PLANS", "methodology": "percent of total billed charges", "standard_charge_dollar": 421.2, "standard_charge_percentage": 52.0, "count": "0", "additional_payer_notes": "Zero final payments for the item or service in the 15 months prior to posting the file." }, { "payer_name": "AETNA", "plan_name": "AETNA ALL OTHER PLANS", "methodology": "percent of total billed charges", "standard_charge_dollar": 421.2, "standard_charge_percentage": 52.0, "count": "0", "additional_payer_notes": "Zero final payments for the item or service in the 15 months prior to posting the file." }, { "payer_name": "MERITAIN HEALTH", "plan_name": "AETNA ALL OTHER PLANS", "methodology": "percent of total billed charges", "standard_charge_dollar": 421.2, "standard_charge_percentage": 52.0, "count": "0", "additional_payer_notes": "Zero final payments for the item or service in the 15 months prior to posting the file." }, { "payer_name": "BLUE SHIELD OUT OF STATE", "plan_name": "STANFORD HEALTHCARE ALLIANCE PLAN", "methodology": "percent of total billed charges", "standard_charge_dollar": 393.58, "standard_charge_percentage": 48.59, "count": "0", "additional_payer_notes": "Zero final payments for the item or service in the 15 months prior to posting the file." }, { "payer_name": "BLUE SHIELD", "plan_name": "STANFORD HEALTHCARE ALLIANCE PLAN", "methodology": "percent of total billed charges", "standard_charge_dollar": 393.58, "standard_charge_percentage": 48.59, "count": "0", "additional_payer_notes": "Zero final payments for the item or service in the 15 months prior to posting the file." }, { "payer_name": "BLUE SHIELD", "plan_name": "STANFORD HEALTHCARE ALLIANCE PLAN", "methodology": "percent of total billed charges", "standard_charge_dollar": 393.58, "standard_charge_percentage": 48.59, "count": "0", "additional_payer_notes": "Zero final payments for the item or service in the 15 months prior to posting the file." }, { "payer_name": "BLUE SHIELD", "plan_name": "STANFORD HEALTHCARE ALLIANCE PLAN", "methodology": "percent of total billed charges", "standard_charge_dollar": 393.58, "standard_charge_percentage": 48.59, "count": "0", "additional_payer_notes": "Zero final payments for the item or service in the 15 months prior to posting the file." }, { "payer_name": "CIGNA", "plan_name": "CIGNA COM ALT HMO PLAN", "methodology": "percent of total billed charges", "standard_charge_dollar": 341.82, "standard_charge_percentage": 42.2, "count": "0", "additional_payer_notes": "Zero final payments for the item or service in the 15 months prior to posting the file." }, { "payer_name": "CIGNA", "plan_name": "CIGNA COM ALT HMO PLAN", "methodology": "percent of total billed charges", "standard_charge_dollar": 341.82, "standard_charge_percentage": 42.2, "count": "0", "additional_payer_notes": "Zero final payments for the item or service in the 15 months prior to posting the file." }, { "payer_name": "HEALTH NET", "plan_name": "HEALTHNET HMO, PPO, POS, EPO, CANOPY HEALTHNET HMO, OTHER-IN-NETWORK PLANS", "methodology": "per diem", "standard_charge_dollar": 8000.0, "standard_charge_algorithm": "Expected reimbursement is the lesser of Per diem ($8,000) for the length of stay and 70% of billed.", "count": "0", "additional_payer_notes": "Zero final payments for the item or service in the 15 months prior to posting the file." }, { "payer_name": "HEALTH NET", "plan_name": "HEALTHNET HMO, PPO, POS, EPO, CANOPY HEALTHNET HMO, OTHER-IN-NETWORK PLANS", "methodology": "per diem", "standard_charge_dollar": 8000.0, "standard_charge_algorithm": "Expected reimbursement is the lesser of Per diem ($8,000) for the length of stay and 70% of billed.", "count": "0", "additional_payer_notes": "Zero final payments for the item or service in the 15 months prior to posting the file." }, { "payer_name": "UNITED HEALTHCARE", "plan_name": "SUTTER SELECT & SUTTER HEALTH PLAN HMO PLANS", "methodology": "per diem", "standard_charge_dollar": 28538.0, "standard_charge_algorithm": "Per diem ($28,538).", "count": "0", "additional_payer_notes": "Zero final payments for the item or service in the 15 months prior to posting the file." }, { "payer_name": "UNITED HEALTHCARE", "plan_name": "SUTTER SELECT & SUTTER HEALTH PLAN HMO PLANS", "methodology": "per diem", "standard_charge_dollar": 28538.0, "standard_charge_algorithm": "Per diem ($28,538).", "count": "0", "additional_payer_notes": "Zero final payments for the item or service in the 15 months prior to posting the file." }, { "payer_name": "SUTTER", "plan_name": "SUTTER SELECT & SUTTER HEALTH PLAN HMO PLANS", "methodology": "per diem", "standard_charge_dollar": 28538.0, "standard_charge_algorithm": "Per diem ($28,538).", "count": "0", "additional_payer_notes": "Zero final payments for the item or service in the 15 months prior to posting the file." }, { "payer_name": "UNITED HEALTHCARE", "plan_name": "SUTTER SELECT & SUTTER HEALTH PLAN HMO PLANS", "methodology": "per diem", "standard_charge_dollar": 28538.0, "standard_charge_algorithm": "Per diem ($28,538).", "count": "0", "additional_payer_notes": "Zero final payments for the item or service in the 15 months prior to posting the file." }, { "payer_name": "UMR", "plan_name": "SUTTER SELECT & SUTTER HEALTH PLAN HMO PLANS", "methodology": "per diem", "standard_charge_dollar": 28538.0, "standard_charge_algorithm": "Per diem ($28,538).", "count": "0", "additional_payer_notes": "Zero final payments for the item or service in the 15 months prior to posting the file." }, { "payer_name": "UNITED HEALTHCARE", "plan_name": "SUTTER SELECT & SUTTER HEALTH PLAN HMO PLANS", "methodology": "per diem", "standard_charge_dollar": 28538.0, "standard_charge_algorithm": "Per diem ($28,538).", "count": "0", "additional_payer_notes": "Zero final payments for the item or service in the 15 months prior to posting the file." } ] } ] }, { "description": "HC Cath Fogarty Gp013", "code_information": [ { "code": "PX-2120031013", "type": "CDM" }, { "code": "C1757", "type": "HCPCS" }, { "code": "0272", "type": "RC" } ], "standard_charges": [ { "setting": "outpatient", "gross_charge": 900.0, "discounted_cash": 450.0, "minimum": 379.8, "maximum": 468.0, "additional_generic_notes": "Zero final payments for the item or service in the 15 months prior to posting the file.", "payers_information": [ { "payer_name": "AETNA", "plan_name": "AETNA ALL OTHER PLANS", "methodology": "percent of total billed charges", "standard_charge_dollar": 468.0, "standard_charge_percentage": 52.0, "count": "0", "additional_payer_notes": "Zero final payments for the item or service in the 15 months prior to posting the file." }, { "payer_name": "AETNA", "plan_name": "AETNA ALL OTHER PLANS", "methodology": "percent of total billed charges", "standard_charge_dollar": 468.0, "standard_charge_percentage": 52.0, "count": "0", "additional_payer_notes": "Zero final payments for the item or service in the 15 months prior to posting the file." }, { "payer_name": "MERITAIN HEALTH", "plan_name": "AETNA ALL OTHER PLANS", "methodology": "percent of total billed charges", "standard_charge_dollar": 468.0, "standard_charge_percentage": 52.0, "count": "0", "additional_payer_notes": "Zero final payments for the item or service in the 15 months prior to posting the file." }, { "payer_name": "BLUE SHIELD OUT OF STATE", "plan_name": "STANFORD HEALTHCARE ALLIANCE PLAN", "methodology": "percent of total billed charges", "standard_charge_dollar": 437.31, "standard_charge_percentage": 48.59, "count": "0", "additional_payer_notes": "Zero final payments for the item or service in the 15 months prior to posting the file." }, { "payer_name": "BLUE SHIELD", "plan_name": "STANFORD HEALTHCARE ALLIANCE PLAN", "methodology": "percent of total billed charges", "standard_charge_dollar": 437.31, "standard_charge_percentage": 48.59, "count": "0", "additional_payer_notes": "Zero final payments for the item or service in the 15 months prior to posting the file." }, { "payer_name": "BLUE SHIELD", "plan_name": "STANFORD HEALTHCARE ALLIANCE PLAN", "methodology": "percent of total billed charges", "standard_charge_dollar": 437.31, "standard_charge_percentage": 48.59, "count": "0", "additional_payer_notes": "Zero final payments for the item or service in the 15 months prior to posting the file." }, { "payer_name": "BLUE SHIELD", "plan_name": "STANFORD HEALTHCARE ALLIANCE PLAN", "methodology": "percent of total billed charges", "standard_charge_dollar": 437.31, "standard_charge_percentage": 48.59, "count": "0", "additional_payer_notes": "Zero final payments for the item or service in the 15 months prior to posting the file." }, { "payer_name": "CIGNA", "plan_name": "CIGNA COM ALT HMO PLAN", "methodology": "percent of total billed charges", "standard_charge_dollar": 379.8, "standard_charge_percentage": 42.2, "count": "0", "additional_payer_notes": "Zero final payments for the item or service in the 15 months prior to posting the file." }, { "payer_name": "CIGNA", "plan_name": "CIGNA COM ALT HMO PLAN", "methodology": "percent of total billed charges", "standard_charge_dollar": 379.8, "standard_charge_percentage": 42.2, "count": "0", "additional_payer_notes": "Zero final payments for the item or service in the 15 months prior to posting the file." }, { "payer_name": "HEALTH NET", "plan_name": "HEALTHNET HMO, PPO, POS, EPO, CANOPY HEALTHNET HMO, OTHER-IN-NETWORK PLANS", "methodology": "per diem", "standard_charge_dollar": 8000.0, "standard_charge_algorithm": "Expected reimbursement is the lesser of Per diem ($8,000) for the length of stay and 70% of billed.", "count": "0", "additional_payer_notes": "Zero final payments for the item or service in the 15 months prior to posting the file." }, { "payer_name": "HEALTH NET", "plan_name": "HEALTHNET HMO, PPO, POS, EPO, CANOPY HEALTHNET HMO, OTHER-IN-NETWORK PLANS", "methodology": "per diem", "standard_charge_dollar": 8000.0, "standard_charge_algorithm": "Expected reimbursement is the lesser of Per diem ($8,000) for the length of stay and 70% of billed.", "count": "0", "additional_payer_notes": "Zero final payments for the item or service in the 15 months prior to posting the file." }, { "payer_name": "UNITED HEALTHCARE", "plan_name": "SUTTER SELECT & SUTTER HEALTH PLAN HMO PLANS", "methodology": "per diem", "standard_charge_dollar": 28538.0, "standard_charge_algorithm": "Per diem ($28,538).", "count": "0", "additional_payer_notes": "Zero final payments for the item or service in the 15 months prior to posting the file." }, { "payer_name": "UNITED HEALTHCARE", "plan_name": "SUTTER SELECT & SUTTER HEALTH PLAN HMO PLANS", "methodology": "per diem", "standard_charge_dollar": 28538.0, "standard_charge_algorithm": "Per diem ($28,538).", "count": "0", "additional_payer_notes": "Zero final payments for the item or service in the 15 months prior to posting the file." }, { "payer_name": "SUTTER", "plan_name": "SUTTER SELECT & SUTTER HEALTH PLAN HMO PLANS", "methodology": "per diem", "standard_charge_dollar": 28538.0, "standard_charge_algorithm": "Per diem ($28,538).", "count": "0", "additional_payer_notes": "Zero final payments for the item or service in the 15 months prior to posting the file." }, { "payer_name": "UNITED HEALTHCARE", "plan_name": "SUTTER SELECT & SUTTER HEALTH PLAN HMO PLANS", "methodology": "per diem", "standard_charge_dollar": 28538.0, "standard_charge_algorithm": "Per diem ($28,538).", "count": "0", "additional_payer_notes": "Zero final payments for the item or service in the 15 months prior to posting the file." }, { "payer_name": "UMR", "plan_name": "SUTTER SELECT & SUTTER HEALTH PLAN HMO PLANS", "methodology": "per diem", "standard_charge_dollar": 28538.0, "standard_charge_algorithm": "Per diem ($28,538).", "count": "0", "additional_payer_notes": "Zero final payments for the item or service in the 15 months prior to posting the file." }, { "payer_name": "UNITED HEALTHCARE", "plan_name": "SUTTER SELECT & SUTTER HEALTH PLAN HMO PLANS", "methodology": "per diem", "standard_charge_dollar": 28538.0, "standard_charge_algorithm": "Per diem ($28,538).", "count": "0", "additional_payer_notes": "Zero final payments for the item or service in the 15 months prior to posting the file." } ] } ] }, { "description": "HC Cath Fogarty Gp014", "code_information": [ { "code": "PX-2120031014", "type": "CDM" }, { "code": "C1757", "type": "HCPCS" }, { "code": "0272", "type": "RC" } ], "standard_charges": [ { "setting": "outpatient", "gross_charge": 1080.0, "discounted_cash": 540.0, "minimum": 455.76, "maximum": 561.6, "additional_generic_notes": "Zero final payments for the item or service in the 15 months prior to posting the file.", "payers_information": [ { "payer_name": "AETNA", "plan_name": "AETNA ALL OTHER PLANS", "methodology": "percent of total billed charges", "standard_charge_dollar": 561.6, "standard_charge_percentage": 52.0, "count": "0", "additional_payer_notes": "Zero final payments for the item or service in the 15 months prior to posting the file." }, { "payer_name": "AETNA", "plan_name": "AETNA ALL OTHER PLANS", "methodology": "percent of total billed charges", "standard_charge_dollar": 561.6, "standard_charge_percentage": 52.0, "count": "0", "additional_payer_notes": "Zero final payments for the item or service in the 15 months prior to posting the file." }, { "payer_name": "MERITAIN HEALTH", "plan_name": "AETNA ALL OTHER PLANS", "methodology": "percent of total billed charges", "standard_charge_dollar": 561.6, "standard_charge_percentage": 52.0, "count": "0", "additional_payer_notes": "Zero final payments for the item or service in the 15 months prior to posting the file." }, { "payer_name": "BLUE SHIELD OUT OF STATE", "plan_name": "STANFORD HEALTHCARE ALLIANCE PLAN", "methodology": "percent of total billed charges", "standard_charge_dollar": 524.77, "standard_charge_percentage": 48.59, "count": "0", "additional_payer_notes": "Zero final payments for the item or service in the 15 months prior to posting the file." }, { "payer_name": "BLUE SHIELD", "plan_name": "STANFORD HEALTHCARE ALLIANCE PLAN", "methodology": "percent of total billed charges", "standard_charge_dollar": 524.77, "standard_charge_percentage": 48.59, "count": "0", "additional_payer_notes": "Zero final payments for the item or service in the 15 months prior to posting the file." }, { "payer_name": "BLUE SHIELD", "plan_name": "STANFORD HEALTHCARE ALLIANCE PLAN", "methodology": "percent of total billed charges", "standard_charge_dollar": 524.77, "standard_charge_percentage": 48.59, "count": "0", "additional_payer_notes": "Zero final payments for the item or service in the 15 months prior to posting the file." }, { "payer_name": "BLUE SHIELD", "plan_name": "STANFORD HEALTHCARE ALLIANCE PLAN", "methodology": "percent of total billed charges", "standard_charge_dollar": 524.77, "standard_charge_percentage": 48.59, "count": "0", "additional_payer_notes": "Zero final payments for the item or service in the 15 months prior to posting the file." }, { "payer_name": "CIGNA", "plan_name": "CIGNA COM ALT HMO PLAN", "methodology": "percent of total billed charges", "standard_charge_dollar": 455.76, "standard_charge_percentage": 42.2, "count": "0", "additional_payer_notes": "Zero final payments for the item or service in the 15 months prior to posting the file." }, { "payer_name": "CIGNA", "plan_name": "CIGNA COM ALT HMO PLAN", "methodology": "percent of total billed charges", "standard_charge_dollar": 455.76, "standard_charge_percentage": 42.2, "count": "0", "additional_payer_notes": "Zero final payments for the item or service in the 15 months prior to posting the file." }, { "payer_name": "HEALTH NET", "plan_name": "HEALTHNET HMO, PPO, POS, EPO, CANOPY HEALTHNET HMO, OTHER-IN-NETWORK PLANS", "methodology": "per diem", "standard_charge_dollar": 8000.0, "standard_charge_algorithm": "Expected reimbursement is the lesser of Per diem ($8,000) for the length of stay and 70% of billed.", "count": "0", "additional_payer_notes": "Zero final payments for the item or service in the 15 months prior to posting the file." }, { "payer_name": "HEALTH NET", "plan_name": "HEALTHNET HMO, PPO, POS, EPO, CANOPY HEALTHNET HMO, OTHER-IN-NETWORK PLANS", "methodology": "per diem", "standard_charge_dollar": 8000.0, "standard_charge_algorithm": "Expected reimbursement is the lesser of Per diem ($8,000) for the length of stay and 70% of billed.", "count": "0", "additional_payer_notes": "Zero final payments for the item or service in the 15 months prior to posting the file." }, { "payer_name": "UNITED HEALTHCARE", "plan_name": "SUTTER SELECT & SUTTER HEALTH PLAN HMO PLANS", "methodology": "per diem", "standard_charge_dollar": 28538.0, "standard_charge_algorithm": "Per diem ($28,538).", "count": "0", "additional_payer_notes": "Zero final payments for the item or service in the 15 months prior to posting the file." }, { "payer_name": "UNITED HEALTHCARE", "plan_name": "SUTTER SELECT & SUTTER HEALTH PLAN HMO PLANS", "methodology": "per diem", "standard_charge_dollar": 28538.0, "standard_charge_algorithm": "Per diem ($28,538).", "count": "0", "additional_payer_notes": "Zero final payments for the item or service in the 15 months prior to posting the file." }, { "payer_name": "SUTTER", "plan_name": "SUTTER SELECT & SUTTER HEALTH PLAN HMO PLANS", "methodology": "per diem", "standard_charge_dollar": 28538.0, "standard_charge_algorithm": "Per diem ($28,538).", "count": "0", "additional_payer_notes": "Zero final payments for the item or service in the 15 months prior to posting the file." }, { "payer_name": "UNITED HEALTHCARE", "plan_name": "SUTTER SELECT & SUTTER HEALTH PLAN HMO PLANS", "methodology": "per diem", "standard_charge_dollar": 28538.0, "standard_charge_algorithm": "Per diem ($28,538).", "count": "0", "additional_payer_notes": "Zero final payments for the item or service in the 15 months prior to posting the file." }, { "payer_name": "UMR", "plan_name": "SUTTER SELECT & SUTTER HEALTH PLAN HMO PLANS", "methodology": "per diem", "standard_charge_dollar": 28538.0, "standard_charge_algorithm": "Per diem ($28,538).", "count": "0", "additional_payer_notes": "Zero final payments for the item or service in the 15 months prior to posting the file." }, { "payer_name": "UNITED HEALTHCARE", "plan_name": "SUTTER SELECT & SUTTER HEALTH PLAN HMO PLANS", "methodology": "per diem", "standard_charge_dollar": 28538.0, "standard_charge_algorithm": "Per diem ($28,538).", "count": "0", "additional_payer_notes": "Zero final payments for the item or service in the 15 months prior to posting the file." } ] } ] }, { "description": "HC Cath Fogarty Gp017", "code_information": [ { "code": "PX-2120031017", "type": "CDM" }, { "code": "C1757", "type": "HCPCS" }, { "code": "0272", "type": "RC" } ], "standard_charges": [ { "setting": "outpatient", "gross_charge": 1575.0, "discounted_cash": 787.5, "minimum": 664.65, "maximum": 819.0, "additional_generic_notes": "Zero final payments for the item or service in the 15 months prior to posting the file.", "payers_information": [ { "payer_name": "AETNA", "plan_name": "AETNA ALL OTHER PLANS", "methodology": "percent of total billed charges", "standard_charge_dollar": 819.0, "standard_charge_percentage": 52.0, "count": "0", "additional_payer_notes": "Zero final payments for the item or service in the 15 months prior to posting the file." }, { "payer_name": "AETNA", "plan_name": "AETNA ALL OTHER PLANS", "methodology": "percent of total billed charges", "standard_charge_dollar": 819.0, "standard_charge_percentage": 52.0, "count": "0", "additional_payer_notes": "Zero final payments for the item or service in the 15 months prior to posting the file." }, { "payer_name": "MERITAIN HEALTH", "plan_name": "AETNA ALL OTHER PLANS", "methodology": "percent of total billed charges", "standard_charge_dollar": 819.0, "standard_charge_percentage": 52.0, "count": "0", "additional_payer_notes": "Zero final payments for the item or service in the 15 months prior to posting the file." }, { "payer_name": "BLUE SHIELD OUT OF STATE", "plan_name": "STANFORD HEALTHCARE ALLIANCE PLAN", "methodology": "percent of total billed charges", "standard_charge_dollar": 765.29, "standard_charge_percentage": 48.59, "count": "0", "additional_payer_notes": "Zero final payments for the item or service in the 15 months prior to posting the file." }, { "payer_name": "BLUE SHIELD", "plan_name": "STANFORD HEALTHCARE ALLIANCE PLAN", "methodology": "percent of total billed charges", "standard_charge_dollar": 765.29, "standard_charge_percentage": 48.59, "count": "0", "additional_payer_notes": "Zero final payments for the item or service in the 15 months prior to posting the file." }, { "payer_name": "BLUE SHIELD", "plan_name": "STANFORD HEALTHCARE ALLIANCE PLAN", "methodology": "percent of total billed charges", "standard_charge_dollar": 765.29, "standard_charge_percentage": 48.59, "count": "0", "additional_payer_notes": "Zero final payments for the item or service in the 15 months prior to posting the file." }, { "payer_name": "BLUE SHIELD", "plan_name": "STANFORD HEALTHCARE ALLIANCE PLAN", "methodology": "percent of total billed charges", "standard_charge_dollar": 765.29, "standard_charge_percentage": 48.59, "count": "0", "additional_payer_notes": "Zero final payments for the item or service in the 15 months prior to posting the file." }, { "payer_name": "CIGNA", "plan_name": "CIGNA COM ALT HMO PLAN", "methodology": "percent of total billed charges", "standard_charge_dollar": 664.65, "standard_charge_percentage": 42.2, "count": "0", "additional_payer_notes": "Zero final payments for the item or service in the 15 months prior to posting the file." }, { "payer_name": "CIGNA", "plan_name": "CIGNA COM ALT HMO PLAN", "methodology": "percent of total billed charges", "standard_charge_dollar": 664.65, "standard_charge_percentage": 42.2, "count": "0", "additional_payer_notes": "Zero final payments for the item or service in the 15 months prior to posting the file." }, { "payer_name": "HEALTH NET", "plan_name": "HEALTHNET HMO, PPO, POS, EPO, CANOPY HEALTHNET HMO, OTHER-IN-NETWORK PLANS", "methodology": "per diem", "standard_charge_dollar": 8000.0, "standard_charge_algorithm": "Expected reimbursement is the lesser of Per diem ($8,000) for the length of stay and 70% of billed.", "count": "0", "additional_payer_notes": "Zero final payments for the item or service in the 15 months prior to posting the file." }, { "payer_name": "HEALTH NET", "plan_name": "HEALTHNET HMO, PPO, POS, EPO, CANOPY HEALTHNET HMO, OTHER-IN-NETWORK PLANS", "methodology": "per diem", "standard_charge_dollar": 8000.0, "standard_charge_algorithm": "Expected reimbursement is the lesser of Per diem ($8,000) for the length of stay and 70% of billed.", "count": "0", "additional_payer_notes": "Zero final payments for the item or service in the 15 months prior to posting the file." }, { "payer_name": "UNITED HEALTHCARE", "plan_name": "SUTTER SELECT & SUTTER HEALTH PLAN HMO PLANS", "methodology": "per diem", "standard_charge_dollar": 28538.0, "standard_charge_algorithm": "Per diem ($28,538).", "count": "0", "additional_payer_notes": "Zero final payments for the item or service in the 15 months prior to posting the file." }, { "payer_name": "UNITED HEALTHCARE", "plan_name": "SUTTER SELECT & SUTTER HEALTH PLAN HMO PLANS", "methodology": "per diem", "standard_charge_dollar": 28538.0, "standard_charge_algorithm": "Per diem ($28,538).", "count": "0", "additional_payer_notes": "Zero final payments for the item or service in the 15 months prior to posting the file." }, { "payer_name": "SUTTER", "plan_name": "SUTTER SELECT & SUTTER HEALTH PLAN HMO PLANS", "methodology": "per diem", "standard_charge_dollar": 28538.0, "standard_charge_algorithm": "Per diem ($28,538).", "count": "0", "additional_payer_notes": "Zero final payments for the item or service in the 15 months prior to posting the file." }, { "payer_name": "UNITED HEALTHCARE", "plan_name": "SUTTER SELECT & SUTTER HEALTH PLAN HMO PLANS", "methodology": "per diem", "standard_charge_dollar": 28538.0, "standard_charge_algorithm": "Per diem ($28,538).", "count": "0", "additional_payer_notes": "Zero final payments for the item or service in the 15 months prior to posting the file." }, { "payer_name": "UMR", "plan_name": "SUTTER SELECT & SUTTER HEALTH PLAN HMO PLANS", "methodology": "per diem", "standard_charge_dollar": 28538.0, "standard_charge_algorithm": "Per diem ($28,538).", "count": "0", "additional_payer_notes": "Zero final payments for the item or service in the 15 months prior to posting the file." }, { "payer_name": "UNITED HEALTHCARE", "plan_name": "SUTTER SELECT & SUTTER HEALTH PLAN HMO PLANS", "methodology": "per diem", "standard_charge_dollar": 28538.0, "standard_charge_algorithm": "Per diem ($28,538).", "count": "0", "additional_payer_notes": "Zero final payments for the item or service in the 15 months prior to posting the file." } ] } ] }, { "description": "HC Cath Fogarty Gp018", "code_information": [ { "code": "PX-2120031018", "type": "CDM" }, { "code": "C1757", "type": "HCPCS" }, { "code": "0272", "type": "RC" } ], "standard_charges": [ { "setting": "outpatient", "gross_charge": 1750.0, "discounted_cash": 875.0, "minimum": 738.5, "maximum": 910.0, "additional_generic_notes": "Zero final payments for the item or service in the 15 months prior to posting the file.", "payers_information": [ { "payer_name": "AETNA", "plan_name": "AETNA ALL OTHER PLANS", "methodology": "percent of total billed charges", "standard_charge_dollar": 910.0, "standard_charge_percentage": 52.0, "count": "0", "additional_payer_notes": "Zero final payments for the item or service in the 15 months prior to posting the file." }, { "payer_name": "AETNA", "plan_name": "AETNA ALL OTHER PLANS", "methodology": "percent of total billed charges", "standard_charge_dollar": 910.0, "standard_charge_percentage": 52.0, "count": "0", "additional_payer_notes": "Zero final payments for the item or service in the 15 months prior to posting the file." }, { "payer_name": "MERITAIN HEALTH", "plan_name": "AETNA ALL OTHER PLANS", "methodology": "percent of total billed charges", "standard_charge_dollar": 910.0, "standard_charge_percentage": 52.0, "count": "0", "additional_payer_notes": "Zero final payments for the item or service in the 15 months prior to posting the file." }, { "payer_name": "BLUE SHIELD OUT OF STATE", "plan_name": "STANFORD HEALTHCARE ALLIANCE PLAN", "methodology": "percent of total billed charges", "standard_charge_dollar": 850.33, "standard_charge_percentage": 48.59, "count": "0", "additional_payer_notes": "Zero final payments for the item or service in the 15 months prior to posting the file." }, { "payer_name": "BLUE SHIELD", "plan_name": "STANFORD HEALTHCARE ALLIANCE PLAN", "methodology": "percent of total billed charges", "standard_charge_dollar": 850.33, "standard_charge_percentage": 48.59, "count": "0", "additional_payer_notes": "Zero final payments for the item or service in the 15 months prior to posting the file." }, { "payer_name": "BLUE SHIELD", "plan_name": "STANFORD HEALTHCARE ALLIANCE PLAN", "methodology": "percent of total billed charges", "standard_charge_dollar": 850.33, "standard_charge_percentage": 48.59, "count": "0", "additional_payer_notes": "Zero final payments for the item or service in the 15 months prior to posting the file." }, { "payer_name": "BLUE SHIELD", "plan_name": "STANFORD HEALTHCARE ALLIANCE PLAN", "methodology": "percent of total billed charges", "standard_charge_dollar": 850.33, "standard_charge_percentage": 48.59, "count": "0", "additional_payer_notes": "Zero final payments for the item or service in the 15 months prior to posting the file." }, { "payer_name": "CIGNA", "plan_name": "CIGNA COM ALT HMO PLAN", "methodology": "percent of total billed charges", "standard_charge_dollar": 738.5, "standard_charge_percentage": 42.2, "count": "0", "additional_payer_notes": "Zero final payments for the item or service in the 15 months prior to posting the file." }, { "payer_name": "CIGNA", "plan_name": "CIGNA COM ALT HMO PLAN", "methodology": "percent of total billed charges", "standard_charge_dollar": 738.5, "standard_charge_percentage": 42.2, "count": "0", "additional_payer_notes": "Zero final payments for the item or service in the 15 months prior to posting the file." }, { "payer_name": "HEALTH NET", "plan_name": "HEALTHNET HMO, PPO, POS, EPO, CANOPY HEALTHNET HMO, OTHER-IN-NETWORK PLANS", "methodology": "per diem", "standard_charge_dollar": 8000.0, "standard_charge_algorithm": "Expected reimbursement is the lesser of Per diem ($8,000) for the length of stay and 70% of billed.", "count": "0", "additional_payer_notes": "Zero final payments for the item or service in the 15 months prior to posting the file." }, { "payer_name": "HEALTH NET", "plan_name": "HEALTHNET HMO, PPO, POS, EPO, CANOPY HEALTHNET HMO, OTHER-IN-NETWORK PLANS", "methodology": "per diem", "standard_charge_dollar": 8000.0, "standard_charge_algorithm": "Expected reimbursement is the lesser of Per diem ($8,000) for the length of stay and 70% of billed.", "count": "0", "additional_payer_notes": "Zero final payments for the item or service in the 15 months prior to posting the file." }, { "payer_name": "UNITED HEALTHCARE", "plan_name": "SUTTER SELECT & SUTTER HEALTH PLAN HMO PLANS", "methodology": "per diem", "standard_charge_dollar": 28538.0, "standard_charge_algorithm": "Per diem ($28,538).", "count": "0", "additional_payer_notes": "Zero final payments for the item or service in the 15 months prior to posting the file." }, { "payer_name": "UNITED HEALTHCARE", "plan_name": "SUTTER SELECT & SUTTER HEALTH PLAN HMO PLANS", "methodology": "per diem", "standard_charge_dollar": 28538.0, "standard_charge_algorithm": "Per diem ($28,538).", "count": "0", "additional_payer_notes": "Zero final payments for the item or service in the 15 months prior to posting the file." }, { "payer_name": "SUTTER", "plan_name": "SUTTER SELECT & SUTTER HEALTH PLAN HMO PLANS", "methodology": "per diem", "standard_charge_dollar": 28538.0, "standard_charge_algorithm": "Per diem ($28,538).", "count": "0", "additional_payer_notes": "Zero final payments for the item or service in the 15 months prior to posting the file." }, { "payer_name": "UNITED HEALTHCARE", "plan_name": "SUTTER SELECT & SUTTER HEALTH PLAN HMO PLANS", "methodology": "per diem", "standard_charge_dollar": 28538.0, "standard_charge_algorithm": "Per diem ($28,538).", "count": "0", "additional_payer_notes": "Zero final payments for the item or service in the 15 months prior to posting the file." }, { "payer_name": "UMR", "plan_name": "SUTTER SELECT & SUTTER HEALTH PLAN HMO PLANS", "methodology": "per diem", "standard_charge_dollar": 28538.0, "standard_charge_algorithm": "Per diem ($28,538).", "count": "0", "additional_payer_notes": "Zero final payments for the item or service in the 15 months prior to posting the file." }, { "payer_name": "UNITED HEALTHCARE", "plan_name": "SUTTER SELECT & SUTTER HEALTH PLAN HMO PLANS", "methodology": "per diem", "standard_charge_dollar": 28538.0, "standard_charge_algorithm": "Per diem ($28,538).", "count": "0", "additional_payer_notes": "Zero final payments for the item or service in the 15 months prior to posting the file." } ] } ] }, { "description": "HC Cath Fogarty Gp020", "code_information": [ { "code": "PX-2120031020", "type": "CDM" }, { "code": "C1757", "type": "HCPCS" }, { "code": "0272", "type": "RC" } ], "standard_charges": [ { "setting": "outpatient", "gross_charge": 2550.0, "discounted_cash": 1275.0, "minimum": 1076.1, "maximum": 1326.0, "additional_generic_notes": "Zero final payments for the item or service in the 15 months prior to posting the file.", "payers_information": [ { "payer_name": "AETNA", "plan_name": "AETNA ALL OTHER PLANS", "methodology": "percent of total billed charges", "standard_charge_dollar": 1326.0, "standard_charge_percentage": 52.0, "count": "0", "additional_payer_notes": "Zero final payments for the item or service in the 15 months prior to posting the file." }, { "payer_name": "AETNA", "plan_name": "AETNA ALL OTHER PLANS", "methodology": "percent of total billed charges", "standard_charge_dollar": 1326.0, "standard_charge_percentage": 52.0, "count": "0", "additional_payer_notes": "Zero final payments for the item or service in the 15 months prior to posting the file." }, { "payer_name": "MERITAIN HEALTH", "plan_name": "AETNA ALL OTHER PLANS", "methodology": "percent of total billed charges", "standard_charge_dollar": 1326.0, "standard_charge_percentage": 52.0, "count": "0", "additional_payer_notes": "Zero final payments for the item or service in the 15 months prior to posting the file." }, { "payer_name": "BLUE SHIELD OUT OF STATE", "plan_name": "STANFORD HEALTHCARE ALLIANCE PLAN", "methodology": "percent of total billed charges", "standard_charge_dollar": 1239.05, "standard_charge_percentage": 48.59, "count": "0", "additional_payer_notes": "Zero final payments for the item or service in the 15 months prior to posting the file." }, { "payer_name": "BLUE SHIELD", "plan_name": "STANFORD HEALTHCARE ALLIANCE PLAN", "methodology": "percent of total billed charges", "standard_charge_dollar": 1239.05, "standard_charge_percentage": 48.59, "count": "0", "additional_payer_notes": "Zero final payments for the item or service in the 15 months prior to posting the file." }, { "payer_name": "BLUE SHIELD", "plan_name": "STANFORD HEALTHCARE ALLIANCE PLAN", "methodology": "percent of total billed charges", "standard_charge_dollar": 1239.05, "standard_charge_percentage": 48.59, "count": "0", "additional_payer_notes": "Zero final payments for the item or service in the 15 months prior to posting the file." }, { "payer_name": "BLUE SHIELD", "plan_name": "STANFORD HEALTHCARE ALLIANCE PLAN", "methodology": "percent of total billed charges", "standard_charge_dollar": 1239.05, "standard_charge_percentage": 48.59, "count": "0", "additional_payer_notes": "Zero final payments for the item or service in the 15 months prior to posting the file." }, { "payer_name": "CIGNA", "plan_name": "CIGNA COM ALT HMO PLAN", "methodology": "percent of total billed charges", "standard_charge_dollar": 1076.1, "standard_charge_percentage": 42.2, "count": "0", "additional_payer_notes": "Zero final payments for the item or service in the 15 months prior to posting the file." }, { "payer_name": "CIGNA", "plan_name": "CIGNA COM ALT HMO PLAN", "methodology": "percent of total billed charges", "standard_charge_dollar": 1076.1, "standard_charge_percentage": 42.2, "count": "0", "additional_payer_notes": "Zero final payments for the item or service in the 15 months prior to posting the file." }, { "payer_name": "HEALTH NET", "plan_name": "HEALTHNET HMO, PPO, POS, EPO, CANOPY HEALTHNET HMO, OTHER-IN-NETWORK PLANS", "methodology": "per diem", "standard_charge_dollar": 8000.0, "standard_charge_algorithm": "Expected reimbursement is the lesser of Per diem ($8,000) for the length of stay and 70% of billed.", "count": "0", "additional_payer_notes": "Zero final payments for the item or service in the 15 months prior to posting the file." }, { "payer_name": "HEALTH NET", "plan_name": "HEALTHNET HMO, PPO, POS, EPO, CANOPY HEALTHNET HMO, OTHER-IN-NETWORK PLANS", "methodology": "per diem", "standard_charge_dollar": 8000.0, "standard_charge_algorithm": "Expected reimbursement is the lesser of Per diem ($8,000) for the length of stay and 70% of billed.", "count": "0", "additional_payer_notes": "Zero final payments for the item or service in the 15 months prior to posting the file." }, { "payer_name": "UNITED HEALTHCARE", "plan_name": "SUTTER SELECT & SUTTER HEALTH PLAN HMO PLANS", "methodology": "per diem", "standard_charge_dollar": 28538.0, "standard_charge_algorithm": "Per diem ($28,538).", "count": "0", "additional_payer_notes": "Zero final payments for the item or service in the 15 months prior to posting the file." }, { "payer_name": "UNITED HEALTHCARE", "plan_name": "SUTTER SELECT & SUTTER HEALTH PLAN HMO PLANS", "methodology": "per diem", "standard_charge_dollar": 28538.0, "standard_charge_algorithm": "Per diem ($28,538).", "count": "0", "additional_payer_notes": "Zero final payments for the item or service in the 15 months prior to posting the file." }, { "payer_name": "SUTTER", "plan_name": "SUTTER SELECT & SUTTER HEALTH PLAN HMO PLANS", "methodology": "per diem", "standard_charge_dollar": 28538.0, "standard_charge_algorithm": "Per diem ($28,538).", "count": "0", "additional_payer_notes": "Zero final payments for the item or service in the 15 months prior to posting the file." }, { "payer_name": "UNITED HEALTHCARE", "plan_name": "SUTTER SELECT & SUTTER HEALTH PLAN HMO PLANS", "methodology": "per diem", "standard_charge_dollar": 28538.0, "standard_charge_algorithm": "Per diem ($28,538).", "count": "0", "additional_payer_notes": "Zero final payments for the item or service in the 15 months prior to posting the file." }, { "payer_name": "UMR", "plan_name": "SUTTER SELECT & SUTTER HEALTH PLAN HMO PLANS", "methodology": "per diem", "standard_charge_dollar": 28538.0, "standard_charge_algorithm": "Per diem ($28,538).", "count": "0", "additional_payer_notes": "Zero final payments for the item or service in the 15 months prior to posting the file." }, { "payer_name": "UNITED HEALTHCARE", "plan_name": "SUTTER SELECT & SUTTER HEALTH PLAN HMO PLANS", "methodology": "per diem", "standard_charge_dollar": 28538.0, "standard_charge_algorithm": "Per diem ($28,538).", "count": "0", "additional_payer_notes": "Zero final payments for the item or service in the 15 months prior to posting the file." } ] } ] }, { "description": "HC Cath Fogarty Gp041", "code_information": [ { "code": "PX-2120031041", "type": "CDM" }, { "code": "C1757", "type": "HCPCS" }, { "code": "0272", "type": "RC" } ], "standard_charges": [ { "setting": "outpatient", "gross_charge": 9775.0, "discounted_cash": 4887.5, "minimum": 4125.05, "maximum": 5083.0, "additional_generic_notes": "Zero final payments for the item or service in the 15 months prior to posting the file.", "payers_information": [ { "payer_name": "AETNA", "plan_name": "AETNA ALL OTHER PLANS", "methodology": "percent of total billed charges", "standard_charge_dollar": 5083.0, "standard_charge_percentage": 52.0, "count": "0", "additional_payer_notes": "Zero final payments for the item or service in the 15 months prior to posting the file." }, { "payer_name": "AETNA", "plan_name": "AETNA ALL OTHER PLANS", "methodology": "percent of total billed charges", "standard_charge_dollar": 5083.0, "standard_charge_percentage": 52.0, "count": "0", "additional_payer_notes": "Zero final payments for the item or service in the 15 months prior to posting the file." }, { "payer_name": "MERITAIN HEALTH", "plan_name": "AETNA ALL OTHER PLANS", "methodology": "percent of total billed charges", "standard_charge_dollar": 5083.0, "standard_charge_percentage": 52.0, "count": "0", "additional_payer_notes": "Zero final payments for the item or service in the 15 months prior to posting the file." }, { "payer_name": "BLUE SHIELD OUT OF STATE", "plan_name": "STANFORD HEALTHCARE ALLIANCE PLAN", "methodology": "percent of total billed charges", "standard_charge_dollar": 4749.67, "standard_charge_percentage": 48.59, "count": "0", "additional_payer_notes": "Zero final payments for the item or service in the 15 months prior to posting the file." }, { "payer_name": "BLUE SHIELD", "plan_name": "STANFORD HEALTHCARE ALLIANCE PLAN", "methodology": "percent of total billed charges", "standard_charge_dollar": 4749.67, "standard_charge_percentage": 48.59, "count": "0", "additional_payer_notes": "Zero final payments for the item or service in the 15 months prior to posting the file." }, { "payer_name": "BLUE SHIELD", "plan_name": "STANFORD HEALTHCARE ALLIANCE PLAN", "methodology": "percent of total billed charges", "standard_charge_dollar": 4749.67, "standard_charge_percentage": 48.59, "count": "0", "additional_payer_notes": "Zero final payments for the item or service in the 15 months prior to posting the file." }, { "payer_name": "BLUE SHIELD", "plan_name": "STANFORD HEALTHCARE ALLIANCE PLAN", "methodology": "percent of total billed charges", "standard_charge_dollar": 4749.67, "standard_charge_percentage": 48.59, "count": "0", "additional_payer_notes": "Zero final payments for the item or service in the 15 months prior to posting the file." }, { "payer_name": "CIGNA", "plan_name": "CIGNA COM ALT HMO PLAN", "methodology": "percent of total billed charges", "standard_charge_dollar": 4125.05, "standard_charge_percentage": 42.2, "count": "0", "additional_payer_notes": "Zero final payments for the item or service in the 15 months prior to posting the file." }, { "payer_name": "CIGNA", "plan_name": "CIGNA COM ALT HMO PLAN", "methodology": "percent of total billed charges", "standard_charge_dollar": 4125.05, "standard_charge_percentage": 42.2, "count": "0", "additional_payer_notes": "Zero final payments for the item or service in the 15 months prior to posting the file." }, { "payer_name": "HEALTH NET", "plan_name": "HEALTHNET HMO, PPO, POS, EPO, CANOPY HEALTHNET HMO, OTHER-IN-NETWORK PLANS", "methodology": "per diem", "standard_charge_dollar": 8000.0, "standard_charge_algorithm": "Expected reimbursement is the lesser of Per diem ($8,000) for the length of stay and 70% of billed.", "count": "0", "additional_payer_notes": "Zero final payments for the item or service in the 15 months prior to posting the file." }, { "payer_name": "HEALTH NET", "plan_name": "HEALTHNET HMO, PPO, POS, EPO, CANOPY HEALTHNET HMO, OTHER-IN-NETWORK PLANS", "methodology": "per diem", "standard_charge_dollar": 8000.0, "standard_charge_algorithm": "Expected reimbursement is the lesser of Per diem ($8,000) for the length of stay and 70% of billed.", "count": "0", "additional_payer_notes": "Zero final payments for the item or service in the 15 months prior to posting the file." }, { "payer_name": "UNITED HEALTHCARE", "plan_name": "SUTTER SELECT & SUTTER HEALTH PLAN HMO PLANS", "methodology": "per diem", "standard_charge_dollar": 28538.0, "standard_charge_algorithm": "Per diem ($28,538).", "count": "0", "additional_payer_notes": "Zero final payments for the item or service in the 15 months prior to posting the file." }, { "payer_name": "UNITED HEALTHCARE", "plan_name": "SUTTER SELECT & SUTTER HEALTH PLAN HMO PLANS", "methodology": "per diem", "standard_charge_dollar": 28538.0, "standard_charge_algorithm": "Per diem ($28,538).", "count": "0", "additional_payer_notes": "Zero final payments for the item or service in the 15 months prior to posting the file." }, { "payer_name": "SUTTER", "plan_name": "SUTTER SELECT & SUTTER HEALTH PLAN HMO PLANS", "methodology": "per diem", "standard_charge_dollar": 28538.0, "standard_charge_algorithm": "Per diem ($28,538).", "count": "0", "additional_payer_notes": "Zero final payments for the item or service in the 15 months prior to posting the file." }, { "payer_name": "UNITED HEALTHCARE", "plan_name": "SUTTER SELECT & SUTTER HEALTH PLAN HMO PLANS", "methodology": "per diem", "standard_charge_dollar": 28538.0, "standard_charge_algorithm": "Per diem ($28,538).", "count": "0", "additional_payer_notes": "Zero final payments for the item or service in the 15 months prior to posting the file." }, { "payer_name": "UMR", "plan_name": "SUTTER SELECT & SUTTER HEALTH PLAN HMO PLANS", "methodology": "per diem", "standard_charge_dollar": 28538.0, "standard_charge_algorithm": "Per diem ($28,538).", "count": "0", "additional_payer_notes": "Zero final payments for the item or service in the 15 months prior to posting the file." }, { "payer_name": "UNITED HEALTHCARE", "plan_name": "SUTTER SELECT & SUTTER HEALTH PLAN HMO PLANS", "methodology": "per diem", "standard_charge_dollar": 28538.0, "standard_charge_algorithm": "Per diem ($28,538).", "count": "0", "additional_payer_notes": "Zero final payments for the item or service in the 15 months prior to posting the file." } ] } ] }, { "description": "HC Cath Fogarty Gp043", "code_information": [ { "code": "PX-2120031043", "type": "CDM" }, { "code": "C1757", "type": "HCPCS" }, { "code": "0272", "type": "RC" } ], "standard_charges": [ { "setting": "outpatient", "gross_charge": 10450.0, "discounted_cash": 5225.0, "minimum": 4409.9, "maximum": 5434.0, "additional_generic_notes": "Zero final payments for the item or service in the 15 months prior to posting the file.", "payers_information": [ { "payer_name": "AETNA", "plan_name": "AETNA ALL OTHER PLANS", "methodology": "percent of total billed charges", "standard_charge_dollar": 5434.0, "standard_charge_percentage": 52.0, "count": "0", "additional_payer_notes": "Zero final payments for the item or service in the 15 months prior to posting the file." }, { "payer_name": "AETNA", "plan_name": "AETNA ALL OTHER PLANS", "methodology": "percent of total billed charges", "standard_charge_dollar": 5434.0, "standard_charge_percentage": 52.0, "count": "0", "additional_payer_notes": "Zero final payments for the item or service in the 15 months prior to posting the file." }, { "payer_name": "MERITAIN HEALTH", "plan_name": "AETNA ALL OTHER PLANS", "methodology": "percent of total billed charges", "standard_charge_dollar": 5434.0, "standard_charge_percentage": 52.0, "count": "0", "additional_payer_notes": "Zero final payments for the item or service in the 15 months prior to posting the file." }, { "payer_name": "BLUE SHIELD OUT OF STATE", "plan_name": "STANFORD HEALTHCARE ALLIANCE PLAN", "methodology": "percent of total billed charges", "standard_charge_dollar": 5077.66, "standard_charge_percentage": 48.59, "count": "0", "additional_payer_notes": "Zero final payments for the item or service in the 15 months prior to posting the file." }, { "payer_name": "BLUE SHIELD", "plan_name": "STANFORD HEALTHCARE ALLIANCE PLAN", "methodology": "percent of total billed charges", "standard_charge_dollar": 5077.66, "standard_charge_percentage": 48.59, "count": "0", "additional_payer_notes": "Zero final payments for the item or service in the 15 months prior to posting the file." }, { "payer_name": "BLUE SHIELD", "plan_name": "STANFORD HEALTHCARE ALLIANCE PLAN", "methodology": "percent of total billed charges", "standard_charge_dollar": 5077.66, "standard_charge_percentage": 48.59, "count": "0", "additional_payer_notes": "Zero final payments for the item or service in the 15 months prior to posting the file." }, { "payer_name": "BLUE SHIELD", "plan_name": "STANFORD HEALTHCARE ALLIANCE PLAN", "methodology": "percent of total billed charges", "standard_charge_dollar": 5077.66, "standard_charge_percentage": 48.59, "count": "0", "additional_payer_notes": "Zero final payments for the item or service in the 15 months prior to posting the file." }, { "payer_name": "CIGNA", "plan_name": "CIGNA COM ALT HMO PLAN", "methodology": "percent of total billed charges", "standard_charge_dollar": 4409.9, "standard_charge_percentage": 42.2, "count": "0", "additional_payer_notes": "Zero final payments for the item or service in the 15 months prior to posting the file." }, { "payer_name": "CIGNA", "plan_name": "CIGNA COM ALT HMO PLAN", "methodology": "percent of total billed charges", "standard_charge_dollar": 4409.9, "standard_charge_percentage": 42.2, "count": "0", "additional_payer_notes": "Zero final payments for the item or service in the 15 months prior to posting the file." }, { "payer_name": "HEALTH NET", "plan_name": "HEALTHNET HMO, PPO, POS, EPO, CANOPY HEALTHNET HMO, OTHER-IN-NETWORK PLANS", "methodology": "per diem", "standard_charge_dollar": 8000.0, "standard_charge_algorithm": "Expected reimbursement is the lesser of Per diem ($8,000) for the length of stay and 70% of billed.", "count": "0", "additional_payer_notes": "Zero final payments for the item or service in the 15 months prior to posting the file." }, { "payer_name": "HEALTH NET", "plan_name": "HEALTHNET HMO, PPO, POS, EPO, CANOPY HEALTHNET HMO, OTHER-IN-NETWORK PLANS", "methodology": "per diem", "standard_charge_dollar": 8000.0, "standard_charge_algorithm": "Expected reimbursement is the lesser of Per diem ($8,000) for the length of stay and 70% of billed.", "count": "0", "additional_payer_notes": "Zero final payments for the item or service in the 15 months prior to posting the file." }, { "payer_name": "UNITED HEALTHCARE", "plan_name": "SUTTER SELECT & SUTTER HEALTH PLAN HMO PLANS", "methodology": "per diem", "standard_charge_dollar": 28538.0, "standard_charge_algorithm": "Per diem ($28,538).", "count": "0", "additional_payer_notes": "Zero final payments for the item or service in the 15 months prior to posting the file." }, { "payer_name": "UNITED HEALTHCARE", "plan_name": "SUTTER SELECT & SUTTER HEALTH PLAN HMO PLANS", "methodology": "per diem", "standard_charge_dollar": 28538.0, "standard_charge_algorithm": "Per diem ($28,538).", "count": "0", "additional_payer_notes": "Zero final payments for the item or service in the 15 months prior to posting the file." }, { "payer_name": "SUTTER", "plan_name": "SUTTER SELECT & SUTTER HEALTH PLAN HMO PLANS", "methodology": "per diem", "standard_charge_dollar": 28538.0, "standard_charge_algorithm": "Per diem ($28,538).", "count": "0", "additional_payer_notes": "Zero final payments for the item or service in the 15 months prior to posting the file." }, { "payer_name": "UNITED HEALTHCARE", "plan_name": "SUTTER SELECT & SUTTER HEALTH PLAN HMO PLANS", "methodology": "per diem", "standard_charge_dollar": 28538.0, "standard_charge_algorithm": "Per diem ($28,538).", "count": "0", "additional_payer_notes": "Zero final payments for the item or service in the 15 months prior to posting the file." }, { "payer_name": "UMR", "plan_name": "SUTTER SELECT & SUTTER HEALTH PLAN HMO PLANS", "methodology": "per diem", "standard_charge_dollar": 28538.0, "standard_charge_algorithm": "Per diem ($28,538).", "count": "0", "additional_payer_notes": "Zero final payments for the item or service in the 15 months prior to posting the file." }, { "payer_name": "UNITED HEALTHCARE", "plan_name": "SUTTER SELECT & SUTTER HEALTH PLAN HMO PLANS", "methodology": "per diem", "standard_charge_dollar": 28538.0, "standard_charge_algorithm": "Per diem ($28,538).", "count": "0", "additional_payer_notes": "Zero final payments for the item or service in the 15 months prior to posting the file." } ] } ] }, { "description": "HC Cath Fogarty Gp044", "code_information": [ { "code": "PX-2120031044", "type": "CDM" }, { "code": "C1757", "type": "HCPCS" }, { "code": "0272", "type": "RC" } ], "standard_charges": [ { "setting": "outpatient", "gross_charge": 11000.0, "discounted_cash": 5500.0, "minimum": 4642.0, "maximum": 5720.0, "additional_generic_notes": "Zero final payments for the item or service in the 15 months prior to posting the file.", "payers_information": [ { "payer_name": "AETNA", "plan_name": "AETNA ALL OTHER PLANS", "methodology": "percent of total billed charges", "standard_charge_dollar": 5720.0, "standard_charge_percentage": 52.0, "count": "0", "additional_payer_notes": "Zero final payments for the item or service in the 15 months prior to posting the file." }, { "payer_name": "AETNA", "plan_name": "AETNA ALL OTHER PLANS", "methodology": "percent of total billed charges", "standard_charge_dollar": 5720.0, "standard_charge_percentage": 52.0, "count": "0", "additional_payer_notes": "Zero final payments for the item or service in the 15 months prior to posting the file." }, { "payer_name": "MERITAIN HEALTH", "plan_name": "AETNA ALL OTHER PLANS", "methodology": "percent of total billed charges", "standard_charge_dollar": 5720.0, "standard_charge_percentage": 52.0, "count": "0", "additional_payer_notes": "Zero final payments for the item or service in the 15 months prior to posting the file." }, { "payer_name": "BLUE SHIELD OUT OF STATE", "plan_name": "STANFORD HEALTHCARE ALLIANCE PLAN", "methodology": "percent of total billed charges", "standard_charge_dollar": 5344.9, "standard_charge_percentage": 48.59, "count": "0", "additional_payer_notes": "Zero final payments for the item or service in the 15 months prior to posting the file." }, { "payer_name": "BLUE SHIELD", "plan_name": "STANFORD HEALTHCARE ALLIANCE PLAN", "methodology": "percent of total billed charges", "standard_charge_dollar": 5344.9, "standard_charge_percentage": 48.59, "count": "0", "additional_payer_notes": "Zero final payments for the item or service in the 15 months prior to posting the file." }, { "payer_name": "BLUE SHIELD", "plan_name": "STANFORD HEALTHCARE ALLIANCE PLAN", "methodology": "percent of total billed charges", "standard_charge_dollar": 5344.9, "standard_charge_percentage": 48.59, "count": "0", "additional_payer_notes": "Zero final payments for the item or service in the 15 months prior to posting the file." }, { "payer_name": "BLUE SHIELD", "plan_name": "STANFORD HEALTHCARE ALLIANCE PLAN", "methodology": "percent of total billed charges", "standard_charge_dollar": 5344.9, "standard_charge_percentage": 48.59, "count": "0", "additional_payer_notes": "Zero final payments for the item or service in the 15 months prior to posting the file." }, { "payer_name": "CIGNA", "plan_name": "CIGNA COM ALT HMO PLAN", "methodology": "percent of total billed charges", "standard_charge_dollar": 4642.0, "standard_charge_percentage": 42.2, "count": "0", "additional_payer_notes": "Zero final payments for the item or service in the 15 months prior to posting the file." }, { "payer_name": "CIGNA", "plan_name": "CIGNA COM ALT HMO PLAN", "methodology": "percent of total billed charges", "standard_charge_dollar": 4642.0, "standard_charge_percentage": 42.2, "count": "0", "additional_payer_notes": "Zero final payments for the item or service in the 15 months prior to posting the file." }, { "payer_name": "HEALTH NET", "plan_name": "HEALTHNET HMO, PPO, POS, EPO, CANOPY HEALTHNET HMO, OTHER-IN-NETWORK PLANS", "methodology": "per diem", "standard_charge_dollar": 8000.0, "standard_charge_algorithm": "Expected reimbursement is the lesser of Per diem ($8,000) for the length of stay and 70% of billed.", "count": "0", "additional_payer_notes": "Zero final payments for the item or service in the 15 months prior to posting the file." }, { "payer_name": "HEALTH NET", "plan_name": "HEALTHNET HMO, PPO, POS, EPO, CANOPY HEALTHNET HMO, OTHER-IN-NETWORK PLANS", "methodology": "per diem", "standard_charge_dollar": 8000.0, "standard_charge_algorithm": "Expected reimbursement is the lesser of Per diem ($8,000) for the length of stay and 70% of billed.", "count": "0", "additional_payer_notes": "Zero final payments for the item or service in the 15 months prior to posting the file." }, { "payer_name": "UNITED HEALTHCARE", "plan_name": "SUTTER SELECT & SUTTER HEALTH PLAN HMO PLANS", "methodology": "per diem", "standard_charge_dollar": 28538.0, "standard_charge_algorithm": "Per diem ($28,538).", "count": "0", "additional_payer_notes": "Zero final payments for the item or service in the 15 months prior to posting the file." }, { "payer_name": "UNITED HEALTHCARE", "plan_name": "SUTTER SELECT & SUTTER HEALTH PLAN HMO PLANS", "methodology": "per diem", "standard_charge_dollar": 28538.0, "standard_charge_algorithm": "Per diem ($28,538).", "count": "0", "additional_payer_notes": "Zero final payments for the item or service in the 15 months prior to posting the file." }, { "payer_name": "SUTTER", "plan_name": "SUTTER SELECT & SUTTER HEALTH PLAN HMO PLANS", "methodology": "per diem", "standard_charge_dollar": 28538.0, "standard_charge_algorithm": "Per diem ($28,538).", "count": "0", "additional_payer_notes": "Zero final payments for the item or service in the 15 months prior to posting the file." }, { "payer_name": "UNITED HEALTHCARE", "plan_name": "SUTTER SELECT & SUTTER HEALTH PLAN HMO PLANS", "methodology": "per diem", "standard_charge_dollar": 28538.0, "standard_charge_algorithm": "Per diem ($28,538).", "count": "0", "additional_payer_notes": "Zero final payments for the item or service in the 15 months prior to posting the file." }, { "payer_name": "UMR", "plan_name": "SUTTER SELECT & SUTTER HEALTH PLAN HMO PLANS", "methodology": "per diem", "standard_charge_dollar": 28538.0, "standard_charge_algorithm": "Per diem ($28,538).", "count": "0", "additional_payer_notes": "Zero final payments for the item or service in the 15 months prior to posting the file." }, { "payer_name": "UNITED HEALTHCARE", "plan_name": "SUTTER SELECT & SUTTER HEALTH PLAN HMO PLANS", "methodology": "per diem", "standard_charge_dollar": 28538.0, "standard_charge_algorithm": "Per diem ($28,538).", "count": "0", "additional_payer_notes": "Zero final payments for the item or service in the 15 months prior to posting the file." } ] } ] }, { "description": "HC Cath Fogarty Gp045", "code_information": [ { "code": "PX-2120031045", "type": "CDM" }, { "code": "C1757", "type": "HCPCS" }, { "code": "0272", "type": "RC" } ], "standard_charges": [ { "setting": "outpatient", "gross_charge": 11550.0, "discounted_cash": 5775.0, "minimum": 4874.1, "maximum": 6006.0, "additional_generic_notes": "Zero final payments for the item or service in the 15 months prior to posting the file.", "payers_information": [ { "payer_name": "AETNA", "plan_name": "AETNA ALL OTHER PLANS", "methodology": "percent of total billed charges", "standard_charge_dollar": 6006.0, "standard_charge_percentage": 52.0, "count": "0", "additional_payer_notes": "Zero final payments for the item or service in the 15 months prior to posting the file." }, { "payer_name": "AETNA", "plan_name": "AETNA ALL OTHER PLANS", "methodology": "percent of total billed charges", "standard_charge_dollar": 6006.0, "standard_charge_percentage": 52.0, "count": "0", "additional_payer_notes": "Zero final payments for the item or service in the 15 months prior to posting the file." }, { "payer_name": "MERITAIN HEALTH", "plan_name": "AETNA ALL OTHER PLANS", "methodology": "percent of total billed charges", "standard_charge_dollar": 6006.0, "standard_charge_percentage": 52.0, "count": "0", "additional_payer_notes": "Zero final payments for the item or service in the 15 months prior to posting the file." }, { "payer_name": "BLUE SHIELD OUT OF STATE", "plan_name": "STANFORD HEALTHCARE ALLIANCE PLAN", "methodology": "percent of total billed charges", "standard_charge_dollar": 5612.15, "standard_charge_percentage": 48.59, "count": "0", "additional_payer_notes": "Zero final payments for the item or service in the 15 months prior to posting the file." }, { "payer_name": "BLUE SHIELD", "plan_name": "STANFORD HEALTHCARE ALLIANCE PLAN", "methodology": "percent of total billed charges", "standard_charge_dollar": 5612.15, "standard_charge_percentage": 48.59, "count": "0", "additional_payer_notes": "Zero final payments for the item or service in the 15 months prior to posting the file." }, { "payer_name": "BLUE SHIELD", "plan_name": "STANFORD HEALTHCARE ALLIANCE PLAN", "methodology": "percent of total billed charges", "standard_charge_dollar": 5612.15, "standard_charge_percentage": 48.59, "count": "0", "additional_payer_notes": "Zero final payments for the item or service in the 15 months prior to posting the file." }, { "payer_name": "BLUE SHIELD", "plan_name": "STANFORD HEALTHCARE ALLIANCE PLAN", "methodology": "percent of total billed charges", "standard_charge_dollar": 5612.15, "standard_charge_percentage": 48.59, "count": "0", "additional_payer_notes": "Zero final payments for the item or service in the 15 months prior to posting the file." }, { "payer_name": "CIGNA", "plan_name": "CIGNA COM ALT HMO PLAN", "methodology": "percent of total billed charges", "standard_charge_dollar": 4874.1, "standard_charge_percentage": 42.2, "count": "0", "additional_payer_notes": "Zero final payments for the item or service in the 15 months prior to posting the file." }, { "payer_name": "CIGNA", "plan_name": "CIGNA COM ALT HMO PLAN", "methodology": "percent of total billed charges", "standard_charge_dollar": 4874.1, "standard_charge_percentage": 42.2, "count": "0", "additional_payer_notes": "Zero final payments for the item or service in the 15 months prior to posting the file." }, { "payer_name": "HEALTH NET", "plan_name": "HEALTHNET HMO, PPO, POS, EPO, CANOPY HEALTHNET HMO, OTHER-IN-NETWORK PLANS", "methodology": "per diem", "standard_charge_dollar": 8000.0, "standard_charge_algorithm": "Expected reimbursement is the lesser of Per diem ($8,000) for the length of stay and 70% of billed.", "count": "0", "additional_payer_notes": "Zero final payments for the item or service in the 15 months prior to posting the file." }, { "payer_name": "HEALTH NET", "plan_name": "HEALTHNET HMO, PPO, POS, EPO, CANOPY HEALTHNET HMO, OTHER-IN-NETWORK PLANS", "methodology": "per diem", "standard_charge_dollar": 8000.0, "standard_charge_algorithm": "Expected reimbursement is the lesser of Per diem ($8,000) for the length of stay and 70% of billed.", "count": "0", "additional_payer_notes": "Zero final payments for the item or service in the 15 months prior to posting the file." }, { "payer_name": "UNITED HEALTHCARE", "plan_name": "SUTTER SELECT & SUTTER HEALTH PLAN HMO PLANS", "methodology": "per diem", "standard_charge_dollar": 28538.0, "standard_charge_algorithm": "Per diem ($28,538).", "count": "0", "additional_payer_notes": "Zero final payments for the item or service in the 15 months prior to posting the file." }, { "payer_name": "UNITED HEALTHCARE", "plan_name": "SUTTER SELECT & SUTTER HEALTH PLAN HMO PLANS", "methodology": "per diem", "standard_charge_dollar": 28538.0, "standard_charge_algorithm": "Per diem ($28,538).", "count": "0", "additional_payer_notes": "Zero final payments for the item or service in the 15 months prior to posting the file." }, { "payer_name": "SUTTER", "plan_name": "SUTTER SELECT & SUTTER HEALTH PLAN HMO PLANS", "methodology": "per diem", "standard_charge_dollar": 28538.0, "standard_charge_algorithm": "Per diem ($28,538).", "count": "0", "additional_payer_notes": "Zero final payments for the item or service in the 15 months prior to posting the file." }, { "payer_name": "UNITED HEALTHCARE", "plan_name": "SUTTER SELECT & SUTTER HEALTH PLAN HMO PLANS", "methodology": "per diem", "standard_charge_dollar": 28538.0, "standard_charge_algorithm": "Per diem ($28,538).", "count": "0", "additional_payer_notes": "Zero final payments for the item or service in the 15 months prior to posting the file." }, { "payer_name": "UMR", "plan_name": "SUTTER SELECT & SUTTER HEALTH PLAN HMO PLANS", "methodology": "per diem", "standard_charge_dollar": 28538.0, "standard_charge_algorithm": "Per diem ($28,538).", "count": "0", "additional_payer_notes": "Zero final payments for the item or service in the 15 months prior to posting the file." }, { "payer_name": "UNITED HEALTHCARE", "plan_name": "SUTTER SELECT & SUTTER HEALTH PLAN HMO PLANS", "methodology": "per diem", "standard_charge_dollar": 28538.0, "standard_charge_algorithm": "Per diem ($28,538).", "count": "0", "additional_payer_notes": "Zero final payments for the item or service in the 15 months prior to posting the file." } ] } ] }, { "description": "HC Cath Fogarty Gp062", "code_information": [ { "code": "PX-2120031062", "type": "CDM" }, { "code": "C1757", "type": "HCPCS" }, { "code": "0272", "type": "RC" } ], "standard_charges": [ { "setting": "outpatient", "gross_charge": 22400.0, "discounted_cash": 11200.0, "minimum": 9452.8, "maximum": 11648.0, "additional_generic_notes": "Zero final payments for the item or service in the 15 months prior to posting the file.", "payers_information": [ { "payer_name": "AETNA", "plan_name": "AETNA ALL OTHER PLANS", "methodology": "percent of total billed charges", "standard_charge_dollar": 11648.0, "standard_charge_percentage": 52.0, "count": "0", "additional_payer_notes": "Zero final payments for the item or service in the 15 months prior to posting the file." }, { "payer_name": "AETNA", "plan_name": "AETNA ALL OTHER PLANS", "methodology": "percent of total billed charges", "standard_charge_dollar": 11648.0, "standard_charge_percentage": 52.0, "count": "0", "additional_payer_notes": "Zero final payments for the item or service in the 15 months prior to posting the file." }, { "payer_name": "MERITAIN HEALTH", "plan_name": "AETNA ALL OTHER PLANS", "methodology": "percent of total billed charges", "standard_charge_dollar": 11648.0, "standard_charge_percentage": 52.0, "count": "0", "additional_payer_notes": "Zero final payments for the item or service in the 15 months prior to posting the file." }, { "payer_name": "BLUE SHIELD OUT OF STATE", "plan_name": "STANFORD HEALTHCARE ALLIANCE PLAN", "methodology": "percent of total billed charges", "standard_charge_dollar": 10884.16, "standard_charge_percentage": 48.59, "count": "0", "additional_payer_notes": "Zero final payments for the item or service in the 15 months prior to posting the file." }, { "payer_name": "BLUE SHIELD", "plan_name": "STANFORD HEALTHCARE ALLIANCE PLAN", "methodology": "percent of total billed charges", "standard_charge_dollar": 10884.16, "standard_charge_percentage": 48.59, "count": "0", "additional_payer_notes": "Zero final payments for the item or service in the 15 months prior to posting the file." }, { "payer_name": "BLUE SHIELD", "plan_name": "STANFORD HEALTHCARE ALLIANCE PLAN", "methodology": "percent of total billed charges", "standard_charge_dollar": 10884.16, "standard_charge_percentage": 48.59, "count": "0", "additional_payer_notes": "Zero final payments for the item or service in the 15 months prior to posting the file." }, { "payer_name": "BLUE SHIELD", "plan_name": "STANFORD HEALTHCARE ALLIANCE PLAN", "methodology": "percent of total billed charges", "standard_charge_dollar": 10884.16, "standard_charge_percentage": 48.59, "count": "0", "additional_payer_notes": "Zero final payments for the item or service in the 15 months prior to posting the file." }, { "payer_name": "CIGNA", "plan_name": "CIGNA COM ALT HMO PLAN", "methodology": "percent of total billed charges", "standard_charge_dollar": 9452.8, "standard_charge_percentage": 42.2, "count": "0", "additional_payer_notes": "Zero final payments for the item or service in the 15 months prior to posting the file." }, { "payer_name": "CIGNA", "plan_name": "CIGNA COM ALT HMO PLAN", "methodology": "percent of total billed charges", "standard_charge_dollar": 9452.8, "standard_charge_percentage": 42.2, "count": "0", "additional_payer_notes": "Zero final payments for the item or service in the 15 months prior to posting the file." }, { "payer_name": "HEALTH NET", "plan_name": "HEALTHNET HMO, PPO, POS, EPO, CANOPY HEALTHNET HMO, OTHER-IN-NETWORK PLANS", "methodology": "per diem", "standard_charge_dollar": 8000.0, "standard_charge_algorithm": "Expected reimbursement is the lesser of Per diem ($8,000) for the length of stay and 70% of billed.", "count": "0", "additional_payer_notes": "Zero final payments for the item or service in the 15 months prior to posting the file." }, { "payer_name": "HEALTH NET", "plan_name": "HEALTHNET HMO, PPO, POS, EPO, CANOPY HEALTHNET HMO, OTHER-IN-NETWORK PLANS", "methodology": "per diem", "standard_charge_dollar": 8000.0, "standard_charge_algorithm": "Expected reimbursement is the lesser of Per diem ($8,000) for the length of stay and 70% of billed.", "count": "0", "additional_payer_notes": "Zero final payments for the item or service in the 15 months prior to posting the file." }, { "payer_name": "UNITED HEALTHCARE", "plan_name": "SUTTER SELECT & SUTTER HEALTH PLAN HMO PLANS", "methodology": "per diem", "standard_charge_dollar": 28538.0, "standard_charge_algorithm": "Per diem ($28,538).", "count": "0", "additional_payer_notes": "Zero final payments for the item or service in the 15 months prior to posting the file." }, { "payer_name": "UNITED HEALTHCARE", "plan_name": "SUTTER SELECT & SUTTER HEALTH PLAN HMO PLANS", "methodology": "per diem", "standard_charge_dollar": 28538.0, "standard_charge_algorithm": "Per diem ($28,538).", "count": "0", "additional_payer_notes": "Zero final payments for the item or service in the 15 months prior to posting the file." }, { "payer_name": "SUTTER", "plan_name": "SUTTER SELECT & SUTTER HEALTH PLAN HMO PLANS", "methodology": "per diem", "standard_charge_dollar": 28538.0, "standard_charge_algorithm": "Per diem ($28,538).", "count": "0", "additional_payer_notes": "Zero final payments for the item or service in the 15 months prior to posting the file." }, { "payer_name": "UNITED HEALTHCARE", "plan_name": "SUTTER SELECT & SUTTER HEALTH PLAN HMO PLANS", "methodology": "per diem", "standard_charge_dollar": 28538.0, "standard_charge_algorithm": "Per diem ($28,538).", "count": "0", "additional_payer_notes": "Zero final payments for the item or service in the 15 months prior to posting the file." }, { "payer_name": "UMR", "plan_name": "SUTTER SELECT & SUTTER HEALTH PLAN HMO PLANS", "methodology": "per diem", "standard_charge_dollar": 28538.0, "standard_charge_algorithm": "Per diem ($28,538).", "count": "0", "additional_payer_notes": "Zero final payments for the item or service in the 15 months prior to posting the file." }, { "payer_name": "UNITED HEALTHCARE", "plan_name": "SUTTER SELECT & SUTTER HEALTH PLAN HMO PLANS", "methodology": "per diem", "standard_charge_dollar": 28538.0, "standard_charge_algorithm": "Per diem ($28,538).", "count": "0", "additional_payer_notes": "Zero final payments for the item or service in the 15 months prior to posting the file." } ] } ] }, { "description": "HC Cath Fogarty Gp063", "code_information": [ { "code": "PX-2120031063", "type": "CDM" }, { "code": "C1757", "type": "HCPCS" }, { "code": "0272", "type": "RC" } ], "standard_charges": [ { "setting": "outpatient", "gross_charge": 23200.0, "discounted_cash": 11600.0, "minimum": 9790.4, "maximum": 12064.0, "additional_generic_notes": "Zero final payments for the item or service in the 15 months prior to posting the file.", "payers_information": [ { "payer_name": "AETNA", "plan_name": "AETNA ALL OTHER PLANS", "methodology": "percent of total billed charges", "standard_charge_dollar": 12064.0, "standard_charge_percentage": 52.0, "count": "0", "additional_payer_notes": "Zero final payments for the item or service in the 15 months prior to posting the file." }, { "payer_name": "AETNA", "plan_name": "AETNA ALL OTHER PLANS", "methodology": "percent of total billed charges", "standard_charge_dollar": 12064.0, "standard_charge_percentage": 52.0, "count": "0", "additional_payer_notes": "Zero final payments for the item or service in the 15 months prior to posting the file." }, { "payer_name": "MERITAIN HEALTH", "plan_name": "AETNA ALL OTHER PLANS", "methodology": "percent of total billed charges", "standard_charge_dollar": 12064.0, "standard_charge_percentage": 52.0, "count": "0", "additional_payer_notes": "Zero final payments for the item or service in the 15 months prior to posting the file." }, { "payer_name": "BLUE SHIELD OUT OF STATE", "plan_name": "STANFORD HEALTHCARE ALLIANCE PLAN", "methodology": "percent of total billed charges", "standard_charge_dollar": 11272.88, "standard_charge_percentage": 48.59, "count": "0", "additional_payer_notes": "Zero final payments for the item or service in the 15 months prior to posting the file." }, { "payer_name": "BLUE SHIELD", "plan_name": "STANFORD HEALTHCARE ALLIANCE PLAN", "methodology": "percent of total billed charges", "standard_charge_dollar": 11272.88, "standard_charge_percentage": 48.59, "count": "0", "additional_payer_notes": "Zero final payments for the item or service in the 15 months prior to posting the file." }, { "payer_name": "BLUE SHIELD", "plan_name": "STANFORD HEALTHCARE ALLIANCE PLAN", "methodology": "percent of total billed charges", "standard_charge_dollar": 11272.88, "standard_charge_percentage": 48.59, "count": "0", "additional_payer_notes": "Zero final payments for the item or service in the 15 months prior to posting the file." }, { "payer_name": "BLUE SHIELD", "plan_name": "STANFORD HEALTHCARE ALLIANCE PLAN", "methodology": "percent of total billed charges", "standard_charge_dollar": 11272.88, "standard_charge_percentage": 48.59, "count": "0", "additional_payer_notes": "Zero final payments for the item or service in the 15 months prior to posting the file." }, { "payer_name": "CIGNA", "plan_name": "CIGNA COM ALT HMO PLAN", "methodology": "percent of total billed charges", "standard_charge_dollar": 9790.4, "standard_charge_percentage": 42.2, "count": "0", "additional_payer_notes": "Zero final payments for the item or service in the 15 months prior to posting the file." }, { "payer_name": "CIGNA", "plan_name": "CIGNA COM ALT HMO PLAN", "methodology": "percent of total billed charges", "standard_charge_dollar": 9790.4, "standard_charge_percentage": 42.2, "count": "0", "additional_payer_notes": "Zero final payments for the item or service in the 15 months prior to posting the file." }, { "payer_name": "HEALTH NET", "plan_name": "HEALTHNET HMO, PPO, POS, EPO, CANOPY HEALTHNET HMO, OTHER-IN-NETWORK PLANS", "methodology": "per diem", "standard_charge_dollar": 8000.0, "standard_charge_algorithm": "Expected reimbursement is the lesser of Per diem ($8,000) for the length of stay and 70% of billed.", "count": "0", "additional_payer_notes": "Zero final payments for the item or service in the 15 months prior to posting the file." }, { "payer_name": "HEALTH NET", "plan_name": "HEALTHNET HMO, PPO, POS, EPO, CANOPY HEALTHNET HMO, OTHER-IN-NETWORK PLANS", "methodology": "per diem", "standard_charge_dollar": 8000.0, "standard_charge_algorithm": "Expected reimbursement is the lesser of Per diem ($8,000) for the length of stay and 70% of billed.", "count": "0", "additional_payer_notes": "Zero final payments for the item or service in the 15 months prior to posting the file." }, { "payer_name": "UNITED HEALTHCARE", "plan_name": "SUTTER SELECT & SUTTER HEALTH PLAN HMO PLANS", "methodology": "per diem", "standard_charge_dollar": 28538.0, "standard_charge_algorithm": "Per diem ($28,538).", "count": "0", "additional_payer_notes": "Zero final payments for the item or service in the 15 months prior to posting the file." }, { "payer_name": "UNITED HEALTHCARE", "plan_name": "SUTTER SELECT & SUTTER HEALTH PLAN HMO PLANS", "methodology": "per diem", "standard_charge_dollar": 28538.0, "standard_charge_algorithm": "Per diem ($28,538).", "count": "0", "additional_payer_notes": "Zero final payments for the item or service in the 15 months prior to posting the file." }, { "payer_name": "SUTTER", "plan_name": "SUTTER SELECT & SUTTER HEALTH PLAN HMO PLANS", "methodology": "per diem", "standard_charge_dollar": 28538.0, "standard_charge_algorithm": "Per diem ($28,538).", "count": "0", "additional_payer_notes": "Zero final payments for the item or service in the 15 months prior to posting the file." }, { "payer_name": "UNITED HEALTHCARE", "plan_name": "SUTTER SELECT & SUTTER HEALTH PLAN HMO PLANS", "methodology": "per diem", "standard_charge_dollar": 28538.0, "standard_charge_algorithm": "Per diem ($28,538).", "count": "0", "additional_payer_notes": "Zero final payments for the item or service in the 15 months prior to posting the file." }, { "payer_name": "UMR", "plan_name": "SUTTER SELECT & SUTTER HEALTH PLAN HMO PLANS", "methodology": "per diem", "standard_charge_dollar": 28538.0, "standard_charge_algorithm": "Per diem ($28,538).", "count": "0", "additional_payer_notes": "Zero final payments for the item or service in the 15 months prior to posting the file." }, { "payer_name": "UNITED HEALTHCARE", "plan_name": "SUTTER SELECT & SUTTER HEALTH PLAN HMO PLANS", "methodology": "per diem", "standard_charge_dollar": 28538.0, "standard_charge_algorithm": "Per diem ($28,538).", "count": "0", "additional_payer_notes": "Zero final payments for the item or service in the 15 months prior to posting the file." } ] } ] }, { "description": "HC Cath Fogarty Gp066", "code_information": [ { "code": "PX-2120031066", "type": "CDM" }, { "code": "C1757", "type": "HCPCS" }, { "code": "0272", "type": "RC" } ], "standard_charges": [ { "setting": "outpatient", "gross_charge": 25600.0, "discounted_cash": 12800.0, "minimum": 10803.2, "maximum": 13312.0, "additional_generic_notes": "Zero final payments for the item or service in the 15 months prior to posting the file.", "payers_information": [ { "payer_name": "AETNA", "plan_name": "AETNA ALL OTHER PLANS", "methodology": "percent of total billed charges", "standard_charge_dollar": 13312.0, "standard_charge_percentage": 52.0, "count": "0", "additional_payer_notes": "Zero final payments for the item or service in the 15 months prior to posting the file." }, { "payer_name": "AETNA", "plan_name": "AETNA ALL OTHER PLANS", "methodology": "percent of total billed charges", "standard_charge_dollar": 13312.0, "standard_charge_percentage": 52.0, "count": "0", "additional_payer_notes": "Zero final payments for the item or service in the 15 months prior to posting the file." }, { "payer_name": "MERITAIN HEALTH", "plan_name": "AETNA ALL OTHER PLANS", "methodology": "percent of total billed charges", "standard_charge_dollar": 13312.0, "standard_charge_percentage": 52.0, "count": "0", "additional_payer_notes": "Zero final payments for the item or service in the 15 months prior to posting the file." }, { "payer_name": "BLUE SHIELD OUT OF STATE", "plan_name": "STANFORD HEALTHCARE ALLIANCE PLAN", "methodology": "percent of total billed charges", "standard_charge_dollar": 12439.04, "standard_charge_percentage": 48.59, "count": "0", "additional_payer_notes": "Zero final payments for the item or service in the 15 months prior to posting the file." }, { "payer_name": "BLUE SHIELD", "plan_name": "STANFORD HEALTHCARE ALLIANCE PLAN", "methodology": "percent of total billed charges", "standard_charge_dollar": 12439.04, "standard_charge_percentage": 48.59, "count": "0", "additional_payer_notes": "Zero final payments for the item or service in the 15 months prior to posting the file." }, { "payer_name": "BLUE SHIELD", "plan_name": "STANFORD HEALTHCARE ALLIANCE PLAN", "methodology": "percent of total billed charges", "standard_charge_dollar": 12439.04, "standard_charge_percentage": 48.59, "count": "0", "additional_payer_notes": "Zero final payments for the item or service in the 15 months prior to posting the file." }, { "payer_name": "BLUE SHIELD", "plan_name": "STANFORD HEALTHCARE ALLIANCE PLAN", "methodology": "percent of total billed charges", "standard_charge_dollar": 12439.04, "standard_charge_percentage": 48.59, "count": "0", "additional_payer_notes": "Zero final payments for the item or service in the 15 months prior to posting the file." }, { "payer_name": "CIGNA", "plan_name": "CIGNA COM ALT HMO PLAN", "methodology": "percent of total billed charges", "standard_charge_dollar": 10803.2, "standard_charge_percentage": 42.2, "count": "0", "additional_payer_notes": "Zero final payments for the item or service in the 15 months prior to posting the file." }, { "payer_name": "CIGNA", "plan_name": "CIGNA COM ALT HMO PLAN", "methodology": "percent of total billed charges", "standard_charge_dollar": 10803.2, "standard_charge_percentage": 42.2, "count": "0", "additional_payer_notes": "Zero final payments for the item or service in the 15 months prior to posting the file." }, { "payer_name": "HEALTH NET", "plan_name": "HEALTHNET HMO, PPO, POS, EPO, CANOPY HEALTHNET HMO, OTHER-IN-NETWORK PLANS", "methodology": "per diem", "standard_charge_dollar": 8000.0, "standard_charge_algorithm": "Expected reimbursement is the lesser of Per diem ($8,000) for the length of stay and 70% of billed.", "count": "0", "additional_payer_notes": "Zero final payments for the item or service in the 15 months prior to posting the file." }, { "payer_name": "HEALTH NET", "plan_name": "HEALTHNET HMO, PPO, POS, EPO, CANOPY HEALTHNET HMO, OTHER-IN-NETWORK PLANS", "methodology": "per diem", "standard_charge_dollar": 8000.0, "standard_charge_algorithm": "Expected reimbursement is the lesser of Per diem ($8,000) for the length of stay and 70% of billed.", "count": "0", "additional_payer_notes": "Zero final payments for the item or service in the 15 months prior to posting the file." }, { "payer_name": "UNITED HEALTHCARE", "plan_name": "SUTTER SELECT & SUTTER HEALTH PLAN HMO PLANS", "methodology": "per diem", "standard_charge_dollar": 28538.0, "standard_charge_algorithm": "Per diem ($28,538).", "count": "0", "additional_payer_notes": "Zero final payments for the item or service in the 15 months prior to posting the file." }, { "payer_name": "UNITED HEALTHCARE", "plan_name": "SUTTER SELECT & SUTTER HEALTH PLAN HMO PLANS", "methodology": "per diem", "standard_charge_dollar": 28538.0, "standard_charge_algorithm": "Per diem ($28,538).", "count": "0", "additional_payer_notes": "Zero final payments for the item or service in the 15 months prior to posting the file." }, { "payer_name": "SUTTER", "plan_name": "SUTTER SELECT & SUTTER HEALTH PLAN HMO PLANS", "methodology": "per diem", "standard_charge_dollar": 28538.0, "standard_charge_algorithm": "Per diem ($28,538).", "count": "0", "additional_payer_notes": "Zero final payments for the item or service in the 15 months prior to posting the file." }, { "payer_name": "UNITED HEALTHCARE", "plan_name": "SUTTER SELECT & SUTTER HEALTH PLAN HMO PLANS", "methodology": "per diem", "standard_charge_dollar": 28538.0, "standard_charge_algorithm": "Per diem ($28,538).", "count": "0", "additional_payer_notes": "Zero final payments for the item or service in the 15 months prior to posting the file." }, { "payer_name": "UMR", "plan_name": "SUTTER SELECT & SUTTER HEALTH PLAN HMO PLANS", "methodology": "per diem", "standard_charge_dollar": 28538.0, "standard_charge_algorithm": "Per diem ($28,538).", "count": "0", "additional_payer_notes": "Zero final payments for the item or service in the 15 months prior to posting the file." }, { "payer_name": "UNITED HEALTHCARE", "plan_name": "SUTTER SELECT & SUTTER HEALTH PLAN HMO PLANS", "methodology": "per diem", "standard_charge_dollar": 28538.0, "standard_charge_algorithm": "Per diem ($28,538).", "count": "0", "additional_payer_notes": "Zero final payments for the item or service in the 15 months prior to posting the file." } ] } ] }, { "description": "HC Cath Fogarty Gp074", "code_information": [ { "code": "PX-2120031074", "type": "CDM" }, { "code": "C1757", "type": "CPT" }, { "code": "0272", "type": "RC" } ], "standard_charges": [ { "setting": "outpatient", "gross_charge": 32000.0, "discounted_cash": 16000.0, "minimum": 13504.0, "maximum": 16640.0, "additional_generic_notes": "Zero final payments for the item or service in the 15 months prior to posting the file.", "payers_information": [ { "payer_name": "AETNA", "plan_name": "AETNA ALL OTHER PLANS", "methodology": "percent of total billed charges", "standard_charge_dollar": 16640.0, "standard_charge_percentage": 52.0, "count": "0", "additional_payer_notes": "Zero final payments for the item or service in the 15 months prior to posting the file." }, { "payer_name": "AETNA", "plan_name": "AETNA ALL OTHER PLANS", "methodology": "percent of total billed charges", "standard_charge_dollar": 16640.0, "standard_charge_percentage": 52.0, "count": "0", "additional_payer_notes": "Zero final payments for the item or service in the 15 months prior to posting the file." }, { "payer_name": "MERITAIN HEALTH", "plan_name": "AETNA ALL OTHER PLANS", "methodology": "percent of total billed charges", "standard_charge_dollar": 16640.0, "standard_charge_percentage": 52.0, "count": "0", "additional_payer_notes": "Zero final payments for the item or service in the 15 months prior to posting the file." }, { "payer_name": "BLUE SHIELD OUT OF STATE", "plan_name": "STANFORD HEALTHCARE ALLIANCE PLAN", "methodology": "percent of total billed charges", "standard_charge_dollar": 15548.8, "standard_charge_percentage": 48.59, "count": "0", "additional_payer_notes": "Zero final payments for the item or service in the 15 months prior to posting the file." }, { "payer_name": "BLUE SHIELD", "plan_name": "STANFORD HEALTHCARE ALLIANCE PLAN", "methodology": "percent of total billed charges", "standard_charge_dollar": 15548.8, "standard_charge_percentage": 48.59, "count": "0", "additional_payer_notes": "Zero final payments for the item or service in the 15 months prior to posting the file." }, { "payer_name": "BLUE SHIELD", "plan_name": "STANFORD HEALTHCARE ALLIANCE PLAN", "methodology": "percent of total billed charges", "standard_charge_dollar": 15548.8, "standard_charge_percentage": 48.59, "count": "0", "additional_payer_notes": "Zero final payments for the item or service in the 15 months prior to posting the file." }, { "payer_name": "BLUE SHIELD", "plan_name": "STANFORD HEALTHCARE ALLIANCE PLAN", "methodology": "percent of total billed charges", "standard_charge_dollar": 15548.8, "standard_charge_percentage": 48.59, "count": "0", "additional_payer_notes": "Zero final payments for the item or service in the 15 months prior to posting the file." }, { "payer_name": "CIGNA", "plan_name": "CIGNA COM ALT HMO PLAN", "methodology": "percent of total billed charges", "standard_charge_dollar": 13504.0, "standard_charge_percentage": 42.2, "count": "0", "additional_payer_notes": "Zero final payments for the item or service in the 15 months prior to posting the file." }, { "payer_name": "CIGNA", "plan_name": "CIGNA COM ALT HMO PLAN", "methodology": "percent of total billed charges", "standard_charge_dollar": 13504.0, "standard_charge_percentage": 42.2, "count": "0", "additional_payer_notes": "Zero final payments for the item or service in the 15 months prior to posting the file." }, { "payer_name": "HEALTH NET", "plan_name": "HEALTHNET HMO, PPO, POS, EPO, CANOPY HEALTHNET HMO, OTHER-IN-NETWORK PLANS", "methodology": "per diem", "standard_charge_dollar": 8000.0, "standard_charge_algorithm": "Expected reimbursement is the lesser of Per diem ($8,000) for the length of stay and 70% of billed.", "count": "0", "additional_payer_notes": "Zero final payments for the item or service in the 15 months prior to posting the file." }, { "payer_name": "HEALTH NET", "plan_name": "HEALTHNET HMO, PPO, POS, EPO, CANOPY HEALTHNET HMO, OTHER-IN-NETWORK PLANS", "methodology": "per diem", "standard_charge_dollar": 8000.0, "standard_charge_algorithm": "Expected reimbursement is the lesser of Per diem ($8,000) for the length of stay and 70% of billed.", "count": "0", "additional_payer_notes": "Zero final payments for the item or service in the 15 months prior to posting the file." }, { "payer_name": "UNITED HEALTHCARE", "plan_name": "SUTTER SELECT & SUTTER HEALTH PLAN HMO PLANS", "methodology": "per diem", "standard_charge_dollar": 28538.0, "standard_charge_algorithm": "Per diem ($28,538).", "count": "0", "additional_payer_notes": "Zero final payments for the item or service in the 15 months prior to posting the file." }, { "payer_name": "UNITED HEALTHCARE", "plan_name": "SUTTER SELECT & SUTTER HEALTH PLAN HMO PLANS", "methodology": "per diem", "standard_charge_dollar": 28538.0, "standard_charge_algorithm": "Per diem ($28,538).", "count": "0", "additional_payer_notes": "Zero final payments for the item or service in the 15 months prior to posting the file." }, { "payer_name": "SUTTER", "plan_name": "SUTTER SELECT & SUTTER HEALTH PLAN HMO PLANS", "methodology": "per diem", "standard_charge_dollar": 28538.0, "standard_charge_algorithm": "Per diem ($28,538).", "count": "0", "additional_payer_notes": "Zero final payments for the item or service in the 15 months prior to posting the file." }, { "payer_name": "UNITED HEALTHCARE", "plan_name": "SUTTER SELECT & SUTTER HEALTH PLAN HMO PLANS", "methodology": "per diem", "standard_charge_dollar": 28538.0, "standard_charge_algorithm": "Per diem ($28,538).", "count": "0", "additional_payer_notes": "Zero final payments for the item or service in the 15 months prior to posting the file." }, { "payer_name": "UMR", "plan_name": "SUTTER SELECT & SUTTER HEALTH PLAN HMO PLANS", "methodology": "per diem", "standard_charge_dollar": 28538.0, "standard_charge_algorithm": "Per diem ($28,538).", "count": "0", "additional_payer_notes": "Zero final payments for the item or service in the 15 months prior to posting the file." }, { "payer_name": "UNITED HEALTHCARE", "plan_name": "SUTTER SELECT & SUTTER HEALTH PLAN HMO PLANS", "methodology": "per diem", "standard_charge_dollar": 28538.0, "standard_charge_algorithm": "Per diem ($28,538).", "count": "0", "additional_payer_notes": "Zero final payments for the item or service in the 15 months prior to posting the file." } ] } ] }, { "description": "HC Cath Fogarty Gp082", "code_information": [ { "code": "PX-2120031082", "type": "CDM" }, { "code": "C1757", "type": "HCPCS" }, { "code": "0272", "type": "RC" } ], "standard_charges": [ { "setting": "outpatient", "gross_charge": 38400.0, "discounted_cash": 19200.0, "minimum": 16204.8, "maximum": 19968.0, "additional_generic_notes": "Zero final payments for the item or service in the 15 months prior to posting the file.", "payers_information": [ { "payer_name": "AETNA", "plan_name": "AETNA ALL OTHER PLANS", "methodology": "percent of total billed charges", "standard_charge_dollar": 19968.0, "standard_charge_percentage": 52.0, "count": "0", "additional_payer_notes": "Zero final payments for the item or service in the 15 months prior to posting the file." }, { "payer_name": "AETNA", "plan_name": "AETNA ALL OTHER PLANS", "methodology": "percent of total billed charges", "standard_charge_dollar": 19968.0, "standard_charge_percentage": 52.0, "count": "0", "additional_payer_notes": "Zero final payments for the item or service in the 15 months prior to posting the file." }, { "payer_name": "MERITAIN HEALTH", "plan_name": "AETNA ALL OTHER PLANS", "methodology": "percent of total billed charges", "standard_charge_dollar": 19968.0, "standard_charge_percentage": 52.0, "count": "0", "additional_payer_notes": "Zero final payments for the item or service in the 15 months prior to posting the file." }, { "payer_name": "BLUE SHIELD OUT OF STATE", "plan_name": "STANFORD HEALTHCARE ALLIANCE PLAN", "methodology": "percent of total billed charges", "standard_charge_dollar": 18658.56, "standard_charge_percentage": 48.59, "count": "0", "additional_payer_notes": "Zero final payments for the item or service in the 15 months prior to posting the file." }, { "payer_name": "BLUE SHIELD", "plan_name": "STANFORD HEALTHCARE ALLIANCE PLAN", "methodology": "percent of total billed charges", "standard_charge_dollar": 18658.56, "standard_charge_percentage": 48.59, "count": "0", "additional_payer_notes": "Zero final payments for the item or service in the 15 months prior to posting the file." }, { "payer_name": "BLUE SHIELD", "plan_name": "STANFORD HEALTHCARE ALLIANCE PLAN", "methodology": "percent of total billed charges", "standard_charge_dollar": 18658.56, "standard_charge_percentage": 48.59, "count": "0", "additional_payer_notes": "Zero final payments for the item or service in the 15 months prior to posting the file." }, { "payer_name": "BLUE SHIELD", "plan_name": "STANFORD HEALTHCARE ALLIANCE PLAN", "methodology": "percent of total billed charges", "standard_charge_dollar": 18658.56, "standard_charge_percentage": 48.59, "count": "0", "additional_payer_notes": "Zero final payments for the item or service in the 15 months prior to posting the file." }, { "payer_name": "CIGNA", "plan_name": "CIGNA COM ALT HMO PLAN", "methodology": "percent of total billed charges", "standard_charge_dollar": 16204.8, "standard_charge_percentage": 42.2, "count": "0", "additional_payer_notes": "Zero final payments for the item or service in the 15 months prior to posting the file." }, { "payer_name": "CIGNA", "plan_name": "CIGNA COM ALT HMO PLAN", "methodology": "percent of total billed charges", "standard_charge_dollar": 16204.8, "standard_charge_percentage": 42.2, "count": "0", "additional_payer_notes": "Zero final payments for the item or service in the 15 months prior to posting the file." }, { "payer_name": "HEALTH NET", "plan_name": "HEALTHNET HMO, PPO, POS, EPO, CANOPY HEALTHNET HMO, OTHER-IN-NETWORK PLANS", "methodology": "per diem", "standard_charge_dollar": 8000.0, "standard_charge_algorithm": "Expected reimbursement is the lesser of Per diem ($8,000) for the length of stay and 70% of billed.", "count": "0", "additional_payer_notes": "Zero final payments for the item or service in the 15 months prior to posting the file." }, { "payer_name": "HEALTH NET", "plan_name": "HEALTHNET HMO, PPO, POS, EPO, CANOPY HEALTHNET HMO, OTHER-IN-NETWORK PLANS", "methodology": "per diem", "standard_charge_dollar": 8000.0, "standard_charge_algorithm": "Expected reimbursement is the lesser of Per diem ($8,000) for the length of stay and 70% of billed.", "count": "0", "additional_payer_notes": "Zero final payments for the item or service in the 15 months prior to posting the file." }, { "payer_name": "UNITED HEALTHCARE", "plan_name": "SUTTER SELECT & SUTTER HEALTH PLAN HMO PLANS", "methodology": "per diem", "standard_charge_dollar": 28538.0, "standard_charge_algorithm": "Per diem ($28,538).", "count": "0", "additional_payer_notes": "Zero final payments for the item or service in the 15 months prior to posting the file." }, { "payer_name": "UNITED HEALTHCARE", "plan_name": "SUTTER SELECT & SUTTER HEALTH PLAN HMO PLANS", "methodology": "per diem", "standard_charge_dollar": 28538.0, "standard_charge_algorithm": "Per diem ($28,538).", "count": "0", "additional_payer_notes": "Zero final payments for the item or service in the 15 months prior to posting the file." }, { "payer_name": "SUTTER", "plan_name": "SUTTER SELECT & SUTTER HEALTH PLAN HMO PLANS", "methodology": "per diem", "standard_charge_dollar": 28538.0, "standard_charge_algorithm": "Per diem ($28,538).", "count": "0", "additional_payer_notes": "Zero final payments for the item or service in the 15 months prior to posting the file." }, { "payer_name": "UNITED HEALTHCARE", "plan_name": "SUTTER SELECT & SUTTER HEALTH PLAN HMO PLANS", "methodology": "per diem", "standard_charge_dollar": 28538.0, "standard_charge_algorithm": "Per diem ($28,538).", "count": "0", "additional_payer_notes": "Zero final payments for the item or service in the 15 months prior to posting the file." }, { "payer_name": "UMR", "plan_name": "SUTTER SELECT & SUTTER HEALTH PLAN HMO PLANS", "methodology": "per diem", "standard_charge_dollar": 28538.0, "standard_charge_algorithm": "Per diem ($28,538).", "count": "0", "additional_payer_notes": "Zero final payments for the item or service in the 15 months prior to posting the file." }, { "payer_name": "UNITED HEALTHCARE", "plan_name": "SUTTER SELECT & SUTTER HEALTH PLAN HMO PLANS", "methodology": "per diem", "standard_charge_dollar": 28538.0, "standard_charge_algorithm": "Per diem ($28,538).", "count": "0", "additional_payer_notes": "Zero final payments for the item or service in the 15 months prior to posting the file." } ] } ] }, { "description": "HC Cath Foley Gp002", "code_information": [ { "code": "PX-2120032002", "type": "CDM" }, { "code": "99999", "type": "CPT" }, { "code": "0272", "type": "RC" } ], "standard_charges": [ { "setting": "outpatient", "gross_charge": 50.0, "discounted_cash": 25.0, "minimum": 21.1, "maximum": 26.0, "additional_generic_notes": "Zero final payments for the item or service in the 15 months prior to posting the file.", "payers_information": [ { "payer_name": "AETNA", "plan_name": "AETNA ALL OTHER PLANS", "methodology": "percent of total billed charges", "standard_charge_dollar": 26.0, "standard_charge_percentage": 52.0, "count": "0", "additional_payer_notes": "Zero final payments for the item or service in the 15 months prior to posting the file." }, { "payer_name": "AETNA", "plan_name": "AETNA ALL OTHER PLANS", "methodology": "percent of total billed charges", "standard_charge_dollar": 26.0, "standard_charge_percentage": 52.0, "count": "0", "additional_payer_notes": "Zero final payments for the item or service in the 15 months prior to posting the file." }, { "payer_name": "MERITAIN HEALTH", "plan_name": "AETNA ALL OTHER PLANS", "methodology": "percent of total billed charges", "standard_charge_dollar": 26.0, "standard_charge_percentage": 52.0, "count": "0", "additional_payer_notes": "Zero final payments for the item or service in the 15 months prior to posting the file." }, { "payer_name": "BLUE SHIELD OUT OF STATE", "plan_name": "STANFORD HEALTHCARE ALLIANCE PLAN", "methodology": "percent of total billed charges", "standard_charge_dollar": 24.3, "standard_charge_percentage": 48.59, "count": "0", "additional_payer_notes": "Zero final payments for the item or service in the 15 months prior to posting the file." }, { "payer_name": "BLUE SHIELD", "plan_name": "STANFORD HEALTHCARE ALLIANCE PLAN", "methodology": "percent of total billed charges", "standard_charge_dollar": 24.3, "standard_charge_percentage": 48.59, "count": "0", "additional_payer_notes": "Zero final payments for the item or service in the 15 months prior to posting the file." }, { "payer_name": "BLUE SHIELD", "plan_name": "STANFORD HEALTHCARE ALLIANCE PLAN", "methodology": "percent of total billed charges", "standard_charge_dollar": 24.3, "standard_charge_percentage": 48.59, "count": "0", "additional_payer_notes": "Zero final payments for the item or service in the 15 months prior to posting the file." }, { "payer_name": "CIGNA", "plan_name": "CIGNA COM ALT HMO PLAN", "methodology": "percent of total billed charges", "standard_charge_dollar": 21.1, "standard_charge_percentage": 42.2, "count": "0", "additional_payer_notes": "Zero final payments for the item or service in the 15 months prior to posting the file." }, { "payer_name": "CIGNA", "plan_name": "CIGNA COM ALT HMO PLAN", "methodology": "percent of total billed charges", "standard_charge_dollar": 21.1, "standard_charge_percentage": 42.2, "count": "0", "additional_payer_notes": "Zero final payments for the item or service in the 15 months prior to posting the file." }, { "payer_name": "HEALTH NET", "plan_name": "HEALTHNET HMO, PPO, POS, EPO, CANOPY HEALTHNET HMO, OTHER-IN-NETWORK PLANS", "methodology": "per diem", "standard_charge_dollar": 8000.0, "standard_charge_algorithm": "Expected reimbursement is the lesser of Per diem ($8,000) for the length of stay and 70% of billed.", "count": "0", "additional_payer_notes": "Zero final payments for the item or service in the 15 months prior to posting the file." }, { "payer_name": "HEALTH NET", "plan_name": "HEALTHNET HMO, PPO, POS, EPO, CANOPY HEALTHNET HMO, OTHER-IN-NETWORK PLANS", "methodology": "per diem", "standard_charge_dollar": 8000.0, "standard_charge_algorithm": "Expected reimbursement is the lesser of Per diem ($8,000) for the length of stay and 70% of billed.", "count": "0", "additional_payer_notes": "Zero final payments for the item or service in the 15 months prior to posting the file." }, { "payer_name": "UNITED HEALTHCARE", "plan_name": "SUTTER SELECT & SUTTER HEALTH PLAN HMO PLANS", "methodology": "per diem", "standard_charge_dollar": 28538.0, "standard_charge_algorithm": "Per diem ($28,538).", "count": "0", "additional_payer_notes": "Zero final payments for the item or service in the 15 months prior to posting the file." }, { "payer_name": "UNITED HEALTHCARE", "plan_name": "SUTTER SELECT & SUTTER HEALTH PLAN HMO PLANS", "methodology": "per diem", "standard_charge_dollar": 28538.0, "standard_charge_algorithm": "Per diem ($28,538).", "count": "0", "additional_payer_notes": "Zero final payments for the item or service in the 15 months prior to posting the file." }, { "payer_name": "SUTTER", "plan_name": "SUTTER SELECT & SUTTER HEALTH PLAN HMO PLANS", "methodology": "per diem", "standard_charge_dollar": 28538.0, "standard_charge_algorithm": "Per diem ($28,538).", "count": "0", "additional_payer_notes": "Zero final payments for the item or service in the 15 months prior to posting the file." }, { "payer_name": "UNITED HEALTHCARE", "plan_name": "SUTTER SELECT & SUTTER HEALTH PLAN HMO PLANS", "methodology": "per diem", "standard_charge_dollar": 28538.0, "standard_charge_algorithm": "Per diem ($28,538).", "count": "0", "additional_payer_notes": "Zero final payments for the item or service in the 15 months prior to posting the file." }, { "payer_name": "UMR", "plan_name": "SUTTER SELECT & SUTTER HEALTH PLAN HMO PLANS", "methodology": "per diem", "standard_charge_dollar": 28538.0, "standard_charge_algorithm": "Per diem ($28,538).", "count": "0", "additional_payer_notes": "Zero final payments for the item or service in the 15 months prior to posting the file." } ] } ] }, { "description": "HC Cath Foley Gp003", "code_information": [ { "code": "PX-2120032003", "type": "CDM" }, { "code": "99999", "type": "CPT" }, { "code": "0272", "type": "RC" } ], "standard_charges": [ { "setting": "outpatient", "gross_charge": 100.0, "discounted_cash": 50.0, "minimum": 42.2, "maximum": 52.0, "additional_generic_notes": "Zero final payments for the item or service in the 15 months prior to posting the file.", "payers_information": [ { "payer_name": "AETNA", "plan_name": "AETNA ALL OTHER PLANS", "methodology": "percent of total billed charges", "standard_charge_dollar": 52.0, "standard_charge_percentage": 52.0, "count": "0", "additional_payer_notes": "Zero final payments for the item or service in the 15 months prior to posting the file." }, { "payer_name": "AETNA", "plan_name": "AETNA ALL OTHER PLANS", "methodology": "percent of total billed charges", "standard_charge_dollar": 52.0, "standard_charge_percentage": 52.0, "count": "0", "additional_payer_notes": "Zero final payments for the item or service in the 15 months prior to posting the file." }, { "payer_name": "MERITAIN HEALTH", "plan_name": "AETNA ALL OTHER PLANS", "methodology": "percent of total billed charges", "standard_charge_dollar": 52.0, "standard_charge_percentage": 52.0, "count": "0", "additional_payer_notes": "Zero final payments for the item or service in the 15 months prior to posting the file." }, { "payer_name": "BLUE SHIELD OUT OF STATE", "plan_name": "STANFORD HEALTHCARE ALLIANCE PLAN", "methodology": "percent of total billed charges", "standard_charge_dollar": 48.59, "standard_charge_percentage": 48.59, "count": "0", "additional_payer_notes": "Zero final payments for the item or service in the 15 months prior to posting the file." }, { "payer_name": "BLUE SHIELD", "plan_name": "STANFORD HEALTHCARE ALLIANCE PLAN", "methodology": "percent of total billed charges", "standard_charge_dollar": 48.59, "standard_charge_percentage": 48.59, "count": "0", "additional_payer_notes": "Zero final payments for the item or service in the 15 months prior to posting the file." }, { "payer_name": "BLUE SHIELD", "plan_name": "STANFORD HEALTHCARE ALLIANCE PLAN", "methodology": "percent of total billed charges", "standard_charge_dollar": 48.59, "standard_charge_percentage": 48.59, "count": "0", "additional_payer_notes": "Zero final payments for the item or service in the 15 months prior to posting the file." }, { "payer_name": "CIGNA", "plan_name": "CIGNA COM ALT HMO PLAN", "methodology": "percent of total billed charges", "standard_charge_dollar": 42.2, "standard_charge_percentage": 42.2, "count": "0", "additional_payer_notes": "Zero final payments for the item or service in the 15 months prior to posting the file." }, { "payer_name": "CIGNA", "plan_name": "CIGNA COM ALT HMO PLAN", "methodology": "percent of total billed charges", "standard_charge_dollar": 42.2, "standard_charge_percentage": 42.2, "count": "0", "additional_payer_notes": "Zero final payments for the item or service in the 15 months prior to posting the file." }, { "payer_name": "HEALTH NET", "plan_name": "HEALTHNET HMO, PPO, POS, EPO, CANOPY HEALTHNET HMO, OTHER-IN-NETWORK PLANS", "methodology": "per diem", "standard_charge_dollar": 8000.0, "standard_charge_algorithm": "Expected reimbursement is the lesser of Per diem ($8,000) for the length of stay and 70% of billed.", "count": "0", "additional_payer_notes": "Zero final payments for the item or service in the 15 months prior to posting the file." }, { "payer_name": "HEALTH NET", "plan_name": "HEALTHNET HMO, PPO, POS, EPO, CANOPY HEALTHNET HMO, OTHER-IN-NETWORK PLANS", "methodology": "per diem", "standard_charge_dollar": 8000.0, "standard_charge_algorithm": "Expected reimbursement is the lesser of Per diem ($8,000) for the length of stay and 70% of billed.", "count": "0", "additional_payer_notes": "Zero final payments for the item or service in the 15 months prior to posting the file." }, { "payer_name": "UNITED HEALTHCARE", "plan_name": "SUTTER SELECT & SUTTER HEALTH PLAN HMO PLANS", "methodology": "per diem", "standard_charge_dollar": 28538.0, "standard_charge_algorithm": "Per diem ($28,538).", "count": "0", "additional_payer_notes": "Zero final payments for the item or service in the 15 months prior to posting the file." }, { "payer_name": "UNITED HEALTHCARE", "plan_name": "SUTTER SELECT & SUTTER HEALTH PLAN HMO PLANS", "methodology": "per diem", "standard_charge_dollar": 28538.0, "standard_charge_algorithm": "Per diem ($28,538).", "count": "0", "additional_payer_notes": "Zero final payments for the item or service in the 15 months prior to posting the file." }, { "payer_name": "SUTTER", "plan_name": "SUTTER SELECT & SUTTER HEALTH PLAN HMO PLANS", "methodology": "per diem", "standard_charge_dollar": 28538.0, "standard_charge_algorithm": "Per diem ($28,538).", "count": "0", "additional_payer_notes": "Zero final payments for the item or service in the 15 months prior to posting the file." }, { "payer_name": "UNITED HEALTHCARE", "plan_name": "SUTTER SELECT & SUTTER HEALTH PLAN HMO PLANS", "methodology": "per diem", "standard_charge_dollar": 28538.0, "standard_charge_algorithm": "Per diem ($28,538).", "count": "0", "additional_payer_notes": "Zero final payments for the item or service in the 15 months prior to posting the file." }, { "payer_name": "UMR", "plan_name": "SUTTER SELECT & SUTTER HEALTH PLAN HMO PLANS", "methodology": "per diem", "standard_charge_dollar": 28538.0, "standard_charge_algorithm": "Per diem ($28,538).", "count": "0", "additional_payer_notes": "Zero final payments for the item or service in the 15 months prior to posting the file." } ] } ] }, { "description": "HC Cath Foley Gp004", "code_information": [ { "code": "PX-2120032004", "type": "CDM" }, { "code": "99999", "type": "CPT" }, { "code": "0272", "type": "RC" } ], "standard_charges": [ { "setting": "outpatient", "gross_charge": 146.0, "discounted_cash": 73.0, "minimum": 61.61, "maximum": 75.92, "additional_generic_notes": "Zero final payments for the item or service in the 15 months prior to posting the file.", "payers_information": [ { "payer_name": "AETNA", "plan_name": "AETNA ALL OTHER PLANS", "methodology": "percent of total billed charges", "standard_charge_dollar": 75.92, "standard_charge_percentage": 52.0, "count": "0", "additional_payer_notes": "Zero final payments for the item or service in the 15 months prior to posting the file." }, { "payer_name": "AETNA", "plan_name": "AETNA ALL OTHER PLANS", "methodology": "percent of total billed charges", "standard_charge_dollar": 75.92, "standard_charge_percentage": 52.0, "count": "0", "additional_payer_notes": "Zero final payments for the item or service in the 15 months prior to posting the file." }, { "payer_name": "MERITAIN HEALTH", "plan_name": "AETNA ALL OTHER PLANS", "methodology": "percent of total billed charges", "standard_charge_dollar": 75.92, "standard_charge_percentage": 52.0, "count": "0", "additional_payer_notes": "Zero final payments for the item or service in the 15 months prior to posting the file." }, { "payer_name": "BLUE SHIELD OUT OF STATE", "plan_name": "STANFORD HEALTHCARE ALLIANCE PLAN", "methodology": "percent of total billed charges", "standard_charge_dollar": 70.94, "standard_charge_percentage": 48.59, "count": "0", "additional_payer_notes": "Zero final payments for the item or service in the 15 months prior to posting the file." }, { "payer_name": "BLUE SHIELD", "plan_name": "STANFORD HEALTHCARE ALLIANCE PLAN", "methodology": "percent of total billed charges", "standard_charge_dollar": 70.94, "standard_charge_percentage": 48.59, "count": "0", "additional_payer_notes": "Zero final payments for the item or service in the 15 months prior to posting the file." }, { "payer_name": "BLUE SHIELD", "plan_name": "STANFORD HEALTHCARE ALLIANCE PLAN", "methodology": "percent of total billed charges", "standard_charge_dollar": 70.94, "standard_charge_percentage": 48.59, "count": "0", "additional_payer_notes": "Zero final payments for the item or service in the 15 months prior to posting the file." }, { "payer_name": "CIGNA", "plan_name": "CIGNA COM ALT HMO PLAN", "methodology": "percent of total billed charges", "standard_charge_dollar": 61.61, "standard_charge_percentage": 42.2, "count": "0", "additional_payer_notes": "Zero final payments for the item or service in the 15 months prior to posting the file." }, { "payer_name": "CIGNA", "plan_name": "CIGNA COM ALT HMO PLAN", "methodology": "percent of total billed charges", "standard_charge_dollar": 61.61, "standard_charge_percentage": 42.2, "count": "0", "additional_payer_notes": "Zero final payments for the item or service in the 15 months prior to posting the file." }, { "payer_name": "HEALTH NET", "plan_name": "HEALTHNET HMO, PPO, POS, EPO, CANOPY HEALTHNET HMO, OTHER-IN-NETWORK PLANS", "methodology": "per diem", "standard_charge_dollar": 8000.0, "standard_charge_algorithm": "Expected reimbursement is the lesser of Per diem ($8,000) for the length of stay and 70% of billed.", "count": "0", "additional_payer_notes": "Zero final payments for the item or service in the 15 months prior to posting the file." }, { "payer_name": "HEALTH NET", "plan_name": "HEALTHNET HMO, PPO, POS, EPO, CANOPY HEALTHNET HMO, OTHER-IN-NETWORK PLANS", "methodology": "per diem", "standard_charge_dollar": 8000.0, "standard_charge_algorithm": "Expected reimbursement is the lesser of Per diem ($8,000) for the length of stay and 70% of billed.", "count": "0", "additional_payer_notes": "Zero final payments for the item or service in the 15 months prior to posting the file." }, { "payer_name": "UNITED HEALTHCARE", "plan_name": "SUTTER SELECT & SUTTER HEALTH PLAN HMO PLANS", "methodology": "per diem", "standard_charge_dollar": 28538.0, "standard_charge_algorithm": "Per diem ($28,538).", "count": "0", "additional_payer_notes": "Zero final payments for the item or service in the 15 months prior to posting the file." }, { "payer_name": "UNITED HEALTHCARE", "plan_name": "SUTTER SELECT & SUTTER HEALTH PLAN HMO PLANS", "methodology": "per diem", "standard_charge_dollar": 28538.0, "standard_charge_algorithm": "Per diem ($28,538).", "count": "0", "additional_payer_notes": "Zero final payments for the item or service in the 15 months prior to posting the file." }, { "payer_name": "SUTTER", "plan_name": "SUTTER SELECT & SUTTER HEALTH PLAN HMO PLANS", "methodology": "per diem", "standard_charge_dollar": 28538.0, "standard_charge_algorithm": "Per diem ($28,538).", "count": "0", "additional_payer_notes": "Zero final payments for the item or service in the 15 months prior to posting the file." }, { "payer_name": "UNITED HEALTHCARE", "plan_name": "SUTTER SELECT & SUTTER HEALTH PLAN HMO PLANS", "methodology": "per diem", "standard_charge_dollar": 28538.0, "standard_charge_algorithm": "Per diem ($28,538).", "count": "0", "additional_payer_notes": "Zero final payments for the item or service in the 15 months prior to posting the file." }, { "payer_name": "UMR", "plan_name": "SUTTER SELECT & SUTTER HEALTH PLAN HMO PLANS", "methodology": "per diem", "standard_charge_dollar": 28538.0, "standard_charge_algorithm": "Per diem ($28,538).", "count": "0", "additional_payer_notes": "Zero final payments for the item or service in the 15 months prior to posting the file." } ] } ] }, { "description": "HC Cath Foley Gp005", "code_information": [ { "code": "PX-2120032005", "type": "CDM" }, { "code": "99999", "type": "CPT" }, { "code": "0272", "type": "RC" } ], "standard_charges": [ { "setting": "outpatient", "gross_charge": 195.0, "discounted_cash": 97.5, "minimum": 82.29, "maximum": 101.4, "additional_generic_notes": "Zero final payments for the item or service in the 15 months prior to posting the file.", "payers_information": [ { "payer_name": "AETNA", "plan_name": "AETNA ALL OTHER PLANS", "methodology": "percent of total billed charges", "standard_charge_dollar": 101.4, "standard_charge_percentage": 52.0, "count": "0", "additional_payer_notes": "Zero final payments for the item or service in the 15 months prior to posting the file." }, { "payer_name": "AETNA", "plan_name": "AETNA ALL OTHER PLANS", "methodology": "percent of total billed charges", "standard_charge_dollar": 101.4, "standard_charge_percentage": 52.0, "count": "0", "additional_payer_notes": "Zero final payments for the item or service in the 15 months prior to posting the file." }, { "payer_name": "MERITAIN HEALTH", "plan_name": "AETNA ALL OTHER PLANS", "methodology": "percent of total billed charges", "standard_charge_dollar": 101.4, "standard_charge_percentage": 52.0, "count": "0", "additional_payer_notes": "Zero final payments for the item or service in the 15 months prior to posting the file." }, { "payer_name": "BLUE SHIELD OUT OF STATE", "plan_name": "STANFORD HEALTHCARE ALLIANCE PLAN", "methodology": "percent of total billed charges", "standard_charge_dollar": 94.75, "standard_charge_percentage": 48.59, "count": "0", "additional_payer_notes": "Zero final payments for the item or service in the 15 months prior to posting the file." }, { "payer_name": "BLUE SHIELD", "plan_name": "STANFORD HEALTHCARE ALLIANCE PLAN", "methodology": "percent of total billed charges", "standard_charge_dollar": 94.75, "standard_charge_percentage": 48.59, "count": "0", "additional_payer_notes": "Zero final payments for the item or service in the 15 months prior to posting the file." }, { "payer_name": "BLUE SHIELD", "plan_name": "STANFORD HEALTHCARE ALLIANCE PLAN", "methodology": "percent of total billed charges", "standard_charge_dollar": 94.75, "standard_charge_percentage": 48.59, "count": "0", "additional_payer_notes": "Zero final payments for the item or service in the 15 months prior to posting the file." }, { "payer_name": "CIGNA", "plan_name": "CIGNA COM ALT HMO PLAN", "methodology": "percent of total billed charges", "standard_charge_dollar": 82.29, "standard_charge_percentage": 42.2, "count": "0", "additional_payer_notes": "Zero final payments for the item or service in the 15 months prior to posting the file." }, { "payer_name": "CIGNA", "plan_name": "CIGNA COM ALT HMO PLAN", "methodology": "percent of total billed charges", "standard_charge_dollar": 82.29, "standard_charge_percentage": 42.2, "count": "0", "additional_payer_notes": "Zero final payments for the item or service in the 15 months prior to posting the file." }, { "payer_name": "HEALTH NET", "plan_name": "HEALTHNET HMO, PPO, POS, EPO, CANOPY HEALTHNET HMO, OTHER-IN-NETWORK PLANS", "methodology": "per diem", "standard_charge_dollar": 8000.0, "standard_charge_algorithm": "Expected reimbursement is the lesser of Per diem ($8,000) for the length of stay and 70% of billed.", "count": "0", "additional_payer_notes": "Zero final payments for the item or service in the 15 months prior to posting the file." }, { "payer_name": "HEALTH NET", "plan_name": "HEALTHNET HMO, PPO, POS, EPO, CANOPY HEALTHNET HMO, OTHER-IN-NETWORK PLANS", "methodology": "per diem", "standard_charge_dollar": 8000.0, "standard_charge_algorithm": "Expected reimbursement is the lesser of Per diem ($8,000) for the length of stay and 70% of billed.", "count": "0", "additional_payer_notes": "Zero final payments for the item or service in the 15 months prior to posting the file." }, { "payer_name": "UNITED HEALTHCARE", "plan_name": "SUTTER SELECT & SUTTER HEALTH PLAN HMO PLANS", "methodology": "per diem", "standard_charge_dollar": 28538.0, "standard_charge_algorithm": "Per diem ($28,538).", "count": "0", "additional_payer_notes": "Zero final payments for the item or service in the 15 months prior to posting the file." }, { "payer_name": "UNITED HEALTHCARE", "plan_name": "SUTTER SELECT & SUTTER HEALTH PLAN HMO PLANS", "methodology": "per diem", "standard_charge_dollar": 28538.0, "standard_charge_algorithm": "Per diem ($28,538).", "count": "0", "additional_payer_notes": "Zero final payments for the item or service in the 15 months prior to posting the file." }, { "payer_name": "SUTTER", "plan_name": "SUTTER SELECT & SUTTER HEALTH PLAN HMO PLANS", "methodology": "per diem", "standard_charge_dollar": 28538.0, "standard_charge_algorithm": "Per diem ($28,538).", "count": "0", "additional_payer_notes": "Zero final payments for the item or service in the 15 months prior to posting the file." }, { "payer_name": "UNITED HEALTHCARE", "plan_name": "SUTTER SELECT & SUTTER HEALTH PLAN HMO PLANS", "methodology": "per diem", "standard_charge_dollar": 28538.0, "standard_charge_algorithm": "Per diem ($28,538).", "count": "0", "additional_payer_notes": "Zero final payments for the item or service in the 15 months prior to posting the file." }, { "payer_name": "UMR", "plan_name": "SUTTER SELECT & SUTTER HEALTH PLAN HMO PLANS", "methodology": "per diem", "standard_charge_dollar": 28538.0, "standard_charge_algorithm": "Per diem ($28,538).", "count": "0", "additional_payer_notes": "Zero final payments for the item or service in the 15 months prior to posting the file." } ] } ] }, { "description": "HC Cath Foley Gp006", "code_information": [ { "code": "PX-2120032006", "type": "CDM" }, { "code": "99999", "type": "CPT" }, { "code": "0272", "type": "RC" } ], "standard_charges": [ { "setting": "outpatient", "gross_charge": 293.0, "discounted_cash": 146.5, "minimum": 123.65, "maximum": 152.36, "additional_generic_notes": "Zero final payments for the item or service in the 15 months prior to posting the file.", "payers_information": [ { "payer_name": "AETNA", "plan_name": "AETNA ALL OTHER PLANS", "methodology": "percent of total billed charges", "standard_charge_dollar": 152.36, "standard_charge_percentage": 52.0, "count": "0", "additional_payer_notes": "Zero final payments for the item or service in the 15 months prior to posting the file." }, { "payer_name": "AETNA", "plan_name": "AETNA ALL OTHER PLANS", "methodology": "percent of total billed charges", "standard_charge_dollar": 152.36, "standard_charge_percentage": 52.0, "count": "0", "additional_payer_notes": "Zero final payments for the item or service in the 15 months prior to posting the file." }, { "payer_name": "MERITAIN HEALTH", "plan_name": "AETNA ALL OTHER PLANS", "methodology": "percent of total billed charges", "standard_charge_dollar": 152.36, "standard_charge_percentage": 52.0, "count": "0", "additional_payer_notes": "Zero final payments for the item or service in the 15 months prior to posting the file." }, { "payer_name": "BLUE SHIELD OUT OF STATE", "plan_name": "STANFORD HEALTHCARE ALLIANCE PLAN", "methodology": "percent of total billed charges", "standard_charge_dollar": 142.37, "standard_charge_percentage": 48.59, "count": "0", "additional_payer_notes": "Zero final payments for the item or service in the 15 months prior to posting the file." }, { "payer_name": "BLUE SHIELD", "plan_name": "STANFORD HEALTHCARE ALLIANCE PLAN", "methodology": "percent of total billed charges", "standard_charge_dollar": 142.37, "standard_charge_percentage": 48.59, "count": "0", "additional_payer_notes": "Zero final payments for the item or service in the 15 months prior to posting the file." }, { "payer_name": "BLUE SHIELD", "plan_name": "STANFORD HEALTHCARE ALLIANCE PLAN", "methodology": "percent of total billed charges", "standard_charge_dollar": 142.37, "standard_charge_percentage": 48.59, "count": "0", "additional_payer_notes": "Zero final payments for the item or service in the 15 months prior to posting the file." }, { "payer_name": "CIGNA", "plan_name": "CIGNA COM ALT HMO PLAN", "methodology": "percent of total billed charges", "standard_charge_dollar": 123.65, "standard_charge_percentage": 42.2, "count": "0", "additional_payer_notes": "Zero final payments for the item or service in the 15 months prior to posting the file." }, { "payer_name": "CIGNA", "plan_name": "CIGNA COM ALT HMO PLAN", "methodology": "percent of total billed charges", "standard_charge_dollar": 123.65, "standard_charge_percentage": 42.2, "count": "0", "additional_payer_notes": "Zero final payments for the item or service in the 15 months prior to posting the file." }, { "payer_name": "HEALTH NET", "plan_name": "HEALTHNET HMO, PPO, POS, EPO, CANOPY HEALTHNET HMO, OTHER-IN-NETWORK PLANS", "methodology": "per diem", "standard_charge_dollar": 8000.0, "standard_charge_algorithm": "Expected reimbursement is the lesser of Per diem ($8,000) for the length of stay and 70% of billed.", "count": "0", "additional_payer_notes": "Zero final payments for the item or service in the 15 months prior to posting the file." }, { "payer_name": "HEALTH NET", "plan_name": "HEALTHNET HMO, PPO, POS, EPO, CANOPY HEALTHNET HMO, OTHER-IN-NETWORK PLANS", "methodology": "per diem", "standard_charge_dollar": 8000.0, "standard_charge_algorithm": "Expected reimbursement is the lesser of Per diem ($8,000) for the length of stay and 70% of billed.", "count": "0", "additional_payer_notes": "Zero final payments for the item or service in the 15 months prior to posting the file." }, { "payer_name": "UNITED HEALTHCARE", "plan_name": "SUTTER SELECT & SUTTER HEALTH PLAN HMO PLANS", "methodology": "per diem", "standard_charge_dollar": 28538.0, "standard_charge_algorithm": "Per diem ($28,538).", "count": "0", "additional_payer_notes": "Zero final payments for the item or service in the 15 months prior to posting the file." }, { "payer_name": "UNITED HEALTHCARE", "plan_name": "SUTTER SELECT & SUTTER HEALTH PLAN HMO PLANS", "methodology": "per diem", "standard_charge_dollar": 28538.0, "standard_charge_algorithm": "Per diem ($28,538).", "count": "0", "additional_payer_notes": "Zero final payments for the item or service in the 15 months prior to posting the file." }, { "payer_name": "SUTTER", "plan_name": "SUTTER SELECT & SUTTER HEALTH PLAN HMO PLANS", "methodology": "per diem", "standard_charge_dollar": 28538.0, "standard_charge_algorithm": "Per diem ($28,538).", "count": "0", "additional_payer_notes": "Zero final payments for the item or service in the 15 months prior to posting the file." }, { "payer_name": "UNITED HEALTHCARE", "plan_name": "SUTTER SELECT & SUTTER HEALTH PLAN HMO PLANS", "methodology": "per diem", "standard_charge_dollar": 28538.0, "standard_charge_algorithm": "Per diem ($28,538).", "count": "0", "additional_payer_notes": "Zero final payments for the item or service in the 15 months prior to posting the file." }, { "payer_name": "UMR", "plan_name": "SUTTER SELECT & SUTTER HEALTH PLAN HMO PLANS", "methodology": "per diem", "standard_charge_dollar": 28538.0, "standard_charge_algorithm": "Per diem ($28,538).", "count": "0", "additional_payer_notes": "Zero final payments for the item or service in the 15 months prior to posting the file." } ] } ] }, { "description": "HC Cath Foley Gp015", "code_information": [ { "code": "PX-2120032015", "type": "CDM" }, { "code": "99999", "type": "CPT" }, { "code": "0272", "type": "RC" } ], "standard_charges": [ { "setting": "outpatient", "gross_charge": 1225.0, "discounted_cash": 612.5, "minimum": 516.95, "maximum": 637.0, "additional_generic_notes": "Zero final payments for the item or service in the 15 months prior to posting the file.", "payers_information": [ { "payer_name": "AETNA", "plan_name": "AETNA ALL OTHER PLANS", "methodology": "percent of total billed charges", "standard_charge_dollar": 637.0, "standard_charge_percentage": 52.0, "count": "0", "additional_payer_notes": "Zero final payments for the item or service in the 15 months prior to posting the file." }, { "payer_name": "AETNA", "plan_name": "AETNA ALL OTHER PLANS", "methodology": "percent of total billed charges", "standard_charge_dollar": 637.0, "standard_charge_percentage": 52.0, "count": "0", "additional_payer_notes": "Zero final payments for the item or service in the 15 months prior to posting the file." }, { "payer_name": "MERITAIN HEALTH", "plan_name": "AETNA ALL OTHER PLANS", "methodology": "percent of total billed charges", "standard_charge_dollar": 637.0, "standard_charge_percentage": 52.0, "count": "0", "additional_payer_notes": "Zero final payments for the item or service in the 15 months prior to posting the file." }, { "payer_name": "BLUE SHIELD OUT OF STATE", "plan_name": "STANFORD HEALTHCARE ALLIANCE PLAN", "methodology": "percent of total billed charges", "standard_charge_dollar": 595.23, "standard_charge_percentage": 48.59, "count": "0", "additional_payer_notes": "Zero final payments for the item or service in the 15 months prior to posting the file." }, { "payer_name": "BLUE SHIELD", "plan_name": "STANFORD HEALTHCARE ALLIANCE PLAN", "methodology": "percent of total billed charges", "standard_charge_dollar": 595.23, "standard_charge_percentage": 48.59, "median_amount": 68.24, "10th_percentile": 13.6, "90th_percentile": 1043.06, "count": "30" }, { "payer_name": "BLUE SHIELD", "plan_name": "STANFORD HEALTHCARE ALLIANCE PLAN", "methodology": "percent of total billed charges", "standard_charge_dollar": 595.23, "standard_charge_percentage": 48.59, "count": "0", "additional_payer_notes": "Zero final payments for the item or service in the 15 months prior to posting the file." }, { "payer_name": "BLUE SHIELD", "plan_name": "STANFORD HEALTHCARE ALLIANCE PLAN", "methodology": "percent of total billed charges", "standard_charge_dollar": 595.23, "standard_charge_percentage": 48.59, "count": "0", "additional_payer_notes": "Zero final payments for the item or service in the 15 months prior to posting the file." }, { "payer_name": "CIGNA", "plan_name": "CIGNA COM ALT HMO PLAN", "methodology": "percent of total billed charges", "standard_charge_dollar": 516.95, "standard_charge_percentage": 42.2, "count": "0", "additional_payer_notes": "Zero final payments for the item or service in the 15 months prior to posting the file." }, { "payer_name": "CIGNA", "plan_name": "CIGNA COM ALT HMO PLAN", "methodology": "percent of total billed charges", "standard_charge_dollar": 516.95, "standard_charge_percentage": 42.2, "count": "0", "additional_payer_notes": "Zero final payments for the item or service in the 15 months prior to posting the file." }, { "payer_name": "HEALTH NET", "plan_name": "HEALTHNET HMO, PPO, POS, EPO, CANOPY HEALTHNET HMO, OTHER-IN-NETWORK PLANS", "methodology": "per diem", "standard_charge_dollar": 8000.0, "standard_charge_algorithm": "Expected reimbursement is the lesser of Per diem ($8,000) for the length of stay and 70% of billed.", "count": "0", "additional_payer_notes": "Zero final payments for the item or service in the 15 months prior to posting the file." }, { "payer_name": "HEALTH NET", "plan_name": "HEALTHNET HMO, PPO, POS, EPO, CANOPY HEALTHNET HMO, OTHER-IN-NETWORK PLANS", "methodology": "per diem", "standard_charge_dollar": 8000.0, "standard_charge_algorithm": "Expected reimbursement is the lesser of Per diem ($8,000) for the length of stay and 70% of billed.", "count": "0", "additional_payer_notes": "Zero final payments for the item or service in the 15 months prior to posting the file." }, { "payer_name": "UNITED HEALTHCARE", "plan_name": "SUTTER SELECT & SUTTER HEALTH PLAN HMO PLANS", "methodology": "per diem", "standard_charge_dollar": 28538.0, "standard_charge_algorithm": "Per diem ($28,538).", "count": "0", "additional_payer_notes": "Zero final payments for the item or service in the 15 months prior to posting the file." }, { "payer_name": "UNITED HEALTHCARE", "plan_name": "SUTTER SELECT & SUTTER HEALTH PLAN HMO PLANS", "methodology": "per diem", "standard_charge_dollar": 28538.0, "standard_charge_algorithm": "Per diem ($28,538).", "count": "0", "additional_payer_notes": "Zero final payments for the item or service in the 15 months prior to posting the file." }, { "payer_name": "SUTTER", "plan_name": "SUTTER SELECT & SUTTER HEALTH PLAN HMO PLANS", "methodology": "per diem", "standard_charge_dollar": 28538.0, "standard_charge_algorithm": "Per diem ($28,538).", "count": "0", "additional_payer_notes": "Zero final payments for the item or service in the 15 months prior to posting the file." }, { "payer_name": "UNITED HEALTHCARE", "plan_name": "SUTTER SELECT & SUTTER HEALTH PLAN HMO PLANS", "methodology": "per diem", "standard_charge_dollar": 28538.0, "standard_charge_algorithm": "Per diem ($28,538).", "count": "0", "additional_payer_notes": "Zero final payments for the item or service in the 15 months prior to posting the file." }, { "payer_name": "UMR", "plan_name": "SUTTER SELECT & SUTTER HEALTH PLAN HMO PLANS", "methodology": "per diem", "standard_charge_dollar": 28538.0, "standard_charge_algorithm": "Per diem ($28,538).", "count": "0", "additional_payer_notes": "Zero final payments for the item or service in the 15 months prior to posting the file." } ] } ] }, { "description": "HC Cath Foley Gp018", "code_information": [ { "code": "PX-2120032018", "type": "CDM" }, { "code": "99999", "type": "CPT" }, { "code": "0272", "type": "RC" } ], "standard_charges": [ { "setting": "outpatient", "gross_charge": 1750.0, "discounted_cash": 875.0, "minimum": 738.5, "maximum": 910.0, "additional_generic_notes": "Zero final payments for the item or service in the 15 months prior to posting the file.", "payers_information": [ { "payer_name": "AETNA", "plan_name": "AETNA ALL OTHER PLANS", "methodology": "percent of total billed charges", "standard_charge_dollar": 910.0, "standard_charge_percentage": 52.0, "count": "0", "additional_payer_notes": "Zero final payments for the item or service in the 15 months prior to posting the file." }, { "payer_name": "AETNA", "plan_name": "AETNA ALL OTHER PLANS", "methodology": "percent of total billed charges", "standard_charge_dollar": 910.0, "standard_charge_percentage": 52.0, "count": "0", "additional_payer_notes": "Zero final payments for the item or service in the 15 months prior to posting the file." }, { "payer_name": "MERITAIN HEALTH", "plan_name": "AETNA ALL OTHER PLANS", "methodology": "percent of total billed charges", "standard_charge_dollar": 910.0, "standard_charge_percentage": 52.0, "count": "0", "additional_payer_notes": "Zero final payments for the item or service in the 15 months prior to posting the file." }, { "payer_name": "BLUE SHIELD OUT OF STATE", "plan_name": "STANFORD HEALTHCARE ALLIANCE PLAN", "methodology": "percent of total billed charges", "standard_charge_dollar": 850.33, "standard_charge_percentage": 48.59, "count": "0", "additional_payer_notes": "Zero final payments for the item or service in the 15 months prior to posting the file." }, { "payer_name": "BLUE SHIELD", "plan_name": "STANFORD HEALTHCARE ALLIANCE PLAN", "methodology": "percent of total billed charges", "standard_charge_dollar": 850.33, "standard_charge_percentage": 48.59, "median_amount": 68.24, "10th_percentile": 13.6, "90th_percentile": 1043.06, "count": "30" }, { "payer_name": "BLUE SHIELD", "plan_name": "STANFORD HEALTHCARE ALLIANCE PLAN", "methodology": "percent of total billed charges", "standard_charge_dollar": 850.33, "standard_charge_percentage": 48.59, "count": "0", "additional_payer_notes": "Zero final payments for the item or service in the 15 months prior to posting the file." }, { "payer_name": "BLUE SHIELD", "plan_name": "STANFORD HEALTHCARE ALLIANCE PLAN", "methodology": "percent of total billed charges", "standard_charge_dollar": 850.33, "standard_charge_percentage": 48.59, "count": "0", "additional_payer_notes": "Zero final payments for the item or service in the 15 months prior to posting the file." }, { "payer_name": "CIGNA", "plan_name": "CIGNA COM ALT HMO PLAN", "methodology": "percent of total billed charges", "standard_charge_dollar": 738.5, "standard_charge_percentage": 42.2, "count": "0", "additional_payer_notes": "Zero final payments for the item or service in the 15 months prior to posting the file." }, { "payer_name": "CIGNA", "plan_name": "CIGNA COM ALT HMO PLAN", "methodology": "percent of total billed charges", "standard_charge_dollar": 738.5, "standard_charge_percentage": 42.2, "count": "0", "additional_payer_notes": "Zero final payments for the item or service in the 15 months prior to posting the file." }, { "payer_name": "HEALTH NET", "plan_name": "HEALTHNET HMO, PPO, POS, EPO, CANOPY HEALTHNET HMO, OTHER-IN-NETWORK PLANS", "methodology": "per diem", "standard_charge_dollar": 8000.0, "standard_charge_algorithm": "Expected reimbursement is the lesser of Per diem ($8,000) for the length of stay and 70% of billed.", "count": "0", "additional_payer_notes": "Zero final payments for the item or service in the 15 months prior to posting the file." }, { "payer_name": "HEALTH NET", "plan_name": "HEALTHNET HMO, PPO, POS, EPO, CANOPY HEALTHNET HMO, OTHER-IN-NETWORK PLANS", "methodology": "per diem", "standard_charge_dollar": 8000.0, "standard_charge_algorithm": "Expected reimbursement is the lesser of Per diem ($8,000) for the length of stay and 70% of billed.", "count": "0", "additional_payer_notes": "Zero final payments for the item or service in the 15 months prior to posting the file." }, { "payer_name": "UNITED HEALTHCARE", "plan_name": "SUTTER SELECT & SUTTER HEALTH PLAN HMO PLANS", "methodology": "per diem", "standard_charge_dollar": 28538.0, "standard_charge_algorithm": "Per diem ($28,538).", "count": "0", "additional_payer_notes": "Zero final payments for the item or service in the 15 months prior to posting the file." }, { "payer_name": "UNITED HEALTHCARE", "plan_name": "SUTTER SELECT & SUTTER HEALTH PLAN HMO PLANS", "methodology": "per diem", "standard_charge_dollar": 28538.0, "standard_charge_algorithm": "Per diem ($28,538).", "count": "0", "additional_payer_notes": "Zero final payments for the item or service in the 15 months prior to posting the file." }, { "payer_name": "SUTTER", "plan_name": "SUTTER SELECT & SUTTER HEALTH PLAN HMO PLANS", "methodology": "per diem", "standard_charge_dollar": 28538.0, "standard_charge_algorithm": "Per diem ($28,538).", "count": "0", "additional_payer_notes": "Zero final payments for the item or service in the 15 months prior to posting the file." }, { "payer_name": "UNITED HEALTHCARE", "plan_name": "SUTTER SELECT & SUTTER HEALTH PLAN HMO PLANS", "methodology": "per diem", "standard_charge_dollar": 28538.0, "standard_charge_algorithm": "Per diem ($28,538).", "count": "0", "additional_payer_notes": "Zero final payments for the item or service in the 15 months prior to posting the file." }, { "payer_name": "UMR", "plan_name": "SUTTER SELECT & SUTTER HEALTH PLAN HMO PLANS", "methodology": "per diem", "standard_charge_dollar": 28538.0, "standard_charge_algorithm": "Per diem ($28,538).", "count": "0", "additional_payer_notes": "Zero final payments for the item or service in the 15 months prior to posting the file." } ] } ] }, { "description": "HC Cath Foley Gp019", "code_information": [ { "code": "PX-2120032019", "type": "CDM" }, { "code": "99999", "type": "CPT" }, { "code": "0272", "type": "RC" } ], "standard_charges": [ { "setting": "outpatient", "gross_charge": 2125.0, "discounted_cash": 1062.5, "minimum": 896.75, "maximum": 1105.0, "additional_generic_notes": "Zero final payments for the item or service in the 15 months prior to posting the file.", "payers_information": [ { "payer_name": "AETNA", "plan_name": "AETNA ALL OTHER PLANS", "methodology": "percent of total billed charges", "standard_charge_dollar": 1105.0, "standard_charge_percentage": 52.0, "count": "0", "additional_payer_notes": "Zero final payments for the item or service in the 15 months prior to posting the file." }, { "payer_name": "AETNA", "plan_name": "AETNA ALL OTHER PLANS", "methodology": "percent of total billed charges", "standard_charge_dollar": 1105.0, "standard_charge_percentage": 52.0, "count": "0", "additional_payer_notes": "Zero final payments for the item or service in the 15 months prior to posting the file." }, { "payer_name": "MERITAIN HEALTH", "plan_name": "AETNA ALL OTHER PLANS", "methodology": "percent of total billed charges", "standard_charge_dollar": 1105.0, "standard_charge_percentage": 52.0, "count": "0", "additional_payer_notes": "Zero final payments for the item or service in the 15 months prior to posting the file." }, { "payer_name": "BLUE SHIELD OUT OF STATE", "plan_name": "STANFORD HEALTHCARE ALLIANCE PLAN", "methodology": "percent of total billed charges", "standard_charge_dollar": 1032.54, "standard_charge_percentage": 48.59, "count": "0", "additional_payer_notes": "Zero final payments for the item or service in the 15 months prior to posting the file." }, { "payer_name": "BLUE SHIELD", "plan_name": "STANFORD HEALTHCARE ALLIANCE PLAN", "methodology": "percent of total billed charges", "standard_charge_dollar": 1032.54, "standard_charge_percentage": 48.59, "median_amount": 68.24, "10th_percentile": 13.6, "90th_percentile": 1043.06, "count": "30" }, { "payer_name": "BLUE SHIELD", "plan_name": "STANFORD HEALTHCARE ALLIANCE PLAN", "methodology": "percent of total billed charges", "standard_charge_dollar": 1032.54, "standard_charge_percentage": 48.59, "count": "0", "additional_payer_notes": "Zero final payments for the item or service in the 15 months prior to posting the file." }, { "payer_name": "BLUE SHIELD", "plan_name": "STANFORD HEALTHCARE ALLIANCE PLAN", "methodology": "percent of total billed charges", "standard_charge_dollar": 1032.54, "standard_charge_percentage": 48.59, "count": "0", "additional_payer_notes": "Zero final payments for the item or service in the 15 months prior to posting the file." }, { "payer_name": "CIGNA", "plan_name": "CIGNA COM ALT HMO PLAN", "methodology": "percent of total billed charges", "standard_charge_dollar": 896.75, "standard_charge_percentage": 42.2, "count": "0", "additional_payer_notes": "Zero final payments for the item or service in the 15 months prior to posting the file." }, { "payer_name": "CIGNA", "plan_name": "CIGNA COM ALT HMO PLAN", "methodology": "percent of total billed charges", "standard_charge_dollar": 896.75, "standard_charge_percentage": 42.2, "count": "0", "additional_payer_notes": "Zero final payments for the item or service in the 15 months prior to posting the file." }, { "payer_name": "HEALTH NET", "plan_name": "HEALTHNET HMO, PPO, POS, EPO, CANOPY HEALTHNET HMO, OTHER-IN-NETWORK PLANS", "methodology": "per diem", "standard_charge_dollar": 8000.0, "standard_charge_algorithm": "Expected reimbursement is the lesser of Per diem ($8,000) for the length of stay and 70% of billed.", "count": "0", "additional_payer_notes": "Zero final payments for the item or service in the 15 months prior to posting the file." }, { "payer_name": "HEALTH NET", "plan_name": "HEALTHNET HMO, PPO, POS, EPO, CANOPY HEALTHNET HMO, OTHER-IN-NETWORK PLANS", "methodology": "per diem", "standard_charge_dollar": 8000.0, "standard_charge_algorithm": "Expected reimbursement is the lesser of Per diem ($8,000) for the length of stay and 70% of billed.", "count": "0", "additional_payer_notes": "Zero final payments for the item or service in the 15 months prior to posting the file." }, { "payer_name": "UNITED HEALTHCARE", "plan_name": "SUTTER SELECT & SUTTER HEALTH PLAN HMO PLANS", "methodology": "per diem", "standard_charge_dollar": 28538.0, "standard_charge_algorithm": "Per diem ($28,538).", "count": "0", "additional_payer_notes": "Zero final payments for the item or service in the 15 months prior to posting the file." }, { "payer_name": "UNITED HEALTHCARE", "plan_name": "SUTTER SELECT & SUTTER HEALTH PLAN HMO PLANS", "methodology": "per diem", "standard_charge_dollar": 28538.0, "standard_charge_algorithm": "Per diem ($28,538).", "count": "0", "additional_payer_notes": "Zero final payments for the item or service in the 15 months prior to posting the file." }, { "payer_name": "SUTTER", "plan_name": "SUTTER SELECT & SUTTER HEALTH PLAN HMO PLANS", "methodology": "per diem", "standard_charge_dollar": 28538.0, "standard_charge_algorithm": "Per diem ($28,538).", "count": "0", "additional_payer_notes": "Zero final payments for the item or service in the 15 months prior to posting the file." }, { "payer_name": "UNITED HEALTHCARE", "plan_name": "SUTTER SELECT & SUTTER HEALTH PLAN HMO PLANS", "methodology": "per diem", "standard_charge_dollar": 28538.0, "standard_charge_algorithm": "Per diem ($28,538).", "count": "0", "additional_payer_notes": "Zero final payments for the item or service in the 15 months prior to posting the file." }, { "payer_name": "UMR", "plan_name": "SUTTER SELECT & SUTTER HEALTH PLAN HMO PLANS", "methodology": "per diem", "standard_charge_dollar": 28538.0, "standard_charge_algorithm": "Per diem ($28,538).", "count": "0", "additional_payer_notes": "Zero final payments for the item or service in the 15 months prior to posting the file." } ] } ] }, { "description": "HC Cath Foley Gp025", "code_information": [ { "code": "PX-2120032025", "type": "CDM" }, { "code": "99999", "type": "CPT" }, { "code": "0272", "type": "RC" } ], "standard_charges": [ { "setting": "outpatient", "gross_charge": 4263.0, "discounted_cash": 2131.5, "minimum": 1798.99, "maximum": 2216.76, "additional_generic_notes": "Zero final payments for the item or service in the 15 months prior to posting the file.", "payers_information": [ { "payer_name": "AETNA", "plan_name": "AETNA ALL OTHER PLANS", "methodology": "percent of total billed charges", "standard_charge_dollar": 2216.76, "standard_charge_percentage": 52.0, "count": "0", "additional_payer_notes": "Zero final payments for the item or service in the 15 months prior to posting the file." }, { "payer_name": "AETNA", "plan_name": "AETNA ALL OTHER PLANS", "methodology": "percent of total billed charges", "standard_charge_dollar": 2216.76, "standard_charge_percentage": 52.0, "count": "0", "additional_payer_notes": "Zero final payments for the item or service in the 15 months prior to posting the file." }, { "payer_name": "MERITAIN HEALTH", "plan_name": "AETNA ALL OTHER PLANS", "methodology": "percent of total billed charges", "standard_charge_dollar": 2216.76, "standard_charge_percentage": 52.0, "count": "0", "additional_payer_notes": "Zero final payments for the item or service in the 15 months prior to posting the file." }, { "payer_name": "BLUE SHIELD OUT OF STATE", "plan_name": "STANFORD HEALTHCARE ALLIANCE PLAN", "methodology": "percent of total billed charges", "standard_charge_dollar": 2071.39, "standard_charge_percentage": 48.59, "count": "0", "additional_payer_notes": "Zero final payments for the item or service in the 15 months prior to posting the file." }, { "payer_name": "BLUE SHIELD", "plan_name": "STANFORD HEALTHCARE ALLIANCE PLAN", "methodology": "percent of total billed charges", "standard_charge_dollar": 2071.39, "standard_charge_percentage": 48.59, "median_amount": 68.24, "10th_percentile": 13.6, "90th_percentile": 1043.06, "count": "30" }, { "payer_name": "BLUE SHIELD", "plan_name": "STANFORD HEALTHCARE ALLIANCE PLAN", "methodology": "percent of total billed charges", "standard_charge_dollar": 2071.39, "standard_charge_percentage": 48.59, "count": "0", "additional_payer_notes": "Zero final payments for the item or service in the 15 months prior to posting the file." }, { "payer_name": "BLUE SHIELD", "plan_name": "STANFORD HEALTHCARE ALLIANCE PLAN", "methodology": "percent of total billed charges", "standard_charge_dollar": 2071.39, "standard_charge_percentage": 48.59, "count": "0", "additional_payer_notes": "Zero final payments for the item or service in the 15 months prior to posting the file." }, { "payer_name": "CIGNA", "plan_name": "CIGNA COM ALT HMO PLAN", "methodology": "percent of total billed charges", "standard_charge_dollar": 1798.99, "standard_charge_percentage": 42.2, "count": "0", "additional_payer_notes": "Zero final payments for the item or service in the 15 months prior to posting the file." }, { "payer_name": "CIGNA", "plan_name": "CIGNA COM ALT HMO PLAN", "methodology": "percent of total billed charges", "standard_charge_dollar": 1798.99, "standard_charge_percentage": 42.2, "count": "0", "additional_payer_notes": "Zero final payments for the item or service in the 15 months prior to posting the file." }, { "payer_name": "HEALTH NET", "plan_name": "HEALTHNET HMO, PPO, POS, EPO, CANOPY HEALTHNET HMO, OTHER-IN-NETWORK PLANS", "methodology": "per diem", "standard_charge_dollar": 8000.0, "standard_charge_algorithm": "Expected reimbursement is the lesser of Per diem ($8,000) for the length of stay and 70% of billed.", "count": "0", "additional_payer_notes": "Zero final payments for the item or service in the 15 months prior to posting the file." }, { "payer_name": "HEALTH NET", "plan_name": "HEALTHNET HMO, PPO, POS, EPO, CANOPY HEALTHNET HMO, OTHER-IN-NETWORK PLANS", "methodology": "per diem", "standard_charge_dollar": 8000.0, "standard_charge_algorithm": "Expected reimbursement is the lesser of Per diem ($8,000) for the length of stay and 70% of billed.", "count": "0", "additional_payer_notes": "Zero final payments for the item or service in the 15 months prior to posting the file." }, { "payer_name": "UNITED HEALTHCARE", "plan_name": "SUTTER SELECT & SUTTER HEALTH PLAN HMO PLANS", "methodology": "per diem", "standard_charge_dollar": 28538.0, "standard_charge_algorithm": "Per diem ($28,538).", "count": "0", "additional_payer_notes": "Zero final payments for the item or service in the 15 months prior to posting the file." }, { "payer_name": "UNITED HEALTHCARE", "plan_name": "SUTTER SELECT & SUTTER HEALTH PLAN HMO PLANS", "methodology": "per diem", "standard_charge_dollar": 28538.0, "standard_charge_algorithm": "Per diem ($28,538).", "count": "0", "additional_payer_notes": "Zero final payments for the item or service in the 15 months prior to posting the file." }, { "payer_name": "SUTTER", "plan_name": "SUTTER SELECT & SUTTER HEALTH PLAN HMO PLANS", "methodology": "per diem", "standard_charge_dollar": 28538.0, "standard_charge_algorithm": "Per diem ($28,538).", "count": "0", "additional_payer_notes": "Zero final payments for the item or service in the 15 months prior to posting the file." }, { "payer_name": "UNITED HEALTHCARE", "plan_name": "SUTTER SELECT & SUTTER HEALTH PLAN HMO PLANS", "methodology": "per diem", "standard_charge_dollar": 28538.0, "standard_charge_algorithm": "Per diem ($28,538).", "count": "0", "additional_payer_notes": "Zero final payments for the item or service in the 15 months prior to posting the file." }, { "payer_name": "UMR", "plan_name": "SUTTER SELECT & SUTTER HEALTH PLAN HMO PLANS", "methodology": "per diem", "standard_charge_dollar": 28538.0, "standard_charge_algorithm": "Per diem ($28,538).", "count": "0", "additional_payer_notes": "Zero final payments for the item or service in the 15 months prior to posting the file." } ] } ] }, { "description": "Hc Cath Intraspinal Gp024", "code_information": [ { "code": "PX-2120034024", "type": "CDM" }, { "code": "C1755", "type": "HCPCS" }, { "code": "0272", "type": "RC" } ], "standard_charges": [ { "setting": "outpatient", "gross_charge": 4000.0, "discounted_cash": 2000.0, "minimum": 1688.0, "maximum": 2080.0, "additional_generic_notes": "Zero final payments for the item or service in the 15 months prior to posting the file.", "payers_information": [ { "payer_name": "AETNA", "plan_name": "AETNA ALL OTHER PLANS", "methodology": "percent of total billed charges", "standard_charge_dollar": 2080.0, "standard_charge_percentage": 52.0, "count": "0", "additional_payer_notes": "Zero final payments for the item or service in the 15 months prior to posting the file." }, { "payer_name": "AETNA", "plan_name": "AETNA ALL OTHER PLANS", "methodology": "percent of total billed charges", "standard_charge_dollar": 2080.0, "standard_charge_percentage": 52.0, "count": "0", "additional_payer_notes": "Zero final payments for the item or service in the 15 months prior to posting the file." }, { "payer_name": "MERITAIN HEALTH", "plan_name": "AETNA ALL OTHER PLANS", "methodology": "percent of total billed charges", "standard_charge_dollar": 2080.0, "standard_charge_percentage": 52.0, "count": "0", "additional_payer_notes": "Zero final payments for the item or service in the 15 months prior to posting the file." }, { "payer_name": "BLUE SHIELD OUT OF STATE", "plan_name": "STANFORD HEALTHCARE ALLIANCE PLAN", "methodology": "percent of total billed charges", "standard_charge_dollar": 1943.6, "standard_charge_percentage": 48.59, "count": "0", "additional_payer_notes": "Zero final payments for the item or service in the 15 months prior to posting the file." }, { "payer_name": "BLUE SHIELD", "plan_name": "STANFORD HEALTHCARE ALLIANCE PLAN", "methodology": "percent of total billed charges", "standard_charge_dollar": 1943.6, "standard_charge_percentage": 48.59, "count": "0", "additional_payer_notes": "Zero final payments for the item or service in the 15 months prior to posting the file." }, { "payer_name": "BLUE SHIELD", "plan_name": "STANFORD HEALTHCARE ALLIANCE PLAN", "methodology": "percent of total billed charges", "standard_charge_dollar": 1943.6, "standard_charge_percentage": 48.59, "count": "0", "additional_payer_notes": "Zero final payments for the item or service in the 15 months prior to posting the file." }, { "payer_name": "BLUE SHIELD", "plan_name": "STANFORD HEALTHCARE ALLIANCE PLAN", "methodology": "percent of total billed charges", "standard_charge_dollar": 1943.6, "standard_charge_percentage": 48.59, "count": "0", "additional_payer_notes": "Zero final payments for the item or service in the 15 months prior to posting the file." }, { "payer_name": "CIGNA", "plan_name": "CIGNA COM ALT HMO PLAN", "methodology": "percent of total billed charges", "standard_charge_dollar": 1688.0, "standard_charge_percentage": 42.2, "count": "0", "additional_payer_notes": "Zero final payments for the item or service in the 15 months prior to posting the file." }, { "payer_name": "CIGNA", "plan_name": "CIGNA COM ALT HMO PLAN", "methodology": "percent of total billed charges", "standard_charge_dollar": 1688.0, "standard_charge_percentage": 42.2, "count": "0", "additional_payer_notes": "Zero final payments for the item or service in the 15 months prior to posting the file." }, { "payer_name": "HEALTH NET", "plan_name": "HEALTHNET HMO, PPO, POS, EPO, CANOPY HEALTHNET HMO, OTHER-IN-NETWORK PLANS", "methodology": "per diem", "standard_charge_dollar": 8000.0, "standard_charge_algorithm": "Expected reimbursement is the lesser of Per diem ($8,000) for the length of stay and 70% of billed.", "count": "0", "additional_payer_notes": "Zero final payments for the item or service in the 15 months prior to posting the file." }, { "payer_name": "HEALTH NET", "plan_name": "HEALTHNET HMO, PPO, POS, EPO, CANOPY HEALTHNET HMO, OTHER-IN-NETWORK PLANS", "methodology": "per diem", "standard_charge_dollar": 8000.0, "standard_charge_algorithm": "Expected reimbursement is the lesser of Per diem ($8,000) for the length of stay and 70% of billed.", "count": "0", "additional_payer_notes": "Zero final payments for the item or service in the 15 months prior to posting the file." }, { "payer_name": "UNITED HEALTHCARE", "plan_name": "SUTTER SELECT & SUTTER HEALTH PLAN HMO PLANS", "methodology": "per diem", "standard_charge_dollar": 28538.0, "standard_charge_algorithm": "Per diem ($28,538).", "count": "0", "additional_payer_notes": "Zero final payments for the item or service in the 15 months prior to posting the file." }, { "payer_name": "UNITED HEALTHCARE", "plan_name": "SUTTER SELECT & SUTTER HEALTH PLAN HMO PLANS", "methodology": "per diem", "standard_charge_dollar": 28538.0, "standard_charge_algorithm": "Per diem ($28,538).", "count": "0", "additional_payer_notes": "Zero final payments for the item or service in the 15 months prior to posting the file." }, { "payer_name": "SUTTER", "plan_name": "SUTTER SELECT & SUTTER HEALTH PLAN HMO PLANS", "methodology": "per diem", "standard_charge_dollar": 28538.0, "standard_charge_algorithm": "Per diem ($28,538).", "count": "0", "additional_payer_notes": "Zero final payments for the item or service in the 15 months prior to posting the file." }, { "payer_name": "UNITED HEALTHCARE", "plan_name": "SUTTER SELECT & SUTTER HEALTH PLAN HMO PLANS", "methodology": "per diem", "standard_charge_dollar": 28538.0, "standard_charge_algorithm": "Per diem ($28,538).", "count": "0", "additional_payer_notes": "Zero final payments for the item or service in the 15 months prior to posting the file." }, { "payer_name": "UMR", "plan_name": "SUTTER SELECT & SUTTER HEALTH PLAN HMO PLANS", "methodology": "per diem", "standard_charge_dollar": 28538.0, "standard_charge_algorithm": "Per diem ($28,538).", "count": "0", "additional_payer_notes": "Zero final payments for the item or service in the 15 months prior to posting the file." }, { "payer_name": "UNITED HEALTHCARE", "plan_name": "SUTTER SELECT & SUTTER HEALTH PLAN HMO PLANS", "methodology": "per diem", "standard_charge_dollar": 28538.0, "standard_charge_algorithm": "Per diem ($28,538).", "count": "0", "additional_payer_notes": "Zero final payments for the item or service in the 15 months prior to posting the file." } ] } ] }, { "description": "HC Cath Intraspinal Gp025", "code_information": [ { "code": "PX-2120034025", "type": "CDM" }, { "code": "C1755", "type": "HCPCS" }, { "code": "0272", "type": "RC" } ], "standard_charges": [ { "setting": "outpatient", "gross_charge": 4263.0, "discounted_cash": 2131.5, "minimum": 1798.99, "maximum": 2216.76, "additional_generic_notes": "Zero final payments for the item or service in the 15 months prior to posting the file.", "payers_information": [ { "payer_name": "AETNA", "plan_name": "AETNA ALL OTHER PLANS", "methodology": "percent of total billed charges", "standard_charge_dollar": 2216.76, "standard_charge_percentage": 52.0, "count": "0", "additional_payer_notes": "Zero final payments for the item or service in the 15 months prior to posting the file." }, { "payer_name": "AETNA", "plan_name": "AETNA ALL OTHER PLANS", "methodology": "percent of total billed charges", "standard_charge_dollar": 2216.76, "standard_charge_percentage": 52.0, "count": "0", "additional_payer_notes": "Zero final payments for the item or service in the 15 months prior to posting the file." }, { "payer_name": "MERITAIN HEALTH", "plan_name": "AETNA ALL OTHER PLANS", "methodology": "percent of total billed charges", "standard_charge_dollar": 2216.76, "standard_charge_percentage": 52.0, "count": "0", "additional_payer_notes": "Zero final payments for the item or service in the 15 months prior to posting the file." }, { "payer_name": "BLUE SHIELD OUT OF STATE", "plan_name": "STANFORD HEALTHCARE ALLIANCE PLAN", "methodology": "percent of total billed charges", "standard_charge_dollar": 2071.39, "standard_charge_percentage": 48.59, "count": "0", "additional_payer_notes": "Zero final payments for the item or service in the 15 months prior to posting the file." }, { "payer_name": "BLUE SHIELD", "plan_name": "STANFORD HEALTHCARE ALLIANCE PLAN", "methodology": "percent of total billed charges", "standard_charge_dollar": 2071.39, "standard_charge_percentage": 48.59, "count": "0", "additional_payer_notes": "Zero final payments for the item or service in the 15 months prior to posting the file." }, { "payer_name": "BLUE SHIELD", "plan_name": "STANFORD HEALTHCARE ALLIANCE PLAN", "methodology": "percent of total billed charges", "standard_charge_dollar": 2071.39, "standard_charge_percentage": 48.59, "count": "0", "additional_payer_notes": "Zero final payments for the item or service in the 15 months prior to posting the file." }, { "payer_name": "BLUE SHIELD", "plan_name": "STANFORD HEALTHCARE ALLIANCE PLAN", "methodology": "percent of total billed charges", "standard_charge_dollar": 2071.39, "standard_charge_percentage": 48.59, "count": "0", "additional_payer_notes": "Zero final payments for the item or service in the 15 months prior to posting the file." }, { "payer_name": "CIGNA", "plan_name": "CIGNA COM ALT HMO PLAN", "methodology": "percent of total billed charges", "standard_charge_dollar": 1798.99, "standard_charge_percentage": 42.2, "count": "0", "additional_payer_notes": "Zero final payments for the item or service in the 15 months prior to posting the file." }, { "payer_name": "CIGNA", "plan_name": "CIGNA COM ALT HMO PLAN", "methodology": "percent of total billed charges", "standard_charge_dollar": 1798.99, "standard_charge_percentage": 42.2, "count": "0", "additional_payer_notes": "Zero final payments for the item or service in the 15 months prior to posting the file." }, { "payer_name": "HEALTH NET", "plan_name": "HEALTHNET HMO, PPO, POS, EPO, CANOPY HEALTHNET HMO, OTHER-IN-NETWORK PLANS", "methodology": "per diem", "standard_charge_dollar": 8000.0, "standard_charge_algorithm": "Expected reimbursement is the lesser of Per diem ($8,000) for the length of stay and 70% of billed.", "count": "0", "additional_payer_notes": "Zero final payments for the item or service in the 15 months prior to posting the file." }, { "payer_name": "HEALTH NET", "plan_name": "HEALTHNET HMO, PPO, POS, EPO, CANOPY HEALTHNET HMO, OTHER-IN-NETWORK PLANS", "methodology": "per diem", "standard_charge_dollar": 8000.0, "standard_charge_algorithm": "Expected reimbursement is the lesser of Per diem ($8,000) for the length of stay and 70% of billed.", "count": "0", "additional_payer_notes": "Zero final payments for the item or service in the 15 months prior to posting the file." }, { "payer_name": "UNITED HEALTHCARE", "plan_name": "SUTTER SELECT & SUTTER HEALTH PLAN HMO PLANS", "methodology": "per diem", "standard_charge_dollar": 28538.0, "standard_charge_algorithm": "Per diem ($28,538).", "count": "0", "additional_payer_notes": "Zero final payments for the item or service in the 15 months prior to posting the file." }, { "payer_name": "UNITED HEALTHCARE", "plan_name": "SUTTER SELECT & SUTTER HEALTH PLAN HMO PLANS", "methodology": "per diem", "standard_charge_dollar": 28538.0, "standard_charge_algorithm": "Per diem ($28,538).", "count": "0", "additional_payer_notes": "Zero final payments for the item or service in the 15 months prior to posting the file." }, { "payer_name": "SUTTER", "plan_name": "SUTTER SELECT & SUTTER HEALTH PLAN HMO PLANS", "methodology": "per diem", "standard_charge_dollar": 28538.0, "standard_charge_algorithm": "Per diem ($28,538).", "count": "0", "additional_payer_notes": "Zero final payments for the item or service in the 15 months prior to posting the file." }, { "payer_name": "UNITED HEALTHCARE", "plan_name": "SUTTER SELECT & SUTTER HEALTH PLAN HMO PLANS", "methodology": "per diem", "standard_charge_dollar": 28538.0, "standard_charge_algorithm": "Per diem ($28,538).", "count": "0", "additional_payer_notes": "Zero final payments for the item or service in the 15 months prior to posting the file." }, { "payer_name": "UMR", "plan_name": "SUTTER SELECT & SUTTER HEALTH PLAN HMO PLANS", "methodology": "per diem", "standard_charge_dollar": 28538.0, "standard_charge_algorithm": "Per diem ($28,538).", "count": "0", "additional_payer_notes": "Zero final payments for the item or service in the 15 months prior to posting the file." }, { "payer_name": "UNITED HEALTHCARE", "plan_name": "SUTTER SELECT & SUTTER HEALTH PLAN HMO PLANS", "methodology": "per diem", "standard_charge_dollar": 28538.0, "standard_charge_algorithm": "Per diem ($28,538).", "count": "0", "additional_payer_notes": "Zero final payments for the item or service in the 15 months prior to posting the file." } ] } ] }, { "description": "HC Cath Intraspinal Gp034", "code_information": [ { "code": "PX-2120034034", "type": "CDM" }, { "code": "C1755", "type": "HCPCS" }, { "code": "0272", "type": "RC" } ], "standard_charges": [ { "setting": "outpatient", "gross_charge": 6750.0, "discounted_cash": 3375.0, "minimum": 2848.5, "maximum": 3510.0, "additional_generic_notes": "Zero final payments for the item or service in the 15 months prior to posting the file.", "payers_information": [ { "payer_name": "AETNA", "plan_name": "AETNA ALL OTHER PLANS", "methodology": "percent of total billed charges", "standard_charge_dollar": 3510.0, "standard_charge_percentage": 52.0, "count": "0", "additional_payer_notes": "Zero final payments for the item or service in the 15 months prior to posting the file." }, { "payer_name": "AETNA", "plan_name": "AETNA ALL OTHER PLANS", "methodology": "percent of total billed charges", "standard_charge_dollar": 3510.0, "standard_charge_percentage": 52.0, "count": "0", "additional_payer_notes": "Zero final payments for the item or service in the 15 months prior to posting the file." }, { "payer_name": "MERITAIN HEALTH", "plan_name": "AETNA ALL OTHER PLANS", "methodology": "percent of total billed charges", "standard_charge_dollar": 3510.0, "standard_charge_percentage": 52.0, "count": "0", "additional_payer_notes": "Zero final payments for the item or service in the 15 months prior to posting the file." }, { "payer_name": "BLUE SHIELD OUT OF STATE", "plan_name": "STANFORD HEALTHCARE ALLIANCE PLAN", "methodology": "percent of total billed charges", "standard_charge_dollar": 3279.83, "standard_charge_percentage": 48.59, "count": "0", "additional_payer_notes": "Zero final payments for the item or service in the 15 months prior to posting the file." }, { "payer_name": "BLUE SHIELD", "plan_name": "STANFORD HEALTHCARE ALLIANCE PLAN", "methodology": "percent of total billed charges", "standard_charge_dollar": 3279.83, "standard_charge_percentage": 48.59, "count": "0", "additional_payer_notes": "Zero final payments for the item or service in the 15 months prior to posting the file." }, { "payer_name": "BLUE SHIELD", "plan_name": "STANFORD HEALTHCARE ALLIANCE PLAN", "methodology": "percent of total billed charges", "standard_charge_dollar": 3279.83, "standard_charge_percentage": 48.59, "count": "0", "additional_payer_notes": "Zero final payments for the item or service in the 15 months prior to posting the file." }, { "payer_name": "BLUE SHIELD", "plan_name": "STANFORD HEALTHCARE ALLIANCE PLAN", "methodology": "percent of total billed charges", "standard_charge_dollar": 3279.83, "standard_charge_percentage": 48.59, "count": "0", "additional_payer_notes": "Zero final payments for the item or service in the 15 months prior to posting the file." }, { "payer_name": "CIGNA", "plan_name": "CIGNA COM ALT HMO PLAN", "methodology": "percent of total billed charges", "standard_charge_dollar": 2848.5, "standard_charge_percentage": 42.2, "count": "0", "additional_payer_notes": "Zero final payments for the item or service in the 15 months prior to posting the file." }, { "payer_name": "CIGNA", "plan_name": "CIGNA COM ALT HMO PLAN", "methodology": "percent of total billed charges", "standard_charge_dollar": 2848.5, "standard_charge_percentage": 42.2, "count": "0", "additional_payer_notes": "Zero final payments for the item or service in the 15 months prior to posting the file." }, { "payer_name": "HEALTH NET", "plan_name": "HEALTHNET HMO, PPO, POS, EPO, CANOPY HEALTHNET HMO, OTHER-IN-NETWORK PLANS", "methodology": "per diem", "standard_charge_dollar": 8000.0, "standard_charge_algorithm": "Expected reimbursement is the lesser of Per diem ($8,000) for the length of stay and 70% of billed.", "count": "0", "additional_payer_notes": "Zero final payments for the item or service in the 15 months prior to posting the file." }, { "payer_name": "HEALTH NET", "plan_name": "HEALTHNET HMO, PPO, POS, EPO, CANOPY HEALTHNET HMO, OTHER-IN-NETWORK PLANS", "methodology": "per diem", "standard_charge_dollar": 8000.0, "standard_charge_algorithm": "Expected reimbursement is the lesser of Per diem ($8,000) for the length of stay and 70% of billed.", "count": "0", "additional_payer_notes": "Zero final payments for the item or service in the 15 months prior to posting the file." }, { "payer_name": "UNITED HEALTHCARE", "plan_name": "SUTTER SELECT & SUTTER HEALTH PLAN HMO PLANS", "methodology": "per diem", "standard_charge_dollar": 28538.0, "standard_charge_algorithm": "Per diem ($28,538).", "count": "0", "additional_payer_notes": "Zero final payments for the item or service in the 15 months prior to posting the file." }, { "payer_name": "UNITED HEALTHCARE", "plan_name": "SUTTER SELECT & SUTTER HEALTH PLAN HMO PLANS", "methodology": "per diem", "standard_charge_dollar": 28538.0, "standard_charge_algorithm": "Per diem ($28,538).", "count": "0", "additional_payer_notes": "Zero final payments for the item or service in the 15 months prior to posting the file." }, { "payer_name": "SUTTER", "plan_name": "SUTTER SELECT & SUTTER HEALTH PLAN HMO PLANS", "methodology": "per diem", "standard_charge_dollar": 28538.0, "standard_charge_algorithm": "Per diem ($28,538).", "count": "0", "additional_payer_notes": "Zero final payments for the item or service in the 15 months prior to posting the file." }, { "payer_name": "UNITED HEALTHCARE", "plan_name": "SUTTER SELECT & SUTTER HEALTH PLAN HMO PLANS", "methodology": "per diem", "standard_charge_dollar": 28538.0, "standard_charge_algorithm": "Per diem ($28,538).", "count": "0", "additional_payer_notes": "Zero final payments for the item or service in the 15 months prior to posting the file." }, { "payer_name": "UMR", "plan_name": "SUTTER SELECT & SUTTER HEALTH PLAN HMO PLANS", "methodology": "per diem", "standard_charge_dollar": 28538.0, "standard_charge_algorithm": "Per diem ($28,538).", "count": "0", "additional_payer_notes": "Zero final payments for the item or service in the 15 months prior to posting the file." }, { "payer_name": "UNITED HEALTHCARE", "plan_name": "SUTTER SELECT & SUTTER HEALTH PLAN HMO PLANS", "methodology": "per diem", "standard_charge_dollar": 28538.0, "standard_charge_algorithm": "Per diem ($28,538).", "count": "0", "additional_payer_notes": "Zero final payments for the item or service in the 15 months prior to posting the file." } ] } ] }, { "description": "HC Cath Ped Ultramer Gp002", "code_information": [ { "code": "PX-2120035002", "type": "CDM" }, { "code": "99999", "type": "CPT" }, { "code": "0272", "type": "RC" } ], "standard_charges": [ { "setting": "outpatient", "gross_charge": 50.0, "discounted_cash": 25.0, "minimum": 21.1, "maximum": 26.0, "additional_generic_notes": "Zero final payments for the item or service in the 15 months prior to posting the file.", "payers_information": [ { "payer_name": "AETNA", "plan_name": "AETNA ALL OTHER PLANS", "methodology": "percent of total billed charges", "standard_charge_dollar": 26.0, "standard_charge_percentage": 52.0, "count": "0", "additional_payer_notes": "Zero final payments for the item or service in the 15 months prior to posting the file." }, { "payer_name": "AETNA", "plan_name": "AETNA ALL OTHER PLANS", "methodology": "percent of total billed charges", "standard_charge_dollar": 26.0, "standard_charge_percentage": 52.0, "count": "0", "additional_payer_notes": "Zero final payments for the item or service in the 15 months prior to posting the file." }, { "payer_name": "MERITAIN HEALTH", "plan_name": "AETNA ALL OTHER PLANS", "methodology": "percent of total billed charges", "standard_charge_dollar": 26.0, "standard_charge_percentage": 52.0, "count": "0", "additional_payer_notes": "Zero final payments for the item or service in the 15 months prior to posting the file." }, { "payer_name": "BLUE SHIELD OUT OF STATE", "plan_name": "STANFORD HEALTHCARE ALLIANCE PLAN", "methodology": "percent of total billed charges", "standard_charge_dollar": 24.3, "standard_charge_percentage": 48.59, "count": "0", "additional_payer_notes": "Zero final payments for the item or service in the 15 months prior to posting the file." }, { "payer_name": "BLUE SHIELD", "plan_name": "STANFORD HEALTHCARE ALLIANCE PLAN", "methodology": "percent of total billed charges", "standard_charge_dollar": 24.3, "standard_charge_percentage": 48.59, "count": "0", "additional_payer_notes": "Zero final payments for the item or service in the 15 months prior to posting the file." }, { "payer_name": "BLUE SHIELD", "plan_name": "STANFORD HEALTHCARE ALLIANCE PLAN", "methodology": "percent of total billed charges", "standard_charge_dollar": 24.3, "standard_charge_percentage": 48.59, "count": "0", "additional_payer_notes": "Zero final payments for the item or service in the 15 months prior to posting the file." }, { "payer_name": "CIGNA", "plan_name": "CIGNA COM ALT HMO PLAN", "methodology": "percent of total billed charges", "standard_charge_dollar": 21.1, "standard_charge_percentage": 42.2, "count": "0", "additional_payer_notes": "Zero final payments for the item or service in the 15 months prior to posting the file." }, { "payer_name": "CIGNA", "plan_name": "CIGNA COM ALT HMO PLAN", "methodology": "percent of total billed charges", "standard_charge_dollar": 21.1, "standard_charge_percentage": 42.2, "count": "0", "additional_payer_notes": "Zero final payments for the item or service in the 15 months prior to posting the file." }, { "payer_name": "HEALTH NET", "plan_name": "HEALTHNET HMO, PPO, POS, EPO, CANOPY HEALTHNET HMO, OTHER-IN-NETWORK PLANS", "methodology": "per diem", "standard_charge_dollar": 8000.0, "standard_charge_algorithm": "Expected reimbursement is the lesser of Per diem ($8,000) for the length of stay and 70% of billed.", "count": "0", "additional_payer_notes": "Zero final payments for the item or service in the 15 months prior to posting the file." }, { "payer_name": "HEALTH NET", "plan_name": "HEALTHNET HMO, PPO, POS, EPO, CANOPY HEALTHNET HMO, OTHER-IN-NETWORK PLANS", "methodology": "per diem", "standard_charge_dollar": 8000.0, "standard_charge_algorithm": "Expected reimbursement is the lesser of Per diem ($8,000) for the length of stay and 70% of billed.", "count": "0", "additional_payer_notes": "Zero final payments for the item or service in the 15 months prior to posting the file." }, { "payer_name": "UNITED HEALTHCARE", "plan_name": "SUTTER SELECT & SUTTER HEALTH PLAN HMO PLANS", "methodology": "per diem", "standard_charge_dollar": 28538.0, "standard_charge_algorithm": "Per diem ($28,538).", "count": "0", "additional_payer_notes": "Zero final payments for the item or service in the 15 months prior to posting the file." }, { "payer_name": "UNITED HEALTHCARE", "plan_name": "SUTTER SELECT & SUTTER HEALTH PLAN HMO PLANS", "methodology": "per diem", "standard_charge_dollar": 28538.0, "standard_charge_algorithm": "Per diem ($28,538).", "count": "0", "additional_payer_notes": "Zero final payments for the item or service in the 15 months prior to posting the file." }, { "payer_name": "SUTTER", "plan_name": "SUTTER SELECT & SUTTER HEALTH PLAN HMO PLANS", "methodology": "per diem", "standard_charge_dollar": 28538.0, "standard_charge_algorithm": "Per diem ($28,538).", "count": "0", "additional_payer_notes": "Zero final payments for the item or service in the 15 months prior to posting the file." }, { "payer_name": "UNITED HEALTHCARE", "plan_name": "SUTTER SELECT & SUTTER HEALTH PLAN HMO PLANS", "methodology": "per diem", "standard_charge_dollar": 28538.0, "standard_charge_algorithm": "Per diem ($28,538).", "count": "0", "additional_payer_notes": "Zero final payments for the item or service in the 15 months prior to posting the file." }, { "payer_name": "UMR", "plan_name": "SUTTER SELECT & SUTTER HEALTH PLAN HMO PLANS", "methodology": "per diem", "standard_charge_dollar": 28538.0, "standard_charge_algorithm": "Per diem ($28,538).", "count": "0", "additional_payer_notes": "Zero final payments for the item or service in the 15 months prior to posting the file." } ] } ] }, { "description": "HC Cath Ped Ultramer Gp003", "code_information": [ { "code": "PX-2120035003", "type": "CDM" }, { "code": "99999", "type": "CPT" }, { "code": "0272", "type": "RC" } ], "standard_charges": [ { "setting": "outpatient", "gross_charge": 100.0, "discounted_cash": 50.0, "minimum": 42.2, "maximum": 52.0, "additional_generic_notes": "Zero final payments for the item or service in the 15 months prior to posting the file.", "payers_information": [ { "payer_name": "AETNA", "plan_name": "AETNA ALL OTHER PLANS", "methodology": "percent of total billed charges", "standard_charge_dollar": 52.0, "standard_charge_percentage": 52.0, "count": "0", "additional_payer_notes": "Zero final payments for the item or service in the 15 months prior to posting the file." }, { "payer_name": "AETNA", "plan_name": "AETNA ALL OTHER PLANS", "methodology": "percent of total billed charges", "standard_charge_dollar": 52.0, "standard_charge_percentage": 52.0, "count": "0", "additional_payer_notes": "Zero final payments for the item or service in the 15 months prior to posting the file." }, { "payer_name": "MERITAIN HEALTH", "plan_name": "AETNA ALL OTHER PLANS", "methodology": "percent of total billed charges", "standard_charge_dollar": 52.0, "standard_charge_percentage": 52.0, "count": "0", "additional_payer_notes": "Zero final payments for the item or service in the 15 months prior to posting the file." }, { "payer_name": "BLUE SHIELD OUT OF STATE", "plan_name": "STANFORD HEALTHCARE ALLIANCE PLAN", "methodology": "percent of total billed charges", "standard_charge_dollar": 48.59, "standard_charge_percentage": 48.59, "count": "0", "additional_payer_notes": "Zero final payments for the item or service in the 15 months prior to posting the file." }, { "payer_name": "BLUE SHIELD", "plan_name": "STANFORD HEALTHCARE ALLIANCE PLAN", "methodology": "percent of total billed charges", "standard_charge_dollar": 48.59, "standard_charge_percentage": 48.59, "count": "0", "additional_payer_notes": "Zero final payments for the item or service in the 15 months prior to posting the file." }, { "payer_name": "BLUE SHIELD", "plan_name": "STANFORD HEALTHCARE ALLIANCE PLAN", "methodology": "percent of total billed charges", "standard_charge_dollar": 48.59, "standard_charge_percentage": 48.59, "count": "0", "additional_payer_notes": "Zero final payments for the item or service in the 15 months prior to posting the file." }, { "payer_name": "CIGNA", "plan_name": "CIGNA COM ALT HMO PLAN", "methodology": "percent of total billed charges", "standard_charge_dollar": 42.2, "standard_charge_percentage": 42.2, "count": "0", "additional_payer_notes": "Zero final payments for the item or service in the 15 months prior to posting the file." }, { "payer_name": "CIGNA", "plan_name": "CIGNA COM ALT HMO PLAN", "methodology": "percent of total billed charges", "standard_charge_dollar": 42.2, "standard_charge_percentage": 42.2, "count": "0", "additional_payer_notes": "Zero final payments for the item or service in the 15 months prior to posting the file." }, { "payer_name": "HEALTH NET", "plan_name": "HEALTHNET HMO, PPO, POS, EPO, CANOPY HEALTHNET HMO, OTHER-IN-NETWORK PLANS", "methodology": "per diem", "standard_charge_dollar": 8000.0, "standard_charge_algorithm": "Expected reimbursement is the lesser of Per diem ($8,000) for the length of stay and 70% of billed.", "count": "0", "additional_payer_notes": "Zero final payments for the item or service in the 15 months prior to posting the file." }, { "payer_name": "HEALTH NET", "plan_name": "HEALTHNET HMO, PPO, POS, EPO, CANOPY HEALTHNET HMO, OTHER-IN-NETWORK PLANS", "methodology": "per diem", "standard_charge_dollar": 8000.0, "standard_charge_algorithm": "Expected reimbursement is the lesser of Per diem ($8,000) for the length of stay and 70% of billed.", "count": "0", "additional_payer_notes": "Zero final payments for the item or service in the 15 months prior to posting the file." }, { "payer_name": "UNITED HEALTHCARE", "plan_name": "SUTTER SELECT & SUTTER HEALTH PLAN HMO PLANS", "methodology": "per diem", "standard_charge_dollar": 28538.0, "standard_charge_algorithm": "Per diem ($28,538).", "count": "0", "additional_payer_notes": "Zero final payments for the item or service in the 15 months prior to posting the file." }, { "payer_name": "UNITED HEALTHCARE", "plan_name": "SUTTER SELECT & SUTTER HEALTH PLAN HMO PLANS", "methodology": "per diem", "standard_charge_dollar": 28538.0, "standard_charge_algorithm": "Per diem ($28,538).", "count": "0", "additional_payer_notes": "Zero final payments for the item or service in the 15 months prior to posting the file." }, { "payer_name": "SUTTER", "plan_name": "SUTTER SELECT & SUTTER HEALTH PLAN HMO PLANS", "methodology": "per diem", "standard_charge_dollar": 28538.0, "standard_charge_algorithm": "Per diem ($28,538).", "count": "0", "additional_payer_notes": "Zero final payments for the item or service in the 15 months prior to posting the file." }, { "payer_name": "UNITED HEALTHCARE", "plan_name": "SUTTER SELECT & SUTTER HEALTH PLAN HMO PLANS", "methodology": "per diem", "standard_charge_dollar": 28538.0, "standard_charge_algorithm": "Per diem ($28,538).", "count": "0", "additional_payer_notes": "Zero final payments for the item or service in the 15 months prior to posting the file." }, { "payer_name": "UMR", "plan_name": "SUTTER SELECT & SUTTER HEALTH PLAN HMO PLANS", "methodology": "per diem", "standard_charge_dollar": 28538.0, "standard_charge_algorithm": "Per diem ($28,538).", "count": "0", "additional_payer_notes": "Zero final payments for the item or service in the 15 months prior to posting the file." } ] } ] }, { "description": "HC Impl Cath Perit/Hemodial Gp012", "code_information": [ { "code": "PX-2120036012", "type": "CDM" }, { "code": "99999", "type": "CPT" }, { "code": "0272", "type": "RC" } ], "standard_charges": [ { "setting": "outpatient", "gross_charge": 810.0, "discounted_cash": 405.0, "minimum": 341.82, "maximum": 421.2, "additional_generic_notes": "Zero final payments for the item or service in the 15 months prior to posting the file.", "payers_information": [ { "payer_name": "AETNA", "plan_name": "AETNA ALL OTHER PLANS", "methodology": "percent of total billed charges", "standard_charge_dollar": 421.2, "standard_charge_percentage": 52.0, "count": "0", "additional_payer_notes": "Zero final payments for the item or service in the 15 months prior to posting the file." }, { "payer_name": "AETNA", "plan_name": "AETNA ALL OTHER PLANS", "methodology": "percent of total billed charges", "standard_charge_dollar": 421.2, "standard_charge_percentage": 52.0, "count": "0", "additional_payer_notes": "Zero final payments for the item or service in the 15 months prior to posting the file." }, { "payer_name": "MERITAIN HEALTH", "plan_name": "AETNA ALL OTHER PLANS", "methodology": "percent of total billed charges", "standard_charge_dollar": 421.2, "standard_charge_percentage": 52.0, "count": "0", "additional_payer_notes": "Zero final payments for the item or service in the 15 months prior to posting the file." }, { "payer_name": "BLUE SHIELD OUT OF STATE", "plan_name": "STANFORD HEALTHCARE ALLIANCE PLAN", "methodology": "percent of total billed charges", "standard_charge_dollar": 393.58, "standard_charge_percentage": 48.59, "count": "0", "additional_payer_notes": "Zero final payments for the item or service in the 15 months prior to posting the file." }, { "payer_name": "BLUE SHIELD", "plan_name": "STANFORD HEALTHCARE ALLIANCE PLAN", "methodology": "percent of total billed charges", "standard_charge_dollar": 393.58, "standard_charge_percentage": 48.59, "count": "0", "additional_payer_notes": "Zero final payments for the item or service in the 15 months prior to posting the file." }, { "payer_name": "BLUE SHIELD", "plan_name": "STANFORD HEALTHCARE ALLIANCE PLAN", "methodology": "percent of total billed charges", "standard_charge_dollar": 393.58, "standard_charge_percentage": 48.59, "count": "0", "additional_payer_notes": "Zero final payments for the item or service in the 15 months prior to posting the file." }, { "payer_name": "CIGNA", "plan_name": "CIGNA COM ALT HMO PLAN", "methodology": "percent of total billed charges", "standard_charge_dollar": 341.82, "standard_charge_percentage": 42.2, "count": "0", "additional_payer_notes": "Zero final payments for the item or service in the 15 months prior to posting the file." }, { "payer_name": "CIGNA", "plan_name": "CIGNA COM ALT HMO PLAN", "methodology": "percent of total billed charges", "standard_charge_dollar": 341.82, "standard_charge_percentage": 42.2, "count": "0", "additional_payer_notes": "Zero final payments for the item or service in the 15 months prior to posting the file." }, { "payer_name": "HEALTH NET", "plan_name": "HEALTHNET HMO, PPO, POS, EPO, CANOPY HEALTHNET HMO, OTHER-IN-NETWORK PLANS", "methodology": "per diem", "standard_charge_dollar": 8000.0, "standard_charge_algorithm": "Expected reimbursement is the lesser of Per diem ($8,000) for the length of stay and 70% of billed.", "count": "0", "additional_payer_notes": "Zero final payments for the item or service in the 15 months prior to posting the file." }, { "payer_name": "HEALTH NET", "plan_name": "HEALTHNET HMO, PPO, POS, EPO, CANOPY HEALTHNET HMO, OTHER-IN-NETWORK PLANS", "methodology": "per diem", "standard_charge_dollar": 8000.0, "standard_charge_algorithm": "Expected reimbursement is the lesser of Per diem ($8,000) for the length of stay and 70% of billed.", "count": "0", "additional_payer_notes": "Zero final payments for the item or service in the 15 months prior to posting the file." }, { "payer_name": "UNITED HEALTHCARE", "plan_name": "SUTTER SELECT & SUTTER HEALTH PLAN HMO PLANS", "methodology": "per diem", "standard_charge_dollar": 28538.0, "standard_charge_algorithm": "Per diem ($28,538).", "count": "0", "additional_payer_notes": "Zero final payments for the item or service in the 15 months prior to posting the file." }, { "payer_name": "UNITED HEALTHCARE", "plan_name": "SUTTER SELECT & SUTTER HEALTH PLAN HMO PLANS", "methodology": "per diem", "standard_charge_dollar": 28538.0, "standard_charge_algorithm": "Per diem ($28,538).", "count": "0", "additional_payer_notes": "Zero final payments for the item or service in the 15 months prior to posting the file." }, { "payer_name": "SUTTER", "plan_name": "SUTTER SELECT & SUTTER HEALTH PLAN HMO PLANS", "methodology": "per diem", "standard_charge_dollar": 28538.0, "standard_charge_algorithm": "Per diem ($28,538).", "count": "0", "additional_payer_notes": "Zero final payments for the item or service in the 15 months prior to posting the file." }, { "payer_name": "UNITED HEALTHCARE", "plan_name": "SUTTER SELECT & SUTTER HEALTH PLAN HMO PLANS", "methodology": "per diem", "standard_charge_dollar": 28538.0, "standard_charge_algorithm": "Per diem ($28,538).", "count": "0", "additional_payer_notes": "Zero final payments for the item or service in the 15 months prior to posting the file." }, { "payer_name": "UMR", "plan_name": "SUTTER SELECT & SUTTER HEALTH PLAN HMO PLANS", "methodology": "per diem", "standard_charge_dollar": 28538.0, "standard_charge_algorithm": "Per diem ($28,538).", "count": "0", "additional_payer_notes": "Zero final payments for the item or service in the 15 months prior to posting the file." } ] } ] }, { "description": "HC Cath Quinton Gp013", "code_information": [ { "code": "PX-2120037013", "type": "CDM" }, { "code": "99999", "type": "CPT" }, { "code": "0272", "type": "RC" } ], "standard_charges": [ { "setting": "outpatient", "gross_charge": 900.0, "discounted_cash": 450.0, "minimum": 379.8, "maximum": 468.0, "additional_generic_notes": "Zero final payments for the item or service in the 15 months prior to posting the file.", "payers_information": [ { "payer_name": "AETNA", "plan_name": "AETNA ALL OTHER PLANS", "methodology": "percent of total billed charges", "standard_charge_dollar": 468.0, "standard_charge_percentage": 52.0, "count": "0", "additional_payer_notes": "Zero final payments for the item or service in the 15 months prior to posting the file." }, { "payer_name": "AETNA", "plan_name": "AETNA ALL OTHER PLANS", "methodology": "percent of total billed charges", "standard_charge_dollar": 468.0, "standard_charge_percentage": 52.0, "count": "0", "additional_payer_notes": "Zero final payments for the item or service in the 15 months prior to posting the file." }, { "payer_name": "MERITAIN HEALTH", "plan_name": "AETNA ALL OTHER PLANS", "methodology": "percent of total billed charges", "standard_charge_dollar": 468.0, "standard_charge_percentage": 52.0, "count": "0", "additional_payer_notes": "Zero final payments for the item or service in the 15 months prior to posting the file." }, { "payer_name": "BLUE SHIELD OUT OF STATE", "plan_name": "STANFORD HEALTHCARE ALLIANCE PLAN", "methodology": "percent of total billed charges", "standard_charge_dollar": 437.31, "standard_charge_percentage": 48.59, "count": "0", "additional_payer_notes": "Zero final payments for the item or service in the 15 months prior to posting the file." }, { "payer_name": "BLUE SHIELD", "plan_name": "STANFORD HEALTHCARE ALLIANCE PLAN", "methodology": "percent of total billed charges", "standard_charge_dollar": 437.31, "standard_charge_percentage": 48.59, "count": "0", "additional_payer_notes": "Zero final payments for the item or service in the 15 months prior to posting the file." }, { "payer_name": "BLUE SHIELD", "plan_name": "STANFORD HEALTHCARE ALLIANCE PLAN", "methodology": "percent of total billed charges", "standard_charge_dollar": 437.31, "standard_charge_percentage": 48.59, "count": "0", "additional_payer_notes": "Zero final payments for the item or service in the 15 months prior to posting the file." }, { "payer_name": "CIGNA", "plan_name": "CIGNA COM ALT HMO PLAN", "methodology": "percent of total billed charges", "standard_charge_dollar": 379.8, "standard_charge_percentage": 42.2, "count": "0", "additional_payer_notes": "Zero final payments for the item or service in the 15 months prior to posting the file." }, { "payer_name": "CIGNA", "plan_name": "CIGNA COM ALT HMO PLAN", "methodology": "percent of total billed charges", "standard_charge_dollar": 379.8, "standard_charge_percentage": 42.2, "count": "0", "additional_payer_notes": "Zero final payments for the item or service in the 15 months prior to posting the file." }, { "payer_name": "HEALTH NET", "plan_name": "HEALTHNET HMO, PPO, POS, EPO, CANOPY HEALTHNET HMO, OTHER-IN-NETWORK PLANS", "methodology": "per diem", "standard_charge_dollar": 8000.0, "standard_charge_algorithm": "Expected reimbursement is the lesser of Per diem ($8,000) for the length of stay and 70% of billed.", "count": "0", "additional_payer_notes": "Zero final payments for the item or service in the 15 months prior to posting the file." }, { "payer_name": "HEALTH NET", "plan_name": "HEALTHNET HMO, PPO, POS, EPO, CANOPY HEALTHNET HMO, OTHER-IN-NETWORK PLANS", "methodology": "per diem", "standard_charge_dollar": 8000.0, "standard_charge_algorithm": "Expected reimbursement is the lesser of Per diem ($8,000) for the length of stay and 70% of billed.", "count": "0", "additional_payer_notes": "Zero final payments for the item or service in the 15 months prior to posting the file." }, { "payer_name": "UNITED HEALTHCARE", "plan_name": "SUTTER SELECT & SUTTER HEALTH PLAN HMO PLANS", "methodology": "per diem", "standard_charge_dollar": 28538.0, "standard_charge_algorithm": "Per diem ($28,538).", "count": "0", "additional_payer_notes": "Zero final payments for the item or service in the 15 months prior to posting the file." }, { "payer_name": "UNITED HEALTHCARE", "plan_name": "SUTTER SELECT & SUTTER HEALTH PLAN HMO PLANS", "methodology": "per diem", "standard_charge_dollar": 28538.0, "standard_charge_algorithm": "Per diem ($28,538).", "count": "0", "additional_payer_notes": "Zero final payments for the item or service in the 15 months prior to posting the file." }, { "payer_name": "SUTTER", "plan_name": "SUTTER SELECT & SUTTER HEALTH PLAN HMO PLANS", "methodology": "per diem", "standard_charge_dollar": 28538.0, "standard_charge_algorithm": "Per diem ($28,538).", "count": "0", "additional_payer_notes": "Zero final payments for the item or service in the 15 months prior to posting the file." }, { "payer_name": "UNITED HEALTHCARE", "plan_name": "SUTTER SELECT & SUTTER HEALTH PLAN HMO PLANS", "methodology": "per diem", "standard_charge_dollar": 28538.0, "standard_charge_algorithm": "Per diem ($28,538).", "count": "0", "additional_payer_notes": "Zero final payments for the item or service in the 15 months prior to posting the file." }, { "payer_name": "UMR", "plan_name": "SUTTER SELECT & SUTTER HEALTH PLAN HMO PLANS", "methodology": "per diem", "standard_charge_dollar": 28538.0, "standard_charge_algorithm": "Per diem ($28,538).", "count": "0", "additional_payer_notes": "Zero final payments for the item or service in the 15 months prior to posting the file." } ] } ] }, { "description": "HC Cath Quinton Gp014", "code_information": [ { "code": "PX-2120037014", "type": "CDM" }, { "code": "99999", "type": "CPT" }, { "code": "0272", "type": "RC" } ], "standard_charges": [ { "setting": "outpatient", "gross_charge": 1080.0, "discounted_cash": 540.0, "minimum": 455.76, "maximum": 561.6, "additional_generic_notes": "Zero final payments for the item or service in the 15 months prior to posting the file.", "payers_information": [ { "payer_name": "AETNA", "plan_name": "AETNA ALL OTHER PLANS", "methodology": "percent of total billed charges", "standard_charge_dollar": 561.6, "standard_charge_percentage": 52.0, "count": "0", "additional_payer_notes": "Zero final payments for the item or service in the 15 months prior to posting the file." }, { "payer_name": "AETNA", "plan_name": "AETNA ALL OTHER PLANS", "methodology": "percent of total billed charges", "standard_charge_dollar": 561.6, "standard_charge_percentage": 52.0, "count": "0", "additional_payer_notes": "Zero final payments for the item or service in the 15 months prior to posting the file." }, { "payer_name": "MERITAIN HEALTH", "plan_name": "AETNA ALL OTHER PLANS", "methodology": "percent of total billed charges", "standard_charge_dollar": 561.6, "standard_charge_percentage": 52.0, "count": "0", "additional_payer_notes": "Zero final payments for the item or service in the 15 months prior to posting the file." }, { "payer_name": "BLUE SHIELD OUT OF STATE", "plan_name": "STANFORD HEALTHCARE ALLIANCE PLAN", "methodology": "percent of total billed charges", "standard_charge_dollar": 524.77, "standard_charge_percentage": 48.59, "count": "0", "additional_payer_notes": "Zero final payments for the item or service in the 15 months prior to posting the file." }, { "payer_name": "BLUE SHIELD", "plan_name": "STANFORD HEALTHCARE ALLIANCE PLAN", "methodology": "percent of total billed charges", "standard_charge_dollar": 524.77, "standard_charge_percentage": 48.59, "median_amount": 68.24, "10th_percentile": 13.6, "90th_percentile": 1043.06, "count": "30" }, { "payer_name": "BLUE SHIELD", "plan_name": "STANFORD HEALTHCARE ALLIANCE PLAN", "methodology": "percent of total billed charges", "standard_charge_dollar": 524.77, "standard_charge_percentage": 48.59, "count": "0", "additional_payer_notes": "Zero final payments for the item or service in the 15 months prior to posting the file." }, { "payer_name": "BLUE SHIELD", "plan_name": "STANFORD HEALTHCARE ALLIANCE PLAN", "methodology": "percent of total billed charges", "standard_charge_dollar": 524.77, "standard_charge_percentage": 48.59, "count": "0", "additional_payer_notes": "Zero final payments for the item or service in the 15 months prior to posting the file." }, { "payer_name": "CIGNA", "plan_name": "CIGNA COM ALT HMO PLAN", "methodology": "percent of total billed charges", "standard_charge_dollar": 455.76, "standard_charge_percentage": 42.2, "count": "0", "additional_payer_notes": "Zero final payments for the item or service in the 15 months prior to posting the file." }, { "payer_name": "CIGNA", "plan_name": "CIGNA COM ALT HMO PLAN", "methodology": "percent of total billed charges", "standard_charge_dollar": 455.76, "standard_charge_percentage": 42.2, "count": "0", "additional_payer_notes": "Zero final payments for the item or service in the 15 months prior to posting the file." }, { "payer_name": "HEALTH NET", "plan_name": "HEALTHNET HMO, PPO, POS, EPO, CANOPY HEALTHNET HMO, OTHER-IN-NETWORK PLANS", "methodology": "per diem", "standard_charge_dollar": 8000.0, "standard_charge_algorithm": "Expected reimbursement is the lesser of Per diem ($8,000) for the length of stay and 70% of billed.", "count": "0", "additional_payer_notes": "Zero final payments for the item or service in the 15 months prior to posting the file." }, { "payer_name": "HEALTH NET", "plan_name": "HEALTHNET HMO, PPO, POS, EPO, CANOPY HEALTHNET HMO, OTHER-IN-NETWORK PLANS", "methodology": "per diem", "standard_charge_dollar": 8000.0, "standard_charge_algorithm": "Expected reimbursement is the lesser of Per diem ($8,000) for the length of stay and 70% of billed.", "count": "0", "additional_payer_notes": "Zero final payments for the item or service in the 15 months prior to posting the file." }, { "payer_name": "UNITED HEALTHCARE", "plan_name": "SUTTER SELECT & SUTTER HEALTH PLAN HMO PLANS", "methodology": "per diem", "standard_charge_dollar": 28538.0, "standard_charge_algorithm": "Per diem ($28,538).", "count": "0", "additional_payer_notes": "Zero final payments for the item or service in the 15 months prior to posting the file." }, { "payer_name": "UNITED HEALTHCARE", "plan_name": "SUTTER SELECT & SUTTER HEALTH PLAN HMO PLANS", "methodology": "per diem", "standard_charge_dollar": 28538.0, "standard_charge_algorithm": "Per diem ($28,538).", "count": "0", "additional_payer_notes": "Zero final payments for the item or service in the 15 months prior to posting the file." }, { "payer_name": "SUTTER", "plan_name": "SUTTER SELECT & SUTTER HEALTH PLAN HMO PLANS", "methodology": "per diem", "standard_charge_dollar": 28538.0, "standard_charge_algorithm": "Per diem ($28,538).", "count": "0", "additional_payer_notes": "Zero final payments for the item or service in the 15 months prior to posting the file." }, { "payer_name": "UNITED HEALTHCARE", "plan_name": "SUTTER SELECT & SUTTER HEALTH PLAN HMO PLANS", "methodology": "per diem", "standard_charge_dollar": 28538.0, "standard_charge_algorithm": "Per diem ($28,538).", "count": "0", "additional_payer_notes": "Zero final payments for the item or service in the 15 months prior to posting the file." }, { "payer_name": "UMR", "plan_name": "SUTTER SELECT & SUTTER HEALTH PLAN HMO PLANS", "methodology": "per diem", "standard_charge_dollar": 28538.0, "standard_charge_algorithm": "Per diem ($28,538).", "count": "0", "additional_payer_notes": "Zero final payments for the item or service in the 15 months prior to posting the file." } ] } ] }, { "description": "HC Cath Quinton Gp016", "code_information": [ { "code": "PX-2120037016", "type": "CDM" }, { "code": "99999", "type": "CPT" }, { "code": "0272", "type": "RC" } ], "standard_charges": [ { "setting": "outpatient", "gross_charge": 1400.0, "discounted_cash": 700.0, "minimum": 590.8, "maximum": 728.0, "additional_generic_notes": "Zero final payments for the item or service in the 15 months prior to posting the file.", "payers_information": [ { "payer_name": "AETNA", "plan_name": "AETNA ALL OTHER PLANS", "methodology": "percent of total billed charges", "standard_charge_dollar": 728.0, "standard_charge_percentage": 52.0, "count": "0", "additional_payer_notes": "Zero final payments for the item or service in the 15 months prior to posting the file." }, { "payer_name": "AETNA", "plan_name": "AETNA ALL OTHER PLANS", "methodology": "percent of total billed charges", "standard_charge_dollar": 728.0, "standard_charge_percentage": 52.0, "count": "0", "additional_payer_notes": "Zero final payments for the item or service in the 15 months prior to posting the file." }, { "payer_name": "MERITAIN HEALTH", "plan_name": "AETNA ALL OTHER PLANS", "methodology": "percent of total billed charges", "standard_charge_dollar": 728.0, "standard_charge_percentage": 52.0, "count": "0", "additional_payer_notes": "Zero final payments for the item or service in the 15 months prior to posting the file." }, { "payer_name": "BLUE SHIELD OUT OF STATE", "plan_name": "STANFORD HEALTHCARE ALLIANCE PLAN", "methodology": "percent of total billed charges", "standard_charge_dollar": 680.26, "standard_charge_percentage": 48.59, "count": "0", "additional_payer_notes": "Zero final payments for the item or service in the 15 months prior to posting the file." }, { "payer_name": "BLUE SHIELD", "plan_name": "STANFORD HEALTHCARE ALLIANCE PLAN", "methodology": "percent of total billed charges", "standard_charge_dollar": 680.26, "standard_charge_percentage": 48.59, "median_amount": 68.24, "10th_percentile": 13.6, "90th_percentile": 1043.06, "count": "30" }, { "payer_name": "BLUE SHIELD", "plan_name": "STANFORD HEALTHCARE ALLIANCE PLAN", "methodology": "percent of total billed charges", "standard_charge_dollar": 680.26, "standard_charge_percentage": 48.59, "count": "0", "additional_payer_notes": "Zero final payments for the item or service in the 15 months prior to posting the file." }, { "payer_name": "BLUE SHIELD", "plan_name": "STANFORD HEALTHCARE ALLIANCE PLAN", "methodology": "percent of total billed charges", "standard_charge_dollar": 680.26, "standard_charge_percentage": 48.59, "count": "0", "additional_payer_notes": "Zero final payments for the item or service in the 15 months prior to posting the file." }, { "payer_name": "CIGNA", "plan_name": "CIGNA COM ALT HMO PLAN", "methodology": "percent of total billed charges", "standard_charge_dollar": 590.8, "standard_charge_percentage": 42.2, "count": "0", "additional_payer_notes": "Zero final payments for the item or service in the 15 months prior to posting the file." }, { "payer_name": "CIGNA", "plan_name": "CIGNA COM ALT HMO PLAN", "methodology": "percent of total billed charges", "standard_charge_dollar": 590.8, "standard_charge_percentage": 42.2, "count": "0", "additional_payer_notes": "Zero final payments for the item or service in the 15 months prior to posting the file." }, { "payer_name": "HEALTH NET", "plan_name": "HEALTHNET HMO, PPO, POS, EPO, CANOPY HEALTHNET HMO, OTHER-IN-NETWORK PLANS", "methodology": "per diem", "standard_charge_dollar": 8000.0, "standard_charge_algorithm": "Expected reimbursement is the lesser of Per diem ($8,000) for the length of stay and 70% of billed.", "count": "0", "additional_payer_notes": "Zero final payments for the item or service in the 15 months prior to posting the file." }, { "payer_name": "HEALTH NET", "plan_name": "HEALTHNET HMO, PPO, POS, EPO, CANOPY HEALTHNET HMO, OTHER-IN-NETWORK PLANS", "methodology": "per diem", "standard_charge_dollar": 8000.0, "standard_charge_algorithm": "Expected reimbursement is the lesser of Per diem ($8,000) for the length of stay and 70% of billed.", "count": "0", "additional_payer_notes": "Zero final payments for the item or service in the 15 months prior to posting the file." }, { "payer_name": "UNITED HEALTHCARE", "plan_name": "SUTTER SELECT & SUTTER HEALTH PLAN HMO PLANS", "methodology": "per diem", "standard_charge_dollar": 28538.0, "standard_charge_algorithm": "Per diem ($28,538).", "count": "0", "additional_payer_notes": "Zero final payments for the item or service in the 15 months prior to posting the file." }, { "payer_name": "UNITED HEALTHCARE", "plan_name": "SUTTER SELECT & SUTTER HEALTH PLAN HMO PLANS", "methodology": "per diem", "standard_charge_dollar": 28538.0, "standard_charge_algorithm": "Per diem ($28,538).", "count": "0", "additional_payer_notes": "Zero final payments for the item or service in the 15 months prior to posting the file." }, { "payer_name": "SUTTER", "plan_name": "SUTTER SELECT & SUTTER HEALTH PLAN HMO PLANS", "methodology": "per diem", "standard_charge_dollar": 28538.0, "standard_charge_algorithm": "Per diem ($28,538).", "count": "0", "additional_payer_notes": "Zero final payments for the item or service in the 15 months prior to posting the file." }, { "payer_name": "UNITED HEALTHCARE", "plan_name": "SUTTER SELECT & SUTTER HEALTH PLAN HMO PLANS", "methodology": "per diem", "standard_charge_dollar": 28538.0, "standard_charge_algorithm": "Per diem ($28,538).", "count": "0", "additional_payer_notes": "Zero final payments for the item or service in the 15 months prior to posting the file." }, { "payer_name": "UMR", "plan_name": "SUTTER SELECT & SUTTER HEALTH PLAN HMO PLANS", "methodology": "per diem", "standard_charge_dollar": 28538.0, "standard_charge_algorithm": "Per diem ($28,538).", "count": "0", "additional_payer_notes": "Zero final payments for the item or service in the 15 months prior to posting the file." } ] } ] }, { "description": "HC Cath Quinton Gp017", "code_information": [ { "code": "PX-2120037017", "type": "CDM" }, { "code": "99999", "type": "CPT" }, { "code": "0272", "type": "RC" } ], "standard_charges": [ { "setting": "outpatient", "gross_charge": 1575.0, "discounted_cash": 787.5, "minimum": 664.65, "maximum": 819.0, "additional_generic_notes": "Zero final payments for the item or service in the 15 months prior to posting the file.", "payers_information": [ { "payer_name": "AETNA", "plan_name": "AETNA ALL OTHER PLANS", "methodology": "percent of total billed charges", "standard_charge_dollar": 819.0, "standard_charge_percentage": 52.0, "count": "0", "additional_payer_notes": "Zero final payments for the item or service in the 15 months prior to posting the file." }, { "payer_name": "AETNA", "plan_name": "AETNA ALL OTHER PLANS", "methodology": "percent of total billed charges", "standard_charge_dollar": 819.0, "standard_charge_percentage": 52.0, "count": "0", "additional_payer_notes": "Zero final payments for the item or service in the 15 months prior to posting the file." }, { "payer_name": "MERITAIN HEALTH", "plan_name": "AETNA ALL OTHER PLANS", "methodology": "percent of total billed charges", "standard_charge_dollar": 819.0, "standard_charge_percentage": 52.0, "count": "0", "additional_payer_notes": "Zero final payments for the item or service in the 15 months prior to posting the file." }, { "payer_name": "BLUE SHIELD OUT OF STATE", "plan_name": "STANFORD HEALTHCARE ALLIANCE PLAN", "methodology": "percent of total billed charges", "standard_charge_dollar": 765.29, "standard_charge_percentage": 48.59, "count": "0", "additional_payer_notes": "Zero final payments for the item or service in the 15 months prior to posting the file." }, { "payer_name": "BLUE SHIELD", "plan_name": "STANFORD HEALTHCARE ALLIANCE PLAN", "methodology": "percent of total billed charges", "standard_charge_dollar": 765.29, "standard_charge_percentage": 48.59, "median_amount": 68.24, "10th_percentile": 13.6, "90th_percentile": 1043.06, "count": "30" }, { "payer_name": "BLUE SHIELD", "plan_name": "STANFORD HEALTHCARE ALLIANCE PLAN", "methodology": "percent of total billed charges", "standard_charge_dollar": 765.29, "standard_charge_percentage": 48.59, "count": "0", "additional_payer_notes": "Zero final payments for the item or service in the 15 months prior to posting the file." }, { "payer_name": "BLUE SHIELD", "plan_name": "STANFORD HEALTHCARE ALLIANCE PLAN", "methodology": "percent of total billed charges", "standard_charge_dollar": 765.29, "standard_charge_percentage": 48.59, "count": "0", "additional_payer_notes": "Zero final payments for the item or service in the 15 months prior to posting the file." }, { "payer_name": "CIGNA", "plan_name": "CIGNA COM ALT HMO PLAN", "methodology": "percent of total billed charges", "standard_charge_dollar": 664.65, "standard_charge_percentage": 42.2, "count": "0", "additional_payer_notes": "Zero final payments for the item or service in the 15 months prior to posting the file." }, { "payer_name": "CIGNA", "plan_name": "CIGNA COM ALT HMO PLAN", "methodology": "percent of total billed charges", "standard_charge_dollar": 664.65, "standard_charge_percentage": 42.2, "count": "0", "additional_payer_notes": "Zero final payments for the item or service in the 15 months prior to posting the file." }, { "payer_name": "HEALTH NET", "plan_name": "HEALTHNET HMO, PPO, POS, EPO, CANOPY HEALTHNET HMO, OTHER-IN-NETWORK PLANS", "methodology": "per diem", "standard_charge_dollar": 8000.0, "standard_charge_algorithm": "Expected reimbursement is the lesser of Per diem ($8,000) for the length of stay and 70% of billed.", "count": "0", "additional_payer_notes": "Zero final payments for the item or service in the 15 months prior to posting the file." }, { "payer_name": "HEALTH NET", "plan_name": "HEALTHNET HMO, PPO, POS, EPO, CANOPY HEALTHNET HMO, OTHER-IN-NETWORK PLANS", "methodology": "per diem", "standard_charge_dollar": 8000.0, "standard_charge_algorithm": "Expected reimbursement is the lesser of Per diem ($8,000) for the length of stay and 70% of billed.", "count": "0", "additional_payer_notes": "Zero final payments for the item or service in the 15 months prior to posting the file." }, { "payer_name": "UNITED HEALTHCARE", "plan_name": "SUTTER SELECT & SUTTER HEALTH PLAN HMO PLANS", "methodology": "per diem", "standard_charge_dollar": 28538.0, "standard_charge_algorithm": "Per diem ($28,538).", "count": "0", "additional_payer_notes": "Zero final payments for the item or service in the 15 months prior to posting the file." }, { "payer_name": "UNITED HEALTHCARE", "plan_name": "SUTTER SELECT & SUTTER HEALTH PLAN HMO PLANS", "methodology": "per diem", "standard_charge_dollar": 28538.0, "standard_charge_algorithm": "Per diem ($28,538).", "count": "0", "additional_payer_notes": "Zero final payments for the item or service in the 15 months prior to posting the file." }, { "payer_name": "SUTTER", "plan_name": "SUTTER SELECT & SUTTER HEALTH PLAN HMO PLANS", "methodology": "per diem", "standard_charge_dollar": 28538.0, "standard_charge_algorithm": "Per diem ($28,538).", "count": "0", "additional_payer_notes": "Zero final payments for the item or service in the 15 months prior to posting the file." }, { "payer_name": "UNITED HEALTHCARE", "plan_name": "SUTTER SELECT & SUTTER HEALTH PLAN HMO PLANS", "methodology": "per diem", "standard_charge_dollar": 28538.0, "standard_charge_algorithm": "Per diem ($28,538).", "count": "0", "additional_payer_notes": "Zero final payments for the item or service in the 15 months prior to posting the file." }, { "payer_name": "UMR", "plan_name": "SUTTER SELECT & SUTTER HEALTH PLAN HMO PLANS", "methodology": "per diem", "standard_charge_dollar": 28538.0, "standard_charge_algorithm": "Per diem ($28,538).", "count": "0", "additional_payer_notes": "Zero final payments for the item or service in the 15 months prior to posting the file." } ] } ] }, { "description": "HC Cath Quinton Gp018", "code_information": [ { "code": "PX-2120037018", "type": "CDM" }, { "code": "99999", "type": "CPT" }, { "code": "0272", "type": "RC" } ], "standard_charges": [ { "setting": "outpatient", "gross_charge": 1750.0, "discounted_cash": 875.0, "minimum": 738.5, "maximum": 910.0, "additional_generic_notes": "Zero final payments for the item or service in the 15 months prior to posting the file.", "payers_information": [ { "payer_name": "AETNA", "plan_name": "AETNA ALL OTHER PLANS", "methodology": "percent of total billed charges", "standard_charge_dollar": 910.0, "standard_charge_percentage": 52.0, "count": "0", "additional_payer_notes": "Zero final payments for the item or service in the 15 months prior to posting the file." }, { "payer_name": "AETNA", "plan_name": "AETNA ALL OTHER PLANS", "methodology": "percent of total billed charges", "standard_charge_dollar": 910.0, "standard_charge_percentage": 52.0, "count": "0", "additional_payer_notes": "Zero final payments for the item or service in the 15 months prior to posting the file." }, { "payer_name": "MERITAIN HEALTH", "plan_name": "AETNA ALL OTHER PLANS", "methodology": "percent of total billed charges", "standard_charge_dollar": 910.0, "standard_charge_percentage": 52.0, "count": "0", "additional_payer_notes": "Zero final payments for the item or service in the 15 months prior to posting the file." }, { "payer_name": "BLUE SHIELD OUT OF STATE", "plan_name": "STANFORD HEALTHCARE ALLIANCE PLAN", "methodology": "percent of total billed charges", "standard_charge_dollar": 850.33, "standard_charge_percentage": 48.59, "count": "0", "additional_payer_notes": "Zero final payments for the item or service in the 15 months prior to posting the file." }, { "payer_name": "BLUE SHIELD", "plan_name": "STANFORD HEALTHCARE ALLIANCE PLAN", "methodology": "percent of total billed charges", "standard_charge_dollar": 850.33, "standard_charge_percentage": 48.59, "median_amount": 68.24, "10th_percentile": 13.6, "90th_percentile": 1043.06, "count": "30" }, { "payer_name": "BLUE SHIELD", "plan_name": "STANFORD HEALTHCARE ALLIANCE PLAN", "methodology": "percent of total billed charges", "standard_charge_dollar": 850.33, "standard_charge_percentage": 48.59, "count": "0", "additional_payer_notes": "Zero final payments for the item or service in the 15 months prior to posting the file." }, { "payer_name": "BLUE SHIELD", "plan_name": "STANFORD HEALTHCARE ALLIANCE PLAN", "methodology": "percent of total billed charges", "standard_charge_dollar": 850.33, "standard_charge_percentage": 48.59, "count": "0", "additional_payer_notes": "Zero final payments for the item or service in the 15 months prior to posting the file." }, { "payer_name": "CIGNA", "plan_name": "CIGNA COM ALT HMO PLAN", "methodology": "percent of total billed charges", "standard_charge_dollar": 738.5, "standard_charge_percentage": 42.2, "count": "0", "additional_payer_notes": "Zero final payments for the item or service in the 15 months prior to posting the file." }, { "payer_name": "CIGNA", "plan_name": "CIGNA COM ALT HMO PLAN", "methodology": "percent of total billed charges", "standard_charge_dollar": 738.5, "standard_charge_percentage": 42.2, "count": "0", "additional_payer_notes": "Zero final payments for the item or service in the 15 months prior to posting the file." }, { "payer_name": "HEALTH NET", "plan_name": "HEALTHNET HMO, PPO, POS, EPO, CANOPY HEALTHNET HMO, OTHER-IN-NETWORK PLANS", "methodology": "per diem", "standard_charge_dollar": 8000.0, "standard_charge_algorithm": "Expected reimbursement is the lesser of Per diem ($8,000) for the length of stay and 70% of billed.", "count": "0", "additional_payer_notes": "Zero final payments for the item or service in the 15 months prior to posting the file." }, { "payer_name": "HEALTH NET", "plan_name": "HEALTHNET HMO, PPO, POS, EPO, CANOPY HEALTHNET HMO, OTHER-IN-NETWORK PLANS", "methodology": "per diem", "standard_charge_dollar": 8000.0, "standard_charge_algorithm": "Expected reimbursement is the lesser of Per diem ($8,000) for the length of stay and 70% of billed.", "count": "0", "additional_payer_notes": "Zero final payments for the item or service in the 15 months prior to posting the file." }, { "payer_name": "UNITED HEALTHCARE", "plan_name": "SUTTER SELECT & SUTTER HEALTH PLAN HMO PLANS", "methodology": "per diem", "standard_charge_dollar": 28538.0, "standard_charge_algorithm": "Per diem ($28,538).", "count": "0", "additional_payer_notes": "Zero final payments for the item or service in the 15 months prior to posting the file." }, { "payer_name": "UNITED HEALTHCARE", "plan_name": "SUTTER SELECT & SUTTER HEALTH PLAN HMO PLANS", "methodology": "per diem", "standard_charge_dollar": 28538.0, "standard_charge_algorithm": "Per diem ($28,538).", "count": "0", "additional_payer_notes": "Zero final payments for the item or service in the 15 months prior to posting the file." }, { "payer_name": "SUTTER", "plan_name": "SUTTER SELECT & SUTTER HEALTH PLAN HMO PLANS", "methodology": "per diem", "standard_charge_dollar": 28538.0, "standard_charge_algorithm": "Per diem ($28,538).", "count": "0", "additional_payer_notes": "Zero final payments for the item or service in the 15 months prior to posting the file." }, { "payer_name": "UNITED HEALTHCARE", "plan_name": "SUTTER SELECT & SUTTER HEALTH PLAN HMO PLANS", "methodology": "per diem", "standard_charge_dollar": 28538.0, "standard_charge_algorithm": "Per diem ($28,538).", "count": "0", "additional_payer_notes": "Zero final payments for the item or service in the 15 months prior to posting the file." }, { "payer_name": "UMR", "plan_name": "SUTTER SELECT & SUTTER HEALTH PLAN HMO PLANS", "methodology": "per diem", "standard_charge_dollar": 28538.0, "standard_charge_algorithm": "Per diem ($28,538).", "count": "0", "additional_payer_notes": "Zero final payments for the item or service in the 15 months prior to posting the file." } ] } ] }, { "description": "HC Cath Quinton Gp023", "code_information": [ { "code": "PX-2120037023", "type": "CDM" }, { "code": "99999", "type": "CPT" }, { "code": "0272", "type": "RC" } ], "standard_charges": [ { "setting": "outpatient", "gross_charge": 3600.0, "discounted_cash": 1800.0, "minimum": 1519.2, "maximum": 1872.0, "additional_generic_notes": "Zero final payments for the item or service in the 15 months prior to posting the file.", "payers_information": [ { "payer_name": "AETNA", "plan_name": "AETNA ALL OTHER PLANS", "methodology": "percent of total billed charges", "standard_charge_dollar": 1872.0, "standard_charge_percentage": 52.0, "count": "0", "additional_payer_notes": "Zero final payments for the item or service in the 15 months prior to posting the file." }, { "payer_name": "AETNA", "plan_name": "AETNA ALL OTHER PLANS", "methodology": "percent of total billed charges", "standard_charge_dollar": 1872.0, "standard_charge_percentage": 52.0, "count": "0", "additional_payer_notes": "Zero final payments for the item or service in the 15 months prior to posting the file." }, { "payer_name": "MERITAIN HEALTH", "plan_name": "AETNA ALL OTHER PLANS", "methodology": "percent of total billed charges", "standard_charge_dollar": 1872.0, "standard_charge_percentage": 52.0, "count": "0", "additional_payer_notes": "Zero final payments for the item or service in the 15 months prior to posting the file." }, { "payer_name": "BLUE SHIELD OUT OF STATE", "plan_name": "STANFORD HEALTHCARE ALLIANCE PLAN", "methodology": "percent of total billed charges", "standard_charge_dollar": 1749.24, "standard_charge_percentage": 48.59, "count": "0", "additional_payer_notes": "Zero final payments for the item or service in the 15 months prior to posting the file." }, { "payer_name": "BLUE SHIELD", "plan_name": "STANFORD HEALTHCARE ALLIANCE PLAN", "methodology": "percent of total billed charges", "standard_charge_dollar": 1749.24, "standard_charge_percentage": 48.59, "median_amount": 68.24, "10th_percentile": 13.6, "90th_percentile": 1043.06, "count": "30" }, { "payer_name": "BLUE SHIELD", "plan_name": "STANFORD HEALTHCARE ALLIANCE PLAN", "methodology": "percent of total billed charges", "standard_charge_dollar": 1749.24, "standard_charge_percentage": 48.59, "count": "0", "additional_payer_notes": "Zero final payments for the item or service in the 15 months prior to posting the file." }, { "payer_name": "BLUE SHIELD", "plan_name": "STANFORD HEALTHCARE ALLIANCE PLAN", "methodology": "percent of total billed charges", "standard_charge_dollar": 1749.24, "standard_charge_percentage": 48.59, "count": "0", "additional_payer_notes": "Zero final payments for the item or service in the 15 months prior to posting the file." }, { "payer_name": "CIGNA", "plan_name": "CIGNA COM ALT HMO PLAN", "methodology": "percent of total billed charges", "standard_charge_dollar": 1519.2, "standard_charge_percentage": 42.2, "count": "0", "additional_payer_notes": "Zero final payments for the item or service in the 15 months prior to posting the file." }, { "payer_name": "CIGNA", "plan_name": "CIGNA COM ALT HMO PLAN", "methodology": "percent of total billed charges", "standard_charge_dollar": 1519.2, "standard_charge_percentage": 42.2, "count": "0", "additional_payer_notes": "Zero final payments for the item or service in the 15 months prior to posting the file." }, { "payer_name": "HEALTH NET", "plan_name": "HEALTHNET HMO, PPO, POS, EPO, CANOPY HEALTHNET HMO, OTHER-IN-NETWORK PLANS", "methodology": "per diem", "standard_charge_dollar": 8000.0, "standard_charge_algorithm": "Expected reimbursement is the lesser of Per diem ($8,000) for the length of stay and 70% of billed.", "count": "0", "additional_payer_notes": "Zero final payments for the item or service in the 15 months prior to posting the file." }, { "payer_name": "HEALTH NET", "plan_name": "HEALTHNET HMO, PPO, POS, EPO, CANOPY HEALTHNET HMO, OTHER-IN-NETWORK PLANS", "methodology": "per diem", "standard_charge_dollar": 8000.0, "standard_charge_algorithm": "Expected reimbursement is the lesser of Per diem ($8,000) for the length of stay and 70% of billed.", "count": "0", "additional_payer_notes": "Zero final payments for the item or service in the 15 months prior to posting the file." }, { "payer_name": "UNITED HEALTHCARE", "plan_name": "SUTTER SELECT & SUTTER HEALTH PLAN HMO PLANS", "methodology": "per diem", "standard_charge_dollar": 28538.0, "standard_charge_algorithm": "Per diem ($28,538).", "count": "0", "additional_payer_notes": "Zero final payments for the item or service in the 15 months prior to posting the file." }, { "payer_name": "UNITED HEALTHCARE", "plan_name": "SUTTER SELECT & SUTTER HEALTH PLAN HMO PLANS", "methodology": "per diem", "standard_charge_dollar": 28538.0, "standard_charge_algorithm": "Per diem ($28,538).", "count": "0", "additional_payer_notes": "Zero final payments for the item or service in the 15 months prior to posting the file." }, { "payer_name": "SUTTER", "plan_name": "SUTTER SELECT & SUTTER HEALTH PLAN HMO PLANS", "methodology": "per diem", "standard_charge_dollar": 28538.0, "standard_charge_algorithm": "Per diem ($28,538).", "count": "0", "additional_payer_notes": "Zero final payments for the item or service in the 15 months prior to posting the file." }, { "payer_name": "UNITED HEALTHCARE", "plan_name": "SUTTER SELECT & SUTTER HEALTH PLAN HMO PLANS", "methodology": "per diem", "standard_charge_dollar": 28538.0, "standard_charge_algorithm": "Per diem ($28,538).", "count": "0", "additional_payer_notes": "Zero final payments for the item or service in the 15 months prior to posting the file." }, { "payer_name": "UMR", "plan_name": "SUTTER SELECT & SUTTER HEALTH PLAN HMO PLANS", "methodology": "per diem", "standard_charge_dollar": 28538.0, "standard_charge_algorithm": "Per diem ($28,538).", "count": "0", "additional_payer_notes": "Zero final payments for the item or service in the 15 months prior to posting the file." } ] } ] }, { "description": "HC Cath Trocar Gp003", "code_information": [ { "code": "PX-2120038003", "type": "CDM" }, { "code": "99999", "type": "CPT" }, { "code": "0272", "type": "RC" } ], "standard_charges": [ { "setting": "outpatient", "gross_charge": 100.0, "discounted_cash": 50.0, "minimum": 42.2, "maximum": 52.0, "additional_generic_notes": "Zero final payments for the item or service in the 15 months prior to posting the file.", "payers_information": [ { "payer_name": "AETNA", "plan_name": "AETNA ALL OTHER PLANS", "methodology": "percent of total billed charges", "standard_charge_dollar": 52.0, "standard_charge_percentage": 52.0, "count": "0", "additional_payer_notes": "Zero final payments for the item or service in the 15 months prior to posting the file." }, { "payer_name": "AETNA", "plan_name": "AETNA ALL OTHER PLANS", "methodology": "percent of total billed charges", "standard_charge_dollar": 52.0, "standard_charge_percentage": 52.0, "count": "0", "additional_payer_notes": "Zero final payments for the item or service in the 15 months prior to posting the file." }, { "payer_name": "MERITAIN HEALTH", "plan_name": "AETNA ALL OTHER PLANS", "methodology": "percent of total billed charges", "standard_charge_dollar": 52.0, "standard_charge_percentage": 52.0, "count": "0", "additional_payer_notes": "Zero final payments for the item or service in the 15 months prior to posting the file." }, { "payer_name": "BLUE SHIELD OUT OF STATE", "plan_name": "STANFORD HEALTHCARE ALLIANCE PLAN", "methodology": "percent of total billed charges", "standard_charge_dollar": 48.59, "standard_charge_percentage": 48.59, "count": "0", "additional_payer_notes": "Zero final payments for the item or service in the 15 months prior to posting the file." }, { "payer_name": "BLUE SHIELD", "plan_name": "STANFORD HEALTHCARE ALLIANCE PLAN", "methodology": "percent of total billed charges", "standard_charge_dollar": 48.59, "standard_charge_percentage": 48.59, "count": "0", "additional_payer_notes": "Zero final payments for the item or service in the 15 months prior to posting the file." }, { "payer_name": "BLUE SHIELD", "plan_name": "STANFORD HEALTHCARE ALLIANCE PLAN", "methodology": "percent of total billed charges", "standard_charge_dollar": 48.59, "standard_charge_percentage": 48.59, "count": "0", "additional_payer_notes": "Zero final payments for the item or service in the 15 months prior to posting the file." }, { "payer_name": "CIGNA", "plan_name": "CIGNA COM ALT HMO PLAN", "methodology": "percent of total billed charges", "standard_charge_dollar": 42.2, "standard_charge_percentage": 42.2, "count": "0", "additional_payer_notes": "Zero final payments for the item or service in the 15 months prior to posting the file." }, { "payer_name": "CIGNA", "plan_name": "CIGNA COM ALT HMO PLAN", "methodology": "percent of total billed charges", "standard_charge_dollar": 42.2, "standard_charge_percentage": 42.2, "count": "0", "additional_payer_notes": "Zero final payments for the item or service in the 15 months prior to posting the file." }, { "payer_name": "HEALTH NET", "plan_name": "HEALTHNET HMO, PPO, POS, EPO, CANOPY HEALTHNET HMO, OTHER-IN-NETWORK PLANS", "methodology": "per diem", "standard_charge_dollar": 8000.0, "standard_charge_algorithm": "Expected reimbursement is the lesser of Per diem ($8,000) for the length of stay and 70% of billed.", "count": "0", "additional_payer_notes": "Zero final payments for the item or service in the 15 months prior to posting the file." }, { "payer_name": "HEALTH NET", "plan_name": "HEALTHNET HMO, PPO, POS, EPO, CANOPY HEALTHNET HMO, OTHER-IN-NETWORK PLANS", "methodology": "per diem", "standard_charge_dollar": 8000.0, "standard_charge_algorithm": "Expected reimbursement is the lesser of Per diem ($8,000) for the length of stay and 70% of billed.", "count": "0", "additional_payer_notes": "Zero final payments for the item or service in the 15 months prior to posting the file." }, { "payer_name": "UNITED HEALTHCARE", "plan_name": "SUTTER SELECT & SUTTER HEALTH PLAN HMO PLANS", "methodology": "per diem", "standard_charge_dollar": 28538.0, "standard_charge_algorithm": "Per diem ($28,538).", "count": "0", "additional_payer_notes": "Zero final payments for the item or service in the 15 months prior to posting the file." }, { "payer_name": "UNITED HEALTHCARE", "plan_name": "SUTTER SELECT & SUTTER HEALTH PLAN HMO PLANS", "methodology": "per diem", "standard_charge_dollar": 28538.0, "standard_charge_algorithm": "Per diem ($28,538).", "count": "0", "additional_payer_notes": "Zero final payments for the item or service in the 15 months prior to posting the file." }, { "payer_name": "SUTTER", "plan_name": "SUTTER SELECT & SUTTER HEALTH PLAN HMO PLANS", "methodology": "per diem", "standard_charge_dollar": 28538.0, "standard_charge_algorithm": "Per diem ($28,538).", "count": "0", "additional_payer_notes": "Zero final payments for the item or service in the 15 months prior to posting the file." }, { "payer_name": "UNITED HEALTHCARE", "plan_name": "SUTTER SELECT & SUTTER HEALTH PLAN HMO PLANS", "methodology": "per diem", "standard_charge_dollar": 28538.0, "standard_charge_algorithm": "Per diem ($28,538).", "count": "0", "additional_payer_notes": "Zero final payments for the item or service in the 15 months prior to posting the file." }, { "payer_name": "UMR", "plan_name": "SUTTER SELECT & SUTTER HEALTH PLAN HMO PLANS", "methodology": "per diem", "standard_charge_dollar": 28538.0, "standard_charge_algorithm": "Per diem ($28,538).", "count": "0", "additional_payer_notes": "Zero final payments for the item or service in the 15 months prior to posting the file." } ] } ] }, { "description": "HC Cath Trocar Gp004", "code_information": [ { "code": "PX-2120038004", "type": "CDM" }, { "code": "99999", "type": "CPT" }, { "code": "0272", "type": "RC" } ], "standard_charges": [ { "setting": "outpatient", "gross_charge": 146.0, "discounted_cash": 73.0, "minimum": 61.61, "maximum": 75.92, "additional_generic_notes": "Zero final payments for the item or service in the 15 months prior to posting the file.", "payers_information": [ { "payer_name": "AETNA", "plan_name": "AETNA ALL OTHER PLANS", "methodology": "percent of total billed charges", "standard_charge_dollar": 75.92, "standard_charge_percentage": 52.0, "count": "0", "additional_payer_notes": "Zero final payments for the item or service in the 15 months prior to posting the file." }, { "payer_name": "AETNA", "plan_name": "AETNA ALL OTHER PLANS", "methodology": "percent of total billed charges", "standard_charge_dollar": 75.92, "standard_charge_percentage": 52.0, "count": "0", "additional_payer_notes": "Zero final payments for the item or service in the 15 months prior to posting the file." }, { "payer_name": "MERITAIN HEALTH", "plan_name": "AETNA ALL OTHER PLANS", "methodology": "percent of total billed charges", "standard_charge_dollar": 75.92, "standard_charge_percentage": 52.0, "count": "0", "additional_payer_notes": "Zero final payments for the item or service in the 15 months prior to posting the file." }, { "payer_name": "BLUE SHIELD OUT OF STATE", "plan_name": "STANFORD HEALTHCARE ALLIANCE PLAN", "methodology": "percent of total billed charges", "standard_charge_dollar": 70.94, "standard_charge_percentage": 48.59, "count": "0", "additional_payer_notes": "Zero final payments for the item or service in the 15 months prior to posting the file." }, { "payer_name": "BLUE SHIELD", "plan_name": "STANFORD HEALTHCARE ALLIANCE PLAN", "methodology": "percent of total billed charges", "standard_charge_dollar": 70.94, "standard_charge_percentage": 48.59, "count": "0", "additional_payer_notes": "Zero final payments for the item or service in the 15 months prior to posting the file." }, { "payer_name": "BLUE SHIELD", "plan_name": "STANFORD HEALTHCARE ALLIANCE PLAN", "methodology": "percent of total billed charges", "standard_charge_dollar": 70.94, "standard_charge_percentage": 48.59, "count": "0", "additional_payer_notes": "Zero final payments for the item or service in the 15 months prior to posting the file." }, { "payer_name": "CIGNA", "plan_name": "CIGNA COM ALT HMO PLAN", "methodology": "percent of total billed charges", "standard_charge_dollar": 61.61, "standard_charge_percentage": 42.2, "count": "0", "additional_payer_notes": "Zero final payments for the item or service in the 15 months prior to posting the file." }, { "payer_name": "CIGNA", "plan_name": "CIGNA COM ALT HMO PLAN", "methodology": "percent of total billed charges", "standard_charge_dollar": 61.61, "standard_charge_percentage": 42.2, "count": "0", "additional_payer_notes": "Zero final payments for the item or service in the 15 months prior to posting the file." }, { "payer_name": "HEALTH NET", "plan_name": "HEALTHNET HMO, PPO, POS, EPO, CANOPY HEALTHNET HMO, OTHER-IN-NETWORK PLANS", "methodology": "per diem", "standard_charge_dollar": 8000.0, "standard_charge_algorithm": "Expected reimbursement is the lesser of Per diem ($8,000) for the length of stay and 70% of billed.", "count": "0", "additional_payer_notes": "Zero final payments for the item or service in the 15 months prior to posting the file." }, { "payer_name": "HEALTH NET", "plan_name": "HEALTHNET HMO, PPO, POS, EPO, CANOPY HEALTHNET HMO, OTHER-IN-NETWORK PLANS", "methodology": "per diem", "standard_charge_dollar": 8000.0, "standard_charge_algorithm": "Expected reimbursement is the lesser of Per diem ($8,000) for the length of stay and 70% of billed.", "count": "0", "additional_payer_notes": "Zero final payments for the item or service in the 15 months prior to posting the file." }, { "payer_name": "UNITED HEALTHCARE", "plan_name": "SUTTER SELECT & SUTTER HEALTH PLAN HMO PLANS", "methodology": "per diem", "standard_charge_dollar": 28538.0, "standard_charge_algorithm": "Per diem ($28,538).", "count": "0", "additional_payer_notes": "Zero final payments for the item or service in the 15 months prior to posting the file." }, { "payer_name": "UNITED HEALTHCARE", "plan_name": "SUTTER SELECT & SUTTER HEALTH PLAN HMO PLANS", "methodology": "per diem", "standard_charge_dollar": 28538.0, "standard_charge_algorithm": "Per diem ($28,538).", "count": "0", "additional_payer_notes": "Zero final payments for the item or service in the 15 months prior to posting the file." }, { "payer_name": "SUTTER", "plan_name": "SUTTER SELECT & SUTTER HEALTH PLAN HMO PLANS", "methodology": "per diem", "standard_charge_dollar": 28538.0, "standard_charge_algorithm": "Per diem ($28,538).", "count": "0", "additional_payer_notes": "Zero final payments for the item or service in the 15 months prior to posting the file." }, { "payer_name": "UNITED HEALTHCARE", "plan_name": "SUTTER SELECT & SUTTER HEALTH PLAN HMO PLANS", "methodology": "per diem", "standard_charge_dollar": 28538.0, "standard_charge_algorithm": "Per diem ($28,538).", "count": "0", "additional_payer_notes": "Zero final payments for the item or service in the 15 months prior to posting the file." }, { "payer_name": "UMR", "plan_name": "SUTTER SELECT & SUTTER HEALTH PLAN HMO PLANS", "methodology": "per diem", "standard_charge_dollar": 28538.0, "standard_charge_algorithm": "Per diem ($28,538).", "count": "0", "additional_payer_notes": "Zero final payments for the item or service in the 15 months prior to posting the file." } ] } ] }, { "description": "HC Cath Troc Gp005", "code_information": [ { "code": "PX-2120038005", "type": "CDM" }, { "code": "99999", "type": "CPT" }, { "code": "0272", "type": "RC" } ], "standard_charges": [ { "setting": "outpatient", "gross_charge": 195.0, "discounted_cash": 97.5, "minimum": 82.29, "maximum": 101.4, "additional_generic_notes": "Zero final payments for the item or service in the 15 months prior to posting the file.", "payers_information": [ { "payer_name": "AETNA", "plan_name": "AETNA ALL OTHER PLANS", "methodology": "percent of total billed charges", "standard_charge_dollar": 101.4, "standard_charge_percentage": 52.0, "count": "0", "additional_payer_notes": "Zero final payments for the item or service in the 15 months prior to posting the file." }, { "payer_name": "AETNA", "plan_name": "AETNA ALL OTHER PLANS", "methodology": "percent of total billed charges", "standard_charge_dollar": 101.4, "standard_charge_percentage": 52.0, "count": "0", "additional_payer_notes": "Zero final payments for the item or service in the 15 months prior to posting the file." }, { "payer_name": "MERITAIN HEALTH", "plan_name": "AETNA ALL OTHER PLANS", "methodology": "percent of total billed charges", "standard_charge_dollar": 101.4, "standard_charge_percentage": 52.0, "count": "0", "additional_payer_notes": "Zero final payments for the item or service in the 15 months prior to posting the file." }, { "payer_name": "BLUE SHIELD OUT OF STATE", "plan_name": "STANFORD HEALTHCARE ALLIANCE PLAN", "methodology": "percent of total billed charges", "standard_charge_dollar": 94.75, "standard_charge_percentage": 48.59, "count": "0", "additional_payer_notes": "Zero final payments for the item or service in the 15 months prior to posting the file." }, { "payer_name": "BLUE SHIELD", "plan_name": "STANFORD HEALTHCARE ALLIANCE PLAN", "methodology": "percent of total billed charges", "standard_charge_dollar": 94.75, "standard_charge_percentage": 48.59, "count": "0", "additional_payer_notes": "Zero final payments for the item or service in the 15 months prior to posting the file." }, { "payer_name": "BLUE SHIELD", "plan_name": "STANFORD HEALTHCARE ALLIANCE PLAN", "methodology": "percent of total billed charges", "standard_charge_dollar": 94.75, "standard_charge_percentage": 48.59, "count": "0", "additional_payer_notes": "Zero final payments for the item or service in the 15 months prior to posting the file." }, { "payer_name": "CIGNA", "plan_name": "CIGNA COM ALT HMO PLAN", "methodology": "percent of total billed charges", "standard_charge_dollar": 82.29, "standard_charge_percentage": 42.2, "count": "0", "additional_payer_notes": "Zero final payments for the item or service in the 15 months prior to posting the file." }, { "payer_name": "CIGNA", "plan_name": "CIGNA COM ALT HMO PLAN", "methodology": "percent of total billed charges", "standard_charge_dollar": 82.29, "standard_charge_percentage": 42.2, "count": "0", "additional_payer_notes": "Zero final payments for the item or service in the 15 months prior to posting the file." }, { "payer_name": "HEALTH NET", "plan_name": "HEALTHNET HMO, PPO, POS, EPO, CANOPY HEALTHNET HMO, OTHER-IN-NETWORK PLANS", "methodology": "per diem", "standard_charge_dollar": 8000.0, "standard_charge_algorithm": "Expected reimbursement is the lesser of Per diem ($8,000) for the length of stay and 70% of billed.", "count": "0", "additional_payer_notes": "Zero final payments for the item or service in the 15 months prior to posting the file." }, { "payer_name": "HEALTH NET", "plan_name": "HEALTHNET HMO, PPO, POS, EPO, CANOPY HEALTHNET HMO, OTHER-IN-NETWORK PLANS", "methodology": "per diem", "standard_charge_dollar": 8000.0, "standard_charge_algorithm": "Expected reimbursement is the lesser of Per diem ($8,000) for the length of stay and 70% of billed.", "count": "0", "additional_payer_notes": "Zero final payments for the item or service in the 15 months prior to posting the file." }, { "payer_name": "UNITED HEALTHCARE", "plan_name": "SUTTER SELECT & SUTTER HEALTH PLAN HMO PLANS", "methodology": "per diem", "standard_charge_dollar": 28538.0, "standard_charge_algorithm": "Per diem ($28,538).", "count": "0", "additional_payer_notes": "Zero final payments for the item or service in the 15 months prior to posting the file." }, { "payer_name": "UNITED HEALTHCARE", "plan_name": "SUTTER SELECT & SUTTER HEALTH PLAN HMO PLANS", "methodology": "per diem", "standard_charge_dollar": 28538.0, "standard_charge_algorithm": "Per diem ($28,538).", "count": "0", "additional_payer_notes": "Zero final payments for the item or service in the 15 months prior to posting the file." }, { "payer_name": "SUTTER", "plan_name": "SUTTER SELECT & SUTTER HEALTH PLAN HMO PLANS", "methodology": "per diem", "standard_charge_dollar": 28538.0, "standard_charge_algorithm": "Per diem ($28,538).", "count": "0", "additional_payer_notes": "Zero final payments for the item or service in the 15 months prior to posting the file." }, { "payer_name": "UNITED HEALTHCARE", "plan_name": "SUTTER SELECT & SUTTER HEALTH PLAN HMO PLANS", "methodology": "per diem", "standard_charge_dollar": 28538.0, "standard_charge_algorithm": "Per diem ($28,538).", "count": "0", "additional_payer_notes": "Zero final payments for the item or service in the 15 months prior to posting the file." }, { "payer_name": "UMR", "plan_name": "SUTTER SELECT & SUTTER HEALTH PLAN HMO PLANS", "methodology": "per diem", "standard_charge_dollar": 28538.0, "standard_charge_algorithm": "Per diem ($28,538).", "count": "0", "additional_payer_notes": "Zero final payments for the item or service in the 15 months prior to posting the file." } ] } ] }, { "description": "HC Cath Umbilical Gp003", "code_information": [ { "code": "PX-2120039003", "type": "CDM" }, { "code": "99999", "type": "CPT" }, { "code": "0272", "type": "RC" } ], "standard_charges": [ { "setting": "outpatient", "gross_charge": 100.0, "discounted_cash": 50.0, "minimum": 42.2, "maximum": 52.0, "additional_generic_notes": "Zero final payments for the item or service in the 15 months prior to posting the file.", "payers_information": [ { "payer_name": "AETNA", "plan_name": "AETNA ALL OTHER PLANS", "methodology": "percent of total billed charges", "standard_charge_dollar": 52.0, "standard_charge_percentage": 52.0, "count": "0", "additional_payer_notes": "Zero final payments for the item or service in the 15 months prior to posting the file." }, { "payer_name": "AETNA", "plan_name": "AETNA ALL OTHER PLANS", "methodology": "percent of total billed charges", "standard_charge_dollar": 52.0, "standard_charge_percentage": 52.0, "count": "0", "additional_payer_notes": "Zero final payments for the item or service in the 15 months prior to posting the file." }, { "payer_name": "MERITAIN HEALTH", "plan_name": "AETNA ALL OTHER PLANS", "methodology": "percent of total billed charges", "standard_charge_dollar": 52.0, "standard_charge_percentage": 52.0, "count": "0", "additional_payer_notes": "Zero final payments for the item or service in the 15 months prior to posting the file." }, { "payer_name": "BLUE SHIELD OUT OF STATE", "plan_name": "STANFORD HEALTHCARE ALLIANCE PLAN", "methodology": "percent of total billed charges", "standard_charge_dollar": 48.59, "standard_charge_percentage": 48.59, "count": "0", "additional_payer_notes": "Zero final payments for the item or service in the 15 months prior to posting the file." }, { "payer_name": "BLUE SHIELD", "plan_name": "STANFORD HEALTHCARE ALLIANCE PLAN", "methodology": "percent of total billed charges", "standard_charge_dollar": 48.59, "standard_charge_percentage": 48.59, "count": "0", "additional_payer_notes": "Zero final payments for the item or service in the 15 months prior to posting the file." }, { "payer_name": "BLUE SHIELD", "plan_name": "STANFORD HEALTHCARE ALLIANCE PLAN", "methodology": "percent of total billed charges", "standard_charge_dollar": 48.59, "standard_charge_percentage": 48.59, "count": "0", "additional_payer_notes": "Zero final payments for the item or service in the 15 months prior to posting the file." }, { "payer_name": "CIGNA", "plan_name": "CIGNA COM ALT HMO PLAN", "methodology": "percent of total billed charges", "standard_charge_dollar": 42.2, "standard_charge_percentage": 42.2, "count": "0", "additional_payer_notes": "Zero final payments for the item or service in the 15 months prior to posting the file." }, { "payer_name": "CIGNA", "plan_name": "CIGNA COM ALT HMO PLAN", "methodology": "percent of total billed charges", "standard_charge_dollar": 42.2, "standard_charge_percentage": 42.2, "count": "0", "additional_payer_notes": "Zero final payments for the item or service in the 15 months prior to posting the file." }, { "payer_name": "HEALTH NET", "plan_name": "HEALTHNET HMO, PPO, POS, EPO, CANOPY HEALTHNET HMO, OTHER-IN-NETWORK PLANS", "methodology": "per diem", "standard_charge_dollar": 8000.0, "standard_charge_algorithm": "Expected reimbursement is the lesser of Per diem ($8,000) for the length of stay and 70% of billed.", "count": "0", "additional_payer_notes": "Zero final payments for the item or service in the 15 months prior to posting the file." }, { "payer_name": "HEALTH NET", "plan_name": "HEALTHNET HMO, PPO, POS, EPO, CANOPY HEALTHNET HMO, OTHER-IN-NETWORK PLANS", "methodology": "per diem", "standard_charge_dollar": 8000.0, "standard_charge_algorithm": "Expected reimbursement is the lesser of Per diem ($8,000) for the length of stay and 70% of billed.", "count": "0", "additional_payer_notes": "Zero final payments for the item or service in the 15 months prior to posting the file." }, { "payer_name": "UNITED HEALTHCARE", "plan_name": "SUTTER SELECT & SUTTER HEALTH PLAN HMO PLANS", "methodology": "per diem", "standard_charge_dollar": 28538.0, "standard_charge_algorithm": "Per diem ($28,538).", "count": "0", "additional_payer_notes": "Zero final payments for the item or service in the 15 months prior to posting the file." }, { "payer_name": "UNITED HEALTHCARE", "plan_name": "SUTTER SELECT & SUTTER HEALTH PLAN HMO PLANS", "methodology": "per diem", "standard_charge_dollar": 28538.0, "standard_charge_algorithm": "Per diem ($28,538).", "count": "0", "additional_payer_notes": "Zero final payments for the item or service in the 15 months prior to posting the file." }, { "payer_name": "SUTTER", "plan_name": "SUTTER SELECT & SUTTER HEALTH PLAN HMO PLANS", "methodology": "per diem", "standard_charge_dollar": 28538.0, "standard_charge_algorithm": "Per diem ($28,538).", "count": "0", "additional_payer_notes": "Zero final payments for the item or service in the 15 months prior to posting the file." }, { "payer_name": "UNITED HEALTHCARE", "plan_name": "SUTTER SELECT & SUTTER HEALTH PLAN HMO PLANS", "methodology": "per diem", "standard_charge_dollar": 28538.0, "standard_charge_algorithm": "Per diem ($28,538).", "count": "0", "additional_payer_notes": "Zero final payments for the item or service in the 15 months prior to posting the file." }, { "payer_name": "UMR", "plan_name": "SUTTER SELECT & SUTTER HEALTH PLAN HMO PLANS", "methodology": "per diem", "standard_charge_dollar": 28538.0, "standard_charge_algorithm": "Per diem ($28,538).", "count": "0", "additional_payer_notes": "Zero final payments for the item or service in the 15 months prior to posting the file." } ] } ] }, { "description": "HC Cath Umbilical Gp004", "code_information": [ { "code": "PX-2120039004", "type": "CDM" }, { "code": "99999", "type": "CPT" }, { "code": "0272", "type": "RC" } ], "standard_charges": [ { "setting": "outpatient", "gross_charge": 146.0, "discounted_cash": 73.0, "minimum": 61.61, "maximum": 75.92, "additional_generic_notes": "Zero final payments for the item or service in the 15 months prior to posting the file.", "payers_information": [ { "payer_name": "AETNA", "plan_name": "AETNA ALL OTHER PLANS", "methodology": "percent of total billed charges", "standard_charge_dollar": 75.92, "standard_charge_percentage": 52.0, "count": "0", "additional_payer_notes": "Zero final payments for the item or service in the 15 months prior to posting the file." }, { "payer_name": "AETNA", "plan_name": "AETNA ALL OTHER PLANS", "methodology": "percent of total billed charges", "standard_charge_dollar": 75.92, "standard_charge_percentage": 52.0, "count": "0", "additional_payer_notes": "Zero final payments for the item or service in the 15 months prior to posting the file." }, { "payer_name": "MERITAIN HEALTH", "plan_name": "AETNA ALL OTHER PLANS", "methodology": "percent of total billed charges", "standard_charge_dollar": 75.92, "standard_charge_percentage": 52.0, "count": "0", "additional_payer_notes": "Zero final payments for the item or service in the 15 months prior to posting the file." }, { "payer_name": "BLUE SHIELD OUT OF STATE", "plan_name": "STANFORD HEALTHCARE ALLIANCE PLAN", "methodology": "percent of total billed charges", "standard_charge_dollar": 70.94, "standard_charge_percentage": 48.59, "count": "0", "additional_payer_notes": "Zero final payments for the item or service in the 15 months prior to posting the file." }, { "payer_name": "BLUE SHIELD", "plan_name": "STANFORD HEALTHCARE ALLIANCE PLAN", "methodology": "percent of total billed charges", "standard_charge_dollar": 70.94, "standard_charge_percentage": 48.59, "count": "0", "additional_payer_notes": "Zero final payments for the item or service in the 15 months prior to posting the file." }, { "payer_name": "BLUE SHIELD", "plan_name": "STANFORD HEALTHCARE ALLIANCE PLAN", "methodology": "percent of total billed charges", "standard_charge_dollar": 70.94, "standard_charge_percentage": 48.59, "count": "0", "additional_payer_notes": "Zero final payments for the item or service in the 15 months prior to posting the file." }, { "payer_name": "CIGNA", "plan_name": "CIGNA COM ALT HMO PLAN", "methodology": "percent of total billed charges", "standard_charge_dollar": 61.61, "standard_charge_percentage": 42.2, "count": "0", "additional_payer_notes": "Zero final payments for the item or service in the 15 months prior to posting the file." }, { "payer_name": "CIGNA", "plan_name": "CIGNA COM ALT HMO PLAN", "methodology": "percent of total billed charges", "standard_charge_dollar": 61.61, "standard_charge_percentage": 42.2, "count": "0", "additional_payer_notes": "Zero final payments for the item or service in the 15 months prior to posting the file." }, { "payer_name": "HEALTH NET", "plan_name": "HEALTHNET HMO, PPO, POS, EPO, CANOPY HEALTHNET HMO, OTHER-IN-NETWORK PLANS", "methodology": "per diem", "standard_charge_dollar": 8000.0, "standard_charge_algorithm": "Expected reimbursement is the lesser of Per diem ($8,000) for the length of stay and 70% of billed.", "count": "0", "additional_payer_notes": "Zero final payments for the item or service in the 15 months prior to posting the file." }, { "payer_name": "HEALTH NET", "plan_name": "HEALTHNET HMO, PPO, POS, EPO, CANOPY HEALTHNET HMO, OTHER-IN-NETWORK PLANS", "methodology": "per diem", "standard_charge_dollar": 8000.0, "standard_charge_algorithm": "Expected reimbursement is the lesser of Per diem ($8,000) for the length of stay and 70% of billed.", "count": "0", "additional_payer_notes": "Zero final payments for the item or service in the 15 months prior to posting the file." }, { "payer_name": "UNITED HEALTHCARE", "plan_name": "SUTTER SELECT & SUTTER HEALTH PLAN HMO PLANS", "methodology": "per diem", "standard_charge_dollar": 28538.0, "standard_charge_algorithm": "Per diem ($28,538).", "count": "0", "additional_payer_notes": "Zero final payments for the item or service in the 15 months prior to posting the file." }, { "payer_name": "UNITED HEALTHCARE", "plan_name": "SUTTER SELECT & SUTTER HEALTH PLAN HMO PLANS", "methodology": "per diem", "standard_charge_dollar": 28538.0, "standard_charge_algorithm": "Per diem ($28,538).", "count": "0", "additional_payer_notes": "Zero final payments for the item or service in the 15 months prior to posting the file." }, { "payer_name": "SUTTER", "plan_name": "SUTTER SELECT & SUTTER HEALTH PLAN HMO PLANS", "methodology": "per diem", "standard_charge_dollar": 28538.0, "standard_charge_algorithm": "Per diem ($28,538).", "count": "0", "additional_payer_notes": "Zero final payments for the item or service in the 15 months prior to posting the file." }, { "payer_name": "UNITED HEALTHCARE", "plan_name": "SUTTER SELECT & SUTTER HEALTH PLAN HMO PLANS", "methodology": "per diem", "standard_charge_dollar": 28538.0, "standard_charge_algorithm": "Per diem ($28,538).", "count": "0", "additional_payer_notes": "Zero final payments for the item or service in the 15 months prior to posting the file." }, { "payer_name": "UMR", "plan_name": "SUTTER SELECT & SUTTER HEALTH PLAN HMO PLANS", "methodology": "per diem", "standard_charge_dollar": 28538.0, "standard_charge_algorithm": "Per diem ($28,538).", "count": "0", "additional_payer_notes": "Zero final payments for the item or service in the 15 months prior to posting the file." } ] } ] }, { "description": "HC Cath Umbilical Gp005", "code_information": [ { "code": "PX-2120039005", "type": "CDM" }, { "code": "99999", "type": "CPT" }, { "code": "0272", "type": "RC" } ], "standard_charges": [ { "setting": "outpatient", "gross_charge": 195.0, "discounted_cash": 97.5, "minimum": 82.29, "maximum": 101.4, "additional_generic_notes": "Zero final payments for the item or service in the 15 months prior to posting the file.", "payers_information": [ { "payer_name": "AETNA", "plan_name": "AETNA ALL OTHER PLANS", "methodology": "percent of total billed charges", "standard_charge_dollar": 101.4, "standard_charge_percentage": 52.0, "count": "0", "additional_payer_notes": "Zero final payments for the item or service in the 15 months prior to posting the file." }, { "payer_name": "AETNA", "plan_name": "AETNA ALL OTHER PLANS", "methodology": "percent of total billed charges", "standard_charge_dollar": 101.4, "standard_charge_percentage": 52.0, "count": "0", "additional_payer_notes": "Zero final payments for the item or service in the 15 months prior to posting the file." }, { "payer_name": "MERITAIN HEALTH", "plan_name": "AETNA ALL OTHER PLANS", "methodology": "percent of total billed charges", "standard_charge_dollar": 101.4, "standard_charge_percentage": 52.0, "count": "0", "additional_payer_notes": "Zero final payments for the item or service in the 15 months prior to posting the file." }, { "payer_name": "BLUE SHIELD OUT OF STATE", "plan_name": "STANFORD HEALTHCARE ALLIANCE PLAN", "methodology": "percent of total billed charges", "standard_charge_dollar": 94.75, "standard_charge_percentage": 48.59, "count": "0", "additional_payer_notes": "Zero final payments for the item or service in the 15 months prior to posting the file." }, { "payer_name": "BLUE SHIELD", "plan_name": "STANFORD HEALTHCARE ALLIANCE PLAN", "methodology": "percent of total billed charges", "standard_charge_dollar": 94.75, "standard_charge_percentage": 48.59, "count": "0", "additional_payer_notes": "Zero final payments for the item or service in the 15 months prior to posting the file." }, { "payer_name": "BLUE SHIELD", "plan_name": "STANFORD HEALTHCARE ALLIANCE PLAN", "methodology": "percent of total billed charges", "standard_charge_dollar": 94.75, "standard_charge_percentage": 48.59, "count": "0", "additional_payer_notes": "Zero final payments for the item or service in the 15 months prior to posting the file." }, { "payer_name": "CIGNA", "plan_name": "CIGNA COM ALT HMO PLAN", "methodology": "percent of total billed charges", "standard_charge_dollar": 82.29, "standard_charge_percentage": 42.2, "count": "0", "additional_payer_notes": "Zero final payments for the item or service in the 15 months prior to posting the file." }, { "payer_name": "CIGNA", "plan_name": "CIGNA COM ALT HMO PLAN", "methodology": "percent of total billed charges", "standard_charge_dollar": 82.29, "standard_charge_percentage": 42.2, "count": "0", "additional_payer_notes": "Zero final payments for the item or service in the 15 months prior to posting the file." }, { "payer_name": "HEALTH NET", "plan_name": "HEALTHNET HMO, PPO, POS, EPO, CANOPY HEALTHNET HMO, OTHER-IN-NETWORK PLANS", "methodology": "per diem", "standard_charge_dollar": 8000.0, "standard_charge_algorithm": "Expected reimbursement is the lesser of Per diem ($8,000) for the length of stay and 70% of billed.", "count": "0", "additional_payer_notes": "Zero final payments for the item or service in the 15 months prior to posting the file." }, { "payer_name": "HEALTH NET", "plan_name": "HEALTHNET HMO, PPO, POS, EPO, CANOPY HEALTHNET HMO, OTHER-IN-NETWORK PLANS", "methodology": "per diem", "standard_charge_dollar": 8000.0, "standard_charge_algorithm": "Expected reimbursement is the lesser of Per diem ($8,000) for the length of stay and 70% of billed.", "count": "0", "additional_payer_notes": "Zero final payments for the item or service in the 15 months prior to posting the file." }, { "payer_name": "UNITED HEALTHCARE", "plan_name": "SUTTER SELECT & SUTTER HEALTH PLAN HMO PLANS", "methodology": "per diem", "standard_charge_dollar": 28538.0, "standard_charge_algorithm": "Per diem ($28,538).", "count": "0", "additional_payer_notes": "Zero final payments for the item or service in the 15 months prior to posting the file." }, { "payer_name": "UNITED HEALTHCARE", "plan_name": "SUTTER SELECT & SUTTER HEALTH PLAN HMO PLANS", "methodology": "per diem", "standard_charge_dollar": 28538.0, "standard_charge_algorithm": "Per diem ($28,538).", "count": "0", "additional_payer_notes": "Zero final payments for the item or service in the 15 months prior to posting the file." }, { "payer_name": "SUTTER", "plan_name": "SUTTER SELECT & SUTTER HEALTH PLAN HMO PLANS", "methodology": "per diem", "standard_charge_dollar": 28538.0, "standard_charge_algorithm": "Per diem ($28,538).", "count": "0", "additional_payer_notes": "Zero final payments for the item or service in the 15 months prior to posting the file." }, { "payer_name": "UNITED HEALTHCARE", "plan_name": "SUTTER SELECT & SUTTER HEALTH PLAN HMO PLANS", "methodology": "per diem", "standard_charge_dollar": 28538.0, "standard_charge_algorithm": "Per diem ($28,538).", "count": "0", "additional_payer_notes": "Zero final payments for the item or service in the 15 months prior to posting the file." }, { "payer_name": "UMR", "plan_name": "SUTTER SELECT & SUTTER HEALTH PLAN HMO PLANS", "methodology": "per diem", "standard_charge_dollar": 28538.0, "standard_charge_algorithm": "Per diem ($28,538).", "count": "0", "additional_payer_notes": "Zero final payments for the item or service in the 15 months prior to posting the file." } ] } ] }, { "description": "HC Cath Umbilical Gp006", "code_information": [ { "code": "PX-2120039006", "type": "CDM" }, { "code": "99999", "type": "CPT" }, { "code": "0272", "type": "RC" } ], "standard_charges": [ { "setting": "outpatient", "gross_charge": 293.0, "discounted_cash": 146.5, "minimum": 123.65, "maximum": 152.36, "additional_generic_notes": "Zero final payments for the item or service in the 15 months prior to posting the file.", "payers_information": [ { "payer_name": "AETNA", "plan_name": "AETNA ALL OTHER PLANS", "methodology": "percent of total billed charges", "standard_charge_dollar": 152.36, "standard_charge_percentage": 52.0, "count": "0", "additional_payer_notes": "Zero final payments for the item or service in the 15 months prior to posting the file." }, { "payer_name": "AETNA", "plan_name": "AETNA ALL OTHER PLANS", "methodology": "percent of total billed charges", "standard_charge_dollar": 152.36, "standard_charge_percentage": 52.0, "count": "0", "additional_payer_notes": "Zero final payments for the item or service in the 15 months prior to posting the file." }, { "payer_name": "MERITAIN HEALTH", "plan_name": "AETNA ALL OTHER PLANS", "methodology": "percent of total billed charges", "standard_charge_dollar": 152.36, "standard_charge_percentage": 52.0, "count": "0", "additional_payer_notes": "Zero final payments for the item or service in the 15 months prior to posting the file." }, { "payer_name": "BLUE SHIELD OUT OF STATE", "plan_name": "STANFORD HEALTHCARE ALLIANCE PLAN", "methodology": "percent of total billed charges", "standard_charge_dollar": 142.37, "standard_charge_percentage": 48.59, "count": "0", "additional_payer_notes": "Zero final payments for the item or service in the 15 months prior to posting the file." }, { "payer_name": "BLUE SHIELD", "plan_name": "STANFORD HEALTHCARE ALLIANCE PLAN", "methodology": "percent of total billed charges", "standard_charge_dollar": 142.37, "standard_charge_percentage": 48.59, "count": "0", "additional_payer_notes": "Zero final payments for the item or service in the 15 months prior to posting the file." }, { "payer_name": "BLUE SHIELD", "plan_name": "STANFORD HEALTHCARE ALLIANCE PLAN", "methodology": "percent of total billed charges", "standard_charge_dollar": 142.37, "standard_charge_percentage": 48.59, "count": "0", "additional_payer_notes": "Zero final payments for the item or service in the 15 months prior to posting the file." }, { "payer_name": "CIGNA", "plan_name": "CIGNA COM ALT HMO PLAN", "methodology": "percent of total billed charges", "standard_charge_dollar": 123.65, "standard_charge_percentage": 42.2, "count": "0", "additional_payer_notes": "Zero final payments for the item or service in the 15 months prior to posting the file." }, { "payer_name": "CIGNA", "plan_name": "CIGNA COM ALT HMO PLAN", "methodology": "percent of total billed charges", "standard_charge_dollar": 123.65, "standard_charge_percentage": 42.2, "count": "0", "additional_payer_notes": "Zero final payments for the item or service in the 15 months prior to posting the file." }, { "payer_name": "HEALTH NET", "plan_name": "HEALTHNET HMO, PPO, POS, EPO, CANOPY HEALTHNET HMO, OTHER-IN-NETWORK PLANS", "methodology": "per diem", "standard_charge_dollar": 8000.0, "standard_charge_algorithm": "Expected reimbursement is the lesser of Per diem ($8,000) for the length of stay and 70% of billed.", "count": "0", "additional_payer_notes": "Zero final payments for the item or service in the 15 months prior to posting the file." }, { "payer_name": "HEALTH NET", "plan_name": "HEALTHNET HMO, PPO, POS, EPO, CANOPY HEALTHNET HMO, OTHER-IN-NETWORK PLANS", "methodology": "per diem", "standard_charge_dollar": 8000.0, "standard_charge_algorithm": "Expected reimbursement is the lesser of Per diem ($8,000) for the length of stay and 70% of billed.", "count": "0", "additional_payer_notes": "Zero final payments for the item or service in the 15 months prior to posting the file." }, { "payer_name": "UNITED HEALTHCARE", "plan_name": "SUTTER SELECT & SUTTER HEALTH PLAN HMO PLANS", "methodology": "per diem", "standard_charge_dollar": 28538.0, "standard_charge_algorithm": "Per diem ($28,538).", "count": "0", "additional_payer_notes": "Zero final payments for the item or service in the 15 months prior to posting the file." }, { "payer_name": "UNITED HEALTHCARE", "plan_name": "SUTTER SELECT & SUTTER HEALTH PLAN HMO PLANS", "methodology": "per diem", "standard_charge_dollar": 28538.0, "standard_charge_algorithm": "Per diem ($28,538).", "count": "0", "additional_payer_notes": "Zero final payments for the item or service in the 15 months prior to posting the file." }, { "payer_name": "SUTTER", "plan_name": "SUTTER SELECT & SUTTER HEALTH PLAN HMO PLANS", "methodology": "per diem", "standard_charge_dollar": 28538.0, "standard_charge_algorithm": "Per diem ($28,538).", "count": "0", "additional_payer_notes": "Zero final payments for the item or service in the 15 months prior to posting the file." }, { "payer_name": "UNITED HEALTHCARE", "plan_name": "SUTTER SELECT & SUTTER HEALTH PLAN HMO PLANS", "methodology": "per diem", "standard_charge_dollar": 28538.0, "standard_charge_algorithm": "Per diem ($28,538).", "count": "0", "additional_payer_notes": "Zero final payments for the item or service in the 15 months prior to posting the file." }, { "payer_name": "UMR", "plan_name": "SUTTER SELECT & SUTTER HEALTH PLAN HMO PLANS", "methodology": "per diem", "standard_charge_dollar": 28538.0, "standard_charge_algorithm": "Per diem ($28,538).", "count": "0", "additional_payer_notes": "Zero final payments for the item or service in the 15 months prior to posting the file." } ] } ] }, { "description": "Hc Cath Umbilical Gp007", "code_information": [ { "code": "PX-2120039007", "type": "CDM" }, { "code": "99999", "type": "CPT" }, { "code": "0272", "type": "RC" } ], "standard_charges": [ { "setting": "outpatient", "gross_charge": 380.0, "discounted_cash": 190.0, "minimum": 160.36, "maximum": 197.6, "additional_generic_notes": "Zero final payments for the item or service in the 15 months prior to posting the file.", "payers_information": [ { "payer_name": "AETNA", "plan_name": "AETNA ALL OTHER PLANS", "methodology": "percent of total billed charges", "standard_charge_dollar": 197.6, "standard_charge_percentage": 52.0, "count": "0", "additional_payer_notes": "Zero final payments for the item or service in the 15 months prior to posting the file." }, { "payer_name": "AETNA", "plan_name": "AETNA ALL OTHER PLANS", "methodology": "percent of total billed charges", "standard_charge_dollar": 197.6, "standard_charge_percentage": 52.0, "count": "0", "additional_payer_notes": "Zero final payments for the item or service in the 15 months prior to posting the file." }, { "payer_name": "MERITAIN HEALTH", "plan_name": "AETNA ALL OTHER PLANS", "methodology": "percent of total billed charges", "standard_charge_dollar": 197.6, "standard_charge_percentage": 52.0, "count": "0", "additional_payer_notes": "Zero final payments for the item or service in the 15 months prior to posting the file." }, { "payer_name": "BLUE SHIELD OUT OF STATE", "plan_name": "STANFORD HEALTHCARE ALLIANCE PLAN", "methodology": "percent of total billed charges", "standard_charge_dollar": 184.64, "standard_charge_percentage": 48.59, "count": "0", "additional_payer_notes": "Zero final payments for the item or service in the 15 months prior to posting the file." }, { "payer_name": "BLUE SHIELD", "plan_name": "STANFORD HEALTHCARE ALLIANCE PLAN", "methodology": "percent of total billed charges", "standard_charge_dollar": 184.64, "standard_charge_percentage": 48.59, "count": "0", "additional_payer_notes": "Zero final payments for the item or service in the 15 months prior to posting the file." }, { "payer_name": "BLUE SHIELD", "plan_name": "STANFORD HEALTHCARE ALLIANCE PLAN", "methodology": "percent of total billed charges", "standard_charge_dollar": 184.64, "standard_charge_percentage": 48.59, "count": "0", "additional_payer_notes": "Zero final payments for the item or service in the 15 months prior to posting the file." }, { "payer_name": "CIGNA", "plan_name": "CIGNA COM ALT HMO PLAN", "methodology": "percent of total billed charges", "standard_charge_dollar": 160.36, "standard_charge_percentage": 42.2, "count": "0", "additional_payer_notes": "Zero final payments for the item or service in the 15 months prior to posting the file." }, { "payer_name": "CIGNA", "plan_name": "CIGNA COM ALT HMO PLAN", "methodology": "percent of total billed charges", "standard_charge_dollar": 160.36, "standard_charge_percentage": 42.2, "count": "0", "additional_payer_notes": "Zero final payments for the item or service in the 15 months prior to posting the file." }, { "payer_name": "HEALTH NET", "plan_name": "HEALTHNET HMO, PPO, POS, EPO, CANOPY HEALTHNET HMO, OTHER-IN-NETWORK PLANS", "methodology": "per diem", "standard_charge_dollar": 8000.0, "standard_charge_algorithm": "Expected reimbursement is the lesser of Per diem ($8,000) for the length of stay and 70% of billed.", "count": "0", "additional_payer_notes": "Zero final payments for the item or service in the 15 months prior to posting the file." }, { "payer_name": "HEALTH NET", "plan_name": "HEALTHNET HMO, PPO, POS, EPO, CANOPY HEALTHNET HMO, OTHER-IN-NETWORK PLANS", "methodology": "per diem", "standard_charge_dollar": 8000.0, "standard_charge_algorithm": "Expected reimbursement is the lesser of Per diem ($8,000) for the length of stay and 70% of billed.", "count": "0", "additional_payer_notes": "Zero final payments for the item or service in the 15 months prior to posting the file." }, { "payer_name": "UNITED HEALTHCARE", "plan_name": "SUTTER SELECT & SUTTER HEALTH PLAN HMO PLANS", "methodology": "per diem", "standard_charge_dollar": 28538.0, "standard_charge_algorithm": "Per diem ($28,538).", "count": "0", "additional_payer_notes": "Zero final payments for the item or service in the 15 months prior to posting the file." }, { "payer_name": "UNITED HEALTHCARE", "plan_name": "SUTTER SELECT & SUTTER HEALTH PLAN HMO PLANS", "methodology": "per diem", "standard_charge_dollar": 28538.0, "standard_charge_algorithm": "Per diem ($28,538).", "count": "0", "additional_payer_notes": "Zero final payments for the item or service in the 15 months prior to posting the file." }, { "payer_name": "SUTTER", "plan_name": "SUTTER SELECT & SUTTER HEALTH PLAN HMO PLANS", "methodology": "per diem", "standard_charge_dollar": 28538.0, "standard_charge_algorithm": "Per diem ($28,538).", "count": "0", "additional_payer_notes": "Zero final payments for the item or service in the 15 months prior to posting the file." }, { "payer_name": "UNITED HEALTHCARE", "plan_name": "SUTTER SELECT & SUTTER HEALTH PLAN HMO PLANS", "methodology": "per diem", "standard_charge_dollar": 28538.0, "standard_charge_algorithm": "Per diem ($28,538).", "count": "0", "additional_payer_notes": "Zero final payments for the item or service in the 15 months prior to posting the file." }, { "payer_name": "UMR", "plan_name": "SUTTER SELECT & SUTTER HEALTH PLAN HMO PLANS", "methodology": "per diem", "standard_charge_dollar": 28538.0, "standard_charge_algorithm": "Per diem ($28,538).", "count": "0", "additional_payer_notes": "Zero final payments for the item or service in the 15 months prior to posting the file." } ] } ] }, { "description": "HC Cath Vent Gp004", "code_information": [ { "code": "PX-2120040004", "type": "CDM" }, { "code": "99999", "type": "CPT" }, { "code": "0272", "type": "RC" } ], "standard_charges": [ { "setting": "outpatient", "gross_charge": 146.0, "discounted_cash": 73.0, "minimum": 61.61, "maximum": 75.92, "additional_generic_notes": "Zero final payments for the item or service in the 15 months prior to posting the file.", "payers_information": [ { "payer_name": "AETNA", "plan_name": "AETNA ALL OTHER PLANS", "methodology": "percent of total billed charges", "standard_charge_dollar": 75.92, "standard_charge_percentage": 52.0, "count": "0", "additional_payer_notes": "Zero final payments for the item or service in the 15 months prior to posting the file." }, { "payer_name": "AETNA", "plan_name": "AETNA ALL OTHER PLANS", "methodology": "percent of total billed charges", "standard_charge_dollar": 75.92, "standard_charge_percentage": 52.0, "count": "0", "additional_payer_notes": "Zero final payments for the item or service in the 15 months prior to posting the file." }, { "payer_name": "MERITAIN HEALTH", "plan_name": "AETNA ALL OTHER PLANS", "methodology": "percent of total billed charges", "standard_charge_dollar": 75.92, "standard_charge_percentage": 52.0, "count": "0", "additional_payer_notes": "Zero final payments for the item or service in the 15 months prior to posting the file." }, { "payer_name": "BLUE SHIELD OUT OF STATE", "plan_name": "STANFORD HEALTHCARE ALLIANCE PLAN", "methodology": "percent of total billed charges", "standard_charge_dollar": 70.94, "standard_charge_percentage": 48.59, "count": "0", "additional_payer_notes": "Zero final payments for the item or service in the 15 months prior to posting the file." }, { "payer_name": "BLUE SHIELD", "plan_name": "STANFORD HEALTHCARE ALLIANCE PLAN", "methodology": "percent of total billed charges", "standard_charge_dollar": 70.94, "standard_charge_percentage": 48.59, "count": "0", "additional_payer_notes": "Zero final payments for the item or service in the 15 months prior to posting the file." }, { "payer_name": "BLUE SHIELD", "plan_name": "STANFORD HEALTHCARE ALLIANCE PLAN", "methodology": "percent of total billed charges", "standard_charge_dollar": 70.94, "standard_charge_percentage": 48.59, "count": "0", "additional_payer_notes": "Zero final payments for the item or service in the 15 months prior to posting the file." }, { "payer_name": "CIGNA", "plan_name": "CIGNA COM ALT HMO PLAN", "methodology": "percent of total billed charges", "standard_charge_dollar": 61.61, "standard_charge_percentage": 42.2, "count": "0", "additional_payer_notes": "Zero final payments for the item or service in the 15 months prior to posting the file." }, { "payer_name": "CIGNA", "plan_name": "CIGNA COM ALT HMO PLAN", "methodology": "percent of total billed charges", "standard_charge_dollar": 61.61, "standard_charge_percentage": 42.2, "count": "0", "additional_payer_notes": "Zero final payments for the item or service in the 15 months prior to posting the file." }, { "payer_name": "HEALTH NET", "plan_name": "HEALTHNET HMO, PPO, POS, EPO, CANOPY HEALTHNET HMO, OTHER-IN-NETWORK PLANS", "methodology": "per diem", "standard_charge_dollar": 8000.0, "standard_charge_algorithm": "Expected reimbursement is the lesser of Per diem ($8,000) for the length of stay and 70% of billed.", "count": "0", "additional_payer_notes": "Zero final payments for the item or service in the 15 months prior to posting the file." }, { "payer_name": "HEALTH NET", "plan_name": "HEALTHNET HMO, PPO, POS, EPO, CANOPY HEALTHNET HMO, OTHER-IN-NETWORK PLANS", "methodology": "per diem", "standard_charge_dollar": 8000.0, "standard_charge_algorithm": "Expected reimbursement is the lesser of Per diem ($8,000) for the length of stay and 70% of billed.", "count": "0", "additional_payer_notes": "Zero final payments for the item or service in the 15 months prior to posting the file." }, { "payer_name": "UNITED HEALTHCARE", "plan_name": "SUTTER SELECT & SUTTER HEALTH PLAN HMO PLANS", "methodology": "per diem", "standard_charge_dollar": 28538.0, "standard_charge_algorithm": "Per diem ($28,538).", "count": "0", "additional_payer_notes": "Zero final payments for the item or service in the 15 months prior to posting the file." }, { "payer_name": "UNITED HEALTHCARE", "plan_name": "SUTTER SELECT & SUTTER HEALTH PLAN HMO PLANS", "methodology": "per diem", "standard_charge_dollar": 28538.0, "standard_charge_algorithm": "Per diem ($28,538).", "count": "0", "additional_payer_notes": "Zero final payments for the item or service in the 15 months prior to posting the file." }, { "payer_name": "SUTTER", "plan_name": "SUTTER SELECT & SUTTER HEALTH PLAN HMO PLANS", "methodology": "per diem", "standard_charge_dollar": 28538.0, "standard_charge_algorithm": "Per diem ($28,538).", "count": "0", "additional_payer_notes": "Zero final payments for the item or service in the 15 months prior to posting the file." }, { "payer_name": "UNITED HEALTHCARE", "plan_name": "SUTTER SELECT & SUTTER HEALTH PLAN HMO PLANS", "methodology": "per diem", "standard_charge_dollar": 28538.0, "standard_charge_algorithm": "Per diem ($28,538).", "count": "0", "additional_payer_notes": "Zero final payments for the item or service in the 15 months prior to posting the file." }, { "payer_name": "UMR", "plan_name": "SUTTER SELECT & SUTTER HEALTH PLAN HMO PLANS", "methodology": "per diem", "standard_charge_dollar": 28538.0, "standard_charge_algorithm": "Per diem ($28,538).", "count": "0", "additional_payer_notes": "Zero final payments for the item or service in the 15 months prior to posting the file." } ] } ] }, { "description": "HC Cath Vent Gp005", "code_information": [ { "code": "PX-2120040005", "type": "CDM" }, { "code": "99999", "type": "CPT" }, { "code": "0272", "type": "RC" } ], "standard_charges": [ { "setting": "outpatient", "gross_charge": 195.0, "discounted_cash": 97.5, "minimum": 82.29, "maximum": 101.4, "additional_generic_notes": "Zero final payments for the item or service in the 15 months prior to posting the file.", "payers_information": [ { "payer_name": "AETNA", "plan_name": "AETNA ALL OTHER PLANS", "methodology": "percent of total billed charges", "standard_charge_dollar": 101.4, "standard_charge_percentage": 52.0, "count": "0", "additional_payer_notes": "Zero final payments for the item or service in the 15 months prior to posting the file." }, { "payer_name": "AETNA", "plan_name": "AETNA ALL OTHER PLANS", "methodology": "percent of total billed charges", "standard_charge_dollar": 101.4, "standard_charge_percentage": 52.0, "count": "0", "additional_payer_notes": "Zero final payments for the item or service in the 15 months prior to posting the file." }, { "payer_name": "MERITAIN HEALTH", "plan_name": "AETNA ALL OTHER PLANS", "methodology": "percent of total billed charges", "standard_charge_dollar": 101.4, "standard_charge_percentage": 52.0, "count": "0", "additional_payer_notes": "Zero final payments for the item or service in the 15 months prior to posting the file." }, { "payer_name": "BLUE SHIELD OUT OF STATE", "plan_name": "STANFORD HEALTHCARE ALLIANCE PLAN", "methodology": "percent of total billed charges", "standard_charge_dollar": 94.75, "standard_charge_percentage": 48.59, "count": "0", "additional_payer_notes": "Zero final payments for the item or service in the 15 months prior to posting the file." }, { "payer_name": "BLUE SHIELD", "plan_name": "STANFORD HEALTHCARE ALLIANCE PLAN", "methodology": "percent of total billed charges", "standard_charge_dollar": 94.75, "standard_charge_percentage": 48.59, "count": "0", "additional_payer_notes": "Zero final payments for the item or service in the 15 months prior to posting the file." }, { "payer_name": "BLUE SHIELD", "plan_name": "STANFORD HEALTHCARE ALLIANCE PLAN", "methodology": "percent of total billed charges", "standard_charge_dollar": 94.75, "standard_charge_percentage": 48.59, "count": "0", "additional_payer_notes": "Zero final payments for the item or service in the 15 months prior to posting the file." }, { "payer_name": "CIGNA", "plan_name": "CIGNA COM ALT HMO PLAN", "methodology": "percent of total billed charges", "standard_charge_dollar": 82.29, "standard_charge_percentage": 42.2, "count": "0", "additional_payer_notes": "Zero final payments for the item or service in the 15 months prior to posting the file." }, { "payer_name": "CIGNA", "plan_name": "CIGNA COM ALT HMO PLAN", "methodology": "percent of total billed charges", "standard_charge_dollar": 82.29, "standard_charge_percentage": 42.2, "count": "0", "additional_payer_notes": "Zero final payments for the item or service in the 15 months prior to posting the file." }, { "payer_name": "HEALTH NET", "plan_name": "HEALTHNET HMO, PPO, POS, EPO, CANOPY HEALTHNET HMO, OTHER-IN-NETWORK PLANS", "methodology": "per diem", "standard_charge_dollar": 8000.0, "standard_charge_algorithm": "Expected reimbursement is the lesser of Per diem ($8,000) for the length of stay and 70% of billed.", "count": "0", "additional_payer_notes": "Zero final payments for the item or service in the 15 months prior to posting the file." }, { "payer_name": "HEALTH NET", "plan_name": "HEALTHNET HMO, PPO, POS, EPO, CANOPY HEALTHNET HMO, OTHER-IN-NETWORK PLANS", "methodology": "per diem", "standard_charge_dollar": 8000.0, "standard_charge_algorithm": "Expected reimbursement is the lesser of Per diem ($8,000) for the length of stay and 70% of billed.", "count": "0", "additional_payer_notes": "Zero final payments for the item or service in the 15 months prior to posting the file." }, { "payer_name": "UNITED HEALTHCARE", "plan_name": "SUTTER SELECT & SUTTER HEALTH PLAN HMO PLANS", "methodology": "per diem", "standard_charge_dollar": 28538.0, "standard_charge_algorithm": "Per diem ($28,538).", "count": "0", "additional_payer_notes": "Zero final payments for the item or service in the 15 months prior to posting the file." }, { "payer_name": "UNITED HEALTHCARE", "plan_name": "SUTTER SELECT & SUTTER HEALTH PLAN HMO PLANS", "methodology": "per diem", "standard_charge_dollar": 28538.0, "standard_charge_algorithm": "Per diem ($28,538).", "count": "0", "additional_payer_notes": "Zero final payments for the item or service in the 15 months prior to posting the file." }, { "payer_name": "SUTTER", "plan_name": "SUTTER SELECT & SUTTER HEALTH PLAN HMO PLANS", "methodology": "per diem", "standard_charge_dollar": 28538.0, "standard_charge_algorithm": "Per diem ($28,538).", "count": "0", "additional_payer_notes": "Zero final payments for the item or service in the 15 months prior to posting the file." }, { "payer_name": "UNITED HEALTHCARE", "plan_name": "SUTTER SELECT & SUTTER HEALTH PLAN HMO PLANS", "methodology": "per diem", "standard_charge_dollar": 28538.0, "standard_charge_algorithm": "Per diem ($28,538).", "count": "0", "additional_payer_notes": "Zero final payments for the item or service in the 15 months prior to posting the file." }, { "payer_name": "UMR", "plan_name": "SUTTER SELECT & SUTTER HEALTH PLAN HMO PLANS", "methodology": "per diem", "standard_charge_dollar": 28538.0, "standard_charge_algorithm": "Per diem ($28,538).", "count": "0", "additional_payer_notes": "Zero final payments for the item or service in the 15 months prior to posting the file." } ] } ] }, { "description": "HC Cath Vent Gp006", "code_information": [ { "code": "PX-2120040006", "type": "CDM" }, { "code": "99999", "type": "CPT" }, { "code": "0272", "type": "RC" } ], "standard_charges": [ { "setting": "outpatient", "gross_charge": 293.0, "discounted_cash": 146.5, "minimum": 123.65, "maximum": 152.36, "additional_generic_notes": "Zero final payments for the item or service in the 15 months prior to posting the file.", "payers_information": [ { "payer_name": "AETNA", "plan_name": "AETNA ALL OTHER PLANS", "methodology": "percent of total billed charges", "standard_charge_dollar": 152.36, "standard_charge_percentage": 52.0, "count": "0", "additional_payer_notes": "Zero final payments for the item or service in the 15 months prior to posting the file." }, { "payer_name": "AETNA", "plan_name": "AETNA ALL OTHER PLANS", "methodology": "percent of total billed charges", "standard_charge_dollar": 152.36, "standard_charge_percentage": 52.0, "count": "0", "additional_payer_notes": "Zero final payments for the item or service in the 15 months prior to posting the file." }, { "payer_name": "MERITAIN HEALTH", "plan_name": "AETNA ALL OTHER PLANS", "methodology": "percent of total billed charges", "standard_charge_dollar": 152.36, "standard_charge_percentage": 52.0, "count": "0", "additional_payer_notes": "Zero final payments for the item or service in the 15 months prior to posting the file." }, { "payer_name": "BLUE SHIELD OUT OF STATE", "plan_name": "STANFORD HEALTHCARE ALLIANCE PLAN", "methodology": "percent of total billed charges", "standard_charge_dollar": 142.37, "standard_charge_percentage": 48.59, "count": "0", "additional_payer_notes": "Zero final payments for the item or service in the 15 months prior to posting the file." }, { "payer_name": "BLUE SHIELD", "plan_name": "STANFORD HEALTHCARE ALLIANCE PLAN", "methodology": "percent of total billed charges", "standard_charge_dollar": 142.37, "standard_charge_percentage": 48.59, "count": "0", "additional_payer_notes": "Zero final payments for the item or service in the 15 months prior to posting the file." }, { "payer_name": "BLUE SHIELD", "plan_name": "STANFORD HEALTHCARE ALLIANCE PLAN", "methodology": "percent of total billed charges", "standard_charge_dollar": 142.37, "standard_charge_percentage": 48.59, "count": "0", "additional_payer_notes": "Zero final payments for the item or service in the 15 months prior to posting the file." }, { "payer_name": "CIGNA", "plan_name": "CIGNA COM ALT HMO PLAN", "methodology": "percent of total billed charges", "standard_charge_dollar": 123.65, "standard_charge_percentage": 42.2, "count": "0", "additional_payer_notes": "Zero final payments for the item or service in the 15 months prior to posting the file." }, { "payer_name": "CIGNA", "plan_name": "CIGNA COM ALT HMO PLAN", "methodology": "percent of total billed charges", "standard_charge_dollar": 123.65, "standard_charge_percentage": 42.2, "count": "0", "additional_payer_notes": "Zero final payments for the item or service in the 15 months prior to posting the file." }, { "payer_name": "HEALTH NET", "plan_name": "HEALTHNET HMO, PPO, POS, EPO, CANOPY HEALTHNET HMO, OTHER-IN-NETWORK PLANS", "methodology": "per diem", "standard_charge_dollar": 8000.0, "standard_charge_algorithm": "Expected reimbursement is the lesser of Per diem ($8,000) for the length of stay and 70% of billed.", "count": "0", "additional_payer_notes": "Zero final payments for the item or service in the 15 months prior to posting the file." }, { "payer_name": "HEALTH NET", "plan_name": "HEALTHNET HMO, PPO, POS, EPO, CANOPY HEALTHNET HMO, OTHER-IN-NETWORK PLANS", "methodology": "per diem", "standard_charge_dollar": 8000.0, "standard_charge_algorithm": "Expected reimbursement is the lesser of Per diem ($8,000) for the length of stay and 70% of billed.", "count": "0", "additional_payer_notes": "Zero final payments for the item or service in the 15 months prior to posting the file." }, { "payer_name": "UNITED HEALTHCARE", "plan_name": "SUTTER SELECT & SUTTER HEALTH PLAN HMO PLANS", "methodology": "per diem", "standard_charge_dollar": 28538.0, "standard_charge_algorithm": "Per diem ($28,538).", "count": "0", "additional_payer_notes": "Zero final payments for the item or service in the 15 months prior to posting the file." }, { "payer_name": "UNITED HEALTHCARE", "plan_name": "SUTTER SELECT & SUTTER HEALTH PLAN HMO PLANS", "methodology": "per diem", "standard_charge_dollar": 28538.0, "standard_charge_algorithm": "Per diem ($28,538).", "count": "0", "additional_payer_notes": "Zero final payments for the item or service in the 15 months prior to posting the file." }, { "payer_name": "SUTTER", "plan_name": "SUTTER SELECT & SUTTER HEALTH PLAN HMO PLANS", "methodology": "per diem", "standard_charge_dollar": 28538.0, "standard_charge_algorithm": "Per diem ($28,538).", "count": "0", "additional_payer_notes": "Zero final payments for the item or service in the 15 months prior to posting the file." }, { "payer_name": "UNITED HEALTHCARE", "plan_name": "SUTTER SELECT & SUTTER HEALTH PLAN HMO PLANS", "methodology": "per diem", "standard_charge_dollar": 28538.0, "standard_charge_algorithm": "Per diem ($28,538).", "count": "0", "additional_payer_notes": "Zero final payments for the item or service in the 15 months prior to posting the file." }, { "payer_name": "UMR", "plan_name": "SUTTER SELECT & SUTTER HEALTH PLAN HMO PLANS", "methodology": "per diem", "standard_charge_dollar": 28538.0, "standard_charge_algorithm": "Per diem ($28,538).", "count": "0", "additional_payer_notes": "Zero final payments for the item or service in the 15 months prior to posting the file." } ] } ] }, { "description": "HC Cath Vent Gp012", "code_information": [ { "code": "PX-2120040012", "type": "CDM" }, { "code": "99999", "type": "CPT" }, { "code": "0272", "type": "RC" } ], "standard_charges": [ { "setting": "outpatient", "gross_charge": 810.0, "discounted_cash": 405.0, "minimum": 341.82, "maximum": 421.2, "additional_generic_notes": "Zero final payments for the item or service in the 15 months prior to posting the file.", "payers_information": [ { "payer_name": "AETNA", "plan_name": "AETNA ALL OTHER PLANS", "methodology": "percent of total billed charges", "standard_charge_dollar": 421.2, "standard_charge_percentage": 52.0, "count": "0", "additional_payer_notes": "Zero final payments for the item or service in the 15 months prior to posting the file." }, { "payer_name": "AETNA", "plan_name": "AETNA ALL OTHER PLANS", "methodology": "percent of total billed charges", "standard_charge_dollar": 421.2, "standard_charge_percentage": 52.0, "count": "0", "additional_payer_notes": "Zero final payments for the item or service in the 15 months prior to posting the file." }, { "payer_name": "MERITAIN HEALTH", "plan_name": "AETNA ALL OTHER PLANS", "methodology": "percent of total billed charges", "standard_charge_dollar": 421.2, "standard_charge_percentage": 52.0, "count": "0", "additional_payer_notes": "Zero final payments for the item or service in the 15 months prior to posting the file." }, { "payer_name": "BLUE SHIELD OUT OF STATE", "plan_name": "STANFORD HEALTHCARE ALLIANCE PLAN", "methodology": "percent of total billed charges", "standard_charge_dollar": 393.58, "standard_charge_percentage": 48.59, "count": "0", "additional_payer_notes": "Zero final payments for the item or service in the 15 months prior to posting the file." }, { "payer_name": "BLUE SHIELD", "plan_name": "STANFORD HEALTHCARE ALLIANCE PLAN", "methodology": "percent of total billed charges", "standard_charge_dollar": 393.58, "standard_charge_percentage": 48.59, "count": "0", "additional_payer_notes": "Zero final payments for the item or service in the 15 months prior to posting the file." }, { "payer_name": "BLUE SHIELD", "plan_name": "STANFORD HEALTHCARE ALLIANCE PLAN", "methodology": "percent of total billed charges", "standard_charge_dollar": 393.58, "standard_charge_percentage": 48.59, "count": "0", "additional_payer_notes": "Zero final payments for the item or service in the 15 months prior to posting the file." }, { "payer_name": "CIGNA", "plan_name": "CIGNA COM ALT HMO PLAN", "methodology": "percent of total billed charges", "standard_charge_dollar": 341.82, "standard_charge_percentage": 42.2, "count": "0", "additional_payer_notes": "Zero final payments for the item or service in the 15 months prior to posting the file." }, { "payer_name": "CIGNA", "plan_name": "CIGNA COM ALT HMO PLAN", "methodology": "percent of total billed charges", "standard_charge_dollar": 341.82, "standard_charge_percentage": 42.2, "count": "0", "additional_payer_notes": "Zero final payments for the item or service in the 15 months prior to posting the file." }, { "payer_name": "HEALTH NET", "plan_name": "HEALTHNET HMO, PPO, POS, EPO, CANOPY HEALTHNET HMO, OTHER-IN-NETWORK PLANS", "methodology": "per diem", "standard_charge_dollar": 8000.0, "standard_charge_algorithm": "Expected reimbursement is the lesser of Per diem ($8,000) for the length of stay and 70% of billed.", "count": "0", "additional_payer_notes": "Zero final payments for the item or service in the 15 months prior to posting the file." }, { "payer_name": "HEALTH NET", "plan_name": "HEALTHNET HMO, PPO, POS, EPO, CANOPY HEALTHNET HMO, OTHER-IN-NETWORK PLANS", "methodology": "per diem", "standard_charge_dollar": 8000.0, "standard_charge_algorithm": "Expected reimbursement is the lesser of Per diem ($8,000) for the length of stay and 70% of billed.", "count": "0", "additional_payer_notes": "Zero final payments for the item or service in the 15 months prior to posting the file." }, { "payer_name": "UNITED HEALTHCARE", "plan_name": "SUTTER SELECT & SUTTER HEALTH PLAN HMO PLANS", "methodology": "per diem", "standard_charge_dollar": 28538.0, "standard_charge_algorithm": "Per diem ($28,538).", "count": "0", "additional_payer_notes": "Zero final payments for the item or service in the 15 months prior to posting the file." }, { "payer_name": "UNITED HEALTHCARE", "plan_name": "SUTTER SELECT & SUTTER HEALTH PLAN HMO PLANS", "methodology": "per diem", "standard_charge_dollar": 28538.0, "standard_charge_algorithm": "Per diem ($28,538).", "count": "0", "additional_payer_notes": "Zero final payments for the item or service in the 15 months prior to posting the file." }, { "payer_name": "SUTTER", "plan_name": "SUTTER SELECT & SUTTER HEALTH PLAN HMO PLANS", "methodology": "per diem", "standard_charge_dollar": 28538.0, "standard_charge_algorithm": "Per diem ($28,538).", "count": "0", "additional_payer_notes": "Zero final payments for the item or service in the 15 months prior to posting the file." }, { "payer_name": "UNITED HEALTHCARE", "plan_name": "SUTTER SELECT & SUTTER HEALTH PLAN HMO PLANS", "methodology": "per diem", "standard_charge_dollar": 28538.0, "standard_charge_algorithm": "Per diem ($28,538).", "count": "0", "additional_payer_notes": "Zero final payments for the item or service in the 15 months prior to posting the file." }, { "payer_name": "UMR", "plan_name": "SUTTER SELECT & SUTTER HEALTH PLAN HMO PLANS", "methodology": "per diem", "standard_charge_dollar": 28538.0, "standard_charge_algorithm": "Per diem ($28,538).", "count": "0", "additional_payer_notes": "Zero final payments for the item or service in the 15 months prior to posting the file." } ] } ] }, { "description": "HC Cath Vent Gp013", "code_information": [ { "code": "PX-2120040013", "type": "CDM" }, { "code": "99999", "type": "CPT" }, { "code": "0272", "type": "RC" } ], "standard_charges": [ { "setting": "outpatient", "gross_charge": 900.0, "discounted_cash": 450.0, "minimum": 379.8, "maximum": 468.0, "additional_generic_notes": "Zero final payments for the item or service in the 15 months prior to posting the file.", "payers_information": [ { "payer_name": "AETNA", "plan_name": "AETNA ALL OTHER PLANS", "methodology": "percent of total billed charges", "standard_charge_dollar": 468.0, "standard_charge_percentage": 52.0, "count": "0", "additional_payer_notes": "Zero final payments for the item or service in the 15 months prior to posting the file." }, { "payer_name": "AETNA", "plan_name": "AETNA ALL OTHER PLANS", "methodology": "percent of total billed charges", "standard_charge_dollar": 468.0, "standard_charge_percentage": 52.0, "count": "0", "additional_payer_notes": "Zero final payments for the item or service in the 15 months prior to posting the file." }, { "payer_name": "MERITAIN HEALTH", "plan_name": "AETNA ALL OTHER PLANS", "methodology": "percent of total billed charges", "standard_charge_dollar": 468.0, "standard_charge_percentage": 52.0, "count": "0", "additional_payer_notes": "Zero final payments for the item or service in the 15 months prior to posting the file." }, { "payer_name": "BLUE SHIELD OUT OF STATE", "plan_name": "STANFORD HEALTHCARE ALLIANCE PLAN", "methodology": "percent of total billed charges", "standard_charge_dollar": 437.31, "standard_charge_percentage": 48.59, "count": "0", "additional_payer_notes": "Zero final payments for the item or service in the 15 months prior to posting the file." }, { "payer_name": "BLUE SHIELD", "plan_name": "STANFORD HEALTHCARE ALLIANCE PLAN", "methodology": "percent of total billed charges", "standard_charge_dollar": 437.31, "standard_charge_percentage": 48.59, "count": "0", "additional_payer_notes": "Zero final payments for the item or service in the 15 months prior to posting the file." }, { "payer_name": "BLUE SHIELD", "plan_name": "STANFORD HEALTHCARE ALLIANCE PLAN", "methodology": "percent of total billed charges", "standard_charge_dollar": 437.31, "standard_charge_percentage": 48.59, "count": "0", "additional_payer_notes": "Zero final payments for the item or service in the 15 months prior to posting the file." }, { "payer_name": "CIGNA", "plan_name": "CIGNA COM ALT HMO PLAN", "methodology": "percent of total billed charges", "standard_charge_dollar": 379.8, "standard_charge_percentage": 42.2, "count": "0", "additional_payer_notes": "Zero final payments for the item or service in the 15 months prior to posting the file." }, { "payer_name": "CIGNA", "plan_name": "CIGNA COM ALT HMO PLAN", "methodology": "percent of total billed charges", "standard_charge_dollar": 379.8, "standard_charge_percentage": 42.2, "count": "0", "additional_payer_notes": "Zero final payments for the item or service in the 15 months prior to posting the file." }, { "payer_name": "HEALTH NET", "plan_name": "HEALTHNET HMO, PPO, POS, EPO, CANOPY HEALTHNET HMO, OTHER-IN-NETWORK PLANS", "methodology": "per diem", "standard_charge_dollar": 8000.0, "standard_charge_algorithm": "Expected reimbursement is the lesser of Per diem ($8,000) for the length of stay and 70% of billed.", "count": "0", "additional_payer_notes": "Zero final payments for the item or service in the 15 months prior to posting the file." }, { "payer_name": "HEALTH NET", "plan_name": "HEALTHNET HMO, PPO, POS, EPO, CANOPY HEALTHNET HMO, OTHER-IN-NETWORK PLANS", "methodology": "per diem", "standard_charge_dollar": 8000.0, "standard_charge_algorithm": "Expected reimbursement is the lesser of Per diem ($8,000) for the length of stay and 70% of billed.", "count": "0", "additional_payer_notes": "Zero final payments for the item or service in the 15 months prior to posting the file." }, { "payer_name": "UNITED HEALTHCARE", "plan_name": "SUTTER SELECT & SUTTER HEALTH PLAN HMO PLANS", "methodology": "per diem", "standard_charge_dollar": 28538.0, "standard_charge_algorithm": "Per diem ($28,538).", "count": "0", "additional_payer_notes": "Zero final payments for the item or service in the 15 months prior to posting the file." }, { "payer_name": "UNITED HEALTHCARE", "plan_name": "SUTTER SELECT & SUTTER HEALTH PLAN HMO PLANS", "methodology": "per diem", "standard_charge_dollar": 28538.0, "standard_charge_algorithm": "Per diem ($28,538).", "count": "0", "additional_payer_notes": "Zero final payments for the item or service in the 15 months prior to posting the file." }, { "payer_name": "SUTTER", "plan_name": "SUTTER SELECT & SUTTER HEALTH PLAN HMO PLANS", "methodology": "per diem", "standard_charge_dollar": 28538.0, "standard_charge_algorithm": "Per diem ($28,538).", "count": "0", "additional_payer_notes": "Zero final payments for the item or service in the 15 months prior to posting the file." }, { "payer_name": "UNITED HEALTHCARE", "plan_name": "SUTTER SELECT & SUTTER HEALTH PLAN HMO PLANS", "methodology": "per diem", "standard_charge_dollar": 28538.0, "standard_charge_algorithm": "Per diem ($28,538).", "count": "0", "additional_payer_notes": "Zero final payments for the item or service in the 15 months prior to posting the file." }, { "payer_name": "UMR", "plan_name": "SUTTER SELECT & SUTTER HEALTH PLAN HMO PLANS", "methodology": "per diem", "standard_charge_dollar": 28538.0, "standard_charge_algorithm": "Per diem ($28,538).", "count": "0", "additional_payer_notes": "Zero final payments for the item or service in the 15 months prior to posting the file." } ] } ] }, { "description": "HC Cath Vent Gp014", "code_information": [ { "code": "PX-2120040014", "type": "CDM" }, { "code": "99999", "type": "CPT" }, { "code": "0272", "type": "RC" } ], "standard_charges": [ { "setting": "outpatient", "gross_charge": 1080.0, "discounted_cash": 540.0, "minimum": 455.76, "maximum": 561.6, "additional_generic_notes": "Zero final payments for the item or service in the 15 months prior to posting the file.", "payers_information": [ { "payer_name": "AETNA", "plan_name": "AETNA ALL OTHER PLANS", "methodology": "percent of total billed charges", "standard_charge_dollar": 561.6, "standard_charge_percentage": 52.0, "count": "0", "additional_payer_notes": "Zero final payments for the item or service in the 15 months prior to posting the file." }, { "payer_name": "AETNA", "plan_name": "AETNA ALL OTHER PLANS", "methodology": "percent of total billed charges", "standard_charge_dollar": 561.6, "standard_charge_percentage": 52.0, "count": "0", "additional_payer_notes": "Zero final payments for the item or service in the 15 months prior to posting the file." }, { "payer_name": "MERITAIN HEALTH", "plan_name": "AETNA ALL OTHER PLANS", "methodology": "percent of total billed charges", "standard_charge_dollar": 561.6, "standard_charge_percentage": 52.0, "count": "0", "additional_payer_notes": "Zero final payments for the item or service in the 15 months prior to posting the file." }, { "payer_name": "BLUE SHIELD OUT OF STATE", "plan_name": "STANFORD HEALTHCARE ALLIANCE PLAN", "methodology": "percent of total billed charges", "standard_charge_dollar": 524.77, "standard_charge_percentage": 48.59, "count": "0", "additional_payer_notes": "Zero final payments for the item or service in the 15 months prior to posting the file." }, { "payer_name": "BLUE SHIELD", "plan_name": "STANFORD HEALTHCARE ALLIANCE PLAN", "methodology": "percent of total billed charges", "standard_charge_dollar": 524.77, "standard_charge_percentage": 48.59, "median_amount": 68.24, "10th_percentile": 13.6, "90th_percentile": 1043.06, "count": "30" }, { "payer_name": "BLUE SHIELD", "plan_name": "STANFORD HEALTHCARE ALLIANCE PLAN", "methodology": "percent of total billed charges", "standard_charge_dollar": 524.77, "standard_charge_percentage": 48.59, "count": "0", "additional_payer_notes": "Zero final payments for the item or service in the 15 months prior to posting the file." }, { "payer_name": "BLUE SHIELD", "plan_name": "STANFORD HEALTHCARE ALLIANCE PLAN", "methodology": "percent of total billed charges", "standard_charge_dollar": 524.77, "standard_charge_percentage": 48.59, "count": "0", "additional_payer_notes": "Zero final payments for the item or service in the 15 months prior to posting the file." }, { "payer_name": "CIGNA", "plan_name": "CIGNA COM ALT HMO PLAN", "methodology": "percent of total billed charges", "standard_charge_dollar": 455.76, "standard_charge_percentage": 42.2, "count": "0", "additional_payer_notes": "Zero final payments for the item or service in the 15 months prior to posting the file." }, { "payer_name": "CIGNA", "plan_name": "CIGNA COM ALT HMO PLAN", "methodology": "percent of total billed charges", "standard_charge_dollar": 455.76, "standard_charge_percentage": 42.2, "count": "0", "additional_payer_notes": "Zero final payments for the item or service in the 15 months prior to posting the file." }, { "payer_name": "HEALTH NET", "plan_name": "HEALTHNET HMO, PPO, POS, EPO, CANOPY HEALTHNET HMO, OTHER-IN-NETWORK PLANS", "methodology": "per diem", "standard_charge_dollar": 8000.0, "standard_charge_algorithm": "Expected reimbursement is the lesser of Per diem ($8,000) for the length of stay and 70% of billed.", "count": "0", "additional_payer_notes": "Zero final payments for the item or service in the 15 months prior to posting the file." }, { "payer_name": "HEALTH NET", "plan_name": "HEALTHNET HMO, PPO, POS, EPO, CANOPY HEALTHNET HMO, OTHER-IN-NETWORK PLANS", "methodology": "per diem", "standard_charge_dollar": 8000.0, "standard_charge_algorithm": "Expected reimbursement is the lesser of Per diem ($8,000) for the length of stay and 70% of billed.", "count": "0", "additional_payer_notes": "Zero final payments for the item or service in the 15 months prior to posting the file." }, { "payer_name": "UNITED HEALTHCARE", "plan_name": "SUTTER SELECT & SUTTER HEALTH PLAN HMO PLANS", "methodology": "per diem", "standard_charge_dollar": 28538.0, "standard_charge_algorithm": "Per diem ($28,538).", "count": "0", "additional_payer_notes": "Zero final payments for the item or service in the 15 months prior to posting the file." }, { "payer_name": "UNITED HEALTHCARE", "plan_name": "SUTTER SELECT & SUTTER HEALTH PLAN HMO PLANS", "methodology": "per diem", "standard_charge_dollar": 28538.0, "standard_charge_algorithm": "Per diem ($28,538).", "count": "0", "additional_payer_notes": "Zero final payments for the item or service in the 15 months prior to posting the file." }, { "payer_name": "SUTTER", "plan_name": "SUTTER SELECT & SUTTER HEALTH PLAN HMO PLANS", "methodology": "per diem", "standard_charge_dollar": 28538.0, "standard_charge_algorithm": "Per diem ($28,538).", "count": "0", "additional_payer_notes": "Zero final payments for the item or service in the 15 months prior to posting the file." }, { "payer_name": "UNITED HEALTHCARE", "plan_name": "SUTTER SELECT & SUTTER HEALTH PLAN HMO PLANS", "methodology": "per diem", "standard_charge_dollar": 28538.0, "standard_charge_algorithm": "Per diem ($28,538).", "count": "0", "additional_payer_notes": "Zero final payments for the item or service in the 15 months prior to posting the file." }, { "payer_name": "UMR", "plan_name": "SUTTER SELECT & SUTTER HEALTH PLAN HMO PLANS", "methodology": "per diem", "standard_charge_dollar": 28538.0, "standard_charge_algorithm": "Per diem ($28,538).", "count": "0", "additional_payer_notes": "Zero final payments for the item or service in the 15 months prior to posting the file." } ] } ] }, { "description": "HC Cath Vent Gp015", "code_information": [ { "code": "PX-2120040015", "type": "CDM" }, { "code": "99999", "type": "CPT" }, { "code": "0272", "type": "RC" } ], "standard_charges": [ { "setting": "outpatient", "gross_charge": 1225.0, "discounted_cash": 612.5, "minimum": 516.95, "maximum": 637.0, "additional_generic_notes": "Zero final payments for the item or service in the 15 months prior to posting the file.", "payers_information": [ { "payer_name": "AETNA", "plan_name": "AETNA ALL OTHER PLANS", "methodology": "percent of total billed charges", "standard_charge_dollar": 637.0, "standard_charge_percentage": 52.0, "count": "0", "additional_payer_notes": "Zero final payments for the item or service in the 15 months prior to posting the file." }, { "payer_name": "AETNA", "plan_name": "AETNA ALL OTHER PLANS", "methodology": "percent of total billed charges", "standard_charge_dollar": 637.0, "standard_charge_percentage": 52.0, "count": "0", "additional_payer_notes": "Zero final payments for the item or service in the 15 months prior to posting the file." }, { "payer_name": "MERITAIN HEALTH", "plan_name": "AETNA ALL OTHER PLANS", "methodology": "percent of total billed charges", "standard_charge_dollar": 637.0, "standard_charge_percentage": 52.0, "count": "0", "additional_payer_notes": "Zero final payments for the item or service in the 15 months prior to posting the file." }, { "payer_name": "BLUE SHIELD OUT OF STATE", "plan_name": "STANFORD HEALTHCARE ALLIANCE PLAN", "methodology": "percent of total billed charges", "standard_charge_dollar": 595.23, "standard_charge_percentage": 48.59, "count": "0", "additional_payer_notes": "Zero final payments for the item or service in the 15 months prior to posting the file." }, { "payer_name": "BLUE SHIELD", "plan_name": "STANFORD HEALTHCARE ALLIANCE PLAN", "methodology": "percent of total billed charges", "standard_charge_dollar": 595.23, "standard_charge_percentage": 48.59, "median_amount": 68.24, "10th_percentile": 13.6, "90th_percentile": 1043.06, "count": "30" }, { "payer_name": "BLUE SHIELD", "plan_name": "STANFORD HEALTHCARE ALLIANCE PLAN", "methodology": "percent of total billed charges", "standard_charge_dollar": 595.23, "standard_charge_percentage": 48.59, "count": "0", "additional_payer_notes": "Zero final payments for the item or service in the 15 months prior to posting the file." }, { "payer_name": "BLUE SHIELD", "plan_name": "STANFORD HEALTHCARE ALLIANCE PLAN", "methodology": "percent of total billed charges", "standard_charge_dollar": 595.23, "standard_charge_percentage": 48.59, "count": "0", "additional_payer_notes": "Zero final payments for the item or service in the 15 months prior to posting the file." }, { "payer_name": "CIGNA", "plan_name": "CIGNA COM ALT HMO PLAN", "methodology": "percent of total billed charges", "standard_charge_dollar": 516.95, "standard_charge_percentage": 42.2, "count": "0", "additional_payer_notes": "Zero final payments for the item or service in the 15 months prior to posting the file." }, { "payer_name": "CIGNA", "plan_name": "CIGNA COM ALT HMO PLAN", "methodology": "percent of total billed charges", "standard_charge_dollar": 516.95, "standard_charge_percentage": 42.2, "count": "0", "additional_payer_notes": "Zero final payments for the item or service in the 15 months prior to posting the file." }, { "payer_name": "HEALTH NET", "plan_name": "HEALTHNET HMO, PPO, POS, EPO, CANOPY HEALTHNET HMO, OTHER-IN-NETWORK PLANS", "methodology": "per diem", "standard_charge_dollar": 8000.0, "standard_charge_algorithm": "Expected reimbursement is the lesser of Per diem ($8,000) for the length of stay and 70% of billed.", "count": "0", "additional_payer_notes": "Zero final payments for the item or service in the 15 months prior to posting the file." }, { "payer_name": "HEALTH NET", "plan_name": "HEALTHNET HMO, PPO, POS, EPO, CANOPY HEALTHNET HMO, OTHER-IN-NETWORK PLANS", "methodology": "per diem", "standard_charge_dollar": 8000.0, "standard_charge_algorithm": "Expected reimbursement is the lesser of Per diem ($8,000) for the length of stay and 70% of billed.", "count": "0", "additional_payer_notes": "Zero final payments for the item or service in the 15 months prior to posting the file." }, { "payer_name": "UNITED HEALTHCARE", "plan_name": "SUTTER SELECT & SUTTER HEALTH PLAN HMO PLANS", "methodology": "per diem", "standard_charge_dollar": 28538.0, "standard_charge_algorithm": "Per diem ($28,538).", "count": "0", "additional_payer_notes": "Zero final payments for the item or service in the 15 months prior to posting the file." }, { "payer_name": "UNITED HEALTHCARE", "plan_name": "SUTTER SELECT & SUTTER HEALTH PLAN HMO PLANS", "methodology": "per diem", "standard_charge_dollar": 28538.0, "standard_charge_algorithm": "Per diem ($28,538).", "count": "0", "additional_payer_notes": "Zero final payments for the item or service in the 15 months prior to posting the file." }, { "payer_name": "SUTTER", "plan_name": "SUTTER SELECT & SUTTER HEALTH PLAN HMO PLANS", "methodology": "per diem", "standard_charge_dollar": 28538.0, "standard_charge_algorithm": "Per diem ($28,538).", "count": "0", "additional_payer_notes": "Zero final payments for the item or service in the 15 months prior to posting the file." }, { "payer_name": "UNITED HEALTHCARE", "plan_name": "SUTTER SELECT & SUTTER HEALTH PLAN HMO PLANS", "methodology": "per diem", "standard_charge_dollar": 28538.0, "standard_charge_algorithm": "Per diem ($28,538).", "count": "0", "additional_payer_notes": "Zero final payments for the item or service in the 15 months prior to posting the file." }, { "payer_name": "UMR", "plan_name": "SUTTER SELECT & SUTTER HEALTH PLAN HMO PLANS", "methodology": "per diem", "standard_charge_dollar": 28538.0, "standard_charge_algorithm": "Per diem ($28,538).", "count": "0", "additional_payer_notes": "Zero final payments for the item or service in the 15 months prior to posting the file." } ] } ] }, { "description": "HC Cath Vent Gp016", "code_information": [ { "code": "PX-2120040016", "type": "CDM" }, { "code": "99999", "type": "CPT" }, { "code": "0272", "type": "RC" } ], "standard_charges": [ { "setting": "outpatient", "gross_charge": 1400.0, "discounted_cash": 700.0, "minimum": 590.8, "maximum": 728.0, "additional_generic_notes": "Zero final payments for the item or service in the 15 months prior to posting the file.", "payers_information": [ { "payer_name": "AETNA", "plan_name": "AETNA ALL OTHER PLANS", "methodology": "percent of total billed charges", "standard_charge_dollar": 728.0, "standard_charge_percentage": 52.0, "count": "0", "additional_payer_notes": "Zero final payments for the item or service in the 15 months prior to posting the file." }, { "payer_name": "AETNA", "plan_name": "AETNA ALL OTHER PLANS", "methodology": "percent of total billed charges", "standard_charge_dollar": 728.0, "standard_charge_percentage": 52.0, "count": "0", "additional_payer_notes": "Zero final payments for the item or service in the 15 months prior to posting the file." }, { "payer_name": "MERITAIN HEALTH", "plan_name": "AETNA ALL OTHER PLANS", "methodology": "percent of total billed charges", "standard_charge_dollar": 728.0, "standard_charge_percentage": 52.0, "count": "0", "additional_payer_notes": "Zero final payments for the item or service in the 15 months prior to posting the file." }, { "payer_name": "BLUE SHIELD OUT OF STATE", "plan_name": "STANFORD HEALTHCARE ALLIANCE PLAN", "methodology": "percent of total billed charges", "standard_charge_dollar": 680.26, "standard_charge_percentage": 48.59, "count": "0", "additional_payer_notes": "Zero final payments for the item or service in the 15 months prior to posting the file." }, { "payer_name": "BLUE SHIELD", "plan_name": "STANFORD HEALTHCARE ALLIANCE PLAN", "methodology": "percent of total billed charges", "standard_charge_dollar": 680.26, "standard_charge_percentage": 48.59, "median_amount": 68.24, "10th_percentile": 13.6, "90th_percentile": 1043.06, "count": "30" }, { "payer_name": "BLUE SHIELD", "plan_name": "STANFORD HEALTHCARE ALLIANCE PLAN", "methodology": "percent of total billed charges", "standard_charge_dollar": 680.26, "standard_charge_percentage": 48.59, "count": "0", "additional_payer_notes": "Zero final payments for the item or service in the 15 months prior to posting the file." }, { "payer_name": "BLUE SHIELD", "plan_name": "STANFORD HEALTHCARE ALLIANCE PLAN", "methodology": "percent of total billed charges", "standard_charge_dollar": 680.26, "standard_charge_percentage": 48.59, "count": "0", "additional_payer_notes": "Zero final payments for the item or service in the 15 months prior to posting the file." }, { "payer_name": "CIGNA", "plan_name": "CIGNA COM ALT HMO PLAN", "methodology": "percent of total billed charges", "standard_charge_dollar": 590.8, "standard_charge_percentage": 42.2, "count": "0", "additional_payer_notes": "Zero final payments for the item or service in the 15 months prior to posting the file." }, { "payer_name": "CIGNA", "plan_name": "CIGNA COM ALT HMO PLAN", "methodology": "percent of total billed charges", "standard_charge_dollar": 590.8, "standard_charge_percentage": 42.2, "count": "0", "additional_payer_notes": "Zero final payments for the item or service in the 15 months prior to posting the file." }, { "payer_name": "HEALTH NET", "plan_name": "HEALTHNET HMO, PPO, POS, EPO, CANOPY HEALTHNET HMO, OTHER-IN-NETWORK PLANS", "methodology": "per diem", "standard_charge_dollar": 8000.0, "standard_charge_algorithm": "Expected reimbursement is the lesser of Per diem ($8,000) for the length of stay and 70% of billed.", "count": "0", "additional_payer_notes": "Zero final payments for the item or service in the 15 months prior to posting the file." }, { "payer_name": "HEALTH NET", "plan_name": "HEALTHNET HMO, PPO, POS, EPO, CANOPY HEALTHNET HMO, OTHER-IN-NETWORK PLANS", "methodology": "per diem", "standard_charge_dollar": 8000.0, "standard_charge_algorithm": "Expected reimbursement is the lesser of Per diem ($8,000) for the length of stay and 70% of billed.", "count": "0", "additional_payer_notes": "Zero final payments for the item or service in the 15 months prior to posting the file." }, { "payer_name": "UNITED HEALTHCARE", "plan_name": "SUTTER SELECT & SUTTER HEALTH PLAN HMO PLANS", "methodology": "per diem", "standard_charge_dollar": 28538.0, "standard_charge_algorithm": "Per diem ($28,538).", "count": "0", "additional_payer_notes": "Zero final payments for the item or service in the 15 months prior to posting the file." }, { "payer_name": "UNITED HEALTHCARE", "plan_name": "SUTTER SELECT & SUTTER HEALTH PLAN HMO PLANS", "methodology": "per diem", "standard_charge_dollar": 28538.0, "standard_charge_algorithm": "Per diem ($28,538).", "count": "0", "additional_payer_notes": "Zero final payments for the item or service in the 15 months prior to posting the file." }, { "payer_name": "SUTTER", "plan_name": "SUTTER SELECT & SUTTER HEALTH PLAN HMO PLANS", "methodology": "per diem", "standard_charge_dollar": 28538.0, "standard_charge_algorithm": "Per diem ($28,538).", "count": "0", "additional_payer_notes": "Zero final payments for the item or service in the 15 months prior to posting the file." }, { "payer_name": "UNITED HEALTHCARE", "plan_name": "SUTTER SELECT & SUTTER HEALTH PLAN HMO PLANS", "methodology": "per diem", "standard_charge_dollar": 28538.0, "standard_charge_algorithm": "Per diem ($28,538).", "count": "0", "additional_payer_notes": "Zero final payments for the item or service in the 15 months prior to posting the file." }, { "payer_name": "UMR", "plan_name": "SUTTER SELECT & SUTTER HEALTH PLAN HMO PLANS", "methodology": "per diem", "standard_charge_dollar": 28538.0, "standard_charge_algorithm": "Per diem ($28,538).", "count": "0", "additional_payer_notes": "Zero final payments for the item or service in the 15 months prior to posting the file." } ] } ] }, { "description": "HC Cath Vent Gp017", "code_information": [ { "code": "PX-2120040017", "type": "CDM" }, { "code": "99999", "type": "CPT" }, { "code": "0272", "type": "RC" } ], "standard_charges": [ { "setting": "outpatient", "gross_charge": 1575.0, "discounted_cash": 787.5, "minimum": 664.65, "maximum": 819.0, "additional_generic_notes": "Zero final payments for the item or service in the 15 months prior to posting the file.", "payers_information": [ { "payer_name": "AETNA", "plan_name": "AETNA ALL OTHER PLANS", "methodology": "percent of total billed charges", "standard_charge_dollar": 819.0, "standard_charge_percentage": 52.0, "count": "0", "additional_payer_notes": "Zero final payments for the item or service in the 15 months prior to posting the file." }, { "payer_name": "AETNA", "plan_name": "AETNA ALL OTHER PLANS", "methodology": "percent of total billed charges", "standard_charge_dollar": 819.0, "standard_charge_percentage": 52.0, "count": "0", "additional_payer_notes": "Zero final payments for the item or service in the 15 months prior to posting the file." }, { "payer_name": "MERITAIN HEALTH", "plan_name": "AETNA ALL OTHER PLANS", "methodology": "percent of total billed charges", "standard_charge_dollar": 819.0, "standard_charge_percentage": 52.0, "count": "0", "additional_payer_notes": "Zero final payments for the item or service in the 15 months prior to posting the file." }, { "payer_name": "BLUE SHIELD OUT OF STATE", "plan_name": "STANFORD HEALTHCARE ALLIANCE PLAN", "methodology": "percent of total billed charges", "standard_charge_dollar": 765.29, "standard_charge_percentage": 48.59, "count": "0", "additional_payer_notes": "Zero final payments for the item or service in the 15 months prior to posting the file." }, { "payer_name": "BLUE SHIELD", "plan_name": "STANFORD HEALTHCARE ALLIANCE PLAN", "methodology": "percent of total billed charges", "standard_charge_dollar": 765.29, "standard_charge_percentage": 48.59, "median_amount": 68.24, "10th_percentile": 13.6, "90th_percentile": 1043.06, "count": "30" }, { "payer_name": "BLUE SHIELD", "plan_name": "STANFORD HEALTHCARE ALLIANCE PLAN", "methodology": "percent of total billed charges", "standard_charge_dollar": 765.29, "standard_charge_percentage": 48.59, "count": "0", "additional_payer_notes": "Zero final payments for the item or service in the 15 months prior to posting the file." }, { "payer_name": "BLUE SHIELD", "plan_name": "STANFORD HEALTHCARE ALLIANCE PLAN", "methodology": "percent of total billed charges", "standard_charge_dollar": 765.29, "standard_charge_percentage": 48.59, "count": "0", "additional_payer_notes": "Zero final payments for the item or service in the 15 months prior to posting the file." }, { "payer_name": "CIGNA", "plan_name": "CIGNA COM ALT HMO PLAN", "methodology": "percent of total billed charges", "standard_charge_dollar": 664.65, "standard_charge_percentage": 42.2, "count": "0", "additional_payer_notes": "Zero final payments for the item or service in the 15 months prior to posting the file." }, { "payer_name": "CIGNA", "plan_name": "CIGNA COM ALT HMO PLAN", "methodology": "percent of total billed charges", "standard_charge_dollar": 664.65, "standard_charge_percentage": 42.2, "count": "0", "additional_payer_notes": "Zero final payments for the item or service in the 15 months prior to posting the file." }, { "payer_name": "HEALTH NET", "plan_name": "HEALTHNET HMO, PPO, POS, EPO, CANOPY HEALTHNET HMO, OTHER-IN-NETWORK PLANS", "methodology": "per diem", "standard_charge_dollar": 8000.0, "standard_charge_algorithm": "Expected reimbursement is the lesser of Per diem ($8,000) for the length of stay and 70% of billed.", "count": "0", "additional_payer_notes": "Zero final payments for the item or service in the 15 months prior to posting the file." }, { "payer_name": "HEALTH NET", "plan_name": "HEALTHNET HMO, PPO, POS, EPO, CANOPY HEALTHNET HMO, OTHER-IN-NETWORK PLANS", "methodology": "per diem", "standard_charge_dollar": 8000.0, "standard_charge_algorithm": "Expected reimbursement is the lesser of Per diem ($8,000) for the length of stay and 70% of billed.", "count": "0", "additional_payer_notes": "Zero final payments for the item or service in the 15 months prior to posting the file." }, { "payer_name": "UNITED HEALTHCARE", "plan_name": "SUTTER SELECT & SUTTER HEALTH PLAN HMO PLANS", "methodology": "per diem", "standard_charge_dollar": 28538.0, "standard_charge_algorithm": "Per diem ($28,538).", "count": "0", "additional_payer_notes": "Zero final payments for the item or service in the 15 months prior to posting the file." }, { "payer_name": "UNITED HEALTHCARE", "plan_name": "SUTTER SELECT & SUTTER HEALTH PLAN HMO PLANS", "methodology": "per diem", "standard_charge_dollar": 28538.0, "standard_charge_algorithm": "Per diem ($28,538).", "count": "0", "additional_payer_notes": "Zero final payments for the item or service in the 15 months prior to posting the file." }, { "payer_name": "SUTTER", "plan_name": "SUTTER SELECT & SUTTER HEALTH PLAN HMO PLANS", "methodology": "per diem", "standard_charge_dollar": 28538.0, "standard_charge_algorithm": "Per diem ($28,538).", "count": "0", "additional_payer_notes": "Zero final payments for the item or service in the 15 months prior to posting the file." }, { "payer_name": "UNITED HEALTHCARE", "plan_name": "SUTTER SELECT & SUTTER HEALTH PLAN HMO PLANS", "methodology": "per diem", "standard_charge_dollar": 28538.0, "standard_charge_algorithm": "Per diem ($28,538).", "count": "0", "additional_payer_notes": "Zero final payments for the item or service in the 15 months prior to posting the file." }, { "payer_name": "UMR", "plan_name": "SUTTER SELECT & SUTTER HEALTH PLAN HMO PLANS", "methodology": "per diem", "standard_charge_dollar": 28538.0, "standard_charge_algorithm": "Per diem ($28,538).", "count": "0", "additional_payer_notes": "Zero final payments for the item or service in the 15 months prior to posting the file." } ] } ] }, { "description": "HC Cath Vent Gp018", "code_information": [ { "code": "PX-2120040018", "type": "CDM" }, { "code": "99999", "type": "CPT" }, { "code": "0272", "type": "RC" } ], "standard_charges": [ { "setting": "outpatient", "gross_charge": 1750.0, "discounted_cash": 875.0, "minimum": 738.5, "maximum": 910.0, "additional_generic_notes": "Zero final payments for the item or service in the 15 months prior to posting the file.", "payers_information": [ { "payer_name": "AETNA", "plan_name": "AETNA ALL OTHER PLANS", "methodology": "percent of total billed charges", "standard_charge_dollar": 910.0, "standard_charge_percentage": 52.0, "count": "0", "additional_payer_notes": "Zero final payments for the item or service in the 15 months prior to posting the file." }, { "payer_name": "AETNA", "plan_name": "AETNA ALL OTHER PLANS", "methodology": "percent of total billed charges", "standard_charge_dollar": 910.0, "standard_charge_percentage": 52.0, "count": "0", "additional_payer_notes": "Zero final payments for the item or service in the 15 months prior to posting the file." }, { "payer_name": "MERITAIN HEALTH", "plan_name": "AETNA ALL OTHER PLANS", "methodology": "percent of total billed charges", "standard_charge_dollar": 910.0, "standard_charge_percentage": 52.0, "count": "0", "additional_payer_notes": "Zero final payments for the item or service in the 15 months prior to posting the file." }, { "payer_name": "BLUE SHIELD OUT OF STATE", "plan_name": "STANFORD HEALTHCARE ALLIANCE PLAN", "methodology": "percent of total billed charges", "standard_charge_dollar": 850.33, "standard_charge_percentage": 48.59, "count": "0", "additional_payer_notes": "Zero final payments for the item or service in the 15 months prior to posting the file." }, { "payer_name": "BLUE SHIELD", "plan_name": "STANFORD HEALTHCARE ALLIANCE PLAN", "methodology": "percent of total billed charges", "standard_charge_dollar": 850.33, "standard_charge_percentage": 48.59, "median_amount": 68.24, "10th_percentile": 13.6, "90th_percentile": 1043.06, "count": "30" }, { "payer_name": "BLUE SHIELD", "plan_name": "STANFORD HEALTHCARE ALLIANCE PLAN", "methodology": "percent of total billed charges", "standard_charge_dollar": 850.33, "standard_charge_percentage": 48.59, "count": "0", "additional_payer_notes": "Zero final payments for the item or service in the 15 months prior to posting the file." }, { "payer_name": "BLUE SHIELD", "plan_name": "STANFORD HEALTHCARE ALLIANCE PLAN", "methodology": "percent of total billed charges", "standard_charge_dollar": 850.33, "standard_charge_percentage": 48.59, "count": "0", "additional_payer_notes": "Zero final payments for the item or service in the 15 months prior to posting the file." }, { "payer_name": "CIGNA", "plan_name": "CIGNA COM ALT HMO PLAN", "methodology": "percent of total billed charges", "standard_charge_dollar": 738.5, "standard_charge_percentage": 42.2, "count": "0", "additional_payer_notes": "Zero final payments for the item or service in the 15 months prior to posting the file." }, { "payer_name": "CIGNA", "plan_name": "CIGNA COM ALT HMO PLAN", "methodology": "percent of total billed charges", "standard_charge_dollar": 738.5, "standard_charge_percentage": 42.2, "count": "0", "additional_payer_notes": "Zero final payments for the item or service in the 15 months prior to posting the file." }, { "payer_name": "HEALTH NET", "plan_name": "HEALTHNET HMO, PPO, POS, EPO, CANOPY HEALTHNET HMO, OTHER-IN-NETWORK PLANS", "methodology": "per diem", "standard_charge_dollar": 8000.0, "standard_charge_algorithm": "Expected reimbursement is the lesser of Per diem ($8,000) for the length of stay and 70% of billed.", "count": "0", "additional_payer_notes": "Zero final payments for the item or service in the 15 months prior to posting the file." }, { "payer_name": "HEALTH NET", "plan_name": "HEALTHNET HMO, PPO, POS, EPO, CANOPY HEALTHNET HMO, OTHER-IN-NETWORK PLANS", "methodology": "per diem", "standard_charge_dollar": 8000.0, "standard_charge_algorithm": "Expected reimbursement is the lesser of Per diem ($8,000) for the length of stay and 70% of billed.", "count": "0", "additional_payer_notes": "Zero final payments for the item or service in the 15 months prior to posting the file." }, { "payer_name": "UNITED HEALTHCARE", "plan_name": "SUTTER SELECT & SUTTER HEALTH PLAN HMO PLANS", "methodology": "per diem", "standard_charge_dollar": 28538.0, "standard_charge_algorithm": "Per diem ($28,538).", "count": "0", "additional_payer_notes": "Zero final payments for the item or service in the 15 months prior to posting the file." }, { "payer_name": "UNITED HEALTHCARE", "plan_name": "SUTTER SELECT & SUTTER HEALTH PLAN HMO PLANS", "methodology": "per diem", "standard_charge_dollar": 28538.0, "standard_charge_algorithm": "Per diem ($28,538).", "count": "0", "additional_payer_notes": "Zero final payments for the item or service in the 15 months prior to posting the file." }, { "payer_name": "SUTTER", "plan_name": "SUTTER SELECT & SUTTER HEALTH PLAN HMO PLANS", "methodology": "per diem", "standard_charge_dollar": 28538.0, "standard_charge_algorithm": "Per diem ($28,538).", "count": "0", "additional_payer_notes": "Zero final payments for the item or service in the 15 months prior to posting the file." }, { "payer_name": "UNITED HEALTHCARE", "plan_name": "SUTTER SELECT & SUTTER HEALTH PLAN HMO PLANS", "methodology": "per diem", "standard_charge_dollar": 28538.0, "standard_charge_algorithm": "Per diem ($28,538).", "count": "0", "additional_payer_notes": "Zero final payments for the item or service in the 15 months prior to posting the file." }, { "payer_name": "UMR", "plan_name": "SUTTER SELECT & SUTTER HEALTH PLAN HMO PLANS", "methodology": "per diem", "standard_charge_dollar": 28538.0, "standard_charge_algorithm": "Per diem ($28,538).", "count": "0", "additional_payer_notes": "Zero final payments for the item or service in the 15 months prior to posting the file." } ] } ] }, { "description": "HC Cath Vent Gp019", "code_information": [ { "code": "PX-2120040019", "type": "CDM" }, { "code": "99999", "type": "CPT" }, { "code": "0272", "type": "RC" } ], "standard_charges": [ { "setting": "outpatient", "gross_charge": 2125.0, "discounted_cash": 1062.5, "minimum": 896.75, "maximum": 1105.0, "additional_generic_notes": "Zero final payments for the item or service in the 15 months prior to posting the file.", "payers_information": [ { "payer_name": "AETNA", "plan_name": "AETNA ALL OTHER PLANS", "methodology": "percent of total billed charges", "standard_charge_dollar": 1105.0, "standard_charge_percentage": 52.0, "count": "0", "additional_payer_notes": "Zero final payments for the item or service in the 15 months prior to posting the file." }, { "payer_name": "AETNA", "plan_name": "AETNA ALL OTHER PLANS", "methodology": "percent of total billed charges", "standard_charge_dollar": 1105.0, "standard_charge_percentage": 52.0, "count": "0", "additional_payer_notes": "Zero final payments for the item or service in the 15 months prior to posting the file." }, { "payer_name": "MERITAIN HEALTH", "plan_name": "AETNA ALL OTHER PLANS", "methodology": "percent of total billed charges", "standard_charge_dollar": 1105.0, "standard_charge_percentage": 52.0, "count": "0", "additional_payer_notes": "Zero final payments for the item or service in the 15 months prior to posting the file." }, { "payer_name": "BLUE SHIELD OUT OF STATE", "plan_name": "STANFORD HEALTHCARE ALLIANCE PLAN", "methodology": "percent of total billed charges", "standard_charge_dollar": 1032.54, "standard_charge_percentage": 48.59, "count": "0", "additional_payer_notes": "Zero final payments for the item or service in the 15 months prior to posting the file." }, { "payer_name": "BLUE SHIELD", "plan_name": "STANFORD HEALTHCARE ALLIANCE PLAN", "methodology": "percent of total billed charges", "standard_charge_dollar": 1032.54, "standard_charge_percentage": 48.59, "median_amount": 68.24, "10th_percentile": 13.6, "90th_percentile": 1043.06, "count": "30" }, { "payer_name": "BLUE SHIELD", "plan_name": "STANFORD HEALTHCARE ALLIANCE PLAN", "methodology": "percent of total billed charges", "standard_charge_dollar": 1032.54, "standard_charge_percentage": 48.59, "count": "0", "additional_payer_notes": "Zero final payments for the item or service in the 15 months prior to posting the file." }, { "payer_name": "BLUE SHIELD", "plan_name": "STANFORD HEALTHCARE ALLIANCE PLAN", "methodology": "percent of total billed charges", "standard_charge_dollar": 1032.54, "standard_charge_percentage": 48.59, "count": "0", "additional_payer_notes": "Zero final payments for the item or service in the 15 months prior to posting the file." }, { "payer_name": "CIGNA", "plan_name": "CIGNA COM ALT HMO PLAN", "methodology": "percent of total billed charges", "standard_charge_dollar": 896.75, "standard_charge_percentage": 42.2, "count": "0", "additional_payer_notes": "Zero final payments for the item or service in the 15 months prior to posting the file." }, { "payer_name": "CIGNA", "plan_name": "CIGNA COM ALT HMO PLAN", "methodology": "percent of total billed charges", "standard_charge_dollar": 896.75, "standard_charge_percentage": 42.2, "count": "0", "additional_payer_notes": "Zero final payments for the item or service in the 15 months prior to posting the file." }, { "payer_name": "HEALTH NET", "plan_name": "HEALTHNET HMO, PPO, POS, EPO, CANOPY HEALTHNET HMO, OTHER-IN-NETWORK PLANS", "methodology": "per diem", "standard_charge_dollar": 8000.0, "standard_charge_algorithm": "Expected reimbursement is the lesser of Per diem ($8,000) for the length of stay and 70% of billed.", "count": "0", "additional_payer_notes": "Zero final payments for the item or service in the 15 months prior to posting the file." }, { "payer_name": "HEALTH NET", "plan_name": "HEALTHNET HMO, PPO, POS, EPO, CANOPY HEALTHNET HMO, OTHER-IN-NETWORK PLANS", "methodology": "per diem", "standard_charge_dollar": 8000.0, "standard_charge_algorithm": "Expected reimbursement is the lesser of Per diem ($8,000) for the length of stay and 70% of billed.", "count": "0", "additional_payer_notes": "Zero final payments for the item or service in the 15 months prior to posting the file." }, { "payer_name": "UNITED HEALTHCARE", "plan_name": "SUTTER SELECT & SUTTER HEALTH PLAN HMO PLANS", "methodology": "per diem", "standard_charge_dollar": 28538.0, "standard_charge_algorithm": "Per diem ($28,538).", "count": "0", "additional_payer_notes": "Zero final payments for the item or service in the 15 months prior to posting the file." }, { "payer_name": "UNITED HEALTHCARE", "plan_name": "SUTTER SELECT & SUTTER HEALTH PLAN HMO PLANS", "methodology": "per diem", "standard_charge_dollar": 28538.0, "standard_charge_algorithm": "Per diem ($28,538).", "count": "0", "additional_payer_notes": "Zero final payments for the item or service in the 15 months prior to posting the file." }, { "payer_name": "SUTTER", "plan_name": "SUTTER SELECT & SUTTER HEALTH PLAN HMO PLANS", "methodology": "per diem", "standard_charge_dollar": 28538.0, "standard_charge_algorithm": "Per diem ($28,538).", "count": "0", "additional_payer_notes": "Zero final payments for the item or service in the 15 months prior to posting the file." }, { "payer_name": "UNITED HEALTHCARE", "plan_name": "SUTTER SELECT & SUTTER HEALTH PLAN HMO PLANS", "methodology": "per diem", "standard_charge_dollar": 28538.0, "standard_charge_algorithm": "Per diem ($28,538).", "count": "0", "additional_payer_notes": "Zero final payments for the item or service in the 15 months prior to posting the file." }, { "payer_name": "UMR", "plan_name": "SUTTER SELECT & SUTTER HEALTH PLAN HMO PLANS", "methodology": "per diem", "standard_charge_dollar": 28538.0, "standard_charge_algorithm": "Per diem ($28,538).", "count": "0", "additional_payer_notes": "Zero final payments for the item or service in the 15 months prior to posting the file." } ] } ] }, { "description": "Hc Cath Vent Gp020", "code_information": [ { "code": "PX-2120040020", "type": "CDM" }, { "code": "99999", "type": "CPT" }, { "code": "0272", "type": "RC" } ], "standard_charges": [ { "setting": "outpatient", "gross_charge": 2550.0, "discounted_cash": 1275.0, "minimum": 1076.1, "maximum": 1326.0, "additional_generic_notes": "Zero final payments for the item or service in the 15 months prior to posting the file.", "payers_information": [ { "payer_name": "AETNA", "plan_name": "AETNA ALL OTHER PLANS", "methodology": "percent of total billed charges", "standard_charge_dollar": 1326.0, "standard_charge_percentage": 52.0, "count": "0", "additional_payer_notes": "Zero final payments for the item or service in the 15 months prior to posting the file." }, { "payer_name": "AETNA", "plan_name": "AETNA ALL OTHER PLANS", "methodology": "percent of total billed charges", "standard_charge_dollar": 1326.0, "standard_charge_percentage": 52.0, "count": "0", "additional_payer_notes": "Zero final payments for the item or service in the 15 months prior to posting the file." }, { "payer_name": "MERITAIN HEALTH", "plan_name": "AETNA ALL OTHER PLANS", "methodology": "percent of total billed charges", "standard_charge_dollar": 1326.0, "standard_charge_percentage": 52.0, "count": "0", "additional_payer_notes": "Zero final payments for the item or service in the 15 months prior to posting the file." }, { "payer_name": "BLUE SHIELD OUT OF STATE", "plan_name": "STANFORD HEALTHCARE ALLIANCE PLAN", "methodology": "percent of total billed charges", "standard_charge_dollar": 1239.05, "standard_charge_percentage": 48.59, "count": "0", "additional_payer_notes": "Zero final payments for the item or service in the 15 months prior to posting the file." }, { "payer_name": "BLUE SHIELD", "plan_name": "STANFORD HEALTHCARE ALLIANCE PLAN", "methodology": "percent of total billed charges", "standard_charge_dollar": 1239.05, "standard_charge_percentage": 48.59, "median_amount": 68.24, "10th_percentile": 13.6, "90th_percentile": 1043.06, "count": "30" }, { "payer_name": "BLUE SHIELD", "plan_name": "STANFORD HEALTHCARE ALLIANCE PLAN", "methodology": "percent of total billed charges", "standard_charge_dollar": 1239.05, "standard_charge_percentage": 48.59, "count": "0", "additional_payer_notes": "Zero final payments for the item or service in the 15 months prior to posting the file." }, { "payer_name": "BLUE SHIELD", "plan_name": "STANFORD HEALTHCARE ALLIANCE PLAN", "methodology": "percent of total billed charges", "standard_charge_dollar": 1239.05, "standard_charge_percentage": 48.59, "count": "0", "additional_payer_notes": "Zero final payments for the item or service in the 15 months prior to posting the file." }, { "payer_name": "CIGNA", "plan_name": "CIGNA COM ALT HMO PLAN", "methodology": "percent of total billed charges", "standard_charge_dollar": 1076.1, "standard_charge_percentage": 42.2, "count": "0", "additional_payer_notes": "Zero final payments for the item or service in the 15 months prior to posting the file." }, { "payer_name": "CIGNA", "plan_name": "CIGNA COM ALT HMO PLAN", "methodology": "percent of total billed charges", "standard_charge_dollar": 1076.1, "standard_charge_percentage": 42.2, "count": "0", "additional_payer_notes": "Zero final payments for the item or service in the 15 months prior to posting the file." }, { "payer_name": "HEALTH NET", "plan_name": "HEALTHNET HMO, PPO, POS, EPO, CANOPY HEALTHNET HMO, OTHER-IN-NETWORK PLANS", "methodology": "per diem", "standard_charge_dollar": 8000.0, "standard_charge_algorithm": "Expected reimbursement is the lesser of Per diem ($8,000) for the length of stay and 70% of billed.", "count": "0", "additional_payer_notes": "Zero final payments for the item or service in the 15 months prior to posting the file." }, { "payer_name": "HEALTH NET", "plan_name": "HEALTHNET HMO, PPO, POS, EPO, CANOPY HEALTHNET HMO, OTHER-IN-NETWORK PLANS", "methodology": "per diem", "standard_charge_dollar": 8000.0, "standard_charge_algorithm": "Expected reimbursement is the lesser of Per diem ($8,000) for the length of stay and 70% of billed.", "count": "0", "additional_payer_notes": "Zero final payments for the item or service in the 15 months prior to posting the file." }, { "payer_name": "UNITED HEALTHCARE", "plan_name": "SUTTER SELECT & SUTTER HEALTH PLAN HMO PLANS", "methodology": "per diem", "standard_charge_dollar": 28538.0, "standard_charge_algorithm": "Per diem ($28,538).", "count": "0", "additional_payer_notes": "Zero final payments for the item or service in the 15 months prior to posting the file." }, { "payer_name": "UNITED HEALTHCARE", "plan_name": "SUTTER SELECT & SUTTER HEALTH PLAN HMO PLANS", "methodology": "per diem", "standard_charge_dollar": 28538.0, "standard_charge_algorithm": "Per diem ($28,538).", "count": "0", "additional_payer_notes": "Zero final payments for the item or service in the 15 months prior to posting the file." }, { "payer_name": "SUTTER", "plan_name": "SUTTER SELECT & SUTTER HEALTH PLAN HMO PLANS", "methodology": "per diem", "standard_charge_dollar": 28538.0, "standard_charge_algorithm": "Per diem ($28,538).", "count": "0", "additional_payer_notes": "Zero final payments for the item or service in the 15 months prior to posting the file." }, { "payer_name": "UNITED HEALTHCARE", "plan_name": "SUTTER SELECT & SUTTER HEALTH PLAN HMO PLANS", "methodology": "per diem", "standard_charge_dollar": 28538.0, "standard_charge_algorithm": "Per diem ($28,538).", "count": "0", "additional_payer_notes": "Zero final payments for the item or service in the 15 months prior to posting the file." }, { "payer_name": "UMR", "plan_name": "SUTTER SELECT & SUTTER HEALTH PLAN HMO PLANS", "methodology": "per diem", "standard_charge_dollar": 28538.0, "standard_charge_algorithm": "Per diem ($28,538).", "count": "0", "additional_payer_notes": "Zero final payments for the item or service in the 15 months prior to posting the file." } ] } ] }, { "description": "Hc Cath Vent Gp023", "code_information": [ { "code": "PX-2120040023", "type": "CDM" }, { "code": "99999", "type": "CPT" }, { "code": "0272", "type": "RC" } ], "standard_charges": [ { "setting": "outpatient", "gross_charge": 3600.0, "discounted_cash": 1800.0, "minimum": 1519.2, "maximum": 1872.0, "additional_generic_notes": "Zero final payments for the item or service in the 15 months prior to posting the file.", "payers_information": [ { "payer_name": "AETNA", "plan_name": "AETNA ALL OTHER PLANS", "methodology": "percent of total billed charges", "standard_charge_dollar": 1872.0, "standard_charge_percentage": 52.0, "count": "0", "additional_payer_notes": "Zero final payments for the item or service in the 15 months prior to posting the file." }, { "payer_name": "AETNA", "plan_name": "AETNA ALL OTHER PLANS", "methodology": "percent of total billed charges", "standard_charge_dollar": 1872.0, "standard_charge_percentage": 52.0, "count": "0", "additional_payer_notes": "Zero final payments for the item or service in the 15 months prior to posting the file." }, { "payer_name": "MERITAIN HEALTH", "plan_name": "AETNA ALL OTHER PLANS", "methodology": "percent of total billed charges", "standard_charge_dollar": 1872.0, "standard_charge_percentage": 52.0, "count": "0", "additional_payer_notes": "Zero final payments for the item or service in the 15 months prior to posting the file." }, { "payer_name": "BLUE SHIELD OUT OF STATE", "plan_name": "STANFORD HEALTHCARE ALLIANCE PLAN", "methodology": "percent of total billed charges", "standard_charge_dollar": 1749.24, "standard_charge_percentage": 48.59, "count": "0", "additional_payer_notes": "Zero final payments for the item or service in the 15 months prior to posting the file." }, { "payer_name": "BLUE SHIELD", "plan_name": "STANFORD HEALTHCARE ALLIANCE PLAN", "methodology": "percent of total billed charges", "standard_charge_dollar": 1749.24, "standard_charge_percentage": 48.59, "median_amount": 68.24, "10th_percentile": 13.6, "90th_percentile": 1043.06, "count": "30" }, { "payer_name": "BLUE SHIELD", "plan_name": "STANFORD HEALTHCARE ALLIANCE PLAN", "methodology": "percent of total billed charges", "standard_charge_dollar": 1749.24, "standard_charge_percentage": 48.59, "count": "0", "additional_payer_notes": "Zero final payments for the item or service in the 15 months prior to posting the file." }, { "payer_name": "BLUE SHIELD", "plan_name": "STANFORD HEALTHCARE ALLIANCE PLAN", "methodology": "percent of total billed charges", "standard_charge_dollar": 1749.24, "standard_charge_percentage": 48.59, "count": "0", "additional_payer_notes": "Zero final payments for the item or service in the 15 months prior to posting the file." }, { "payer_name": "CIGNA", "plan_name": "CIGNA COM ALT HMO PLAN", "methodology": "percent of total billed charges", "standard_charge_dollar": 1519.2, "standard_charge_percentage": 42.2, "count": "0", "additional_payer_notes": "Zero final payments for the item or service in the 15 months prior to posting the file." }, { "payer_name": "CIGNA", "plan_name": "CIGNA COM ALT HMO PLAN", "methodology": "percent of total billed charges", "standard_charge_dollar": 1519.2, "standard_charge_percentage": 42.2, "count": "0", "additional_payer_notes": "Zero final payments for the item or service in the 15 months prior to posting the file." }, { "payer_name": "HEALTH NET", "plan_name": "HEALTHNET HMO, PPO, POS, EPO, CANOPY HEALTHNET HMO, OTHER-IN-NETWORK PLANS", "methodology": "per diem", "standard_charge_dollar": 8000.0, "standard_charge_algorithm": "Expected reimbursement is the lesser of Per diem ($8,000) for the length of stay and 70% of billed.", "count": "0", "additional_payer_notes": "Zero final payments for the item or service in the 15 months prior to posting the file." }, { "payer_name": "HEALTH NET", "plan_name": "HEALTHNET HMO, PPO, POS, EPO, CANOPY HEALTHNET HMO, OTHER-IN-NETWORK PLANS", "methodology": "per diem", "standard_charge_dollar": 8000.0, "standard_charge_algorithm": "Expected reimbursement is the lesser of Per diem ($8,000) for the length of stay and 70% of billed.", "count": "0", "additional_payer_notes": "Zero final payments for the item or service in the 15 months prior to posting the file." }, { "payer_name": "UNITED HEALTHCARE", "plan_name": "SUTTER SELECT & SUTTER HEALTH PLAN HMO PLANS", "methodology": "per diem", "standard_charge_dollar": 28538.0, "standard_charge_algorithm": "Per diem ($28,538).", "count": "0", "additional_payer_notes": "Zero final payments for the item or service in the 15 months prior to posting the file." }, { "payer_name": "UNITED HEALTHCARE", "plan_name": "SUTTER SELECT & SUTTER HEALTH PLAN HMO PLANS", "methodology": "per diem", "standard_charge_dollar": 28538.0, "standard_charge_algorithm": "Per diem ($28,538).", "count": "0", "additional_payer_notes": "Zero final payments for the item or service in the 15 months prior to posting the file." }, { "payer_name": "SUTTER", "plan_name": "SUTTER SELECT & SUTTER HEALTH PLAN HMO PLANS", "methodology": "per diem", "standard_charge_dollar": 28538.0, "standard_charge_algorithm": "Per diem ($28,538).", "count": "0", "additional_payer_notes": "Zero final payments for the item or service in the 15 months prior to posting the file." }, { "payer_name": "UNITED HEALTHCARE", "plan_name": "SUTTER SELECT & SUTTER HEALTH PLAN HMO PLANS", "methodology": "per diem", "standard_charge_dollar": 28538.0, "standard_charge_algorithm": "Per diem ($28,538).", "count": "0", "additional_payer_notes": "Zero final payments for the item or service in the 15 months prior to posting the file." }, { "payer_name": "UMR", "plan_name": "SUTTER SELECT & SUTTER HEALTH PLAN HMO PLANS", "methodology": "per diem", "standard_charge_dollar": 28538.0, "standard_charge_algorithm": "Per diem ($28,538).", "count": "0", "additional_payer_notes": "Zero final payments for the item or service in the 15 months prior to posting the file." } ] } ] }, { "description": "HC Impl Cement Bone Gp028", "code_information": [ { "code": "PX-2120041028", "type": "CDM" }, { "code": "C1713", "type": "HCPCS" }, { "code": "0272", "type": "RC" } ], "standard_charges": [ { "setting": "outpatient", "gross_charge": 5250.0, "discounted_cash": 2625.0, "minimum": 2215.5, "maximum": 2730.0, "additional_generic_notes": "Zero final payments for the item or service in the 15 months prior to posting the file.", "payers_information": [ { "payer_name": "AETNA", "plan_name": "AETNA ALL OTHER PLANS", "methodology": "percent of total billed charges", "standard_charge_dollar": 2730.0, "standard_charge_percentage": 52.0, "median_amount": 1305.56, "10th_percentile": 413.89, "90th_percentile": 2555.63, "count": "131" }, { "payer_name": "AETNA", "plan_name": "AETNA ALL OTHER PLANS", "methodology": "percent of total billed charges", "standard_charge_dollar": 2730.0, "standard_charge_percentage": 52.0, "count": "0", "additional_payer_notes": "Zero final payments for the item or service in the 15 months prior to posting the file." }, { "payer_name": "BLUE SHIELD OUT OF STATE", "plan_name": "STANFORD HEALTHCARE ALLIANCE PLAN", "methodology": "percent of total billed charges", "standard_charge_dollar": 2550.98, "standard_charge_percentage": 48.59, "median_amount": 2123.96, "10th_percentile": 503.27, "90th_percentile": 5098.94, "count": "60" }, { "payer_name": "BLUE SHIELD", "plan_name": "STANFORD HEALTHCARE ALLIANCE PLAN", "methodology": "percent of total billed charges", "standard_charge_dollar": 2550.98, "standard_charge_percentage": 48.59, "count": "0", "additional_payer_notes": "Zero final payments for the item or service in the 15 months prior to posting the file." }, { "payer_name": "CIGNA", "plan_name": "CIGNA COM ALT HMO PLAN", "methodology": "percent of total billed charges", "standard_charge_dollar": 2215.5, "standard_charge_percentage": 42.2, "count": "0", "additional_payer_notes": "Zero final payments for the item or service in the 15 months prior to posting the file." }, { "payer_name": "HEALTH NET", "plan_name": "HEALTHNET HMO, PPO, POS, EPO, CANOPY HEALTHNET HMO, OTHER-IN-NETWORK PLANS", "methodology": "per diem", "standard_charge_dollar": 8000.0, "standard_charge_algorithm": "Expected reimbursement is the lesser of Per diem ($8,000) for the length of stay and 70% of billed.", "median_amount": 1252.06, "10th_percentile": 875.0, "90th_percentile": 2406.5, "count": "1 through 10" }, { "payer_name": "UNITED HEALTHCARE", "plan_name": "SUTTER SELECT & SUTTER HEALTH PLAN HMO PLANS", "methodology": "per diem", "standard_charge_dollar": 28538.0, "standard_charge_algorithm": "Per diem ($28,538).", "count": "0", "additional_payer_notes": "Zero final payments for the item or service in the 15 months prior to posting the file." }, { "payer_name": "SUTTER", "plan_name": "SUTTER SELECT & SUTTER HEALTH PLAN HMO PLANS", "methodology": "per diem", "standard_charge_dollar": 28538.0, "standard_charge_algorithm": "Per diem ($28,538).", "median_amount": 133.01, "10th_percentile": 18.13, "90th_percentile": 4039.34, "count": "1 through 10" }, { "payer_name": "UNITED HEALTHCARE", "plan_name": "SUTTER SELECT & SUTTER HEALTH PLAN HMO PLANS", "methodology": "per diem", "standard_charge_dollar": 28538.0, "standard_charge_algorithm": "Per diem ($28,538).", "count": "0", "additional_payer_notes": "Zero final payments for the item or service in the 15 months prior to posting the file." } ] } ] }, { "description": "HC Centralizer Gp005", "code_information": [ { "code": "PX-2120043005", "type": "CDM" }, { "code": "99999", "type": "CPT" }, { "code": "0272", "type": "RC" } ], "standard_charges": [ { "setting": "outpatient", "gross_charge": 195.0, "discounted_cash": 97.5, "minimum": 82.29, "maximum": 101.4, "additional_generic_notes": "Zero final payments for the item or service in the 15 months prior to posting the file.", "payers_information": [ { "payer_name": "AETNA", "plan_name": "AETNA ALL OTHER PLANS", "methodology": "percent of total billed charges", "standard_charge_dollar": 101.4, "standard_charge_percentage": 52.0, "count": "0", "additional_payer_notes": "Zero final payments for the item or service in the 15 months prior to posting the file." }, { "payer_name": "AETNA", "plan_name": "AETNA ALL OTHER PLANS", "methodology": "percent of total billed charges", "standard_charge_dollar": 101.4, "standard_charge_percentage": 52.0, "count": "0", "additional_payer_notes": "Zero final payments for the item or service in the 15 months prior to posting the file." }, { "payer_name": "MERITAIN HEALTH", "plan_name": "AETNA ALL OTHER PLANS", "methodology": "percent of total billed charges", "standard_charge_dollar": 101.4, "standard_charge_percentage": 52.0, "count": "0", "additional_payer_notes": "Zero final payments for the item or service in the 15 months prior to posting the file." }, { "payer_name": "BLUE SHIELD OUT OF STATE", "plan_name": "STANFORD HEALTHCARE ALLIANCE PLAN", "methodology": "percent of total billed charges", "standard_charge_dollar": 94.75, "standard_charge_percentage": 48.59, "count": "0", "additional_payer_notes": "Zero final payments for the item or service in the 15 months prior to posting the file." }, { "payer_name": "BLUE SHIELD", "plan_name": "STANFORD HEALTHCARE ALLIANCE PLAN", "methodology": "percent of total billed charges", "standard_charge_dollar": 94.75, "standard_charge_percentage": 48.59, "count": "0", "additional_payer_notes": "Zero final payments for the item or service in the 15 months prior to posting the file." }, { "payer_name": "BLUE SHIELD", "plan_name": "STANFORD HEALTHCARE ALLIANCE PLAN", "methodology": "percent of total billed charges", "standard_charge_dollar": 94.75, "standard_charge_percentage": 48.59, "count": "0", "additional_payer_notes": "Zero final payments for the item or service in the 15 months prior to posting the file." }, { "payer_name": "CIGNA", "plan_name": "CIGNA COM ALT HMO PLAN", "methodology": "percent of total billed charges", "standard_charge_dollar": 82.29, "standard_charge_percentage": 42.2, "count": "0", "additional_payer_notes": "Zero final payments for the item or service in the 15 months prior to posting the file." }, { "payer_name": "CIGNA", "plan_name": "CIGNA COM ALT HMO PLAN", "methodology": "percent of total billed charges", "standard_charge_dollar": 82.29, "standard_charge_percentage": 42.2, "count": "0", "additional_payer_notes": "Zero final payments for the item or service in the 15 months prior to posting the file." }, { "payer_name": "HEALTH NET", "plan_name": "HEALTHNET HMO, PPO, POS, EPO, CANOPY HEALTHNET HMO, OTHER-IN-NETWORK PLANS", "methodology": "per diem", "standard_charge_dollar": 8000.0, "standard_charge_algorithm": "Expected reimbursement is the lesser of Per diem ($8,000) for the length of stay and 70% of billed.", "count": "0", "additional_payer_notes": "Zero final payments for the item or service in the 15 months prior to posting the file." }, { "payer_name": "HEALTH NET", "plan_name": "HEALTHNET HMO, PPO, POS, EPO, CANOPY HEALTHNET HMO, OTHER-IN-NETWORK PLANS", "methodology": "per diem", "standard_charge_dollar": 8000.0, "standard_charge_algorithm": "Expected reimbursement is the lesser of Per diem ($8,000) for the length of stay and 70% of billed.", "count": "0", "additional_payer_notes": "Zero final payments for the item or service in the 15 months prior to posting the file." }, { "payer_name": "UNITED HEALTHCARE", "plan_name": "SUTTER SELECT & SUTTER HEALTH PLAN HMO PLANS", "methodology": "per diem", "standard_charge_dollar": 28538.0, "standard_charge_algorithm": "Per diem ($28,538).", "count": "0", "additional_payer_notes": "Zero final payments for the item or service in the 15 months prior to posting the file." }, { "payer_name": "UNITED HEALTHCARE", "plan_name": "SUTTER SELECT & SUTTER HEALTH PLAN HMO PLANS", "methodology": "per diem", "standard_charge_dollar": 28538.0, "standard_charge_algorithm": "Per diem ($28,538).", "count": "0", "additional_payer_notes": "Zero final payments for the item or service in the 15 months prior to posting the file." }, { "payer_name": "SUTTER", "plan_name": "SUTTER SELECT & SUTTER HEALTH PLAN HMO PLANS", "methodology": "per diem", "standard_charge_dollar": 28538.0, "standard_charge_algorithm": "Per diem ($28,538).", "count": "0", "additional_payer_notes": "Zero final payments for the item or service in the 15 months prior to posting the file." }, { "payer_name": "UNITED HEALTHCARE", "plan_name": "SUTTER SELECT & SUTTER HEALTH PLAN HMO PLANS", "methodology": "per diem", "standard_charge_dollar": 28538.0, "standard_charge_algorithm": "Per diem ($28,538).", "count": "0", "additional_payer_notes": "Zero final payments for the item or service in the 15 months prior to posting the file." }, { "payer_name": "UMR", "plan_name": "SUTTER SELECT & SUTTER HEALTH PLAN HMO PLANS", "methodology": "per diem", "standard_charge_dollar": 28538.0, "standard_charge_algorithm": "Per diem ($28,538).", "count": "0", "additional_payer_notes": "Zero final payments for the item or service in the 15 months prior to posting the file." } ] } ] }, { "description": "HC Centralizer Gp010", "code_information": [ { "code": "PX-2120043010", "type": "CDM" }, { "code": "99999", "type": "CPT" }, { "code": "0272", "type": "RC" } ], "standard_charges": [ { "setting": "outpatient", "gross_charge": 665.0, "discounted_cash": 332.5, "minimum": 280.63, "maximum": 345.8, "additional_generic_notes": "Zero final payments for the item or service in the 15 months prior to posting the file.", "payers_information": [ { "payer_name": "AETNA", "plan_name": "AETNA ALL OTHER PLANS", "methodology": "percent of total billed charges", "standard_charge_dollar": 345.8, "standard_charge_percentage": 52.0, "count": "0", "additional_payer_notes": "Zero final payments for the item or service in the 15 months prior to posting the file." }, { "payer_name": "AETNA", "plan_name": "AETNA ALL OTHER PLANS", "methodology": "percent of total billed charges", "standard_charge_dollar": 345.8, "standard_charge_percentage": 52.0, "count": "0", "additional_payer_notes": "Zero final payments for the item or service in the 15 months prior to posting the file." }, { "payer_name": "MERITAIN HEALTH", "plan_name": "AETNA ALL OTHER PLANS", "methodology": "percent of total billed charges", "standard_charge_dollar": 345.8, "standard_charge_percentage": 52.0, "count": "0", "additional_payer_notes": "Zero final payments for the item or service in the 15 months prior to posting the file." }, { "payer_name": "BLUE SHIELD OUT OF STATE", "plan_name": "STANFORD HEALTHCARE ALLIANCE PLAN", "methodology": "percent of total billed charges", "standard_charge_dollar": 323.12, "standard_charge_percentage": 48.59, "count": "0", "additional_payer_notes": "Zero final payments for the item or service in the 15 months prior to posting the file." }, { "payer_name": "BLUE SHIELD", "plan_name": "STANFORD HEALTHCARE ALLIANCE PLAN", "methodology": "percent of total billed charges", "standard_charge_dollar": 323.12, "standard_charge_percentage": 48.59, "count": "0", "additional_payer_notes": "Zero final payments for the item or service in the 15 months prior to posting the file." }, { "payer_name": "BLUE SHIELD", "plan_name": "STANFORD HEALTHCARE ALLIANCE PLAN", "methodology": "percent of total billed charges", "standard_charge_dollar": 323.12, "standard_charge_percentage": 48.59, "count": "0", "additional_payer_notes": "Zero final payments for the item or service in the 15 months prior to posting the file." }, { "payer_name": "CIGNA", "plan_name": "CIGNA COM ALT HMO PLAN", "methodology": "percent of total billed charges", "standard_charge_dollar": 280.63, "standard_charge_percentage": 42.2, "count": "0", "additional_payer_notes": "Zero final payments for the item or service in the 15 months prior to posting the file." }, { "payer_name": "CIGNA", "plan_name": "CIGNA COM ALT HMO PLAN", "methodology": "percent of total billed charges", "standard_charge_dollar": 280.63, "standard_charge_percentage": 42.2, "count": "0", "additional_payer_notes": "Zero final payments for the item or service in the 15 months prior to posting the file." }, { "payer_name": "HEALTH NET", "plan_name": "HEALTHNET HMO, PPO, POS, EPO, CANOPY HEALTHNET HMO, OTHER-IN-NETWORK PLANS", "methodology": "per diem", "standard_charge_dollar": 8000.0, "standard_charge_algorithm": "Expected reimbursement is the lesser of Per diem ($8,000) for the length of stay and 70% of billed.", "count": "0", "additional_payer_notes": "Zero final payments for the item or service in the 15 months prior to posting the file." }, { "payer_name": "HEALTH NET", "plan_name": "HEALTHNET HMO, PPO, POS, EPO, CANOPY HEALTHNET HMO, OTHER-IN-NETWORK PLANS", "methodology": "per diem", "standard_charge_dollar": 8000.0, "standard_charge_algorithm": "Expected reimbursement is the lesser of Per diem ($8,000) for the length of stay and 70% of billed.", "count": "0", "additional_payer_notes": "Zero final payments for the item or service in the 15 months prior to posting the file." }, { "payer_name": "UNITED HEALTHCARE", "plan_name": "SUTTER SELECT & SUTTER HEALTH PLAN HMO PLANS", "methodology": "per diem", "standard_charge_dollar": 28538.0, "standard_charge_algorithm": "Per diem ($28,538).", "count": "0", "additional_payer_notes": "Zero final payments for the item or service in the 15 months prior to posting the file." }, { "payer_name": "UNITED HEALTHCARE", "plan_name": "SUTTER SELECT & SUTTER HEALTH PLAN HMO PLANS", "methodology": "per diem", "standard_charge_dollar": 28538.0, "standard_charge_algorithm": "Per diem ($28,538).", "count": "0", "additional_payer_notes": "Zero final payments for the item or service in the 15 months prior to posting the file." }, { "payer_name": "SUTTER", "plan_name": "SUTTER SELECT & SUTTER HEALTH PLAN HMO PLANS", "methodology": "per diem", "standard_charge_dollar": 28538.0, "standard_charge_algorithm": "Per diem ($28,538).", "count": "0", "additional_payer_notes": "Zero final payments for the item or service in the 15 months prior to posting the file." }, { "payer_name": "UNITED HEALTHCARE", "plan_name": "SUTTER SELECT & SUTTER HEALTH PLAN HMO PLANS", "methodology": "per diem", "standard_charge_dollar": 28538.0, "standard_charge_algorithm": "Per diem ($28,538).", "count": "0", "additional_payer_notes": "Zero final payments for the item or service in the 15 months prior to posting the file." }, { "payer_name": "UMR", "plan_name": "SUTTER SELECT & SUTTER HEALTH PLAN HMO PLANS", "methodology": "per diem", "standard_charge_dollar": 28538.0, "standard_charge_algorithm": "Per diem ($28,538).", "count": "0", "additional_payer_notes": "Zero final payments for the item or service in the 15 months prior to posting the file." } ] } ] }, { "description": "HC Centralizer Gp011", "code_information": [ { "code": "PX-2120043011", "type": "CDM" }, { "code": "99999", "type": "CPT" }, { "code": "0272", "type": "RC" } ], "standard_charges": [ { "setting": "outpatient", "gross_charge": 740.0, "discounted_cash": 370.0, "minimum": 312.28, "maximum": 384.8, "additional_generic_notes": "Zero final payments for the item or service in the 15 months prior to posting the file.", "payers_information": [ { "payer_name": "AETNA", "plan_name": "AETNA ALL OTHER PLANS", "methodology": "percent of total billed charges", "standard_charge_dollar": 384.8, "standard_charge_percentage": 52.0, "count": "0", "additional_payer_notes": "Zero final payments for the item or service in the 15 months prior to posting the file." }, { "payer_name": "AETNA", "plan_name": "AETNA ALL OTHER PLANS", "methodology": "percent of total billed charges", "standard_charge_dollar": 384.8, "standard_charge_percentage": 52.0, "count": "0", "additional_payer_notes": "Zero final payments for the item or service in the 15 months prior to posting the file." }, { "payer_name": "MERITAIN HEALTH", "plan_name": "AETNA ALL OTHER PLANS", "methodology": "percent of total billed charges", "standard_charge_dollar": 384.8, "standard_charge_percentage": 52.0, "count": "0", "additional_payer_notes": "Zero final payments for the item or service in the 15 months prior to posting the file." }, { "payer_name": "BLUE SHIELD OUT OF STATE", "plan_name": "STANFORD HEALTHCARE ALLIANCE PLAN", "methodology": "percent of total billed charges", "standard_charge_dollar": 359.57, "standard_charge_percentage": 48.59, "count": "0", "additional_payer_notes": "Zero final payments for the item or service in the 15 months prior to posting the file." }, { "payer_name": "BLUE SHIELD", "plan_name": "STANFORD HEALTHCARE ALLIANCE PLAN", "methodology": "percent of total billed charges", "standard_charge_dollar": 359.57, "standard_charge_percentage": 48.59, "count": "0", "additional_payer_notes": "Zero final payments for the item or service in the 15 months prior to posting the file." }, { "payer_name": "BLUE SHIELD", "plan_name": "STANFORD HEALTHCARE ALLIANCE PLAN", "methodology": "percent of total billed charges", "standard_charge_dollar": 359.57, "standard_charge_percentage": 48.59, "count": "0", "additional_payer_notes": "Zero final payments for the item or service in the 15 months prior to posting the file." }, { "payer_name": "CIGNA", "plan_name": "CIGNA COM ALT HMO PLAN", "methodology": "percent of total billed charges", "standard_charge_dollar": 312.28, "standard_charge_percentage": 42.2, "count": "0", "additional_payer_notes": "Zero final payments for the item or service in the 15 months prior to posting the file." }, { "payer_name": "CIGNA", "plan_name": "CIGNA COM ALT HMO PLAN", "methodology": "percent of total billed charges", "standard_charge_dollar": 312.28, "standard_charge_percentage": 42.2, "count": "0", "additional_payer_notes": "Zero final payments for the item or service in the 15 months prior to posting the file." }, { "payer_name": "HEALTH NET", "plan_name": "HEALTHNET HMO, PPO, POS, EPO, CANOPY HEALTHNET HMO, OTHER-IN-NETWORK PLANS", "methodology": "per diem", "standard_charge_dollar": 8000.0, "standard_charge_algorithm": "Expected reimbursement is the lesser of Per diem ($8,000) for the length of stay and 70% of billed.", "count": "0", "additional_payer_notes": "Zero final payments for the item or service in the 15 months prior to posting the file." }, { "payer_name": "HEALTH NET", "plan_name": "HEALTHNET HMO, PPO, POS, EPO, CANOPY HEALTHNET HMO, OTHER-IN-NETWORK PLANS", "methodology": "per diem", "standard_charge_dollar": 8000.0, "standard_charge_algorithm": "Expected reimbursement is the lesser of Per diem ($8,000) for the length of stay and 70% of billed.", "count": "0", "additional_payer_notes": "Zero final payments for the item or service in the 15 months prior to posting the file." }, { "payer_name": "UNITED HEALTHCARE", "plan_name": "SUTTER SELECT & SUTTER HEALTH PLAN HMO PLANS", "methodology": "per diem", "standard_charge_dollar": 28538.0, "standard_charge_algorithm": "Per diem ($28,538).", "count": "0", "additional_payer_notes": "Zero final payments for the item or service in the 15 months prior to posting the file." }, { "payer_name": "UNITED HEALTHCARE", "plan_name": "SUTTER SELECT & SUTTER HEALTH PLAN HMO PLANS", "methodology": "per diem", "standard_charge_dollar": 28538.0, "standard_charge_algorithm": "Per diem ($28,538).", "count": "0", "additional_payer_notes": "Zero final payments for the item or service in the 15 months prior to posting the file." }, { "payer_name": "SUTTER", "plan_name": "SUTTER SELECT & SUTTER HEALTH PLAN HMO PLANS", "methodology": "per diem", "standard_charge_dollar": 28538.0, "standard_charge_algorithm": "Per diem ($28,538).", "count": "0", "additional_payer_notes": "Zero final payments for the item or service in the 15 months prior to posting the file." }, { "payer_name": "UNITED HEALTHCARE", "plan_name": "SUTTER SELECT & SUTTER HEALTH PLAN HMO PLANS", "methodology": "per diem", "standard_charge_dollar": 28538.0, "standard_charge_algorithm": "Per diem ($28,538).", "count": "0", "additional_payer_notes": "Zero final payments for the item or service in the 15 months prior to posting the file." }, { "payer_name": "UMR", "plan_name": "SUTTER SELECT & SUTTER HEALTH PLAN HMO PLANS", "methodology": "per diem", "standard_charge_dollar": 28538.0, "standard_charge_algorithm": "Per diem ($28,538).", "count": "0", "additional_payer_notes": "Zero final payments for the item or service in the 15 months prior to posting the file." } ] } ] }, { "description": "HC Centralizer Gp013", "code_information": [ { "code": "PX-2120043013", "type": "CDM" }, { "code": "99999", "type": "CPT" }, { "code": "0272", "type": "RC" } ], "standard_charges": [ { "setting": "outpatient", "gross_charge": 900.0, "discounted_cash": 450.0, "minimum": 379.8, "maximum": 468.0, "additional_generic_notes": "Zero final payments for the item or service in the 15 months prior to posting the file.", "payers_information": [ { "payer_name": "AETNA", "plan_name": "AETNA ALL OTHER PLANS", "methodology": "percent of total billed charges", "standard_charge_dollar": 468.0, "standard_charge_percentage": 52.0, "count": "0", "additional_payer_notes": "Zero final payments for the item or service in the 15 months prior to posting the file." }, { "payer_name": "AETNA", "plan_name": "AETNA ALL OTHER PLANS", "methodology": "percent of total billed charges", "standard_charge_dollar": 468.0, "standard_charge_percentage": 52.0, "count": "0", "additional_payer_notes": "Zero final payments for the item or service in the 15 months prior to posting the file." }, { "payer_name": "MERITAIN HEALTH", "plan_name": "AETNA ALL OTHER PLANS", "methodology": "percent of total billed charges", "standard_charge_dollar": 468.0, "standard_charge_percentage": 52.0, "count": "0", "additional_payer_notes": "Zero final payments for the item or service in the 15 months prior to posting the file." }, { "payer_name": "BLUE SHIELD OUT OF STATE", "plan_name": "STANFORD HEALTHCARE ALLIANCE PLAN", "methodology": "percent of total billed charges", "standard_charge_dollar": 437.31, "standard_charge_percentage": 48.59, "count": "0", "additional_payer_notes": "Zero final payments for the item or service in the 15 months prior to posting the file." }, { "payer_name": "BLUE SHIELD", "plan_name": "STANFORD HEALTHCARE ALLIANCE PLAN", "methodology": "percent of total billed charges", "standard_charge_dollar": 437.31, "standard_charge_percentage": 48.59, "count": "0", "additional_payer_notes": "Zero final payments for the item or service in the 15 months prior to posting the file." }, { "payer_name": "BLUE SHIELD", "plan_name": "STANFORD HEALTHCARE ALLIANCE PLAN", "methodology": "percent of total billed charges", "standard_charge_dollar": 437.31, "standard_charge_percentage": 48.59, "count": "0", "additional_payer_notes": "Zero final payments for the item or service in the 15 months prior to posting the file." }, { "payer_name": "CIGNA", "plan_name": "CIGNA COM ALT HMO PLAN", "methodology": "percent of total billed charges", "standard_charge_dollar": 379.8, "standard_charge_percentage": 42.2, "count": "0", "additional_payer_notes": "Zero final payments for the item or service in the 15 months prior to posting the file." }, { "payer_name": "CIGNA", "plan_name": "CIGNA COM ALT HMO PLAN", "methodology": "percent of total billed charges", "standard_charge_dollar": 379.8, "standard_charge_percentage": 42.2, "count": "0", "additional_payer_notes": "Zero final payments for the item or service in the 15 months prior to posting the file." }, { "payer_name": "HEALTH NET", "plan_name": "HEALTHNET HMO, PPO, POS, EPO, CANOPY HEALTHNET HMO, OTHER-IN-NETWORK PLANS", "methodology": "per diem", "standard_charge_dollar": 8000.0, "standard_charge_algorithm": "Expected reimbursement is the lesser of Per diem ($8,000) for the length of stay and 70% of billed.", "count": "0", "additional_payer_notes": "Zero final payments for the item or service in the 15 months prior to posting the file." }, { "payer_name": "HEALTH NET", "plan_name": "HEALTHNET HMO, PPO, POS, EPO, CANOPY HEALTHNET HMO, OTHER-IN-NETWORK PLANS", "methodology": "per diem", "standard_charge_dollar": 8000.0, "standard_charge_algorithm": "Expected reimbursement is the lesser of Per diem ($8,000) for the length of stay and 70% of billed.", "count": "0", "additional_payer_notes": "Zero final payments for the item or service in the 15 months prior to posting the file." }, { "payer_name": "UNITED HEALTHCARE", "plan_name": "SUTTER SELECT & SUTTER HEALTH PLAN HMO PLANS", "methodology": "per diem", "standard_charge_dollar": 28538.0, "standard_charge_algorithm": "Per diem ($28,538).", "count": "0", "additional_payer_notes": "Zero final payments for the item or service in the 15 months prior to posting the file." }, { "payer_name": "UNITED HEALTHCARE", "plan_name": "SUTTER SELECT & SUTTER HEALTH PLAN HMO PLANS", "methodology": "per diem", "standard_charge_dollar": 28538.0, "standard_charge_algorithm": "Per diem ($28,538).", "count": "0", "additional_payer_notes": "Zero final payments for the item or service in the 15 months prior to posting the file." }, { "payer_name": "SUTTER", "plan_name": "SUTTER SELECT & SUTTER HEALTH PLAN HMO PLANS", "methodology": "per diem", "standard_charge_dollar": 28538.0, "standard_charge_algorithm": "Per diem ($28,538).", "count": "0", "additional_payer_notes": "Zero final payments for the item or service in the 15 months prior to posting the file." }, { "payer_name": "UNITED HEALTHCARE", "plan_name": "SUTTER SELECT & SUTTER HEALTH PLAN HMO PLANS", "methodology": "per diem", "standard_charge_dollar": 28538.0, "standard_charge_algorithm": "Per diem ($28,538).", "count": "0", "additional_payer_notes": "Zero final payments for the item or service in the 15 months prior to posting the file." }, { "payer_name": "UMR", "plan_name": "SUTTER SELECT & SUTTER HEALTH PLAN HMO PLANS", "methodology": "per diem", "standard_charge_dollar": 28538.0, "standard_charge_algorithm": "Per diem ($28,538).", "count": "0", "additional_payer_notes": "Zero final payments for the item or service in the 15 months prior to posting the file." } ] } ] }, { "description": "HC Centralizer Gp014", "code_information": [ { "code": "PX-2120043014", "type": "CDM" }, { "code": "99999", "type": "CPT" }, { "code": "0272", "type": "RC" } ], "standard_charges": [ { "setting": "outpatient", "gross_charge": 1080.0, "discounted_cash": 540.0, "minimum": 455.76, "maximum": 561.6, "additional_generic_notes": "Zero final payments for the item or service in the 15 months prior to posting the file.", "payers_information": [ { "payer_name": "AETNA", "plan_name": "AETNA ALL OTHER PLANS", "methodology": "percent of total billed charges", "standard_charge_dollar": 561.6, "standard_charge_percentage": 52.0, "count": "0", "additional_payer_notes": "Zero final payments for the item or service in the 15 months prior to posting the file." }, { "payer_name": "AETNA", "plan_name": "AETNA ALL OTHER PLANS", "methodology": "percent of total billed charges", "standard_charge_dollar": 561.6, "standard_charge_percentage": 52.0, "count": "0", "additional_payer_notes": "Zero final payments for the item or service in the 15 months prior to posting the file." }, { "payer_name": "MERITAIN HEALTH", "plan_name": "AETNA ALL OTHER PLANS", "methodology": "percent of total billed charges", "standard_charge_dollar": 561.6, "standard_charge_percentage": 52.0, "count": "0", "additional_payer_notes": "Zero final payments for the item or service in the 15 months prior to posting the file." }, { "payer_name": "BLUE SHIELD OUT OF STATE", "plan_name": "STANFORD HEALTHCARE ALLIANCE PLAN", "methodology": "percent of total billed charges", "standard_charge_dollar": 524.77, "standard_charge_percentage": 48.59, "count": "0", "additional_payer_notes": "Zero final payments for the item or service in the 15 months prior to posting the file." }, { "payer_name": "BLUE SHIELD", "plan_name": "STANFORD HEALTHCARE ALLIANCE PLAN", "methodology": "percent of total billed charges", "standard_charge_dollar": 524.77, "standard_charge_percentage": 48.59, "median_amount": 68.24, "10th_percentile": 13.6, "90th_percentile": 1043.06, "count": "30" }, { "payer_name": "BLUE SHIELD", "plan_name": "STANFORD HEALTHCARE ALLIANCE PLAN", "methodology": "percent of total billed charges", "standard_charge_dollar": 524.77, "standard_charge_percentage": 48.59, "count": "0", "additional_payer_notes": "Zero final payments for the item or service in the 15 months prior to posting the file." }, { "payer_name": "BLUE SHIELD", "plan_name": "STANFORD HEALTHCARE ALLIANCE PLAN", "methodology": "percent of total billed charges", "standard_charge_dollar": 524.77, "standard_charge_percentage": 48.59, "count": "0", "additional_payer_notes": "Zero final payments for the item or service in the 15 months prior to posting the file." }, { "payer_name": "CIGNA", "plan_name": "CIGNA COM ALT HMO PLAN", "methodology": "percent of total billed charges", "standard_charge_dollar": 455.76, "standard_charge_percentage": 42.2, "count": "0", "additional_payer_notes": "Zero final payments for the item or service in the 15 months prior to posting the file." }, { "payer_name": "CIGNA", "plan_name": "CIGNA COM ALT HMO PLAN", "methodology": "percent of total billed charges", "standard_charge_dollar": 455.76, "standard_charge_percentage": 42.2, "count": "0", "additional_payer_notes": "Zero final payments for the item or service in the 15 months prior to posting the file." }, { "payer_name": "HEALTH NET", "plan_name": "HEALTHNET HMO, PPO, POS, EPO, CANOPY HEALTHNET HMO, OTHER-IN-NETWORK PLANS", "methodology": "per diem", "standard_charge_dollar": 8000.0, "standard_charge_algorithm": "Expected reimbursement is the lesser of Per diem ($8,000) for the length of stay and 70% of billed.", "count": "0", "additional_payer_notes": "Zero final payments for the item or service in the 15 months prior to posting the file." }, { "payer_name": "HEALTH NET", "plan_name": "HEALTHNET HMO, PPO, POS, EPO, CANOPY HEALTHNET HMO, OTHER-IN-NETWORK PLANS", "methodology": "per diem", "standard_charge_dollar": 8000.0, "standard_charge_algorithm": "Expected reimbursement is the lesser of Per diem ($8,000) for the length of stay and 70% of billed.", "count": "0", "additional_payer_notes": "Zero final payments for the item or service in the 15 months prior to posting the file." }, { "payer_name": "UNITED HEALTHCARE", "plan_name": "SUTTER SELECT & SUTTER HEALTH PLAN HMO PLANS", "methodology": "per diem", "standard_charge_dollar": 28538.0, "standard_charge_algorithm": "Per diem ($28,538).", "count": "0", "additional_payer_notes": "Zero final payments for the item or service in the 15 months prior to posting the file." }, { "payer_name": "UNITED HEALTHCARE", "plan_name": "SUTTER SELECT & SUTTER HEALTH PLAN HMO PLANS", "methodology": "per diem", "standard_charge_dollar": 28538.0, "standard_charge_algorithm": "Per diem ($28,538).", "count": "0", "additional_payer_notes": "Zero final payments for the item or service in the 15 months prior to posting the file." }, { "payer_name": "SUTTER", "plan_name": "SUTTER SELECT & SUTTER HEALTH PLAN HMO PLANS", "methodology": "per diem", "standard_charge_dollar": 28538.0, "standard_charge_algorithm": "Per diem ($28,538).", "count": "0", "additional_payer_notes": "Zero final payments for the item or service in the 15 months prior to posting the file." }, { "payer_name": "UNITED HEALTHCARE", "plan_name": "SUTTER SELECT & SUTTER HEALTH PLAN HMO PLANS", "methodology": "per diem", "standard_charge_dollar": 28538.0, "standard_charge_algorithm": "Per diem ($28,538).", "count": "0", "additional_payer_notes": "Zero final payments for the item or service in the 15 months prior to posting the file." }, { "payer_name": "UMR", "plan_name": "SUTTER SELECT & SUTTER HEALTH PLAN HMO PLANS", "methodology": "per diem", "standard_charge_dollar": 28538.0, "standard_charge_algorithm": "Per diem ($28,538).", "count": "0", "additional_payer_notes": "Zero final payments for the item or service in the 15 months prior to posting the file." } ] } ] }, { "description": "HC Centralizer Gp042", "code_information": [ { "code": "PX-2120043042", "type": "CDM" }, { "code": "99999", "type": "CPT" }, { "code": "0272", "type": "RC" } ], "standard_charges": [ { "setting": "outpatient", "gross_charge": 10350.0, "discounted_cash": 5175.0, "minimum": 4367.7, "maximum": 5382.0, "additional_generic_notes": "Zero final payments for the item or service in the 15 months prior to posting the file.", "payers_information": [ { "payer_name": "AETNA", "plan_name": "AETNA ALL OTHER PLANS", "methodology": "percent of total billed charges", "standard_charge_dollar": 5382.0, "standard_charge_percentage": 52.0, "count": "0", "additional_payer_notes": "Zero final payments for the item or service in the 15 months prior to posting the file." }, { "payer_name": "AETNA", "plan_name": "AETNA ALL OTHER PLANS", "methodology": "percent of total billed charges", "standard_charge_dollar": 5382.0, "standard_charge_percentage": 52.0, "count": "0", "additional_payer_notes": "Zero final payments for the item or service in the 15 months prior to posting the file." }, { "payer_name": "MERITAIN HEALTH", "plan_name": "AETNA ALL OTHER PLANS", "methodology": "percent of total billed charges", "standard_charge_dollar": 5382.0, "standard_charge_percentage": 52.0, "count": "0", "additional_payer_notes": "Zero final payments for the item or service in the 15 months prior to posting the file." }, { "payer_name": "BLUE SHIELD OUT OF STATE", "plan_name": "STANFORD HEALTHCARE ALLIANCE PLAN", "methodology": "percent of total billed charges", "standard_charge_dollar": 5029.07, "standard_charge_percentage": 48.59, "count": "0", "additional_payer_notes": "Zero final payments for the item or service in the 15 months prior to posting the file." }, { "payer_name": "BLUE SHIELD", "plan_name": "STANFORD HEALTHCARE ALLIANCE PLAN", "methodology": "percent of total billed charges", "standard_charge_dollar": 5029.07, "standard_charge_percentage": 48.59, "median_amount": 68.24, "10th_percentile": 13.6, "90th_percentile": 1043.06, "count": "30" }, { "payer_name": "BLUE SHIELD", "plan_name": "STANFORD HEALTHCARE ALLIANCE PLAN", "methodology": "percent of total billed charges", "standard_charge_dollar": 5029.07, "standard_charge_percentage": 48.59, "count": "0", "additional_payer_notes": "Zero final payments for the item or service in the 15 months prior to posting the file." }, { "payer_name": "BLUE SHIELD", "plan_name": "STANFORD HEALTHCARE ALLIANCE PLAN", "methodology": "percent of total billed charges", "standard_charge_dollar": 5029.07, "standard_charge_percentage": 48.59, "count": "0", "additional_payer_notes": "Zero final payments for the item or service in the 15 months prior to posting the file." }, { "payer_name": "CIGNA", "plan_name": "CIGNA COM ALT HMO PLAN", "methodology": "percent of total billed charges", "standard_charge_dollar": 4367.7, "standard_charge_percentage": 42.2, "count": "0", "additional_payer_notes": "Zero final payments for the item or service in the 15 months prior to posting the file." }, { "payer_name": "CIGNA", "plan_name": "CIGNA COM ALT HMO PLAN", "methodology": "percent of total billed charges", "standard_charge_dollar": 4367.7, "standard_charge_percentage": 42.2, "count": "0", "additional_payer_notes": "Zero final payments for the item or service in the 15 months prior to posting the file." }, { "payer_name": "HEALTH NET", "plan_name": "HEALTHNET HMO, PPO, POS, EPO, CANOPY HEALTHNET HMO, OTHER-IN-NETWORK PLANS", "methodology": "per diem", "standard_charge_dollar": 8000.0, "standard_charge_algorithm": "Expected reimbursement is the lesser of Per diem ($8,000) for the length of stay and 70% of billed.", "count": "0", "additional_payer_notes": "Zero final payments for the item or service in the 15 months prior to posting the file." }, { "payer_name": "HEALTH NET", "plan_name": "HEALTHNET HMO, PPO, POS, EPO, CANOPY HEALTHNET HMO, OTHER-IN-NETWORK PLANS", "methodology": "per diem", "standard_charge_dollar": 8000.0, "standard_charge_algorithm": "Expected reimbursement is the lesser of Per diem ($8,000) for the length of stay and 70% of billed.", "count": "0", "additional_payer_notes": "Zero final payments for the item or service in the 15 months prior to posting the file." }, { "payer_name": "UNITED HEALTHCARE", "plan_name": "SUTTER SELECT & SUTTER HEALTH PLAN HMO PLANS", "methodology": "per diem", "standard_charge_dollar": 28538.0, "standard_charge_algorithm": "Per diem ($28,538).", "count": "0", "additional_payer_notes": "Zero final payments for the item or service in the 15 months prior to posting the file." }, { "payer_name": "UNITED HEALTHCARE", "plan_name": "SUTTER SELECT & SUTTER HEALTH PLAN HMO PLANS", "methodology": "per diem", "standard_charge_dollar": 28538.0, "standard_charge_algorithm": "Per diem ($28,538).", "count": "0", "additional_payer_notes": "Zero final payments for the item or service in the 15 months prior to posting the file." }, { "payer_name": "SUTTER", "plan_name": "SUTTER SELECT & SUTTER HEALTH PLAN HMO PLANS", "methodology": "per diem", "standard_charge_dollar": 28538.0, "standard_charge_algorithm": "Per diem ($28,538).", "count": "0", "additional_payer_notes": "Zero final payments for the item or service in the 15 months prior to posting the file." }, { "payer_name": "UNITED HEALTHCARE", "plan_name": "SUTTER SELECT & SUTTER HEALTH PLAN HMO PLANS", "methodology": "per diem", "standard_charge_dollar": 28538.0, "standard_charge_algorithm": "Per diem ($28,538).", "count": "0", "additional_payer_notes": "Zero final payments for the item or service in the 15 months prior to posting the file." }, { "payer_name": "UMR", "plan_name": "SUTTER SELECT & SUTTER HEALTH PLAN HMO PLANS", "methodology": "per diem", "standard_charge_dollar": 28538.0, "standard_charge_algorithm": "Per diem ($28,538).", "count": "0", "additional_payer_notes": "Zero final payments for the item or service in the 15 months prior to posting the file." } ] } ] }, { "description": "HC Centralizer Gp043", "code_information": [ { "code": "PX-2120043043", "type": "CDM" }, { "code": "99999", "type": "CPT" }, { "code": "0272", "type": "RC" } ], "standard_charges": [ { "setting": "outpatient", "gross_charge": 10450.0, "discounted_cash": 5225.0, "minimum": 4409.9, "maximum": 5434.0, "additional_generic_notes": "Zero final payments for the item or service in the 15 months prior to posting the file.", "payers_information": [ { "payer_name": "AETNA", "plan_name": "AETNA ALL OTHER PLANS", "methodology": "percent of total billed charges", "standard_charge_dollar": 5434.0, "standard_charge_percentage": 52.0, "count": "0", "additional_payer_notes": "Zero final payments for the item or service in the 15 months prior to posting the file." }, { "payer_name": "AETNA", "plan_name": "AETNA ALL OTHER PLANS", "methodology": "percent of total billed charges", "standard_charge_dollar": 5434.0, "standard_charge_percentage": 52.0, "count": "0", "additional_payer_notes": "Zero final payments for the item or service in the 15 months prior to posting the file." }, { "payer_name": "MERITAIN HEALTH", "plan_name": "AETNA ALL OTHER PLANS", "methodology": "percent of total billed charges", "standard_charge_dollar": 5434.0, "standard_charge_percentage": 52.0, "count": "0", "additional_payer_notes": "Zero final payments for the item or service in the 15 months prior to posting the file." }, { "payer_name": "BLUE SHIELD OUT OF STATE", "plan_name": "STANFORD HEALTHCARE ALLIANCE PLAN", "methodology": "percent of total billed charges", "standard_charge_dollar": 5077.66, "standard_charge_percentage": 48.59, "count": "0", "additional_payer_notes": "Zero final payments for the item or service in the 15 months prior to posting the file." }, { "payer_name": "BLUE SHIELD", "plan_name": "STANFORD HEALTHCARE ALLIANCE PLAN", "methodology": "percent of total billed charges", "standard_charge_dollar": 5077.66, "standard_charge_percentage": 48.59, "median_amount": 68.24, "10th_percentile": 13.6, "90th_percentile": 1043.06, "count": "30" }, { "payer_name": "BLUE SHIELD", "plan_name": "STANFORD HEALTHCARE ALLIANCE PLAN", "methodology": "percent of total billed charges", "standard_charge_dollar": 5077.66, "standard_charge_percentage": 48.59, "count": "0", "additional_payer_notes": "Zero final payments for the item or service in the 15 months prior to posting the file." }, { "payer_name": "BLUE SHIELD", "plan_name": "STANFORD HEALTHCARE ALLIANCE PLAN", "methodology": "percent of total billed charges", "standard_charge_dollar": 5077.66, "standard_charge_percentage": 48.59, "count": "0", "additional_payer_notes": "Zero final payments for the item or service in the 15 months prior to posting the file." }, { "payer_name": "CIGNA", "plan_name": "CIGNA COM ALT HMO PLAN", "methodology": "percent of total billed charges", "standard_charge_dollar": 4409.9, "standard_charge_percentage": 42.2, "count": "0", "additional_payer_notes": "Zero final payments for the item or service in the 15 months prior to posting the file." }, { "payer_name": "CIGNA", "plan_name": "CIGNA COM ALT HMO PLAN", "methodology": "percent of total billed charges", "standard_charge_dollar": 4409.9, "standard_charge_percentage": 42.2, "count": "0", "additional_payer_notes": "Zero final payments for the item or service in the 15 months prior to posting the file." }, { "payer_name": "HEALTH NET", "plan_name": "HEALTHNET HMO, PPO, POS, EPO, CANOPY HEALTHNET HMO, OTHER-IN-NETWORK PLANS", "methodology": "per diem", "standard_charge_dollar": 8000.0, "standard_charge_algorithm": "Expected reimbursement is the lesser of Per diem ($8,000) for the length of stay and 70% of billed.", "count": "0", "additional_payer_notes": "Zero final payments for the item or service in the 15 months prior to posting the file." }, { "payer_name": "HEALTH NET", "plan_name": "HEALTHNET HMO, PPO, POS, EPO, CANOPY HEALTHNET HMO, OTHER-IN-NETWORK PLANS", "methodology": "per diem", "standard_charge_dollar": 8000.0, "standard_charge_algorithm": "Expected reimbursement is the lesser of Per diem ($8,000) for the length of stay and 70% of billed.", "count": "0", "additional_payer_notes": "Zero final payments for the item or service in the 15 months prior to posting the file." }, { "payer_name": "UNITED HEALTHCARE", "plan_name": "SUTTER SELECT & SUTTER HEALTH PLAN HMO PLANS", "methodology": "per diem", "standard_charge_dollar": 28538.0, "standard_charge_algorithm": "Per diem ($28,538).", "count": "0", "additional_payer_notes": "Zero final payments for the item or service in the 15 months prior to posting the file." }, { "payer_name": "UNITED HEALTHCARE", "plan_name": "SUTTER SELECT & SUTTER HEALTH PLAN HMO PLANS", "methodology": "per diem", "standard_charge_dollar": 28538.0, "standard_charge_algorithm": "Per diem ($28,538).", "count": "0", "additional_payer_notes": "Zero final payments for the item or service in the 15 months prior to posting the file." }, { "payer_name": "SUTTER", "plan_name": "SUTTER SELECT & SUTTER HEALTH PLAN HMO PLANS", "methodology": "per diem", "standard_charge_dollar": 28538.0, "standard_charge_algorithm": "Per diem ($28,538).", "count": "0", "additional_payer_notes": "Zero final payments for the item or service in the 15 months prior to posting the file." }, { "payer_name": "UNITED HEALTHCARE", "plan_name": "SUTTER SELECT & SUTTER HEALTH PLAN HMO PLANS", "methodology": "per diem", "standard_charge_dollar": 28538.0, "standard_charge_algorithm": "Per diem ($28,538).", "count": "0", "additional_payer_notes": "Zero final payments for the item or service in the 15 months prior to posting the file." }, { "payer_name": "UMR", "plan_name": "SUTTER SELECT & SUTTER HEALTH PLAN HMO PLANS", "methodology": "per diem", "standard_charge_dollar": 28538.0, "standard_charge_algorithm": "Per diem ($28,538).", "count": "0", "additional_payer_notes": "Zero final payments for the item or service in the 15 months prior to posting the file." } ] } ] }, { "description": "HC Clip Applier Gp007", "code_information": [ { "code": "PX-2120045007", "type": "CDM" }, { "code": "99999", "type": "CPT" }, { "code": "0272", "type": "RC" } ], "standard_charges": [ { "setting": "outpatient", "gross_charge": 380.0, "discounted_cash": 190.0, "minimum": 160.36, "maximum": 197.6, "additional_generic_notes": "Zero final payments for the item or service in the 15 months prior to posting the file.", "payers_information": [ { "payer_name": "AETNA", "plan_name": "AETNA ALL OTHER PLANS", "methodology": "percent of total billed charges", "standard_charge_dollar": 197.6, "standard_charge_percentage": 52.0, "count": "0", "additional_payer_notes": "Zero final payments for the item or service in the 15 months prior to posting the file." }, { "payer_name": "AETNA", "plan_name": "AETNA ALL OTHER PLANS", "methodology": "percent of total billed charges", "standard_charge_dollar": 197.6, "standard_charge_percentage": 52.0, "count": "0", "additional_payer_notes": "Zero final payments for the item or service in the 15 months prior to posting the file." }, { "payer_name": "MERITAIN HEALTH", "plan_name": "AETNA ALL OTHER PLANS", "methodology": "percent of total billed charges", "standard_charge_dollar": 197.6, "standard_charge_percentage": 52.0, "count": "0", "additional_payer_notes": "Zero final payments for the item or service in the 15 months prior to posting the file." }, { "payer_name": "BLUE SHIELD OUT OF STATE", "plan_name": "STANFORD HEALTHCARE ALLIANCE PLAN", "methodology": "percent of total billed charges", "standard_charge_dollar": 184.64, "standard_charge_percentage": 48.59, "count": "0", "additional_payer_notes": "Zero final payments for the item or service in the 15 months prior to posting the file." }, { "payer_name": "BLUE SHIELD", "plan_name": "STANFORD HEALTHCARE ALLIANCE PLAN", "methodology": "percent of total billed charges", "standard_charge_dollar": 184.64, "standard_charge_percentage": 48.59, "count": "0", "additional_payer_notes": "Zero final payments for the item or service in the 15 months prior to posting the file." }, { "payer_name": "BLUE SHIELD", "plan_name": "STANFORD HEALTHCARE ALLIANCE PLAN", "methodology": "percent of total billed charges", "standard_charge_dollar": 184.64, "standard_charge_percentage": 48.59, "count": "0", "additional_payer_notes": "Zero final payments for the item or service in the 15 months prior to posting the file." }, { "payer_name": "CIGNA", "plan_name": "CIGNA COM ALT HMO PLAN", "methodology": "percent of total billed charges", "standard_charge_dollar": 160.36, "standard_charge_percentage": 42.2, "count": "0", "additional_payer_notes": "Zero final payments for the item or service in the 15 months prior to posting the file." }, { "payer_name": "CIGNA", "plan_name": "CIGNA COM ALT HMO PLAN", "methodology": "percent of total billed charges", "standard_charge_dollar": 160.36, "standard_charge_percentage": 42.2, "count": "0", "additional_payer_notes": "Zero final payments for the item or service in the 15 months prior to posting the file." }, { "payer_name": "HEALTH NET", "plan_name": "HEALTHNET HMO, PPO, POS, EPO, CANOPY HEALTHNET HMO, OTHER-IN-NETWORK PLANS", "methodology": "per diem", "standard_charge_dollar": 8000.0, "standard_charge_algorithm": "Expected reimbursement is the lesser of Per diem ($8,000) for the length of stay and 70% of billed.", "count": "0", "additional_payer_notes": "Zero final payments for the item or service in the 15 months prior to posting the file." }, { "payer_name": "HEALTH NET", "plan_name": "HEALTHNET HMO, PPO, POS, EPO, CANOPY HEALTHNET HMO, OTHER-IN-NETWORK PLANS", "methodology": "per diem", "standard_charge_dollar": 8000.0, "standard_charge_algorithm": "Expected reimbursement is the lesser of Per diem ($8,000) for the length of stay and 70% of billed.", "count": "0", "additional_payer_notes": "Zero final payments for the item or service in the 15 months prior to posting the file." }, { "payer_name": "UNITED HEALTHCARE", "plan_name": "SUTTER SELECT & SUTTER HEALTH PLAN HMO PLANS", "methodology": "per diem", "standard_charge_dollar": 28538.0, "standard_charge_algorithm": "Per diem ($28,538).", "count": "0", "additional_payer_notes": "Zero final payments for the item or service in the 15 months prior to posting the file." }, { "payer_name": "UNITED HEALTHCARE", "plan_name": "SUTTER SELECT & SUTTER HEALTH PLAN HMO PLANS", "methodology": "per diem", "standard_charge_dollar": 28538.0, "standard_charge_algorithm": "Per diem ($28,538).", "count": "0", "additional_payer_notes": "Zero final payments for the item or service in the 15 months prior to posting the file." }, { "payer_name": "SUTTER", "plan_name": "SUTTER SELECT & SUTTER HEALTH PLAN HMO PLANS", "methodology": "per diem", "standard_charge_dollar": 28538.0, "standard_charge_algorithm": "Per diem ($28,538).", "count": "0", "additional_payer_notes": "Zero final payments for the item or service in the 15 months prior to posting the file." }, { "payer_name": "UNITED HEALTHCARE", "plan_name": "SUTTER SELECT & SUTTER HEALTH PLAN HMO PLANS", "methodology": "per diem", "standard_charge_dollar": 28538.0, "standard_charge_algorithm": "Per diem ($28,538).", "count": "0", "additional_payer_notes": "Zero final payments for the item or service in the 15 months prior to posting the file." }, { "payer_name": "UMR", "plan_name": "SUTTER SELECT & SUTTER HEALTH PLAN HMO PLANS", "methodology": "per diem", "standard_charge_dollar": 28538.0, "standard_charge_algorithm": "Per diem ($28,538).", "count": "0", "additional_payer_notes": "Zero final payments for the item or service in the 15 months prior to posting the file." } ] } ] }, { "description": "HC Clip Applier Gp008", "code_information": [ { "code": "PX-2120045008", "type": "CDM" }, { "code": "99999", "type": "CPT" }, { "code": "0272", "type": "RC" } ], "standard_charges": [ { "setting": "outpatient", "gross_charge": 475.0, "discounted_cash": 237.5, "minimum": 200.45, "maximum": 247.0, "additional_generic_notes": "Zero final payments for the item or service in the 15 months prior to posting the file.", "payers_information": [ { "payer_name": "AETNA", "plan_name": "AETNA ALL OTHER PLANS", "methodology": "percent of total billed charges", "standard_charge_dollar": 247.0, "standard_charge_percentage": 52.0, "count": "0", "additional_payer_notes": "Zero final payments for the item or service in the 15 months prior to posting the file." }, { "payer_name": "AETNA", "plan_name": "AETNA ALL OTHER PLANS", "methodology": "percent of total billed charges", "standard_charge_dollar": 247.0, "standard_charge_percentage": 52.0, "count": "0", "additional_payer_notes": "Zero final payments for the item or service in the 15 months prior to posting the file." }, { "payer_name": "MERITAIN HEALTH", "plan_name": "AETNA ALL OTHER PLANS", "methodology": "percent of total billed charges", "standard_charge_dollar": 247.0, "standard_charge_percentage": 52.0, "count": "0", "additional_payer_notes": "Zero final payments for the item or service in the 15 months prior to posting the file." }, { "payer_name": "BLUE SHIELD OUT OF STATE", "plan_name": "STANFORD HEALTHCARE ALLIANCE PLAN", "methodology": "percent of total billed charges", "standard_charge_dollar": 230.8, "standard_charge_percentage": 48.59, "count": "0", "additional_payer_notes": "Zero final payments for the item or service in the 15 months prior to posting the file." }, { "payer_name": "BLUE SHIELD", "plan_name": "STANFORD HEALTHCARE ALLIANCE PLAN", "methodology": "percent of total billed charges", "standard_charge_dollar": 230.8, "standard_charge_percentage": 48.59, "count": "0", "additional_payer_notes": "Zero final payments for the item or service in the 15 months prior to posting the file." }, { "payer_name": "BLUE SHIELD", "plan_name": "STANFORD HEALTHCARE ALLIANCE PLAN", "methodology": "percent of total billed charges", "standard_charge_dollar": 230.8, "standard_charge_percentage": 48.59, "count": "0", "additional_payer_notes": "Zero final payments for the item or service in the 15 months prior to posting the file." }, { "payer_name": "CIGNA", "plan_name": "CIGNA COM ALT HMO PLAN", "methodology": "percent of total billed charges", "standard_charge_dollar": 200.45, "standard_charge_percentage": 42.2, "count": "0", "additional_payer_notes": "Zero final payments for the item or service in the 15 months prior to posting the file." }, { "payer_name": "CIGNA", "plan_name": "CIGNA COM ALT HMO PLAN", "methodology": "percent of total billed charges", "standard_charge_dollar": 200.45, "standard_charge_percentage": 42.2, "count": "0", "additional_payer_notes": "Zero final payments for the item or service in the 15 months prior to posting the file." }, { "payer_name": "HEALTH NET", "plan_name": "HEALTHNET HMO, PPO, POS, EPO, CANOPY HEALTHNET HMO, OTHER-IN-NETWORK PLANS", "methodology": "per diem", "standard_charge_dollar": 8000.0, "standard_charge_algorithm": "Expected reimbursement is the lesser of Per diem ($8,000) for the length of stay and 70% of billed.", "count": "0", "additional_payer_notes": "Zero final payments for the item or service in the 15 months prior to posting the file." }, { "payer_name": "HEALTH NET", "plan_name": "HEALTHNET HMO, PPO, POS, EPO, CANOPY HEALTHNET HMO, OTHER-IN-NETWORK PLANS", "methodology": "per diem", "standard_charge_dollar": 8000.0, "standard_charge_algorithm": "Expected reimbursement is the lesser of Per diem ($8,000) for the length of stay and 70% of billed.", "count": "0", "additional_payer_notes": "Zero final payments for the item or service in the 15 months prior to posting the file." }, { "payer_name": "UNITED HEALTHCARE", "plan_name": "SUTTER SELECT & SUTTER HEALTH PLAN HMO PLANS", "methodology": "per diem", "standard_charge_dollar": 28538.0, "standard_charge_algorithm": "Per diem ($28,538).", "count": "0", "additional_payer_notes": "Zero final payments for the item or service in the 15 months prior to posting the file." }, { "payer_name": "UNITED HEALTHCARE", "plan_name": "SUTTER SELECT & SUTTER HEALTH PLAN HMO PLANS", "methodology": "per diem", "standard_charge_dollar": 28538.0, "standard_charge_algorithm": "Per diem ($28,538).", "count": "0", "additional_payer_notes": "Zero final payments for the item or service in the 15 months prior to posting the file." }, { "payer_name": "SUTTER", "plan_name": "SUTTER SELECT & SUTTER HEALTH PLAN HMO PLANS", "methodology": "per diem", "standard_charge_dollar": 28538.0, "standard_charge_algorithm": "Per diem ($28,538).", "count": "0", "additional_payer_notes": "Zero final payments for the item or service in the 15 months prior to posting the file." }, { "payer_name": "UNITED HEALTHCARE", "plan_name": "SUTTER SELECT & SUTTER HEALTH PLAN HMO PLANS", "methodology": "per diem", "standard_charge_dollar": 28538.0, "standard_charge_algorithm": "Per diem ($28,538).", "count": "0", "additional_payer_notes": "Zero final payments for the item or service in the 15 months prior to posting the file." }, { "payer_name": "UMR", "plan_name": "SUTTER SELECT & SUTTER HEALTH PLAN HMO PLANS", "methodology": "per diem", "standard_charge_dollar": 28538.0, "standard_charge_algorithm": "Per diem ($28,538).", "count": "0", "additional_payer_notes": "Zero final payments for the item or service in the 15 months prior to posting the file." } ] } ] }, { "description": "HC Clip Applier Gp009", "code_information": [ { "code": "PX-2120045009", "type": "CDM" }, { "code": "99999", "type": "CPT" }, { "code": "0272", "type": "RC" } ], "standard_charges": [ { "setting": "outpatient", "gross_charge": 570.0, "discounted_cash": 285.0, "minimum": 240.54, "maximum": 296.4, "additional_generic_notes": "Zero final payments for the item or service in the 15 months prior to posting the file.", "payers_information": [ { "payer_name": "AETNA", "plan_name": "AETNA ALL OTHER PLANS", "methodology": "percent of total billed charges", "standard_charge_dollar": 296.4, "standard_charge_percentage": 52.0, "count": "0", "additional_payer_notes": "Zero final payments for the item or service in the 15 months prior to posting the file." }, { "payer_name": "AETNA", "plan_name": "AETNA ALL OTHER PLANS", "methodology": "percent of total billed charges", "standard_charge_dollar": 296.4, "standard_charge_percentage": 52.0, "count": "0", "additional_payer_notes": "Zero final payments for the item or service in the 15 months prior to posting the file." }, { "payer_name": "MERITAIN HEALTH", "plan_name": "AETNA ALL OTHER PLANS", "methodology": "percent of total billed charges", "standard_charge_dollar": 296.4, "standard_charge_percentage": 52.0, "count": "0", "additional_payer_notes": "Zero final payments for the item or service in the 15 months prior to posting the file." }, { "payer_name": "BLUE SHIELD OUT OF STATE", "plan_name": "STANFORD HEALTHCARE ALLIANCE PLAN", "methodology": "percent of total billed charges", "standard_charge_dollar": 276.96, "standard_charge_percentage": 48.59, "count": "0", "additional_payer_notes": "Zero final payments for the item or service in the 15 months prior to posting the file." }, { "payer_name": "BLUE SHIELD", "plan_name": "STANFORD HEALTHCARE ALLIANCE PLAN", "methodology": "percent of total billed charges", "standard_charge_dollar": 276.96, "standard_charge_percentage": 48.59, "count": "0", "additional_payer_notes": "Zero final payments for the item or service in the 15 months prior to posting the file." }, { "payer_name": "BLUE SHIELD", "plan_name": "STANFORD HEALTHCARE ALLIANCE PLAN", "methodology": "percent of total billed charges", "standard_charge_dollar": 276.96, "standard_charge_percentage": 48.59, "count": "0", "additional_payer_notes": "Zero final payments for the item or service in the 15 months prior to posting the file." }, { "payer_name": "CIGNA", "plan_name": "CIGNA COM ALT HMO PLAN", "methodology": "percent of total billed charges", "standard_charge_dollar": 240.54, "standard_charge_percentage": 42.2, "count": "0", "additional_payer_notes": "Zero final payments for the item or service in the 15 months prior to posting the file." }, { "payer_name": "CIGNA", "plan_name": "CIGNA COM ALT HMO PLAN", "methodology": "percent of total billed charges", "standard_charge_dollar": 240.54, "standard_charge_percentage": 42.2, "count": "0", "additional_payer_notes": "Zero final payments for the item or service in the 15 months prior to posting the file." }, { "payer_name": "HEALTH NET", "plan_name": "HEALTHNET HMO, PPO, POS, EPO, CANOPY HEALTHNET HMO, OTHER-IN-NETWORK PLANS", "methodology": "per diem", "standard_charge_dollar": 8000.0, "standard_charge_algorithm": "Expected reimbursement is the lesser of Per diem ($8,000) for the length of stay and 70% of billed.", "count": "0", "additional_payer_notes": "Zero final payments for the item or service in the 15 months prior to posting the file." }, { "payer_name": "HEALTH NET", "plan_name": "HEALTHNET HMO, PPO, POS, EPO, CANOPY HEALTHNET HMO, OTHER-IN-NETWORK PLANS", "methodology": "per diem", "standard_charge_dollar": 8000.0, "standard_charge_algorithm": "Expected reimbursement is the lesser of Per diem ($8,000) for the length of stay and 70% of billed.", "count": "0", "additional_payer_notes": "Zero final payments for the item or service in the 15 months prior to posting the file." }, { "payer_name": "UNITED HEALTHCARE", "plan_name": "SUTTER SELECT & SUTTER HEALTH PLAN HMO PLANS", "methodology": "per diem", "standard_charge_dollar": 28538.0, "standard_charge_algorithm": "Per diem ($28,538).", "count": "0", "additional_payer_notes": "Zero final payments for the item or service in the 15 months prior to posting the file." }, { "payer_name": "UNITED HEALTHCARE", "plan_name": "SUTTER SELECT & SUTTER HEALTH PLAN HMO PLANS", "methodology": "per diem", "standard_charge_dollar": 28538.0, "standard_charge_algorithm": "Per diem ($28,538).", "count": "0", "additional_payer_notes": "Zero final payments for the item or service in the 15 months prior to posting the file." }, { "payer_name": "SUTTER", "plan_name": "SUTTER SELECT & SUTTER HEALTH PLAN HMO PLANS", "methodology": "per diem", "standard_charge_dollar": 28538.0, "standard_charge_algorithm": "Per diem ($28,538).", "count": "0", "additional_payer_notes": "Zero final payments for the item or service in the 15 months prior to posting the file." }, { "payer_name": "UNITED HEALTHCARE", "plan_name": "SUTTER SELECT & SUTTER HEALTH PLAN HMO PLANS", "methodology": "per diem", "standard_charge_dollar": 28538.0, "standard_charge_algorithm": "Per diem ($28,538).", "count": "0", "additional_payer_notes": "Zero final payments for the item or service in the 15 months prior to posting the file." }, { "payer_name": "UMR", "plan_name": "SUTTER SELECT & SUTTER HEALTH PLAN HMO PLANS", "methodology": "per diem", "standard_charge_dollar": 28538.0, "standard_charge_algorithm": "Per diem ($28,538).", "count": "0", "additional_payer_notes": "Zero final payments for the item or service in the 15 months prior to posting the file." } ] } ] }, { "description": "HC Clip Applier Gp010", "code_information": [ { "code": "PX-2120045010", "type": "CDM" }, { "code": "99999", "type": "CPT" }, { "code": "0272", "type": "RC" } ], "standard_charges": [ { "setting": "outpatient", "gross_charge": 665.0, "discounted_cash": 332.5, "minimum": 280.63, "maximum": 345.8, "additional_generic_notes": "Zero final payments for the item or service in the 15 months prior to posting the file.", "payers_information": [ { "payer_name": "AETNA", "plan_name": "AETNA ALL OTHER PLANS", "methodology": "percent of total billed charges", "standard_charge_dollar": 345.8, "standard_charge_percentage": 52.0, "count": "0", "additional_payer_notes": "Zero final payments for the item or service in the 15 months prior to posting the file." }, { "payer_name": "AETNA", "plan_name": "AETNA ALL OTHER PLANS", "methodology": "percent of total billed charges", "standard_charge_dollar": 345.8, "standard_charge_percentage": 52.0, "count": "0", "additional_payer_notes": "Zero final payments for the item or service in the 15 months prior to posting the file." }, { "payer_name": "MERITAIN HEALTH", "plan_name": "AETNA ALL OTHER PLANS", "methodology": "percent of total billed charges", "standard_charge_dollar": 345.8, "standard_charge_percentage": 52.0, "count": "0", "additional_payer_notes": "Zero final payments for the item or service in the 15 months prior to posting the file." }, { "payer_name": "BLUE SHIELD OUT OF STATE", "plan_name": "STANFORD HEALTHCARE ALLIANCE PLAN", "methodology": "percent of total billed charges", "standard_charge_dollar": 323.12, "standard_charge_percentage": 48.59, "count": "0", "additional_payer_notes": "Zero final payments for the item or service in the 15 months prior to posting the file." }, { "payer_name": "BLUE SHIELD", "plan_name": "STANFORD HEALTHCARE ALLIANCE PLAN", "methodology": "percent of total billed charges", "standard_charge_dollar": 323.12, "standard_charge_percentage": 48.59, "count": "0", "additional_payer_notes": "Zero final payments for the item or service in the 15 months prior to posting the file." }, { "payer_name": "BLUE SHIELD", "plan_name": "STANFORD HEALTHCARE ALLIANCE PLAN", "methodology": "percent of total billed charges", "standard_charge_dollar": 323.12, "standard_charge_percentage": 48.59, "count": "0", "additional_payer_notes": "Zero final payments for the item or service in the 15 months prior to posting the file." }, { "payer_name": "CIGNA", "plan_name": "CIGNA COM ALT HMO PLAN", "methodology": "percent of total billed charges", "standard_charge_dollar": 280.63, "standard_charge_percentage": 42.2, "count": "0", "additional_payer_notes": "Zero final payments for the item or service in the 15 months prior to posting the file." }, { "payer_name": "CIGNA", "plan_name": "CIGNA COM ALT HMO PLAN", "methodology": "percent of total billed charges", "standard_charge_dollar": 280.63, "standard_charge_percentage": 42.2, "count": "0", "additional_payer_notes": "Zero final payments for the item or service in the 15 months prior to posting the file." }, { "payer_name": "HEALTH NET", "plan_name": "HEALTHNET HMO, PPO, POS, EPO, CANOPY HEALTHNET HMO, OTHER-IN-NETWORK PLANS", "methodology": "per diem", "standard_charge_dollar": 8000.0, "standard_charge_algorithm": "Expected reimbursement is the lesser of Per diem ($8,000) for the length of stay and 70% of billed.", "count": "0", "additional_payer_notes": "Zero final payments for the item or service in the 15 months prior to posting the file." }, { "payer_name": "HEALTH NET", "plan_name": "HEALTHNET HMO, PPO, POS, EPO, CANOPY HEALTHNET HMO, OTHER-IN-NETWORK PLANS", "methodology": "per diem", "standard_charge_dollar": 8000.0, "standard_charge_algorithm": "Expected reimbursement is the lesser of Per diem ($8,000) for the length of stay and 70% of billed.", "count": "0", "additional_payer_notes": "Zero final payments for the item or service in the 15 months prior to posting the file." }, { "payer_name": "UNITED HEALTHCARE", "plan_name": "SUTTER SELECT & SUTTER HEALTH PLAN HMO PLANS", "methodology": "per diem", "standard_charge_dollar": 28538.0, "standard_charge_algorithm": "Per diem ($28,538).", "count": "0", "additional_payer_notes": "Zero final payments for the item or service in the 15 months prior to posting the file." }, { "payer_name": "UNITED HEALTHCARE", "plan_name": "SUTTER SELECT & SUTTER HEALTH PLAN HMO PLANS", "methodology": "per diem", "standard_charge_dollar": 28538.0, "standard_charge_algorithm": "Per diem ($28,538).", "count": "0", "additional_payer_notes": "Zero final payments for the item or service in the 15 months prior to posting the file." }, { "payer_name": "SUTTER", "plan_name": "SUTTER SELECT & SUTTER HEALTH PLAN HMO PLANS", "methodology": "per diem", "standard_charge_dollar": 28538.0, "standard_charge_algorithm": "Per diem ($28,538).", "count": "0", "additional_payer_notes": "Zero final payments for the item or service in the 15 months prior to posting the file." }, { "payer_name": "UNITED HEALTHCARE", "plan_name": "SUTTER SELECT & SUTTER HEALTH PLAN HMO PLANS", "methodology": "per diem", "standard_charge_dollar": 28538.0, "standard_charge_algorithm": "Per diem ($28,538).", "count": "0", "additional_payer_notes": "Zero final payments for the item or service in the 15 months prior to posting the file." }, { "payer_name": "UMR", "plan_name": "SUTTER SELECT & SUTTER HEALTH PLAN HMO PLANS", "methodology": "per diem", "standard_charge_dollar": 28538.0, "standard_charge_algorithm": "Per diem ($28,538).", "count": "0", "additional_payer_notes": "Zero final payments for the item or service in the 15 months prior to posting the file." } ] } ] }, { "description": "HC Clip Applier Gp012", "code_information": [ { "code": "PX-2120045012", "type": "CDM" }, { "code": "99999", "type": "CPT" }, { "code": "0272", "type": "RC" } ], "standard_charges": [ { "setting": "outpatient", "gross_charge": 810.0, "discounted_cash": 405.0, "minimum": 341.82, "maximum": 421.2, "additional_generic_notes": "Zero final payments for the item or service in the 15 months prior to posting the file.", "payers_information": [ { "payer_name": "AETNA", "plan_name": "AETNA ALL OTHER PLANS", "methodology": "percent of total billed charges", "standard_charge_dollar": 421.2, "standard_charge_percentage": 52.0, "count": "0", "additional_payer_notes": "Zero final payments for the item or service in the 15 months prior to posting the file." }, { "payer_name": "AETNA", "plan_name": "AETNA ALL OTHER PLANS", "methodology": "percent of total billed charges", "standard_charge_dollar": 421.2, "standard_charge_percentage": 52.0, "count": "0", "additional_payer_notes": "Zero final payments for the item or service in the 15 months prior to posting the file." }, { "payer_name": "MERITAIN HEALTH", "plan_name": "AETNA ALL OTHER PLANS", "methodology": "percent of total billed charges", "standard_charge_dollar": 421.2, "standard_charge_percentage": 52.0, "count": "0", "additional_payer_notes": "Zero final payments for the item or service in the 15 months prior to posting the file." }, { "payer_name": "BLUE SHIELD OUT OF STATE", "plan_name": "STANFORD HEALTHCARE ALLIANCE PLAN", "methodology": "percent of total billed charges", "standard_charge_dollar": 393.58, "standard_charge_percentage": 48.59, "count": "0", "additional_payer_notes": "Zero final payments for the item or service in the 15 months prior to posting the file." }, { "payer_name": "BLUE SHIELD", "plan_name": "STANFORD HEALTHCARE ALLIANCE PLAN", "methodology": "percent of total billed charges", "standard_charge_dollar": 393.58, "standard_charge_percentage": 48.59, "count": "0", "additional_payer_notes": "Zero final payments for the item or service in the 15 months prior to posting the file." }, { "payer_name": "BLUE SHIELD", "plan_name": "STANFORD HEALTHCARE ALLIANCE PLAN", "methodology": "percent of total billed charges", "standard_charge_dollar": 393.58, "standard_charge_percentage": 48.59, "count": "0", "additional_payer_notes": "Zero final payments for the item or service in the 15 months prior to posting the file." }, { "payer_name": "CIGNA", "plan_name": "CIGNA COM ALT HMO PLAN", "methodology": "percent of total billed charges", "standard_charge_dollar": 341.82, "standard_charge_percentage": 42.2, "count": "0", "additional_payer_notes": "Zero final payments for the item or service in the 15 months prior to posting the file." }, { "payer_name": "CIGNA", "plan_name": "CIGNA COM ALT HMO PLAN", "methodology": "percent of total billed charges", "standard_charge_dollar": 341.82, "standard_charge_percentage": 42.2, "count": "0", "additional_payer_notes": "Zero final payments for the item or service in the 15 months prior to posting the file." }, { "payer_name": "HEALTH NET", "plan_name": "HEALTHNET HMO, PPO, POS, EPO, CANOPY HEALTHNET HMO, OTHER-IN-NETWORK PLANS", "methodology": "per diem", "standard_charge_dollar": 8000.0, "standard_charge_algorithm": "Expected reimbursement is the lesser of Per diem ($8,000) for the length of stay and 70% of billed.", "count": "0", "additional_payer_notes": "Zero final payments for the item or service in the 15 months prior to posting the file." }, { "payer_name": "HEALTH NET", "plan_name": "HEALTHNET HMO, PPO, POS, EPO, CANOPY HEALTHNET HMO, OTHER-IN-NETWORK PLANS", "methodology": "per diem", "standard_charge_dollar": 8000.0, "standard_charge_algorithm": "Expected reimbursement is the lesser of Per diem ($8,000) for the length of stay and 70% of billed.", "count": "0", "additional_payer_notes": "Zero final payments for the item or service in the 15 months prior to posting the file." }, { "payer_name": "UNITED HEALTHCARE", "plan_name": "SUTTER SELECT & SUTTER HEALTH PLAN HMO PLANS", "methodology": "per diem", "standard_charge_dollar": 28538.0, "standard_charge_algorithm": "Per diem ($28,538).", "count": "0", "additional_payer_notes": "Zero final payments for the item or service in the 15 months prior to posting the file." }, { "payer_name": "UNITED HEALTHCARE", "plan_name": "SUTTER SELECT & SUTTER HEALTH PLAN HMO PLANS", "methodology": "per diem", "standard_charge_dollar": 28538.0, "standard_charge_algorithm": "Per diem ($28,538).", "count": "0", "additional_payer_notes": "Zero final payments for the item or service in the 15 months prior to posting the file." }, { "payer_name": "SUTTER", "plan_name": "SUTTER SELECT & SUTTER HEALTH PLAN HMO PLANS", "methodology": "per diem", "standard_charge_dollar": 28538.0, "standard_charge_algorithm": "Per diem ($28,538).", "count": "0", "additional_payer_notes": "Zero final payments for the item or service in the 15 months prior to posting the file." }, { "payer_name": "UNITED HEALTHCARE", "plan_name": "SUTTER SELECT & SUTTER HEALTH PLAN HMO PLANS", "methodology": "per diem", "standard_charge_dollar": 28538.0, "standard_charge_algorithm": "Per diem ($28,538).", "count": "0", "additional_payer_notes": "Zero final payments for the item or service in the 15 months prior to posting the file." }, { "payer_name": "UMR", "plan_name": "SUTTER SELECT & SUTTER HEALTH PLAN HMO PLANS", "methodology": "per diem", "standard_charge_dollar": 28538.0, "standard_charge_algorithm": "Per diem ($28,538).", "count": "0", "additional_payer_notes": "Zero final payments for the item or service in the 15 months prior to posting the file." } ] } ] }, { "description": "HC Clip Applier Gp013", "code_information": [ { "code": "PX-2120045013", "type": "CDM" }, { "code": "99999", "type": "CPT" }, { "code": "0272", "type": "RC" } ], "standard_charges": [ { "setting": "outpatient", "gross_charge": 900.0, "discounted_cash": 450.0, "minimum": 379.8, "maximum": 468.0, "additional_generic_notes": "Zero final payments for the item or service in the 15 months prior to posting the file.", "payers_information": [ { "payer_name": "AETNA", "plan_name": "AETNA ALL OTHER PLANS", "methodology": "percent of total billed charges", "standard_charge_dollar": 468.0, "standard_charge_percentage": 52.0, "count": "0", "additional_payer_notes": "Zero final payments for the item or service in the 15 months prior to posting the file." }, { "payer_name": "AETNA", "plan_name": "AETNA ALL OTHER PLANS", "methodology": "percent of total billed charges", "standard_charge_dollar": 468.0, "standard_charge_percentage": 52.0, "count": "0", "additional_payer_notes": "Zero final payments for the item or service in the 15 months prior to posting the file." }, { "payer_name": "MERITAIN HEALTH", "plan_name": "AETNA ALL OTHER PLANS", "methodology": "percent of total billed charges", "standard_charge_dollar": 468.0, "standard_charge_percentage": 52.0, "count": "0", "additional_payer_notes": "Zero final payments for the item or service in the 15 months prior to posting the file." }, { "payer_name": "BLUE SHIELD OUT OF STATE", "plan_name": "STANFORD HEALTHCARE ALLIANCE PLAN", "methodology": "percent of total billed charges", "standard_charge_dollar": 437.31, "standard_charge_percentage": 48.59, "count": "0", "additional_payer_notes": "Zero final payments for the item or service in the 15 months prior to posting the file." }, { "payer_name": "BLUE SHIELD", "plan_name": "STANFORD HEALTHCARE ALLIANCE PLAN", "methodology": "percent of total billed charges", "standard_charge_dollar": 437.31, "standard_charge_percentage": 48.59, "count": "0", "additional_payer_notes": "Zero final payments for the item or service in the 15 months prior to posting the file." }, { "payer_name": "BLUE SHIELD", "plan_name": "STANFORD HEALTHCARE ALLIANCE PLAN", "methodology": "percent of total billed charges", "standard_charge_dollar": 437.31, "standard_charge_percentage": 48.59, "count": "0", "additional_payer_notes": "Zero final payments for the item or service in the 15 months prior to posting the file." }, { "payer_name": "CIGNA", "plan_name": "CIGNA COM ALT HMO PLAN", "methodology": "percent of total billed charges", "standard_charge_dollar": 379.8, "standard_charge_percentage": 42.2, "count": "0", "additional_payer_notes": "Zero final payments for the item or service in the 15 months prior to posting the file." }, { "payer_name": "CIGNA", "plan_name": "CIGNA COM ALT HMO PLAN", "methodology": "percent of total billed charges", "standard_charge_dollar": 379.8, "standard_charge_percentage": 42.2, "count": "0", "additional_payer_notes": "Zero final payments for the item or service in the 15 months prior to posting the file." }, { "payer_name": "HEALTH NET", "plan_name": "HEALTHNET HMO, PPO, POS, EPO, CANOPY HEALTHNET HMO, OTHER-IN-NETWORK PLANS", "methodology": "per diem", "standard_charge_dollar": 8000.0, "standard_charge_algorithm": "Expected reimbursement is the lesser of Per diem ($8,000) for the length of stay and 70% of billed.", "count": "0", "additional_payer_notes": "Zero final payments for the item or service in the 15 months prior to posting the file." }, { "payer_name": "HEALTH NET", "plan_name": "HEALTHNET HMO, PPO, POS, EPO, CANOPY HEALTHNET HMO, OTHER-IN-NETWORK PLANS", "methodology": "per diem", "standard_charge_dollar": 8000.0, "standard_charge_algorithm": "Expected reimbursement is the lesser of Per diem ($8,000) for the length of stay and 70% of billed.", "count": "0", "additional_payer_notes": "Zero final payments for the item or service in the 15 months prior to posting the file." }, { "payer_name": "UNITED HEALTHCARE", "plan_name": "SUTTER SELECT & SUTTER HEALTH PLAN HMO PLANS", "methodology": "per diem", "standard_charge_dollar": 28538.0, "standard_charge_algorithm": "Per diem ($28,538).", "count": "0", "additional_payer_notes": "Zero final payments for the item or service in the 15 months prior to posting the file." }, { "payer_name": "UNITED HEALTHCARE", "plan_name": "SUTTER SELECT & SUTTER HEALTH PLAN HMO PLANS", "methodology": "per diem", "standard_charge_dollar": 28538.0, "standard_charge_algorithm": "Per diem ($28,538).", "count": "0", "additional_payer_notes": "Zero final payments for the item or service in the 15 months prior to posting the file." }, { "payer_name": "SUTTER", "plan_name": "SUTTER SELECT & SUTTER HEALTH PLAN HMO PLANS", "methodology": "per diem", "standard_charge_dollar": 28538.0, "standard_charge_algorithm": "Per diem ($28,538).", "count": "0", "additional_payer_notes": "Zero final payments for the item or service in the 15 months prior to posting the file." }, { "payer_name": "UNITED HEALTHCARE", "plan_name": "SUTTER SELECT & SUTTER HEALTH PLAN HMO PLANS", "methodology": "per diem", "standard_charge_dollar": 28538.0, "standard_charge_algorithm": "Per diem ($28,538).", "count": "0", "additional_payer_notes": "Zero final payments for the item or service in the 15 months prior to posting the file." }, { "payer_name": "UMR", "plan_name": "SUTTER SELECT & SUTTER HEALTH PLAN HMO PLANS", "methodology": "per diem", "standard_charge_dollar": 28538.0, "standard_charge_algorithm": "Per diem ($28,538).", "count": "0", "additional_payer_notes": "Zero final payments for the item or service in the 15 months prior to posting the file." } ] } ] }, { "description": "HC Clip Applier Gp014", "code_information": [ { "code": "PX-2120045014", "type": "CDM" }, { "code": "99999", "type": "CPT" }, { "code": "0272", "type": "RC" } ], "standard_charges": [ { "setting": "outpatient", "gross_charge": 1080.0, "discounted_cash": 540.0, "minimum": 455.76, "maximum": 561.6, "additional_generic_notes": "Zero final payments for the item or service in the 15 months prior to posting the file.", "payers_information": [ { "payer_name": "AETNA", "plan_name": "AETNA ALL OTHER PLANS", "methodology": "percent of total billed charges", "standard_charge_dollar": 561.6, "standard_charge_percentage": 52.0, "count": "0", "additional_payer_notes": "Zero final payments for the item or service in the 15 months prior to posting the file." }, { "payer_name": "AETNA", "plan_name": "AETNA ALL OTHER PLANS", "methodology": "percent of total billed charges", "standard_charge_dollar": 561.6, "standard_charge_percentage": 52.0, "count": "0", "additional_payer_notes": "Zero final payments for the item or service in the 15 months prior to posting the file." }, { "payer_name": "MERITAIN HEALTH", "plan_name": "AETNA ALL OTHER PLANS", "methodology": "percent of total billed charges", "standard_charge_dollar": 561.6, "standard_charge_percentage": 52.0, "count": "0", "additional_payer_notes": "Zero final payments for the item or service in the 15 months prior to posting the file." }, { "payer_name": "BLUE SHIELD OUT OF STATE", "plan_name": "STANFORD HEALTHCARE ALLIANCE PLAN", "methodology": "percent of total billed charges", "standard_charge_dollar": 524.77, "standard_charge_percentage": 48.59, "count": "0", "additional_payer_notes": "Zero final payments for the item or service in the 15 months prior to posting the file." }, { "payer_name": "BLUE SHIELD", "plan_name": "STANFORD HEALTHCARE ALLIANCE PLAN", "methodology": "percent of total billed charges", "standard_charge_dollar": 524.77, "standard_charge_percentage": 48.59, "median_amount": 68.24, "10th_percentile": 13.6, "90th_percentile": 1043.06, "count": "30" }, { "payer_name": "BLUE SHIELD", "plan_name": "STANFORD HEALTHCARE ALLIANCE PLAN", "methodology": "percent of total billed charges", "standard_charge_dollar": 524.77, "standard_charge_percentage": 48.59, "count": "0", "additional_payer_notes": "Zero final payments for the item or service in the 15 months prior to posting the file." }, { "payer_name": "BLUE SHIELD", "plan_name": "STANFORD HEALTHCARE ALLIANCE PLAN", "methodology": "percent of total billed charges", "standard_charge_dollar": 524.77, "standard_charge_percentage": 48.59, "count": "0", "additional_payer_notes": "Zero final payments for the item or service in the 15 months prior to posting the file." }, { "payer_name": "CIGNA", "plan_name": "CIGNA COM ALT HMO PLAN", "methodology": "percent of total billed charges", "standard_charge_dollar": 455.76, "standard_charge_percentage": 42.2, "count": "0", "additional_payer_notes": "Zero final payments for the item or service in the 15 months prior to posting the file." }, { "payer_name": "CIGNA", "plan_name": "CIGNA COM ALT HMO PLAN", "methodology": "percent of total billed charges", "standard_charge_dollar": 455.76, "standard_charge_percentage": 42.2, "count": "0", "additional_payer_notes": "Zero final payments for the item or service in the 15 months prior to posting the file." }, { "payer_name": "HEALTH NET", "plan_name": "HEALTHNET HMO, PPO, POS, EPO, CANOPY HEALTHNET HMO, OTHER-IN-NETWORK PLANS", "methodology": "per diem", "standard_charge_dollar": 8000.0, "standard_charge_algorithm": "Expected reimbursement is the lesser of Per diem ($8,000) for the length of stay and 70% of billed.", "count": "0", "additional_payer_notes": "Zero final payments for the item or service in the 15 months prior to posting the file." }, { "payer_name": "HEALTH NET", "plan_name": "HEALTHNET HMO, PPO, POS, EPO, CANOPY HEALTHNET HMO, OTHER-IN-NETWORK PLANS", "methodology": "per diem", "standard_charge_dollar": 8000.0, "standard_charge_algorithm": "Expected reimbursement is the lesser of Per diem ($8,000) for the length of stay and 70% of billed.", "count": "0", "additional_payer_notes": "Zero final payments for the item or service in the 15 months prior to posting the file." }, { "payer_name": "UNITED HEALTHCARE", "plan_name": "SUTTER SELECT & SUTTER HEALTH PLAN HMO PLANS", "methodology": "per diem", "standard_charge_dollar": 28538.0, "standard_charge_algorithm": "Per diem ($28,538).", "count": "0", "additional_payer_notes": "Zero final payments for the item or service in the 15 months prior to posting the file." }, { "payer_name": "UNITED HEALTHCARE", "plan_name": "SUTTER SELECT & SUTTER HEALTH PLAN HMO PLANS", "methodology": "per diem", "standard_charge_dollar": 28538.0, "standard_charge_algorithm": "Per diem ($28,538).", "count": "0", "additional_payer_notes": "Zero final payments for the item or service in the 15 months prior to posting the file." }, { "payer_name": "SUTTER", "plan_name": "SUTTER SELECT & SUTTER HEALTH PLAN HMO PLANS", "methodology": "per diem", "standard_charge_dollar": 28538.0, "standard_charge_algorithm": "Per diem ($28,538).", "count": "0", "additional_payer_notes": "Zero final payments for the item or service in the 15 months prior to posting the file." }, { "payer_name": "UNITED HEALTHCARE", "plan_name": "SUTTER SELECT & SUTTER HEALTH PLAN HMO PLANS", "methodology": "per diem", "standard_charge_dollar": 28538.0, "standard_charge_algorithm": "Per diem ($28,538).", "count": "0", "additional_payer_notes": "Zero final payments for the item or service in the 15 months prior to posting the file." }, { "payer_name": "UMR", "plan_name": "SUTTER SELECT & SUTTER HEALTH PLAN HMO PLANS", "methodology": "per diem", "standard_charge_dollar": 28538.0, "standard_charge_algorithm": "Per diem ($28,538).", "count": "0", "additional_payer_notes": "Zero final payments for the item or service in the 15 months prior to posting the file." } ] } ] }, { "description": "HC Clip Applier Gp015", "code_information": [ { "code": "PX-2120045015", "type": "CDM" }, { "code": "99999", "type": "CPT" }, { "code": "0272", "type": "RC" } ], "standard_charges": [ { "setting": "outpatient", "gross_charge": 1225.0, "discounted_cash": 612.5, "minimum": 516.95, "maximum": 637.0, "additional_generic_notes": "Zero final payments for the item or service in the 15 months prior to posting the file.", "payers_information": [ { "payer_name": "AETNA", "plan_name": "AETNA ALL OTHER PLANS", "methodology": "percent of total billed charges", "standard_charge_dollar": 637.0, "standard_charge_percentage": 52.0, "count": "0", "additional_payer_notes": "Zero final payments for the item or service in the 15 months prior to posting the file." }, { "payer_name": "AETNA", "plan_name": "AETNA ALL OTHER PLANS", "methodology": "percent of total billed charges", "standard_charge_dollar": 637.0, "standard_charge_percentage": 52.0, "count": "0", "additional_payer_notes": "Zero final payments for the item or service in the 15 months prior to posting the file." }, { "payer_name": "MERITAIN HEALTH", "plan_name": "AETNA ALL OTHER PLANS", "methodology": "percent of total billed charges", "standard_charge_dollar": 637.0, "standard_charge_percentage": 52.0, "count": "0", "additional_payer_notes": "Zero final payments for the item or service in the 15 months prior to posting the file." }, { "payer_name": "BLUE SHIELD OUT OF STATE", "plan_name": "STANFORD HEALTHCARE ALLIANCE PLAN", "methodology": "percent of total billed charges", "standard_charge_dollar": 595.23, "standard_charge_percentage": 48.59, "count": "0", "additional_payer_notes": "Zero final payments for the item or service in the 15 months prior to posting the file." }, { "payer_name": "BLUE SHIELD", "plan_name": "STANFORD HEALTHCARE ALLIANCE PLAN", "methodology": "percent of total billed charges", "standard_charge_dollar": 595.23, "standard_charge_percentage": 48.59, "median_amount": 68.24, "10th_percentile": 13.6, "90th_percentile": 1043.06, "count": "30" }, { "payer_name": "BLUE SHIELD", "plan_name": "STANFORD HEALTHCARE ALLIANCE PLAN", "methodology": "percent of total billed charges", "standard_charge_dollar": 595.23, "standard_charge_percentage": 48.59, "count": "0", "additional_payer_notes": "Zero final payments for the item or service in the 15 months prior to posting the file." }, { "payer_name": "BLUE SHIELD", "plan_name": "STANFORD HEALTHCARE ALLIANCE PLAN", "methodology": "percent of total billed charges", "standard_charge_dollar": 595.23, "standard_charge_percentage": 48.59, "count": "0", "additional_payer_notes": "Zero final payments for the item or service in the 15 months prior to posting the file." }, { "payer_name": "CIGNA", "plan_name": "CIGNA COM ALT HMO PLAN", "methodology": "percent of total billed charges", "standard_charge_dollar": 516.95, "standard_charge_percentage": 42.2, "count": "0", "additional_payer_notes": "Zero final payments for the item or service in the 15 months prior to posting the file." }, { "payer_name": "CIGNA", "plan_name": "CIGNA COM ALT HMO PLAN", "methodology": "percent of total billed charges", "standard_charge_dollar": 516.95, "standard_charge_percentage": 42.2, "count": "0", "additional_payer_notes": "Zero final payments for the item or service in the 15 months prior to posting the file." }, { "payer_name": "HEALTH NET", "plan_name": "HEALTHNET HMO, PPO, POS, EPO, CANOPY HEALTHNET HMO, OTHER-IN-NETWORK PLANS", "methodology": "per diem", "standard_charge_dollar": 8000.0, "standard_charge_algorithm": "Expected reimbursement is the lesser of Per diem ($8,000) for the length of stay and 70% of billed.", "count": "0", "additional_payer_notes": "Zero final payments for the item or service in the 15 months prior to posting the file." }, { "payer_name": "HEALTH NET", "plan_name": "HEALTHNET HMO, PPO, POS, EPO, CANOPY HEALTHNET HMO, OTHER-IN-NETWORK PLANS", "methodology": "per diem", "standard_charge_dollar": 8000.0, "standard_charge_algorithm": "Expected reimbursement is the lesser of Per diem ($8,000) for the length of stay and 70% of billed.", "count": "0", "additional_payer_notes": "Zero final payments for the item or service in the 15 months prior to posting the file." }, { "payer_name": "UNITED HEALTHCARE", "plan_name": "SUTTER SELECT & SUTTER HEALTH PLAN HMO PLANS", "methodology": "per diem", "standard_charge_dollar": 28538.0, "standard_charge_algorithm": "Per diem ($28,538).", "count": "0", "additional_payer_notes": "Zero final payments for the item or service in the 15 months prior to posting the file." }, { "payer_name": "UNITED HEALTHCARE", "plan_name": "SUTTER SELECT & SUTTER HEALTH PLAN HMO PLANS", "methodology": "per diem", "standard_charge_dollar": 28538.0, "standard_charge_algorithm": "Per diem ($28,538).", "count": "0", "additional_payer_notes": "Zero final payments for the item or service in the 15 months prior to posting the file." }, { "payer_name": "SUTTER", "plan_name": "SUTTER SELECT & SUTTER HEALTH PLAN HMO PLANS", "methodology": "per diem", "standard_charge_dollar": 28538.0, "standard_charge_algorithm": "Per diem ($28,538).", "count": "0", "additional_payer_notes": "Zero final payments for the item or service in the 15 months prior to posting the file." }, { "payer_name": "UNITED HEALTHCARE", "plan_name": "SUTTER SELECT & SUTTER HEALTH PLAN HMO PLANS", "methodology": "per diem", "standard_charge_dollar": 28538.0, "standard_charge_algorithm": "Per diem ($28,538).", "count": "0", "additional_payer_notes": "Zero final payments for the item or service in the 15 months prior to posting the file." }, { "payer_name": "UMR", "plan_name": "SUTTER SELECT & SUTTER HEALTH PLAN HMO PLANS", "methodology": "per diem", "standard_charge_dollar": 28538.0, "standard_charge_algorithm": "Per diem ($28,538).", "count": "0", "additional_payer_notes": "Zero final payments for the item or service in the 15 months prior to posting the file." } ] } ] }, { "description": "HC Clip Applier Gp016", "code_information": [ { "code": "PX-2120045016", "type": "CDM" }, { "code": "99999", "type": "CPT" }, { "code": "0272", "type": "RC" } ], "standard_charges": [ { "setting": "outpatient", "gross_charge": 1400.0, "discounted_cash": 700.0, "minimum": 590.8, "maximum": 728.0, "additional_generic_notes": "Zero final payments for the item or service in the 15 months prior to posting the file.", "payers_information": [ { "payer_name": "AETNA", "plan_name": "AETNA ALL OTHER PLANS", "methodology": "percent of total billed charges", "standard_charge_dollar": 728.0, "standard_charge_percentage": 52.0, "count": "0", "additional_payer_notes": "Zero final payments for the item or service in the 15 months prior to posting the file." }, { "payer_name": "AETNA", "plan_name": "AETNA ALL OTHER PLANS", "methodology": "percent of total billed charges", "standard_charge_dollar": 728.0, "standard_charge_percentage": 52.0, "count": "0", "additional_payer_notes": "Zero final payments for the item or service in the 15 months prior to posting the file." }, { "payer_name": "MERITAIN HEALTH", "plan_name": "AETNA ALL OTHER PLANS", "methodology": "percent of total billed charges", "standard_charge_dollar": 728.0, "standard_charge_percentage": 52.0, "count": "0", "additional_payer_notes": "Zero final payments for the item or service in the 15 months prior to posting the file." }, { "payer_name": "BLUE SHIELD OUT OF STATE", "plan_name": "STANFORD HEALTHCARE ALLIANCE PLAN", "methodology": "percent of total billed charges", "standard_charge_dollar": 680.26, "standard_charge_percentage": 48.59, "count": "0", "additional_payer_notes": "Zero final payments for the item or service in the 15 months prior to posting the file." }, { "payer_name": "BLUE SHIELD", "plan_name": "STANFORD HEALTHCARE ALLIANCE PLAN", "methodology": "percent of total billed charges", "standard_charge_dollar": 680.26, "standard_charge_percentage": 48.59, "median_amount": 68.24, "10th_percentile": 13.6, "90th_percentile": 1043.06, "count": "30" }, { "payer_name": "BLUE SHIELD", "plan_name": "STANFORD HEALTHCARE ALLIANCE PLAN", "methodology": "percent of total billed charges", "standard_charge_dollar": 680.26, "standard_charge_percentage": 48.59, "count": "0", "additional_payer_notes": "Zero final payments for the item or service in the 15 months prior to posting the file." }, { "payer_name": "BLUE SHIELD", "plan_name": "STANFORD HEALTHCARE ALLIANCE PLAN", "methodology": "percent of total billed charges", "standard_charge_dollar": 680.26, "standard_charge_percentage": 48.59, "count": "0", "additional_payer_notes": "Zero final payments for the item or service in the 15 months prior to posting the file." }, { "payer_name": "CIGNA", "plan_name": "CIGNA COM ALT HMO PLAN", "methodology": "percent of total billed charges", "standard_charge_dollar": 590.8, "standard_charge_percentage": 42.2, "count": "0", "additional_payer_notes": "Zero final payments for the item or service in the 15 months prior to posting the file." }, { "payer_name": "CIGNA", "plan_name": "CIGNA COM ALT HMO PLAN", "methodology": "percent of total billed charges", "standard_charge_dollar": 590.8, "standard_charge_percentage": 42.2, "count": "0", "additional_payer_notes": "Zero final payments for the item or service in the 15 months prior to posting the file." }, { "payer_name": "HEALTH NET", "plan_name": "HEALTHNET HMO, PPO, POS, EPO, CANOPY HEALTHNET HMO, OTHER-IN-NETWORK PLANS", "methodology": "per diem", "standard_charge_dollar": 8000.0, "standard_charge_algorithm": "Expected reimbursement is the lesser of Per diem ($8,000) for the length of stay and 70% of billed.", "count": "0", "additional_payer_notes": "Zero final payments for the item or service in the 15 months prior to posting the file." }, { "payer_name": "HEALTH NET", "plan_name": "HEALTHNET HMO, PPO, POS, EPO, CANOPY HEALTHNET HMO, OTHER-IN-NETWORK PLANS", "methodology": "per diem", "standard_charge_dollar": 8000.0, "standard_charge_algorithm": "Expected reimbursement is the lesser of Per diem ($8,000) for the length of stay and 70% of billed.", "count": "0", "additional_payer_notes": "Zero final payments for the item or service in the 15 months prior to posting the file." }, { "payer_name": "UNITED HEALTHCARE", "plan_name": "SUTTER SELECT & SUTTER HEALTH PLAN HMO PLANS", "methodology": "per diem", "standard_charge_dollar": 28538.0, "standard_charge_algorithm": "Per diem ($28,538).", "count": "0", "additional_payer_notes": "Zero final payments for the item or service in the 15 months prior to posting the file." }, { "payer_name": "UNITED HEALTHCARE", "plan_name": "SUTTER SELECT & SUTTER HEALTH PLAN HMO PLANS", "methodology": "per diem", "standard_charge_dollar": 28538.0, "standard_charge_algorithm": "Per diem ($28,538).", "count": "0", "additional_payer_notes": "Zero final payments for the item or service in the 15 months prior to posting the file." }, { "payer_name": "SUTTER", "plan_name": "SUTTER SELECT & SUTTER HEALTH PLAN HMO PLANS", "methodology": "per diem", "standard_charge_dollar": 28538.0, "standard_charge_algorithm": "Per diem ($28,538).", "count": "0", "additional_payer_notes": "Zero final payments for the item or service in the 15 months prior to posting the file." }, { "payer_name": "UNITED HEALTHCARE", "plan_name": "SUTTER SELECT & SUTTER HEALTH PLAN HMO PLANS", "methodology": "per diem", "standard_charge_dollar": 28538.0, "standard_charge_algorithm": "Per diem ($28,538).", "count": "0", "additional_payer_notes": "Zero final payments for the item or service in the 15 months prior to posting the file." }, { "payer_name": "UMR", "plan_name": "SUTTER SELECT & SUTTER HEALTH PLAN HMO PLANS", "methodology": "per diem", "standard_charge_dollar": 28538.0, "standard_charge_algorithm": "Per diem ($28,538).", "count": "0", "additional_payer_notes": "Zero final payments for the item or service in the 15 months prior to posting the file." } ] } ] }, { "description": "HC Clip Applier Gp018", "code_information": [ { "code": "PX-2120045018", "type": "CDM" }, { "code": "99999", "type": "CPT" }, { "code": "0272", "type": "RC" } ], "standard_charges": [ { "setting": "outpatient", "gross_charge": 1750.0, "discounted_cash": 875.0, "minimum": 738.5, "maximum": 910.0, "additional_generic_notes": "Zero final payments for the item or service in the 15 months prior to posting the file.", "payers_information": [ { "payer_name": "AETNA", "plan_name": "AETNA ALL OTHER PLANS", "methodology": "percent of total billed charges", "standard_charge_dollar": 910.0, "standard_charge_percentage": 52.0, "count": "0", "additional_payer_notes": "Zero final payments for the item or service in the 15 months prior to posting the file." }, { "payer_name": "AETNA", "plan_name": "AETNA ALL OTHER PLANS", "methodology": "percent of total billed charges", "standard_charge_dollar": 910.0, "standard_charge_percentage": 52.0, "count": "0", "additional_payer_notes": "Zero final payments for the item or service in the 15 months prior to posting the file." }, { "payer_name": "MERITAIN HEALTH", "plan_name": "AETNA ALL OTHER PLANS", "methodology": "percent of total billed charges", "standard_charge_dollar": 910.0, "standard_charge_percentage": 52.0, "count": "0", "additional_payer_notes": "Zero final payments for the item or service in the 15 months prior to posting the file." }, { "payer_name": "BLUE SHIELD OUT OF STATE", "plan_name": "STANFORD HEALTHCARE ALLIANCE PLAN", "methodology": "percent of total billed charges", "standard_charge_dollar": 850.33, "standard_charge_percentage": 48.59, "count": "0", "additional_payer_notes": "Zero final payments for the item or service in the 15 months prior to posting the file." }, { "payer_name": "BLUE SHIELD", "plan_name": "STANFORD HEALTHCARE ALLIANCE PLAN", "methodology": "percent of total billed charges", "standard_charge_dollar": 850.33, "standard_charge_percentage": 48.59, "median_amount": 68.24, "10th_percentile": 13.6, "90th_percentile": 1043.06, "count": "30" }, { "payer_name": "BLUE SHIELD", "plan_name": "STANFORD HEALTHCARE ALLIANCE PLAN", "methodology": "percent of total billed charges", "standard_charge_dollar": 850.33, "standard_charge_percentage": 48.59, "count": "0", "additional_payer_notes": "Zero final payments for the item or service in the 15 months prior to posting the file." }, { "payer_name": "BLUE SHIELD", "plan_name": "STANFORD HEALTHCARE ALLIANCE PLAN", "methodology": "percent of total billed charges", "standard_charge_dollar": 850.33, "standard_charge_percentage": 48.59, "count": "0", "additional_payer_notes": "Zero final payments for the item or service in the 15 months prior to posting the file." }, { "payer_name": "CIGNA", "plan_name": "CIGNA COM ALT HMO PLAN", "methodology": "percent of total billed charges", "standard_charge_dollar": 738.5, "standard_charge_percentage": 42.2, "count": "0", "additional_payer_notes": "Zero final payments for the item or service in the 15 months prior to posting the file." }, { "payer_name": "CIGNA", "plan_name": "CIGNA COM ALT HMO PLAN", "methodology": "percent of total billed charges", "standard_charge_dollar": 738.5, "standard_charge_percentage": 42.2, "count": "0", "additional_payer_notes": "Zero final payments for the item or service in the 15 months prior to posting the file." }, { "payer_name": "HEALTH NET", "plan_name": "HEALTHNET HMO, PPO, POS, EPO, CANOPY HEALTHNET HMO, OTHER-IN-NETWORK PLANS", "methodology": "per diem", "standard_charge_dollar": 8000.0, "standard_charge_algorithm": "Expected reimbursement is the lesser of Per diem ($8,000) for the length of stay and 70% of billed.", "count": "0", "additional_payer_notes": "Zero final payments for the item or service in the 15 months prior to posting the file." }, { "payer_name": "HEALTH NET", "plan_name": "HEALTHNET HMO, PPO, POS, EPO, CANOPY HEALTHNET HMO, OTHER-IN-NETWORK PLANS", "methodology": "per diem", "standard_charge_dollar": 8000.0, "standard_charge_algorithm": "Expected reimbursement is the lesser of Per diem ($8,000) for the length of stay and 70% of billed.", "count": "0", "additional_payer_notes": "Zero final payments for the item or service in the 15 months prior to posting the file." }, { "payer_name": "UNITED HEALTHCARE", "plan_name": "SUTTER SELECT & SUTTER HEALTH PLAN HMO PLANS", "methodology": "per diem", "standard_charge_dollar": 28538.0, "standard_charge_algorithm": "Per diem ($28,538).", "count": "0", "additional_payer_notes": "Zero final payments for the item or service in the 15 months prior to posting the file." }, { "payer_name": "UNITED HEALTHCARE", "plan_name": "SUTTER SELECT & SUTTER HEALTH PLAN HMO PLANS", "methodology": "per diem", "standard_charge_dollar": 28538.0, "standard_charge_algorithm": "Per diem ($28,538).", "count": "0", "additional_payer_notes": "Zero final payments for the item or service in the 15 months prior to posting the file." }, { "payer_name": "SUTTER", "plan_name": "SUTTER SELECT & SUTTER HEALTH PLAN HMO PLANS", "methodology": "per diem", "standard_charge_dollar": 28538.0, "standard_charge_algorithm": "Per diem ($28,538).", "count": "0", "additional_payer_notes": "Zero final payments for the item or service in the 15 months prior to posting the file." }, { "payer_name": "UNITED HEALTHCARE", "plan_name": "SUTTER SELECT & SUTTER HEALTH PLAN HMO PLANS", "methodology": "per diem", "standard_charge_dollar": 28538.0, "standard_charge_algorithm": "Per diem ($28,538).", "count": "0", "additional_payer_notes": "Zero final payments for the item or service in the 15 months prior to posting the file." }, { "payer_name": "UMR", "plan_name": "SUTTER SELECT & SUTTER HEALTH PLAN HMO PLANS", "methodology": "per diem", "standard_charge_dollar": 28538.0, "standard_charge_algorithm": "Per diem ($28,538).", "count": "0", "additional_payer_notes": "Zero final payments for the item or service in the 15 months prior to posting the file." } ] } ] }, { "description": "HC Clip Applier Gp020", "code_information": [ { "code": "PX-2120045020", "type": "CDM" }, { "code": "99999", "type": "CPT" }, { "code": "0272", "type": "RC" } ], "standard_charges": [ { "setting": "outpatient", "gross_charge": 2550.0, "discounted_cash": 1275.0, "minimum": 1076.1, "maximum": 1326.0, "additional_generic_notes": "Zero final payments for the item or service in the 15 months prior to posting the file.", "payers_information": [ { "payer_name": "AETNA", "plan_name": "AETNA ALL OTHER PLANS", "methodology": "percent of total billed charges", "standard_charge_dollar": 1326.0, "standard_charge_percentage": 52.0, "count": "0", "additional_payer_notes": "Zero final payments for the item or service in the 15 months prior to posting the file." }, { "payer_name": "AETNA", "plan_name": "AETNA ALL OTHER PLANS", "methodology": "percent of total billed charges", "standard_charge_dollar": 1326.0, "standard_charge_percentage": 52.0, "count": "0", "additional_payer_notes": "Zero final payments for the item or service in the 15 months prior to posting the file." }, { "payer_name": "MERITAIN HEALTH", "plan_name": "AETNA ALL OTHER PLANS", "methodology": "percent of total billed charges", "standard_charge_dollar": 1326.0, "standard_charge_percentage": 52.0, "count": "0", "additional_payer_notes": "Zero final payments for the item or service in the 15 months prior to posting the file." }, { "payer_name": "BLUE SHIELD OUT OF STATE", "plan_name": "STANFORD HEALTHCARE ALLIANCE PLAN", "methodology": "percent of total billed charges", "standard_charge_dollar": 1239.05, "standard_charge_percentage": 48.59, "count": "0", "additional_payer_notes": "Zero final payments for the item or service in the 15 months prior to posting the file." }, { "payer_name": "BLUE SHIELD", "plan_name": "STANFORD HEALTHCARE ALLIANCE PLAN", "methodology": "percent of total billed charges", "standard_charge_dollar": 1239.05, "standard_charge_percentage": 48.59, "median_amount": 68.24, "10th_percentile": 13.6, "90th_percentile": 1043.06, "count": "30" }, { "payer_name": "BLUE SHIELD", "plan_name": "STANFORD HEALTHCARE ALLIANCE PLAN", "methodology": "percent of total billed charges", "standard_charge_dollar": 1239.05, "standard_charge_percentage": 48.59, "count": "0", "additional_payer_notes": "Zero final payments for the item or service in the 15 months prior to posting the file." }, { "payer_name": "BLUE SHIELD", "plan_name": "STANFORD HEALTHCARE ALLIANCE PLAN", "methodology": "percent of total billed charges", "standard_charge_dollar": 1239.05, "standard_charge_percentage": 48.59, "count": "0", "additional_payer_notes": "Zero final payments for the item or service in the 15 months prior to posting the file." }, { "payer_name": "CIGNA", "plan_name": "CIGNA COM ALT HMO PLAN", "methodology": "percent of total billed charges", "standard_charge_dollar": 1076.1, "standard_charge_percentage": 42.2, "count": "0", "additional_payer_notes": "Zero final payments for the item or service in the 15 months prior to posting the file." }, { "payer_name": "CIGNA", "plan_name": "CIGNA COM ALT HMO PLAN", "methodology": "percent of total billed charges", "standard_charge_dollar": 1076.1, "standard_charge_percentage": 42.2, "count": "0", "additional_payer_notes": "Zero final payments for the item or service in the 15 months prior to posting the file." }, { "payer_name": "HEALTH NET", "plan_name": "HEALTHNET HMO, PPO, POS, EPO, CANOPY HEALTHNET HMO, OTHER-IN-NETWORK PLANS", "methodology": "per diem", "standard_charge_dollar": 8000.0, "standard_charge_algorithm": "Expected reimbursement is the lesser of Per diem ($8,000) for the length of stay and 70% of billed.", "count": "0", "additional_payer_notes": "Zero final payments for the item or service in the 15 months prior to posting the file." }, { "payer_name": "HEALTH NET", "plan_name": "HEALTHNET HMO, PPO, POS, EPO, CANOPY HEALTHNET HMO, OTHER-IN-NETWORK PLANS", "methodology": "per diem", "standard_charge_dollar": 8000.0, "standard_charge_algorithm": "Expected reimbursement is the lesser of Per diem ($8,000) for the length of stay and 70% of billed.", "count": "0", "additional_payer_notes": "Zero final payments for the item or service in the 15 months prior to posting the file." }, { "payer_name": "UNITED HEALTHCARE", "plan_name": "SUTTER SELECT & SUTTER HEALTH PLAN HMO PLANS", "methodology": "per diem", "standard_charge_dollar": 28538.0, "standard_charge_algorithm": "Per diem ($28,538).", "count": "0", "additional_payer_notes": "Zero final payments for the item or service in the 15 months prior to posting the file." }, { "payer_name": "UNITED HEALTHCARE", "plan_name": "SUTTER SELECT & SUTTER HEALTH PLAN HMO PLANS", "methodology": "per diem", "standard_charge_dollar": 28538.0, "standard_charge_algorithm": "Per diem ($28,538).", "count": "0", "additional_payer_notes": "Zero final payments for the item or service in the 15 months prior to posting the file." }, { "payer_name": "SUTTER", "plan_name": "SUTTER SELECT & SUTTER HEALTH PLAN HMO PLANS", "methodology": "per diem", "standard_charge_dollar": 28538.0, "standard_charge_algorithm": "Per diem ($28,538).", "count": "0", "additional_payer_notes": "Zero final payments for the item or service in the 15 months prior to posting the file." }, { "payer_name": "UNITED HEALTHCARE", "plan_name": "SUTTER SELECT & SUTTER HEALTH PLAN HMO PLANS", "methodology": "per diem", "standard_charge_dollar": 28538.0, "standard_charge_algorithm": "Per diem ($28,538).", "count": "0", "additional_payer_notes": "Zero final payments for the item or service in the 15 months prior to posting the file." }, { "payer_name": "UMR", "plan_name": "SUTTER SELECT & SUTTER HEALTH PLAN HMO PLANS", "methodology": "per diem", "standard_charge_dollar": 28538.0, "standard_charge_algorithm": "Per diem ($28,538).", "count": "0", "additional_payer_notes": "Zero final payments for the item or service in the 15 months prior to posting the file." } ] } ] }, { "description": "HC Clip Applier Gp021", "code_information": [ { "code": "PX-2120045021", "type": "CDM" }, { "code": "99999", "type": "CPT" }, { "code": "0272", "type": "RC" } ], "standard_charges": [ { "setting": "outpatient", "gross_charge": 2888.0, "discounted_cash": 1444.0, "minimum": 1218.74, "maximum": 1501.76, "additional_generic_notes": "Zero final payments for the item or service in the 15 months prior to posting the file.", "payers_information": [ { "payer_name": "AETNA", "plan_name": "AETNA ALL OTHER PLANS", "methodology": "percent of total billed charges", "standard_charge_dollar": 1501.76, "standard_charge_percentage": 52.0, "count": "0", "additional_payer_notes": "Zero final payments for the item or service in the 15 months prior to posting the file." }, { "payer_name": "AETNA", "plan_name": "AETNA ALL OTHER PLANS", "methodology": "percent of total billed charges", "standard_charge_dollar": 1501.76, "standard_charge_percentage": 52.0, "count": "0", "additional_payer_notes": "Zero final payments for the item or service in the 15 months prior to posting the file." }, { "payer_name": "MERITAIN HEALTH", "plan_name": "AETNA ALL OTHER PLANS", "methodology": "percent of total billed charges", "standard_charge_dollar": 1501.76, "standard_charge_percentage": 52.0, "count": "0", "additional_payer_notes": "Zero final payments for the item or service in the 15 months prior to posting the file." }, { "payer_name": "BLUE SHIELD OUT OF STATE", "plan_name": "STANFORD HEALTHCARE ALLIANCE PLAN", "methodology": "percent of total billed charges", "standard_charge_dollar": 1403.28, "standard_charge_percentage": 48.59, "count": "0", "additional_payer_notes": "Zero final payments for the item or service in the 15 months prior to posting the file." }, { "payer_name": "BLUE SHIELD", "plan_name": "STANFORD HEALTHCARE ALLIANCE PLAN", "methodology": "percent of total billed charges", "standard_charge_dollar": 1403.28, "standard_charge_percentage": 48.59, "median_amount": 68.24, "10th_percentile": 13.6, "90th_percentile": 1043.06, "count": "30" }, { "payer_name": "BLUE SHIELD", "plan_name": "STANFORD HEALTHCARE ALLIANCE PLAN", "methodology": "percent of total billed charges", "standard_charge_dollar": 1403.28, "standard_charge_percentage": 48.59, "count": "0", "additional_payer_notes": "Zero final payments for the item or service in the 15 months prior to posting the file." }, { "payer_name": "BLUE SHIELD", "plan_name": "STANFORD HEALTHCARE ALLIANCE PLAN", "methodology": "percent of total billed charges", "standard_charge_dollar": 1403.28, "standard_charge_percentage": 48.59, "count": "0", "additional_payer_notes": "Zero final payments for the item or service in the 15 months prior to posting the file." }, { "payer_name": "CIGNA", "plan_name": "CIGNA COM ALT HMO PLAN", "methodology": "percent of total billed charges", "standard_charge_dollar": 1218.74, "standard_charge_percentage": 42.2, "count": "0", "additional_payer_notes": "Zero final payments for the item or service in the 15 months prior to posting the file." }, { "payer_name": "CIGNA", "plan_name": "CIGNA COM ALT HMO PLAN", "methodology": "percent of total billed charges", "standard_charge_dollar": 1218.74, "standard_charge_percentage": 42.2, "count": "0", "additional_payer_notes": "Zero final payments for the item or service in the 15 months prior to posting the file." }, { "payer_name": "HEALTH NET", "plan_name": "HEALTHNET HMO, PPO, POS, EPO, CANOPY HEALTHNET HMO, OTHER-IN-NETWORK PLANS", "methodology": "per diem", "standard_charge_dollar": 8000.0, "standard_charge_algorithm": "Expected reimbursement is the lesser of Per diem ($8,000) for the length of stay and 70% of billed.", "count": "0", "additional_payer_notes": "Zero final payments for the item or service in the 15 months prior to posting the file." }, { "payer_name": "HEALTH NET", "plan_name": "HEALTHNET HMO, PPO, POS, EPO, CANOPY HEALTHNET HMO, OTHER-IN-NETWORK PLANS", "methodology": "per diem", "standard_charge_dollar": 8000.0, "standard_charge_algorithm": "Expected reimbursement is the lesser of Per diem ($8,000) for the length of stay and 70% of billed.", "count": "0", "additional_payer_notes": "Zero final payments for the item or service in the 15 months prior to posting the file." }, { "payer_name": "UNITED HEALTHCARE", "plan_name": "SUTTER SELECT & SUTTER HEALTH PLAN HMO PLANS", "methodology": "per diem", "standard_charge_dollar": 28538.0, "standard_charge_algorithm": "Per diem ($28,538).", "count": "0", "additional_payer_notes": "Zero final payments for the item or service in the 15 months prior to posting the file." }, { "payer_name": "UNITED HEALTHCARE", "plan_name": "SUTTER SELECT & SUTTER HEALTH PLAN HMO PLANS", "methodology": "per diem", "standard_charge_dollar": 28538.0, "standard_charge_algorithm": "Per diem ($28,538).", "count": "0", "additional_payer_notes": "Zero final payments for the item or service in the 15 months prior to posting the file." }, { "payer_name": "SUTTER", "plan_name": "SUTTER SELECT & SUTTER HEALTH PLAN HMO PLANS", "methodology": "per diem", "standard_charge_dollar": 28538.0, "standard_charge_algorithm": "Per diem ($28,538).", "count": "0", "additional_payer_notes": "Zero final payments for the item or service in the 15 months prior to posting the file." }, { "payer_name": "UNITED HEALTHCARE", "plan_name": "SUTTER SELECT & SUTTER HEALTH PLAN HMO PLANS", "methodology": "per diem", "standard_charge_dollar": 28538.0, "standard_charge_algorithm": "Per diem ($28,538).", "count": "0", "additional_payer_notes": "Zero final payments for the item or service in the 15 months prior to posting the file." }, { "payer_name": "UMR", "plan_name": "SUTTER SELECT & SUTTER HEALTH PLAN HMO PLANS", "methodology": "per diem", "standard_charge_dollar": 28538.0, "standard_charge_algorithm": "Per diem ($28,538).", "count": "0", "additional_payer_notes": "Zero final payments for the item or service in the 15 months prior to posting the file." } ] } ] }, { "description": "HC Clip Applier Gp022", "code_information": [ { "code": "PX-2120045022", "type": "CDM" }, { "code": "99999", "type": "CPT" }, { "code": "0272", "type": "RC" } ], "standard_charges": [ { "setting": "outpatient", "gross_charge": 3300.0, "discounted_cash": 1650.0, "minimum": 1392.6, "maximum": 1716.0, "additional_generic_notes": "Zero final payments for the item or service in the 15 months prior to posting the file.", "payers_information": [ { "payer_name": "AETNA", "plan_name": "AETNA ALL OTHER PLANS", "methodology": "percent of total billed charges", "standard_charge_dollar": 1716.0, "standard_charge_percentage": 52.0, "count": "0", "additional_payer_notes": "Zero final payments for the item or service in the 15 months prior to posting the file." }, { "payer_name": "AETNA", "plan_name": "AETNA ALL OTHER PLANS", "methodology": "percent of total billed charges", "standard_charge_dollar": 1716.0, "standard_charge_percentage": 52.0, "count": "0", "additional_payer_notes": "Zero final payments for the item or service in the 15 months prior to posting the file." }, { "payer_name": "MERITAIN HEALTH", "plan_name": "AETNA ALL OTHER PLANS", "methodology": "percent of total billed charges", "standard_charge_dollar": 1716.0, "standard_charge_percentage": 52.0, "count": "0", "additional_payer_notes": "Zero final payments for the item or service in the 15 months prior to posting the file." }, { "payer_name": "BLUE SHIELD OUT OF STATE", "plan_name": "STANFORD HEALTHCARE ALLIANCE PLAN", "methodology": "percent of total billed charges", "standard_charge_dollar": 1603.47, "standard_charge_percentage": 48.59, "count": "0", "additional_payer_notes": "Zero final payments for the item or service in the 15 months prior to posting the file." }, { "payer_name": "BLUE SHIELD", "plan_name": "STANFORD HEALTHCARE ALLIANCE PLAN", "methodology": "percent of total billed charges", "standard_charge_dollar": 1603.47, "standard_charge_percentage": 48.59, "median_amount": 68.24, "10th_percentile": 13.6, "90th_percentile": 1043.06, "count": "30" }, { "payer_name": "BLUE SHIELD", "plan_name": "STANFORD HEALTHCARE ALLIANCE PLAN", "methodology": "percent of total billed charges", "standard_charge_dollar": 1603.47, "standard_charge_percentage": 48.59, "count": "0", "additional_payer_notes": "Zero final payments for the item or service in the 15 months prior to posting the file." }, { "payer_name": "BLUE SHIELD", "plan_name": "STANFORD HEALTHCARE ALLIANCE PLAN", "methodology": "percent of total billed charges", "standard_charge_dollar": 1603.47, "standard_charge_percentage": 48.59, "count": "0", "additional_payer_notes": "Zero final payments for the item or service in the 15 months prior to posting the file." }, { "payer_name": "CIGNA", "plan_name": "CIGNA COM ALT HMO PLAN", "methodology": "percent of total billed charges", "standard_charge_dollar": 1392.6, "standard_charge_percentage": 42.2, "count": "0", "additional_payer_notes": "Zero final payments for the item or service in the 15 months prior to posting the file." }, { "payer_name": "CIGNA", "plan_name": "CIGNA COM ALT HMO PLAN", "methodology": "percent of total billed charges", "standard_charge_dollar": 1392.6, "standard_charge_percentage": 42.2, "count": "0", "additional_payer_notes": "Zero final payments for the item or service in the 15 months prior to posting the file." }, { "payer_name": "HEALTH NET", "plan_name": "HEALTHNET HMO, PPO, POS, EPO, CANOPY HEALTHNET HMO, OTHER-IN-NETWORK PLANS", "methodology": "per diem", "standard_charge_dollar": 8000.0, "standard_charge_algorithm": "Expected reimbursement is the lesser of Per diem ($8,000) for the length of stay and 70% of billed.", "count": "0", "additional_payer_notes": "Zero final payments for the item or service in the 15 months prior to posting the file." }, { "payer_name": "HEALTH NET", "plan_name": "HEALTHNET HMO, PPO, POS, EPO, CANOPY HEALTHNET HMO, OTHER-IN-NETWORK PLANS", "methodology": "per diem", "standard_charge_dollar": 8000.0, "standard_charge_algorithm": "Expected reimbursement is the lesser of Per diem ($8,000) for the length of stay and 70% of billed.", "count": "0", "additional_payer_notes": "Zero final payments for the item or service in the 15 months prior to posting the file." }, { "payer_name": "UNITED HEALTHCARE", "plan_name": "SUTTER SELECT & SUTTER HEALTH PLAN HMO PLANS", "methodology": "per diem", "standard_charge_dollar": 28538.0, "standard_charge_algorithm": "Per diem ($28,538).", "count": "0", "additional_payer_notes": "Zero final payments for the item or service in the 15 months prior to posting the file." }, { "payer_name": "UNITED HEALTHCARE", "plan_name": "SUTTER SELECT & SUTTER HEALTH PLAN HMO PLANS", "methodology": "per diem", "standard_charge_dollar": 28538.0, "standard_charge_algorithm": "Per diem ($28,538).", "count": "0", "additional_payer_notes": "Zero final payments for the item or service in the 15 months prior to posting the file." }, { "payer_name": "SUTTER", "plan_name": "SUTTER SELECT & SUTTER HEALTH PLAN HMO PLANS", "methodology": "per diem", "standard_charge_dollar": 28538.0, "standard_charge_algorithm": "Per diem ($28,538).", "count": "0", "additional_payer_notes": "Zero final payments for the item or service in the 15 months prior to posting the file." }, { "payer_name": "UNITED HEALTHCARE", "plan_name": "SUTTER SELECT & SUTTER HEALTH PLAN HMO PLANS", "methodology": "per diem", "standard_charge_dollar": 28538.0, "standard_charge_algorithm": "Per diem ($28,538).", "count": "0", "additional_payer_notes": "Zero final payments for the item or service in the 15 months prior to posting the file." }, { "payer_name": "UMR", "plan_name": "SUTTER SELECT & SUTTER HEALTH PLAN HMO PLANS", "methodology": "per diem", "standard_charge_dollar": 28538.0, "standard_charge_algorithm": "Per diem ($28,538).", "count": "0", "additional_payer_notes": "Zero final payments for the item or service in the 15 months prior to posting the file." } ] } ] }, { "description": "HC Clip Applier Gp027", "code_information": [ { "code": "PX-2120045027", "type": "CDM" }, { "code": "99999", "type": "CPT" }, { "code": "0272", "type": "RC" } ], "standard_charges": [ { "setting": "outpatient", "gross_charge": 4875.0, "discounted_cash": 2437.5, "minimum": 2057.25, "maximum": 2535.0, "additional_generic_notes": "Zero final payments for the item or service in the 15 months prior to posting the file.", "payers_information": [ { "payer_name": "AETNA", "plan_name": "AETNA ALL OTHER PLANS", "methodology": "percent of total billed charges", "standard_charge_dollar": 2535.0, "standard_charge_percentage": 52.0, "count": "0", "additional_payer_notes": "Zero final payments for the item or service in the 15 months prior to posting the file." }, { "payer_name": "AETNA", "plan_name": "AETNA ALL OTHER PLANS", "methodology": "percent of total billed charges", "standard_charge_dollar": 2535.0, "standard_charge_percentage": 52.0, "count": "0", "additional_payer_notes": "Zero final payments for the item or service in the 15 months prior to posting the file." }, { "payer_name": "MERITAIN HEALTH", "plan_name": "AETNA ALL OTHER PLANS", "methodology": "percent of total billed charges", "standard_charge_dollar": 2535.0, "standard_charge_percentage": 52.0, "count": "0", "additional_payer_notes": "Zero final payments for the item or service in the 15 months prior to posting the file." }, { "payer_name": "BLUE SHIELD OUT OF STATE", "plan_name": "STANFORD HEALTHCARE ALLIANCE PLAN", "methodology": "percent of total billed charges", "standard_charge_dollar": 2368.76, "standard_charge_percentage": 48.59, "count": "0", "additional_payer_notes": "Zero final payments for the item or service in the 15 months prior to posting the file." }, { "payer_name": "BLUE SHIELD", "plan_name": "STANFORD HEALTHCARE ALLIANCE PLAN", "methodology": "percent of total billed charges", "standard_charge_dollar": 2368.76, "standard_charge_percentage": 48.59, "median_amount": 68.24, "10th_percentile": 13.6, "90th_percentile": 1043.06, "count": "30" }, { "payer_name": "BLUE SHIELD", "plan_name": "STANFORD HEALTHCARE ALLIANCE PLAN", "methodology": "percent of total billed charges", "standard_charge_dollar": 2368.76, "standard_charge_percentage": 48.59, "count": "0", "additional_payer_notes": "Zero final payments for the item or service in the 15 months prior to posting the file." }, { "payer_name": "BLUE SHIELD", "plan_name": "STANFORD HEALTHCARE ALLIANCE PLAN", "methodology": "percent of total billed charges", "standard_charge_dollar": 2368.76, "standard_charge_percentage": 48.59, "count": "0", "additional_payer_notes": "Zero final payments for the item or service in the 15 months prior to posting the file." }, { "payer_name": "CIGNA", "plan_name": "CIGNA COM ALT HMO PLAN", "methodology": "percent of total billed charges", "standard_charge_dollar": 2057.25, "standard_charge_percentage": 42.2, "count": "0", "additional_payer_notes": "Zero final payments for the item or service in the 15 months prior to posting the file." }, { "payer_name": "CIGNA", "plan_name": "CIGNA COM ALT HMO PLAN", "methodology": "percent of total billed charges", "standard_charge_dollar": 2057.25, "standard_charge_percentage": 42.2, "count": "0", "additional_payer_notes": "Zero final payments for the item or service in the 15 months prior to posting the file." }, { "payer_name": "HEALTH NET", "plan_name": "HEALTHNET HMO, PPO, POS, EPO, CANOPY HEALTHNET HMO, OTHER-IN-NETWORK PLANS", "methodology": "per diem", "standard_charge_dollar": 8000.0, "standard_charge_algorithm": "Expected reimbursement is the lesser of Per diem ($8,000) for the length of stay and 70% of billed.", "count": "0", "additional_payer_notes": "Zero final payments for the item or service in the 15 months prior to posting the file." }, { "payer_name": "HEALTH NET", "plan_name": "HEALTHNET HMO, PPO, POS, EPO, CANOPY HEALTHNET HMO, OTHER-IN-NETWORK PLANS", "methodology": "per diem", "standard_charge_dollar": 8000.0, "standard_charge_algorithm": "Expected reimbursement is the lesser of Per diem ($8,000) for the length of stay and 70% of billed.", "count": "0", "additional_payer_notes": "Zero final payments for the item or service in the 15 months prior to posting the file." }, { "payer_name": "UNITED HEALTHCARE", "plan_name": "SUTTER SELECT & SUTTER HEALTH PLAN HMO PLANS", "methodology": "per diem", "standard_charge_dollar": 28538.0, "standard_charge_algorithm": "Per diem ($28,538).", "count": "0", "additional_payer_notes": "Zero final payments for the item or service in the 15 months prior to posting the file." }, { "payer_name": "UNITED HEALTHCARE", "plan_name": "SUTTER SELECT & SUTTER HEALTH PLAN HMO PLANS", "methodology": "per diem", "standard_charge_dollar": 28538.0, "standard_charge_algorithm": "Per diem ($28,538).", "count": "0", "additional_payer_notes": "Zero final payments for the item or service in the 15 months prior to posting the file." }, { "payer_name": "SUTTER", "plan_name": "SUTTER SELECT & SUTTER HEALTH PLAN HMO PLANS", "methodology": "per diem", "standard_charge_dollar": 28538.0, "standard_charge_algorithm": "Per diem ($28,538).", "count": "0", "additional_payer_notes": "Zero final payments for the item or service in the 15 months prior to posting the file." }, { "payer_name": "UNITED HEALTHCARE", "plan_name": "SUTTER SELECT & SUTTER HEALTH PLAN HMO PLANS", "methodology": "per diem", "standard_charge_dollar": 28538.0, "standard_charge_algorithm": "Per diem ($28,538).", "count": "0", "additional_payer_notes": "Zero final payments for the item or service in the 15 months prior to posting the file." }, { "payer_name": "UMR", "plan_name": "SUTTER SELECT & SUTTER HEALTH PLAN HMO PLANS", "methodology": "per diem", "standard_charge_dollar": 28538.0, "standard_charge_algorithm": "Per diem ($28,538).", "count": "0", "additional_payer_notes": "Zero final payments for the item or service in the 15 months prior to posting the file." } ] } ] }, { "description": "HC Clip Applier Gp030", "code_information": [ { "code": "PX-2120045030", "type": "CDM" }, { "code": "99999", "type": "CPT" }, { "code": "0272", "type": "RC" } ], "standard_charges": [ { "setting": "outpatient", "gross_charge": 5800.0, "discounted_cash": 2900.0, "minimum": 2447.6, "maximum": 3016.0, "additional_generic_notes": "Zero final payments for the item or service in the 15 months prior to posting the file.", "payers_information": [ { "payer_name": "AETNA", "plan_name": "AETNA ALL OTHER PLANS", "methodology": "percent of total billed charges", "standard_charge_dollar": 3016.0, "standard_charge_percentage": 52.0, "count": "0", "additional_payer_notes": "Zero final payments for the item or service in the 15 months prior to posting the file." }, { "payer_name": "AETNA", "plan_name": "AETNA ALL OTHER PLANS", "methodology": "percent of total billed charges", "standard_charge_dollar": 3016.0, "standard_charge_percentage": 52.0, "count": "0", "additional_payer_notes": "Zero final payments for the item or service in the 15 months prior to posting the file." }, { "payer_name": "MERITAIN HEALTH", "plan_name": "AETNA ALL OTHER PLANS", "methodology": "percent of total billed charges", "standard_charge_dollar": 3016.0, "standard_charge_percentage": 52.0, "count": "0", "additional_payer_notes": "Zero final payments for the item or service in the 15 months prior to posting the file." }, { "payer_name": "BLUE SHIELD OUT OF STATE", "plan_name": "STANFORD HEALTHCARE ALLIANCE PLAN", "methodology": "percent of total billed charges", "standard_charge_dollar": 2818.22, "standard_charge_percentage": 48.59, "count": "0", "additional_payer_notes": "Zero final payments for the item or service in the 15 months prior to posting the file." }, { "payer_name": "BLUE SHIELD", "plan_name": "STANFORD HEALTHCARE ALLIANCE PLAN", "methodology": "percent of total billed charges", "standard_charge_dollar": 2818.22, "standard_charge_percentage": 48.59, "median_amount": 68.24, "10th_percentile": 13.6, "90th_percentile": 1043.06, "count": "30" }, { "payer_name": "BLUE SHIELD", "plan_name": "STANFORD HEALTHCARE ALLIANCE PLAN", "methodology": "percent of total billed charges", "standard_charge_dollar": 2818.22, "standard_charge_percentage": 48.59, "count": "0", "additional_payer_notes": "Zero final payments for the item or service in the 15 months prior to posting the file." }, { "payer_name": "BLUE SHIELD", "plan_name": "STANFORD HEALTHCARE ALLIANCE PLAN", "methodology": "percent of total billed charges", "standard_charge_dollar": 2818.22, "standard_charge_percentage": 48.59, "count": "0", "additional_payer_notes": "Zero final payments for the item or service in the 15 months prior to posting the file." }, { "payer_name": "CIGNA", "plan_name": "CIGNA COM ALT HMO PLAN", "methodology": "percent of total billed charges", "standard_charge_dollar": 2447.6, "standard_charge_percentage": 42.2, "count": "0", "additional_payer_notes": "Zero final payments for the item or service in the 15 months prior to posting the file." }, { "payer_name": "CIGNA", "plan_name": "CIGNA COM ALT HMO PLAN", "methodology": "percent of total billed charges", "standard_charge_dollar": 2447.6, "standard_charge_percentage": 42.2, "count": "0", "additional_payer_notes": "Zero final payments for the item or service in the 15 months prior to posting the file." }, { "payer_name": "HEALTH NET", "plan_name": "HEALTHNET HMO, PPO, POS, EPO, CANOPY HEALTHNET HMO, OTHER-IN-NETWORK PLANS", "methodology": "per diem", "standard_charge_dollar": 8000.0, "standard_charge_algorithm": "Expected reimbursement is the lesser of Per diem ($8,000) for the length of stay and 70% of billed.", "count": "0", "additional_payer_notes": "Zero final payments for the item or service in the 15 months prior to posting the file." }, { "payer_name": "HEALTH NET", "plan_name": "HEALTHNET HMO, PPO, POS, EPO, CANOPY HEALTHNET HMO, OTHER-IN-NETWORK PLANS", "methodology": "per diem", "standard_charge_dollar": 8000.0, "standard_charge_algorithm": "Expected reimbursement is the lesser of Per diem ($8,000) for the length of stay and 70% of billed.", "count": "0", "additional_payer_notes": "Zero final payments for the item or service in the 15 months prior to posting the file." }, { "payer_name": "UNITED HEALTHCARE", "plan_name": "SUTTER SELECT & SUTTER HEALTH PLAN HMO PLANS", "methodology": "per diem", "standard_charge_dollar": 28538.0, "standard_charge_algorithm": "Per diem ($28,538).", "count": "0", "additional_payer_notes": "Zero final payments for the item or service in the 15 months prior to posting the file." }, { "payer_name": "UNITED HEALTHCARE", "plan_name": "SUTTER SELECT & SUTTER HEALTH PLAN HMO PLANS", "methodology": "per diem", "standard_charge_dollar": 28538.0, "standard_charge_algorithm": "Per diem ($28,538).", "count": "0", "additional_payer_notes": "Zero final payments for the item or service in the 15 months prior to posting the file." }, { "payer_name": "SUTTER", "plan_name": "SUTTER SELECT & SUTTER HEALTH PLAN HMO PLANS", "methodology": "per diem", "standard_charge_dollar": 28538.0, "standard_charge_algorithm": "Per diem ($28,538).", "count": "0", "additional_payer_notes": "Zero final payments for the item or service in the 15 months prior to posting the file." }, { "payer_name": "UNITED HEALTHCARE", "plan_name": "SUTTER SELECT & SUTTER HEALTH PLAN HMO PLANS", "methodology": "per diem", "standard_charge_dollar": 28538.0, "standard_charge_algorithm": "Per diem ($28,538).", "count": "0", "additional_payer_notes": "Zero final payments for the item or service in the 15 months prior to posting the file." }, { "payer_name": "UMR", "plan_name": "SUTTER SELECT & SUTTER HEALTH PLAN HMO PLANS", "methodology": "per diem", "standard_charge_dollar": 28538.0, "standard_charge_algorithm": "Per diem ($28,538).", "count": "0", "additional_payer_notes": "Zero final payments for the item or service in the 15 months prior to posting the file." } ] } ] }, { "description": "HC Clip Applier Gp033", "code_information": [ { "code": "PX-2120045033", "type": "CDM" }, { "code": "99999", "type": "CPT" }, { "code": "0272", "type": "RC" } ], "standard_charges": [ { "setting": "outpatient", "gross_charge": 6413.0, "discounted_cash": 3206.5, "minimum": 2706.29, "maximum": 3334.76, "additional_generic_notes": "Zero final payments for the item or service in the 15 months prior to posting the file.", "payers_information": [ { "payer_name": "AETNA", "plan_name": "AETNA ALL OTHER PLANS", "methodology": "percent of total billed charges", "standard_charge_dollar": 3334.76, "standard_charge_percentage": 52.0, "count": "0", "additional_payer_notes": "Zero final payments for the item or service in the 15 months prior to posting the file." }, { "payer_name": "AETNA", "plan_name": "AETNA ALL OTHER PLANS", "methodology": "percent of total billed charges", "standard_charge_dollar": 3334.76, "standard_charge_percentage": 52.0, "count": "0", "additional_payer_notes": "Zero final payments for the item or service in the 15 months prior to posting the file." }, { "payer_name": "MERITAIN HEALTH", "plan_name": "AETNA ALL OTHER PLANS", "methodology": "percent of total billed charges", "standard_charge_dollar": 3334.76, "standard_charge_percentage": 52.0, "count": "0", "additional_payer_notes": "Zero final payments for the item or service in the 15 months prior to posting the file." }, { "payer_name": "BLUE SHIELD OUT OF STATE", "plan_name": "STANFORD HEALTHCARE ALLIANCE PLAN", "methodology": "percent of total billed charges", "standard_charge_dollar": 3116.08, "standard_charge_percentage": 48.59, "count": "0", "additional_payer_notes": "Zero final payments for the item or service in the 15 months prior to posting the file." }, { "payer_name": "BLUE SHIELD", "plan_name": "STANFORD HEALTHCARE ALLIANCE PLAN", "methodology": "percent of total billed charges", "standard_charge_dollar": 3116.08, "standard_charge_percentage": 48.59, "median_amount": 68.24, "10th_percentile": 13.6, "90th_percentile": 1043.06, "count": "30" }, { "payer_name": "BLUE SHIELD", "plan_name": "STANFORD HEALTHCARE ALLIANCE PLAN", "methodology": "percent of total billed charges", "standard_charge_dollar": 3116.08, "standard_charge_percentage": 48.59, "count": "0", "additional_payer_notes": "Zero final payments for the item or service in the 15 months prior to posting the file." }, { "payer_name": "BLUE SHIELD", "plan_name": "STANFORD HEALTHCARE ALLIANCE PLAN", "methodology": "percent of total billed charges", "standard_charge_dollar": 3116.08, "standard_charge_percentage": 48.59, "count": "0", "additional_payer_notes": "Zero final payments for the item or service in the 15 months prior to posting the file." }, { "payer_name": "CIGNA", "plan_name": "CIGNA COM ALT HMO PLAN", "methodology": "percent of total billed charges", "standard_charge_dollar": 2706.29, "standard_charge_percentage": 42.2, "count": "0", "additional_payer_notes": "Zero final payments for the item or service in the 15 months prior to posting the file." }, { "payer_name": "CIGNA", "plan_name": "CIGNA COM ALT HMO PLAN", "methodology": "percent of total billed charges", "standard_charge_dollar": 2706.29, "standard_charge_percentage": 42.2, "count": "0", "additional_payer_notes": "Zero final payments for the item or service in the 15 months prior to posting the file." }, { "payer_name": "HEALTH NET", "plan_name": "HEALTHNET HMO, PPO, POS, EPO, CANOPY HEALTHNET HMO, OTHER-IN-NETWORK PLANS", "methodology": "per diem", "standard_charge_dollar": 8000.0, "standard_charge_algorithm": "Expected reimbursement is the lesser of Per diem ($8,000) for the length of stay and 70% of billed.", "count": "0", "additional_payer_notes": "Zero final payments for the item or service in the 15 months prior to posting the file." }, { "payer_name": "HEALTH NET", "plan_name": "HEALTHNET HMO, PPO, POS, EPO, CANOPY HEALTHNET HMO, OTHER-IN-NETWORK PLANS", "methodology": "per diem", "standard_charge_dollar": 8000.0, "standard_charge_algorithm": "Expected reimbursement is the lesser of Per diem ($8,000) for the length of stay and 70% of billed.", "count": "0", "additional_payer_notes": "Zero final payments for the item or service in the 15 months prior to posting the file." }, { "payer_name": "UNITED HEALTHCARE", "plan_name": "SUTTER SELECT & SUTTER HEALTH PLAN HMO PLANS", "methodology": "per diem", "standard_charge_dollar": 28538.0, "standard_charge_algorithm": "Per diem ($28,538).", "count": "0", "additional_payer_notes": "Zero final payments for the item or service in the 15 months prior to posting the file." }, { "payer_name": "UNITED HEALTHCARE", "plan_name": "SUTTER SELECT & SUTTER HEALTH PLAN HMO PLANS", "methodology": "per diem", "standard_charge_dollar": 28538.0, "standard_charge_algorithm": "Per diem ($28,538).", "count": "0", "additional_payer_notes": "Zero final payments for the item or service in the 15 months prior to posting the file." }, { "payer_name": "SUTTER", "plan_name": "SUTTER SELECT & SUTTER HEALTH PLAN HMO PLANS", "methodology": "per diem", "standard_charge_dollar": 28538.0, "standard_charge_algorithm": "Per diem ($28,538).", "count": "0", "additional_payer_notes": "Zero final payments for the item or service in the 15 months prior to posting the file." }, { "payer_name": "UNITED HEALTHCARE", "plan_name": "SUTTER SELECT & SUTTER HEALTH PLAN HMO PLANS", "methodology": "per diem", "standard_charge_dollar": 28538.0, "standard_charge_algorithm": "Per diem ($28,538).", "count": "0", "additional_payer_notes": "Zero final payments for the item or service in the 15 months prior to posting the file." }, { "payer_name": "UMR", "plan_name": "SUTTER SELECT & SUTTER HEALTH PLAN HMO PLANS", "methodology": "per diem", "standard_charge_dollar": 28538.0, "standard_charge_algorithm": "Per diem ($28,538).", "count": "0", "additional_payer_notes": "Zero final payments for the item or service in the 15 months prior to posting the file." } ] } ] }, { "description": "HC Clip Applier Gp035", "code_information": [ { "code": "PX-2120045035", "type": "CDM" }, { "code": "99999", "type": "CPT" }, { "code": "0272", "type": "RC" } ], "standard_charges": [ { "setting": "outpatient", "gross_charge": 7150.0, "discounted_cash": 3575.0, "minimum": 3017.3, "maximum": 3718.0, "additional_generic_notes": "Zero final payments for the item or service in the 15 months prior to posting the file.", "payers_information": [ { "payer_name": "AETNA", "plan_name": "AETNA ALL OTHER PLANS", "methodology": "percent of total billed charges", "standard_charge_dollar": 3718.0, "standard_charge_percentage": 52.0, "count": "0", "additional_payer_notes": "Zero final payments for the item or service in the 15 months prior to posting the file." }, { "payer_name": "AETNA", "plan_name": "AETNA ALL OTHER PLANS", "methodology": "percent of total billed charges", "standard_charge_dollar": 3718.0, "standard_charge_percentage": 52.0, "count": "0", "additional_payer_notes": "Zero final payments for the item or service in the 15 months prior to posting the file." }, { "payer_name": "MERITAIN HEALTH", "plan_name": "AETNA ALL OTHER PLANS", "methodology": "percent of total billed charges", "standard_charge_dollar": 3718.0, "standard_charge_percentage": 52.0, "count": "0", "additional_payer_notes": "Zero final payments for the item or service in the 15 months prior to posting the file." }, { "payer_name": "BLUE SHIELD OUT OF STATE", "plan_name": "STANFORD HEALTHCARE ALLIANCE PLAN", "methodology": "percent of total billed charges", "standard_charge_dollar": 3474.19, "standard_charge_percentage": 48.59, "count": "0", "additional_payer_notes": "Zero final payments for the item or service in the 15 months prior to posting the file." }, { "payer_name": "BLUE SHIELD", "plan_name": "STANFORD HEALTHCARE ALLIANCE PLAN", "methodology": "percent of total billed charges", "standard_charge_dollar": 3474.19, "standard_charge_percentage": 48.59, "median_amount": 68.24, "10th_percentile": 13.6, "90th_percentile": 1043.06, "count": "30" }, { "payer_name": "BLUE SHIELD", "plan_name": "STANFORD HEALTHCARE ALLIANCE PLAN", "methodology": "percent of total billed charges", "standard_charge_dollar": 3474.19, "standard_charge_percentage": 48.59, "count": "0", "additional_payer_notes": "Zero final payments for the item or service in the 15 months prior to posting the file." }, { "payer_name": "BLUE SHIELD", "plan_name": "STANFORD HEALTHCARE ALLIANCE PLAN", "methodology": "percent of total billed charges", "standard_charge_dollar": 3474.19, "standard_charge_percentage": 48.59, "count": "0", "additional_payer_notes": "Zero final payments for the item or service in the 15 months prior to posting the file." }, { "payer_name": "CIGNA", "plan_name": "CIGNA COM ALT HMO PLAN", "methodology": "percent of total billed charges", "standard_charge_dollar": 3017.3, "standard_charge_percentage": 42.2, "count": "0", "additional_payer_notes": "Zero final payments for the item or service in the 15 months prior to posting the file." }, { "payer_name": "CIGNA", "plan_name": "CIGNA COM ALT HMO PLAN", "methodology": "percent of total billed charges", "standard_charge_dollar": 3017.3, "standard_charge_percentage": 42.2, "count": "0", "additional_payer_notes": "Zero final payments for the item or service in the 15 months prior to posting the file." }, { "payer_name": "HEALTH NET", "plan_name": "HEALTHNET HMO, PPO, POS, EPO, CANOPY HEALTHNET HMO, OTHER-IN-NETWORK PLANS", "methodology": "per diem", "standard_charge_dollar": 8000.0, "standard_charge_algorithm": "Expected reimbursement is the lesser of Per diem ($8,000) for the length of stay and 70% of billed.", "count": "0", "additional_payer_notes": "Zero final payments for the item or service in the 15 months prior to posting the file." }, { "payer_name": "HEALTH NET", "plan_name": "HEALTHNET HMO, PPO, POS, EPO, CANOPY HEALTHNET HMO, OTHER-IN-NETWORK PLANS", "methodology": "per diem", "standard_charge_dollar": 8000.0, "standard_charge_algorithm": "Expected reimbursement is the lesser of Per diem ($8,000) for the length of stay and 70% of billed.", "count": "0", "additional_payer_notes": "Zero final payments for the item or service in the 15 months prior to posting the file." }, { "payer_name": "UNITED HEALTHCARE", "plan_name": "SUTTER SELECT & SUTTER HEALTH PLAN HMO PLANS", "methodology": "per diem", "standard_charge_dollar": 28538.0, "standard_charge_algorithm": "Per diem ($28,538).", "count": "0", "additional_payer_notes": "Zero final payments for the item or service in the 15 months prior to posting the file." }, { "payer_name": "UNITED HEALTHCARE", "plan_name": "SUTTER SELECT & SUTTER HEALTH PLAN HMO PLANS", "methodology": "per diem", "standard_charge_dollar": 28538.0, "standard_charge_algorithm": "Per diem ($28,538).", "count": "0", "additional_payer_notes": "Zero final payments for the item or service in the 15 months prior to posting the file." }, { "payer_name": "SUTTER", "plan_name": "SUTTER SELECT & SUTTER HEALTH PLAN HMO PLANS", "methodology": "per diem", "standard_charge_dollar": 28538.0, "standard_charge_algorithm": "Per diem ($28,538).", "count": "0", "additional_payer_notes": "Zero final payments for the item or service in the 15 months prior to posting the file." }, { "payer_name": "UNITED HEALTHCARE", "plan_name": "SUTTER SELECT & SUTTER HEALTH PLAN HMO PLANS", "methodology": "per diem", "standard_charge_dollar": 28538.0, "standard_charge_algorithm": "Per diem ($28,538).", "count": "0", "additional_payer_notes": "Zero final payments for the item or service in the 15 months prior to posting the file." }, { "payer_name": "UMR", "plan_name": "SUTTER SELECT & SUTTER HEALTH PLAN HMO PLANS", "methodology": "per diem", "standard_charge_dollar": 28538.0, "standard_charge_algorithm": "Per diem ($28,538).", "count": "0", "additional_payer_notes": "Zero final payments for the item or service in the 15 months prior to posting the file." } ] } ] }, { "description": "HC Clip Applier Gp037", "code_information": [ { "code": "PX-2120045037", "type": "CDM" }, { "code": "99999", "type": "CPT" }, { "code": "0272", "type": "RC" } ], "standard_charges": [ { "setting": "outpatient", "gross_charge": 8125.0, "discounted_cash": 4062.5, "minimum": 3428.75, "maximum": 4225.0, "additional_generic_notes": "Zero final payments for the item or service in the 15 months prior to posting the file.", "payers_information": [ { "payer_name": "AETNA", "plan_name": "AETNA ALL OTHER PLANS", "methodology": "percent of total billed charges", "standard_charge_dollar": 4225.0, "standard_charge_percentage": 52.0, "count": "0", "additional_payer_notes": "Zero final payments for the item or service in the 15 months prior to posting the file." }, { "payer_name": "AETNA", "plan_name": "AETNA ALL OTHER PLANS", "methodology": "percent of total billed charges", "standard_charge_dollar": 4225.0, "standard_charge_percentage": 52.0, "count": "0", "additional_payer_notes": "Zero final payments for the item or service in the 15 months prior to posting the file." }, { "payer_name": "MERITAIN HEALTH", "plan_name": "AETNA ALL OTHER PLANS", "methodology": "percent of total billed charges", "standard_charge_dollar": 4225.0, "standard_charge_percentage": 52.0, "count": "0", "additional_payer_notes": "Zero final payments for the item or service in the 15 months prior to posting the file." }, { "payer_name": "BLUE SHIELD OUT OF STATE", "plan_name": "STANFORD HEALTHCARE ALLIANCE PLAN", "methodology": "percent of total billed charges", "standard_charge_dollar": 3947.94, "standard_charge_percentage": 48.59, "count": "0", "additional_payer_notes": "Zero final payments for the item or service in the 15 months prior to posting the file." }, { "payer_name": "BLUE SHIELD", "plan_name": "STANFORD HEALTHCARE ALLIANCE PLAN", "methodology": "percent of total billed charges", "standard_charge_dollar": 3947.94, "standard_charge_percentage": 48.59, "median_amount": 68.24, "10th_percentile": 13.6, "90th_percentile": 1043.06, "count": "30" }, { "payer_name": "BLUE SHIELD", "plan_name": "STANFORD HEALTHCARE ALLIANCE PLAN", "methodology": "percent of total billed charges", "standard_charge_dollar": 3947.94, "standard_charge_percentage": 48.59, "count": "0", "additional_payer_notes": "Zero final payments for the item or service in the 15 months prior to posting the file." }, { "payer_name": "BLUE SHIELD", "plan_name": "STANFORD HEALTHCARE ALLIANCE PLAN", "methodology": "percent of total billed charges", "standard_charge_dollar": 3947.94, "standard_charge_percentage": 48.59, "count": "0", "additional_payer_notes": "Zero final payments for the item or service in the 15 months prior to posting the file." }, { "payer_name": "CIGNA", "plan_name": "CIGNA COM ALT HMO PLAN", "methodology": "percent of total billed charges", "standard_charge_dollar": 3428.75, "standard_charge_percentage": 42.2, "count": "0", "additional_payer_notes": "Zero final payments for the item or service in the 15 months prior to posting the file." }, { "payer_name": "CIGNA", "plan_name": "CIGNA COM ALT HMO PLAN", "methodology": "percent of total billed charges", "standard_charge_dollar": 3428.75, "standard_charge_percentage": 42.2, "count": "0", "additional_payer_notes": "Zero final payments for the item or service in the 15 months prior to posting the file." }, { "payer_name": "HEALTH NET", "plan_name": "HEALTHNET HMO, PPO, POS, EPO, CANOPY HEALTHNET HMO, OTHER-IN-NETWORK PLANS", "methodology": "per diem", "standard_charge_dollar": 8000.0, "standard_charge_algorithm": "Expected reimbursement is the lesser of Per diem ($8,000) for the length of stay and 70% of billed.", "count": "0", "additional_payer_notes": "Zero final payments for the item or service in the 15 months prior to posting the file." }, { "payer_name": "HEALTH NET", "plan_name": "HEALTHNET HMO, PPO, POS, EPO, CANOPY HEALTHNET HMO, OTHER-IN-NETWORK PLANS", "methodology": "per diem", "standard_charge_dollar": 8000.0, "standard_charge_algorithm": "Expected reimbursement is the lesser of Per diem ($8,000) for the length of stay and 70% of billed.", "count": "0", "additional_payer_notes": "Zero final payments for the item or service in the 15 months prior to posting the file." }, { "payer_name": "UNITED HEALTHCARE", "plan_name": "SUTTER SELECT & SUTTER HEALTH PLAN HMO PLANS", "methodology": "per diem", "standard_charge_dollar": 28538.0, "standard_charge_algorithm": "Per diem ($28,538).", "count": "0", "additional_payer_notes": "Zero final payments for the item or service in the 15 months prior to posting the file." }, { "payer_name": "UNITED HEALTHCARE", "plan_name": "SUTTER SELECT & SUTTER HEALTH PLAN HMO PLANS", "methodology": "per diem", "standard_charge_dollar": 28538.0, "standard_charge_algorithm": "Per diem ($28,538).", "count": "0", "additional_payer_notes": "Zero final payments for the item or service in the 15 months prior to posting the file." }, { "payer_name": "SUTTER", "plan_name": "SUTTER SELECT & SUTTER HEALTH PLAN HMO PLANS", "methodology": "per diem", "standard_charge_dollar": 28538.0, "standard_charge_algorithm": "Per diem ($28,538).", "count": "0", "additional_payer_notes": "Zero final payments for the item or service in the 15 months prior to posting the file." }, { "payer_name": "UNITED HEALTHCARE", "plan_name": "SUTTER SELECT & SUTTER HEALTH PLAN HMO PLANS", "methodology": "per diem", "standard_charge_dollar": 28538.0, "standard_charge_algorithm": "Per diem ($28,538).", "count": "0", "additional_payer_notes": "Zero final payments for the item or service in the 15 months prior to posting the file." }, { "payer_name": "UMR", "plan_name": "SUTTER SELECT & SUTTER HEALTH PLAN HMO PLANS", "methodology": "per diem", "standard_charge_dollar": 28538.0, "standard_charge_algorithm": "Per diem ($28,538).", "count": "0", "additional_payer_notes": "Zero final payments for the item or service in the 15 months prior to posting the file." } ] } ] }, { "description": "HC Impl Clip Hemo Gp009", "code_information": [ { "code": "PX-2120046009", "type": "CDM" }, { "code": "99999", "type": "CPT" }, { "code": "0272", "type": "RC" } ], "standard_charges": [ { "setting": "outpatient", "gross_charge": 570.0, "discounted_cash": 285.0, "minimum": 240.54, "maximum": 296.4, "additional_generic_notes": "Zero final payments for the item or service in the 15 months prior to posting the file.", "payers_information": [ { "payer_name": "AETNA", "plan_name": "AETNA ALL OTHER PLANS", "methodology": "percent of total billed charges", "standard_charge_dollar": 296.4, "standard_charge_percentage": 52.0, "count": "0", "additional_payer_notes": "Zero final payments for the item or service in the 15 months prior to posting the file." }, { "payer_name": "AETNA", "plan_name": "AETNA ALL OTHER PLANS", "methodology": "percent of total billed charges", "standard_charge_dollar": 296.4, "standard_charge_percentage": 52.0, "count": "0", "additional_payer_notes": "Zero final payments for the item or service in the 15 months prior to posting the file." }, { "payer_name": "MERITAIN HEALTH", "plan_name": "AETNA ALL OTHER PLANS", "methodology": "percent of total billed charges", "standard_charge_dollar": 296.4, "standard_charge_percentage": 52.0, "count": "0", "additional_payer_notes": "Zero final payments for the item or service in the 15 months prior to posting the file." }, { "payer_name": "BLUE SHIELD OUT OF STATE", "plan_name": "STANFORD HEALTHCARE ALLIANCE PLAN", "methodology": "percent of total billed charges", "standard_charge_dollar": 276.96, "standard_charge_percentage": 48.59, "count": "0", "additional_payer_notes": "Zero final payments for the item or service in the 15 months prior to posting the file." }, { "payer_name": "BLUE SHIELD", "plan_name": "STANFORD HEALTHCARE ALLIANCE PLAN", "methodology": "percent of total billed charges", "standard_charge_dollar": 276.96, "standard_charge_percentage": 48.59, "count": "0", "additional_payer_notes": "Zero final payments for the item or service in the 15 months prior to posting the file." }, { "payer_name": "BLUE SHIELD", "plan_name": "STANFORD HEALTHCARE ALLIANCE PLAN", "methodology": "percent of total billed charges", "standard_charge_dollar": 276.96, "standard_charge_percentage": 48.59, "count": "0", "additional_payer_notes": "Zero final payments for the item or service in the 15 months prior to posting the file." }, { "payer_name": "CIGNA", "plan_name": "CIGNA COM ALT HMO PLAN", "methodology": "percent of total billed charges", "standard_charge_dollar": 240.54, "standard_charge_percentage": 42.2, "count": "0", "additional_payer_notes": "Zero final payments for the item or service in the 15 months prior to posting the file." }, { "payer_name": "CIGNA", "plan_name": "CIGNA COM ALT HMO PLAN", "methodology": "percent of total billed charges", "standard_charge_dollar": 240.54, "standard_charge_percentage": 42.2, "count": "0", "additional_payer_notes": "Zero final payments for the item or service in the 15 months prior to posting the file." }, { "payer_name": "HEALTH NET", "plan_name": "HEALTHNET HMO, PPO, POS, EPO, CANOPY HEALTHNET HMO, OTHER-IN-NETWORK PLANS", "methodology": "per diem", "standard_charge_dollar": 8000.0, "standard_charge_algorithm": "Expected reimbursement is the lesser of Per diem ($8,000) for the length of stay and 70% of billed.", "count": "0", "additional_payer_notes": "Zero final payments for the item or service in the 15 months prior to posting the file." }, { "payer_name": "HEALTH NET", "plan_name": "HEALTHNET HMO, PPO, POS, EPO, CANOPY HEALTHNET HMO, OTHER-IN-NETWORK PLANS", "methodology": "per diem", "standard_charge_dollar": 8000.0, "standard_charge_algorithm": "Expected reimbursement is the lesser of Per diem ($8,000) for the length of stay and 70% of billed.", "count": "0", "additional_payer_notes": "Zero final payments for the item or service in the 15 months prior to posting the file." }, { "payer_name": "UNITED HEALTHCARE", "plan_name": "SUTTER SELECT & SUTTER HEALTH PLAN HMO PLANS", "methodology": "per diem", "standard_charge_dollar": 28538.0, "standard_charge_algorithm": "Per diem ($28,538).", "count": "0", "additional_payer_notes": "Zero final payments for the item or service in the 15 months prior to posting the file." }, { "payer_name": "UNITED HEALTHCARE", "plan_name": "SUTTER SELECT & SUTTER HEALTH PLAN HMO PLANS", "methodology": "per diem", "standard_charge_dollar": 28538.0, "standard_charge_algorithm": "Per diem ($28,538).", "count": "0", "additional_payer_notes": "Zero final payments for the item or service in the 15 months prior to posting the file." }, { "payer_name": "SUTTER", "plan_name": "SUTTER SELECT & SUTTER HEALTH PLAN HMO PLANS", "methodology": "per diem", "standard_charge_dollar": 28538.0, "standard_charge_algorithm": "Per diem ($28,538).", "count": "0", "additional_payer_notes": "Zero final payments for the item or service in the 15 months prior to posting the file." }, { "payer_name": "UNITED HEALTHCARE", "plan_name": "SUTTER SELECT & SUTTER HEALTH PLAN HMO PLANS", "methodology": "per diem", "standard_charge_dollar": 28538.0, "standard_charge_algorithm": "Per diem ($28,538).", "count": "0", "additional_payer_notes": "Zero final payments for the item or service in the 15 months prior to posting the file." }, { "payer_name": "UMR", "plan_name": "SUTTER SELECT & SUTTER HEALTH PLAN HMO PLANS", "methodology": "per diem", "standard_charge_dollar": 28538.0, "standard_charge_algorithm": "Per diem ($28,538).", "count": "0", "additional_payer_notes": "Zero final payments for the item or service in the 15 months prior to posting the file." } ] } ] }, { "description": "HC Impl Clip Hemo Gp010", "code_information": [ { "code": "PX-2120046010", "type": "CDM" }, { "code": "99999", "type": "CPT" }, { "code": "0272", "type": "RC" } ], "standard_charges": [ { "setting": "outpatient", "gross_charge": 665.0, "discounted_cash": 332.5, "minimum": 280.63, "maximum": 345.8, "additional_generic_notes": "Zero final payments for the item or service in the 15 months prior to posting the file.", "payers_information": [ { "payer_name": "AETNA", "plan_name": "AETNA ALL OTHER PLANS", "methodology": "percent of total billed charges", "standard_charge_dollar": 345.8, "standard_charge_percentage": 52.0, "count": "0", "additional_payer_notes": "Zero final payments for the item or service in the 15 months prior to posting the file." }, { "payer_name": "AETNA", "plan_name": "AETNA ALL OTHER PLANS", "methodology": "percent of total billed charges", "standard_charge_dollar": 345.8, "standard_charge_percentage": 52.0, "count": "0", "additional_payer_notes": "Zero final payments for the item or service in the 15 months prior to posting the file." }, { "payer_name": "MERITAIN HEALTH", "plan_name": "AETNA ALL OTHER PLANS", "methodology": "percent of total billed charges", "standard_charge_dollar": 345.8, "standard_charge_percentage": 52.0, "count": "0", "additional_payer_notes": "Zero final payments for the item or service in the 15 months prior to posting the file." }, { "payer_name": "BLUE SHIELD OUT OF STATE", "plan_name": "STANFORD HEALTHCARE ALLIANCE PLAN", "methodology": "percent of total billed charges", "standard_charge_dollar": 323.12, "standard_charge_percentage": 48.59, "count": "0", "additional_payer_notes": "Zero final payments for the item or service in the 15 months prior to posting the file." }, { "payer_name": "BLUE SHIELD", "plan_name": "STANFORD HEALTHCARE ALLIANCE PLAN", "methodology": "percent of total billed charges", "standard_charge_dollar": 323.12, "standard_charge_percentage": 48.59, "count": "0", "additional_payer_notes": "Zero final payments for the item or service in the 15 months prior to posting the file." }, { "payer_name": "BLUE SHIELD", "plan_name": "STANFORD HEALTHCARE ALLIANCE PLAN", "methodology": "percent of total billed charges", "standard_charge_dollar": 323.12, "standard_charge_percentage": 48.59, "count": "0", "additional_payer_notes": "Zero final payments for the item or service in the 15 months prior to posting the file." }, { "payer_name": "CIGNA", "plan_name": "CIGNA COM ALT HMO PLAN", "methodology": "percent of total billed charges", "standard_charge_dollar": 280.63, "standard_charge_percentage": 42.2, "count": "0", "additional_payer_notes": "Zero final payments for the item or service in the 15 months prior to posting the file." }, { "payer_name": "CIGNA", "plan_name": "CIGNA COM ALT HMO PLAN", "methodology": "percent of total billed charges", "standard_charge_dollar": 280.63, "standard_charge_percentage": 42.2, "count": "0", "additional_payer_notes": "Zero final payments for the item or service in the 15 months prior to posting the file." }, { "payer_name": "HEALTH NET", "plan_name": "HEALTHNET HMO, PPO, POS, EPO, CANOPY HEALTHNET HMO, OTHER-IN-NETWORK PLANS", "methodology": "per diem", "standard_charge_dollar": 8000.0, "standard_charge_algorithm": "Expected reimbursement is the lesser of Per diem ($8,000) for the length of stay and 70% of billed.", "count": "0", "additional_payer_notes": "Zero final payments for the item or service in the 15 months prior to posting the file." }, { "payer_name": "HEALTH NET", "plan_name": "HEALTHNET HMO, PPO, POS, EPO, CANOPY HEALTHNET HMO, OTHER-IN-NETWORK PLANS", "methodology": "per diem", "standard_charge_dollar": 8000.0, "standard_charge_algorithm": "Expected reimbursement is the lesser of Per diem ($8,000) for the length of stay and 70% of billed.", "count": "0", "additional_payer_notes": "Zero final payments for the item or service in the 15 months prior to posting the file." }, { "payer_name": "UNITED HEALTHCARE", "plan_name": "SUTTER SELECT & SUTTER HEALTH PLAN HMO PLANS", "methodology": "per diem", "standard_charge_dollar": 28538.0, "standard_charge_algorithm": "Per diem ($28,538).", "count": "0", "additional_payer_notes": "Zero final payments for the item or service in the 15 months prior to posting the file." }, { "payer_name": "UNITED HEALTHCARE", "plan_name": "SUTTER SELECT & SUTTER HEALTH PLAN HMO PLANS", "methodology": "per diem", "standard_charge_dollar": 28538.0, "standard_charge_algorithm": "Per diem ($28,538).", "count": "0", "additional_payer_notes": "Zero final payments for the item or service in the 15 months prior to posting the file." }, { "payer_name": "SUTTER", "plan_name": "SUTTER SELECT & SUTTER HEALTH PLAN HMO PLANS", "methodology": "per diem", "standard_charge_dollar": 28538.0, "standard_charge_algorithm": "Per diem ($28,538).", "count": "0", "additional_payer_notes": "Zero final payments for the item or service in the 15 months prior to posting the file." }, { "payer_name": "UNITED HEALTHCARE", "plan_name": "SUTTER SELECT & SUTTER HEALTH PLAN HMO PLANS", "methodology": "per diem", "standard_charge_dollar": 28538.0, "standard_charge_algorithm": "Per diem ($28,538).", "count": "0", "additional_payer_notes": "Zero final payments for the item or service in the 15 months prior to posting the file." }, { "payer_name": "UMR", "plan_name": "SUTTER SELECT & SUTTER HEALTH PLAN HMO PLANS", "methodology": "per diem", "standard_charge_dollar": 28538.0, "standard_charge_algorithm": "Per diem ($28,538).", "count": "0", "additional_payer_notes": "Zero final payments for the item or service in the 15 months prior to posting the file." } ] } ] }, { "description": "HC Clip Lap Gp019", "code_information": [ { "code": "PX-2120047019", "type": "CDM" }, { "code": "99999", "type": "CPT" }, { "code": "0272", "type": "RC" } ], "standard_charges": [ { "setting": "outpatient", "gross_charge": 2125.0, "discounted_cash": 1062.5, "minimum": 896.75, "maximum": 1105.0, "additional_generic_notes": "Zero final payments for the item or service in the 15 months prior to posting the file.", "payers_information": [ { "payer_name": "AETNA", "plan_name": "AETNA ALL OTHER PLANS", "methodology": "percent of total billed charges", "standard_charge_dollar": 1105.0, "standard_charge_percentage": 52.0, "count": "0", "additional_payer_notes": "Zero final payments for the item or service in the 15 months prior to posting the file." }, { "payer_name": "AETNA", "plan_name": "AETNA ALL OTHER PLANS", "methodology": "percent of total billed charges", "standard_charge_dollar": 1105.0, "standard_charge_percentage": 52.0, "count": "0", "additional_payer_notes": "Zero final payments for the item or service in the 15 months prior to posting the file." }, { "payer_name": "MERITAIN HEALTH", "plan_name": "AETNA ALL OTHER PLANS", "methodology": "percent of total billed charges", "standard_charge_dollar": 1105.0, "standard_charge_percentage": 52.0, "count": "0", "additional_payer_notes": "Zero final payments for the item or service in the 15 months prior to posting the file." }, { "payer_name": "BLUE SHIELD OUT OF STATE", "plan_name": "STANFORD HEALTHCARE ALLIANCE PLAN", "methodology": "percent of total billed charges", "standard_charge_dollar": 1032.54, "standard_charge_percentage": 48.59, "count": "0", "additional_payer_notes": "Zero final payments for the item or service in the 15 months prior to posting the file." }, { "payer_name": "BLUE SHIELD", "plan_name": "STANFORD HEALTHCARE ALLIANCE PLAN", "methodology": "percent of total billed charges", "standard_charge_dollar": 1032.54, "standard_charge_percentage": 48.59, "median_amount": 68.24, "10th_percentile": 13.6, "90th_percentile": 1043.06, "count": "30" }, { "payer_name": "BLUE SHIELD", "plan_name": "STANFORD HEALTHCARE ALLIANCE PLAN", "methodology": "percent of total billed charges", "standard_charge_dollar": 1032.54, "standard_charge_percentage": 48.59, "count": "0", "additional_payer_notes": "Zero final payments for the item or service in the 15 months prior to posting the file." }, { "payer_name": "BLUE SHIELD", "plan_name": "STANFORD HEALTHCARE ALLIANCE PLAN", "methodology": "percent of total billed charges", "standard_charge_dollar": 1032.54, "standard_charge_percentage": 48.59, "count": "0", "additional_payer_notes": "Zero final payments for the item or service in the 15 months prior to posting the file." }, { "payer_name": "CIGNA", "plan_name": "CIGNA COM ALT HMO PLAN", "methodology": "percent of total billed charges", "standard_charge_dollar": 896.75, "standard_charge_percentage": 42.2, "count": "0", "additional_payer_notes": "Zero final payments for the item or service in the 15 months prior to posting the file." }, { "payer_name": "CIGNA", "plan_name": "CIGNA COM ALT HMO PLAN", "methodology": "percent of total billed charges", "standard_charge_dollar": 896.75, "standard_charge_percentage": 42.2, "count": "0", "additional_payer_notes": "Zero final payments for the item or service in the 15 months prior to posting the file." }, { "payer_name": "HEALTH NET", "plan_name": "HEALTHNET HMO, PPO, POS, EPO, CANOPY HEALTHNET HMO, OTHER-IN-NETWORK PLANS", "methodology": "per diem", "standard_charge_dollar": 8000.0, "standard_charge_algorithm": "Expected reimbursement is the lesser of Per diem ($8,000) for the length of stay and 70% of billed.", "count": "0", "additional_payer_notes": "Zero final payments for the item or service in the 15 months prior to posting the file." }, { "payer_name": "HEALTH NET", "plan_name": "HEALTHNET HMO, PPO, POS, EPO, CANOPY HEALTHNET HMO, OTHER-IN-NETWORK PLANS", "methodology": "per diem", "standard_charge_dollar": 8000.0, "standard_charge_algorithm": "Expected reimbursement is the lesser of Per diem ($8,000) for the length of stay and 70% of billed.", "count": "0", "additional_payer_notes": "Zero final payments for the item or service in the 15 months prior to posting the file." }, { "payer_name": "UNITED HEALTHCARE", "plan_name": "SUTTER SELECT & SUTTER HEALTH PLAN HMO PLANS", "methodology": "per diem", "standard_charge_dollar": 28538.0, "standard_charge_algorithm": "Per diem ($28,538).", "count": "0", "additional_payer_notes": "Zero final payments for the item or service in the 15 months prior to posting the file." }, { "payer_name": "UNITED HEALTHCARE", "plan_name": "SUTTER SELECT & SUTTER HEALTH PLAN HMO PLANS", "methodology": "per diem", "standard_charge_dollar": 28538.0, "standard_charge_algorithm": "Per diem ($28,538).", "count": "0", "additional_payer_notes": "Zero final payments for the item or service in the 15 months prior to posting the file." }, { "payer_name": "SUTTER", "plan_name": "SUTTER SELECT & SUTTER HEALTH PLAN HMO PLANS", "methodology": "per diem", "standard_charge_dollar": 28538.0, "standard_charge_algorithm": "Per diem ($28,538).", "count": "0", "additional_payer_notes": "Zero final payments for the item or service in the 15 months prior to posting the file." }, { "payer_name": "UNITED HEALTHCARE", "plan_name": "SUTTER SELECT & SUTTER HEALTH PLAN HMO PLANS", "methodology": "per diem", "standard_charge_dollar": 28538.0, "standard_charge_algorithm": "Per diem ($28,538).", "count": "0", "additional_payer_notes": "Zero final payments for the item or service in the 15 months prior to posting the file." }, { "payer_name": "UMR", "plan_name": "SUTTER SELECT & SUTTER HEALTH PLAN HMO PLANS", "methodology": "per diem", "standard_charge_dollar": 28538.0, "standard_charge_algorithm": "Per diem ($28,538).", "count": "0", "additional_payer_notes": "Zero final payments for the item or service in the 15 months prior to posting the file." } ] } ] }, { "description": "HC Impl Clip Liga Gp005", "code_information": [ { "code": "PX-2120048005", "type": "CDM" }, { "code": "99999", "type": "CPT" }, { "code": "0272", "type": "RC" } ], "standard_charges": [ { "setting": "outpatient", "gross_charge": 195.0, "discounted_cash": 97.5, "minimum": 82.29, "maximum": 101.4, "additional_generic_notes": "Zero final payments for the item or service in the 15 months prior to posting the file.", "payers_information": [ { "payer_name": "AETNA", "plan_name": "AETNA ALL OTHER PLANS", "methodology": "percent of total billed charges", "standard_charge_dollar": 101.4, "standard_charge_percentage": 52.0, "count": "0", "additional_payer_notes": "Zero final payments for the item or service in the 15 months prior to posting the file." }, { "payer_name": "AETNA", "plan_name": "AETNA ALL OTHER PLANS", "methodology": "percent of total billed charges", "standard_charge_dollar": 101.4, "standard_charge_percentage": 52.0, "count": "0", "additional_payer_notes": "Zero final payments for the item or service in the 15 months prior to posting the file." }, { "payer_name": "MERITAIN HEALTH", "plan_name": "AETNA ALL OTHER PLANS", "methodology": "percent of total billed charges", "standard_charge_dollar": 101.4, "standard_charge_percentage": 52.0, "count": "0", "additional_payer_notes": "Zero final payments for the item or service in the 15 months prior to posting the file." }, { "payer_name": "BLUE SHIELD OUT OF STATE", "plan_name": "STANFORD HEALTHCARE ALLIANCE PLAN", "methodology": "percent of total billed charges", "standard_charge_dollar": 94.75, "standard_charge_percentage": 48.59, "count": "0", "additional_payer_notes": "Zero final payments for the item or service in the 15 months prior to posting the file." }, { "payer_name": "BLUE SHIELD", "plan_name": "STANFORD HEALTHCARE ALLIANCE PLAN", "methodology": "percent of total billed charges", "standard_charge_dollar": 94.75, "standard_charge_percentage": 48.59, "count": "0", "additional_payer_notes": "Zero final payments for the item or service in the 15 months prior to posting the file." }, { "payer_name": "BLUE SHIELD", "plan_name": "STANFORD HEALTHCARE ALLIANCE PLAN", "methodology": "percent of total billed charges", "standard_charge_dollar": 94.75, "standard_charge_percentage": 48.59, "count": "0", "additional_payer_notes": "Zero final payments for the item or service in the 15 months prior to posting the file." }, { "payer_name": "CIGNA", "plan_name": "CIGNA COM ALT HMO PLAN", "methodology": "percent of total billed charges", "standard_charge_dollar": 82.29, "standard_charge_percentage": 42.2, "count": "0", "additional_payer_notes": "Zero final payments for the item or service in the 15 months prior to posting the file." }, { "payer_name": "CIGNA", "plan_name": "CIGNA COM ALT HMO PLAN", "methodology": "percent of total billed charges", "standard_charge_dollar": 82.29, "standard_charge_percentage": 42.2, "count": "0", "additional_payer_notes": "Zero final payments for the item or service in the 15 months prior to posting the file." }, { "payer_name": "HEALTH NET", "plan_name": "HEALTHNET HMO, PPO, POS, EPO, CANOPY HEALTHNET HMO, OTHER-IN-NETWORK PLANS", "methodology": "per diem", "standard_charge_dollar": 8000.0, "standard_charge_algorithm": "Expected reimbursement is the lesser of Per diem ($8,000) for the length of stay and 70% of billed.", "count": "0", "additional_payer_notes": "Zero final payments for the item or service in the 15 months prior to posting the file." }, { "payer_name": "HEALTH NET", "plan_name": "HEALTHNET HMO, PPO, POS, EPO, CANOPY HEALTHNET HMO, OTHER-IN-NETWORK PLANS", "methodology": "per diem", "standard_charge_dollar": 8000.0, "standard_charge_algorithm": "Expected reimbursement is the lesser of Per diem ($8,000) for the length of stay and 70% of billed.", "count": "0", "additional_payer_notes": "Zero final payments for the item or service in the 15 months prior to posting the file." }, { "payer_name": "UNITED HEALTHCARE", "plan_name": "SUTTER SELECT & SUTTER HEALTH PLAN HMO PLANS", "methodology": "per diem", "standard_charge_dollar": 28538.0, "standard_charge_algorithm": "Per diem ($28,538).", "count": "0", "additional_payer_notes": "Zero final payments for the item or service in the 15 months prior to posting the file." }, { "payer_name": "UNITED HEALTHCARE", "plan_name": "SUTTER SELECT & SUTTER HEALTH PLAN HMO PLANS", "methodology": "per diem", "standard_charge_dollar": 28538.0, "standard_charge_algorithm": "Per diem ($28,538).", "count": "0", "additional_payer_notes": "Zero final payments for the item or service in the 15 months prior to posting the file." }, { "payer_name": "SUTTER", "plan_name": "SUTTER SELECT & SUTTER HEALTH PLAN HMO PLANS", "methodology": "per diem", "standard_charge_dollar": 28538.0, "standard_charge_algorithm": "Per diem ($28,538).", "count": "0", "additional_payer_notes": "Zero final payments for the item or service in the 15 months prior to posting the file." }, { "payer_name": "UNITED HEALTHCARE", "plan_name": "SUTTER SELECT & SUTTER HEALTH PLAN HMO PLANS", "methodology": "per diem", "standard_charge_dollar": 28538.0, "standard_charge_algorithm": "Per diem ($28,538).", "count": "0", "additional_payer_notes": "Zero final payments for the item or service in the 15 months prior to posting the file." }, { "payer_name": "UMR", "plan_name": "SUTTER SELECT & SUTTER HEALTH PLAN HMO PLANS", "methodology": "per diem", "standard_charge_dollar": 28538.0, "standard_charge_algorithm": "Per diem ($28,538).", "count": "0", "additional_payer_notes": "Zero final payments for the item or service in the 15 months prior to posting the file." } ] } ] }, { "description": "HC Clip Spring Gp002", "code_information": [ { "code": "PX-2120049002", "type": "CDM" }, { "code": "99999", "type": "CPT" }, { "code": "0272", "type": "RC" } ], "standard_charges": [ { "setting": "outpatient", "gross_charge": 50.0, "discounted_cash": 25.0, "minimum": 21.1, "maximum": 26.0, "additional_generic_notes": "Zero final payments for the item or service in the 15 months prior to posting the file.", "payers_information": [ { "payer_name": "AETNA", "plan_name": "AETNA ALL OTHER PLANS", "methodology": "percent of total billed charges", "standard_charge_dollar": 26.0, "standard_charge_percentage": 52.0, "count": "0", "additional_payer_notes": "Zero final payments for the item or service in the 15 months prior to posting the file." }, { "payer_name": "AETNA", "plan_name": "AETNA ALL OTHER PLANS", "methodology": "percent of total billed charges", "standard_charge_dollar": 26.0, "standard_charge_percentage": 52.0, "count": "0", "additional_payer_notes": "Zero final payments for the item or service in the 15 months prior to posting the file." }, { "payer_name": "MERITAIN HEALTH", "plan_name": "AETNA ALL OTHER PLANS", "methodology": "percent of total billed charges", "standard_charge_dollar": 26.0, "standard_charge_percentage": 52.0, "count": "0", "additional_payer_notes": "Zero final payments for the item or service in the 15 months prior to posting the file." }, { "payer_name": "BLUE SHIELD OUT OF STATE", "plan_name": "STANFORD HEALTHCARE ALLIANCE PLAN", "methodology": "percent of total billed charges", "standard_charge_dollar": 24.3, "standard_charge_percentage": 48.59, "count": "0", "additional_payer_notes": "Zero final payments for the item or service in the 15 months prior to posting the file." }, { "payer_name": "BLUE SHIELD", "plan_name": "STANFORD HEALTHCARE ALLIANCE PLAN", "methodology": "percent of total billed charges", "standard_charge_dollar": 24.3, "standard_charge_percentage": 48.59, "count": "0", "additional_payer_notes": "Zero final payments for the item or service in the 15 months prior to posting the file." }, { "payer_name": "BLUE SHIELD", "plan_name": "STANFORD HEALTHCARE ALLIANCE PLAN", "methodology": "percent of total billed charges", "standard_charge_dollar": 24.3, "standard_charge_percentage": 48.59, "count": "0", "additional_payer_notes": "Zero final payments for the item or service in the 15 months prior to posting the file." }, { "payer_name": "CIGNA", "plan_name": "CIGNA COM ALT HMO PLAN", "methodology": "percent of total billed charges", "standard_charge_dollar": 21.1, "standard_charge_percentage": 42.2, "count": "0", "additional_payer_notes": "Zero final payments for the item or service in the 15 months prior to posting the file." }, { "payer_name": "CIGNA", "plan_name": "CIGNA COM ALT HMO PLAN", "methodology": "percent of total billed charges", "standard_charge_dollar": 21.1, "standard_charge_percentage": 42.2, "count": "0", "additional_payer_notes": "Zero final payments for the item or service in the 15 months prior to posting the file." }, { "payer_name": "HEALTH NET", "plan_name": "HEALTHNET HMO, PPO, POS, EPO, CANOPY HEALTHNET HMO, OTHER-IN-NETWORK PLANS", "methodology": "per diem", "standard_charge_dollar": 8000.0, "standard_charge_algorithm": "Expected reimbursement is the lesser of Per diem ($8,000) for the length of stay and 70% of billed.", "count": "0", "additional_payer_notes": "Zero final payments for the item or service in the 15 months prior to posting the file." }, { "payer_name": "HEALTH NET", "plan_name": "HEALTHNET HMO, PPO, POS, EPO, CANOPY HEALTHNET HMO, OTHER-IN-NETWORK PLANS", "methodology": "per diem", "standard_charge_dollar": 8000.0, "standard_charge_algorithm": "Expected reimbursement is the lesser of Per diem ($8,000) for the length of stay and 70% of billed.", "count": "0", "additional_payer_notes": "Zero final payments for the item or service in the 15 months prior to posting the file." }, { "payer_name": "UNITED HEALTHCARE", "plan_name": "SUTTER SELECT & SUTTER HEALTH PLAN HMO PLANS", "methodology": "per diem", "standard_charge_dollar": 28538.0, "standard_charge_algorithm": "Per diem ($28,538).", "count": "0", "additional_payer_notes": "Zero final payments for the item or service in the 15 months prior to posting the file." }, { "payer_name": "UNITED HEALTHCARE", "plan_name": "SUTTER SELECT & SUTTER HEALTH PLAN HMO PLANS", "methodology": "per diem", "standard_charge_dollar": 28538.0, "standard_charge_algorithm": "Per diem ($28,538).", "count": "0", "additional_payer_notes": "Zero final payments for the item or service in the 15 months prior to posting the file." }, { "payer_name": "SUTTER", "plan_name": "SUTTER SELECT & SUTTER HEALTH PLAN HMO PLANS", "methodology": "per diem", "standard_charge_dollar": 28538.0, "standard_charge_algorithm": "Per diem ($28,538).", "count": "0", "additional_payer_notes": "Zero final payments for the item or service in the 15 months prior to posting the file." }, { "payer_name": "UNITED HEALTHCARE", "plan_name": "SUTTER SELECT & SUTTER HEALTH PLAN HMO PLANS", "methodology": "per diem", "standard_charge_dollar": 28538.0, "standard_charge_algorithm": "Per diem ($28,538).", "count": "0", "additional_payer_notes": "Zero final payments for the item or service in the 15 months prior to posting the file." }, { "payer_name": "UMR", "plan_name": "SUTTER SELECT & SUTTER HEALTH PLAN HMO PLANS", "methodology": "per diem", "standard_charge_dollar": 28538.0, "standard_charge_algorithm": "Per diem ($28,538).", "count": "0", "additional_payer_notes": "Zero final payments for the item or service in the 15 months prior to posting the file." } ] } ] }, { "description": "HC Clip Spring Gp009", "code_information": [ { "code": "PX-2120049009", "type": "CDM" }, { "code": "99999", "type": "CPT" }, { "code": "0272", "type": "RC" } ], "standard_charges": [ { "setting": "outpatient", "gross_charge": 570.0, "discounted_cash": 285.0, "minimum": 240.54, "maximum": 296.4, "additional_generic_notes": "Zero final payments for the item or service in the 15 months prior to posting the file.", "payers_information": [ { "payer_name": "AETNA", "plan_name": "AETNA ALL OTHER PLANS", "methodology": "percent of total billed charges", "standard_charge_dollar": 296.4, "standard_charge_percentage": 52.0, "count": "0", "additional_payer_notes": "Zero final payments for the item or service in the 15 months prior to posting the file." }, { "payer_name": "AETNA", "plan_name": "AETNA ALL OTHER PLANS", "methodology": "percent of total billed charges", "standard_charge_dollar": 296.4, "standard_charge_percentage": 52.0, "count": "0", "additional_payer_notes": "Zero final payments for the item or service in the 15 months prior to posting the file." }, { "payer_name": "MERITAIN HEALTH", "plan_name": "AETNA ALL OTHER PLANS", "methodology": "percent of total billed charges", "standard_charge_dollar": 296.4, "standard_charge_percentage": 52.0, "count": "0", "additional_payer_notes": "Zero final payments for the item or service in the 15 months prior to posting the file." }, { "payer_name": "BLUE SHIELD OUT OF STATE", "plan_name": "STANFORD HEALTHCARE ALLIANCE PLAN", "methodology": "percent of total billed charges", "standard_charge_dollar": 276.96, "standard_charge_percentage": 48.59, "count": "0", "additional_payer_notes": "Zero final payments for the item or service in the 15 months prior to posting the file." }, { "payer_name": "BLUE SHIELD", "plan_name": "STANFORD HEALTHCARE ALLIANCE PLAN", "methodology": "percent of total billed charges", "standard_charge_dollar": 276.96, "standard_charge_percentage": 48.59, "count": "0", "additional_payer_notes": "Zero final payments for the item or service in the 15 months prior to posting the file." }, { "payer_name": "BLUE SHIELD", "plan_name": "STANFORD HEALTHCARE ALLIANCE PLAN", "methodology": "percent of total billed charges", "standard_charge_dollar": 276.96, "standard_charge_percentage": 48.59, "count": "0", "additional_payer_notes": "Zero final payments for the item or service in the 15 months prior to posting the file." }, { "payer_name": "CIGNA", "plan_name": "CIGNA COM ALT HMO PLAN", "methodology": "percent of total billed charges", "standard_charge_dollar": 240.54, "standard_charge_percentage": 42.2, "count": "0", "additional_payer_notes": "Zero final payments for the item or service in the 15 months prior to posting the file." }, { "payer_name": "CIGNA", "plan_name": "CIGNA COM ALT HMO PLAN", "methodology": "percent of total billed charges", "standard_charge_dollar": 240.54, "standard_charge_percentage": 42.2, "count": "0", "additional_payer_notes": "Zero final payments for the item or service in the 15 months prior to posting the file." }, { "payer_name": "HEALTH NET", "plan_name": "HEALTHNET HMO, PPO, POS, EPO, CANOPY HEALTHNET HMO, OTHER-IN-NETWORK PLANS", "methodology": "per diem", "standard_charge_dollar": 8000.0, "standard_charge_algorithm": "Expected reimbursement is the lesser of Per diem ($8,000) for the length of stay and 70% of billed.", "count": "0", "additional_payer_notes": "Zero final payments for the item or service in the 15 months prior to posting the file." }, { "payer_name": "HEALTH NET", "plan_name": "HEALTHNET HMO, PPO, POS, EPO, CANOPY HEALTHNET HMO, OTHER-IN-NETWORK PLANS", "methodology": "per diem", "standard_charge_dollar": 8000.0, "standard_charge_algorithm": "Expected reimbursement is the lesser of Per diem ($8,000) for the length of stay and 70% of billed.", "count": "0", "additional_payer_notes": "Zero final payments for the item or service in the 15 months prior to posting the file." }, { "payer_name": "UNITED HEALTHCARE", "plan_name": "SUTTER SELECT & SUTTER HEALTH PLAN HMO PLANS", "methodology": "per diem", "standard_charge_dollar": 28538.0, "standard_charge_algorithm": "Per diem ($28,538).", "count": "0", "additional_payer_notes": "Zero final payments for the item or service in the 15 months prior to posting the file." }, { "payer_name": "UNITED HEALTHCARE", "plan_name": "SUTTER SELECT & SUTTER HEALTH PLAN HMO PLANS", "methodology": "per diem", "standard_charge_dollar": 28538.0, "standard_charge_algorithm": "Per diem ($28,538).", "count": "0", "additional_payer_notes": "Zero final payments for the item or service in the 15 months prior to posting the file." }, { "payer_name": "SUTTER", "plan_name": "SUTTER SELECT & SUTTER HEALTH PLAN HMO PLANS", "methodology": "per diem", "standard_charge_dollar": 28538.0, "standard_charge_algorithm": "Per diem ($28,538).", "count": "0", "additional_payer_notes": "Zero final payments for the item or service in the 15 months prior to posting the file." }, { "payer_name": "UNITED HEALTHCARE", "plan_name": "SUTTER SELECT & SUTTER HEALTH PLAN HMO PLANS", "methodology": "per diem", "standard_charge_dollar": 28538.0, "standard_charge_algorithm": "Per diem ($28,538).", "count": "0", "additional_payer_notes": "Zero final payments for the item or service in the 15 months prior to posting the file." }, { "payer_name": "UMR", "plan_name": "SUTTER SELECT & SUTTER HEALTH PLAN HMO PLANS", "methodology": "per diem", "standard_charge_dollar": 28538.0, "standard_charge_algorithm": "Per diem ($28,538).", "count": "0", "additional_payer_notes": "Zero final payments for the item or service in the 15 months prior to posting the file." } ] } ] }, { "description": "HC Clip Spring Gp014", "code_information": [ { "code": "PX-2120049014", "type": "CDM" }, { "code": "99999", "type": "CPT" }, { "code": "0272", "type": "RC" } ], "standard_charges": [ { "setting": "outpatient", "gross_charge": 1080.0, "discounted_cash": 540.0, "minimum": 455.76, "maximum": 561.6, "additional_generic_notes": "Zero final payments for the item or service in the 15 months prior to posting the file.", "payers_information": [ { "payer_name": "AETNA", "plan_name": "AETNA ALL OTHER PLANS", "methodology": "percent of total billed charges", "standard_charge_dollar": 561.6, "standard_charge_percentage": 52.0, "count": "0", "additional_payer_notes": "Zero final payments for the item or service in the 15 months prior to posting the file." }, { "payer_name": "AETNA", "plan_name": "AETNA ALL OTHER PLANS", "methodology": "percent of total billed charges", "standard_charge_dollar": 561.6, "standard_charge_percentage": 52.0, "count": "0", "additional_payer_notes": "Zero final payments for the item or service in the 15 months prior to posting the file." }, { "payer_name": "MERITAIN HEALTH", "plan_name": "AETNA ALL OTHER PLANS", "methodology": "percent of total billed charges", "standard_charge_dollar": 561.6, "standard_charge_percentage": 52.0, "count": "0", "additional_payer_notes": "Zero final payments for the item or service in the 15 months prior to posting the file." }, { "payer_name": "BLUE SHIELD OUT OF STATE", "plan_name": "STANFORD HEALTHCARE ALLIANCE PLAN", "methodology": "percent of total billed charges", "standard_charge_dollar": 524.77, "standard_charge_percentage": 48.59, "count": "0", "additional_payer_notes": "Zero final payments for the item or service in the 15 months prior to posting the file." }, { "payer_name": "BLUE SHIELD", "plan_name": "STANFORD HEALTHCARE ALLIANCE PLAN", "methodology": "percent of total billed charges", "standard_charge_dollar": 524.77, "standard_charge_percentage": 48.59, "median_amount": 68.24, "10th_percentile": 13.6, "90th_percentile": 1043.06, "count": "30" }, { "payer_name": "BLUE SHIELD", "plan_name": "STANFORD HEALTHCARE ALLIANCE PLAN", "methodology": "percent of total billed charges", "standard_charge_dollar": 524.77, "standard_charge_percentage": 48.59, "count": "0", "additional_payer_notes": "Zero final payments for the item or service in the 15 months prior to posting the file." }, { "payer_name": "BLUE SHIELD", "plan_name": "STANFORD HEALTHCARE ALLIANCE PLAN", "methodology": "percent of total billed charges", "standard_charge_dollar": 524.77, "standard_charge_percentage": 48.59, "count": "0", "additional_payer_notes": "Zero final payments for the item or service in the 15 months prior to posting the file." }, { "payer_name": "CIGNA", "plan_name": "CIGNA COM ALT HMO PLAN", "methodology": "percent of total billed charges", "standard_charge_dollar": 455.76, "standard_charge_percentage": 42.2, "count": "0", "additional_payer_notes": "Zero final payments for the item or service in the 15 months prior to posting the file." }, { "payer_name": "CIGNA", "plan_name": "CIGNA COM ALT HMO PLAN", "methodology": "percent of total billed charges", "standard_charge_dollar": 455.76, "standard_charge_percentage": 42.2, "count": "0", "additional_payer_notes": "Zero final payments for the item or service in the 15 months prior to posting the file." }, { "payer_name": "HEALTH NET", "plan_name": "HEALTHNET HMO, PPO, POS, EPO, CANOPY HEALTHNET HMO, OTHER-IN-NETWORK PLANS", "methodology": "per diem", "standard_charge_dollar": 8000.0, "standard_charge_algorithm": "Expected reimbursement is the lesser of Per diem ($8,000) for the length of stay and 70% of billed.", "count": "0", "additional_payer_notes": "Zero final payments for the item or service in the 15 months prior to posting the file." }, { "payer_name": "HEALTH NET", "plan_name": "HEALTHNET HMO, PPO, POS, EPO, CANOPY HEALTHNET HMO, OTHER-IN-NETWORK PLANS", "methodology": "per diem", "standard_charge_dollar": 8000.0, "standard_charge_algorithm": "Expected reimbursement is the lesser of Per diem ($8,000) for the length of stay and 70% of billed.", "count": "0", "additional_payer_notes": "Zero final payments for the item or service in the 15 months prior to posting the file." }, { "payer_name": "UNITED HEALTHCARE", "plan_name": "SUTTER SELECT & SUTTER HEALTH PLAN HMO PLANS", "methodology": "per diem", "standard_charge_dollar": 28538.0, "standard_charge_algorithm": "Per diem ($28,538).", "count": "0", "additional_payer_notes": "Zero final payments for the item or service in the 15 months prior to posting the file." }, { "payer_name": "UNITED HEALTHCARE", "plan_name": "SUTTER SELECT & SUTTER HEALTH PLAN HMO PLANS", "methodology": "per diem", "standard_charge_dollar": 28538.0, "standard_charge_algorithm": "Per diem ($28,538).", "count": "0", "additional_payer_notes": "Zero final payments for the item or service in the 15 months prior to posting the file." }, { "payer_name": "SUTTER", "plan_name": "SUTTER SELECT & SUTTER HEALTH PLAN HMO PLANS", "methodology": "per diem", "standard_charge_dollar": 28538.0, "standard_charge_algorithm": "Per diem ($28,538).", "count": "0", "additional_payer_notes": "Zero final payments for the item or service in the 15 months prior to posting the file." }, { "payer_name": "UNITED HEALTHCARE", "plan_name": "SUTTER SELECT & SUTTER HEALTH PLAN HMO PLANS", "methodology": "per diem", "standard_charge_dollar": 28538.0, "standard_charge_algorithm": "Per diem ($28,538).", "count": "0", "additional_payer_notes": "Zero final payments for the item or service in the 15 months prior to posting the file." }, { "payer_name": "UMR", "plan_name": "SUTTER SELECT & SUTTER HEALTH PLAN HMO PLANS", "methodology": "per diem", "standard_charge_dollar": 28538.0, "standard_charge_algorithm": "Per diem ($28,538).", "count": "0", "additional_payer_notes": "Zero final payments for the item or service in the 15 months prior to posting the file." } ] } ] }, { "description": "HC Impl Clip Sugita Gp021", "code_information": [ { "code": "PX-2120050021", "type": "CDM" }, { "code": "99999", "type": "CPT" }, { "code": "0272", "type": "RC" } ], "standard_charges": [ { "setting": "outpatient", "gross_charge": 2888.0, "discounted_cash": 1444.0, "minimum": 1218.74, "maximum": 1501.76, "additional_generic_notes": "Zero final payments for the item or service in the 15 months prior to posting the file.", "payers_information": [ { "payer_name": "AETNA", "plan_name": "AETNA ALL OTHER PLANS", "methodology": "percent of total billed charges", "standard_charge_dollar": 1501.76, "standard_charge_percentage": 52.0, "count": "0", "additional_payer_notes": "Zero final payments for the item or service in the 15 months prior to posting the file." }, { "payer_name": "AETNA", "plan_name": "AETNA ALL OTHER PLANS", "methodology": "percent of total billed charges", "standard_charge_dollar": 1501.76, "standard_charge_percentage": 52.0, "count": "0", "additional_payer_notes": "Zero final payments for the item or service in the 15 months prior to posting the file." }, { "payer_name": "MERITAIN HEALTH", "plan_name": "AETNA ALL OTHER PLANS", "methodology": "percent of total billed charges", "standard_charge_dollar": 1501.76, "standard_charge_percentage": 52.0, "count": "0", "additional_payer_notes": "Zero final payments for the item or service in the 15 months prior to posting the file." }, { "payer_name": "BLUE SHIELD OUT OF STATE", "plan_name": "STANFORD HEALTHCARE ALLIANCE PLAN", "methodology": "percent of total billed charges", "standard_charge_dollar": 1403.28, "standard_charge_percentage": 48.59, "count": "0", "additional_payer_notes": "Zero final payments for the item or service in the 15 months prior to posting the file." }, { "payer_name": "BLUE SHIELD", "plan_name": "STANFORD HEALTHCARE ALLIANCE PLAN", "methodology": "percent of total billed charges", "standard_charge_dollar": 1403.28, "standard_charge_percentage": 48.59, "median_amount": 68.24, "10th_percentile": 13.6, "90th_percentile": 1043.06, "count": "30" }, { "payer_name": "BLUE SHIELD", "plan_name": "STANFORD HEALTHCARE ALLIANCE PLAN", "methodology": "percent of total billed charges", "standard_charge_dollar": 1403.28, "standard_charge_percentage": 48.59, "count": "0", "additional_payer_notes": "Zero final payments for the item or service in the 15 months prior to posting the file." }, { "payer_name": "BLUE SHIELD", "plan_name": "STANFORD HEALTHCARE ALLIANCE PLAN", "methodology": "percent of total billed charges", "standard_charge_dollar": 1403.28, "standard_charge_percentage": 48.59, "count": "0", "additional_payer_notes": "Zero final payments for the item or service in the 15 months prior to posting the file." }, { "payer_name": "CIGNA", "plan_name": "CIGNA COM ALT HMO PLAN", "methodology": "percent of total billed charges", "standard_charge_dollar": 1218.74, "standard_charge_percentage": 42.2, "count": "0", "additional_payer_notes": "Zero final payments for the item or service in the 15 months prior to posting the file." }, { "payer_name": "CIGNA", "plan_name": "CIGNA COM ALT HMO PLAN", "methodology": "percent of total billed charges", "standard_charge_dollar": 1218.74, "standard_charge_percentage": 42.2, "count": "0", "additional_payer_notes": "Zero final payments for the item or service in the 15 months prior to posting the file." }, { "payer_name": "HEALTH NET", "plan_name": "HEALTHNET HMO, PPO, POS, EPO, CANOPY HEALTHNET HMO, OTHER-IN-NETWORK PLANS", "methodology": "per diem", "standard_charge_dollar": 8000.0, "standard_charge_algorithm": "Expected reimbursement is the lesser of Per diem ($8,000) for the length of stay and 70% of billed.", "count": "0", "additional_payer_notes": "Zero final payments for the item or service in the 15 months prior to posting the file." }, { "payer_name": "HEALTH NET", "plan_name": "HEALTHNET HMO, PPO, POS, EPO, CANOPY HEALTHNET HMO, OTHER-IN-NETWORK PLANS", "methodology": "per diem", "standard_charge_dollar": 8000.0, "standard_charge_algorithm": "Expected reimbursement is the lesser of Per diem ($8,000) for the length of stay and 70% of billed.", "count": "0", "additional_payer_notes": "Zero final payments for the item or service in the 15 months prior to posting the file." }, { "payer_name": "UNITED HEALTHCARE", "plan_name": "SUTTER SELECT & SUTTER HEALTH PLAN HMO PLANS", "methodology": "per diem", "standard_charge_dollar": 28538.0, "standard_charge_algorithm": "Per diem ($28,538).", "count": "0", "additional_payer_notes": "Zero final payments for the item or service in the 15 months prior to posting the file." }, { "payer_name": "UNITED HEALTHCARE", "plan_name": "SUTTER SELECT & SUTTER HEALTH PLAN HMO PLANS", "methodology": "per diem", "standard_charge_dollar": 28538.0, "standard_charge_algorithm": "Per diem ($28,538).", "count": "0", "additional_payer_notes": "Zero final payments for the item or service in the 15 months prior to posting the file." }, { "payer_name": "SUTTER", "plan_name": "SUTTER SELECT & SUTTER HEALTH PLAN HMO PLANS", "methodology": "per diem", "standard_charge_dollar": 28538.0, "standard_charge_algorithm": "Per diem ($28,538).", "count": "0", "additional_payer_notes": "Zero final payments for the item or service in the 15 months prior to posting the file." }, { "payer_name": "UNITED HEALTHCARE", "plan_name": "SUTTER SELECT & SUTTER HEALTH PLAN HMO PLANS", "methodology": "per diem", "standard_charge_dollar": 28538.0, "standard_charge_algorithm": "Per diem ($28,538).", "count": "0", "additional_payer_notes": "Zero final payments for the item or service in the 15 months prior to posting the file." }, { "payer_name": "UMR", "plan_name": "SUTTER SELECT & SUTTER HEALTH PLAN HMO PLANS", "methodology": "per diem", "standard_charge_dollar": 28538.0, "standard_charge_algorithm": "Per diem ($28,538).", "count": "0", "additional_payer_notes": "Zero final payments for the item or service in the 15 months prior to posting the file." } ] } ] }, { "description": "HC Collodion Gp005", "code_information": [ { "code": "PX-2120051005", "type": "CDM" }, { "code": "99999", "type": "CPT" }, { "code": "0272", "type": "RC" } ], "standard_charges": [ { "setting": "outpatient", "gross_charge": 195.0, "discounted_cash": 97.5, "minimum": 82.29, "maximum": 101.4, "additional_generic_notes": "Zero final payments for the item or service in the 15 months prior to posting the file.", "payers_information": [ { "payer_name": "AETNA", "plan_name": "AETNA ALL OTHER PLANS", "methodology": "percent of total billed charges", "standard_charge_dollar": 101.4, "standard_charge_percentage": 52.0, "count": "0", "additional_payer_notes": "Zero final payments for the item or service in the 15 months prior to posting the file." }, { "payer_name": "AETNA", "plan_name": "AETNA ALL OTHER PLANS", "methodology": "percent of total billed charges", "standard_charge_dollar": 101.4, "standard_charge_percentage": 52.0, "count": "0", "additional_payer_notes": "Zero final payments for the item or service in the 15 months prior to posting the file." }, { "payer_name": "MERITAIN HEALTH", "plan_name": "AETNA ALL OTHER PLANS", "methodology": "percent of total billed charges", "standard_charge_dollar": 101.4, "standard_charge_percentage": 52.0, "count": "0", "additional_payer_notes": "Zero final payments for the item or service in the 15 months prior to posting the file." }, { "payer_name": "BLUE SHIELD OUT OF STATE", "plan_name": "STANFORD HEALTHCARE ALLIANCE PLAN", "methodology": "percent of total billed charges", "standard_charge_dollar": 94.75, "standard_charge_percentage": 48.59, "count": "0", "additional_payer_notes": "Zero final payments for the item or service in the 15 months prior to posting the file." }, { "payer_name": "BLUE SHIELD", "plan_name": "STANFORD HEALTHCARE ALLIANCE PLAN", "methodology": "percent of total billed charges", "standard_charge_dollar": 94.75, "standard_charge_percentage": 48.59, "count": "0", "additional_payer_notes": "Zero final payments for the item or service in the 15 months prior to posting the file." }, { "payer_name": "BLUE SHIELD", "plan_name": "STANFORD HEALTHCARE ALLIANCE PLAN", "methodology": "percent of total billed charges", "standard_charge_dollar": 94.75, "standard_charge_percentage": 48.59, "count": "0", "additional_payer_notes": "Zero final payments for the item or service in the 15 months prior to posting the file." }, { "payer_name": "CIGNA", "plan_name": "CIGNA COM ALT HMO PLAN", "methodology": "percent of total billed charges", "standard_charge_dollar": 82.29, "standard_charge_percentage": 42.2, "count": "0", "additional_payer_notes": "Zero final payments for the item or service in the 15 months prior to posting the file." }, { "payer_name": "CIGNA", "plan_name": "CIGNA COM ALT HMO PLAN", "methodology": "percent of total billed charges", "standard_charge_dollar": 82.29, "standard_charge_percentage": 42.2, "count": "0", "additional_payer_notes": "Zero final payments for the item or service in the 15 months prior to posting the file." }, { "payer_name": "HEALTH NET", "plan_name": "HEALTHNET HMO, PPO, POS, EPO, CANOPY HEALTHNET HMO, OTHER-IN-NETWORK PLANS", "methodology": "per diem", "standard_charge_dollar": 8000.0, "standard_charge_algorithm": "Expected reimbursement is the lesser of Per diem ($8,000) for the length of stay and 70% of billed.", "count": "0", "additional_payer_notes": "Zero final payments for the item or service in the 15 months prior to posting the file." }, { "payer_name": "HEALTH NET", "plan_name": "HEALTHNET HMO, PPO, POS, EPO, CANOPY HEALTHNET HMO, OTHER-IN-NETWORK PLANS", "methodology": "per diem", "standard_charge_dollar": 8000.0, "standard_charge_algorithm": "Expected reimbursement is the lesser of Per diem ($8,000) for the length of stay and 70% of billed.", "count": "0", "additional_payer_notes": "Zero final payments for the item or service in the 15 months prior to posting the file." }, { "payer_name": "UNITED HEALTHCARE", "plan_name": "SUTTER SELECT & SUTTER HEALTH PLAN HMO PLANS", "methodology": "per diem", "standard_charge_dollar": 28538.0, "standard_charge_algorithm": "Per diem ($28,538).", "count": "0", "additional_payer_notes": "Zero final payments for the item or service in the 15 months prior to posting the file." }, { "payer_name": "UNITED HEALTHCARE", "plan_name": "SUTTER SELECT & SUTTER HEALTH PLAN HMO PLANS", "methodology": "per diem", "standard_charge_dollar": 28538.0, "standard_charge_algorithm": "Per diem ($28,538).", "count": "0", "additional_payer_notes": "Zero final payments for the item or service in the 15 months prior to posting the file." }, { "payer_name": "SUTTER", "plan_name": "SUTTER SELECT & SUTTER HEALTH PLAN HMO PLANS", "methodology": "per diem", "standard_charge_dollar": 28538.0, "standard_charge_algorithm": "Per diem ($28,538).", "count": "0", "additional_payer_notes": "Zero final payments for the item or service in the 15 months prior to posting the file." }, { "payer_name": "UNITED HEALTHCARE", "plan_name": "SUTTER SELECT & SUTTER HEALTH PLAN HMO PLANS", "methodology": "per diem", "standard_charge_dollar": 28538.0, "standard_charge_algorithm": "Per diem ($28,538).", "count": "0", "additional_payer_notes": "Zero final payments for the item or service in the 15 months prior to posting the file." }, { "payer_name": "UMR", "plan_name": "SUTTER SELECT & SUTTER HEALTH PLAN HMO PLANS", "methodology": "per diem", "standard_charge_dollar": 28538.0, "standard_charge_algorithm": "Per diem ($28,538).", "count": "0", "additional_payer_notes": "Zero final payments for the item or service in the 15 months prior to posting the file." } ] } ] }, { "description": "HC Dermacarrier Gp005", "code_information": [ { "code": "PX-2120053005", "type": "CDM" }, { "code": "99999", "type": "CPT" }, { "code": "0272", "type": "RC" } ], "standard_charges": [ { "setting": "outpatient", "gross_charge": 195.0, "discounted_cash": 97.5, "minimum": 82.29, "maximum": 101.4, "additional_generic_notes": "Zero final payments for the item or service in the 15 months prior to posting the file.", "payers_information": [ { "payer_name": "AETNA", "plan_name": "AETNA ALL OTHER PLANS", "methodology": "percent of total billed charges", "standard_charge_dollar": 101.4, "standard_charge_percentage": 52.0, "count": "0", "additional_payer_notes": "Zero final payments for the item or service in the 15 months prior to posting the file." }, { "payer_name": "AETNA", "plan_name": "AETNA ALL OTHER PLANS", "methodology": "percent of total billed charges", "standard_charge_dollar": 101.4, "standard_charge_percentage": 52.0, "count": "0", "additional_payer_notes": "Zero final payments for the item or service in the 15 months prior to posting the file." }, { "payer_name": "MERITAIN HEALTH", "plan_name": "AETNA ALL OTHER PLANS", "methodology": "percent of total billed charges", "standard_charge_dollar": 101.4, "standard_charge_percentage": 52.0, "count": "0", "additional_payer_notes": "Zero final payments for the item or service in the 15 months prior to posting the file." }, { "payer_name": "BLUE SHIELD OUT OF STATE", "plan_name": "STANFORD HEALTHCARE ALLIANCE PLAN", "methodology": "percent of total billed charges", "standard_charge_dollar": 94.75, "standard_charge_percentage": 48.59, "count": "0", "additional_payer_notes": "Zero final payments for the item or service in the 15 months prior to posting the file." }, { "payer_name": "BLUE SHIELD", "plan_name": "STANFORD HEALTHCARE ALLIANCE PLAN", "methodology": "percent of total billed charges", "standard_charge_dollar": 94.75, "standard_charge_percentage": 48.59, "count": "0", "additional_payer_notes": "Zero final payments for the item or service in the 15 months prior to posting the file." }, { "payer_name": "BLUE SHIELD", "plan_name": "STANFORD HEALTHCARE ALLIANCE PLAN", "methodology": "percent of total billed charges", "standard_charge_dollar": 94.75, "standard_charge_percentage": 48.59, "count": "0", "additional_payer_notes": "Zero final payments for the item or service in the 15 months prior to posting the file." }, { "payer_name": "CIGNA", "plan_name": "CIGNA COM ALT HMO PLAN", "methodology": "percent of total billed charges", "standard_charge_dollar": 82.29, "standard_charge_percentage": 42.2, "count": "0", "additional_payer_notes": "Zero final payments for the item or service in the 15 months prior to posting the file." }, { "payer_name": "CIGNA", "plan_name": "CIGNA COM ALT HMO PLAN", "methodology": "percent of total billed charges", "standard_charge_dollar": 82.29, "standard_charge_percentage": 42.2, "count": "0", "additional_payer_notes": "Zero final payments for the item or service in the 15 months prior to posting the file." }, { "payer_name": "HEALTH NET", "plan_name": "HEALTHNET HMO, PPO, POS, EPO, CANOPY HEALTHNET HMO, OTHER-IN-NETWORK PLANS", "methodology": "per diem", "standard_charge_dollar": 8000.0, "standard_charge_algorithm": "Expected reimbursement is the lesser of Per diem ($8,000) for the length of stay and 70% of billed.", "count": "0", "additional_payer_notes": "Zero final payments for the item or service in the 15 months prior to posting the file." }, { "payer_name": "HEALTH NET", "plan_name": "HEALTHNET HMO, PPO, POS, EPO, CANOPY HEALTHNET HMO, OTHER-IN-NETWORK PLANS", "methodology": "per diem", "standard_charge_dollar": 8000.0, "standard_charge_algorithm": "Expected reimbursement is the lesser of Per diem ($8,000) for the length of stay and 70% of billed.", "count": "0", "additional_payer_notes": "Zero final payments for the item or service in the 15 months prior to posting the file." }, { "payer_name": "UNITED HEALTHCARE", "plan_name": "SUTTER SELECT & SUTTER HEALTH PLAN HMO PLANS", "methodology": "per diem", "standard_charge_dollar": 28538.0, "standard_charge_algorithm": "Per diem ($28,538).", "count": "0", "additional_payer_notes": "Zero final payments for the item or service in the 15 months prior to posting the file." }, { "payer_name": "UNITED HEALTHCARE", "plan_name": "SUTTER SELECT & SUTTER HEALTH PLAN HMO PLANS", "methodology": "per diem", "standard_charge_dollar": 28538.0, "standard_charge_algorithm": "Per diem ($28,538).", "count": "0", "additional_payer_notes": "Zero final payments for the item or service in the 15 months prior to posting the file." }, { "payer_name": "SUTTER", "plan_name": "SUTTER SELECT & SUTTER HEALTH PLAN HMO PLANS", "methodology": "per diem", "standard_charge_dollar": 28538.0, "standard_charge_algorithm": "Per diem ($28,538).", "count": "0", "additional_payer_notes": "Zero final payments for the item or service in the 15 months prior to posting the file." }, { "payer_name": "UNITED HEALTHCARE", "plan_name": "SUTTER SELECT & SUTTER HEALTH PLAN HMO PLANS", "methodology": "per diem", "standard_charge_dollar": 28538.0, "standard_charge_algorithm": "Per diem ($28,538).", "count": "0", "additional_payer_notes": "Zero final payments for the item or service in the 15 months prior to posting the file." }, { "payer_name": "UMR", "plan_name": "SUTTER SELECT & SUTTER HEALTH PLAN HMO PLANS", "methodology": "per diem", "standard_charge_dollar": 28538.0, "standard_charge_algorithm": "Per diem ($28,538).", "count": "0", "additional_payer_notes": "Zero final payments for the item or service in the 15 months prior to posting the file." } ] } ] }, { "description": "HC Dermacarrier Gp006", "code_information": [ { "code": "PX-2120053006", "type": "CDM" }, { "code": "99999", "type": "CPT" }, { "code": "0272", "type": "RC" } ], "standard_charges": [ { "setting": "outpatient", "gross_charge": 293.0, "discounted_cash": 146.5, "minimum": 123.65, "maximum": 152.36, "additional_generic_notes": "Zero final payments for the item or service in the 15 months prior to posting the file.", "payers_information": [ { "payer_name": "AETNA", "plan_name": "AETNA ALL OTHER PLANS", "methodology": "percent of total billed charges", "standard_charge_dollar": 152.36, "standard_charge_percentage": 52.0, "count": "0", "additional_payer_notes": "Zero final payments for the item or service in the 15 months prior to posting the file." }, { "payer_name": "AETNA", "plan_name": "AETNA ALL OTHER PLANS", "methodology": "percent of total billed charges", "standard_charge_dollar": 152.36, "standard_charge_percentage": 52.0, "count": "0", "additional_payer_notes": "Zero final payments for the item or service in the 15 months prior to posting the file." }, { "payer_name": "MERITAIN HEALTH", "plan_name": "AETNA ALL OTHER PLANS", "methodology": "percent of total billed charges", "standard_charge_dollar": 152.36, "standard_charge_percentage": 52.0, "count": "0", "additional_payer_notes": "Zero final payments for the item or service in the 15 months prior to posting the file." }, { "payer_name": "BLUE SHIELD OUT OF STATE", "plan_name": "STANFORD HEALTHCARE ALLIANCE PLAN", "methodology": "percent of total billed charges", "standard_charge_dollar": 142.37, "standard_charge_percentage": 48.59, "count": "0", "additional_payer_notes": "Zero final payments for the item or service in the 15 months prior to posting the file." }, { "payer_name": "BLUE SHIELD", "plan_name": "STANFORD HEALTHCARE ALLIANCE PLAN", "methodology": "percent of total billed charges", "standard_charge_dollar": 142.37, "standard_charge_percentage": 48.59, "count": "0", "additional_payer_notes": "Zero final payments for the item or service in the 15 months prior to posting the file." }, { "payer_name": "BLUE SHIELD", "plan_name": "STANFORD HEALTHCARE ALLIANCE PLAN", "methodology": "percent of total billed charges", "standard_charge_dollar": 142.37, "standard_charge_percentage": 48.59, "count": "0", "additional_payer_notes": "Zero final payments for the item or service in the 15 months prior to posting the file." }, { "payer_name": "CIGNA", "plan_name": "CIGNA COM ALT HMO PLAN", "methodology": "percent of total billed charges", "standard_charge_dollar": 123.65, "standard_charge_percentage": 42.2, "count": "0", "additional_payer_notes": "Zero final payments for the item or service in the 15 months prior to posting the file." }, { "payer_name": "CIGNA", "plan_name": "CIGNA COM ALT HMO PLAN", "methodology": "percent of total billed charges", "standard_charge_dollar": 123.65, "standard_charge_percentage": 42.2, "count": "0", "additional_payer_notes": "Zero final payments for the item or service in the 15 months prior to posting the file." }, { "payer_name": "HEALTH NET", "plan_name": "HEALTHNET HMO, PPO, POS, EPO, CANOPY HEALTHNET HMO, OTHER-IN-NETWORK PLANS", "methodology": "per diem", "standard_charge_dollar": 8000.0, "standard_charge_algorithm": "Expected reimbursement is the lesser of Per diem ($8,000) for the length of stay and 70% of billed.", "count": "0", "additional_payer_notes": "Zero final payments for the item or service in the 15 months prior to posting the file." }, { "payer_name": "HEALTH NET", "plan_name": "HEALTHNET HMO, PPO, POS, EPO, CANOPY HEALTHNET HMO, OTHER-IN-NETWORK PLANS", "methodology": "per diem", "standard_charge_dollar": 8000.0, "standard_charge_algorithm": "Expected reimbursement is the lesser of Per diem ($8,000) for the length of stay and 70% of billed.", "count": "0", "additional_payer_notes": "Zero final payments for the item or service in the 15 months prior to posting the file." }, { "payer_name": "UNITED HEALTHCARE", "plan_name": "SUTTER SELECT & SUTTER HEALTH PLAN HMO PLANS", "methodology": "per diem", "standard_charge_dollar": 28538.0, "standard_charge_algorithm": "Per diem ($28,538).", "count": "0", "additional_payer_notes": "Zero final payments for the item or service in the 15 months prior to posting the file." }, { "payer_name": "UNITED HEALTHCARE", "plan_name": "SUTTER SELECT & SUTTER HEALTH PLAN HMO PLANS", "methodology": "per diem", "standard_charge_dollar": 28538.0, "standard_charge_algorithm": "Per diem ($28,538).", "count": "0", "additional_payer_notes": "Zero final payments for the item or service in the 15 months prior to posting the file." }, { "payer_name": "SUTTER", "plan_name": "SUTTER SELECT & SUTTER HEALTH PLAN HMO PLANS", "methodology": "per diem", "standard_charge_dollar": 28538.0, "standard_charge_algorithm": "Per diem ($28,538).", "count": "0", "additional_payer_notes": "Zero final payments for the item or service in the 15 months prior to posting the file." }, { "payer_name": "UNITED HEALTHCARE", "plan_name": "SUTTER SELECT & SUTTER HEALTH PLAN HMO PLANS", "methodology": "per diem", "standard_charge_dollar": 28538.0, "standard_charge_algorithm": "Per diem ($28,538).", "count": "0", "additional_payer_notes": "Zero final payments for the item or service in the 15 months prior to posting the file." }, { "payer_name": "UMR", "plan_name": "SUTTER SELECT & SUTTER HEALTH PLAN HMO PLANS", "methodology": "per diem", "standard_charge_dollar": 28538.0, "standard_charge_algorithm": "Per diem ($28,538).", "count": "0", "additional_payer_notes": "Zero final payments for the item or service in the 15 months prior to posting the file." } ] } ] }, { "description": "HC Dermagraft Gp024", "code_information": [ { "code": "PX-2120054024", "type": "CDM" }, { "code": "99999", "type": "CPT" }, { "code": "0272", "type": "RC" } ], "standard_charges": [ { "setting": "outpatient", "gross_charge": 4000.0, "discounted_cash": 2000.0, "minimum": 1688.0, "maximum": 2080.0, "additional_generic_notes": "Zero final payments for the item or service in the 15 months prior to posting the file.", "payers_information": [ { "payer_name": "AETNA", "plan_name": "AETNA ALL OTHER PLANS", "methodology": "percent of total billed charges", "standard_charge_dollar": 2080.0, "standard_charge_percentage": 52.0, "count": "0", "additional_payer_notes": "Zero final payments for the item or service in the 15 months prior to posting the file." }, { "payer_name": "AETNA", "plan_name": "AETNA ALL OTHER PLANS", "methodology": "percent of total billed charges", "standard_charge_dollar": 2080.0, "standard_charge_percentage": 52.0, "count": "0", "additional_payer_notes": "Zero final payments for the item or service in the 15 months prior to posting the file." }, { "payer_name": "MERITAIN HEALTH", "plan_name": "AETNA ALL OTHER PLANS", "methodology": "percent of total billed charges", "standard_charge_dollar": 2080.0, "standard_charge_percentage": 52.0, "count": "0", "additional_payer_notes": "Zero final payments for the item or service in the 15 months prior to posting the file." }, { "payer_name": "BLUE SHIELD OUT OF STATE", "plan_name": "STANFORD HEALTHCARE ALLIANCE PLAN", "methodology": "percent of total billed charges", "standard_charge_dollar": 1943.6, "standard_charge_percentage": 48.59, "count": "0", "additional_payer_notes": "Zero final payments for the item or service in the 15 months prior to posting the file." }, { "payer_name": "BLUE SHIELD", "plan_name": "STANFORD HEALTHCARE ALLIANCE PLAN", "methodology": "percent of total billed charges", "standard_charge_dollar": 1943.6, "standard_charge_percentage": 48.59, "median_amount": 68.24, "10th_percentile": 13.6, "90th_percentile": 1043.06, "count": "30" }, { "payer_name": "BLUE SHIELD", "plan_name": "STANFORD HEALTHCARE ALLIANCE PLAN", "methodology": "percent of total billed charges", "standard_charge_dollar": 1943.6, "standard_charge_percentage": 48.59, "count": "0", "additional_payer_notes": "Zero final payments for the item or service in the 15 months prior to posting the file." }, { "payer_name": "BLUE SHIELD", "plan_name": "STANFORD HEALTHCARE ALLIANCE PLAN", "methodology": "percent of total billed charges", "standard_charge_dollar": 1943.6, "standard_charge_percentage": 48.59, "count": "0", "additional_payer_notes": "Zero final payments for the item or service in the 15 months prior to posting the file." }, { "payer_name": "CIGNA", "plan_name": "CIGNA COM ALT HMO PLAN", "methodology": "percent of total billed charges", "standard_charge_dollar": 1688.0, "standard_charge_percentage": 42.2, "count": "0", "additional_payer_notes": "Zero final payments for the item or service in the 15 months prior to posting the file." }, { "payer_name": "CIGNA", "plan_name": "CIGNA COM ALT HMO PLAN", "methodology": "percent of total billed charges", "standard_charge_dollar": 1688.0, "standard_charge_percentage": 42.2, "count": "0", "additional_payer_notes": "Zero final payments for the item or service in the 15 months prior to posting the file." }, { "payer_name": "HEALTH NET", "plan_name": "HEALTHNET HMO, PPO, POS, EPO, CANOPY HEALTHNET HMO, OTHER-IN-NETWORK PLANS", "methodology": "per diem", "standard_charge_dollar": 8000.0, "standard_charge_algorithm": "Expected reimbursement is the lesser of Per diem ($8,000) for the length of stay and 70% of billed.", "count": "0", "additional_payer_notes": "Zero final payments for the item or service in the 15 months prior to posting the file." }, { "payer_name": "HEALTH NET", "plan_name": "HEALTHNET HMO, PPO, POS, EPO, CANOPY HEALTHNET HMO, OTHER-IN-NETWORK PLANS", "methodology": "per diem", "standard_charge_dollar": 8000.0, "standard_charge_algorithm": "Expected reimbursement is the lesser of Per diem ($8,000) for the length of stay and 70% of billed.", "count": "0", "additional_payer_notes": "Zero final payments for the item or service in the 15 months prior to posting the file." }, { "payer_name": "UNITED HEALTHCARE", "plan_name": "SUTTER SELECT & SUTTER HEALTH PLAN HMO PLANS", "methodology": "per diem", "standard_charge_dollar": 28538.0, "standard_charge_algorithm": "Per diem ($28,538).", "count": "0", "additional_payer_notes": "Zero final payments for the item or service in the 15 months prior to posting the file." }, { "payer_name": "UNITED HEALTHCARE", "plan_name": "SUTTER SELECT & SUTTER HEALTH PLAN HMO PLANS", "methodology": "per diem", "standard_charge_dollar": 28538.0, "standard_charge_algorithm": "Per diem ($28,538).", "count": "0", "additional_payer_notes": "Zero final payments for the item or service in the 15 months prior to posting the file." }, { "payer_name": "SUTTER", "plan_name": "SUTTER SELECT & SUTTER HEALTH PLAN HMO PLANS", "methodology": "per diem", "standard_charge_dollar": 28538.0, "standard_charge_algorithm": "Per diem ($28,538).", "count": "0", "additional_payer_notes": "Zero final payments for the item or service in the 15 months prior to posting the file." }, { "payer_name": "UNITED HEALTHCARE", "plan_name": "SUTTER SELECT & SUTTER HEALTH PLAN HMO PLANS", "methodology": "per diem", "standard_charge_dollar": 28538.0, "standard_charge_algorithm": "Per diem ($28,538).", "count": "0", "additional_payer_notes": "Zero final payments for the item or service in the 15 months prior to posting the file." }, { "payer_name": "UMR", "plan_name": "SUTTER SELECT & SUTTER HEALTH PLAN HMO PLANS", "methodology": "per diem", "standard_charge_dollar": 28538.0, "standard_charge_algorithm": "Per diem ($28,538).", "count": "0", "additional_payer_notes": "Zero final payments for the item or service in the 15 months prior to posting the file." } ] } ] }, { "description": "HC Device Ligasure Cutting Gp014", "code_information": [ { "code": "PX-2120055014", "type": "CDM" }, { "code": "99999", "type": "CPT" }, { "code": "0272", "type": "RC" } ], "standard_charges": [ { "setting": "outpatient", "gross_charge": 1080.0, "discounted_cash": 540.0, "minimum": 455.76, "maximum": 561.6, "additional_generic_notes": "Zero final payments for the item or service in the 15 months prior to posting the file.", "payers_information": [ { "payer_name": "AETNA", "plan_name": "AETNA ALL OTHER PLANS", "methodology": "percent of total billed charges", "standard_charge_dollar": 561.6, "standard_charge_percentage": 52.0, "count": "0", "additional_payer_notes": "Zero final payments for the item or service in the 15 months prior to posting the file." }, { "payer_name": "AETNA", "plan_name": "AETNA ALL OTHER PLANS", "methodology": "percent of total billed charges", "standard_charge_dollar": 561.6, "standard_charge_percentage": 52.0, "count": "0", "additional_payer_notes": "Zero final payments for the item or service in the 15 months prior to posting the file." }, { "payer_name": "MERITAIN HEALTH", "plan_name": "AETNA ALL OTHER PLANS", "methodology": "percent of total billed charges", "standard_charge_dollar": 561.6, "standard_charge_percentage": 52.0, "count": "0", "additional_payer_notes": "Zero final payments for the item or service in the 15 months prior to posting the file." }, { "payer_name": "BLUE SHIELD OUT OF STATE", "plan_name": "STANFORD HEALTHCARE ALLIANCE PLAN", "methodology": "percent of total billed charges", "standard_charge_dollar": 524.77, "standard_charge_percentage": 48.59, "count": "0", "additional_payer_notes": "Zero final payments for the item or service in the 15 months prior to posting the file." }, { "payer_name": "BLUE SHIELD", "plan_name": "STANFORD HEALTHCARE ALLIANCE PLAN", "methodology": "percent of total billed charges", "standard_charge_dollar": 524.77, "standard_charge_percentage": 48.59, "median_amount": 68.24, "10th_percentile": 13.6, "90th_percentile": 1043.06, "count": "30" }, { "payer_name": "BLUE SHIELD", "plan_name": "STANFORD HEALTHCARE ALLIANCE PLAN", "methodology": "percent of total billed charges", "standard_charge_dollar": 524.77, "standard_charge_percentage": 48.59, "count": "0", "additional_payer_notes": "Zero final payments for the item or service in the 15 months prior to posting the file." }, { "payer_name": "BLUE SHIELD", "plan_name": "STANFORD HEALTHCARE ALLIANCE PLAN", "methodology": "percent of total billed charges", "standard_charge_dollar": 524.77, "standard_charge_percentage": 48.59, "count": "0", "additional_payer_notes": "Zero final payments for the item or service in the 15 months prior to posting the file." }, { "payer_name": "CIGNA", "plan_name": "CIGNA COM ALT HMO PLAN", "methodology": "percent of total billed charges", "standard_charge_dollar": 455.76, "standard_charge_percentage": 42.2, "count": "0", "additional_payer_notes": "Zero final payments for the item or service in the 15 months prior to posting the file." }, { "payer_name": "CIGNA", "plan_name": "CIGNA COM ALT HMO PLAN", "methodology": "percent of total billed charges", "standard_charge_dollar": 455.76, "standard_charge_percentage": 42.2, "count": "0", "additional_payer_notes": "Zero final payments for the item or service in the 15 months prior to posting the file." }, { "payer_name": "HEALTH NET", "plan_name": "HEALTHNET HMO, PPO, POS, EPO, CANOPY HEALTHNET HMO, OTHER-IN-NETWORK PLANS", "methodology": "per diem", "standard_charge_dollar": 8000.0, "standard_charge_algorithm": "Expected reimbursement is the lesser of Per diem ($8,000) for the length of stay and 70% of billed.", "count": "0", "additional_payer_notes": "Zero final payments for the item or service in the 15 months prior to posting the file." }, { "payer_name": "HEALTH NET", "plan_name": "HEALTHNET HMO, PPO, POS, EPO, CANOPY HEALTHNET HMO, OTHER-IN-NETWORK PLANS", "methodology": "per diem", "standard_charge_dollar": 8000.0, "standard_charge_algorithm": "Expected reimbursement is the lesser of Per diem ($8,000) for the length of stay and 70% of billed.", "count": "0", "additional_payer_notes": "Zero final payments for the item or service in the 15 months prior to posting the file." }, { "payer_name": "UNITED HEALTHCARE", "plan_name": "SUTTER SELECT & SUTTER HEALTH PLAN HMO PLANS", "methodology": "per diem", "standard_charge_dollar": 28538.0, "standard_charge_algorithm": "Per diem ($28,538).", "count": "0", "additional_payer_notes": "Zero final payments for the item or service in the 15 months prior to posting the file." }, { "payer_name": "UNITED HEALTHCARE", "plan_name": "SUTTER SELECT & SUTTER HEALTH PLAN HMO PLANS", "methodology": "per diem", "standard_charge_dollar": 28538.0, "standard_charge_algorithm": "Per diem ($28,538).", "count": "0", "additional_payer_notes": "Zero final payments for the item or service in the 15 months prior to posting the file." }, { "payer_name": "SUTTER", "plan_name": "SUTTER SELECT & SUTTER HEALTH PLAN HMO PLANS", "methodology": "per diem", "standard_charge_dollar": 28538.0, "standard_charge_algorithm": "Per diem ($28,538).", "count": "0", "additional_payer_notes": "Zero final payments for the item or service in the 15 months prior to posting the file." }, { "payer_name": "UNITED HEALTHCARE", "plan_name": "SUTTER SELECT & SUTTER HEALTH PLAN HMO PLANS", "methodology": "per diem", "standard_charge_dollar": 28538.0, "standard_charge_algorithm": "Per diem ($28,538).", "count": "0", "additional_payer_notes": "Zero final payments for the item or service in the 15 months prior to posting the file." }, { "payer_name": "UMR", "plan_name": "SUTTER SELECT & SUTTER HEALTH PLAN HMO PLANS", "methodology": "per diem", "standard_charge_dollar": 28538.0, "standard_charge_algorithm": "Per diem ($28,538).", "count": "0", "additional_payer_notes": "Zero final payments for the item or service in the 15 months prior to posting the file." } ] } ] }, { "description": "HC Device Ligasure Cutting Gp018", "code_information": [ { "code": "PX-2120055018", "type": "CDM" }, { "code": "99999", "type": "CPT" }, { "code": "0272", "type": "RC" } ], "standard_charges": [ { "setting": "outpatient", "gross_charge": 1750.0, "discounted_cash": 875.0, "minimum": 738.5, "maximum": 910.0, "additional_generic_notes": "Zero final payments for the item or service in the 15 months prior to posting the file.", "payers_information": [ { "payer_name": "AETNA", "plan_name": "AETNA ALL OTHER PLANS", "methodology": "percent of total billed charges", "standard_charge_dollar": 910.0, "standard_charge_percentage": 52.0, "count": "0", "additional_payer_notes": "Zero final payments for the item or service in the 15 months prior to posting the file." }, { "payer_name": "AETNA", "plan_name": "AETNA ALL OTHER PLANS", "methodology": "percent of total billed charges", "standard_charge_dollar": 910.0, "standard_charge_percentage": 52.0, "count": "0", "additional_payer_notes": "Zero final payments for the item or service in the 15 months prior to posting the file." }, { "payer_name": "MERITAIN HEALTH", "plan_name": "AETNA ALL OTHER PLANS", "methodology": "percent of total billed charges", "standard_charge_dollar": 910.0, "standard_charge_percentage": 52.0, "count": "0", "additional_payer_notes": "Zero final payments for the item or service in the 15 months prior to posting the file." }, { "payer_name": "BLUE SHIELD OUT OF STATE", "plan_name": "STANFORD HEALTHCARE ALLIANCE PLAN", "methodology": "percent of total billed charges", "standard_charge_dollar": 850.33, "standard_charge_percentage": 48.59, "count": "0", "additional_payer_notes": "Zero final payments for the item or service in the 15 months prior to posting the file." }, { "payer_name": "BLUE SHIELD", "plan_name": "STANFORD HEALTHCARE ALLIANCE PLAN", "methodology": "percent of total billed charges", "standard_charge_dollar": 850.33, "standard_charge_percentage": 48.59, "median_amount": 68.24, "10th_percentile": 13.6, "90th_percentile": 1043.06, "count": "30" }, { "payer_name": "BLUE SHIELD", "plan_name": "STANFORD HEALTHCARE ALLIANCE PLAN", "methodology": "percent of total billed charges", "standard_charge_dollar": 850.33, "standard_charge_percentage": 48.59, "count": "0", "additional_payer_notes": "Zero final payments for the item or service in the 15 months prior to posting the file." }, { "payer_name": "BLUE SHIELD", "plan_name": "STANFORD HEALTHCARE ALLIANCE PLAN", "methodology": "percent of total billed charges", "standard_charge_dollar": 850.33, "standard_charge_percentage": 48.59, "count": "0", "additional_payer_notes": "Zero final payments for the item or service in the 15 months prior to posting the file." }, { "payer_name": "CIGNA", "plan_name": "CIGNA COM ALT HMO PLAN", "methodology": "percent of total billed charges", "standard_charge_dollar": 738.5, "standard_charge_percentage": 42.2, "count": "0", "additional_payer_notes": "Zero final payments for the item or service in the 15 months prior to posting the file." }, { "payer_name": "CIGNA", "plan_name": "CIGNA COM ALT HMO PLAN", "methodology": "percent of total billed charges", "standard_charge_dollar": 738.5, "standard_charge_percentage": 42.2, "count": "0", "additional_payer_notes": "Zero final payments for the item or service in the 15 months prior to posting the file." }, { "payer_name": "HEALTH NET", "plan_name": "HEALTHNET HMO, PPO, POS, EPO, CANOPY HEALTHNET HMO, OTHER-IN-NETWORK PLANS", "methodology": "per diem", "standard_charge_dollar": 8000.0, "standard_charge_algorithm": "Expected reimbursement is the lesser of Per diem ($8,000) for the length of stay and 70% of billed.", "count": "0", "additional_payer_notes": "Zero final payments for the item or service in the 15 months prior to posting the file." }, { "payer_name": "HEALTH NET", "plan_name": "HEALTHNET HMO, PPO, POS, EPO, CANOPY HEALTHNET HMO, OTHER-IN-NETWORK PLANS", "methodology": "per diem", "standard_charge_dollar": 8000.0, "standard_charge_algorithm": "Expected reimbursement is the lesser of Per diem ($8,000) for the length of stay and 70% of billed.", "count": "0", "additional_payer_notes": "Zero final payments for the item or service in the 15 months prior to posting the file." }, { "payer_name": "UNITED HEALTHCARE", "plan_name": "SUTTER SELECT & SUTTER HEALTH PLAN HMO PLANS", "methodology": "per diem", "standard_charge_dollar": 28538.0, "standard_charge_algorithm": "Per diem ($28,538).", "count": "0", "additional_payer_notes": "Zero final payments for the item or service in the 15 months prior to posting the file." }, { "payer_name": "UNITED HEALTHCARE", "plan_name": "SUTTER SELECT & SUTTER HEALTH PLAN HMO PLANS", "methodology": "per diem", "standard_charge_dollar": 28538.0, "standard_charge_algorithm": "Per diem ($28,538).", "count": "0", "additional_payer_notes": "Zero final payments for the item or service in the 15 months prior to posting the file." }, { "payer_name": "SUTTER", "plan_name": "SUTTER SELECT & SUTTER HEALTH PLAN HMO PLANS", "methodology": "per diem", "standard_charge_dollar": 28538.0, "standard_charge_algorithm": "Per diem ($28,538).", "count": "0", "additional_payer_notes": "Zero final payments for the item or service in the 15 months prior to posting the file." }, { "payer_name": "UNITED HEALTHCARE", "plan_name": "SUTTER SELECT & SUTTER HEALTH PLAN HMO PLANS", "methodology": "per diem", "standard_charge_dollar": 28538.0, "standard_charge_algorithm": "Per diem ($28,538).", "count": "0", "additional_payer_notes": "Zero final payments for the item or service in the 15 months prior to posting the file." }, { "payer_name": "UMR", "plan_name": "SUTTER SELECT & SUTTER HEALTH PLAN HMO PLANS", "methodology": "per diem", "standard_charge_dollar": 28538.0, "standard_charge_algorithm": "Per diem ($28,538).", "count": "0", "additional_payer_notes": "Zero final payments for the item or service in the 15 months prior to posting the file." } ] } ] }, { "description": "HC Device Ligasure Cutting Gp019", "code_information": [ { "code": "PX-2120055019", "type": "CDM" }, { "code": "99999", "type": "CPT" }, { "code": "0272", "type": "RC" } ], "standard_charges": [ { "setting": "outpatient", "gross_charge": 2125.0, "discounted_cash": 1062.5, "minimum": 896.75, "maximum": 1105.0, "additional_generic_notes": "Zero final payments for the item or service in the 15 months prior to posting the file.", "payers_information": [ { "payer_name": "AETNA", "plan_name": "AETNA ALL OTHER PLANS", "methodology": "percent of total billed charges", "standard_charge_dollar": 1105.0, "standard_charge_percentage": 52.0, "count": "0", "additional_payer_notes": "Zero final payments for the item or service in the 15 months prior to posting the file." }, { "payer_name": "AETNA", "plan_name": "AETNA ALL OTHER PLANS", "methodology": "percent of total billed charges", "standard_charge_dollar": 1105.0, "standard_charge_percentage": 52.0, "count": "0", "additional_payer_notes": "Zero final payments for the item or service in the 15 months prior to posting the file." }, { "payer_name": "MERITAIN HEALTH", "plan_name": "AETNA ALL OTHER PLANS", "methodology": "percent of total billed charges", "standard_charge_dollar": 1105.0, "standard_charge_percentage": 52.0, "count": "0", "additional_payer_notes": "Zero final payments for the item or service in the 15 months prior to posting the file." }, { "payer_name": "BLUE SHIELD OUT OF STATE", "plan_name": "STANFORD HEALTHCARE ALLIANCE PLAN", "methodology": "percent of total billed charges", "standard_charge_dollar": 1032.54, "standard_charge_percentage": 48.59, "count": "0", "additional_payer_notes": "Zero final payments for the item or service in the 15 months prior to posting the file." }, { "payer_name": "BLUE SHIELD", "plan_name": "STANFORD HEALTHCARE ALLIANCE PLAN", "methodology": "percent of total billed charges", "standard_charge_dollar": 1032.54, "standard_charge_percentage": 48.59, "median_amount": 68.24, "10th_percentile": 13.6, "90th_percentile": 1043.06, "count": "30" }, { "payer_name": "BLUE SHIELD", "plan_name": "STANFORD HEALTHCARE ALLIANCE PLAN", "methodology": "percent of total billed charges", "standard_charge_dollar": 1032.54, "standard_charge_percentage": 48.59, "count": "0", "additional_payer_notes": "Zero final payments for the item or service in the 15 months prior to posting the file." }, { "payer_name": "BLUE SHIELD", "plan_name": "STANFORD HEALTHCARE ALLIANCE PLAN", "methodology": "percent of total billed charges", "standard_charge_dollar": 1032.54, "standard_charge_percentage": 48.59, "count": "0", "additional_payer_notes": "Zero final payments for the item or service in the 15 months prior to posting the file." }, { "payer_name": "CIGNA", "plan_name": "CIGNA COM ALT HMO PLAN", "methodology": "percent of total billed charges", "standard_charge_dollar": 896.75, "standard_charge_percentage": 42.2, "count": "0", "additional_payer_notes": "Zero final payments for the item or service in the 15 months prior to posting the file." }, { "payer_name": "CIGNA", "plan_name": "CIGNA COM ALT HMO PLAN", "methodology": "percent of total billed charges", "standard_charge_dollar": 896.75, "standard_charge_percentage": 42.2, "count": "0", "additional_payer_notes": "Zero final payments for the item or service in the 15 months prior to posting the file." }, { "payer_name": "HEALTH NET", "plan_name": "HEALTHNET HMO, PPO, POS, EPO, CANOPY HEALTHNET HMO, OTHER-IN-NETWORK PLANS", "methodology": "per diem", "standard_charge_dollar": 8000.0, "standard_charge_algorithm": "Expected reimbursement is the lesser of Per diem ($8,000) for the length of stay and 70% of billed.", "count": "0", "additional_payer_notes": "Zero final payments for the item or service in the 15 months prior to posting the file." }, { "payer_name": "HEALTH NET", "plan_name": "HEALTHNET HMO, PPO, POS, EPO, CANOPY HEALTHNET HMO, OTHER-IN-NETWORK PLANS", "methodology": "per diem", "standard_charge_dollar": 8000.0, "standard_charge_algorithm": "Expected reimbursement is the lesser of Per diem ($8,000) for the length of stay and 70% of billed.", "count": "0", "additional_payer_notes": "Zero final payments for the item or service in the 15 months prior to posting the file." }, { "payer_name": "UNITED HEALTHCARE", "plan_name": "SUTTER SELECT & SUTTER HEALTH PLAN HMO PLANS", "methodology": "per diem", "standard_charge_dollar": 28538.0, "standard_charge_algorithm": "Per diem ($28,538).", "count": "0", "additional_payer_notes": "Zero final payments for the item or service in the 15 months prior to posting the file." }, { "payer_name": "UNITED HEALTHCARE", "plan_name": "SUTTER SELECT & SUTTER HEALTH PLAN HMO PLANS", "methodology": "per diem", "standard_charge_dollar": 28538.0, "standard_charge_algorithm": "Per diem ($28,538).", "count": "0", "additional_payer_notes": "Zero final payments for the item or service in the 15 months prior to posting the file." }, { "payer_name": "SUTTER", "plan_name": "SUTTER SELECT & SUTTER HEALTH PLAN HMO PLANS", "methodology": "per diem", "standard_charge_dollar": 28538.0, "standard_charge_algorithm": "Per diem ($28,538).", "count": "0", "additional_payer_notes": "Zero final payments for the item or service in the 15 months prior to posting the file." }, { "payer_name": "UNITED HEALTHCARE", "plan_name": "SUTTER SELECT & SUTTER HEALTH PLAN HMO PLANS", "methodology": "per diem", "standard_charge_dollar": 28538.0, "standard_charge_algorithm": "Per diem ($28,538).", "count": "0", "additional_payer_notes": "Zero final payments for the item or service in the 15 months prior to posting the file." }, { "payer_name": "UMR", "plan_name": "SUTTER SELECT & SUTTER HEALTH PLAN HMO PLANS", "methodology": "per diem", "standard_charge_dollar": 28538.0, "standard_charge_algorithm": "Per diem ($28,538).", "count": "0", "additional_payer_notes": "Zero final payments for the item or service in the 15 months prior to posting the file." } ] } ] }, { "description": "Hc Device Ligasure Cutting Gp021", "code_information": [ { "code": "PX-2120055021", "type": "CDM" }, { "code": "99999", "type": "CPT" }, { "code": "0272", "type": "RC" } ], "standard_charges": [ { "setting": "outpatient", "gross_charge": 2888.0, "discounted_cash": 1444.0, "minimum": 1218.74, "maximum": 1501.76, "additional_generic_notes": "Zero final payments for the item or service in the 15 months prior to posting the file.", "payers_information": [ { "payer_name": "AETNA", "plan_name": "AETNA ALL OTHER PLANS", "methodology": "percent of total billed charges", "standard_charge_dollar": 1501.76, "standard_charge_percentage": 52.0, "count": "0", "additional_payer_notes": "Zero final payments for the item or service in the 15 months prior to posting the file." }, { "payer_name": "AETNA", "plan_name": "AETNA ALL OTHER PLANS", "methodology": "percent of total billed charges", "standard_charge_dollar": 1501.76, "standard_charge_percentage": 52.0, "count": "0", "additional_payer_notes": "Zero final payments for the item or service in the 15 months prior to posting the file." }, { "payer_name": "MERITAIN HEALTH", "plan_name": "AETNA ALL OTHER PLANS", "methodology": "percent of total billed charges", "standard_charge_dollar": 1501.76, "standard_charge_percentage": 52.0, "count": "0", "additional_payer_notes": "Zero final payments for the item or service in the 15 months prior to posting the file." }, { "payer_name": "BLUE SHIELD OUT OF STATE", "plan_name": "STANFORD HEALTHCARE ALLIANCE PLAN", "methodology": "percent of total billed charges", "standard_charge_dollar": 1403.28, "standard_charge_percentage": 48.59, "count": "0", "additional_payer_notes": "Zero final payments for the item or service in the 15 months prior to posting the file." }, { "payer_name": "BLUE SHIELD", "plan_name": "STANFORD HEALTHCARE ALLIANCE PLAN", "methodology": "percent of total billed charges", "standard_charge_dollar": 1403.28, "standard_charge_percentage": 48.59, "median_amount": 68.24, "10th_percentile": 13.6, "90th_percentile": 1043.06, "count": "30" }, { "payer_name": "BLUE SHIELD", "plan_name": "STANFORD HEALTHCARE ALLIANCE PLAN", "methodology": "percent of total billed charges", "standard_charge_dollar": 1403.28, "standard_charge_percentage": 48.59, "count": "0", "additional_payer_notes": "Zero final payments for the item or service in the 15 months prior to posting the file." }, { "payer_name": "BLUE SHIELD", "plan_name": "STANFORD HEALTHCARE ALLIANCE PLAN", "methodology": "percent of total billed charges", "standard_charge_dollar": 1403.28, "standard_charge_percentage": 48.59, "count": "0", "additional_payer_notes": "Zero final payments for the item or service in the 15 months prior to posting the file." }, { "payer_name": "CIGNA", "plan_name": "CIGNA COM ALT HMO PLAN", "methodology": "percent of total billed charges", "standard_charge_dollar": 1218.74, "standard_charge_percentage": 42.2, "count": "0", "additional_payer_notes": "Zero final payments for the item or service in the 15 months prior to posting the file." }, { "payer_name": "CIGNA", "plan_name": "CIGNA COM ALT HMO PLAN", "methodology": "percent of total billed charges", "standard_charge_dollar": 1218.74, "standard_charge_percentage": 42.2, "count": "0", "additional_payer_notes": "Zero final payments for the item or service in the 15 months prior to posting the file." }, { "payer_name": "HEALTH NET", "plan_name": "HEALTHNET HMO, PPO, POS, EPO, CANOPY HEALTHNET HMO, OTHER-IN-NETWORK PLANS", "methodology": "per diem", "standard_charge_dollar": 8000.0, "standard_charge_algorithm": "Expected reimbursement is the lesser of Per diem ($8,000) for the length of stay and 70% of billed.", "count": "0", "additional_payer_notes": "Zero final payments for the item or service in the 15 months prior to posting the file." }, { "payer_name": "HEALTH NET", "plan_name": "HEALTHNET HMO, PPO, POS, EPO, CANOPY HEALTHNET HMO, OTHER-IN-NETWORK PLANS", "methodology": "per diem", "standard_charge_dollar": 8000.0, "standard_charge_algorithm": "Expected reimbursement is the lesser of Per diem ($8,000) for the length of stay and 70% of billed.", "count": "0", "additional_payer_notes": "Zero final payments for the item or service in the 15 months prior to posting the file." }, { "payer_name": "UNITED HEALTHCARE", "plan_name": "SUTTER SELECT & SUTTER HEALTH PLAN HMO PLANS", "methodology": "per diem", "standard_charge_dollar": 28538.0, "standard_charge_algorithm": "Per diem ($28,538).", "count": "0", "additional_payer_notes": "Zero final payments for the item or service in the 15 months prior to posting the file." }, { "payer_name": "UNITED HEALTHCARE", "plan_name": "SUTTER SELECT & SUTTER HEALTH PLAN HMO PLANS", "methodology": "per diem", "standard_charge_dollar": 28538.0, "standard_charge_algorithm": "Per diem ($28,538).", "count": "0", "additional_payer_notes": "Zero final payments for the item or service in the 15 months prior to posting the file." }, { "payer_name": "SUTTER", "plan_name": "SUTTER SELECT & SUTTER HEALTH PLAN HMO PLANS", "methodology": "per diem", "standard_charge_dollar": 28538.0, "standard_charge_algorithm": "Per diem ($28,538).", "count": "0", "additional_payer_notes": "Zero final payments for the item or service in the 15 months prior to posting the file." }, { "payer_name": "UNITED HEALTHCARE", "plan_name": "SUTTER SELECT & SUTTER HEALTH PLAN HMO PLANS", "methodology": "per diem", "standard_charge_dollar": 28538.0, "standard_charge_algorithm": "Per diem ($28,538).", "count": "0", "additional_payer_notes": "Zero final payments for the item or service in the 15 months prior to posting the file." }, { "payer_name": "UMR", "plan_name": "SUTTER SELECT & SUTTER HEALTH PLAN HMO PLANS", "methodology": "per diem", "standard_charge_dollar": 28538.0, "standard_charge_algorithm": "Per diem ($28,538).", "count": "0", "additional_payer_notes": "Zero final payments for the item or service in the 15 months prior to posting the file." } ] } ] }, { "description": "HC Device Ligasure Cutting Gp022", "code_information": [ { "code": "PX-2120055022", "type": "CDM" }, { "code": "99999", "type": "CPT" }, { "code": "0272", "type": "RC" } ], "standard_charges": [ { "setting": "outpatient", "gross_charge": 3300.0, "discounted_cash": 1650.0, "minimum": 1392.6, "maximum": 1716.0, "additional_generic_notes": "Zero final payments for the item or service in the 15 months prior to posting the file.", "payers_information": [ { "payer_name": "AETNA", "plan_name": "AETNA ALL OTHER PLANS", "methodology": "percent of total billed charges", "standard_charge_dollar": 1716.0, "standard_charge_percentage": 52.0, "count": "0", "additional_payer_notes": "Zero final payments for the item or service in the 15 months prior to posting the file." }, { "payer_name": "AETNA", "plan_name": "AETNA ALL OTHER PLANS", "methodology": "percent of total billed charges", "standard_charge_dollar": 1716.0, "standard_charge_percentage": 52.0, "count": "0", "additional_payer_notes": "Zero final payments for the item or service in the 15 months prior to posting the file." }, { "payer_name": "MERITAIN HEALTH", "plan_name": "AETNA ALL OTHER PLANS", "methodology": "percent of total billed charges", "standard_charge_dollar": 1716.0, "standard_charge_percentage": 52.0, "count": "0", "additional_payer_notes": "Zero final payments for the item or service in the 15 months prior to posting the file." }, { "payer_name": "BLUE SHIELD OUT OF STATE", "plan_name": "STANFORD HEALTHCARE ALLIANCE PLAN", "methodology": "percent of total billed charges", "standard_charge_dollar": 1603.47, "standard_charge_percentage": 48.59, "count": "0", "additional_payer_notes": "Zero final payments for the item or service in the 15 months prior to posting the file." }, { "payer_name": "BLUE SHIELD", "plan_name": "STANFORD HEALTHCARE ALLIANCE PLAN", "methodology": "percent of total billed charges", "standard_charge_dollar": 1603.47, "standard_charge_percentage": 48.59, "median_amount": 68.24, "10th_percentile": 13.6, "90th_percentile": 1043.06, "count": "30" }, { "payer_name": "BLUE SHIELD", "plan_name": "STANFORD HEALTHCARE ALLIANCE PLAN", "methodology": "percent of total billed charges", "standard_charge_dollar": 1603.47, "standard_charge_percentage": 48.59, "count": "0", "additional_payer_notes": "Zero final payments for the item or service in the 15 months prior to posting the file." }, { "payer_name": "BLUE SHIELD", "plan_name": "STANFORD HEALTHCARE ALLIANCE PLAN", "methodology": "percent of total billed charges", "standard_charge_dollar": 1603.47, "standard_charge_percentage": 48.59, "count": "0", "additional_payer_notes": "Zero final payments for the item or service in the 15 months prior to posting the file." }, { "payer_name": "CIGNA", "plan_name": "CIGNA COM ALT HMO PLAN", "methodology": "percent of total billed charges", "standard_charge_dollar": 1392.6, "standard_charge_percentage": 42.2, "count": "0", "additional_payer_notes": "Zero final payments for the item or service in the 15 months prior to posting the file." }, { "payer_name": "CIGNA", "plan_name": "CIGNA COM ALT HMO PLAN", "methodology": "percent of total billed charges", "standard_charge_dollar": 1392.6, "standard_charge_percentage": 42.2, "count": "0", "additional_payer_notes": "Zero final payments for the item or service in the 15 months prior to posting the file." }, { "payer_name": "HEALTH NET", "plan_name": "HEALTHNET HMO, PPO, POS, EPO, CANOPY HEALTHNET HMO, OTHER-IN-NETWORK PLANS", "methodology": "per diem", "standard_charge_dollar": 8000.0, "standard_charge_algorithm": "Expected reimbursement is the lesser of Per diem ($8,000) for the length of stay and 70% of billed.", "count": "0", "additional_payer_notes": "Zero final payments for the item or service in the 15 months prior to posting the file." }, { "payer_name": "HEALTH NET", "plan_name": "HEALTHNET HMO, PPO, POS, EPO, CANOPY HEALTHNET HMO, OTHER-IN-NETWORK PLANS", "methodology": "per diem", "standard_charge_dollar": 8000.0, "standard_charge_algorithm": "Expected reimbursement is the lesser of Per diem ($8,000) for the length of stay and 70% of billed.", "count": "0", "additional_payer_notes": "Zero final payments for the item or service in the 15 months prior to posting the file." }, { "payer_name": "UNITED HEALTHCARE", "plan_name": "SUTTER SELECT & SUTTER HEALTH PLAN HMO PLANS", "methodology": "per diem", "standard_charge_dollar": 28538.0, "standard_charge_algorithm": "Per diem ($28,538).", "count": "0", "additional_payer_notes": "Zero final payments for the item or service in the 15 months prior to posting the file." }, { "payer_name": "UNITED HEALTHCARE", "plan_name": "SUTTER SELECT & SUTTER HEALTH PLAN HMO PLANS", "methodology": "per diem", "standard_charge_dollar": 28538.0, "standard_charge_algorithm": "Per diem ($28,538).", "count": "0", "additional_payer_notes": "Zero final payments for the item or service in the 15 months prior to posting the file." }, { "payer_name": "SUTTER", "plan_name": "SUTTER SELECT & SUTTER HEALTH PLAN HMO PLANS", "methodology": "per diem", "standard_charge_dollar": 28538.0, "standard_charge_algorithm": "Per diem ($28,538).", "count": "0", "additional_payer_notes": "Zero final payments for the item or service in the 15 months prior to posting the file." }, { "payer_name": "UNITED HEALTHCARE", "plan_name": "SUTTER SELECT & SUTTER HEALTH PLAN HMO PLANS", "methodology": "per diem", "standard_charge_dollar": 28538.0, "standard_charge_algorithm": "Per diem ($28,538).", "count": "0", "additional_payer_notes": "Zero final payments for the item or service in the 15 months prior to posting the file." }, { "payer_name": "UMR", "plan_name": "SUTTER SELECT & SUTTER HEALTH PLAN HMO PLANS", "methodology": "per diem", "standard_charge_dollar": 28538.0, "standard_charge_algorithm": "Per diem ($28,538).", "count": "0", "additional_payer_notes": "Zero final payments for the item or service in the 15 months prior to posting the file." } ] } ] }, { "description": "HC Device Ligasure Cutting Gp023", "code_information": [ { "code": "PX-2120055023", "type": "CDM" }, { "code": "99999", "type": "CPT" }, { "code": "0272", "type": "RC" } ], "standard_charges": [ { "setting": "outpatient", "gross_charge": 3600.0, "discounted_cash": 1800.0, "minimum": 1519.2, "maximum": 1872.0, "additional_generic_notes": "Zero final payments for the item or service in the 15 months prior to posting the file.", "payers_information": [ { "payer_name": "AETNA", "plan_name": "AETNA ALL OTHER PLANS", "methodology": "percent of total billed charges", "standard_charge_dollar": 1872.0, "standard_charge_percentage": 52.0, "count": "0", "additional_payer_notes": "Zero final payments for the item or service in the 15 months prior to posting the file." }, { "payer_name": "AETNA", "plan_name": "AETNA ALL OTHER PLANS", "methodology": "percent of total billed charges", "standard_charge_dollar": 1872.0, "standard_charge_percentage": 52.0, "count": "0", "additional_payer_notes": "Zero final payments for the item or service in the 15 months prior to posting the file." }, { "payer_name": "MERITAIN HEALTH", "plan_name": "AETNA ALL OTHER PLANS", "methodology": "percent of total billed charges", "standard_charge_dollar": 1872.0, "standard_charge_percentage": 52.0, "count": "0", "additional_payer_notes": "Zero final payments for the item or service in the 15 months prior to posting the file." }, { "payer_name": "BLUE SHIELD OUT OF STATE", "plan_name": "STANFORD HEALTHCARE ALLIANCE PLAN", "methodology": "percent of total billed charges", "standard_charge_dollar": 1749.24, "standard_charge_percentage": 48.59, "count": "0", "additional_payer_notes": "Zero final payments for the item or service in the 15 months prior to posting the file." }, { "payer_name": "BLUE SHIELD", "plan_name": "STANFORD HEALTHCARE ALLIANCE PLAN", "methodology": "percent of total billed charges", "standard_charge_dollar": 1749.24, "standard_charge_percentage": 48.59, "median_amount": 68.24, "10th_percentile": 13.6, "90th_percentile": 1043.06, "count": "30" }, { "payer_name": "BLUE SHIELD", "plan_name": "STANFORD HEALTHCARE ALLIANCE PLAN", "methodology": "percent of total billed charges", "standard_charge_dollar": 1749.24, "standard_charge_percentage": 48.59, "count": "0", "additional_payer_notes": "Zero final payments for the item or service in the 15 months prior to posting the file." }, { "payer_name": "BLUE SHIELD", "plan_name": "STANFORD HEALTHCARE ALLIANCE PLAN", "methodology": "percent of total billed charges", "standard_charge_dollar": 1749.24, "standard_charge_percentage": 48.59, "count": "0", "additional_payer_notes": "Zero final payments for the item or service in the 15 months prior to posting the file." }, { "payer_name": "CIGNA", "plan_name": "CIGNA COM ALT HMO PLAN", "methodology": "percent of total billed charges", "standard_charge_dollar": 1519.2, "standard_charge_percentage": 42.2, "count": "0", "additional_payer_notes": "Zero final payments for the item or service in the 15 months prior to posting the file." }, { "payer_name": "CIGNA", "plan_name": "CIGNA COM ALT HMO PLAN", "methodology": "percent of total billed charges", "standard_charge_dollar": 1519.2, "standard_charge_percentage": 42.2, "count": "0", "additional_payer_notes": "Zero final payments for the item or service in the 15 months prior to posting the file." }, { "payer_name": "HEALTH NET", "plan_name": "HEALTHNET HMO, PPO, POS, EPO, CANOPY HEALTHNET HMO, OTHER-IN-NETWORK PLANS", "methodology": "per diem", "standard_charge_dollar": 8000.0, "standard_charge_algorithm": "Expected reimbursement is the lesser of Per diem ($8,000) for the length of stay and 70% of billed.", "count": "0", "additional_payer_notes": "Zero final payments for the item or service in the 15 months prior to posting the file." }, { "payer_name": "HEALTH NET", "plan_name": "HEALTHNET HMO, PPO, POS, EPO, CANOPY HEALTHNET HMO, OTHER-IN-NETWORK PLANS", "methodology": "per diem", "standard_charge_dollar": 8000.0, "standard_charge_algorithm": "Expected reimbursement is the lesser of Per diem ($8,000) for the length of stay and 70% of billed.", "count": "0", "additional_payer_notes": "Zero final payments for the item or service in the 15 months prior to posting the file." }, { "payer_name": "UNITED HEALTHCARE", "plan_name": "SUTTER SELECT & SUTTER HEALTH PLAN HMO PLANS", "methodology": "per diem", "standard_charge_dollar": 28538.0, "standard_charge_algorithm": "Per diem ($28,538).", "count": "0", "additional_payer_notes": "Zero final payments for the item or service in the 15 months prior to posting the file." }, { "payer_name": "UNITED HEALTHCARE", "plan_name": "SUTTER SELECT & SUTTER HEALTH PLAN HMO PLANS", "methodology": "per diem", "standard_charge_dollar": 28538.0, "standard_charge_algorithm": "Per diem ($28,538).", "count": "0", "additional_payer_notes": "Zero final payments for the item or service in the 15 months prior to posting the file." }, { "payer_name": "SUTTER", "plan_name": "SUTTER SELECT & SUTTER HEALTH PLAN HMO PLANS", "methodology": "per diem", "standard_charge_dollar": 28538.0, "standard_charge_algorithm": "Per diem ($28,538).", "count": "0", "additional_payer_notes": "Zero final payments for the item or service in the 15 months prior to posting the file." }, { "payer_name": "UNITED HEALTHCARE", "plan_name": "SUTTER SELECT & SUTTER HEALTH PLAN HMO PLANS", "methodology": "per diem", "standard_charge_dollar": 28538.0, "standard_charge_algorithm": "Per diem ($28,538).", "count": "0", "additional_payer_notes": "Zero final payments for the item or service in the 15 months prior to posting the file." }, { "payer_name": "UMR", "plan_name": "SUTTER SELECT & SUTTER HEALTH PLAN HMO PLANS", "methodology": "per diem", "standard_charge_dollar": 28538.0, "standard_charge_algorithm": "Per diem ($28,538).", "count": "0", "additional_payer_notes": "Zero final payments for the item or service in the 15 months prior to posting the file." } ] } ] }, { "description": "HC Device Ligasure Cutting Gp024", "code_information": [ { "code": "PX-2120055024", "type": "CDM" }, { "code": "99999", "type": "CPT" }, { "code": "0272", "type": "RC" } ], "standard_charges": [ { "setting": "outpatient", "gross_charge": 4000.0, "discounted_cash": 2000.0, "minimum": 1688.0, "maximum": 2080.0, "additional_generic_notes": "Zero final payments for the item or service in the 15 months prior to posting the file.", "payers_information": [ { "payer_name": "AETNA", "plan_name": "AETNA ALL OTHER PLANS", "methodology": "percent of total billed charges", "standard_charge_dollar": 2080.0, "standard_charge_percentage": 52.0, "count": "0", "additional_payer_notes": "Zero final payments for the item or service in the 15 months prior to posting the file." }, { "payer_name": "AETNA", "plan_name": "AETNA ALL OTHER PLANS", "methodology": "percent of total billed charges", "standard_charge_dollar": 2080.0, "standard_charge_percentage": 52.0, "count": "0", "additional_payer_notes": "Zero final payments for the item or service in the 15 months prior to posting the file." }, { "payer_name": "MERITAIN HEALTH", "plan_name": "AETNA ALL OTHER PLANS", "methodology": "percent of total billed charges", "standard_charge_dollar": 2080.0, "standard_charge_percentage": 52.0, "count": "0", "additional_payer_notes": "Zero final payments for the item or service in the 15 months prior to posting the file." }, { "payer_name": "BLUE SHIELD OUT OF STATE", "plan_name": "STANFORD HEALTHCARE ALLIANCE PLAN", "methodology": "percent of total billed charges", "standard_charge_dollar": 1943.6, "standard_charge_percentage": 48.59, "count": "0", "additional_payer_notes": "Zero final payments for the item or service in the 15 months prior to posting the file." }, { "payer_name": "BLUE SHIELD", "plan_name": "STANFORD HEALTHCARE ALLIANCE PLAN", "methodology": "percent of total billed charges", "standard_charge_dollar": 1943.6, "standard_charge_percentage": 48.59, "median_amount": 68.24, "10th_percentile": 13.6, "90th_percentile": 1043.06, "count": "30" }, { "payer_name": "BLUE SHIELD", "plan_name": "STANFORD HEALTHCARE ALLIANCE PLAN", "methodology": "percent of total billed charges", "standard_charge_dollar": 1943.6, "standard_charge_percentage": 48.59, "count": "0", "additional_payer_notes": "Zero final payments for the item or service in the 15 months prior to posting the file." }, { "payer_name": "BLUE SHIELD", "plan_name": "STANFORD HEALTHCARE ALLIANCE PLAN", "methodology": "percent of total billed charges", "standard_charge_dollar": 1943.6, "standard_charge_percentage": 48.59, "count": "0", "additional_payer_notes": "Zero final payments for the item or service in the 15 months prior to posting the file." }, { "payer_name": "CIGNA", "plan_name": "CIGNA COM ALT HMO PLAN", "methodology": "percent of total billed charges", "standard_charge_dollar": 1688.0, "standard_charge_percentage": 42.2, "count": "0", "additional_payer_notes": "Zero final payments for the item or service in the 15 months prior to posting the file." }, { "payer_name": "CIGNA", "plan_name": "CIGNA COM ALT HMO PLAN", "methodology": "percent of total billed charges", "standard_charge_dollar": 1688.0, "standard_charge_percentage": 42.2, "count": "0", "additional_payer_notes": "Zero final payments for the item or service in the 15 months prior to posting the file." }, { "payer_name": "HEALTH NET", "plan_name": "HEALTHNET HMO, PPO, POS, EPO, CANOPY HEALTHNET HMO, OTHER-IN-NETWORK PLANS", "methodology": "per diem", "standard_charge_dollar": 8000.0, "standard_charge_algorithm": "Expected reimbursement is the lesser of Per diem ($8,000) for the length of stay and 70% of billed.", "count": "0", "additional_payer_notes": "Zero final payments for the item or service in the 15 months prior to posting the file." }, { "payer_name": "HEALTH NET", "plan_name": "HEALTHNET HMO, PPO, POS, EPO, CANOPY HEALTHNET HMO, OTHER-IN-NETWORK PLANS", "methodology": "per diem", "standard_charge_dollar": 8000.0, "standard_charge_algorithm": "Expected reimbursement is the lesser of Per diem ($8,000) for the length of stay and 70% of billed.", "count": "0", "additional_payer_notes": "Zero final payments for the item or service in the 15 months prior to posting the file." }, { "payer_name": "UNITED HEALTHCARE", "plan_name": "SUTTER SELECT & SUTTER HEALTH PLAN HMO PLANS", "methodology": "per diem", "standard_charge_dollar": 28538.0, "standard_charge_algorithm": "Per diem ($28,538).", "count": "0", "additional_payer_notes": "Zero final payments for the item or service in the 15 months prior to posting the file." }, { "payer_name": "UNITED HEALTHCARE", "plan_name": "SUTTER SELECT & SUTTER HEALTH PLAN HMO PLANS", "methodology": "per diem", "standard_charge_dollar": 28538.0, "standard_charge_algorithm": "Per diem ($28,538).", "count": "0", "additional_payer_notes": "Zero final payments for the item or service in the 15 months prior to posting the file." }, { "payer_name": "SUTTER", "plan_name": "SUTTER SELECT & SUTTER HEALTH PLAN HMO PLANS", "methodology": "per diem", "standard_charge_dollar": 28538.0, "standard_charge_algorithm": "Per diem ($28,538).", "count": "0", "additional_payer_notes": "Zero final payments for the item or service in the 15 months prior to posting the file." }, { "payer_name": "UNITED HEALTHCARE", "plan_name": "SUTTER SELECT & SUTTER HEALTH PLAN HMO PLANS", "methodology": "per diem", "standard_charge_dollar": 28538.0, "standard_charge_algorithm": "Per diem ($28,538).", "count": "0", "additional_payer_notes": "Zero final payments for the item or service in the 15 months prior to posting the file." }, { "payer_name": "UMR", "plan_name": "SUTTER SELECT & SUTTER HEALTH PLAN HMO PLANS", "methodology": "per diem", "standard_charge_dollar": 28538.0, "standard_charge_algorithm": "Per diem ($28,538).", "count": "0", "additional_payer_notes": "Zero final payments for the item or service in the 15 months prior to posting the file." } ] } ] }, { "description": "HC Device Ligasure Cutting Gp025", "code_information": [ { "code": "PX-2120055025", "type": "CDM" }, { "code": "99999", "type": "CPT" }, { "code": "0272", "type": "RC" } ], "standard_charges": [ { "setting": "outpatient", "gross_charge": 4263.0, "discounted_cash": 2131.5, "minimum": 1798.99, "maximum": 2216.76, "additional_generic_notes": "Zero final payments for the item or service in the 15 months prior to posting the file.", "payers_information": [ { "payer_name": "AETNA", "plan_name": "AETNA ALL OTHER PLANS", "methodology": "percent of total billed charges", "standard_charge_dollar": 2216.76, "standard_charge_percentage": 52.0, "count": "0", "additional_payer_notes": "Zero final payments for the item or service in the 15 months prior to posting the file." }, { "payer_name": "AETNA", "plan_name": "AETNA ALL OTHER PLANS", "methodology": "percent of total billed charges", "standard_charge_dollar": 2216.76, "standard_charge_percentage": 52.0, "count": "0", "additional_payer_notes": "Zero final payments for the item or service in the 15 months prior to posting the file." }, { "payer_name": "MERITAIN HEALTH", "plan_name": "AETNA ALL OTHER PLANS", "methodology": "percent of total billed charges", "standard_charge_dollar": 2216.76, "standard_charge_percentage": 52.0, "count": "0", "additional_payer_notes": "Zero final payments for the item or service in the 15 months prior to posting the file." }, { "payer_name": "BLUE SHIELD OUT OF STATE", "plan_name": "STANFORD HEALTHCARE ALLIANCE PLAN", "methodology": "percent of total billed charges", "standard_charge_dollar": 2071.39, "standard_charge_percentage": 48.59, "count": "0", "additional_payer_notes": "Zero final payments for the item or service in the 15 months prior to posting the file." }, { "payer_name": "BLUE SHIELD", "plan_name": "STANFORD HEALTHCARE ALLIANCE PLAN", "methodology": "percent of total billed charges", "standard_charge_dollar": 2071.39, "standard_charge_percentage": 48.59, "median_amount": 68.24, "10th_percentile": 13.6, "90th_percentile": 1043.06, "count": "30" }, { "payer_name": "BLUE SHIELD", "plan_name": "STANFORD HEALTHCARE ALLIANCE PLAN", "methodology": "percent of total billed charges", "standard_charge_dollar": 2071.39, "standard_charge_percentage": 48.59, "count": "0", "additional_payer_notes": "Zero final payments for the item or service in the 15 months prior to posting the file." }, { "payer_name": "BLUE SHIELD", "plan_name": "STANFORD HEALTHCARE ALLIANCE PLAN", "methodology": "percent of total billed charges", "standard_charge_dollar": 2071.39, "standard_charge_percentage": 48.59, "count": "0", "additional_payer_notes": "Zero final payments for the item or service in the 15 months prior to posting the file." }, { "payer_name": "CIGNA", "plan_name": "CIGNA COM ALT HMO PLAN", "methodology": "percent of total billed charges", "standard_charge_dollar": 1798.99, "standard_charge_percentage": 42.2, "count": "0", "additional_payer_notes": "Zero final payments for the item or service in the 15 months prior to posting the file." }, { "payer_name": "CIGNA", "plan_name": "CIGNA COM ALT HMO PLAN", "methodology": "percent of total billed charges", "standard_charge_dollar": 1798.99, "standard_charge_percentage": 42.2, "count": "0", "additional_payer_notes": "Zero final payments for the item or service in the 15 months prior to posting the file." }, { "payer_name": "HEALTH NET", "plan_name": "HEALTHNET HMO, PPO, POS, EPO, CANOPY HEALTHNET HMO, OTHER-IN-NETWORK PLANS", "methodology": "per diem", "standard_charge_dollar": 8000.0, "standard_charge_algorithm": "Expected reimbursement is the lesser of Per diem ($8,000) for the length of stay and 70% of billed.", "count": "0", "additional_payer_notes": "Zero final payments for the item or service in the 15 months prior to posting the file." }, { "payer_name": "HEALTH NET", "plan_name": "HEALTHNET HMO, PPO, POS, EPO, CANOPY HEALTHNET HMO, OTHER-IN-NETWORK PLANS", "methodology": "per diem", "standard_charge_dollar": 8000.0, "standard_charge_algorithm": "Expected reimbursement is the lesser of Per diem ($8,000) for the length of stay and 70% of billed.", "count": "0", "additional_payer_notes": "Zero final payments for the item or service in the 15 months prior to posting the file." }, { "payer_name": "UNITED HEALTHCARE", "plan_name": "SUTTER SELECT & SUTTER HEALTH PLAN HMO PLANS", "methodology": "per diem", "standard_charge_dollar": 28538.0, "standard_charge_algorithm": "Per diem ($28,538).", "count": "0", "additional_payer_notes": "Zero final payments for the item or service in the 15 months prior to posting the file." }, { "payer_name": "UNITED HEALTHCARE", "plan_name": "SUTTER SELECT & SUTTER HEALTH PLAN HMO PLANS", "methodology": "per diem", "standard_charge_dollar": 28538.0, "standard_charge_algorithm": "Per diem ($28,538).", "count": "0", "additional_payer_notes": "Zero final payments for the item or service in the 15 months prior to posting the file." }, { "payer_name": "SUTTER", "plan_name": "SUTTER SELECT & SUTTER HEALTH PLAN HMO PLANS", "methodology": "per diem", "standard_charge_dollar": 28538.0, "standard_charge_algorithm": "Per diem ($28,538).", "count": "0", "additional_payer_notes": "Zero final payments for the item or service in the 15 months prior to posting the file." }, { "payer_name": "UNITED HEALTHCARE", "plan_name": "SUTTER SELECT & SUTTER HEALTH PLAN HMO PLANS", "methodology": "per diem", "standard_charge_dollar": 28538.0, "standard_charge_algorithm": "Per diem ($28,538).", "count": "0", "additional_payer_notes": "Zero final payments for the item or service in the 15 months prior to posting the file." }, { "payer_name": "UMR", "plan_name": "SUTTER SELECT & SUTTER HEALTH PLAN HMO PLANS", "methodology": "per diem", "standard_charge_dollar": 28538.0, "standard_charge_algorithm": "Per diem ($28,538).", "count": "0", "additional_payer_notes": "Zero final payments for the item or service in the 15 months prior to posting the file." } ] } ] }, { "description": "HC Device Ligasure Cutting Gp026", "code_information": [ { "code": "PX-2120055026", "type": "CDM" }, { "code": "99999", "type": "CPT" }, { "code": "0272", "type": "RC" } ], "standard_charges": [ { "setting": "outpatient", "gross_charge": 4650.0, "discounted_cash": 2325.0, "minimum": 1962.3, "maximum": 2418.0, "additional_generic_notes": "Zero final payments for the item or service in the 15 months prior to posting the file.", "payers_information": [ { "payer_name": "AETNA", "plan_name": "AETNA ALL OTHER PLANS", "methodology": "percent of total billed charges", "standard_charge_dollar": 2418.0, "standard_charge_percentage": 52.0, "count": "0", "additional_payer_notes": "Zero final payments for the item or service in the 15 months prior to posting the file." }, { "payer_name": "AETNA", "plan_name": "AETNA ALL OTHER PLANS", "methodology": "percent of total billed charges", "standard_charge_dollar": 2418.0, "standard_charge_percentage": 52.0, "count": "0", "additional_payer_notes": "Zero final payments for the item or service in the 15 months prior to posting the file." }, { "payer_name": "MERITAIN HEALTH", "plan_name": "AETNA ALL OTHER PLANS", "methodology": "percent of total billed charges", "standard_charge_dollar": 2418.0, "standard_charge_percentage": 52.0, "count": "0", "additional_payer_notes": "Zero final payments for the item or service in the 15 months prior to posting the file." }, { "payer_name": "BLUE SHIELD OUT OF STATE", "plan_name": "STANFORD HEALTHCARE ALLIANCE PLAN", "methodology": "percent of total billed charges", "standard_charge_dollar": 2259.44, "standard_charge_percentage": 48.59, "count": "0", "additional_payer_notes": "Zero final payments for the item or service in the 15 months prior to posting the file." }, { "payer_name": "BLUE SHIELD", "plan_name": "STANFORD HEALTHCARE ALLIANCE PLAN", "methodology": "percent of total billed charges", "standard_charge_dollar": 2259.44, "standard_charge_percentage": 48.59, "median_amount": 68.24, "10th_percentile": 13.6, "90th_percentile": 1043.06, "count": "30" }, { "payer_name": "BLUE SHIELD", "plan_name": "STANFORD HEALTHCARE ALLIANCE PLAN", "methodology": "percent of total billed charges", "standard_charge_dollar": 2259.44, "standard_charge_percentage": 48.59, "count": "0", "additional_payer_notes": "Zero final payments for the item or service in the 15 months prior to posting the file." }, { "payer_name": "BLUE SHIELD", "plan_name": "STANFORD HEALTHCARE ALLIANCE PLAN", "methodology": "percent of total billed charges", "standard_charge_dollar": 2259.44, "standard_charge_percentage": 48.59, "count": "0", "additional_payer_notes": "Zero final payments for the item or service in the 15 months prior to posting the file." }, { "payer_name": "CIGNA", "plan_name": "CIGNA COM ALT HMO PLAN", "methodology": "percent of total billed charges", "standard_charge_dollar": 1962.3, "standard_charge_percentage": 42.2, "count": "0", "additional_payer_notes": "Zero final payments for the item or service in the 15 months prior to posting the file." }, { "payer_name": "CIGNA", "plan_name": "CIGNA COM ALT HMO PLAN", "methodology": "percent of total billed charges", "standard_charge_dollar": 1962.3, "standard_charge_percentage": 42.2, "count": "0", "additional_payer_notes": "Zero final payments for the item or service in the 15 months prior to posting the file." }, { "payer_name": "HEALTH NET", "plan_name": "HEALTHNET HMO, PPO, POS, EPO, CANOPY HEALTHNET HMO, OTHER-IN-NETWORK PLANS", "methodology": "per diem", "standard_charge_dollar": 8000.0, "standard_charge_algorithm": "Expected reimbursement is the lesser of Per diem ($8,000) for the length of stay and 70% of billed.", "count": "0", "additional_payer_notes": "Zero final payments for the item or service in the 15 months prior to posting the file." }, { "payer_name": "HEALTH NET", "plan_name": "HEALTHNET HMO, PPO, POS, EPO, CANOPY HEALTHNET HMO, OTHER-IN-NETWORK PLANS", "methodology": "per diem", "standard_charge_dollar": 8000.0, "standard_charge_algorithm": "Expected reimbursement is the lesser of Per diem ($8,000) for the length of stay and 70% of billed.", "count": "0", "additional_payer_notes": "Zero final payments for the item or service in the 15 months prior to posting the file." }, { "payer_name": "UNITED HEALTHCARE", "plan_name": "SUTTER SELECT & SUTTER HEALTH PLAN HMO PLANS", "methodology": "per diem", "standard_charge_dollar": 28538.0, "standard_charge_algorithm": "Per diem ($28,538).", "count": "0", "additional_payer_notes": "Zero final payments for the item or service in the 15 months prior to posting the file." }, { "payer_name": "UNITED HEALTHCARE", "plan_name": "SUTTER SELECT & SUTTER HEALTH PLAN HMO PLANS", "methodology": "per diem", "standard_charge_dollar": 28538.0, "standard_charge_algorithm": "Per diem ($28,538).", "count": "0", "additional_payer_notes": "Zero final payments for the item or service in the 15 months prior to posting the file." }, { "payer_name": "SUTTER", "plan_name": "SUTTER SELECT & SUTTER HEALTH PLAN HMO PLANS", "methodology": "per diem", "standard_charge_dollar": 28538.0, "standard_charge_algorithm": "Per diem ($28,538).", "count": "0", "additional_payer_notes": "Zero final payments for the item or service in the 15 months prior to posting the file." }, { "payer_name": "UNITED HEALTHCARE", "plan_name": "SUTTER SELECT & SUTTER HEALTH PLAN HMO PLANS", "methodology": "per diem", "standard_charge_dollar": 28538.0, "standard_charge_algorithm": "Per diem ($28,538).", "count": "0", "additional_payer_notes": "Zero final payments for the item or service in the 15 months prior to posting the file." }, { "payer_name": "UMR", "plan_name": "SUTTER SELECT & SUTTER HEALTH PLAN HMO PLANS", "methodology": "per diem", "standard_charge_dollar": 28538.0, "standard_charge_algorithm": "Per diem ($28,538).", "count": "0", "additional_payer_notes": "Zero final payments for the item or service in the 15 months prior to posting the file." } ] } ] }, { "description": "HC Device Wound Closure Gp008", "code_information": [ { "code": "PX-2120056008", "type": "CDM" }, { "code": "99999", "type": "CPT" }, { "code": "0272", "type": "RC" } ], "standard_charges": [ { "setting": "outpatient", "gross_charge": 475.0, "discounted_cash": 237.5, "minimum": 200.45, "maximum": 247.0, "additional_generic_notes": "Zero final payments for the item or service in the 15 months prior to posting the file.", "payers_information": [ { "payer_name": "AETNA", "plan_name": "AETNA ALL OTHER PLANS", "methodology": "percent of total billed charges", "standard_charge_dollar": 247.0, "standard_charge_percentage": 52.0, "count": "0", "additional_payer_notes": "Zero final payments for the item or service in the 15 months prior to posting the file." }, { "payer_name": "AETNA", "plan_name": "AETNA ALL OTHER PLANS", "methodology": "percent of total billed charges", "standard_charge_dollar": 247.0, "standard_charge_percentage": 52.0, "count": "0", "additional_payer_notes": "Zero final payments for the item or service in the 15 months prior to posting the file." }, { "payer_name": "MERITAIN HEALTH", "plan_name": "AETNA ALL OTHER PLANS", "methodology": "percent of total billed charges", "standard_charge_dollar": 247.0, "standard_charge_percentage": 52.0, "count": "0", "additional_payer_notes": "Zero final payments for the item or service in the 15 months prior to posting the file." }, { "payer_name": "BLUE SHIELD OUT OF STATE", "plan_name": "STANFORD HEALTHCARE ALLIANCE PLAN", "methodology": "percent of total billed charges", "standard_charge_dollar": 230.8, "standard_charge_percentage": 48.59, "count": "0", "additional_payer_notes": "Zero final payments for the item or service in the 15 months prior to posting the file." }, { "payer_name": "BLUE SHIELD", "plan_name": "STANFORD HEALTHCARE ALLIANCE PLAN", "methodology": "percent of total billed charges", "standard_charge_dollar": 230.8, "standard_charge_percentage": 48.59, "count": "0", "additional_payer_notes": "Zero final payments for the item or service in the 15 months prior to posting the file." }, { "payer_name": "BLUE SHIELD", "plan_name": "STANFORD HEALTHCARE ALLIANCE PLAN", "methodology": "percent of total billed charges", "standard_charge_dollar": 230.8, "standard_charge_percentage": 48.59, "count": "0", "additional_payer_notes": "Zero final payments for the item or service in the 15 months prior to posting the file." }, { "payer_name": "CIGNA", "plan_name": "CIGNA COM ALT HMO PLAN", "methodology": "percent of total billed charges", "standard_charge_dollar": 200.45, "standard_charge_percentage": 42.2, "count": "0", "additional_payer_notes": "Zero final payments for the item or service in the 15 months prior to posting the file." }, { "payer_name": "CIGNA", "plan_name": "CIGNA COM ALT HMO PLAN", "methodology": "percent of total billed charges", "standard_charge_dollar": 200.45, "standard_charge_percentage": 42.2, "count": "0", "additional_payer_notes": "Zero final payments for the item or service in the 15 months prior to posting the file." }, { "payer_name": "HEALTH NET", "plan_name": "HEALTHNET HMO, PPO, POS, EPO, CANOPY HEALTHNET HMO, OTHER-IN-NETWORK PLANS", "methodology": "per diem", "standard_charge_dollar": 8000.0, "standard_charge_algorithm": "Expected reimbursement is the lesser of Per diem ($8,000) for the length of stay and 70% of billed.", "count": "0", "additional_payer_notes": "Zero final payments for the item or service in the 15 months prior to posting the file." }, { "payer_name": "HEALTH NET", "plan_name": "HEALTHNET HMO, PPO, POS, EPO, CANOPY HEALTHNET HMO, OTHER-IN-NETWORK PLANS", "methodology": "per diem", "standard_charge_dollar": 8000.0, "standard_charge_algorithm": "Expected reimbursement is the lesser of Per diem ($8,000) for the length of stay and 70% of billed.", "count": "0", "additional_payer_notes": "Zero final payments for the item or service in the 15 months prior to posting the file." }, { "payer_name": "UNITED HEALTHCARE", "plan_name": "SUTTER SELECT & SUTTER HEALTH PLAN HMO PLANS", "methodology": "per diem", "standard_charge_dollar": 28538.0, "standard_charge_algorithm": "Per diem ($28,538).", "count": "0", "additional_payer_notes": "Zero final payments for the item or service in the 15 months prior to posting the file." }, { "payer_name": "UNITED HEALTHCARE", "plan_name": "SUTTER SELECT & SUTTER HEALTH PLAN HMO PLANS", "methodology": "per diem", "standard_charge_dollar": 28538.0, "standard_charge_algorithm": "Per diem ($28,538).", "count": "0", "additional_payer_notes": "Zero final payments for the item or service in the 15 months prior to posting the file." }, { "payer_name": "SUTTER", "plan_name": "SUTTER SELECT & SUTTER HEALTH PLAN HMO PLANS", "methodology": "per diem", "standard_charge_dollar": 28538.0, "standard_charge_algorithm": "Per diem ($28,538).", "count": "0", "additional_payer_notes": "Zero final payments for the item or service in the 15 months prior to posting the file." }, { "payer_name": "UNITED HEALTHCARE", "plan_name": "SUTTER SELECT & SUTTER HEALTH PLAN HMO PLANS", "methodology": "per diem", "standard_charge_dollar": 28538.0, "standard_charge_algorithm": "Per diem ($28,538).", "count": "0", "additional_payer_notes": "Zero final payments for the item or service in the 15 months prior to posting the file." }, { "payer_name": "UMR", "plan_name": "SUTTER SELECT & SUTTER HEALTH PLAN HMO PLANS", "methodology": "per diem", "standard_charge_dollar": 28538.0, "standard_charge_algorithm": "Per diem ($28,538).", "count": "0", "additional_payer_notes": "Zero final payments for the item or service in the 15 months prior to posting the file." } ] } ] }, { "description": "HC Device Wound Closure Gp011", "code_information": [ { "code": "PX-2120056011", "type": "CDM" }, { "code": "99999", "type": "CPT" }, { "code": "0272", "type": "RC" } ], "standard_charges": [ { "setting": "outpatient", "gross_charge": 740.0, "discounted_cash": 370.0, "minimum": 312.28, "maximum": 384.8, "additional_generic_notes": "Zero final payments for the item or service in the 15 months prior to posting the file.", "payers_information": [ { "payer_name": "AETNA", "plan_name": "AETNA ALL OTHER PLANS", "methodology": "percent of total billed charges", "standard_charge_dollar": 384.8, "standard_charge_percentage": 52.0, "count": "0", "additional_payer_notes": "Zero final payments for the item or service in the 15 months prior to posting the file." }, { "payer_name": "AETNA", "plan_name": "AETNA ALL OTHER PLANS", "methodology": "percent of total billed charges", "standard_charge_dollar": 384.8, "standard_charge_percentage": 52.0, "count": "0", "additional_payer_notes": "Zero final payments for the item or service in the 15 months prior to posting the file." }, { "payer_name": "MERITAIN HEALTH", "plan_name": "AETNA ALL OTHER PLANS", "methodology": "percent of total billed charges", "standard_charge_dollar": 384.8, "standard_charge_percentage": 52.0, "count": "0", "additional_payer_notes": "Zero final payments for the item or service in the 15 months prior to posting the file." }, { "payer_name": "BLUE SHIELD OUT OF STATE", "plan_name": "STANFORD HEALTHCARE ALLIANCE PLAN", "methodology": "percent of total billed charges", "standard_charge_dollar": 359.57, "standard_charge_percentage": 48.59, "count": "0", "additional_payer_notes": "Zero final payments for the item or service in the 15 months prior to posting the file." }, { "payer_name": "BLUE SHIELD", "plan_name": "STANFORD HEALTHCARE ALLIANCE PLAN", "methodology": "percent of total billed charges", "standard_charge_dollar": 359.57, "standard_charge_percentage": 48.59, "count": "0", "additional_payer_notes": "Zero final payments for the item or service in the 15 months prior to posting the file." }, { "payer_name": "BLUE SHIELD", "plan_name": "STANFORD HEALTHCARE ALLIANCE PLAN", "methodology": "percent of total billed charges", "standard_charge_dollar": 359.57, "standard_charge_percentage": 48.59, "count": "0", "additional_payer_notes": "Zero final payments for the item or service in the 15 months prior to posting the file." }, { "payer_name": "CIGNA", "plan_name": "CIGNA COM ALT HMO PLAN", "methodology": "percent of total billed charges", "standard_charge_dollar": 312.28, "standard_charge_percentage": 42.2, "count": "0", "additional_payer_notes": "Zero final payments for the item or service in the 15 months prior to posting the file." }, { "payer_name": "CIGNA", "plan_name": "CIGNA COM ALT HMO PLAN", "methodology": "percent of total billed charges", "standard_charge_dollar": 312.28, "standard_charge_percentage": 42.2, "count": "0", "additional_payer_notes": "Zero final payments for the item or service in the 15 months prior to posting the file." }, { "payer_name": "HEALTH NET", "plan_name": "HEALTHNET HMO, PPO, POS, EPO, CANOPY HEALTHNET HMO, OTHER-IN-NETWORK PLANS", "methodology": "per diem", "standard_charge_dollar": 8000.0, "standard_charge_algorithm": "Expected reimbursement is the lesser of Per diem ($8,000) for the length of stay and 70% of billed.", "count": "0", "additional_payer_notes": "Zero final payments for the item or service in the 15 months prior to posting the file." }, { "payer_name": "HEALTH NET", "plan_name": "HEALTHNET HMO, PPO, POS, EPO, CANOPY HEALTHNET HMO, OTHER-IN-NETWORK PLANS", "methodology": "per diem", "standard_charge_dollar": 8000.0, "standard_charge_algorithm": "Expected reimbursement is the lesser of Per diem ($8,000) for the length of stay and 70% of billed.", "count": "0", "additional_payer_notes": "Zero final payments for the item or service in the 15 months prior to posting the file." }, { "payer_name": "UNITED HEALTHCARE", "plan_name": "SUTTER SELECT & SUTTER HEALTH PLAN HMO PLANS", "methodology": "per diem", "standard_charge_dollar": 28538.0, "standard_charge_algorithm": "Per diem ($28,538).", "count": "0", "additional_payer_notes": "Zero final payments for the item or service in the 15 months prior to posting the file." }, { "payer_name": "UNITED HEALTHCARE", "plan_name": "SUTTER SELECT & SUTTER HEALTH PLAN HMO PLANS", "methodology": "per diem", "standard_charge_dollar": 28538.0, "standard_charge_algorithm": "Per diem ($28,538).", "count": "0", "additional_payer_notes": "Zero final payments for the item or service in the 15 months prior to posting the file." }, { "payer_name": "SUTTER", "plan_name": "SUTTER SELECT & SUTTER HEALTH PLAN HMO PLANS", "methodology": "per diem", "standard_charge_dollar": 28538.0, "standard_charge_algorithm": "Per diem ($28,538).", "count": "0", "additional_payer_notes": "Zero final payments for the item or service in the 15 months prior to posting the file." }, { "payer_name": "UNITED HEALTHCARE", "plan_name": "SUTTER SELECT & SUTTER HEALTH PLAN HMO PLANS", "methodology": "per diem", "standard_charge_dollar": 28538.0, "standard_charge_algorithm": "Per diem ($28,538).", "count": "0", "additional_payer_notes": "Zero final payments for the item or service in the 15 months prior to posting the file." }, { "payer_name": "UMR", "plan_name": "SUTTER SELECT & SUTTER HEALTH PLAN HMO PLANS", "methodology": "per diem", "standard_charge_dollar": 28538.0, "standard_charge_algorithm": "Per diem ($28,538).", "count": "0", "additional_payer_notes": "Zero final payments for the item or service in the 15 months prior to posting the file." } ] } ] }, { "description": "HC Device Wound Closure Gp012", "code_information": [ { "code": "PX-2120056012", "type": "CDM" }, { "code": "99999", "type": "CPT" }, { "code": "0272", "type": "RC" } ], "standard_charges": [ { "setting": "outpatient", "gross_charge": 810.0, "discounted_cash": 405.0, "minimum": 341.82, "maximum": 421.2, "additional_generic_notes": "Zero final payments for the item or service in the 15 months prior to posting the file.", "payers_information": [ { "payer_name": "AETNA", "plan_name": "AETNA ALL OTHER PLANS", "methodology": "percent of total billed charges", "standard_charge_dollar": 421.2, "standard_charge_percentage": 52.0, "count": "0", "additional_payer_notes": "Zero final payments for the item or service in the 15 months prior to posting the file." }, { "payer_name": "AETNA", "plan_name": "AETNA ALL OTHER PLANS", "methodology": "percent of total billed charges", "standard_charge_dollar": 421.2, "standard_charge_percentage": 52.0, "count": "0", "additional_payer_notes": "Zero final payments for the item or service in the 15 months prior to posting the file." }, { "payer_name": "MERITAIN HEALTH", "plan_name": "AETNA ALL OTHER PLANS", "methodology": "percent of total billed charges", "standard_charge_dollar": 421.2, "standard_charge_percentage": 52.0, "count": "0", "additional_payer_notes": "Zero final payments for the item or service in the 15 months prior to posting the file." }, { "payer_name": "BLUE SHIELD OUT OF STATE", "plan_name": "STANFORD HEALTHCARE ALLIANCE PLAN", "methodology": "percent of total billed charges", "standard_charge_dollar": 393.58, "standard_charge_percentage": 48.59, "count": "0", "additional_payer_notes": "Zero final payments for the item or service in the 15 months prior to posting the file." }, { "payer_name": "BLUE SHIELD", "plan_name": "STANFORD HEALTHCARE ALLIANCE PLAN", "methodology": "percent of total billed charges", "standard_charge_dollar": 393.58, "standard_charge_percentage": 48.59, "count": "0", "additional_payer_notes": "Zero final payments for the item or service in the 15 months prior to posting the file." }, { "payer_name": "BLUE SHIELD", "plan_name": "STANFORD HEALTHCARE ALLIANCE PLAN", "methodology": "percent of total billed charges", "standard_charge_dollar": 393.58, "standard_charge_percentage": 48.59, "count": "0", "additional_payer_notes": "Zero final payments for the item or service in the 15 months prior to posting the file." }, { "payer_name": "CIGNA", "plan_name": "CIGNA COM ALT HMO PLAN", "methodology": "percent of total billed charges", "standard_charge_dollar": 341.82, "standard_charge_percentage": 42.2, "count": "0", "additional_payer_notes": "Zero final payments for the item or service in the 15 months prior to posting the file." }, { "payer_name": "CIGNA", "plan_name": "CIGNA COM ALT HMO PLAN", "methodology": "percent of total billed charges", "standard_charge_dollar": 341.82, "standard_charge_percentage": 42.2, "count": "0", "additional_payer_notes": "Zero final payments for the item or service in the 15 months prior to posting the file." }, { "payer_name": "HEALTH NET", "plan_name": "HEALTHNET HMO, PPO, POS, EPO, CANOPY HEALTHNET HMO, OTHER-IN-NETWORK PLANS", "methodology": "per diem", "standard_charge_dollar": 8000.0, "standard_charge_algorithm": "Expected reimbursement is the lesser of Per diem ($8,000) for the length of stay and 70% of billed.", "count": "0", "additional_payer_notes": "Zero final payments for the item or service in the 15 months prior to posting the file." }, { "payer_name": "HEALTH NET", "plan_name": "HEALTHNET HMO, PPO, POS, EPO, CANOPY HEALTHNET HMO, OTHER-IN-NETWORK PLANS", "methodology": "per diem", "standard_charge_dollar": 8000.0, "standard_charge_algorithm": "Expected reimbursement is the lesser of Per diem ($8,000) for the length of stay and 70% of billed.", "count": "0", "additional_payer_notes": "Zero final payments for the item or service in the 15 months prior to posting the file." }, { "payer_name": "UNITED HEALTHCARE", "plan_name": "SUTTER SELECT & SUTTER HEALTH PLAN HMO PLANS", "methodology": "per diem", "standard_charge_dollar": 28538.0, "standard_charge_algorithm": "Per diem ($28,538).", "count": "0", "additional_payer_notes": "Zero final payments for the item or service in the 15 months prior to posting the file." }, { "payer_name": "UNITED HEALTHCARE", "plan_name": "SUTTER SELECT & SUTTER HEALTH PLAN HMO PLANS", "methodology": "per diem", "standard_charge_dollar": 28538.0, "standard_charge_algorithm": "Per diem ($28,538).", "count": "0", "additional_payer_notes": "Zero final payments for the item or service in the 15 months prior to posting the file." }, { "payer_name": "SUTTER", "plan_name": "SUTTER SELECT & SUTTER HEALTH PLAN HMO PLANS", "methodology": "per diem", "standard_charge_dollar": 28538.0, "standard_charge_algorithm": "Per diem ($28,538).", "count": "0", "additional_payer_notes": "Zero final payments for the item or service in the 15 months prior to posting the file." }, { "payer_name": "UNITED HEALTHCARE", "plan_name": "SUTTER SELECT & SUTTER HEALTH PLAN HMO PLANS", "methodology": "per diem", "standard_charge_dollar": 28538.0, "standard_charge_algorithm": "Per diem ($28,538).", "count": "0", "additional_payer_notes": "Zero final payments for the item or service in the 15 months prior to posting the file." }, { "payer_name": "UMR", "plan_name": "SUTTER SELECT & SUTTER HEALTH PLAN HMO PLANS", "methodology": "per diem", "standard_charge_dollar": 28538.0, "standard_charge_algorithm": "Per diem ($28,538).", "count": "0", "additional_payer_notes": "Zero final payments for the item or service in the 15 months prior to posting the file." } ] } ] }, { "description": "HC Device Wound Closure Gp013", "code_information": [ { "code": "PX-2120056013", "type": "CDM" }, { "code": "99999", "type": "CPT" }, { "code": "0272", "type": "RC" } ], "standard_charges": [ { "setting": "outpatient", "gross_charge": 900.0, "discounted_cash": 450.0, "minimum": 379.8, "maximum": 468.0, "additional_generic_notes": "Zero final payments for the item or service in the 15 months prior to posting the file.", "payers_information": [ { "payer_name": "AETNA", "plan_name": "AETNA ALL OTHER PLANS", "methodology": "percent of total billed charges", "standard_charge_dollar": 468.0, "standard_charge_percentage": 52.0, "count": "0", "additional_payer_notes": "Zero final payments for the item or service in the 15 months prior to posting the file." }, { "payer_name": "AETNA", "plan_name": "AETNA ALL OTHER PLANS", "methodology": "percent of total billed charges", "standard_charge_dollar": 468.0, "standard_charge_percentage": 52.0, "count": "0", "additional_payer_notes": "Zero final payments for the item or service in the 15 months prior to posting the file." }, { "payer_name": "MERITAIN HEALTH", "plan_name": "AETNA ALL OTHER PLANS", "methodology": "percent of total billed charges", "standard_charge_dollar": 468.0, "standard_charge_percentage": 52.0, "count": "0", "additional_payer_notes": "Zero final payments for the item or service in the 15 months prior to posting the file." }, { "payer_name": "BLUE SHIELD OUT OF STATE", "plan_name": "STANFORD HEALTHCARE ALLIANCE PLAN", "methodology": "percent of total billed charges", "standard_charge_dollar": 437.31, "standard_charge_percentage": 48.59, "count": "0", "additional_payer_notes": "Zero final payments for the item or service in the 15 months prior to posting the file." }, { "payer_name": "BLUE SHIELD", "plan_name": "STANFORD HEALTHCARE ALLIANCE PLAN", "methodology": "percent of total billed charges", "standard_charge_dollar": 437.31, "standard_charge_percentage": 48.59, "count": "0", "additional_payer_notes": "Zero final payments for the item or service in the 15 months prior to posting the file." }, { "payer_name": "BLUE SHIELD", "plan_name": "STANFORD HEALTHCARE ALLIANCE PLAN", "methodology": "percent of total billed charges", "standard_charge_dollar": 437.31, "standard_charge_percentage": 48.59, "count": "0", "additional_payer_notes": "Zero final payments for the item or service in the 15 months prior to posting the file." }, { "payer_name": "CIGNA", "plan_name": "CIGNA COM ALT HMO PLAN", "methodology": "percent of total billed charges", "standard_charge_dollar": 379.8, "standard_charge_percentage": 42.2, "count": "0", "additional_payer_notes": "Zero final payments for the item or service in the 15 months prior to posting the file." }, { "payer_name": "CIGNA", "plan_name": "CIGNA COM ALT HMO PLAN", "methodology": "percent of total billed charges", "standard_charge_dollar": 379.8, "standard_charge_percentage": 42.2, "count": "0", "additional_payer_notes": "Zero final payments for the item or service in the 15 months prior to posting the file." }, { "payer_name": "HEALTH NET", "plan_name": "HEALTHNET HMO, PPO, POS, EPO, CANOPY HEALTHNET HMO, OTHER-IN-NETWORK PLANS", "methodology": "per diem", "standard_charge_dollar": 8000.0, "standard_charge_algorithm": "Expected reimbursement is the lesser of Per diem ($8,000) for the length of stay and 70% of billed.", "count": "0", "additional_payer_notes": "Zero final payments for the item or service in the 15 months prior to posting the file." }, { "payer_name": "HEALTH NET", "plan_name": "HEALTHNET HMO, PPO, POS, EPO, CANOPY HEALTHNET HMO, OTHER-IN-NETWORK PLANS", "methodology": "per diem", "standard_charge_dollar": 8000.0, "standard_charge_algorithm": "Expected reimbursement is the lesser of Per diem ($8,000) for the length of stay and 70% of billed.", "count": "0", "additional_payer_notes": "Zero final payments for the item or service in the 15 months prior to posting the file." }, { "payer_name": "UNITED HEALTHCARE", "plan_name": "SUTTER SELECT & SUTTER HEALTH PLAN HMO PLANS", "methodology": "per diem", "standard_charge_dollar": 28538.0, "standard_charge_algorithm": "Per diem ($28,538).", "count": "0", "additional_payer_notes": "Zero final payments for the item or service in the 15 months prior to posting the file." }, { "payer_name": "UNITED HEALTHCARE", "plan_name": "SUTTER SELECT & SUTTER HEALTH PLAN HMO PLANS", "methodology": "per diem", "standard_charge_dollar": 28538.0, "standard_charge_algorithm": "Per diem ($28,538).", "count": "0", "additional_payer_notes": "Zero final payments for the item or service in the 15 months prior to posting the file." }, { "payer_name": "SUTTER", "plan_name": "SUTTER SELECT & SUTTER HEALTH PLAN HMO PLANS", "methodology": "per diem", "standard_charge_dollar": 28538.0, "standard_charge_algorithm": "Per diem ($28,538).", "count": "0", "additional_payer_notes": "Zero final payments for the item or service in the 15 months prior to posting the file." }, { "payer_name": "UNITED HEALTHCARE", "plan_name": "SUTTER SELECT & SUTTER HEALTH PLAN HMO PLANS", "methodology": "per diem", "standard_charge_dollar": 28538.0, "standard_charge_algorithm": "Per diem ($28,538).", "count": "0", "additional_payer_notes": "Zero final payments for the item or service in the 15 months prior to posting the file." }, { "payer_name": "UMR", "plan_name": "SUTTER SELECT & SUTTER HEALTH PLAN HMO PLANS", "methodology": "per diem", "standard_charge_dollar": 28538.0, "standard_charge_algorithm": "Per diem ($28,538).", "count": "0", "additional_payer_notes": "Zero final payments for the item or service in the 15 months prior to posting the file." } ] } ] }, { "description": "HC Device Wound Closure Gp017", "code_information": [ { "code": "PX-2120056017", "type": "CDM" }, { "code": "99999", "type": "CPT" }, { "code": "0272", "type": "RC" } ], "standard_charges": [ { "setting": "outpatient", "gross_charge": 1575.0, "discounted_cash": 787.5, "minimum": 664.65, "maximum": 819.0, "additional_generic_notes": "Zero final payments for the item or service in the 15 months prior to posting the file.", "payers_information": [ { "payer_name": "AETNA", "plan_name": "AETNA ALL OTHER PLANS", "methodology": "percent of total billed charges", "standard_charge_dollar": 819.0, "standard_charge_percentage": 52.0, "count": "0", "additional_payer_notes": "Zero final payments for the item or service in the 15 months prior to posting the file." }, { "payer_name": "AETNA", "plan_name": "AETNA ALL OTHER PLANS", "methodology": "percent of total billed charges", "standard_charge_dollar": 819.0, "standard_charge_percentage": 52.0, "count": "0", "additional_payer_notes": "Zero final payments for the item or service in the 15 months prior to posting the file." }, { "payer_name": "MERITAIN HEALTH", "plan_name": "AETNA ALL OTHER PLANS", "methodology": "percent of total billed charges", "standard_charge_dollar": 819.0, "standard_charge_percentage": 52.0, "count": "0", "additional_payer_notes": "Zero final payments for the item or service in the 15 months prior to posting the file." }, { "payer_name": "BLUE SHIELD OUT OF STATE", "plan_name": "STANFORD HEALTHCARE ALLIANCE PLAN", "methodology": "percent of total billed charges", "standard_charge_dollar": 765.29, "standard_charge_percentage": 48.59, "count": "0", "additional_payer_notes": "Zero final payments for the item or service in the 15 months prior to posting the file." }, { "payer_name": "BLUE SHIELD", "plan_name": "STANFORD HEALTHCARE ALLIANCE PLAN", "methodology": "percent of total billed charges", "standard_charge_dollar": 765.29, "standard_charge_percentage": 48.59, "median_amount": 68.24, "10th_percentile": 13.6, "90th_percentile": 1043.06, "count": "30" }, { "payer_name": "BLUE SHIELD", "plan_name": "STANFORD HEALTHCARE ALLIANCE PLAN", "methodology": "percent of total billed charges", "standard_charge_dollar": 765.29, "standard_charge_percentage": 48.59, "count": "0", "additional_payer_notes": "Zero final payments for the item or service in the 15 months prior to posting the file." }, { "payer_name": "BLUE SHIELD", "plan_name": "STANFORD HEALTHCARE ALLIANCE PLAN", "methodology": "percent of total billed charges", "standard_charge_dollar": 765.29, "standard_charge_percentage": 48.59, "count": "0", "additional_payer_notes": "Zero final payments for the item or service in the 15 months prior to posting the file." }, { "payer_name": "CIGNA", "plan_name": "CIGNA COM ALT HMO PLAN", "methodology": "percent of total billed charges", "standard_charge_dollar": 664.65, "standard_charge_percentage": 42.2, "count": "0", "additional_payer_notes": "Zero final payments for the item or service in the 15 months prior to posting the file." }, { "payer_name": "CIGNA", "plan_name": "CIGNA COM ALT HMO PLAN", "methodology": "percent of total billed charges", "standard_charge_dollar": 664.65, "standard_charge_percentage": 42.2, "count": "0", "additional_payer_notes": "Zero final payments for the item or service in the 15 months prior to posting the file." }, { "payer_name": "HEALTH NET", "plan_name": "HEALTHNET HMO, PPO, POS, EPO, CANOPY HEALTHNET HMO, OTHER-IN-NETWORK PLANS", "methodology": "per diem", "standard_charge_dollar": 8000.0, "standard_charge_algorithm": "Expected reimbursement is the lesser of Per diem ($8,000) for the length of stay and 70% of billed.", "count": "0", "additional_payer_notes": "Zero final payments for the item or service in the 15 months prior to posting the file." }, { "payer_name": "HEALTH NET", "plan_name": "HEALTHNET HMO, PPO, POS, EPO, CANOPY HEALTHNET HMO, OTHER-IN-NETWORK PLANS", "methodology": "per diem", "standard_charge_dollar": 8000.0, "standard_charge_algorithm": "Expected reimbursement is the lesser of Per diem ($8,000) for the length of stay and 70% of billed.", "count": "0", "additional_payer_notes": "Zero final payments for the item or service in the 15 months prior to posting the file." }, { "payer_name": "UNITED HEALTHCARE", "plan_name": "SUTTER SELECT & SUTTER HEALTH PLAN HMO PLANS", "methodology": "per diem", "standard_charge_dollar": 28538.0, "standard_charge_algorithm": "Per diem ($28,538).", "count": "0", "additional_payer_notes": "Zero final payments for the item or service in the 15 months prior to posting the file." }, { "payer_name": "UNITED HEALTHCARE", "plan_name": "SUTTER SELECT & SUTTER HEALTH PLAN HMO PLANS", "methodology": "per diem", "standard_charge_dollar": 28538.0, "standard_charge_algorithm": "Per diem ($28,538).", "count": "0", "additional_payer_notes": "Zero final payments for the item or service in the 15 months prior to posting the file." }, { "payer_name": "SUTTER", "plan_name": "SUTTER SELECT & SUTTER HEALTH PLAN HMO PLANS", "methodology": "per diem", "standard_charge_dollar": 28538.0, "standard_charge_algorithm": "Per diem ($28,538).", "count": "0", "additional_payer_notes": "Zero final payments for the item or service in the 15 months prior to posting the file." }, { "payer_name": "UNITED HEALTHCARE", "plan_name": "SUTTER SELECT & SUTTER HEALTH PLAN HMO PLANS", "methodology": "per diem", "standard_charge_dollar": 28538.0, "standard_charge_algorithm": "Per diem ($28,538).", "count": "0", "additional_payer_notes": "Zero final payments for the item or service in the 15 months prior to posting the file." }, { "payer_name": "UMR", "plan_name": "SUTTER SELECT & SUTTER HEALTH PLAN HMO PLANS", "methodology": "per diem", "standard_charge_dollar": 28538.0, "standard_charge_algorithm": "Per diem ($28,538).", "count": "0", "additional_payer_notes": "Zero final payments for the item or service in the 15 months prior to posting the file." } ] } ] }, { "description": "HC Device Wound Closure Gp020", "code_information": [ { "code": "PX-2120056020", "type": "CDM" }, { "code": "99999", "type": "CPT" }, { "code": "0272", "type": "RC" } ], "standard_charges": [ { "setting": "outpatient", "gross_charge": 2550.0, "discounted_cash": 1275.0, "minimum": 1076.1, "maximum": 1326.0, "additional_generic_notes": "Zero final payments for the item or service in the 15 months prior to posting the file.", "payers_information": [ { "payer_name": "AETNA", "plan_name": "AETNA ALL OTHER PLANS", "methodology": "percent of total billed charges", "standard_charge_dollar": 1326.0, "standard_charge_percentage": 52.0, "count": "0", "additional_payer_notes": "Zero final payments for the item or service in the 15 months prior to posting the file." }, { "payer_name": "AETNA", "plan_name": "AETNA ALL OTHER PLANS", "methodology": "percent of total billed charges", "standard_charge_dollar": 1326.0, "standard_charge_percentage": 52.0, "count": "0", "additional_payer_notes": "Zero final payments for the item or service in the 15 months prior to posting the file." }, { "payer_name": "MERITAIN HEALTH", "plan_name": "AETNA ALL OTHER PLANS", "methodology": "percent of total billed charges", "standard_charge_dollar": 1326.0, "standard_charge_percentage": 52.0, "count": "0", "additional_payer_notes": "Zero final payments for the item or service in the 15 months prior to posting the file." }, { "payer_name": "BLUE SHIELD OUT OF STATE", "plan_name": "STANFORD HEALTHCARE ALLIANCE PLAN", "methodology": "percent of total billed charges", "standard_charge_dollar": 1239.05, "standard_charge_percentage": 48.59, "count": "0", "additional_payer_notes": "Zero final payments for the item or service in the 15 months prior to posting the file." }, { "payer_name": "BLUE SHIELD", "plan_name": "STANFORD HEALTHCARE ALLIANCE PLAN", "methodology": "percent of total billed charges", "standard_charge_dollar": 1239.05, "standard_charge_percentage": 48.59, "median_amount": 68.24, "10th_percentile": 13.6, "90th_percentile": 1043.06, "count": "30" }, { "payer_name": "BLUE SHIELD", "plan_name": "STANFORD HEALTHCARE ALLIANCE PLAN", "methodology": "percent of total billed charges", "standard_charge_dollar": 1239.05, "standard_charge_percentage": 48.59, "count": "0", "additional_payer_notes": "Zero final payments for the item or service in the 15 months prior to posting the file." }, { "payer_name": "BLUE SHIELD", "plan_name": "STANFORD HEALTHCARE ALLIANCE PLAN", "methodology": "percent of total billed charges", "standard_charge_dollar": 1239.05, "standard_charge_percentage": 48.59, "count": "0", "additional_payer_notes": "Zero final payments for the item or service in the 15 months prior to posting the file." }, { "payer_name": "CIGNA", "plan_name": "CIGNA COM ALT HMO PLAN", "methodology": "percent of total billed charges", "standard_charge_dollar": 1076.1, "standard_charge_percentage": 42.2, "count": "0", "additional_payer_notes": "Zero final payments for the item or service in the 15 months prior to posting the file." }, { "payer_name": "CIGNA", "plan_name": "CIGNA COM ALT HMO PLAN", "methodology": "percent of total billed charges", "standard_charge_dollar": 1076.1, "standard_charge_percentage": 42.2, "count": "0", "additional_payer_notes": "Zero final payments for the item or service in the 15 months prior to posting the file." }, { "payer_name": "HEALTH NET", "plan_name": "HEALTHNET HMO, PPO, POS, EPO, CANOPY HEALTHNET HMO, OTHER-IN-NETWORK PLANS", "methodology": "per diem", "standard_charge_dollar": 8000.0, "standard_charge_algorithm": "Expected reimbursement is the lesser of Per diem ($8,000) for the length of stay and 70% of billed.", "count": "0", "additional_payer_notes": "Zero final payments for the item or service in the 15 months prior to posting the file." }, { "payer_name": "HEALTH NET", "plan_name": "HEALTHNET HMO, PPO, POS, EPO, CANOPY HEALTHNET HMO, OTHER-IN-NETWORK PLANS", "methodology": "per diem", "standard_charge_dollar": 8000.0, "standard_charge_algorithm": "Expected reimbursement is the lesser of Per diem ($8,000) for the length of stay and 70% of billed.", "count": "0", "additional_payer_notes": "Zero final payments for the item or service in the 15 months prior to posting the file." }, { "payer_name": "UNITED HEALTHCARE", "plan_name": "SUTTER SELECT & SUTTER HEALTH PLAN HMO PLANS", "methodology": "per diem", "standard_charge_dollar": 28538.0, "standard_charge_algorithm": "Per diem ($28,538).", "count": "0", "additional_payer_notes": "Zero final payments for the item or service in the 15 months prior to posting the file." }, { "payer_name": "UNITED HEALTHCARE", "plan_name": "SUTTER SELECT & SUTTER HEALTH PLAN HMO PLANS", "methodology": "per diem", "standard_charge_dollar": 28538.0, "standard_charge_algorithm": "Per diem ($28,538).", "count": "0", "additional_payer_notes": "Zero final payments for the item or service in the 15 months prior to posting the file." }, { "payer_name": "SUTTER", "plan_name": "SUTTER SELECT & SUTTER HEALTH PLAN HMO PLANS", "methodology": "per diem", "standard_charge_dollar": 28538.0, "standard_charge_algorithm": "Per diem ($28,538).", "count": "0", "additional_payer_notes": "Zero final payments for the item or service in the 15 months prior to posting the file." }, { "payer_name": "UNITED HEALTHCARE", "plan_name": "SUTTER SELECT & SUTTER HEALTH PLAN HMO PLANS", "methodology": "per diem", "standard_charge_dollar": 28538.0, "standard_charge_algorithm": "Per diem ($28,538).", "count": "0", "additional_payer_notes": "Zero final payments for the item or service in the 15 months prior to posting the file." }, { "payer_name": "UMR", "plan_name": "SUTTER SELECT & SUTTER HEALTH PLAN HMO PLANS", "methodology": "per diem", "standard_charge_dollar": 28538.0, "standard_charge_algorithm": "Per diem ($28,538).", "count": "0", "additional_payer_notes": "Zero final payments for the item or service in the 15 months prior to posting the file." } ] } ] }, { "description": "HC Dilator Gp002", "code_information": [ { "code": "PX-2120057002", "type": "CDM" }, { "code": "99999", "type": "CPT" }, { "code": "0272", "type": "RC" } ], "standard_charges": [ { "setting": "outpatient", "gross_charge": 50.0, "discounted_cash": 25.0, "minimum": 21.1, "maximum": 26.0, "additional_generic_notes": "Zero final payments for the item or service in the 15 months prior to posting the file.", "payers_information": [ { "payer_name": "AETNA", "plan_name": "AETNA ALL OTHER PLANS", "methodology": "percent of total billed charges", "standard_charge_dollar": 26.0, "standard_charge_percentage": 52.0, "count": "0", "additional_payer_notes": "Zero final payments for the item or service in the 15 months prior to posting the file." }, { "payer_name": "AETNA", "plan_name": "AETNA ALL OTHER PLANS", "methodology": "percent of total billed charges", "standard_charge_dollar": 26.0, "standard_charge_percentage": 52.0, "count": "0", "additional_payer_notes": "Zero final payments for the item or service in the 15 months prior to posting the file." }, { "payer_name": "MERITAIN HEALTH", "plan_name": "AETNA ALL OTHER PLANS", "methodology": "percent of total billed charges", "standard_charge_dollar": 26.0, "standard_charge_percentage": 52.0, "count": "0", "additional_payer_notes": "Zero final payments for the item or service in the 15 months prior to posting the file." }, { "payer_name": "BLUE SHIELD OUT OF STATE", "plan_name": "STANFORD HEALTHCARE ALLIANCE PLAN", "methodology": "percent of total billed charges", "standard_charge_dollar": 24.3, "standard_charge_percentage": 48.59, "count": "0", "additional_payer_notes": "Zero final payments for the item or service in the 15 months prior to posting the file." }, { "payer_name": "BLUE SHIELD", "plan_name": "STANFORD HEALTHCARE ALLIANCE PLAN", "methodology": "percent of total billed charges", "standard_charge_dollar": 24.3, "standard_charge_percentage": 48.59, "count": "0", "additional_payer_notes": "Zero final payments for the item or service in the 15 months prior to posting the file." }, { "payer_name": "BLUE SHIELD", "plan_name": "STANFORD HEALTHCARE ALLIANCE PLAN", "methodology": "percent of total billed charges", "standard_charge_dollar": 24.3, "standard_charge_percentage": 48.59, "count": "0", "additional_payer_notes": "Zero final payments for the item or service in the 15 months prior to posting the file." }, { "payer_name": "CIGNA", "plan_name": "CIGNA COM ALT HMO PLAN", "methodology": "percent of total billed charges", "standard_charge_dollar": 21.1, "standard_charge_percentage": 42.2, "count": "0", "additional_payer_notes": "Zero final payments for the item or service in the 15 months prior to posting the file." }, { "payer_name": "CIGNA", "plan_name": "CIGNA COM ALT HMO PLAN", "methodology": "percent of total billed charges", "standard_charge_dollar": 21.1, "standard_charge_percentage": 42.2, "count": "0", "additional_payer_notes": "Zero final payments for the item or service in the 15 months prior to posting the file." }, { "payer_name": "HEALTH NET", "plan_name": "HEALTHNET HMO, PPO, POS, EPO, CANOPY HEALTHNET HMO, OTHER-IN-NETWORK PLANS", "methodology": "per diem", "standard_charge_dollar": 8000.0, "standard_charge_algorithm": "Expected reimbursement is the lesser of Per diem ($8,000) for the length of stay and 70% of billed.", "count": "0", "additional_payer_notes": "Zero final payments for the item or service in the 15 months prior to posting the file." }, { "payer_name": "HEALTH NET", "plan_name": "HEALTHNET HMO, PPO, POS, EPO, CANOPY HEALTHNET HMO, OTHER-IN-NETWORK PLANS", "methodology": "per diem", "standard_charge_dollar": 8000.0, "standard_charge_algorithm": "Expected reimbursement is the lesser of Per diem ($8,000) for the length of stay and 70% of billed.", "count": "0", "additional_payer_notes": "Zero final payments for the item or service in the 15 months prior to posting the file." }, { "payer_name": "UNITED HEALTHCARE", "plan_name": "SUTTER SELECT & SUTTER HEALTH PLAN HMO PLANS", "methodology": "per diem", "standard_charge_dollar": 28538.0, "standard_charge_algorithm": "Per diem ($28,538).", "count": "0", "additional_payer_notes": "Zero final payments for the item or service in the 15 months prior to posting the file." }, { "payer_name": "UNITED HEALTHCARE", "plan_name": "SUTTER SELECT & SUTTER HEALTH PLAN HMO PLANS", "methodology": "per diem", "standard_charge_dollar": 28538.0, "standard_charge_algorithm": "Per diem ($28,538).", "count": "0", "additional_payer_notes": "Zero final payments for the item or service in the 15 months prior to posting the file." }, { "payer_name": "SUTTER", "plan_name": "SUTTER SELECT & SUTTER HEALTH PLAN HMO PLANS", "methodology": "per diem", "standard_charge_dollar": 28538.0, "standard_charge_algorithm": "Per diem ($28,538).", "count": "0", "additional_payer_notes": "Zero final payments for the item or service in the 15 months prior to posting the file." }, { "payer_name": "UNITED HEALTHCARE", "plan_name": "SUTTER SELECT & SUTTER HEALTH PLAN HMO PLANS", "methodology": "per diem", "standard_charge_dollar": 28538.0, "standard_charge_algorithm": "Per diem ($28,538).", "count": "0", "additional_payer_notes": "Zero final payments for the item or service in the 15 months prior to posting the file." }, { "payer_name": "UMR", "plan_name": "SUTTER SELECT & SUTTER HEALTH PLAN HMO PLANS", "methodology": "per diem", "standard_charge_dollar": 28538.0, "standard_charge_algorithm": "Per diem ($28,538).", "count": "0", "additional_payer_notes": "Zero final payments for the item or service in the 15 months prior to posting the file." } ] } ] }, { "description": "HC Dilator Gp003", "code_information": [ { "code": "PX-2120057003", "type": "CDM" }, { "code": "99999", "type": "CPT" }, { "code": "0272", "type": "RC" } ], "standard_charges": [ { "setting": "outpatient", "gross_charge": 100.0, "discounted_cash": 50.0, "minimum": 42.2, "maximum": 52.0, "additional_generic_notes": "Zero final payments for the item or service in the 15 months prior to posting the file.", "payers_information": [ { "payer_name": "AETNA", "plan_name": "AETNA ALL OTHER PLANS", "methodology": "percent of total billed charges", "standard_charge_dollar": 52.0, "standard_charge_percentage": 52.0, "count": "0", "additional_payer_notes": "Zero final payments for the item or service in the 15 months prior to posting the file." }, { "payer_name": "AETNA", "plan_name": "AETNA ALL OTHER PLANS", "methodology": "percent of total billed charges", "standard_charge_dollar": 52.0, "standard_charge_percentage": 52.0, "count": "0", "additional_payer_notes": "Zero final payments for the item or service in the 15 months prior to posting the file." }, { "payer_name": "MERITAIN HEALTH", "plan_name": "AETNA ALL OTHER PLANS", "methodology": "percent of total billed charges", "standard_charge_dollar": 52.0, "standard_charge_percentage": 52.0, "count": "0", "additional_payer_notes": "Zero final payments for the item or service in the 15 months prior to posting the file." }, { "payer_name": "BLUE SHIELD OUT OF STATE", "plan_name": "STANFORD HEALTHCARE ALLIANCE PLAN", "methodology": "percent of total billed charges", "standard_charge_dollar": 48.59, "standard_charge_percentage": 48.59, "count": "0", "additional_payer_notes": "Zero final payments for the item or service in the 15 months prior to posting the file." }, { "payer_name": "BLUE SHIELD", "plan_name": "STANFORD HEALTHCARE ALLIANCE PLAN", "methodology": "percent of total billed charges", "standard_charge_dollar": 48.59, "standard_charge_percentage": 48.59, "count": "0", "additional_payer_notes": "Zero final payments for the item or service in the 15 months prior to posting the file." }, { "payer_name": "BLUE SHIELD", "plan_name": "STANFORD HEALTHCARE ALLIANCE PLAN", "methodology": "percent of total billed charges", "standard_charge_dollar": 48.59, "standard_charge_percentage": 48.59, "count": "0", "additional_payer_notes": "Zero final payments for the item or service in the 15 months prior to posting the file." }, { "payer_name": "CIGNA", "plan_name": "CIGNA COM ALT HMO PLAN", "methodology": "percent of total billed charges", "standard_charge_dollar": 42.2, "standard_charge_percentage": 42.2, "count": "0", "additional_payer_notes": "Zero final payments for the item or service in the 15 months prior to posting the file." }, { "payer_name": "CIGNA", "plan_name": "CIGNA COM ALT HMO PLAN", "methodology": "percent of total billed charges", "standard_charge_dollar": 42.2, "standard_charge_percentage": 42.2, "count": "0", "additional_payer_notes": "Zero final payments for the item or service in the 15 months prior to posting the file." }, { "payer_name": "HEALTH NET", "plan_name": "HEALTHNET HMO, PPO, POS, EPO, CANOPY HEALTHNET HMO, OTHER-IN-NETWORK PLANS", "methodology": "per diem", "standard_charge_dollar": 8000.0, "standard_charge_algorithm": "Expected reimbursement is the lesser of Per diem ($8,000) for the length of stay and 70% of billed.", "count": "0", "additional_payer_notes": "Zero final payments for the item or service in the 15 months prior to posting the file." }, { "payer_name": "HEALTH NET", "plan_name": "HEALTHNET HMO, PPO, POS, EPO, CANOPY HEALTHNET HMO, OTHER-IN-NETWORK PLANS", "methodology": "per diem", "standard_charge_dollar": 8000.0, "standard_charge_algorithm": "Expected reimbursement is the lesser of Per diem ($8,000) for the length of stay and 70% of billed.", "count": "0", "additional_payer_notes": "Zero final payments for the item or service in the 15 months prior to posting the file." }, { "payer_name": "UNITED HEALTHCARE", "plan_name": "SUTTER SELECT & SUTTER HEALTH PLAN HMO PLANS", "methodology": "per diem", "standard_charge_dollar": 28538.0, "standard_charge_algorithm": "Per diem ($28,538).", "count": "0", "additional_payer_notes": "Zero final payments for the item or service in the 15 months prior to posting the file." }, { "payer_name": "UNITED HEALTHCARE", "plan_name": "SUTTER SELECT & SUTTER HEALTH PLAN HMO PLANS", "methodology": "per diem", "standard_charge_dollar": 28538.0, "standard_charge_algorithm": "Per diem ($28,538).", "count": "0", "additional_payer_notes": "Zero final payments for the item or service in the 15 months prior to posting the file." }, { "payer_name": "SUTTER", "plan_name": "SUTTER SELECT & SUTTER HEALTH PLAN HMO PLANS", "methodology": "per diem", "standard_charge_dollar": 28538.0, "standard_charge_algorithm": "Per diem ($28,538).", "count": "0", "additional_payer_notes": "Zero final payments for the item or service in the 15 months prior to posting the file." }, { "payer_name": "UNITED HEALTHCARE", "plan_name": "SUTTER SELECT & SUTTER HEALTH PLAN HMO PLANS", "methodology": "per diem", "standard_charge_dollar": 28538.0, "standard_charge_algorithm": "Per diem ($28,538).", "count": "0", "additional_payer_notes": "Zero final payments for the item or service in the 15 months prior to posting the file." }, { "payer_name": "UMR", "plan_name": "SUTTER SELECT & SUTTER HEALTH PLAN HMO PLANS", "methodology": "per diem", "standard_charge_dollar": 28538.0, "standard_charge_algorithm": "Per diem ($28,538).", "count": "0", "additional_payer_notes": "Zero final payments for the item or service in the 15 months prior to posting the file." } ] } ] }, { "description": "HC Dilator Gp004", "code_information": [ { "code": "PX-2120057004", "type": "CDM" }, { "code": "99999", "type": "CPT" }, { "code": "0272", "type": "RC" } ], "standard_charges": [ { "setting": "outpatient", "gross_charge": 146.0, "discounted_cash": 73.0, "minimum": 61.61, "maximum": 75.92, "additional_generic_notes": "Zero final payments for the item or service in the 15 months prior to posting the file.", "payers_information": [ { "payer_name": "AETNA", "plan_name": "AETNA ALL OTHER PLANS", "methodology": "percent of total billed charges", "standard_charge_dollar": 75.92, "standard_charge_percentage": 52.0, "count": "0", "additional_payer_notes": "Zero final payments for the item or service in the 15 months prior to posting the file." }, { "payer_name": "AETNA", "plan_name": "AETNA ALL OTHER PLANS", "methodology": "percent of total billed charges", "standard_charge_dollar": 75.92, "standard_charge_percentage": 52.0, "count": "0", "additional_payer_notes": "Zero final payments for the item or service in the 15 months prior to posting the file." }, { "payer_name": "MERITAIN HEALTH", "plan_name": "AETNA ALL OTHER PLANS", "methodology": "percent of total billed charges", "standard_charge_dollar": 75.92, "standard_charge_percentage": 52.0, "count": "0", "additional_payer_notes": "Zero final payments for the item or service in the 15 months prior to posting the file." }, { "payer_name": "BLUE SHIELD OUT OF STATE", "plan_name": "STANFORD HEALTHCARE ALLIANCE PLAN", "methodology": "percent of total billed charges", "standard_charge_dollar": 70.94, "standard_charge_percentage": 48.59, "count": "0", "additional_payer_notes": "Zero final payments for the item or service in the 15 months prior to posting the file." }, { "payer_name": "BLUE SHIELD", "plan_name": "STANFORD HEALTHCARE ALLIANCE PLAN", "methodology": "percent of total billed charges", "standard_charge_dollar": 70.94, "standard_charge_percentage": 48.59, "count": "0", "additional_payer_notes": "Zero final payments for the item or service in the 15 months prior to posting the file." }, { "payer_name": "BLUE SHIELD", "plan_name": "STANFORD HEALTHCARE ALLIANCE PLAN", "methodology": "percent of total billed charges", "standard_charge_dollar": 70.94, "standard_charge_percentage": 48.59, "count": "0", "additional_payer_notes": "Zero final payments for the item or service in the 15 months prior to posting the file." }, { "payer_name": "CIGNA", "plan_name": "CIGNA COM ALT HMO PLAN", "methodology": "percent of total billed charges", "standard_charge_dollar": 61.61, "standard_charge_percentage": 42.2, "count": "0", "additional_payer_notes": "Zero final payments for the item or service in the 15 months prior to posting the file." }, { "payer_name": "CIGNA", "plan_name": "CIGNA COM ALT HMO PLAN", "methodology": "percent of total billed charges", "standard_charge_dollar": 61.61, "standard_charge_percentage": 42.2, "count": "0", "additional_payer_notes": "Zero final payments for the item or service in the 15 months prior to posting the file." }, { "payer_name": "HEALTH NET", "plan_name": "HEALTHNET HMO, PPO, POS, EPO, CANOPY HEALTHNET HMO, OTHER-IN-NETWORK PLANS", "methodology": "per diem", "standard_charge_dollar": 8000.0, "standard_charge_algorithm": "Expected reimbursement is the lesser of Per diem ($8,000) for the length of stay and 70% of billed.", "count": "0", "additional_payer_notes": "Zero final payments for the item or service in the 15 months prior to posting the file." }, { "payer_name": "HEALTH NET", "plan_name": "HEALTHNET HMO, PPO, POS, EPO, CANOPY HEALTHNET HMO, OTHER-IN-NETWORK PLANS", "methodology": "per diem", "standard_charge_dollar": 8000.0, "standard_charge_algorithm": "Expected reimbursement is the lesser of Per diem ($8,000) for the length of stay and 70% of billed.", "count": "0", "additional_payer_notes": "Zero final payments for the item or service in the 15 months prior to posting the file." }, { "payer_name": "UNITED HEALTHCARE", "plan_name": "SUTTER SELECT & SUTTER HEALTH PLAN HMO PLANS", "methodology": "per diem", "standard_charge_dollar": 28538.0, "standard_charge_algorithm": "Per diem ($28,538).", "count": "0", "additional_payer_notes": "Zero final payments for the item or service in the 15 months prior to posting the file." }, { "payer_name": "UNITED HEALTHCARE", "plan_name": "SUTTER SELECT & SUTTER HEALTH PLAN HMO PLANS", "methodology": "per diem", "standard_charge_dollar": 28538.0, "standard_charge_algorithm": "Per diem ($28,538).", "count": "0", "additional_payer_notes": "Zero final payments for the item or service in the 15 months prior to posting the file." }, { "payer_name": "SUTTER", "plan_name": "SUTTER SELECT & SUTTER HEALTH PLAN HMO PLANS", "methodology": "per diem", "standard_charge_dollar": 28538.0, "standard_charge_algorithm": "Per diem ($28,538).", "count": "0", "additional_payer_notes": "Zero final payments for the item or service in the 15 months prior to posting the file." }, { "payer_name": "UNITED HEALTHCARE", "plan_name": "SUTTER SELECT & SUTTER HEALTH PLAN HMO PLANS", "methodology": "per diem", "standard_charge_dollar": 28538.0, "standard_charge_algorithm": "Per diem ($28,538).", "count": "0", "additional_payer_notes": "Zero final payments for the item or service in the 15 months prior to posting the file." }, { "payer_name": "UMR", "plan_name": "SUTTER SELECT & SUTTER HEALTH PLAN HMO PLANS", "methodology": "per diem", "standard_charge_dollar": 28538.0, "standard_charge_algorithm": "Per diem ($28,538).", "count": "0", "additional_payer_notes": "Zero final payments for the item or service in the 15 months prior to posting the file." } ] } ] }, { "description": "HC Dilator Gp005", "code_information": [ { "code": "PX-2120057005", "type": "CDM" }, { "code": "99999", "type": "CPT" }, { "code": "0272", "type": "RC" } ], "standard_charges": [ { "setting": "outpatient", "gross_charge": 195.0, "discounted_cash": 97.5, "minimum": 82.29, "maximum": 101.4, "additional_generic_notes": "Zero final payments for the item or service in the 15 months prior to posting the file.", "payers_information": [ { "payer_name": "AETNA", "plan_name": "AETNA ALL OTHER PLANS", "methodology": "percent of total billed charges", "standard_charge_dollar": 101.4, "standard_charge_percentage": 52.0, "count": "0", "additional_payer_notes": "Zero final payments for the item or service in the 15 months prior to posting the file." }, { "payer_name": "AETNA", "plan_name": "AETNA ALL OTHER PLANS", "methodology": "percent of total billed charges", "standard_charge_dollar": 101.4, "standard_charge_percentage": 52.0, "count": "0", "additional_payer_notes": "Zero final payments for the item or service in the 15 months prior to posting the file." }, { "payer_name": "MERITAIN HEALTH", "plan_name": "AETNA ALL OTHER PLANS", "methodology": "percent of total billed charges", "standard_charge_dollar": 101.4, "standard_charge_percentage": 52.0, "count": "0", "additional_payer_notes": "Zero final payments for the item or service in the 15 months prior to posting the file." }, { "payer_name": "BLUE SHIELD OUT OF STATE", "plan_name": "STANFORD HEALTHCARE ALLIANCE PLAN", "methodology": "percent of total billed charges", "standard_charge_dollar": 94.75, "standard_charge_percentage": 48.59, "count": "0", "additional_payer_notes": "Zero final payments for the item or service in the 15 months prior to posting the file." }, { "payer_name": "BLUE SHIELD", "plan_name": "STANFORD HEALTHCARE ALLIANCE PLAN", "methodology": "percent of total billed charges", "standard_charge_dollar": 94.75, "standard_charge_percentage": 48.59, "count": "0", "additional_payer_notes": "Zero final payments for the item or service in the 15 months prior to posting the file." }, { "payer_name": "BLUE SHIELD", "plan_name": "STANFORD HEALTHCARE ALLIANCE PLAN", "methodology": "percent of total billed charges", "standard_charge_dollar": 94.75, "standard_charge_percentage": 48.59, "count": "0", "additional_payer_notes": "Zero final payments for the item or service in the 15 months prior to posting the file." }, { "payer_name": "CIGNA", "plan_name": "CIGNA COM ALT HMO PLAN", "methodology": "percent of total billed charges", "standard_charge_dollar": 82.29, "standard_charge_percentage": 42.2, "count": "0", "additional_payer_notes": "Zero final payments for the item or service in the 15 months prior to posting the file." }, { "payer_name": "CIGNA", "plan_name": "CIGNA COM ALT HMO PLAN", "methodology": "percent of total billed charges", "standard_charge_dollar": 82.29, "standard_charge_percentage": 42.2, "count": "0", "additional_payer_notes": "Zero final payments for the item or service in the 15 months prior to posting the file." }, { "payer_name": "HEALTH NET", "plan_name": "HEALTHNET HMO, PPO, POS, EPO, CANOPY HEALTHNET HMO, OTHER-IN-NETWORK PLANS", "methodology": "per diem", "standard_charge_dollar": 8000.0, "standard_charge_algorithm": "Expected reimbursement is the lesser of Per diem ($8,000) for the length of stay and 70% of billed.", "count": "0", "additional_payer_notes": "Zero final payments for the item or service in the 15 months prior to posting the file." }, { "payer_name": "HEALTH NET", "plan_name": "HEALTHNET HMO, PPO, POS, EPO, CANOPY HEALTHNET HMO, OTHER-IN-NETWORK PLANS", "methodology": "per diem", "standard_charge_dollar": 8000.0, "standard_charge_algorithm": "Expected reimbursement is the lesser of Per diem ($8,000) for the length of stay and 70% of billed.", "count": "0", "additional_payer_notes": "Zero final payments for the item or service in the 15 months prior to posting the file." }, { "payer_name": "UNITED HEALTHCARE", "plan_name": "SUTTER SELECT & SUTTER HEALTH PLAN HMO PLANS", "methodology": "per diem", "standard_charge_dollar": 28538.0, "standard_charge_algorithm": "Per diem ($28,538).", "count": "0", "additional_payer_notes": "Zero final payments for the item or service in the 15 months prior to posting the file." }, { "payer_name": "UNITED HEALTHCARE", "plan_name": "SUTTER SELECT & SUTTER HEALTH PLAN HMO PLANS", "methodology": "per diem", "standard_charge_dollar": 28538.0, "standard_charge_algorithm": "Per diem ($28,538).", "count": "0", "additional_payer_notes": "Zero final payments for the item or service in the 15 months prior to posting the file." }, { "payer_name": "SUTTER", "plan_name": "SUTTER SELECT & SUTTER HEALTH PLAN HMO PLANS", "methodology": "per diem", "standard_charge_dollar": 28538.0, "standard_charge_algorithm": "Per diem ($28,538).", "count": "0", "additional_payer_notes": "Zero final payments for the item or service in the 15 months prior to posting the file." }, { "payer_name": "UNITED HEALTHCARE", "plan_name": "SUTTER SELECT & SUTTER HEALTH PLAN HMO PLANS", "methodology": "per diem", "standard_charge_dollar": 28538.0, "standard_charge_algorithm": "Per diem ($28,538).", "count": "0", "additional_payer_notes": "Zero final payments for the item or service in the 15 months prior to posting the file." }, { "payer_name": "UMR", "plan_name": "SUTTER SELECT & SUTTER HEALTH PLAN HMO PLANS", "methodology": "per diem", "standard_charge_dollar": 28538.0, "standard_charge_algorithm": "Per diem ($28,538).", "count": "0", "additional_payer_notes": "Zero final payments for the item or service in the 15 months prior to posting the file." } ] } ] }, { "description": "HC Dilator Gp006", "code_information": [ { "code": "PX-2120057006", "type": "CDM" }, { "code": "99999", "type": "CPT" }, { "code": "0272", "type": "RC" } ], "standard_charges": [ { "setting": "outpatient", "gross_charge": 293.0, "discounted_cash": 146.5, "minimum": 123.65, "maximum": 152.36, "additional_generic_notes": "Zero final payments for the item or service in the 15 months prior to posting the file.", "payers_information": [ { "payer_name": "AETNA", "plan_name": "AETNA ALL OTHER PLANS", "methodology": "percent of total billed charges", "standard_charge_dollar": 152.36, "standard_charge_percentage": 52.0, "count": "0", "additional_payer_notes": "Zero final payments for the item or service in the 15 months prior to posting the file." }, { "payer_name": "AETNA", "plan_name": "AETNA ALL OTHER PLANS", "methodology": "percent of total billed charges", "standard_charge_dollar": 152.36, "standard_charge_percentage": 52.0, "count": "0", "additional_payer_notes": "Zero final payments for the item or service in the 15 months prior to posting the file." }, { "payer_name": "MERITAIN HEALTH", "plan_name": "AETNA ALL OTHER PLANS", "methodology": "percent of total billed charges", "standard_charge_dollar": 152.36, "standard_charge_percentage": 52.0, "count": "0", "additional_payer_notes": "Zero final payments for the item or service in the 15 months prior to posting the file." }, { "payer_name": "BLUE SHIELD OUT OF STATE", "plan_name": "STANFORD HEALTHCARE ALLIANCE PLAN", "methodology": "percent of total billed charges", "standard_charge_dollar": 142.37, "standard_charge_percentage": 48.59, "count": "0", "additional_payer_notes": "Zero final payments for the item or service in the 15 months prior to posting the file." }, { "payer_name": "BLUE SHIELD", "plan_name": "STANFORD HEALTHCARE ALLIANCE PLAN", "methodology": "percent of total billed charges", "standard_charge_dollar": 142.37, "standard_charge_percentage": 48.59, "count": "0", "additional_payer_notes": "Zero final payments for the item or service in the 15 months prior to posting the file." }, { "payer_name": "BLUE SHIELD", "plan_name": "STANFORD HEALTHCARE ALLIANCE PLAN", "methodology": "percent of total billed charges", "standard_charge_dollar": 142.37, "standard_charge_percentage": 48.59, "count": "0", "additional_payer_notes": "Zero final payments for the item or service in the 15 months prior to posting the file." }, { "payer_name": "CIGNA", "plan_name": "CIGNA COM ALT HMO PLAN", "methodology": "percent of total billed charges", "standard_charge_dollar": 123.65, "standard_charge_percentage": 42.2, "count": "0", "additional_payer_notes": "Zero final payments for the item or service in the 15 months prior to posting the file." }, { "payer_name": "CIGNA", "plan_name": "CIGNA COM ALT HMO PLAN", "methodology": "percent of total billed charges", "standard_charge_dollar": 123.65, "standard_charge_percentage": 42.2, "count": "0", "additional_payer_notes": "Zero final payments for the item or service in the 15 months prior to posting the file." }, { "payer_name": "HEALTH NET", "plan_name": "HEALTHNET HMO, PPO, POS, EPO, CANOPY HEALTHNET HMO, OTHER-IN-NETWORK PLANS", "methodology": "per diem", "standard_charge_dollar": 8000.0, "standard_charge_algorithm": "Expected reimbursement is the lesser of Per diem ($8,000) for the length of stay and 70% of billed.", "count": "0", "additional_payer_notes": "Zero final payments for the item or service in the 15 months prior to posting the file." }, { "payer_name": "HEALTH NET", "plan_name": "HEALTHNET HMO, PPO, POS, EPO, CANOPY HEALTHNET HMO, OTHER-IN-NETWORK PLANS", "methodology": "per diem", "standard_charge_dollar": 8000.0, "standard_charge_algorithm": "Expected reimbursement is the lesser of Per diem ($8,000) for the length of stay and 70% of billed.", "count": "0", "additional_payer_notes": "Zero final payments for the item or service in the 15 months prior to posting the file." }, { "payer_name": "UNITED HEALTHCARE", "plan_name": "SUTTER SELECT & SUTTER HEALTH PLAN HMO PLANS", "methodology": "per diem", "standard_charge_dollar": 28538.0, "standard_charge_algorithm": "Per diem ($28,538).", "count": "0", "additional_payer_notes": "Zero final payments for the item or service in the 15 months prior to posting the file." }, { "payer_name": "UNITED HEALTHCARE", "plan_name": "SUTTER SELECT & SUTTER HEALTH PLAN HMO PLANS", "methodology": "per diem", "standard_charge_dollar": 28538.0, "standard_charge_algorithm": "Per diem ($28,538).", "count": "0", "additional_payer_notes": "Zero final payments for the item or service in the 15 months prior to posting the file." }, { "payer_name": "SUTTER", "plan_name": "SUTTER SELECT & SUTTER HEALTH PLAN HMO PLANS", "methodology": "per diem", "standard_charge_dollar": 28538.0, "standard_charge_algorithm": "Per diem ($28,538).", "count": "0", "additional_payer_notes": "Zero final payments for the item or service in the 15 months prior to posting the file." }, { "payer_name": "UNITED HEALTHCARE", "plan_name": "SUTTER SELECT & SUTTER HEALTH PLAN HMO PLANS", "methodology": "per diem", "standard_charge_dollar": 28538.0, "standard_charge_algorithm": "Per diem ($28,538).", "count": "0", "additional_payer_notes": "Zero final payments for the item or service in the 15 months prior to posting the file." }, { "payer_name": "UMR", "plan_name": "SUTTER SELECT & SUTTER HEALTH PLAN HMO PLANS", "methodology": "per diem", "standard_charge_dollar": 28538.0, "standard_charge_algorithm": "Per diem ($28,538).", "count": "0", "additional_payer_notes": "Zero final payments for the item or service in the 15 months prior to posting the file." } ] } ] }, { "description": "HC Dilator Gp007", "code_information": [ { "code": "PX-2120057007", "type": "CDM" }, { "code": "99999", "type": "CPT" }, { "code": "0272", "type": "RC" } ], "standard_charges": [ { "setting": "outpatient", "gross_charge": 380.0, "discounted_cash": 190.0, "minimum": 160.36, "maximum": 197.6, "additional_generic_notes": "Zero final payments for the item or service in the 15 months prior to posting the file.", "payers_information": [ { "payer_name": "AETNA", "plan_name": "AETNA ALL OTHER PLANS", "methodology": "percent of total billed charges", "standard_charge_dollar": 197.6, "standard_charge_percentage": 52.0, "count": "0", "additional_payer_notes": "Zero final payments for the item or service in the 15 months prior to posting the file." }, { "payer_name": "AETNA", "plan_name": "AETNA ALL OTHER PLANS", "methodology": "percent of total billed charges", "standard_charge_dollar": 197.6, "standard_charge_percentage": 52.0, "count": "0", "additional_payer_notes": "Zero final payments for the item or service in the 15 months prior to posting the file." }, { "payer_name": "MERITAIN HEALTH", "plan_name": "AETNA ALL OTHER PLANS", "methodology": "percent of total billed charges", "standard_charge_dollar": 197.6, "standard_charge_percentage": 52.0, "count": "0", "additional_payer_notes": "Zero final payments for the item or service in the 15 months prior to posting the file." }, { "payer_name": "BLUE SHIELD OUT OF STATE", "plan_name": "STANFORD HEALTHCARE ALLIANCE PLAN", "methodology": "percent of total billed charges", "standard_charge_dollar": 184.64, "standard_charge_percentage": 48.59, "count": "0", "additional_payer_notes": "Zero final payments for the item or service in the 15 months prior to posting the file." }, { "payer_name": "BLUE SHIELD", "plan_name": "STANFORD HEALTHCARE ALLIANCE PLAN", "methodology": "percent of total billed charges", "standard_charge_dollar": 184.64, "standard_charge_percentage": 48.59, "count": "0", "additional_payer_notes": "Zero final payments for the item or service in the 15 months prior to posting the file." }, { "payer_name": "BLUE SHIELD", "plan_name": "STANFORD HEALTHCARE ALLIANCE PLAN", "methodology": "percent of total billed charges", "standard_charge_dollar": 184.64, "standard_charge_percentage": 48.59, "count": "0", "additional_payer_notes": "Zero final payments for the item or service in the 15 months prior to posting the file." }, { "payer_name": "CIGNA", "plan_name": "CIGNA COM ALT HMO PLAN", "methodology": "percent of total billed charges", "standard_charge_dollar": 160.36, "standard_charge_percentage": 42.2, "count": "0", "additional_payer_notes": "Zero final payments for the item or service in the 15 months prior to posting the file." }, { "payer_name": "CIGNA", "plan_name": "CIGNA COM ALT HMO PLAN", "methodology": "percent of total billed charges", "standard_charge_dollar": 160.36, "standard_charge_percentage": 42.2, "count": "0", "additional_payer_notes": "Zero final payments for the item or service in the 15 months prior to posting the file." }, { "payer_name": "HEALTH NET", "plan_name": "HEALTHNET HMO, PPO, POS, EPO, CANOPY HEALTHNET HMO, OTHER-IN-NETWORK PLANS", "methodology": "per diem", "standard_charge_dollar": 8000.0, "standard_charge_algorithm": "Expected reimbursement is the lesser of Per diem ($8,000) for the length of stay and 70% of billed.", "count": "0", "additional_payer_notes": "Zero final payments for the item or service in the 15 months prior to posting the file." }, { "payer_name": "HEALTH NET", "plan_name": "HEALTHNET HMO, PPO, POS, EPO, CANOPY HEALTHNET HMO, OTHER-IN-NETWORK PLANS", "methodology": "per diem", "standard_charge_dollar": 8000.0, "standard_charge_algorithm": "Expected reimbursement is the lesser of Per diem ($8,000) for the length of stay and 70% of billed.", "count": "0", "additional_payer_notes": "Zero final payments for the item or service in the 15 months prior to posting the file." }, { "payer_name": "UNITED HEALTHCARE", "plan_name": "SUTTER SELECT & SUTTER HEALTH PLAN HMO PLANS", "methodology": "per diem", "standard_charge_dollar": 28538.0, "standard_charge_algorithm": "Per diem ($28,538).", "count": "0", "additional_payer_notes": "Zero final payments for the item or service in the 15 months prior to posting the file." }, { "payer_name": "UNITED HEALTHCARE", "plan_name": "SUTTER SELECT & SUTTER HEALTH PLAN HMO PLANS", "methodology": "per diem", "standard_charge_dollar": 28538.0, "standard_charge_algorithm": "Per diem ($28,538).", "count": "0", "additional_payer_notes": "Zero final payments for the item or service in the 15 months prior to posting the file." }, { "payer_name": "SUTTER", "plan_name": "SUTTER SELECT & SUTTER HEALTH PLAN HMO PLANS", "methodology": "per diem", "standard_charge_dollar": 28538.0, "standard_charge_algorithm": "Per diem ($28,538).", "count": "0", "additional_payer_notes": "Zero final payments for the item or service in the 15 months prior to posting the file." }, { "payer_name": "UNITED HEALTHCARE", "plan_name": "SUTTER SELECT & SUTTER HEALTH PLAN HMO PLANS", "methodology": "per diem", "standard_charge_dollar": 28538.0, "standard_charge_algorithm": "Per diem ($28,538).", "count": "0", "additional_payer_notes": "Zero final payments for the item or service in the 15 months prior to posting the file." }, { "payer_name": "UMR", "plan_name": "SUTTER SELECT & SUTTER HEALTH PLAN HMO PLANS", "methodology": "per diem", "standard_charge_dollar": 28538.0, "standard_charge_algorithm": "Per diem ($28,538).", "count": "0", "additional_payer_notes": "Zero final payments for the item or service in the 15 months prior to posting the file." } ] } ] }, { "description": "HC Dilator Gp008", "code_information": [ { "code": "PX-2120057008", "type": "CDM" }, { "code": "99999", "type": "CPT" }, { "code": "0272", "type": "RC" } ], "standard_charges": [ { "setting": "outpatient", "gross_charge": 475.0, "discounted_cash": 237.5, "minimum": 200.45, "maximum": 247.0, "additional_generic_notes": "Zero final payments for the item or service in the 15 months prior to posting the file.", "payers_information": [ { "payer_name": "AETNA", "plan_name": "AETNA ALL OTHER PLANS", "methodology": "percent of total billed charges", "standard_charge_dollar": 247.0, "standard_charge_percentage": 52.0, "count": "0", "additional_payer_notes": "Zero final payments for the item or service in the 15 months prior to posting the file." }, { "payer_name": "AETNA", "plan_name": "AETNA ALL OTHER PLANS", "methodology": "percent of total billed charges", "standard_charge_dollar": 247.0, "standard_charge_percentage": 52.0, "count": "0", "additional_payer_notes": "Zero final payments for the item or service in the 15 months prior to posting the file." }, { "payer_name": "MERITAIN HEALTH", "plan_name": "AETNA ALL OTHER PLANS", "methodology": "percent of total billed charges", "standard_charge_dollar": 247.0, "standard_charge_percentage": 52.0, "count": "0", "additional_payer_notes": "Zero final payments for the item or service in the 15 months prior to posting the file." }, { "payer_name": "BLUE SHIELD OUT OF STATE", "plan_name": "STANFORD HEALTHCARE ALLIANCE PLAN", "methodology": "percent of total billed charges", "standard_charge_dollar": 230.8, "standard_charge_percentage": 48.59, "count": "0", "additional_payer_notes": "Zero final payments for the item or service in the 15 months prior to posting the file." }, { "payer_name": "BLUE SHIELD", "plan_name": "STANFORD HEALTHCARE ALLIANCE PLAN", "methodology": "percent of total billed charges", "standard_charge_dollar": 230.8, "standard_charge_percentage": 48.59, "count": "0", "additional_payer_notes": "Zero final payments for the item or service in the 15 months prior to posting the file." }, { "payer_name": "BLUE SHIELD", "plan_name": "STANFORD HEALTHCARE ALLIANCE PLAN", "methodology": "percent of total billed charges", "standard_charge_dollar": 230.8, "standard_charge_percentage": 48.59, "count": "0", "additional_payer_notes": "Zero final payments for the item or service in the 15 months prior to posting the file." }, { "payer_name": "CIGNA", "plan_name": "CIGNA COM ALT HMO PLAN", "methodology": "percent of total billed charges", "standard_charge_dollar": 200.45, "standard_charge_percentage": 42.2, "count": "0", "additional_payer_notes": "Zero final payments for the item or service in the 15 months prior to posting the file." }, { "payer_name": "CIGNA", "plan_name": "CIGNA COM ALT HMO PLAN", "methodology": "percent of total billed charges", "standard_charge_dollar": 200.45, "standard_charge_percentage": 42.2, "count": "0", "additional_payer_notes": "Zero final payments for the item or service in the 15 months prior to posting the file." }, { "payer_name": "HEALTH NET", "plan_name": "HEALTHNET HMO, PPO, POS, EPO, CANOPY HEALTHNET HMO, OTHER-IN-NETWORK PLANS", "methodology": "per diem", "standard_charge_dollar": 8000.0, "standard_charge_algorithm": "Expected reimbursement is the lesser of Per diem ($8,000) for the length of stay and 70% of billed.", "count": "0", "additional_payer_notes": "Zero final payments for the item or service in the 15 months prior to posting the file." }, { "payer_name": "HEALTH NET", "plan_name": "HEALTHNET HMO, PPO, POS, EPO, CANOPY HEALTHNET HMO, OTHER-IN-NETWORK PLANS", "methodology": "per diem", "standard_charge_dollar": 8000.0, "standard_charge_algorithm": "Expected reimbursement is the lesser of Per diem ($8,000) for the length of stay and 70% of billed.", "count": "0", "additional_payer_notes": "Zero final payments for the item or service in the 15 months prior to posting the file." }, { "payer_name": "UNITED HEALTHCARE", "plan_name": "SUTTER SELECT & SUTTER HEALTH PLAN HMO PLANS", "methodology": "per diem", "standard_charge_dollar": 28538.0, "standard_charge_algorithm": "Per diem ($28,538).", "count": "0", "additional_payer_notes": "Zero final payments for the item or service in the 15 months prior to posting the file." }, { "payer_name": "UNITED HEALTHCARE", "plan_name": "SUTTER SELECT & SUTTER HEALTH PLAN HMO PLANS", "methodology": "per diem", "standard_charge_dollar": 28538.0, "standard_charge_algorithm": "Per diem ($28,538).", "count": "0", "additional_payer_notes": "Zero final payments for the item or service in the 15 months prior to posting the file." }, { "payer_name": "SUTTER", "plan_name": "SUTTER SELECT & SUTTER HEALTH PLAN HMO PLANS", "methodology": "per diem", "standard_charge_dollar": 28538.0, "standard_charge_algorithm": "Per diem ($28,538).", "count": "0", "additional_payer_notes": "Zero final payments for the item or service in the 15 months prior to posting the file." }, { "payer_name": "UNITED HEALTHCARE", "plan_name": "SUTTER SELECT & SUTTER HEALTH PLAN HMO PLANS", "methodology": "per diem", "standard_charge_dollar": 28538.0, "standard_charge_algorithm": "Per diem ($28,538).", "count": "0", "additional_payer_notes": "Zero final payments for the item or service in the 15 months prior to posting the file." }, { "payer_name": "UMR", "plan_name": "SUTTER SELECT & SUTTER HEALTH PLAN HMO PLANS", "methodology": "per diem", "standard_charge_dollar": 28538.0, "standard_charge_algorithm": "Per diem ($28,538).", "count": "0", "additional_payer_notes": "Zero final payments for the item or service in the 15 months prior to posting the file." } ] } ] }, { "description": "HC Dilator Gp009", "code_information": [ { "code": "PX-2120057009", "type": "CDM" }, { "code": "99999", "type": "CPT" }, { "code": "0272", "type": "RC" } ], "standard_charges": [ { "setting": "outpatient", "gross_charge": 570.0, "discounted_cash": 285.0, "minimum": 240.54, "maximum": 296.4, "additional_generic_notes": "Zero final payments for the item or service in the 15 months prior to posting the file.", "payers_information": [ { "payer_name": "AETNA", "plan_name": "AETNA ALL OTHER PLANS", "methodology": "percent of total billed charges", "standard_charge_dollar": 296.4, "standard_charge_percentage": 52.0, "count": "0", "additional_payer_notes": "Zero final payments for the item or service in the 15 months prior to posting the file." }, { "payer_name": "AETNA", "plan_name": "AETNA ALL OTHER PLANS", "methodology": "percent of total billed charges", "standard_charge_dollar": 296.4, "standard_charge_percentage": 52.0, "count": "0", "additional_payer_notes": "Zero final payments for the item or service in the 15 months prior to posting the file." }, { "payer_name": "MERITAIN HEALTH", "plan_name": "AETNA ALL OTHER PLANS", "methodology": "percent of total billed charges", "standard_charge_dollar": 296.4, "standard_charge_percentage": 52.0, "count": "0", "additional_payer_notes": "Zero final payments for the item or service in the 15 months prior to posting the file." }, { "payer_name": "BLUE SHIELD OUT OF STATE", "plan_name": "STANFORD HEALTHCARE ALLIANCE PLAN", "methodology": "percent of total billed charges", "standard_charge_dollar": 276.96, "standard_charge_percentage": 48.59, "count": "0", "additional_payer_notes": "Zero final payments for the item or service in the 15 months prior to posting the file." }, { "payer_name": "BLUE SHIELD", "plan_name": "STANFORD HEALTHCARE ALLIANCE PLAN", "methodology": "percent of total billed charges", "standard_charge_dollar": 276.96, "standard_charge_percentage": 48.59, "count": "0", "additional_payer_notes": "Zero final payments for the item or service in the 15 months prior to posting the file." }, { "payer_name": "BLUE SHIELD", "plan_name": "STANFORD HEALTHCARE ALLIANCE PLAN", "methodology": "percent of total billed charges", "standard_charge_dollar": 276.96, "standard_charge_percentage": 48.59, "count": "0", "additional_payer_notes": "Zero final payments for the item or service in the 15 months prior to posting the file." }, { "payer_name": "CIGNA", "plan_name": "CIGNA COM ALT HMO PLAN", "methodology": "percent of total billed charges", "standard_charge_dollar": 240.54, "standard_charge_percentage": 42.2, "count": "0", "additional_payer_notes": "Zero final payments for the item or service in the 15 months prior to posting the file." }, { "payer_name": "CIGNA", "plan_name": "CIGNA COM ALT HMO PLAN", "methodology": "percent of total billed charges", "standard_charge_dollar": 240.54, "standard_charge_percentage": 42.2, "count": "0", "additional_payer_notes": "Zero final payments for the item or service in the 15 months prior to posting the file." }, { "payer_name": "HEALTH NET", "plan_name": "HEALTHNET HMO, PPO, POS, EPO, CANOPY HEALTHNET HMO, OTHER-IN-NETWORK PLANS", "methodology": "per diem", "standard_charge_dollar": 8000.0, "standard_charge_algorithm": "Expected reimbursement is the lesser of Per diem ($8,000) for the length of stay and 70% of billed.", "count": "0", "additional_payer_notes": "Zero final payments for the item or service in the 15 months prior to posting the file." }, { "payer_name": "HEALTH NET", "plan_name": "HEALTHNET HMO, PPO, POS, EPO, CANOPY HEALTHNET HMO, OTHER-IN-NETWORK PLANS", "methodology": "per diem", "standard_charge_dollar": 8000.0, "standard_charge_algorithm": "Expected reimbursement is the lesser of Per diem ($8,000) for the length of stay and 70% of billed.", "count": "0", "additional_payer_notes": "Zero final payments for the item or service in the 15 months prior to posting the file." }, { "payer_name": "UNITED HEALTHCARE", "plan_name": "SUTTER SELECT & SUTTER HEALTH PLAN HMO PLANS", "methodology": "per diem", "standard_charge_dollar": 28538.0, "standard_charge_algorithm": "Per diem ($28,538).", "count": "0", "additional_payer_notes": "Zero final payments for the item or service in the 15 months prior to posting the file." }, { "payer_name": "UNITED HEALTHCARE", "plan_name": "SUTTER SELECT & SUTTER HEALTH PLAN HMO PLANS", "methodology": "per diem", "standard_charge_dollar": 28538.0, "standard_charge_algorithm": "Per diem ($28,538).", "count": "0", "additional_payer_notes": "Zero final payments for the item or service in the 15 months prior to posting the file." }, { "payer_name": "SUTTER", "plan_name": "SUTTER SELECT & SUTTER HEALTH PLAN HMO PLANS", "methodology": "per diem", "standard_charge_dollar": 28538.0, "standard_charge_algorithm": "Per diem ($28,538).", "count": "0", "additional_payer_notes": "Zero final payments for the item or service in the 15 months prior to posting the file." }, { "payer_name": "UNITED HEALTHCARE", "plan_name": "SUTTER SELECT & SUTTER HEALTH PLAN HMO PLANS", "methodology": "per diem", "standard_charge_dollar": 28538.0, "standard_charge_algorithm": "Per diem ($28,538).", "count": "0", "additional_payer_notes": "Zero final payments for the item or service in the 15 months prior to posting the file." }, { "payer_name": "UMR", "plan_name": "SUTTER SELECT & SUTTER HEALTH PLAN HMO PLANS", "methodology": "per diem", "standard_charge_dollar": 28538.0, "standard_charge_algorithm": "Per diem ($28,538).", "count": "0", "additional_payer_notes": "Zero final payments for the item or service in the 15 months prior to posting the file." } ] } ] }, { "description": "HC Dilator Gp010", "code_information": [ { "code": "PX-2120057010", "type": "CDM" }, { "code": "99999", "type": "CPT" }, { "code": "0272", "type": "RC" } ], "standard_charges": [ { "setting": "outpatient", "gross_charge": 665.0, "discounted_cash": 332.5, "minimum": 280.63, "maximum": 345.8, "additional_generic_notes": "Zero final payments for the item or service in the 15 months prior to posting the file.", "payers_information": [ { "payer_name": "AETNA", "plan_name": "AETNA ALL OTHER PLANS", "methodology": "percent of total billed charges", "standard_charge_dollar": 345.8, "standard_charge_percentage": 52.0, "count": "0", "additional_payer_notes": "Zero final payments for the item or service in the 15 months prior to posting the file." }, { "payer_name": "AETNA", "plan_name": "AETNA ALL OTHER PLANS", "methodology": "percent of total billed charges", "standard_charge_dollar": 345.8, "standard_charge_percentage": 52.0, "count": "0", "additional_payer_notes": "Zero final payments for the item or service in the 15 months prior to posting the file." }, { "payer_name": "MERITAIN HEALTH", "plan_name": "AETNA ALL OTHER PLANS", "methodology": "percent of total billed charges", "standard_charge_dollar": 345.8, "standard_charge_percentage": 52.0, "count": "0", "additional_payer_notes": "Zero final payments for the item or service in the 15 months prior to posting the file." }, { "payer_name": "BLUE SHIELD OUT OF STATE", "plan_name": "STANFORD HEALTHCARE ALLIANCE PLAN", "methodology": "percent of total billed charges", "standard_charge_dollar": 323.12, "standard_charge_percentage": 48.59, "count": "0", "additional_payer_notes": "Zero final payments for the item or service in the 15 months prior to posting the file." }, { "payer_name": "BLUE SHIELD", "plan_name": "STANFORD HEALTHCARE ALLIANCE PLAN", "methodology": "percent of total billed charges", "standard_charge_dollar": 323.12, "standard_charge_percentage": 48.59, "count": "0", "additional_payer_notes": "Zero final payments for the item or service in the 15 months prior to posting the file." }, { "payer_name": "BLUE SHIELD", "plan_name": "STANFORD HEALTHCARE ALLIANCE PLAN", "methodology": "percent of total billed charges", "standard_charge_dollar": 323.12, "standard_charge_percentage": 48.59, "count": "0", "additional_payer_notes": "Zero final payments for the item or service in the 15 months prior to posting the file." }, { "payer_name": "CIGNA", "plan_name": "CIGNA COM ALT HMO PLAN", "methodology": "percent of total billed charges", "standard_charge_dollar": 280.63, "standard_charge_percentage": 42.2, "count": "0", "additional_payer_notes": "Zero final payments for the item or service in the 15 months prior to posting the file." }, { "payer_name": "CIGNA", "plan_name": "CIGNA COM ALT HMO PLAN", "methodology": "percent of total billed charges", "standard_charge_dollar": 280.63, "standard_charge_percentage": 42.2, "count": "0", "additional_payer_notes": "Zero final payments for the item or service in the 15 months prior to posting the file." }, { "payer_name": "HEALTH NET", "plan_name": "HEALTHNET HMO, PPO, POS, EPO, CANOPY HEALTHNET HMO, OTHER-IN-NETWORK PLANS", "methodology": "per diem", "standard_charge_dollar": 8000.0, "standard_charge_algorithm": "Expected reimbursement is the lesser of Per diem ($8,000) for the length of stay and 70% of billed.", "count": "0", "additional_payer_notes": "Zero final payments for the item or service in the 15 months prior to posting the file." }, { "payer_name": "HEALTH NET", "plan_name": "HEALTHNET HMO, PPO, POS, EPO, CANOPY HEALTHNET HMO, OTHER-IN-NETWORK PLANS", "methodology": "per diem", "standard_charge_dollar": 8000.0, "standard_charge_algorithm": "Expected reimbursement is the lesser of Per diem ($8,000) for the length of stay and 70% of billed.", "count": "0", "additional_payer_notes": "Zero final payments for the item or service in the 15 months prior to posting the file." }, { "payer_name": "UNITED HEALTHCARE", "plan_name": "SUTTER SELECT & SUTTER HEALTH PLAN HMO PLANS", "methodology": "per diem", "standard_charge_dollar": 28538.0, "standard_charge_algorithm": "Per diem ($28,538).", "count": "0", "additional_payer_notes": "Zero final payments for the item or service in the 15 months prior to posting the file." }, { "payer_name": "UNITED HEALTHCARE", "plan_name": "SUTTER SELECT & SUTTER HEALTH PLAN HMO PLANS", "methodology": "per diem", "standard_charge_dollar": 28538.0, "standard_charge_algorithm": "Per diem ($28,538).", "count": "0", "additional_payer_notes": "Zero final payments for the item or service in the 15 months prior to posting the file." }, { "payer_name": "SUTTER", "plan_name": "SUTTER SELECT & SUTTER HEALTH PLAN HMO PLANS", "methodology": "per diem", "standard_charge_dollar": 28538.0, "standard_charge_algorithm": "Per diem ($28,538).", "count": "0", "additional_payer_notes": "Zero final payments for the item or service in the 15 months prior to posting the file." }, { "payer_name": "UNITED HEALTHCARE", "plan_name": "SUTTER SELECT & SUTTER HEALTH PLAN HMO PLANS", "methodology": "per diem", "standard_charge_dollar": 28538.0, "standard_charge_algorithm": "Per diem ($28,538).", "count": "0", "additional_payer_notes": "Zero final payments for the item or service in the 15 months prior to posting the file." }, { "payer_name": "UMR", "plan_name": "SUTTER SELECT & SUTTER HEALTH PLAN HMO PLANS", "methodology": "per diem", "standard_charge_dollar": 28538.0, "standard_charge_algorithm": "Per diem ($28,538).", "count": "0", "additional_payer_notes": "Zero final payments for the item or service in the 15 months prior to posting the file." } ] } ] }, { "description": "HC Dilator Gp011", "code_information": [ { "code": "PX-2120057011", "type": "CDM" }, { "code": "99999", "type": "CPT" }, { "code": "0272", "type": "RC" } ], "standard_charges": [ { "setting": "outpatient", "gross_charge": 740.0, "discounted_cash": 370.0, "minimum": 312.28, "maximum": 384.8, "additional_generic_notes": "Zero final payments for the item or service in the 15 months prior to posting the file.", "payers_information": [ { "payer_name": "AETNA", "plan_name": "AETNA ALL OTHER PLANS", "methodology": "percent of total billed charges", "standard_charge_dollar": 384.8, "standard_charge_percentage": 52.0, "count": "0", "additional_payer_notes": "Zero final payments for the item or service in the 15 months prior to posting the file." }, { "payer_name": "AETNA", "plan_name": "AETNA ALL OTHER PLANS", "methodology": "percent of total billed charges", "standard_charge_dollar": 384.8, "standard_charge_percentage": 52.0, "count": "0", "additional_payer_notes": "Zero final payments for the item or service in the 15 months prior to posting the file." }, { "payer_name": "MERITAIN HEALTH", "plan_name": "AETNA ALL OTHER PLANS", "methodology": "percent of total billed charges", "standard_charge_dollar": 384.8, "standard_charge_percentage": 52.0, "count": "0", "additional_payer_notes": "Zero final payments for the item or service in the 15 months prior to posting the file." }, { "payer_name": "BLUE SHIELD OUT OF STATE", "plan_name": "STANFORD HEALTHCARE ALLIANCE PLAN", "methodology": "percent of total billed charges", "standard_charge_dollar": 359.57, "standard_charge_percentage": 48.59, "count": "0", "additional_payer_notes": "Zero final payments for the item or service in the 15 months prior to posting the file." }, { "payer_name": "BLUE SHIELD", "plan_name": "STANFORD HEALTHCARE ALLIANCE PLAN", "methodology": "percent of total billed charges", "standard_charge_dollar": 359.57, "standard_charge_percentage": 48.59, "count": "0", "additional_payer_notes": "Zero final payments for the item or service in the 15 months prior to posting the file." }, { "payer_name": "BLUE SHIELD", "plan_name": "STANFORD HEALTHCARE ALLIANCE PLAN", "methodology": "percent of total billed charges", "standard_charge_dollar": 359.57, "standard_charge_percentage": 48.59, "count": "0", "additional_payer_notes": "Zero final payments for the item or service in the 15 months prior to posting the file." }, { "payer_name": "CIGNA", "plan_name": "CIGNA COM ALT HMO PLAN", "methodology": "percent of total billed charges", "standard_charge_dollar": 312.28, "standard_charge_percentage": 42.2, "count": "0", "additional_payer_notes": "Zero final payments for the item or service in the 15 months prior to posting the file." }, { "payer_name": "CIGNA", "plan_name": "CIGNA COM ALT HMO PLAN", "methodology": "percent of total billed charges", "standard_charge_dollar": 312.28, "standard_charge_percentage": 42.2, "count": "0", "additional_payer_notes": "Zero final payments for the item or service in the 15 months prior to posting the file." }, { "payer_name": "HEALTH NET", "plan_name": "HEALTHNET HMO, PPO, POS, EPO, CANOPY HEALTHNET HMO, OTHER-IN-NETWORK PLANS", "methodology": "per diem", "standard_charge_dollar": 8000.0, "standard_charge_algorithm": "Expected reimbursement is the lesser of Per diem ($8,000) for the length of stay and 70% of billed.", "count": "0", "additional_payer_notes": "Zero final payments for the item or service in the 15 months prior to posting the file." }, { "payer_name": "HEALTH NET", "plan_name": "HEALTHNET HMO, PPO, POS, EPO, CANOPY HEALTHNET HMO, OTHER-IN-NETWORK PLANS", "methodology": "per diem", "standard_charge_dollar": 8000.0, "standard_charge_algorithm": "Expected reimbursement is the lesser of Per diem ($8,000) for the length of stay and 70% of billed.", "count": "0", "additional_payer_notes": "Zero final payments for the item or service in the 15 months prior to posting the file." }, { "payer_name": "UNITED HEALTHCARE", "plan_name": "SUTTER SELECT & SUTTER HEALTH PLAN HMO PLANS", "methodology": "per diem", "standard_charge_dollar": 28538.0, "standard_charge_algorithm": "Per diem ($28,538).", "count": "0", "additional_payer_notes": "Zero final payments for the item or service in the 15 months prior to posting the file." }, { "payer_name": "UNITED HEALTHCARE", "plan_name": "SUTTER SELECT & SUTTER HEALTH PLAN HMO PLANS", "methodology": "per diem", "standard_charge_dollar": 28538.0, "standard_charge_algorithm": "Per diem ($28,538).", "count": "0", "additional_payer_notes": "Zero final payments for the item or service in the 15 months prior to posting the file." }, { "payer_name": "SUTTER", "plan_name": "SUTTER SELECT & SUTTER HEALTH PLAN HMO PLANS", "methodology": "per diem", "standard_charge_dollar": 28538.0, "standard_charge_algorithm": "Per diem ($28,538).", "count": "0", "additional_payer_notes": "Zero final payments for the item or service in the 15 months prior to posting the file." }, { "payer_name": "UNITED HEALTHCARE", "plan_name": "SUTTER SELECT & SUTTER HEALTH PLAN HMO PLANS", "methodology": "per diem", "standard_charge_dollar": 28538.0, "standard_charge_algorithm": "Per diem ($28,538).", "count": "0", "additional_payer_notes": "Zero final payments for the item or service in the 15 months prior to posting the file." }, { "payer_name": "UMR", "plan_name": "SUTTER SELECT & SUTTER HEALTH PLAN HMO PLANS", "methodology": "per diem", "standard_charge_dollar": 28538.0, "standard_charge_algorithm": "Per diem ($28,538).", "count": "0", "additional_payer_notes": "Zero final payments for the item or service in the 15 months prior to posting the file." } ] } ] }, { "description": "HC Dilator Gp018", "code_information": [ { "code": "PX-2120057018", "type": "CDM" }, { "code": "99999", "type": "CPT" }, { "code": "0272", "type": "RC" } ], "standard_charges": [ { "setting": "outpatient", "gross_charge": 1750.0, "discounted_cash": 875.0, "minimum": 738.5, "maximum": 910.0, "additional_generic_notes": "Zero final payments for the item or service in the 15 months prior to posting the file.", "payers_information": [ { "payer_name": "AETNA", "plan_name": "AETNA ALL OTHER PLANS", "methodology": "percent of total billed charges", "standard_charge_dollar": 910.0, "standard_charge_percentage": 52.0, "count": "0", "additional_payer_notes": "Zero final payments for the item or service in the 15 months prior to posting the file." }, { "payer_name": "AETNA", "plan_name": "AETNA ALL OTHER PLANS", "methodology": "percent of total billed charges", "standard_charge_dollar": 910.0, "standard_charge_percentage": 52.0, "count": "0", "additional_payer_notes": "Zero final payments for the item or service in the 15 months prior to posting the file." }, { "payer_name": "MERITAIN HEALTH", "plan_name": "AETNA ALL OTHER PLANS", "methodology": "percent of total billed charges", "standard_charge_dollar": 910.0, "standard_charge_percentage": 52.0, "count": "0", "additional_payer_notes": "Zero final payments for the item or service in the 15 months prior to posting the file." }, { "payer_name": "BLUE SHIELD OUT OF STATE", "plan_name": "STANFORD HEALTHCARE ALLIANCE PLAN", "methodology": "percent of total billed charges", "standard_charge_dollar": 850.33, "standard_charge_percentage": 48.59, "count": "0", "additional_payer_notes": "Zero final payments for the item or service in the 15 months prior to posting the file." }, { "payer_name": "BLUE SHIELD", "plan_name": "STANFORD HEALTHCARE ALLIANCE PLAN", "methodology": "percent of total billed charges", "standard_charge_dollar": 850.33, "standard_charge_percentage": 48.59, "median_amount": 68.24, "10th_percentile": 13.6, "90th_percentile": 1043.06, "count": "30" }, { "payer_name": "BLUE SHIELD", "plan_name": "STANFORD HEALTHCARE ALLIANCE PLAN", "methodology": "percent of total billed charges", "standard_charge_dollar": 850.33, "standard_charge_percentage": 48.59, "count": "0", "additional_payer_notes": "Zero final payments for the item or service in the 15 months prior to posting the file." }, { "payer_name": "BLUE SHIELD", "plan_name": "STANFORD HEALTHCARE ALLIANCE PLAN", "methodology": "percent of total billed charges", "standard_charge_dollar": 850.33, "standard_charge_percentage": 48.59, "count": "0", "additional_payer_notes": "Zero final payments for the item or service in the 15 months prior to posting the file." }, { "payer_name": "CIGNA", "plan_name": "CIGNA COM ALT HMO PLAN", "methodology": "percent of total billed charges", "standard_charge_dollar": 738.5, "standard_charge_percentage": 42.2, "count": "0", "additional_payer_notes": "Zero final payments for the item or service in the 15 months prior to posting the file." }, { "payer_name": "CIGNA", "plan_name": "CIGNA COM ALT HMO PLAN", "methodology": "percent of total billed charges", "standard_charge_dollar": 738.5, "standard_charge_percentage": 42.2, "count": "0", "additional_payer_notes": "Zero final payments for the item or service in the 15 months prior to posting the file." }, { "payer_name": "HEALTH NET", "plan_name": "HEALTHNET HMO, PPO, POS, EPO, CANOPY HEALTHNET HMO, OTHER-IN-NETWORK PLANS", "methodology": "per diem", "standard_charge_dollar": 8000.0, "standard_charge_algorithm": "Expected reimbursement is the lesser of Per diem ($8,000) for the length of stay and 70% of billed.", "count": "0", "additional_payer_notes": "Zero final payments for the item or service in the 15 months prior to posting the file." }, { "payer_name": "HEALTH NET", "plan_name": "HEALTHNET HMO, PPO, POS, EPO, CANOPY HEALTHNET HMO, OTHER-IN-NETWORK PLANS", "methodology": "per diem", "standard_charge_dollar": 8000.0, "standard_charge_algorithm": "Expected reimbursement is the lesser of Per diem ($8,000) for the length of stay and 70% of billed.", "count": "0", "additional_payer_notes": "Zero final payments for the item or service in the 15 months prior to posting the file." }, { "payer_name": "UNITED HEALTHCARE", "plan_name": "SUTTER SELECT & SUTTER HEALTH PLAN HMO PLANS", "methodology": "per diem", "standard_charge_dollar": 28538.0, "standard_charge_algorithm": "Per diem ($28,538).", "count": "0", "additional_payer_notes": "Zero final payments for the item or service in the 15 months prior to posting the file." }, { "payer_name": "UNITED HEALTHCARE", "plan_name": "SUTTER SELECT & SUTTER HEALTH PLAN HMO PLANS", "methodology": "per diem", "standard_charge_dollar": 28538.0, "standard_charge_algorithm": "Per diem ($28,538).", "count": "0", "additional_payer_notes": "Zero final payments for the item or service in the 15 months prior to posting the file." }, { "payer_name": "SUTTER", "plan_name": "SUTTER SELECT & SUTTER HEALTH PLAN HMO PLANS", "methodology": "per diem", "standard_charge_dollar": 28538.0, "standard_charge_algorithm": "Per diem ($28,538).", "count": "0", "additional_payer_notes": "Zero final payments for the item or service in the 15 months prior to posting the file." }, { "payer_name": "UNITED HEALTHCARE", "plan_name": "SUTTER SELECT & SUTTER HEALTH PLAN HMO PLANS", "methodology": "per diem", "standard_charge_dollar": 28538.0, "standard_charge_algorithm": "Per diem ($28,538).", "count": "0", "additional_payer_notes": "Zero final payments for the item or service in the 15 months prior to posting the file." }, { "payer_name": "UMR", "plan_name": "SUTTER SELECT & SUTTER HEALTH PLAN HMO PLANS", "methodology": "per diem", "standard_charge_dollar": 28538.0, "standard_charge_algorithm": "Per diem ($28,538).", "count": "0", "additional_payer_notes": "Zero final payments for the item or service in the 15 months prior to posting the file." } ] } ] }, { "description": "HC Dilator Gp019", "code_information": [ { "code": "PX-2120057019", "type": "CDM" }, { "code": "99999", "type": "CPT" }, { "code": "0272", "type": "RC" } ], "standard_charges": [ { "setting": "outpatient", "gross_charge": 2125.0, "discounted_cash": 1062.5, "minimum": 896.75, "maximum": 1105.0, "additional_generic_notes": "Zero final payments for the item or service in the 15 months prior to posting the file.", "payers_information": [ { "payer_name": "AETNA", "plan_name": "AETNA ALL OTHER PLANS", "methodology": "percent of total billed charges", "standard_charge_dollar": 1105.0, "standard_charge_percentage": 52.0, "count": "0", "additional_payer_notes": "Zero final payments for the item or service in the 15 months prior to posting the file." }, { "payer_name": "AETNA", "plan_name": "AETNA ALL OTHER PLANS", "methodology": "percent of total billed charges", "standard_charge_dollar": 1105.0, "standard_charge_percentage": 52.0, "count": "0", "additional_payer_notes": "Zero final payments for the item or service in the 15 months prior to posting the file." }, { "payer_name": "MERITAIN HEALTH", "plan_name": "AETNA ALL OTHER PLANS", "methodology": "percent of total billed charges", "standard_charge_dollar": 1105.0, "standard_charge_percentage": 52.0, "count": "0", "additional_payer_notes": "Zero final payments for the item or service in the 15 months prior to posting the file." }, { "payer_name": "BLUE SHIELD OUT OF STATE", "plan_name": "STANFORD HEALTHCARE ALLIANCE PLAN", "methodology": "percent of total billed charges", "standard_charge_dollar": 1032.54, "standard_charge_percentage": 48.59, "count": "0", "additional_payer_notes": "Zero final payments for the item or service in the 15 months prior to posting the file." }, { "payer_name": "BLUE SHIELD", "plan_name": "STANFORD HEALTHCARE ALLIANCE PLAN", "methodology": "percent of total billed charges", "standard_charge_dollar": 1032.54, "standard_charge_percentage": 48.59, "median_amount": 68.24, "10th_percentile": 13.6, "90th_percentile": 1043.06, "count": "30" }, { "payer_name": "BLUE SHIELD", "plan_name": "STANFORD HEALTHCARE ALLIANCE PLAN", "methodology": "percent of total billed charges", "standard_charge_dollar": 1032.54, "standard_charge_percentage": 48.59, "count": "0", "additional_payer_notes": "Zero final payments for the item or service in the 15 months prior to posting the file." }, { "payer_name": "BLUE SHIELD", "plan_name": "STANFORD HEALTHCARE ALLIANCE PLAN", "methodology": "percent of total billed charges", "standard_charge_dollar": 1032.54, "standard_charge_percentage": 48.59, "count": "0", "additional_payer_notes": "Zero final payments for the item or service in the 15 months prior to posting the file." }, { "payer_name": "CIGNA", "plan_name": "CIGNA COM ALT HMO PLAN", "methodology": "percent of total billed charges", "standard_charge_dollar": 896.75, "standard_charge_percentage": 42.2, "count": "0", "additional_payer_notes": "Zero final payments for the item or service in the 15 months prior to posting the file." }, { "payer_name": "CIGNA", "plan_name": "CIGNA COM ALT HMO PLAN", "methodology": "percent of total billed charges", "standard_charge_dollar": 896.75, "standard_charge_percentage": 42.2, "count": "0", "additional_payer_notes": "Zero final payments for the item or service in the 15 months prior to posting the file." }, { "payer_name": "HEALTH NET", "plan_name": "HEALTHNET HMO, PPO, POS, EPO, CANOPY HEALTHNET HMO, OTHER-IN-NETWORK PLANS", "methodology": "per diem", "standard_charge_dollar": 8000.0, "standard_charge_algorithm": "Expected reimbursement is the lesser of Per diem ($8,000) for the length of stay and 70% of billed.", "count": "0", "additional_payer_notes": "Zero final payments for the item or service in the 15 months prior to posting the file." }, { "payer_name": "HEALTH NET", "plan_name": "HEALTHNET HMO, PPO, POS, EPO, CANOPY HEALTHNET HMO, OTHER-IN-NETWORK PLANS", "methodology": "per diem", "standard_charge_dollar": 8000.0, "standard_charge_algorithm": "Expected reimbursement is the lesser of Per diem ($8,000) for the length of stay and 70% of billed.", "count": "0", "additional_payer_notes": "Zero final payments for the item or service in the 15 months prior to posting the file." }, { "payer_name": "UNITED HEALTHCARE", "plan_name": "SUTTER SELECT & SUTTER HEALTH PLAN HMO PLANS", "methodology": "per diem", "standard_charge_dollar": 28538.0, "standard_charge_algorithm": "Per diem ($28,538).", "count": "0", "additional_payer_notes": "Zero final payments for the item or service in the 15 months prior to posting the file." }, { "payer_name": "UNITED HEALTHCARE", "plan_name": "SUTTER SELECT & SUTTER HEALTH PLAN HMO PLANS", "methodology": "per diem", "standard_charge_dollar": 28538.0, "standard_charge_algorithm": "Per diem ($28,538).", "count": "0", "additional_payer_notes": "Zero final payments for the item or service in the 15 months prior to posting the file." }, { "payer_name": "SUTTER", "plan_name": "SUTTER SELECT & SUTTER HEALTH PLAN HMO PLANS", "methodology": "per diem", "standard_charge_dollar": 28538.0, "standard_charge_algorithm": "Per diem ($28,538).", "count": "0", "additional_payer_notes": "Zero final payments for the item or service in the 15 months prior to posting the file." }, { "payer_name": "UNITED HEALTHCARE", "plan_name": "SUTTER SELECT & SUTTER HEALTH PLAN HMO PLANS", "methodology": "per diem", "standard_charge_dollar": 28538.0, "standard_charge_algorithm": "Per diem ($28,538).", "count": "0", "additional_payer_notes": "Zero final payments for the item or service in the 15 months prior to posting the file." }, { "payer_name": "UMR", "plan_name": "SUTTER SELECT & SUTTER HEALTH PLAN HMO PLANS", "methodology": "per diem", "standard_charge_dollar": 28538.0, "standard_charge_algorithm": "Per diem ($28,538).", "count": "0", "additional_payer_notes": "Zero final payments for the item or service in the 15 months prior to posting the file." } ] } ] }, { "description": "Hc Dilator Gp020", "code_information": [ { "code": "PX-2120057020", "type": "CDM" }, { "code": "99999", "type": "CPT" }, { "code": "0272", "type": "RC" } ], "standard_charges": [ { "setting": "outpatient", "gross_charge": 2550.0, "discounted_cash": 1275.0, "minimum": 1076.1, "maximum": 1326.0, "additional_generic_notes": "Zero final payments for the item or service in the 15 months prior to posting the file.", "payers_information": [ { "payer_name": "AETNA", "plan_name": "AETNA ALL OTHER PLANS", "methodology": "percent of total billed charges", "standard_charge_dollar": 1326.0, "standard_charge_percentage": 52.0, "count": "0", "additional_payer_notes": "Zero final payments for the item or service in the 15 months prior to posting the file." }, { "payer_name": "AETNA", "plan_name": "AETNA ALL OTHER PLANS", "methodology": "percent of total billed charges", "standard_charge_dollar": 1326.0, "standard_charge_percentage": 52.0, "count": "0", "additional_payer_notes": "Zero final payments for the item or service in the 15 months prior to posting the file." }, { "payer_name": "MERITAIN HEALTH", "plan_name": "AETNA ALL OTHER PLANS", "methodology": "percent of total billed charges", "standard_charge_dollar": 1326.0, "standard_charge_percentage": 52.0, "count": "0", "additional_payer_notes": "Zero final payments for the item or service in the 15 months prior to posting the file." }, { "payer_name": "BLUE SHIELD OUT OF STATE", "plan_name": "STANFORD HEALTHCARE ALLIANCE PLAN", "methodology": "percent of total billed charges", "standard_charge_dollar": 1239.05, "standard_charge_percentage": 48.59, "count": "0", "additional_payer_notes": "Zero final payments for the item or service in the 15 months prior to posting the file." }, { "payer_name": "BLUE SHIELD", "plan_name": "STANFORD HEALTHCARE ALLIANCE PLAN", "methodology": "percent of total billed charges", "standard_charge_dollar": 1239.05, "standard_charge_percentage": 48.59, "median_amount": 68.24, "10th_percentile": 13.6, "90th_percentile": 1043.06, "count": "30" }, { "payer_name": "BLUE SHIELD", "plan_name": "STANFORD HEALTHCARE ALLIANCE PLAN", "methodology": "percent of total billed charges", "standard_charge_dollar": 1239.05, "standard_charge_percentage": 48.59, "count": "0", "additional_payer_notes": "Zero final payments for the item or service in the 15 months prior to posting the file." }, { "payer_name": "BLUE SHIELD", "plan_name": "STANFORD HEALTHCARE ALLIANCE PLAN", "methodology": "percent of total billed charges", "standard_charge_dollar": 1239.05, "standard_charge_percentage": 48.59, "count": "0", "additional_payer_notes": "Zero final payments for the item or service in the 15 months prior to posting the file." }, { "payer_name": "CIGNA", "plan_name": "CIGNA COM ALT HMO PLAN", "methodology": "percent of total billed charges", "standard_charge_dollar": 1076.1, "standard_charge_percentage": 42.2, "count": "0", "additional_payer_notes": "Zero final payments for the item or service in the 15 months prior to posting the file." }, { "payer_name": "CIGNA", "plan_name": "CIGNA COM ALT HMO PLAN", "methodology": "percent of total billed charges", "standard_charge_dollar": 1076.1, "standard_charge_percentage": 42.2, "count": "0", "additional_payer_notes": "Zero final payments for the item or service in the 15 months prior to posting the file." }, { "payer_name": "HEALTH NET", "plan_name": "HEALTHNET HMO, PPO, POS, EPO, CANOPY HEALTHNET HMO, OTHER-IN-NETWORK PLANS", "methodology": "per diem", "standard_charge_dollar": 8000.0, "standard_charge_algorithm": "Expected reimbursement is the lesser of Per diem ($8,000) for the length of stay and 70% of billed.", "count": "0", "additional_payer_notes": "Zero final payments for the item or service in the 15 months prior to posting the file." }, { "payer_name": "HEALTH NET", "plan_name": "HEALTHNET HMO, PPO, POS, EPO, CANOPY HEALTHNET HMO, OTHER-IN-NETWORK PLANS", "methodology": "per diem", "standard_charge_dollar": 8000.0, "standard_charge_algorithm": "Expected reimbursement is the lesser of Per diem ($8,000) for the length of stay and 70% of billed.", "count": "0", "additional_payer_notes": "Zero final payments for the item or service in the 15 months prior to posting the file." }, { "payer_name": "UNITED HEALTHCARE", "plan_name": "SUTTER SELECT & SUTTER HEALTH PLAN HMO PLANS", "methodology": "per diem", "standard_charge_dollar": 28538.0, "standard_charge_algorithm": "Per diem ($28,538).", "count": "0", "additional_payer_notes": "Zero final payments for the item or service in the 15 months prior to posting the file." }, { "payer_name": "UNITED HEALTHCARE", "plan_name": "SUTTER SELECT & SUTTER HEALTH PLAN HMO PLANS", "methodology": "per diem", "standard_charge_dollar": 28538.0, "standard_charge_algorithm": "Per diem ($28,538).", "count": "0", "additional_payer_notes": "Zero final payments for the item or service in the 15 months prior to posting the file." }, { "payer_name": "SUTTER", "plan_name": "SUTTER SELECT & SUTTER HEALTH PLAN HMO PLANS", "methodology": "per diem", "standard_charge_dollar": 28538.0, "standard_charge_algorithm": "Per diem ($28,538).", "count": "0", "additional_payer_notes": "Zero final payments for the item or service in the 15 months prior to posting the file." }, { "payer_name": "UNITED HEALTHCARE", "plan_name": "SUTTER SELECT & SUTTER HEALTH PLAN HMO PLANS", "methodology": "per diem", "standard_charge_dollar": 28538.0, "standard_charge_algorithm": "Per diem ($28,538).", "count": "0", "additional_payer_notes": "Zero final payments for the item or service in the 15 months prior to posting the file." }, { "payer_name": "UMR", "plan_name": "SUTTER SELECT & SUTTER HEALTH PLAN HMO PLANS", "methodology": "per diem", "standard_charge_dollar": 28538.0, "standard_charge_algorithm": "Per diem ($28,538).", "count": "0", "additional_payer_notes": "Zero final payments for the item or service in the 15 months prior to posting the file." } ] } ] }, { "description": "HC Dilator Gp028", "code_information": [ { "code": "PX-2120057028", "type": "CDM" }, { "code": "99999", "type": "CPT" }, { "code": "0272", "type": "RC" } ], "standard_charges": [ { "setting": "outpatient", "gross_charge": 5250.0, "discounted_cash": 2625.0, "minimum": 2215.5, "maximum": 2730.0, "additional_generic_notes": "Zero final payments for the item or service in the 15 months prior to posting the file.", "payers_information": [ { "payer_name": "AETNA", "plan_name": "AETNA ALL OTHER PLANS", "methodology": "percent of total billed charges", "standard_charge_dollar": 2730.0, "standard_charge_percentage": 52.0, "count": "0", "additional_payer_notes": "Zero final payments for the item or service in the 15 months prior to posting the file." }, { "payer_name": "AETNA", "plan_name": "AETNA ALL OTHER PLANS", "methodology": "percent of total billed charges", "standard_charge_dollar": 2730.0, "standard_charge_percentage": 52.0, "count": "0", "additional_payer_notes": "Zero final payments for the item or service in the 15 months prior to posting the file." }, { "payer_name": "MERITAIN HEALTH", "plan_name": "AETNA ALL OTHER PLANS", "methodology": "percent of total billed charges", "standard_charge_dollar": 2730.0, "standard_charge_percentage": 52.0, "count": "0", "additional_payer_notes": "Zero final payments for the item or service in the 15 months prior to posting the file." }, { "payer_name": "BLUE SHIELD OUT OF STATE", "plan_name": "STANFORD HEALTHCARE ALLIANCE PLAN", "methodology": "percent of total billed charges", "standard_charge_dollar": 2550.98, "standard_charge_percentage": 48.59, "count": "0", "additional_payer_notes": "Zero final payments for the item or service in the 15 months prior to posting the file." }, { "payer_name": "BLUE SHIELD", "plan_name": "STANFORD HEALTHCARE ALLIANCE PLAN", "methodology": "percent of total billed charges", "standard_charge_dollar": 2550.98, "standard_charge_percentage": 48.59, "median_amount": 68.24, "10th_percentile": 13.6, "90th_percentile": 1043.06, "count": "30" }, { "payer_name": "BLUE SHIELD", "plan_name": "STANFORD HEALTHCARE ALLIANCE PLAN", "methodology": "percent of total billed charges", "standard_charge_dollar": 2550.98, "standard_charge_percentage": 48.59, "count": "0", "additional_payer_notes": "Zero final payments for the item or service in the 15 months prior to posting the file." }, { "payer_name": "BLUE SHIELD", "plan_name": "STANFORD HEALTHCARE ALLIANCE PLAN", "methodology": "percent of total billed charges", "standard_charge_dollar": 2550.98, "standard_charge_percentage": 48.59, "count": "0", "additional_payer_notes": "Zero final payments for the item or service in the 15 months prior to posting the file." }, { "payer_name": "CIGNA", "plan_name": "CIGNA COM ALT HMO PLAN", "methodology": "percent of total billed charges", "standard_charge_dollar": 2215.5, "standard_charge_percentage": 42.2, "count": "0", "additional_payer_notes": "Zero final payments for the item or service in the 15 months prior to posting the file." }, { "payer_name": "CIGNA", "plan_name": "CIGNA COM ALT HMO PLAN", "methodology": "percent of total billed charges", "standard_charge_dollar": 2215.5, "standard_charge_percentage": 42.2, "count": "0", "additional_payer_notes": "Zero final payments for the item or service in the 15 months prior to posting the file." }, { "payer_name": "HEALTH NET", "plan_name": "HEALTHNET HMO, PPO, POS, EPO, CANOPY HEALTHNET HMO, OTHER-IN-NETWORK PLANS", "methodology": "per diem", "standard_charge_dollar": 8000.0, "standard_charge_algorithm": "Expected reimbursement is the lesser of Per diem ($8,000) for the length of stay and 70% of billed.", "count": "0", "additional_payer_notes": "Zero final payments for the item or service in the 15 months prior to posting the file." }, { "payer_name": "HEALTH NET", "plan_name": "HEALTHNET HMO, PPO, POS, EPO, CANOPY HEALTHNET HMO, OTHER-IN-NETWORK PLANS", "methodology": "per diem", "standard_charge_dollar": 8000.0, "standard_charge_algorithm": "Expected reimbursement is the lesser of Per diem ($8,000) for the length of stay and 70% of billed.", "count": "0", "additional_payer_notes": "Zero final payments for the item or service in the 15 months prior to posting the file." }, { "payer_name": "UNITED HEALTHCARE", "plan_name": "SUTTER SELECT & SUTTER HEALTH PLAN HMO PLANS", "methodology": "per diem", "standard_charge_dollar": 28538.0, "standard_charge_algorithm": "Per diem ($28,538).", "count": "0", "additional_payer_notes": "Zero final payments for the item or service in the 15 months prior to posting the file." }, { "payer_name": "UNITED HEALTHCARE", "plan_name": "SUTTER SELECT & SUTTER HEALTH PLAN HMO PLANS", "methodology": "per diem", "standard_charge_dollar": 28538.0, "standard_charge_algorithm": "Per diem ($28,538).", "count": "0", "additional_payer_notes": "Zero final payments for the item or service in the 15 months prior to posting the file." }, { "payer_name": "SUTTER", "plan_name": "SUTTER SELECT & SUTTER HEALTH PLAN HMO PLANS", "methodology": "per diem", "standard_charge_dollar": 28538.0, "standard_charge_algorithm": "Per diem ($28,538).", "count": "0", "additional_payer_notes": "Zero final payments for the item or service in the 15 months prior to posting the file." }, { "payer_name": "UNITED HEALTHCARE", "plan_name": "SUTTER SELECT & SUTTER HEALTH PLAN HMO PLANS", "methodology": "per diem", "standard_charge_dollar": 28538.0, "standard_charge_algorithm": "Per diem ($28,538).", "count": "0", "additional_payer_notes": "Zero final payments for the item or service in the 15 months prior to posting the file." }, { "payer_name": "UMR", "plan_name": "SUTTER SELECT & SUTTER HEALTH PLAN HMO PLANS", "methodology": "per diem", "standard_charge_dollar": 28538.0, "standard_charge_algorithm": "Per diem ($28,538).", "count": "0", "additional_payer_notes": "Zero final payments for the item or service in the 15 months prior to posting the file." } ] } ] }, { "description": "HC Dilator Gp035", "code_information": [ { "code": "PX-2120057035", "type": "CDM" }, { "code": "99999", "type": "CPT" }, { "code": "0272", "type": "RC" } ], "standard_charges": [ { "setting": "outpatient", "gross_charge": 7150.0, "discounted_cash": 3575.0, "minimum": 3017.3, "maximum": 3718.0, "additional_generic_notes": "Zero final payments for the item or service in the 15 months prior to posting the file.", "payers_information": [ { "payer_name": "AETNA", "plan_name": "AETNA ALL OTHER PLANS", "methodology": "percent of total billed charges", "standard_charge_dollar": 3718.0, "standard_charge_percentage": 52.0, "count": "0", "additional_payer_notes": "Zero final payments for the item or service in the 15 months prior to posting the file." }, { "payer_name": "AETNA", "plan_name": "AETNA ALL OTHER PLANS", "methodology": "percent of total billed charges", "standard_charge_dollar": 3718.0, "standard_charge_percentage": 52.0, "count": "0", "additional_payer_notes": "Zero final payments for the item or service in the 15 months prior to posting the file." }, { "payer_name": "MERITAIN HEALTH", "plan_name": "AETNA ALL OTHER PLANS", "methodology": "percent of total billed charges", "standard_charge_dollar": 3718.0, "standard_charge_percentage": 52.0, "count": "0", "additional_payer_notes": "Zero final payments for the item or service in the 15 months prior to posting the file." }, { "payer_name": "BLUE SHIELD OUT OF STATE", "plan_name": "STANFORD HEALTHCARE ALLIANCE PLAN", "methodology": "percent of total billed charges", "standard_charge_dollar": 3474.19, "standard_charge_percentage": 48.59, "count": "0", "additional_payer_notes": "Zero final payments for the item or service in the 15 months prior to posting the file." }, { "payer_name": "BLUE SHIELD", "plan_name": "STANFORD HEALTHCARE ALLIANCE PLAN", "methodology": "percent of total billed charges", "standard_charge_dollar": 3474.19, "standard_charge_percentage": 48.59, "median_amount": 68.24, "10th_percentile": 13.6, "90th_percentile": 1043.06, "count": "30" }, { "payer_name": "BLUE SHIELD", "plan_name": "STANFORD HEALTHCARE ALLIANCE PLAN", "methodology": "percent of total billed charges", "standard_charge_dollar": 3474.19, "standard_charge_percentage": 48.59, "count": "0", "additional_payer_notes": "Zero final payments for the item or service in the 15 months prior to posting the file." }, { "payer_name": "BLUE SHIELD", "plan_name": "STANFORD HEALTHCARE ALLIANCE PLAN", "methodology": "percent of total billed charges", "standard_charge_dollar": 3474.19, "standard_charge_percentage": 48.59, "count": "0", "additional_payer_notes": "Zero final payments for the item or service in the 15 months prior to posting the file." }, { "payer_name": "CIGNA", "plan_name": "CIGNA COM ALT HMO PLAN", "methodology": "percent of total billed charges", "standard_charge_dollar": 3017.3, "standard_charge_percentage": 42.2, "count": "0", "additional_payer_notes": "Zero final payments for the item or service in the 15 months prior to posting the file." }, { "payer_name": "CIGNA", "plan_name": "CIGNA COM ALT HMO PLAN", "methodology": "percent of total billed charges", "standard_charge_dollar": 3017.3, "standard_charge_percentage": 42.2, "count": "0", "additional_payer_notes": "Zero final payments for the item or service in the 15 months prior to posting the file." }, { "payer_name": "HEALTH NET", "plan_name": "HEALTHNET HMO, PPO, POS, EPO, CANOPY HEALTHNET HMO, OTHER-IN-NETWORK PLANS", "methodology": "per diem", "standard_charge_dollar": 8000.0, "standard_charge_algorithm": "Expected reimbursement is the lesser of Per diem ($8,000) for the length of stay and 70% of billed.", "count": "0", "additional_payer_notes": "Zero final payments for the item or service in the 15 months prior to posting the file." }, { "payer_name": "HEALTH NET", "plan_name": "HEALTHNET HMO, PPO, POS, EPO, CANOPY HEALTHNET HMO, OTHER-IN-NETWORK PLANS", "methodology": "per diem", "standard_charge_dollar": 8000.0, "standard_charge_algorithm": "Expected reimbursement is the lesser of Per diem ($8,000) for the length of stay and 70% of billed.", "count": "0", "additional_payer_notes": "Zero final payments for the item or service in the 15 months prior to posting the file." }, { "payer_name": "UNITED HEALTHCARE", "plan_name": "SUTTER SELECT & SUTTER HEALTH PLAN HMO PLANS", "methodology": "per diem", "standard_charge_dollar": 28538.0, "standard_charge_algorithm": "Per diem ($28,538).", "count": "0", "additional_payer_notes": "Zero final payments for the item or service in the 15 months prior to posting the file." }, { "payer_name": "UNITED HEALTHCARE", "plan_name": "SUTTER SELECT & SUTTER HEALTH PLAN HMO PLANS", "methodology": "per diem", "standard_charge_dollar": 28538.0, "standard_charge_algorithm": "Per diem ($28,538).", "count": "0", "additional_payer_notes": "Zero final payments for the item or service in the 15 months prior to posting the file." }, { "payer_name": "SUTTER", "plan_name": "SUTTER SELECT & SUTTER HEALTH PLAN HMO PLANS", "methodology": "per diem", "standard_charge_dollar": 28538.0, "standard_charge_algorithm": "Per diem ($28,538).", "count": "0", "additional_payer_notes": "Zero final payments for the item or service in the 15 months prior to posting the file." }, { "payer_name": "UNITED HEALTHCARE", "plan_name": "SUTTER SELECT & SUTTER HEALTH PLAN HMO PLANS", "methodology": "per diem", "standard_charge_dollar": 28538.0, "standard_charge_algorithm": "Per diem ($28,538).", "count": "0", "additional_payer_notes": "Zero final payments for the item or service in the 15 months prior to posting the file." }, { "payer_name": "UMR", "plan_name": "SUTTER SELECT & SUTTER HEALTH PLAN HMO PLANS", "methodology": "per diem", "standard_charge_dollar": 28538.0, "standard_charge_algorithm": "Per diem ($28,538).", "count": "0", "additional_payer_notes": "Zero final payments for the item or service in the 15 months prior to posting the file." } ] } ] }, { "description": "HC Drain Gp002", "code_information": [ { "code": "PX-2120058002", "type": "CDM" }, { "code": "99999", "type": "CPT" }, { "code": "0272", "type": "RC" } ], "standard_charges": [ { "setting": "outpatient", "gross_charge": 50.0, "discounted_cash": 25.0, "minimum": 21.1, "maximum": 26.0, "additional_generic_notes": "Zero final payments for the item or service in the 15 months prior to posting the file.", "payers_information": [ { "payer_name": "AETNA", "plan_name": "AETNA ALL OTHER PLANS", "methodology": "percent of total billed charges", "standard_charge_dollar": 26.0, "standard_charge_percentage": 52.0, "count": "0", "additional_payer_notes": "Zero final payments for the item or service in the 15 months prior to posting the file." }, { "payer_name": "AETNA", "plan_name": "AETNA ALL OTHER PLANS", "methodology": "percent of total billed charges", "standard_charge_dollar": 26.0, "standard_charge_percentage": 52.0, "count": "0", "additional_payer_notes": "Zero final payments for the item or service in the 15 months prior to posting the file." }, { "payer_name": "MERITAIN HEALTH", "plan_name": "AETNA ALL OTHER PLANS", "methodology": "percent of total billed charges", "standard_charge_dollar": 26.0, "standard_charge_percentage": 52.0, "count": "0", "additional_payer_notes": "Zero final payments for the item or service in the 15 months prior to posting the file." }, { "payer_name": "BLUE SHIELD OUT OF STATE", "plan_name": "STANFORD HEALTHCARE ALLIANCE PLAN", "methodology": "percent of total billed charges", "standard_charge_dollar": 24.3, "standard_charge_percentage": 48.59, "count": "0", "additional_payer_notes": "Zero final payments for the item or service in the 15 months prior to posting the file." }, { "payer_name": "BLUE SHIELD", "plan_name": "STANFORD HEALTHCARE ALLIANCE PLAN", "methodology": "percent of total billed charges", "standard_charge_dollar": 24.3, "standard_charge_percentage": 48.59, "count": "0", "additional_payer_notes": "Zero final payments for the item or service in the 15 months prior to posting the file." }, { "payer_name": "BLUE SHIELD", "plan_name": "STANFORD HEALTHCARE ALLIANCE PLAN", "methodology": "percent of total billed charges", "standard_charge_dollar": 24.3, "standard_charge_percentage": 48.59, "count": "0", "additional_payer_notes": "Zero final payments for the item or service in the 15 months prior to posting the file." }, { "payer_name": "CIGNA", "plan_name": "CIGNA COM ALT HMO PLAN", "methodology": "percent of total billed charges", "standard_charge_dollar": 21.1, "standard_charge_percentage": 42.2, "count": "0", "additional_payer_notes": "Zero final payments for the item or service in the 15 months prior to posting the file." }, { "payer_name": "CIGNA", "plan_name": "CIGNA COM ALT HMO PLAN", "methodology": "percent of total billed charges", "standard_charge_dollar": 21.1, "standard_charge_percentage": 42.2, "count": "0", "additional_payer_notes": "Zero final payments for the item or service in the 15 months prior to posting the file." }, { "payer_name": "HEALTH NET", "plan_name": "HEALTHNET HMO, PPO, POS, EPO, CANOPY HEALTHNET HMO, OTHER-IN-NETWORK PLANS", "methodology": "per diem", "standard_charge_dollar": 8000.0, "standard_charge_algorithm": "Expected reimbursement is the lesser of Per diem ($8,000) for the length of stay and 70% of billed.", "count": "0", "additional_payer_notes": "Zero final payments for the item or service in the 15 months prior to posting the file." }, { "payer_name": "HEALTH NET", "plan_name": "HEALTHNET HMO, PPO, POS, EPO, CANOPY HEALTHNET HMO, OTHER-IN-NETWORK PLANS", "methodology": "per diem", "standard_charge_dollar": 8000.0, "standard_charge_algorithm": "Expected reimbursement is the lesser of Per diem ($8,000) for the length of stay and 70% of billed.", "count": "0", "additional_payer_notes": "Zero final payments for the item or service in the 15 months prior to posting the file." }, { "payer_name": "UNITED HEALTHCARE", "plan_name": "SUTTER SELECT & SUTTER HEALTH PLAN HMO PLANS", "methodology": "per diem", "standard_charge_dollar": 28538.0, "standard_charge_algorithm": "Per diem ($28,538).", "count": "0", "additional_payer_notes": "Zero final payments for the item or service in the 15 months prior to posting the file." }, { "payer_name": "UNITED HEALTHCARE", "plan_name": "SUTTER SELECT & SUTTER HEALTH PLAN HMO PLANS", "methodology": "per diem", "standard_charge_dollar": 28538.0, "standard_charge_algorithm": "Per diem ($28,538).", "count": "0", "additional_payer_notes": "Zero final payments for the item or service in the 15 months prior to posting the file." }, { "payer_name": "SUTTER", "plan_name": "SUTTER SELECT & SUTTER HEALTH PLAN HMO PLANS", "methodology": "per diem", "standard_charge_dollar": 28538.0, "standard_charge_algorithm": "Per diem ($28,538).", "count": "0", "additional_payer_notes": "Zero final payments for the item or service in the 15 months prior to posting the file." }, { "payer_name": "UNITED HEALTHCARE", "plan_name": "SUTTER SELECT & SUTTER HEALTH PLAN HMO PLANS", "methodology": "per diem", "standard_charge_dollar": 28538.0, "standard_charge_algorithm": "Per diem ($28,538).", "count": "0", "additional_payer_notes": "Zero final payments for the item or service in the 15 months prior to posting the file." }, { "payer_name": "UMR", "plan_name": "SUTTER SELECT & SUTTER HEALTH PLAN HMO PLANS", "methodology": "per diem", "standard_charge_dollar": 28538.0, "standard_charge_algorithm": "Per diem ($28,538).", "count": "0", "additional_payer_notes": "Zero final payments for the item or service in the 15 months prior to posting the file." } ] } ] }, { "description": "HC Drain Gp003", "code_information": [ { "code": "PX-2120058003", "type": "CDM" }, { "code": "99999", "type": "CPT" }, { "code": "0272", "type": "RC" } ], "standard_charges": [ { "setting": "outpatient", "gross_charge": 100.0, "discounted_cash": 50.0, "minimum": 42.2, "maximum": 52.0, "additional_generic_notes": "Zero final payments for the item or service in the 15 months prior to posting the file.", "payers_information": [ { "payer_name": "AETNA", "plan_name": "AETNA ALL OTHER PLANS", "methodology": "percent of total billed charges", "standard_charge_dollar": 52.0, "standard_charge_percentage": 52.0, "count": "0", "additional_payer_notes": "Zero final payments for the item or service in the 15 months prior to posting the file." }, { "payer_name": "AETNA", "plan_name": "AETNA ALL OTHER PLANS", "methodology": "percent of total billed charges", "standard_charge_dollar": 52.0, "standard_charge_percentage": 52.0, "count": "0", "additional_payer_notes": "Zero final payments for the item or service in the 15 months prior to posting the file." }, { "payer_name": "MERITAIN HEALTH", "plan_name": "AETNA ALL OTHER PLANS", "methodology": "percent of total billed charges", "standard_charge_dollar": 52.0, "standard_charge_percentage": 52.0, "count": "0", "additional_payer_notes": "Zero final payments for the item or service in the 15 months prior to posting the file." }, { "payer_name": "BLUE SHIELD OUT OF STATE", "plan_name": "STANFORD HEALTHCARE ALLIANCE PLAN", "methodology": "percent of total billed charges", "standard_charge_dollar": 48.59, "standard_charge_percentage": 48.59, "count": "0", "additional_payer_notes": "Zero final payments for the item or service in the 15 months prior to posting the file." }, { "payer_name": "BLUE SHIELD", "plan_name": "STANFORD HEALTHCARE ALLIANCE PLAN", "methodology": "percent of total billed charges", "standard_charge_dollar": 48.59, "standard_charge_percentage": 48.59, "count": "0", "additional_payer_notes": "Zero final payments for the item or service in the 15 months prior to posting the file." }, { "payer_name": "BLUE SHIELD", "plan_name": "STANFORD HEALTHCARE ALLIANCE PLAN", "methodology": "percent of total billed charges", "standard_charge_dollar": 48.59, "standard_charge_percentage": 48.59, "count": "0", "additional_payer_notes": "Zero final payments for the item or service in the 15 months prior to posting the file." }, { "payer_name": "CIGNA", "plan_name": "CIGNA COM ALT HMO PLAN", "methodology": "percent of total billed charges", "standard_charge_dollar": 42.2, "standard_charge_percentage": 42.2, "count": "0", "additional_payer_notes": "Zero final payments for the item or service in the 15 months prior to posting the file." }, { "payer_name": "CIGNA", "plan_name": "CIGNA COM ALT HMO PLAN", "methodology": "percent of total billed charges", "standard_charge_dollar": 42.2, "standard_charge_percentage": 42.2, "count": "0", "additional_payer_notes": "Zero final payments for the item or service in the 15 months prior to posting the file." }, { "payer_name": "HEALTH NET", "plan_name": "HEALTHNET HMO, PPO, POS, EPO, CANOPY HEALTHNET HMO, OTHER-IN-NETWORK PLANS", "methodology": "per diem", "standard_charge_dollar": 8000.0, "standard_charge_algorithm": "Expected reimbursement is the lesser of Per diem ($8,000) for the length of stay and 70% of billed.", "count": "0", "additional_payer_notes": "Zero final payments for the item or service in the 15 months prior to posting the file." }, { "payer_name": "HEALTH NET", "plan_name": "HEALTHNET HMO, PPO, POS, EPO, CANOPY HEALTHNET HMO, OTHER-IN-NETWORK PLANS", "methodology": "per diem", "standard_charge_dollar": 8000.0, "standard_charge_algorithm": "Expected reimbursement is the lesser of Per diem ($8,000) for the length of stay and 70% of billed.", "count": "0", "additional_payer_notes": "Zero final payments for the item or service in the 15 months prior to posting the file." }, { "payer_name": "UNITED HEALTHCARE", "plan_name": "SUTTER SELECT & SUTTER HEALTH PLAN HMO PLANS", "methodology": "per diem", "standard_charge_dollar": 28538.0, "standard_charge_algorithm": "Per diem ($28,538).", "count": "0", "additional_payer_notes": "Zero final payments for the item or service in the 15 months prior to posting the file." }, { "payer_name": "UNITED HEALTHCARE", "plan_name": "SUTTER SELECT & SUTTER HEALTH PLAN HMO PLANS", "methodology": "per diem", "standard_charge_dollar": 28538.0, "standard_charge_algorithm": "Per diem ($28,538).", "count": "0", "additional_payer_notes": "Zero final payments for the item or service in the 15 months prior to posting the file." }, { "payer_name": "SUTTER", "plan_name": "SUTTER SELECT & SUTTER HEALTH PLAN HMO PLANS", "methodology": "per diem", "standard_charge_dollar": 28538.0, "standard_charge_algorithm": "Per diem ($28,538).", "count": "0", "additional_payer_notes": "Zero final payments for the item or service in the 15 months prior to posting the file." }, { "payer_name": "UNITED HEALTHCARE", "plan_name": "SUTTER SELECT & SUTTER HEALTH PLAN HMO PLANS", "methodology": "per diem", "standard_charge_dollar": 28538.0, "standard_charge_algorithm": "Per diem ($28,538).", "count": "0", "additional_payer_notes": "Zero final payments for the item or service in the 15 months prior to posting the file." }, { "payer_name": "UMR", "plan_name": "SUTTER SELECT & SUTTER HEALTH PLAN HMO PLANS", "methodology": "per diem", "standard_charge_dollar": 28538.0, "standard_charge_algorithm": "Per diem ($28,538).", "count": "0", "additional_payer_notes": "Zero final payments for the item or service in the 15 months prior to posting the file." } ] } ] }, { "description": "HC Drain Gp004", "code_information": [ { "code": "PX-2120058004", "type": "CDM" }, { "code": "99999", "type": "CPT" }, { "code": "0272", "type": "RC" } ], "standard_charges": [ { "setting": "outpatient", "gross_charge": 146.0, "discounted_cash": 73.0, "minimum": 61.61, "maximum": 75.92, "additional_generic_notes": "Zero final payments for the item or service in the 15 months prior to posting the file.", "payers_information": [ { "payer_name": "AETNA", "plan_name": "AETNA ALL OTHER PLANS", "methodology": "percent of total billed charges", "standard_charge_dollar": 75.92, "standard_charge_percentage": 52.0, "count": "0", "additional_payer_notes": "Zero final payments for the item or service in the 15 months prior to posting the file." }, { "payer_name": "AETNA", "plan_name": "AETNA ALL OTHER PLANS", "methodology": "percent of total billed charges", "standard_charge_dollar": 75.92, "standard_charge_percentage": 52.0, "count": "0", "additional_payer_notes": "Zero final payments for the item or service in the 15 months prior to posting the file." }, { "payer_name": "MERITAIN HEALTH", "plan_name": "AETNA ALL OTHER PLANS", "methodology": "percent of total billed charges", "standard_charge_dollar": 75.92, "standard_charge_percentage": 52.0, "count": "0", "additional_payer_notes": "Zero final payments for the item or service in the 15 months prior to posting the file." }, { "payer_name": "BLUE SHIELD OUT OF STATE", "plan_name": "STANFORD HEALTHCARE ALLIANCE PLAN", "methodology": "percent of total billed charges", "standard_charge_dollar": 70.94, "standard_charge_percentage": 48.59, "count": "0", "additional_payer_notes": "Zero final payments for the item or service in the 15 months prior to posting the file." }, { "payer_name": "BLUE SHIELD", "plan_name": "STANFORD HEALTHCARE ALLIANCE PLAN", "methodology": "percent of total billed charges", "standard_charge_dollar": 70.94, "standard_charge_percentage": 48.59, "count": "0", "additional_payer_notes": "Zero final payments for the item or service in the 15 months prior to posting the file." }, { "payer_name": "BLUE SHIELD", "plan_name": "STANFORD HEALTHCARE ALLIANCE PLAN", "methodology": "percent of total billed charges", "standard_charge_dollar": 70.94, "standard_charge_percentage": 48.59, "count": "0", "additional_payer_notes": "Zero final payments for the item or service in the 15 months prior to posting the file." }, { "payer_name": "CIGNA", "plan_name": "CIGNA COM ALT HMO PLAN", "methodology": "percent of total billed charges", "standard_charge_dollar": 61.61, "standard_charge_percentage": 42.2, "count": "0", "additional_payer_notes": "Zero final payments for the item or service in the 15 months prior to posting the file." }, { "payer_name": "CIGNA", "plan_name": "CIGNA COM ALT HMO PLAN", "methodology": "percent of total billed charges", "standard_charge_dollar": 61.61, "standard_charge_percentage": 42.2, "count": "0", "additional_payer_notes": "Zero final payments for the item or service in the 15 months prior to posting the file." }, { "payer_name": "HEALTH NET", "plan_name": "HEALTHNET HMO, PPO, POS, EPO, CANOPY HEALTHNET HMO, OTHER-IN-NETWORK PLANS", "methodology": "per diem", "standard_charge_dollar": 8000.0, "standard_charge_algorithm": "Expected reimbursement is the lesser of Per diem ($8,000) for the length of stay and 70% of billed.", "count": "0", "additional_payer_notes": "Zero final payments for the item or service in the 15 months prior to posting the file." }, { "payer_name": "HEALTH NET", "plan_name": "HEALTHNET HMO, PPO, POS, EPO, CANOPY HEALTHNET HMO, OTHER-IN-NETWORK PLANS", "methodology": "per diem", "standard_charge_dollar": 8000.0, "standard_charge_algorithm": "Expected reimbursement is the lesser of Per diem ($8,000) for the length of stay and 70% of billed.", "count": "0", "additional_payer_notes": "Zero final payments for the item or service in the 15 months prior to posting the file." }, { "payer_name": "UNITED HEALTHCARE", "plan_name": "SUTTER SELECT & SUTTER HEALTH PLAN HMO PLANS", "methodology": "per diem", "standard_charge_dollar": 28538.0, "standard_charge_algorithm": "Per diem ($28,538).", "count": "0", "additional_payer_notes": "Zero final payments for the item or service in the 15 months prior to posting the file." }, { "payer_name": "UNITED HEALTHCARE", "plan_name": "SUTTER SELECT & SUTTER HEALTH PLAN HMO PLANS", "methodology": "per diem", "standard_charge_dollar": 28538.0, "standard_charge_algorithm": "Per diem ($28,538).", "count": "0", "additional_payer_notes": "Zero final payments for the item or service in the 15 months prior to posting the file." }, { "payer_name": "SUTTER", "plan_name": "SUTTER SELECT & SUTTER HEALTH PLAN HMO PLANS", "methodology": "per diem", "standard_charge_dollar": 28538.0, "standard_charge_algorithm": "Per diem ($28,538).", "count": "0", "additional_payer_notes": "Zero final payments for the item or service in the 15 months prior to posting the file." }, { "payer_name": "UNITED HEALTHCARE", "plan_name": "SUTTER SELECT & SUTTER HEALTH PLAN HMO PLANS", "methodology": "per diem", "standard_charge_dollar": 28538.0, "standard_charge_algorithm": "Per diem ($28,538).", "count": "0", "additional_payer_notes": "Zero final payments for the item or service in the 15 months prior to posting the file." }, { "payer_name": "UMR", "plan_name": "SUTTER SELECT & SUTTER HEALTH PLAN HMO PLANS", "methodology": "per diem", "standard_charge_dollar": 28538.0, "standard_charge_algorithm": "Per diem ($28,538).", "count": "0", "additional_payer_notes": "Zero final payments for the item or service in the 15 months prior to posting the file." } ] } ] }, { "description": "HC Drain Gp005", "code_information": [ { "code": "PX-2120058005", "type": "CDM" }, { "code": "99999", "type": "CPT" }, { "code": "0272", "type": "RC" } ], "standard_charges": [ { "setting": "outpatient", "gross_charge": 195.0, "discounted_cash": 97.5, "minimum": 82.29, "maximum": 101.4, "additional_generic_notes": "Zero final payments for the item or service in the 15 months prior to posting the file.", "payers_information": [ { "payer_name": "AETNA", "plan_name": "AETNA ALL OTHER PLANS", "methodology": "percent of total billed charges", "standard_charge_dollar": 101.4, "standard_charge_percentage": 52.0, "count": "0", "additional_payer_notes": "Zero final payments for the item or service in the 15 months prior to posting the file." }, { "payer_name": "AETNA", "plan_name": "AETNA ALL OTHER PLANS", "methodology": "percent of total billed charges", "standard_charge_dollar": 101.4, "standard_charge_percentage": 52.0, "count": "0", "additional_payer_notes": "Zero final payments for the item or service in the 15 months prior to posting the file." }, { "payer_name": "MERITAIN HEALTH", "plan_name": "AETNA ALL OTHER PLANS", "methodology": "percent of total billed charges", "standard_charge_dollar": 101.4, "standard_charge_percentage": 52.0, "count": "0", "additional_payer_notes": "Zero final payments for the item or service in the 15 months prior to posting the file." }, { "payer_name": "BLUE SHIELD OUT OF STATE", "plan_name": "STANFORD HEALTHCARE ALLIANCE PLAN", "methodology": "percent of total billed charges", "standard_charge_dollar": 94.75, "standard_charge_percentage": 48.59, "count": "0", "additional_payer_notes": "Zero final payments for the item or service in the 15 months prior to posting the file." }, { "payer_name": "BLUE SHIELD", "plan_name": "STANFORD HEALTHCARE ALLIANCE PLAN", "methodology": "percent of total billed charges", "standard_charge_dollar": 94.75, "standard_charge_percentage": 48.59, "count": "0", "additional_payer_notes": "Zero final payments for the item or service in the 15 months prior to posting the file." }, { "payer_name": "BLUE SHIELD", "plan_name": "STANFORD HEALTHCARE ALLIANCE PLAN", "methodology": "percent of total billed charges", "standard_charge_dollar": 94.75, "standard_charge_percentage": 48.59, "count": "0", "additional_payer_notes": "Zero final payments for the item or service in the 15 months prior to posting the file." }, { "payer_name": "CIGNA", "plan_name": "CIGNA COM ALT HMO PLAN", "methodology": "percent of total billed charges", "standard_charge_dollar": 82.29, "standard_charge_percentage": 42.2, "count": "0", "additional_payer_notes": "Zero final payments for the item or service in the 15 months prior to posting the file." }, { "payer_name": "CIGNA", "plan_name": "CIGNA COM ALT HMO PLAN", "methodology": "percent of total billed charges", "standard_charge_dollar": 82.29, "standard_charge_percentage": 42.2, "count": "0", "additional_payer_notes": "Zero final payments for the item or service in the 15 months prior to posting the file." }, { "payer_name": "HEALTH NET", "plan_name": "HEALTHNET HMO, PPO, POS, EPO, CANOPY HEALTHNET HMO, OTHER-IN-NETWORK PLANS", "methodology": "per diem", "standard_charge_dollar": 8000.0, "standard_charge_algorithm": "Expected reimbursement is the lesser of Per diem ($8,000) for the length of stay and 70% of billed.", "count": "0", "additional_payer_notes": "Zero final payments for the item or service in the 15 months prior to posting the file." }, { "payer_name": "HEALTH NET", "plan_name": "HEALTHNET HMO, PPO, POS, EPO, CANOPY HEALTHNET HMO, OTHER-IN-NETWORK PLANS", "methodology": "per diem", "standard_charge_dollar": 8000.0, "standard_charge_algorithm": "Expected reimbursement is the lesser of Per diem ($8,000) for the length of stay and 70% of billed.", "count": "0", "additional_payer_notes": "Zero final payments for the item or service in the 15 months prior to posting the file." }, { "payer_name": "UNITED HEALTHCARE", "plan_name": "SUTTER SELECT & SUTTER HEALTH PLAN HMO PLANS", "methodology": "per diem", "standard_charge_dollar": 28538.0, "standard_charge_algorithm": "Per diem ($28,538).", "count": "0", "additional_payer_notes": "Zero final payments for the item or service in the 15 months prior to posting the file." }, { "payer_name": "UNITED HEALTHCARE", "plan_name": "SUTTER SELECT & SUTTER HEALTH PLAN HMO PLANS", "methodology": "per diem", "standard_charge_dollar": 28538.0, "standard_charge_algorithm": "Per diem ($28,538).", "count": "0", "additional_payer_notes": "Zero final payments for the item or service in the 15 months prior to posting the file." }, { "payer_name": "SUTTER", "plan_name": "SUTTER SELECT & SUTTER HEALTH PLAN HMO PLANS", "methodology": "per diem", "standard_charge_dollar": 28538.0, "standard_charge_algorithm": "Per diem ($28,538).", "count": "0", "additional_payer_notes": "Zero final payments for the item or service in the 15 months prior to posting the file." }, { "payer_name": "UNITED HEALTHCARE", "plan_name": "SUTTER SELECT & SUTTER HEALTH PLAN HMO PLANS", "methodology": "per diem", "standard_charge_dollar": 28538.0, "standard_charge_algorithm": "Per diem ($28,538).", "count": "0", "additional_payer_notes": "Zero final payments for the item or service in the 15 months prior to posting the file." }, { "payer_name": "UMR", "plan_name": "SUTTER SELECT & SUTTER HEALTH PLAN HMO PLANS", "methodology": "per diem", "standard_charge_dollar": 28538.0, "standard_charge_algorithm": "Per diem ($28,538).", "count": "0", "additional_payer_notes": "Zero final payments for the item or service in the 15 months prior to posting the file." } ] } ] }, { "description": "HC Drain Gp006", "code_information": [ { "code": "PX-2120058006", "type": "CDM" }, { "code": "99999", "type": "CPT" }, { "code": "0272", "type": "RC" } ], "standard_charges": [ { "setting": "outpatient", "gross_charge": 293.0, "discounted_cash": 146.5, "minimum": 123.65, "maximum": 152.36, "additional_generic_notes": "Zero final payments for the item or service in the 15 months prior to posting the file.", "payers_information": [ { "payer_name": "AETNA", "plan_name": "AETNA ALL OTHER PLANS", "methodology": "percent of total billed charges", "standard_charge_dollar": 152.36, "standard_charge_percentage": 52.0, "count": "0", "additional_payer_notes": "Zero final payments for the item or service in the 15 months prior to posting the file." }, { "payer_name": "AETNA", "plan_name": "AETNA ALL OTHER PLANS", "methodology": "percent of total billed charges", "standard_charge_dollar": 152.36, "standard_charge_percentage": 52.0, "count": "0", "additional_payer_notes": "Zero final payments for the item or service in the 15 months prior to posting the file." }, { "payer_name": "MERITAIN HEALTH", "plan_name": "AETNA ALL OTHER PLANS", "methodology": "percent of total billed charges", "standard_charge_dollar": 152.36, "standard_charge_percentage": 52.0, "count": "0", "additional_payer_notes": "Zero final payments for the item or service in the 15 months prior to posting the file." }, { "payer_name": "BLUE SHIELD OUT OF STATE", "plan_name": "STANFORD HEALTHCARE ALLIANCE PLAN", "methodology": "percent of total billed charges", "standard_charge_dollar": 142.37, "standard_charge_percentage": 48.59, "count": "0", "additional_payer_notes": "Zero final payments for the item or service in the 15 months prior to posting the file." }, { "payer_name": "BLUE SHIELD", "plan_name": "STANFORD HEALTHCARE ALLIANCE PLAN", "methodology": "percent of total billed charges", "standard_charge_dollar": 142.37, "standard_charge_percentage": 48.59, "count": "0", "additional_payer_notes": "Zero final payments for the item or service in the 15 months prior to posting the file." }, { "payer_name": "BLUE SHIELD", "plan_name": "STANFORD HEALTHCARE ALLIANCE PLAN", "methodology": "percent of total billed charges", "standard_charge_dollar": 142.37, "standard_charge_percentage": 48.59, "count": "0", "additional_payer_notes": "Zero final payments for the item or service in the 15 months prior to posting the file." }, { "payer_name": "CIGNA", "plan_name": "CIGNA COM ALT HMO PLAN", "methodology": "percent of total billed charges", "standard_charge_dollar": 123.65, "standard_charge_percentage": 42.2, "count": "0", "additional_payer_notes": "Zero final payments for the item or service in the 15 months prior to posting the file." }, { "payer_name": "CIGNA", "plan_name": "CIGNA COM ALT HMO PLAN", "methodology": "percent of total billed charges", "standard_charge_dollar": 123.65, "standard_charge_percentage": 42.2, "count": "0", "additional_payer_notes": "Zero final payments for the item or service in the 15 months prior to posting the file." }, { "payer_name": "HEALTH NET", "plan_name": "HEALTHNET HMO, PPO, POS, EPO, CANOPY HEALTHNET HMO, OTHER-IN-NETWORK PLANS", "methodology": "per diem", "standard_charge_dollar": 8000.0, "standard_charge_algorithm": "Expected reimbursement is the lesser of Per diem ($8,000) for the length of stay and 70% of billed.", "count": "0", "additional_payer_notes": "Zero final payments for the item or service in the 15 months prior to posting the file." }, { "payer_name": "HEALTH NET", "plan_name": "HEALTHNET HMO, PPO, POS, EPO, CANOPY HEALTHNET HMO, OTHER-IN-NETWORK PLANS", "methodology": "per diem", "standard_charge_dollar": 8000.0, "standard_charge_algorithm": "Expected reimbursement is the lesser of Per diem ($8,000) for the length of stay and 70% of billed.", "count": "0", "additional_payer_notes": "Zero final payments for the item or service in the 15 months prior to posting the file." }, { "payer_name": "UNITED HEALTHCARE", "plan_name": "SUTTER SELECT & SUTTER HEALTH PLAN HMO PLANS", "methodology": "per diem", "standard_charge_dollar": 28538.0, "standard_charge_algorithm": "Per diem ($28,538).", "count": "0", "additional_payer_notes": "Zero final payments for the item or service in the 15 months prior to posting the file." }, { "payer_name": "UNITED HEALTHCARE", "plan_name": "SUTTER SELECT & SUTTER HEALTH PLAN HMO PLANS", "methodology": "per diem", "standard_charge_dollar": 28538.0, "standard_charge_algorithm": "Per diem ($28,538).", "count": "0", "additional_payer_notes": "Zero final payments for the item or service in the 15 months prior to posting the file." }, { "payer_name": "SUTTER", "plan_name": "SUTTER SELECT & SUTTER HEALTH PLAN HMO PLANS", "methodology": "per diem", "standard_charge_dollar": 28538.0, "standard_charge_algorithm": "Per diem ($28,538).", "count": "0", "additional_payer_notes": "Zero final payments for the item or service in the 15 months prior to posting the file." }, { "payer_name": "UNITED HEALTHCARE", "plan_name": "SUTTER SELECT & SUTTER HEALTH PLAN HMO PLANS", "methodology": "per diem", "standard_charge_dollar": 28538.0, "standard_charge_algorithm": "Per diem ($28,538).", "count": "0", "additional_payer_notes": "Zero final payments for the item or service in the 15 months prior to posting the file." }, { "payer_name": "UMR", "plan_name": "SUTTER SELECT & SUTTER HEALTH PLAN HMO PLANS", "methodology": "per diem", "standard_charge_dollar": 28538.0, "standard_charge_algorithm": "Per diem ($28,538).", "count": "0", "additional_payer_notes": "Zero final payments for the item or service in the 15 months prior to posting the file." } ] } ] }, { "description": "HC Drain Gp008", "code_information": [ { "code": "PX-2120058008", "type": "CDM" }, { "code": "99999", "type": "CPT" }, { "code": "0272", "type": "RC" } ], "standard_charges": [ { "setting": "outpatient", "gross_charge": 475.0, "discounted_cash": 237.5, "minimum": 200.45, "maximum": 247.0, "additional_generic_notes": "Zero final payments for the item or service in the 15 months prior to posting the file.", "payers_information": [ { "payer_name": "AETNA", "plan_name": "AETNA ALL OTHER PLANS", "methodology": "percent of total billed charges", "standard_charge_dollar": 247.0, "standard_charge_percentage": 52.0, "count": "0", "additional_payer_notes": "Zero final payments for the item or service in the 15 months prior to posting the file." }, { "payer_name": "AETNA", "plan_name": "AETNA ALL OTHER PLANS", "methodology": "percent of total billed charges", "standard_charge_dollar": 247.0, "standard_charge_percentage": 52.0, "count": "0", "additional_payer_notes": "Zero final payments for the item or service in the 15 months prior to posting the file." }, { "payer_name": "MERITAIN HEALTH", "plan_name": "AETNA ALL OTHER PLANS", "methodology": "percent of total billed charges", "standard_charge_dollar": 247.0, "standard_charge_percentage": 52.0, "count": "0", "additional_payer_notes": "Zero final payments for the item or service in the 15 months prior to posting the file." }, { "payer_name": "BLUE SHIELD OUT OF STATE", "plan_name": "STANFORD HEALTHCARE ALLIANCE PLAN", "methodology": "percent of total billed charges", "standard_charge_dollar": 230.8, "standard_charge_percentage": 48.59, "count": "0", "additional_payer_notes": "Zero final payments for the item or service in the 15 months prior to posting the file." }, { "payer_name": "BLUE SHIELD", "plan_name": "STANFORD HEALTHCARE ALLIANCE PLAN", "methodology": "percent of total billed charges", "standard_charge_dollar": 230.8, "standard_charge_percentage": 48.59, "count": "0", "additional_payer_notes": "Zero final payments for the item or service in the 15 months prior to posting the file." }, { "payer_name": "BLUE SHIELD", "plan_name": "STANFORD HEALTHCARE ALLIANCE PLAN", "methodology": "percent of total billed charges", "standard_charge_dollar": 230.8, "standard_charge_percentage": 48.59, "count": "0", "additional_payer_notes": "Zero final payments for the item or service in the 15 months prior to posting the file." }, { "payer_name": "CIGNA", "plan_name": "CIGNA COM ALT HMO PLAN", "methodology": "percent of total billed charges", "standard_charge_dollar": 200.45, "standard_charge_percentage": 42.2, "count": "0", "additional_payer_notes": "Zero final payments for the item or service in the 15 months prior to posting the file." }, { "payer_name": "CIGNA", "plan_name": "CIGNA COM ALT HMO PLAN", "methodology": "percent of total billed charges", "standard_charge_dollar": 200.45, "standard_charge_percentage": 42.2, "count": "0", "additional_payer_notes": "Zero final payments for the item or service in the 15 months prior to posting the file." }, { "payer_name": "HEALTH NET", "plan_name": "HEALTHNET HMO, PPO, POS, EPO, CANOPY HEALTHNET HMO, OTHER-IN-NETWORK PLANS", "methodology": "per diem", "standard_charge_dollar": 8000.0, "standard_charge_algorithm": "Expected reimbursement is the lesser of Per diem ($8,000) for the length of stay and 70% of billed.", "count": "0", "additional_payer_notes": "Zero final payments for the item or service in the 15 months prior to posting the file." }, { "payer_name": "HEALTH NET", "plan_name": "HEALTHNET HMO, PPO, POS, EPO, CANOPY HEALTHNET HMO, OTHER-IN-NETWORK PLANS", "methodology": "per diem", "standard_charge_dollar": 8000.0, "standard_charge_algorithm": "Expected reimbursement is the lesser of Per diem ($8,000) for the length of stay and 70% of billed.", "count": "0", "additional_payer_notes": "Zero final payments for the item or service in the 15 months prior to posting the file." }, { "payer_name": "UNITED HEALTHCARE", "plan_name": "SUTTER SELECT & SUTTER HEALTH PLAN HMO PLANS", "methodology": "per diem", "standard_charge_dollar": 28538.0, "standard_charge_algorithm": "Per diem ($28,538).", "count": "0", "additional_payer_notes": "Zero final payments for the item or service in the 15 months prior to posting the file." }, { "payer_name": "UNITED HEALTHCARE", "plan_name": "SUTTER SELECT & SUTTER HEALTH PLAN HMO PLANS", "methodology": "per diem", "standard_charge_dollar": 28538.0, "standard_charge_algorithm": "Per diem ($28,538).", "count": "0", "additional_payer_notes": "Zero final payments for the item or service in the 15 months prior to posting the file." }, { "payer_name": "SUTTER", "plan_name": "SUTTER SELECT & SUTTER HEALTH PLAN HMO PLANS", "methodology": "per diem", "standard_charge_dollar": 28538.0, "standard_charge_algorithm": "Per diem ($28,538).", "count": "0", "additional_payer_notes": "Zero final payments for the item or service in the 15 months prior to posting the file." }, { "payer_name": "UNITED HEALTHCARE", "plan_name": "SUTTER SELECT & SUTTER HEALTH PLAN HMO PLANS", "methodology": "per diem", "standard_charge_dollar": 28538.0, "standard_charge_algorithm": "Per diem ($28,538).", "count": "0", "additional_payer_notes": "Zero final payments for the item or service in the 15 months prior to posting the file." }, { "payer_name": "UMR", "plan_name": "SUTTER SELECT & SUTTER HEALTH PLAN HMO PLANS", "methodology": "per diem", "standard_charge_dollar": 28538.0, "standard_charge_algorithm": "Per diem ($28,538).", "count": "0", "additional_payer_notes": "Zero final payments for the item or service in the 15 months prior to posting the file." } ] } ] }, { "description": "HC Drain Gp010", "code_information": [ { "code": "PX-2120058010", "type": "CDM" }, { "code": "99999", "type": "CPT" }, { "code": "0272", "type": "RC" } ], "standard_charges": [ { "setting": "outpatient", "gross_charge": 665.0, "discounted_cash": 332.5, "minimum": 280.63, "maximum": 345.8, "additional_generic_notes": "Zero final payments for the item or service in the 15 months prior to posting the file.", "payers_information": [ { "payer_name": "AETNA", "plan_name": "AETNA ALL OTHER PLANS", "methodology": "percent of total billed charges", "standard_charge_dollar": 345.8, "standard_charge_percentage": 52.0, "count": "0", "additional_payer_notes": "Zero final payments for the item or service in the 15 months prior to posting the file." }, { "payer_name": "AETNA", "plan_name": "AETNA ALL OTHER PLANS", "methodology": "percent of total billed charges", "standard_charge_dollar": 345.8, "standard_charge_percentage": 52.0, "count": "0", "additional_payer_notes": "Zero final payments for the item or service in the 15 months prior to posting the file." }, { "payer_name": "MERITAIN HEALTH", "plan_name": "AETNA ALL OTHER PLANS", "methodology": "percent of total billed charges", "standard_charge_dollar": 345.8, "standard_charge_percentage": 52.0, "count": "0", "additional_payer_notes": "Zero final payments for the item or service in the 15 months prior to posting the file." }, { "payer_name": "BLUE SHIELD OUT OF STATE", "plan_name": "STANFORD HEALTHCARE ALLIANCE PLAN", "methodology": "percent of total billed charges", "standard_charge_dollar": 323.12, "standard_charge_percentage": 48.59, "count": "0", "additional_payer_notes": "Zero final payments for the item or service in the 15 months prior to posting the file." }, { "payer_name": "BLUE SHIELD", "plan_name": "STANFORD HEALTHCARE ALLIANCE PLAN", "methodology": "percent of total billed charges", "standard_charge_dollar": 323.12, "standard_charge_percentage": 48.59, "count": "0", "additional_payer_notes": "Zero final payments for the item or service in the 15 months prior to posting the file." }, { "payer_name": "BLUE SHIELD", "plan_name": "STANFORD HEALTHCARE ALLIANCE PLAN", "methodology": "percent of total billed charges", "standard_charge_dollar": 323.12, "standard_charge_percentage": 48.59, "count": "0", "additional_payer_notes": "Zero final payments for the item or service in the 15 months prior to posting the file." }, { "payer_name": "CIGNA", "plan_name": "CIGNA COM ALT HMO PLAN", "methodology": "percent of total billed charges", "standard_charge_dollar": 280.63, "standard_charge_percentage": 42.2, "count": "0", "additional_payer_notes": "Zero final payments for the item or service in the 15 months prior to posting the file." }, { "payer_name": "CIGNA", "plan_name": "CIGNA COM ALT HMO PLAN", "methodology": "percent of total billed charges", "standard_charge_dollar": 280.63, "standard_charge_percentage": 42.2, "count": "0", "additional_payer_notes": "Zero final payments for the item or service in the 15 months prior to posting the file." }, { "payer_name": "HEALTH NET", "plan_name": "HEALTHNET HMO, PPO, POS, EPO, CANOPY HEALTHNET HMO, OTHER-IN-NETWORK PLANS", "methodology": "per diem", "standard_charge_dollar": 8000.0, "standard_charge_algorithm": "Expected reimbursement is the lesser of Per diem ($8,000) for the length of stay and 70% of billed.", "count": "0", "additional_payer_notes": "Zero final payments for the item or service in the 15 months prior to posting the file." }, { "payer_name": "HEALTH NET", "plan_name": "HEALTHNET HMO, PPO, POS, EPO, CANOPY HEALTHNET HMO, OTHER-IN-NETWORK PLANS", "methodology": "per diem", "standard_charge_dollar": 8000.0, "standard_charge_algorithm": "Expected reimbursement is the lesser of Per diem ($8,000) for the length of stay and 70% of billed.", "count": "0", "additional_payer_notes": "Zero final payments for the item or service in the 15 months prior to posting the file." }, { "payer_name": "UNITED HEALTHCARE", "plan_name": "SUTTER SELECT & SUTTER HEALTH PLAN HMO PLANS", "methodology": "per diem", "standard_charge_dollar": 28538.0, "standard_charge_algorithm": "Per diem ($28,538).", "count": "0", "additional_payer_notes": "Zero final payments for the item or service in the 15 months prior to posting the file." }, { "payer_name": "UNITED HEALTHCARE", "plan_name": "SUTTER SELECT & SUTTER HEALTH PLAN HMO PLANS", "methodology": "per diem", "standard_charge_dollar": 28538.0, "standard_charge_algorithm": "Per diem ($28,538).", "count": "0", "additional_payer_notes": "Zero final payments for the item or service in the 15 months prior to posting the file." }, { "payer_name": "SUTTER", "plan_name": "SUTTER SELECT & SUTTER HEALTH PLAN HMO PLANS", "methodology": "per diem", "standard_charge_dollar": 28538.0, "standard_charge_algorithm": "Per diem ($28,538).", "count": "0", "additional_payer_notes": "Zero final payments for the item or service in the 15 months prior to posting the file." }, { "payer_name": "UNITED HEALTHCARE", "plan_name": "SUTTER SELECT & SUTTER HEALTH PLAN HMO PLANS", "methodology": "per diem", "standard_charge_dollar": 28538.0, "standard_charge_algorithm": "Per diem ($28,538).", "count": "0", "additional_payer_notes": "Zero final payments for the item or service in the 15 months prior to posting the file." }, { "payer_name": "UMR", "plan_name": "SUTTER SELECT & SUTTER HEALTH PLAN HMO PLANS", "methodology": "per diem", "standard_charge_dollar": 28538.0, "standard_charge_algorithm": "Per diem ($28,538).", "count": "0", "additional_payer_notes": "Zero final payments for the item or service in the 15 months prior to posting the file." } ] } ] }, { "description": "Hc Drain Gp012", "code_information": [ { "code": "PX-2120058012", "type": "CDM" }, { "code": "99999", "type": "CPT" }, { "code": "0272", "type": "RC" } ], "standard_charges": [ { "setting": "outpatient", "gross_charge": 810.0, "discounted_cash": 405.0, "minimum": 341.82, "maximum": 421.2, "additional_generic_notes": "Zero final payments for the item or service in the 15 months prior to posting the file.", "payers_information": [ { "payer_name": "AETNA", "plan_name": "AETNA ALL OTHER PLANS", "methodology": "percent of total billed charges", "standard_charge_dollar": 421.2, "standard_charge_percentage": 52.0, "count": "0", "additional_payer_notes": "Zero final payments for the item or service in the 15 months prior to posting the file." }, { "payer_name": "AETNA", "plan_name": "AETNA ALL OTHER PLANS", "methodology": "percent of total billed charges", "standard_charge_dollar": 421.2, "standard_charge_percentage": 52.0, "count": "0", "additional_payer_notes": "Zero final payments for the item or service in the 15 months prior to posting the file." }, { "payer_name": "MERITAIN HEALTH", "plan_name": "AETNA ALL OTHER PLANS", "methodology": "percent of total billed charges", "standard_charge_dollar": 421.2, "standard_charge_percentage": 52.0, "count": "0", "additional_payer_notes": "Zero final payments for the item or service in the 15 months prior to posting the file." }, { "payer_name": "BLUE SHIELD OUT OF STATE", "plan_name": "STANFORD HEALTHCARE ALLIANCE PLAN", "methodology": "percent of total billed charges", "standard_charge_dollar": 393.58, "standard_charge_percentage": 48.59, "count": "0", "additional_payer_notes": "Zero final payments for the item or service in the 15 months prior to posting the file." }, { "payer_name": "BLUE SHIELD", "plan_name": "STANFORD HEALTHCARE ALLIANCE PLAN", "methodology": "percent of total billed charges", "standard_charge_dollar": 393.58, "standard_charge_percentage": 48.59, "count": "0", "additional_payer_notes": "Zero final payments for the item or service in the 15 months prior to posting the file." }, { "payer_name": "BLUE SHIELD", "plan_name": "STANFORD HEALTHCARE ALLIANCE PLAN", "methodology": "percent of total billed charges", "standard_charge_dollar": 393.58, "standard_charge_percentage": 48.59, "count": "0", "additional_payer_notes": "Zero final payments for the item or service in the 15 months prior to posting the file." }, { "payer_name": "CIGNA", "plan_name": "CIGNA COM ALT HMO PLAN", "methodology": "percent of total billed charges", "standard_charge_dollar": 341.82, "standard_charge_percentage": 42.2, "count": "0", "additional_payer_notes": "Zero final payments for the item or service in the 15 months prior to posting the file." }, { "payer_name": "CIGNA", "plan_name": "CIGNA COM ALT HMO PLAN", "methodology": "percent of total billed charges", "standard_charge_dollar": 341.82, "standard_charge_percentage": 42.2, "count": "0", "additional_payer_notes": "Zero final payments for the item or service in the 15 months prior to posting the file." }, { "payer_name": "HEALTH NET", "plan_name": "HEALTHNET HMO, PPO, POS, EPO, CANOPY HEALTHNET HMO, OTHER-IN-NETWORK PLANS", "methodology": "per diem", "standard_charge_dollar": 8000.0, "standard_charge_algorithm": "Expected reimbursement is the lesser of Per diem ($8,000) for the length of stay and 70% of billed.", "count": "0", "additional_payer_notes": "Zero final payments for the item or service in the 15 months prior to posting the file." }, { "payer_name": "HEALTH NET", "plan_name": "HEALTHNET HMO, PPO, POS, EPO, CANOPY HEALTHNET HMO, OTHER-IN-NETWORK PLANS", "methodology": "per diem", "standard_charge_dollar": 8000.0, "standard_charge_algorithm": "Expected reimbursement is the lesser of Per diem ($8,000) for the length of stay and 70% of billed.", "count": "0", "additional_payer_notes": "Zero final payments for the item or service in the 15 months prior to posting the file." }, { "payer_name": "UNITED HEALTHCARE", "plan_name": "SUTTER SELECT & SUTTER HEALTH PLAN HMO PLANS", "methodology": "per diem", "standard_charge_dollar": 28538.0, "standard_charge_algorithm": "Per diem ($28,538).", "count": "0", "additional_payer_notes": "Zero final payments for the item or service in the 15 months prior to posting the file." }, { "payer_name": "UNITED HEALTHCARE", "plan_name": "SUTTER SELECT & SUTTER HEALTH PLAN HMO PLANS", "methodology": "per diem", "standard_charge_dollar": 28538.0, "standard_charge_algorithm": "Per diem ($28,538).", "count": "0", "additional_payer_notes": "Zero final payments for the item or service in the 15 months prior to posting the file." }, { "payer_name": "SUTTER", "plan_name": "SUTTER SELECT & SUTTER HEALTH PLAN HMO PLANS", "methodology": "per diem", "standard_charge_dollar": 28538.0, "standard_charge_algorithm": "Per diem ($28,538).", "count": "0", "additional_payer_notes": "Zero final payments for the item or service in the 15 months prior to posting the file." }, { "payer_name": "UNITED HEALTHCARE", "plan_name": "SUTTER SELECT & SUTTER HEALTH PLAN HMO PLANS", "methodology": "per diem", "standard_charge_dollar": 28538.0, "standard_charge_algorithm": "Per diem ($28,538).", "count": "0", "additional_payer_notes": "Zero final payments for the item or service in the 15 months prior to posting the file." }, { "payer_name": "UMR", "plan_name": "SUTTER SELECT & SUTTER HEALTH PLAN HMO PLANS", "methodology": "per diem", "standard_charge_dollar": 28538.0, "standard_charge_algorithm": "Per diem ($28,538).", "count": "0", "additional_payer_notes": "Zero final payments for the item or service in the 15 months prior to posting the file." } ] } ] }, { "description": "HC Drain Gp013", "code_information": [ { "code": "PX-2120058013", "type": "CDM" }, { "code": "99999", "type": "CPT" }, { "code": "0272", "type": "RC" } ], "standard_charges": [ { "setting": "outpatient", "gross_charge": 900.0, "discounted_cash": 450.0, "minimum": 379.8, "maximum": 468.0, "additional_generic_notes": "Zero final payments for the item or service in the 15 months prior to posting the file.", "payers_information": [ { "payer_name": "AETNA", "plan_name": "AETNA ALL OTHER PLANS", "methodology": "percent of total billed charges", "standard_charge_dollar": 468.0, "standard_charge_percentage": 52.0, "count": "0", "additional_payer_notes": "Zero final payments for the item or service in the 15 months prior to posting the file." }, { "payer_name": "AETNA", "plan_name": "AETNA ALL OTHER PLANS", "methodology": "percent of total billed charges", "standard_charge_dollar": 468.0, "standard_charge_percentage": 52.0, "count": "0", "additional_payer_notes": "Zero final payments for the item or service in the 15 months prior to posting the file." }, { "payer_name": "MERITAIN HEALTH", "plan_name": "AETNA ALL OTHER PLANS", "methodology": "percent of total billed charges", "standard_charge_dollar": 468.0, "standard_charge_percentage": 52.0, "count": "0", "additional_payer_notes": "Zero final payments for the item or service in the 15 months prior to posting the file." }, { "payer_name": "BLUE SHIELD OUT OF STATE", "plan_name": "STANFORD HEALTHCARE ALLIANCE PLAN", "methodology": "percent of total billed charges", "standard_charge_dollar": 437.31, "standard_charge_percentage": 48.59, "count": "0", "additional_payer_notes": "Zero final payments for the item or service in the 15 months prior to posting the file." }, { "payer_name": "BLUE SHIELD", "plan_name": "STANFORD HEALTHCARE ALLIANCE PLAN", "methodology": "percent of total billed charges", "standard_charge_dollar": 437.31, "standard_charge_percentage": 48.59, "count": "0", "additional_payer_notes": "Zero final payments for the item or service in the 15 months prior to posting the file." }, { "payer_name": "BLUE SHIELD", "plan_name": "STANFORD HEALTHCARE ALLIANCE PLAN", "methodology": "percent of total billed charges", "standard_charge_dollar": 437.31, "standard_charge_percentage": 48.59, "count": "0", "additional_payer_notes": "Zero final payments for the item or service in the 15 months prior to posting the file." }, { "payer_name": "CIGNA", "plan_name": "CIGNA COM ALT HMO PLAN", "methodology": "percent of total billed charges", "standard_charge_dollar": 379.8, "standard_charge_percentage": 42.2, "count": "0", "additional_payer_notes": "Zero final payments for the item or service in the 15 months prior to posting the file." }, { "payer_name": "CIGNA", "plan_name": "CIGNA COM ALT HMO PLAN", "methodology": "percent of total billed charges", "standard_charge_dollar": 379.8, "standard_charge_percentage": 42.2, "count": "0", "additional_payer_notes": "Zero final payments for the item or service in the 15 months prior to posting the file." }, { "payer_name": "HEALTH NET", "plan_name": "HEALTHNET HMO, PPO, POS, EPO, CANOPY HEALTHNET HMO, OTHER-IN-NETWORK PLANS", "methodology": "per diem", "standard_charge_dollar": 8000.0, "standard_charge_algorithm": "Expected reimbursement is the lesser of Per diem ($8,000) for the length of stay and 70% of billed.", "count": "0", "additional_payer_notes": "Zero final payments for the item or service in the 15 months prior to posting the file." }, { "payer_name": "HEALTH NET", "plan_name": "HEALTHNET HMO, PPO, POS, EPO, CANOPY HEALTHNET HMO, OTHER-IN-NETWORK PLANS", "methodology": "per diem", "standard_charge_dollar": 8000.0, "standard_charge_algorithm": "Expected reimbursement is the lesser of Per diem ($8,000) for the length of stay and 70% of billed.", "count": "0", "additional_payer_notes": "Zero final payments for the item or service in the 15 months prior to posting the file." }, { "payer_name": "UNITED HEALTHCARE", "plan_name": "SUTTER SELECT & SUTTER HEALTH PLAN HMO PLANS", "methodology": "per diem", "standard_charge_dollar": 28538.0, "standard_charge_algorithm": "Per diem ($28,538).", "count": "0", "additional_payer_notes": "Zero final payments for the item or service in the 15 months prior to posting the file." }, { "payer_name": "UNITED HEALTHCARE", "plan_name": "SUTTER SELECT & SUTTER HEALTH PLAN HMO PLANS", "methodology": "per diem", "standard_charge_dollar": 28538.0, "standard_charge_algorithm": "Per diem ($28,538).", "count": "0", "additional_payer_notes": "Zero final payments for the item or service in the 15 months prior to posting the file." }, { "payer_name": "SUTTER", "plan_name": "SUTTER SELECT & SUTTER HEALTH PLAN HMO PLANS", "methodology": "per diem", "standard_charge_dollar": 28538.0, "standard_charge_algorithm": "Per diem ($28,538).", "count": "0", "additional_payer_notes": "Zero final payments for the item or service in the 15 months prior to posting the file." }, { "payer_name": "UNITED HEALTHCARE", "plan_name": "SUTTER SELECT & SUTTER HEALTH PLAN HMO PLANS", "methodology": "per diem", "standard_charge_dollar": 28538.0, "standard_charge_algorithm": "Per diem ($28,538).", "count": "0", "additional_payer_notes": "Zero final payments for the item or service in the 15 months prior to posting the file." }, { "payer_name": "UMR", "plan_name": "SUTTER SELECT & SUTTER HEALTH PLAN HMO PLANS", "methodology": "per diem", "standard_charge_dollar": 28538.0, "standard_charge_algorithm": "Per diem ($28,538).", "count": "0", "additional_payer_notes": "Zero final payments for the item or service in the 15 months prior to posting the file." } ] } ] }, { "description": "HC Drain Gp014", "code_information": [ { "code": "PX-2120058014", "type": "CDM" }, { "code": "99999", "type": "CPT" }, { "code": "0272", "type": "RC" } ], "standard_charges": [ { "setting": "outpatient", "gross_charge": 1080.0, "discounted_cash": 540.0, "minimum": 455.76, "maximum": 561.6, "additional_generic_notes": "Zero final payments for the item or service in the 15 months prior to posting the file.", "payers_information": [ { "payer_name": "AETNA", "plan_name": "AETNA ALL OTHER PLANS", "methodology": "percent of total billed charges", "standard_charge_dollar": 561.6, "standard_charge_percentage": 52.0, "count": "0", "additional_payer_notes": "Zero final payments for the item or service in the 15 months prior to posting the file." }, { "payer_name": "AETNA", "plan_name": "AETNA ALL OTHER PLANS", "methodology": "percent of total billed charges", "standard_charge_dollar": 561.6, "standard_charge_percentage": 52.0, "count": "0", "additional_payer_notes": "Zero final payments for the item or service in the 15 months prior to posting the file." }, { "payer_name": "MERITAIN HEALTH", "plan_name": "AETNA ALL OTHER PLANS", "methodology": "percent of total billed charges", "standard_charge_dollar": 561.6, "standard_charge_percentage": 52.0, "count": "0", "additional_payer_notes": "Zero final payments for the item or service in the 15 months prior to posting the file." }, { "payer_name": "BLUE SHIELD OUT OF STATE", "plan_name": "STANFORD HEALTHCARE ALLIANCE PLAN", "methodology": "percent of total billed charges", "standard_charge_dollar": 524.77, "standard_charge_percentage": 48.59, "count": "0", "additional_payer_notes": "Zero final payments for the item or service in the 15 months prior to posting the file." }, { "payer_name": "BLUE SHIELD", "plan_name": "STANFORD HEALTHCARE ALLIANCE PLAN", "methodology": "percent of total billed charges", "standard_charge_dollar": 524.77, "standard_charge_percentage": 48.59, "median_amount": 68.24, "10th_percentile": 13.6, "90th_percentile": 1043.06, "count": "30" }, { "payer_name": "BLUE SHIELD", "plan_name": "STANFORD HEALTHCARE ALLIANCE PLAN", "methodology": "percent of total billed charges", "standard_charge_dollar": 524.77, "standard_charge_percentage": 48.59, "count": "0", "additional_payer_notes": "Zero final payments for the item or service in the 15 months prior to posting the file." }, { "payer_name": "BLUE SHIELD", "plan_name": "STANFORD HEALTHCARE ALLIANCE PLAN", "methodology": "percent of total billed charges", "standard_charge_dollar": 524.77, "standard_charge_percentage": 48.59, "count": "0", "additional_payer_notes": "Zero final payments for the item or service in the 15 months prior to posting the file." }, { "payer_name": "CIGNA", "plan_name": "CIGNA COM ALT HMO PLAN", "methodology": "percent of total billed charges", "standard_charge_dollar": 455.76, "standard_charge_percentage": 42.2, "count": "0", "additional_payer_notes": "Zero final payments for the item or service in the 15 months prior to posting the file." }, { "payer_name": "CIGNA", "plan_name": "CIGNA COM ALT HMO PLAN", "methodology": "percent of total billed charges", "standard_charge_dollar": 455.76, "standard_charge_percentage": 42.2, "count": "0", "additional_payer_notes": "Zero final payments for the item or service in the 15 months prior to posting the file." }, { "payer_name": "HEALTH NET", "plan_name": "HEALTHNET HMO, PPO, POS, EPO, CANOPY HEALTHNET HMO, OTHER-IN-NETWORK PLANS", "methodology": "per diem", "standard_charge_dollar": 8000.0, "standard_charge_algorithm": "Expected reimbursement is the lesser of Per diem ($8,000) for the length of stay and 70% of billed.", "count": "0", "additional_payer_notes": "Zero final payments for the item or service in the 15 months prior to posting the file." }, { "payer_name": "HEALTH NET", "plan_name": "HEALTHNET HMO, PPO, POS, EPO, CANOPY HEALTHNET HMO, OTHER-IN-NETWORK PLANS", "methodology": "per diem", "standard_charge_dollar": 8000.0, "standard_charge_algorithm": "Expected reimbursement is the lesser of Per diem ($8,000) for the length of stay and 70% of billed.", "count": "0", "additional_payer_notes": "Zero final payments for the item or service in the 15 months prior to posting the file." }, { "payer_name": "UNITED HEALTHCARE", "plan_name": "SUTTER SELECT & SUTTER HEALTH PLAN HMO PLANS", "methodology": "per diem", "standard_charge_dollar": 28538.0, "standard_charge_algorithm": "Per diem ($28,538).", "count": "0", "additional_payer_notes": "Zero final payments for the item or service in the 15 months prior to posting the file." }, { "payer_name": "UNITED HEALTHCARE", "plan_name": "SUTTER SELECT & SUTTER HEALTH PLAN HMO PLANS", "methodology": "per diem", "standard_charge_dollar": 28538.0, "standard_charge_algorithm": "Per diem ($28,538).", "count": "0", "additional_payer_notes": "Zero final payments for the item or service in the 15 months prior to posting the file." }, { "payer_name": "SUTTER", "plan_name": "SUTTER SELECT & SUTTER HEALTH PLAN HMO PLANS", "methodology": "per diem", "standard_charge_dollar": 28538.0, "standard_charge_algorithm": "Per diem ($28,538).", "count": "0", "additional_payer_notes": "Zero final payments for the item or service in the 15 months prior to posting the file." }, { "payer_name": "UNITED HEALTHCARE", "plan_name": "SUTTER SELECT & SUTTER HEALTH PLAN HMO PLANS", "methodology": "per diem", "standard_charge_dollar": 28538.0, "standard_charge_algorithm": "Per diem ($28,538).", "count": "0", "additional_payer_notes": "Zero final payments for the item or service in the 15 months prior to posting the file." }, { "payer_name": "UMR", "plan_name": "SUTTER SELECT & SUTTER HEALTH PLAN HMO PLANS", "methodology": "per diem", "standard_charge_dollar": 28538.0, "standard_charge_algorithm": "Per diem ($28,538).", "count": "0", "additional_payer_notes": "Zero final payments for the item or service in the 15 months prior to posting the file." } ] } ] }, { "description": "HC Drain Gp015", "code_information": [ { "code": "PX-2120058015", "type": "CDM" }, { "code": "99999", "type": "CPT" }, { "code": "0272", "type": "RC" } ], "standard_charges": [ { "setting": "outpatient", "gross_charge": 1225.0, "discounted_cash": 612.5, "minimum": 516.95, "maximum": 637.0, "additional_generic_notes": "Zero final payments for the item or service in the 15 months prior to posting the file.", "payers_information": [ { "payer_name": "AETNA", "plan_name": "AETNA ALL OTHER PLANS", "methodology": "percent of total billed charges", "standard_charge_dollar": 637.0, "standard_charge_percentage": 52.0, "count": "0", "additional_payer_notes": "Zero final payments for the item or service in the 15 months prior to posting the file." }, { "payer_name": "AETNA", "plan_name": "AETNA ALL OTHER PLANS", "methodology": "percent of total billed charges", "standard_charge_dollar": 637.0, "standard_charge_percentage": 52.0, "count": "0", "additional_payer_notes": "Zero final payments for the item or service in the 15 months prior to posting the file." }, { "payer_name": "MERITAIN HEALTH", "plan_name": "AETNA ALL OTHER PLANS", "methodology": "percent of total billed charges", "standard_charge_dollar": 637.0, "standard_charge_percentage": 52.0, "count": "0", "additional_payer_notes": "Zero final payments for the item or service in the 15 months prior to posting the file." }, { "payer_name": "BLUE SHIELD OUT OF STATE", "plan_name": "STANFORD HEALTHCARE ALLIANCE PLAN", "methodology": "percent of total billed charges", "standard_charge_dollar": 595.23, "standard_charge_percentage": 48.59, "count": "0", "additional_payer_notes": "Zero final payments for the item or service in the 15 months prior to posting the file." }, { "payer_name": "BLUE SHIELD", "plan_name": "STANFORD HEALTHCARE ALLIANCE PLAN", "methodology": "percent of total billed charges", "standard_charge_dollar": 595.23, "standard_charge_percentage": 48.59, "median_amount": 68.24, "10th_percentile": 13.6, "90th_percentile": 1043.06, "count": "30" }, { "payer_name": "BLUE SHIELD", "plan_name": "STANFORD HEALTHCARE ALLIANCE PLAN", "methodology": "percent of total billed charges", "standard_charge_dollar": 595.23, "standard_charge_percentage": 48.59, "count": "0", "additional_payer_notes": "Zero final payments for the item or service in the 15 months prior to posting the file." }, { "payer_name": "BLUE SHIELD", "plan_name": "STANFORD HEALTHCARE ALLIANCE PLAN", "methodology": "percent of total billed charges", "standard_charge_dollar": 595.23, "standard_charge_percentage": 48.59, "count": "0", "additional_payer_notes": "Zero final payments for the item or service in the 15 months prior to posting the file." }, { "payer_name": "CIGNA", "plan_name": "CIGNA COM ALT HMO PLAN", "methodology": "percent of total billed charges", "standard_charge_dollar": 516.95, "standard_charge_percentage": 42.2, "count": "0", "additional_payer_notes": "Zero final payments for the item or service in the 15 months prior to posting the file." }, { "payer_name": "CIGNA", "plan_name": "CIGNA COM ALT HMO PLAN", "methodology": "percent of total billed charges", "standard_charge_dollar": 516.95, "standard_charge_percentage": 42.2, "count": "0", "additional_payer_notes": "Zero final payments for the item or service in the 15 months prior to posting the file." }, { "payer_name": "HEALTH NET", "plan_name": "HEALTHNET HMO, PPO, POS, EPO, CANOPY HEALTHNET HMO, OTHER-IN-NETWORK PLANS", "methodology": "per diem", "standard_charge_dollar": 8000.0, "standard_charge_algorithm": "Expected reimbursement is the lesser of Per diem ($8,000) for the length of stay and 70% of billed.", "count": "0", "additional_payer_notes": "Zero final payments for the item or service in the 15 months prior to posting the file." }, { "payer_name": "HEALTH NET", "plan_name": "HEALTHNET HMO, PPO, POS, EPO, CANOPY HEALTHNET HMO, OTHER-IN-NETWORK PLANS", "methodology": "per diem", "standard_charge_dollar": 8000.0, "standard_charge_algorithm": "Expected reimbursement is the lesser of Per diem ($8,000) for the length of stay and 70% of billed.", "count": "0", "additional_payer_notes": "Zero final payments for the item or service in the 15 months prior to posting the file." }, { "payer_name": "UNITED HEALTHCARE", "plan_name": "SUTTER SELECT & SUTTER HEALTH PLAN HMO PLANS", "methodology": "per diem", "standard_charge_dollar": 28538.0, "standard_charge_algorithm": "Per diem ($28,538).", "count": "0", "additional_payer_notes": "Zero final payments for the item or service in the 15 months prior to posting the file." }, { "payer_name": "UNITED HEALTHCARE", "plan_name": "SUTTER SELECT & SUTTER HEALTH PLAN HMO PLANS", "methodology": "per diem", "standard_charge_dollar": 28538.0, "standard_charge_algorithm": "Per diem ($28,538).", "count": "0", "additional_payer_notes": "Zero final payments for the item or service in the 15 months prior to posting the file." }, { "payer_name": "SUTTER", "plan_name": "SUTTER SELECT & SUTTER HEALTH PLAN HMO PLANS", "methodology": "per diem", "standard_charge_dollar": 28538.0, "standard_charge_algorithm": "Per diem ($28,538).", "count": "0", "additional_payer_notes": "Zero final payments for the item or service in the 15 months prior to posting the file." }, { "payer_name": "UNITED HEALTHCARE", "plan_name": "SUTTER SELECT & SUTTER HEALTH PLAN HMO PLANS", "methodology": "per diem", "standard_charge_dollar": 28538.0, "standard_charge_algorithm": "Per diem ($28,538).", "count": "0", "additional_payer_notes": "Zero final payments for the item or service in the 15 months prior to posting the file." }, { "payer_name": "UMR", "plan_name": "SUTTER SELECT & SUTTER HEALTH PLAN HMO PLANS", "methodology": "per diem", "standard_charge_dollar": 28538.0, "standard_charge_algorithm": "Per diem ($28,538).", "count": "0", "additional_payer_notes": "Zero final payments for the item or service in the 15 months prior to posting the file." } ] } ] }, { "description": "HC Drain Gp018", "code_information": [ { "code": "PX-2120058018", "type": "CDM" }, { "code": "99999", "type": "CPT" }, { "code": "0272", "type": "RC" } ], "standard_charges": [ { "setting": "outpatient", "gross_charge": 1750.0, "discounted_cash": 875.0, "minimum": 738.5, "maximum": 910.0, "additional_generic_notes": "Zero final payments for the item or service in the 15 months prior to posting the file.", "payers_information": [ { "payer_name": "AETNA", "plan_name": "AETNA ALL OTHER PLANS", "methodology": "percent of total billed charges", "standard_charge_dollar": 910.0, "standard_charge_percentage": 52.0, "count": "0", "additional_payer_notes": "Zero final payments for the item or service in the 15 months prior to posting the file." }, { "payer_name": "AETNA", "plan_name": "AETNA ALL OTHER PLANS", "methodology": "percent of total billed charges", "standard_charge_dollar": 910.0, "standard_charge_percentage": 52.0, "count": "0", "additional_payer_notes": "Zero final payments for the item or service in the 15 months prior to posting the file." }, { "payer_name": "MERITAIN HEALTH", "plan_name": "AETNA ALL OTHER PLANS", "methodology": "percent of total billed charges", "standard_charge_dollar": 910.0, "standard_charge_percentage": 52.0, "count": "0", "additional_payer_notes": "Zero final payments for the item or service in the 15 months prior to posting the file." }, { "payer_name": "BLUE SHIELD OUT OF STATE", "plan_name": "STANFORD HEALTHCARE ALLIANCE PLAN", "methodology": "percent of total billed charges", "standard_charge_dollar": 850.33, "standard_charge_percentage": 48.59, "count": "0", "additional_payer_notes": "Zero final payments for the item or service in the 15 months prior to posting the file." }, { "payer_name": "BLUE SHIELD", "plan_name": "STANFORD HEALTHCARE ALLIANCE PLAN", "methodology": "percent of total billed charges", "standard_charge_dollar": 850.33, "standard_charge_percentage": 48.59, "median_amount": 68.24, "10th_percentile": 13.6, "90th_percentile": 1043.06, "count": "30" }, { "payer_name": "BLUE SHIELD", "plan_name": "STANFORD HEALTHCARE ALLIANCE PLAN", "methodology": "percent of total billed charges", "standard_charge_dollar": 850.33, "standard_charge_percentage": 48.59, "count": "0", "additional_payer_notes": "Zero final payments for the item or service in the 15 months prior to posting the file." }, { "payer_name": "BLUE SHIELD", "plan_name": "STANFORD HEALTHCARE ALLIANCE PLAN", "methodology": "percent of total billed charges", "standard_charge_dollar": 850.33, "standard_charge_percentage": 48.59, "count": "0", "additional_payer_notes": "Zero final payments for the item or service in the 15 months prior to posting the file." }, { "payer_name": "CIGNA", "plan_name": "CIGNA COM ALT HMO PLAN", "methodology": "percent of total billed charges", "standard_charge_dollar": 738.5, "standard_charge_percentage": 42.2, "count": "0", "additional_payer_notes": "Zero final payments for the item or service in the 15 months prior to posting the file." }, { "payer_name": "CIGNA", "plan_name": "CIGNA COM ALT HMO PLAN", "methodology": "percent of total billed charges", "standard_charge_dollar": 738.5, "standard_charge_percentage": 42.2, "count": "0", "additional_payer_notes": "Zero final payments for the item or service in the 15 months prior to posting the file." }, { "payer_name": "HEALTH NET", "plan_name": "HEALTHNET HMO, PPO, POS, EPO, CANOPY HEALTHNET HMO, OTHER-IN-NETWORK PLANS", "methodology": "per diem", "standard_charge_dollar": 8000.0, "standard_charge_algorithm": "Expected reimbursement is the lesser of Per diem ($8,000) for the length of stay and 70% of billed.", "count": "0", "additional_payer_notes": "Zero final payments for the item or service in the 15 months prior to posting the file." }, { "payer_name": "HEALTH NET", "plan_name": "HEALTHNET HMO, PPO, POS, EPO, CANOPY HEALTHNET HMO, OTHER-IN-NETWORK PLANS", "methodology": "per diem", "standard_charge_dollar": 8000.0, "standard_charge_algorithm": "Expected reimbursement is the lesser of Per diem ($8,000) for the length of stay and 70% of billed.", "count": "0", "additional_payer_notes": "Zero final payments for the item or service in the 15 months prior to posting the file." }, { "payer_name": "UNITED HEALTHCARE", "plan_name": "SUTTER SELECT & SUTTER HEALTH PLAN HMO PLANS", "methodology": "per diem", "standard_charge_dollar": 28538.0, "standard_charge_algorithm": "Per diem ($28,538).", "count": "0", "additional_payer_notes": "Zero final payments for the item or service in the 15 months prior to posting the file." }, { "payer_name": "UNITED HEALTHCARE", "plan_name": "SUTTER SELECT & SUTTER HEALTH PLAN HMO PLANS", "methodology": "per diem", "standard_charge_dollar": 28538.0, "standard_charge_algorithm": "Per diem ($28,538).", "count": "0", "additional_payer_notes": "Zero final payments for the item or service in the 15 months prior to posting the file." }, { "payer_name": "SUTTER", "plan_name": "SUTTER SELECT & SUTTER HEALTH PLAN HMO PLANS", "methodology": "per diem", "standard_charge_dollar": 28538.0, "standard_charge_algorithm": "Per diem ($28,538).", "count": "0", "additional_payer_notes": "Zero final payments for the item or service in the 15 months prior to posting the file." }, { "payer_name": "UNITED HEALTHCARE", "plan_name": "SUTTER SELECT & SUTTER HEALTH PLAN HMO PLANS", "methodology": "per diem", "standard_charge_dollar": 28538.0, "standard_charge_algorithm": "Per diem ($28,538).", "count": "0", "additional_payer_notes": "Zero final payments for the item or service in the 15 months prior to posting the file." }, { "payer_name": "UMR", "plan_name": "SUTTER SELECT & SUTTER HEALTH PLAN HMO PLANS", "methodology": "per diem", "standard_charge_dollar": 28538.0, "standard_charge_algorithm": "Per diem ($28,538).", "count": "0", "additional_payer_notes": "Zero final payments for the item or service in the 15 months prior to posting the file." } ] } ] }, { "description": "Hc Drain Gp019", "code_information": [ { "code": "PX-2120058019", "type": "CDM" }, { "code": "99999", "type": "CPT" }, { "code": "0272", "type": "RC" } ], "standard_charges": [ { "setting": "outpatient", "gross_charge": 2125.0, "discounted_cash": 1062.5, "minimum": 896.75, "maximum": 1105.0, "additional_generic_notes": "Zero final payments for the item or service in the 15 months prior to posting the file.", "payers_information": [ { "payer_name": "AETNA", "plan_name": "AETNA ALL OTHER PLANS", "methodology": "percent of total billed charges", "standard_charge_dollar": 1105.0, "standard_charge_percentage": 52.0, "count": "0", "additional_payer_notes": "Zero final payments for the item or service in the 15 months prior to posting the file." }, { "payer_name": "AETNA", "plan_name": "AETNA ALL OTHER PLANS", "methodology": "percent of total billed charges", "standard_charge_dollar": 1105.0, "standard_charge_percentage": 52.0, "count": "0", "additional_payer_notes": "Zero final payments for the item or service in the 15 months prior to posting the file." }, { "payer_name": "MERITAIN HEALTH", "plan_name": "AETNA ALL OTHER PLANS", "methodology": "percent of total billed charges", "standard_charge_dollar": 1105.0, "standard_charge_percentage": 52.0, "count": "0", "additional_payer_notes": "Zero final payments for the item or service in the 15 months prior to posting the file." }, { "payer_name": "BLUE SHIELD OUT OF STATE", "plan_name": "STANFORD HEALTHCARE ALLIANCE PLAN", "methodology": "percent of total billed charges", "standard_charge_dollar": 1032.54, "standard_charge_percentage": 48.59, "count": "0", "additional_payer_notes": "Zero final payments for the item or service in the 15 months prior to posting the file." }, { "payer_name": "BLUE SHIELD", "plan_name": "STANFORD HEALTHCARE ALLIANCE PLAN", "methodology": "percent of total billed charges", "standard_charge_dollar": 1032.54, "standard_charge_percentage": 48.59, "median_amount": 68.24, "10th_percentile": 13.6, "90th_percentile": 1043.06, "count": "30" }, { "payer_name": "BLUE SHIELD", "plan_name": "STANFORD HEALTHCARE ALLIANCE PLAN", "methodology": "percent of total billed charges", "standard_charge_dollar": 1032.54, "standard_charge_percentage": 48.59, "count": "0", "additional_payer_notes": "Zero final payments for the item or service in the 15 months prior to posting the file." }, { "payer_name": "BLUE SHIELD", "plan_name": "STANFORD HEALTHCARE ALLIANCE PLAN", "methodology": "percent of total billed charges", "standard_charge_dollar": 1032.54, "standard_charge_percentage": 48.59, "count": "0", "additional_payer_notes": "Zero final payments for the item or service in the 15 months prior to posting the file." }, { "payer_name": "CIGNA", "plan_name": "CIGNA COM ALT HMO PLAN", "methodology": "percent of total billed charges", "standard_charge_dollar": 896.75, "standard_charge_percentage": 42.2, "count": "0", "additional_payer_notes": "Zero final payments for the item or service in the 15 months prior to posting the file." }, { "payer_name": "CIGNA", "plan_name": "CIGNA COM ALT HMO PLAN", "methodology": "percent of total billed charges", "standard_charge_dollar": 896.75, "standard_charge_percentage": 42.2, "count": "0", "additional_payer_notes": "Zero final payments for the item or service in the 15 months prior to posting the file." }, { "payer_name": "HEALTH NET", "plan_name": "HEALTHNET HMO, PPO, POS, EPO, CANOPY HEALTHNET HMO, OTHER-IN-NETWORK PLANS", "methodology": "per diem", "standard_charge_dollar": 8000.0, "standard_charge_algorithm": "Expected reimbursement is the lesser of Per diem ($8,000) for the length of stay and 70% of billed.", "count": "0", "additional_payer_notes": "Zero final payments for the item or service in the 15 months prior to posting the file." }, { "payer_name": "HEALTH NET", "plan_name": "HEALTHNET HMO, PPO, POS, EPO, CANOPY HEALTHNET HMO, OTHER-IN-NETWORK PLANS", "methodology": "per diem", "standard_charge_dollar": 8000.0, "standard_charge_algorithm": "Expected reimbursement is the lesser of Per diem ($8,000) for the length of stay and 70% of billed.", "count": "0", "additional_payer_notes": "Zero final payments for the item or service in the 15 months prior to posting the file." }, { "payer_name": "UNITED HEALTHCARE", "plan_name": "SUTTER SELECT & SUTTER HEALTH PLAN HMO PLANS", "methodology": "per diem", "standard_charge_dollar": 28538.0, "standard_charge_algorithm": "Per diem ($28,538).", "count": "0", "additional_payer_notes": "Zero final payments for the item or service in the 15 months prior to posting the file." }, { "payer_name": "UNITED HEALTHCARE", "plan_name": "SUTTER SELECT & SUTTER HEALTH PLAN HMO PLANS", "methodology": "per diem", "standard_charge_dollar": 28538.0, "standard_charge_algorithm": "Per diem ($28,538).", "count": "0", "additional_payer_notes": "Zero final payments for the item or service in the 15 months prior to posting the file." }, { "payer_name": "SUTTER", "plan_name": "SUTTER SELECT & SUTTER HEALTH PLAN HMO PLANS", "methodology": "per diem", "standard_charge_dollar": 28538.0, "standard_charge_algorithm": "Per diem ($28,538).", "count": "0", "additional_payer_notes": "Zero final payments for the item or service in the 15 months prior to posting the file." }, { "payer_name": "UNITED HEALTHCARE", "plan_name": "SUTTER SELECT & SUTTER HEALTH PLAN HMO PLANS", "methodology": "per diem", "standard_charge_dollar": 28538.0, "standard_charge_algorithm": "Per diem ($28,538).", "count": "0", "additional_payer_notes": "Zero final payments for the item or service in the 15 months prior to posting the file." }, { "payer_name": "UMR", "plan_name": "SUTTER SELECT & SUTTER HEALTH PLAN HMO PLANS", "methodology": "per diem", "standard_charge_dollar": 28538.0, "standard_charge_algorithm": "Per diem ($28,538).", "count": "0", "additional_payer_notes": "Zero final payments for the item or service in the 15 months prior to posting the file." } ] } ] }, { "description": "HC Drain Gp025", "code_information": [ { "code": "PX-2120058025", "type": "CDM" }, { "code": "99999", "type": "CPT" }, { "code": "0272", "type": "RC" } ], "standard_charges": [ { "setting": "outpatient", "gross_charge": 4263.0, "discounted_cash": 2131.5, "minimum": 1798.99, "maximum": 2216.76, "additional_generic_notes": "Zero final payments for the item or service in the 15 months prior to posting the file.", "payers_information": [ { "payer_name": "AETNA", "plan_name": "AETNA ALL OTHER PLANS", "methodology": "percent of total billed charges", "standard_charge_dollar": 2216.76, "standard_charge_percentage": 52.0, "count": "0", "additional_payer_notes": "Zero final payments for the item or service in the 15 months prior to posting the file." }, { "payer_name": "AETNA", "plan_name": "AETNA ALL OTHER PLANS", "methodology": "percent of total billed charges", "standard_charge_dollar": 2216.76, "standard_charge_percentage": 52.0, "count": "0", "additional_payer_notes": "Zero final payments for the item or service in the 15 months prior to posting the file." }, { "payer_name": "MERITAIN HEALTH", "plan_name": "AETNA ALL OTHER PLANS", "methodology": "percent of total billed charges", "standard_charge_dollar": 2216.76, "standard_charge_percentage": 52.0, "count": "0", "additional_payer_notes": "Zero final payments for the item or service in the 15 months prior to posting the file." }, { "payer_name": "BLUE SHIELD OUT OF STATE", "plan_name": "STANFORD HEALTHCARE ALLIANCE PLAN", "methodology": "percent of total billed charges", "standard_charge_dollar": 2071.39, "standard_charge_percentage": 48.59, "count": "0", "additional_payer_notes": "Zero final payments for the item or service in the 15 months prior to posting the file." }, { "payer_name": "BLUE SHIELD", "plan_name": "STANFORD HEALTHCARE ALLIANCE PLAN", "methodology": "percent of total billed charges", "standard_charge_dollar": 2071.39, "standard_charge_percentage": 48.59, "median_amount": 68.24, "10th_percentile": 13.6, "90th_percentile": 1043.06, "count": "30" }, { "payer_name": "BLUE SHIELD", "plan_name": "STANFORD HEALTHCARE ALLIANCE PLAN", "methodology": "percent of total billed charges", "standard_charge_dollar": 2071.39, "standard_charge_percentage": 48.59, "count": "0", "additional_payer_notes": "Zero final payments for the item or service in the 15 months prior to posting the file." }, { "payer_name": "BLUE SHIELD", "plan_name": "STANFORD HEALTHCARE ALLIANCE PLAN", "methodology": "percent of total billed charges", "standard_charge_dollar": 2071.39, "standard_charge_percentage": 48.59, "count": "0", "additional_payer_notes": "Zero final payments for the item or service in the 15 months prior to posting the file." }, { "payer_name": "CIGNA", "plan_name": "CIGNA COM ALT HMO PLAN", "methodology": "percent of total billed charges", "standard_charge_dollar": 1798.99, "standard_charge_percentage": 42.2, "count": "0", "additional_payer_notes": "Zero final payments for the item or service in the 15 months prior to posting the file." }, { "payer_name": "CIGNA", "plan_name": "CIGNA COM ALT HMO PLAN", "methodology": "percent of total billed charges", "standard_charge_dollar": 1798.99, "standard_charge_percentage": 42.2, "count": "0", "additional_payer_notes": "Zero final payments for the item or service in the 15 months prior to posting the file." }, { "payer_name": "HEALTH NET", "plan_name": "HEALTHNET HMO, PPO, POS, EPO, CANOPY HEALTHNET HMO, OTHER-IN-NETWORK PLANS", "methodology": "per diem", "standard_charge_dollar": 8000.0, "standard_charge_algorithm": "Expected reimbursement is the lesser of Per diem ($8,000) for the length of stay and 70% of billed.", "count": "0", "additional_payer_notes": "Zero final payments for the item or service in the 15 months prior to posting the file." }, { "payer_name": "HEALTH NET", "plan_name": "HEALTHNET HMO, PPO, POS, EPO, CANOPY HEALTHNET HMO, OTHER-IN-NETWORK PLANS", "methodology": "per diem", "standard_charge_dollar": 8000.0, "standard_charge_algorithm": "Expected reimbursement is the lesser of Per diem ($8,000) for the length of stay and 70% of billed.", "count": "0", "additional_payer_notes": "Zero final payments for the item or service in the 15 months prior to posting the file." }, { "payer_name": "UNITED HEALTHCARE", "plan_name": "SUTTER SELECT & SUTTER HEALTH PLAN HMO PLANS", "methodology": "per diem", "standard_charge_dollar": 28538.0, "standard_charge_algorithm": "Per diem ($28,538).", "count": "0", "additional_payer_notes": "Zero final payments for the item or service in the 15 months prior to posting the file." }, { "payer_name": "UNITED HEALTHCARE", "plan_name": "SUTTER SELECT & SUTTER HEALTH PLAN HMO PLANS", "methodology": "per diem", "standard_charge_dollar": 28538.0, "standard_charge_algorithm": "Per diem ($28,538).", "count": "0", "additional_payer_notes": "Zero final payments for the item or service in the 15 months prior to posting the file." }, { "payer_name": "SUTTER", "plan_name": "SUTTER SELECT & SUTTER HEALTH PLAN HMO PLANS", "methodology": "per diem", "standard_charge_dollar": 28538.0, "standard_charge_algorithm": "Per diem ($28,538).", "count": "0", "additional_payer_notes": "Zero final payments for the item or service in the 15 months prior to posting the file." }, { "payer_name": "UNITED HEALTHCARE", "plan_name": "SUTTER SELECT & SUTTER HEALTH PLAN HMO PLANS", "methodology": "per diem", "standard_charge_dollar": 28538.0, "standard_charge_algorithm": "Per diem ($28,538).", "count": "0", "additional_payer_notes": "Zero final payments for the item or service in the 15 months prior to posting the file." }, { "payer_name": "UMR", "plan_name": "SUTTER SELECT & SUTTER HEALTH PLAN HMO PLANS", "methodology": "per diem", "standard_charge_dollar": 28538.0, "standard_charge_algorithm": "Per diem ($28,538).", "count": "0", "additional_payer_notes": "Zero final payments for the item or service in the 15 months prior to posting the file." } ] } ] }, { "description": "HC Drain Chest Gp002", "code_information": [ { "code": "PX-2120059002", "type": "CDM" }, { "code": "99999", "type": "CPT" }, { "code": "0272", "type": "RC" } ], "standard_charges": [ { "setting": "outpatient", "gross_charge": 50.0, "discounted_cash": 25.0, "minimum": 21.1, "maximum": 26.0, "additional_generic_notes": "Zero final payments for the item or service in the 15 months prior to posting the file.", "payers_information": [ { "payer_name": "AETNA", "plan_name": "AETNA ALL OTHER PLANS", "methodology": "percent of total billed charges", "standard_charge_dollar": 26.0, "standard_charge_percentage": 52.0, "count": "0", "additional_payer_notes": "Zero final payments for the item or service in the 15 months prior to posting the file." }, { "payer_name": "AETNA", "plan_name": "AETNA ALL OTHER PLANS", "methodology": "percent of total billed charges", "standard_charge_dollar": 26.0, "standard_charge_percentage": 52.0, "count": "0", "additional_payer_notes": "Zero final payments for the item or service in the 15 months prior to posting the file." }, { "payer_name": "MERITAIN HEALTH", "plan_name": "AETNA ALL OTHER PLANS", "methodology": "percent of total billed charges", "standard_charge_dollar": 26.0, "standard_charge_percentage": 52.0, "count": "0", "additional_payer_notes": "Zero final payments for the item or service in the 15 months prior to posting the file." }, { "payer_name": "BLUE SHIELD OUT OF STATE", "plan_name": "STANFORD HEALTHCARE ALLIANCE PLAN", "methodology": "percent of total billed charges", "standard_charge_dollar": 24.3, "standard_charge_percentage": 48.59, "count": "0", "additional_payer_notes": "Zero final payments for the item or service in the 15 months prior to posting the file." }, { "payer_name": "BLUE SHIELD", "plan_name": "STANFORD HEALTHCARE ALLIANCE PLAN", "methodology": "percent of total billed charges", "standard_charge_dollar": 24.3, "standard_charge_percentage": 48.59, "count": "0", "additional_payer_notes": "Zero final payments for the item or service in the 15 months prior to posting the file." }, { "payer_name": "BLUE SHIELD", "plan_name": "STANFORD HEALTHCARE ALLIANCE PLAN", "methodology": "percent of total billed charges", "standard_charge_dollar": 24.3, "standard_charge_percentage": 48.59, "count": "0", "additional_payer_notes": "Zero final payments for the item or service in the 15 months prior to posting the file." }, { "payer_name": "CIGNA", "plan_name": "CIGNA COM ALT HMO PLAN", "methodology": "percent of total billed charges", "standard_charge_dollar": 21.1, "standard_charge_percentage": 42.2, "count": "0", "additional_payer_notes": "Zero final payments for the item or service in the 15 months prior to posting the file." }, { "payer_name": "CIGNA", "plan_name": "CIGNA COM ALT HMO PLAN", "methodology": "percent of total billed charges", "standard_charge_dollar": 21.1, "standard_charge_percentage": 42.2, "count": "0", "additional_payer_notes": "Zero final payments for the item or service in the 15 months prior to posting the file." }, { "payer_name": "HEALTH NET", "plan_name": "HEALTHNET HMO, PPO, POS, EPO, CANOPY HEALTHNET HMO, OTHER-IN-NETWORK PLANS", "methodology": "per diem", "standard_charge_dollar": 8000.0, "standard_charge_algorithm": "Expected reimbursement is the lesser of Per diem ($8,000) for the length of stay and 70% of billed.", "count": "0", "additional_payer_notes": "Zero final payments for the item or service in the 15 months prior to posting the file." }, { "payer_name": "HEALTH NET", "plan_name": "HEALTHNET HMO, PPO, POS, EPO, CANOPY HEALTHNET HMO, OTHER-IN-NETWORK PLANS", "methodology": "per diem", "standard_charge_dollar": 8000.0, "standard_charge_algorithm": "Expected reimbursement is the lesser of Per diem ($8,000) for the length of stay and 70% of billed.", "count": "0", "additional_payer_notes": "Zero final payments for the item or service in the 15 months prior to posting the file." }, { "payer_name": "UNITED HEALTHCARE", "plan_name": "SUTTER SELECT & SUTTER HEALTH PLAN HMO PLANS", "methodology": "per diem", "standard_charge_dollar": 28538.0, "standard_charge_algorithm": "Per diem ($28,538).", "count": "0", "additional_payer_notes": "Zero final payments for the item or service in the 15 months prior to posting the file." }, { "payer_name": "UNITED HEALTHCARE", "plan_name": "SUTTER SELECT & SUTTER HEALTH PLAN HMO PLANS", "methodology": "per diem", "standard_charge_dollar": 28538.0, "standard_charge_algorithm": "Per diem ($28,538).", "count": "0", "additional_payer_notes": "Zero final payments for the item or service in the 15 months prior to posting the file." }, { "payer_name": "SUTTER", "plan_name": "SUTTER SELECT & SUTTER HEALTH PLAN HMO PLANS", "methodology": "per diem", "standard_charge_dollar": 28538.0, "standard_charge_algorithm": "Per diem ($28,538).", "count": "0", "additional_payer_notes": "Zero final payments for the item or service in the 15 months prior to posting the file." }, { "payer_name": "UNITED HEALTHCARE", "plan_name": "SUTTER SELECT & SUTTER HEALTH PLAN HMO PLANS", "methodology": "per diem", "standard_charge_dollar": 28538.0, "standard_charge_algorithm": "Per diem ($28,538).", "count": "0", "additional_payer_notes": "Zero final payments for the item or service in the 15 months prior to posting the file." }, { "payer_name": "UMR", "plan_name": "SUTTER SELECT & SUTTER HEALTH PLAN HMO PLANS", "methodology": "per diem", "standard_charge_dollar": 28538.0, "standard_charge_algorithm": "Per diem ($28,538).", "count": "0", "additional_payer_notes": "Zero final payments for the item or service in the 15 months prior to posting the file." } ] } ] }, { "description": "HC Drain Chest Gp004", "code_information": [ { "code": "PX-2120059004", "type": "CDM" }, { "code": "99999", "type": "CPT" }, { "code": "0272", "type": "RC" } ], "standard_charges": [ { "setting": "outpatient", "gross_charge": 146.0, "discounted_cash": 73.0, "minimum": 61.61, "maximum": 75.92, "additional_generic_notes": "Zero final payments for the item or service in the 15 months prior to posting the file.", "payers_information": [ { "payer_name": "AETNA", "plan_name": "AETNA ALL OTHER PLANS", "methodology": "percent of total billed charges", "standard_charge_dollar": 75.92, "standard_charge_percentage": 52.0, "count": "0", "additional_payer_notes": "Zero final payments for the item or service in the 15 months prior to posting the file." }, { "payer_name": "AETNA", "plan_name": "AETNA ALL OTHER PLANS", "methodology": "percent of total billed charges", "standard_charge_dollar": 75.92, "standard_charge_percentage": 52.0, "count": "0", "additional_payer_notes": "Zero final payments for the item or service in the 15 months prior to posting the file." }, { "payer_name": "MERITAIN HEALTH", "plan_name": "AETNA ALL OTHER PLANS", "methodology": "percent of total billed charges", "standard_charge_dollar": 75.92, "standard_charge_percentage": 52.0, "count": "0", "additional_payer_notes": "Zero final payments for the item or service in the 15 months prior to posting the file." }, { "payer_name": "BLUE SHIELD OUT OF STATE", "plan_name": "STANFORD HEALTHCARE ALLIANCE PLAN", "methodology": "percent of total billed charges", "standard_charge_dollar": 70.94, "standard_charge_percentage": 48.59, "count": "0", "additional_payer_notes": "Zero final payments for the item or service in the 15 months prior to posting the file." }, { "payer_name": "BLUE SHIELD", "plan_name": "STANFORD HEALTHCARE ALLIANCE PLAN", "methodology": "percent of total billed charges", "standard_charge_dollar": 70.94, "standard_charge_percentage": 48.59, "count": "0", "additional_payer_notes": "Zero final payments for the item or service in the 15 months prior to posting the file." }, { "payer_name": "BLUE SHIELD", "plan_name": "STANFORD HEALTHCARE ALLIANCE PLAN", "methodology": "percent of total billed charges", "standard_charge_dollar": 70.94, "standard_charge_percentage": 48.59, "count": "0", "additional_payer_notes": "Zero final payments for the item or service in the 15 months prior to posting the file." }, { "payer_name": "CIGNA", "plan_name": "CIGNA COM ALT HMO PLAN", "methodology": "percent of total billed charges", "standard_charge_dollar": 61.61, "standard_charge_percentage": 42.2, "count": "0", "additional_payer_notes": "Zero final payments for the item or service in the 15 months prior to posting the file." }, { "payer_name": "CIGNA", "plan_name": "CIGNA COM ALT HMO PLAN", "methodology": "percent of total billed charges", "standard_charge_dollar": 61.61, "standard_charge_percentage": 42.2, "count": "0", "additional_payer_notes": "Zero final payments for the item or service in the 15 months prior to posting the file." }, { "payer_name": "HEALTH NET", "plan_name": "HEALTHNET HMO, PPO, POS, EPO, CANOPY HEALTHNET HMO, OTHER-IN-NETWORK PLANS", "methodology": "per diem", "standard_charge_dollar": 8000.0, "standard_charge_algorithm": "Expected reimbursement is the lesser of Per diem ($8,000) for the length of stay and 70% of billed.", "count": "0", "additional_payer_notes": "Zero final payments for the item or service in the 15 months prior to posting the file." }, { "payer_name": "HEALTH NET", "plan_name": "HEALTHNET HMO, PPO, POS, EPO, CANOPY HEALTHNET HMO, OTHER-IN-NETWORK PLANS", "methodology": "per diem", "standard_charge_dollar": 8000.0, "standard_charge_algorithm": "Expected reimbursement is the lesser of Per diem ($8,000) for the length of stay and 70% of billed.", "count": "0", "additional_payer_notes": "Zero final payments for the item or service in the 15 months prior to posting the file." }, { "payer_name": "UNITED HEALTHCARE", "plan_name": "SUTTER SELECT & SUTTER HEALTH PLAN HMO PLANS", "methodology": "per diem", "standard_charge_dollar": 28538.0, "standard_charge_algorithm": "Per diem ($28,538).", "count": "0", "additional_payer_notes": "Zero final payments for the item or service in the 15 months prior to posting the file." }, { "payer_name": "UNITED HEALTHCARE", "plan_name": "SUTTER SELECT & SUTTER HEALTH PLAN HMO PLANS", "methodology": "per diem", "standard_charge_dollar": 28538.0, "standard_charge_algorithm": "Per diem ($28,538).", "count": "0", "additional_payer_notes": "Zero final payments for the item or service in the 15 months prior to posting the file." }, { "payer_name": "SUTTER", "plan_name": "SUTTER SELECT & SUTTER HEALTH PLAN HMO PLANS", "methodology": "per diem", "standard_charge_dollar": 28538.0, "standard_charge_algorithm": "Per diem ($28,538).", "count": "0", "additional_payer_notes": "Zero final payments for the item or service in the 15 months prior to posting the file." }, { "payer_name": "UNITED HEALTHCARE", "plan_name": "SUTTER SELECT & SUTTER HEALTH PLAN HMO PLANS", "methodology": "per diem", "standard_charge_dollar": 28538.0, "standard_charge_algorithm": "Per diem ($28,538).", "count": "0", "additional_payer_notes": "Zero final payments for the item or service in the 15 months prior to posting the file." }, { "payer_name": "UMR", "plan_name": "SUTTER SELECT & SUTTER HEALTH PLAN HMO PLANS", "methodology": "per diem", "standard_charge_dollar": 28538.0, "standard_charge_algorithm": "Per diem ($28,538).", "count": "0", "additional_payer_notes": "Zero final payments for the item or service in the 15 months prior to posting the file." } ] } ] }, { "description": "HC Drain Chest Gp005", "code_information": [ { "code": "PX-2120059005", "type": "CDM" }, { "code": "99999", "type": "CPT" }, { "code": "0272", "type": "RC" } ], "standard_charges": [ { "setting": "outpatient", "gross_charge": 195.0, "discounted_cash": 97.5, "minimum": 82.29, "maximum": 101.4, "additional_generic_notes": "Zero final payments for the item or service in the 15 months prior to posting the file.", "payers_information": [ { "payer_name": "AETNA", "plan_name": "AETNA ALL OTHER PLANS", "methodology": "percent of total billed charges", "standard_charge_dollar": 101.4, "standard_charge_percentage": 52.0, "count": "0", "additional_payer_notes": "Zero final payments for the item or service in the 15 months prior to posting the file." }, { "payer_name": "AETNA", "plan_name": "AETNA ALL OTHER PLANS", "methodology": "percent of total billed charges", "standard_charge_dollar": 101.4, "standard_charge_percentage": 52.0, "count": "0", "additional_payer_notes": "Zero final payments for the item or service in the 15 months prior to posting the file." }, { "payer_name": "MERITAIN HEALTH", "plan_name": "AETNA ALL OTHER PLANS", "methodology": "percent of total billed charges", "standard_charge_dollar": 101.4, "standard_charge_percentage": 52.0, "count": "0", "additional_payer_notes": "Zero final payments for the item or service in the 15 months prior to posting the file." }, { "payer_name": "BLUE SHIELD OUT OF STATE", "plan_name": "STANFORD HEALTHCARE ALLIANCE PLAN", "methodology": "percent of total billed charges", "standard_charge_dollar": 94.75, "standard_charge_percentage": 48.59, "count": "0", "additional_payer_notes": "Zero final payments for the item or service in the 15 months prior to posting the file." }, { "payer_name": "BLUE SHIELD", "plan_name": "STANFORD HEALTHCARE ALLIANCE PLAN", "methodology": "percent of total billed charges", "standard_charge_dollar": 94.75, "standard_charge_percentage": 48.59, "count": "0", "additional_payer_notes": "Zero final payments for the item or service in the 15 months prior to posting the file." }, { "payer_name": "BLUE SHIELD", "plan_name": "STANFORD HEALTHCARE ALLIANCE PLAN", "methodology": "percent of total billed charges", "standard_charge_dollar": 94.75, "standard_charge_percentage": 48.59, "count": "0", "additional_payer_notes": "Zero final payments for the item or service in the 15 months prior to posting the file." }, { "payer_name": "CIGNA", "plan_name": "CIGNA COM ALT HMO PLAN", "methodology": "percent of total billed charges", "standard_charge_dollar": 82.29, "standard_charge_percentage": 42.2, "count": "0", "additional_payer_notes": "Zero final payments for the item or service in the 15 months prior to posting the file." }, { "payer_name": "CIGNA", "plan_name": "CIGNA COM ALT HMO PLAN", "methodology": "percent of total billed charges", "standard_charge_dollar": 82.29, "standard_charge_percentage": 42.2, "count": "0", "additional_payer_notes": "Zero final payments for the item or service in the 15 months prior to posting the file." }, { "payer_name": "HEALTH NET", "plan_name": "HEALTHNET HMO, PPO, POS, EPO, CANOPY HEALTHNET HMO, OTHER-IN-NETWORK PLANS", "methodology": "per diem", "standard_charge_dollar": 8000.0, "standard_charge_algorithm": "Expected reimbursement is the lesser of Per diem ($8,000) for the length of stay and 70% of billed.", "count": "0", "additional_payer_notes": "Zero final payments for the item or service in the 15 months prior to posting the file." }, { "payer_name": "HEALTH NET", "plan_name": "HEALTHNET HMO, PPO, POS, EPO, CANOPY HEALTHNET HMO, OTHER-IN-NETWORK PLANS", "methodology": "per diem", "standard_charge_dollar": 8000.0, "standard_charge_algorithm": "Expected reimbursement is the lesser of Per diem ($8,000) for the length of stay and 70% of billed.", "count": "0", "additional_payer_notes": "Zero final payments for the item or service in the 15 months prior to posting the file." }, { "payer_name": "UNITED HEALTHCARE", "plan_name": "SUTTER SELECT & SUTTER HEALTH PLAN HMO PLANS", "methodology": "per diem", "standard_charge_dollar": 28538.0, "standard_charge_algorithm": "Per diem ($28,538).", "count": "0", "additional_payer_notes": "Zero final payments for the item or service in the 15 months prior to posting the file." }, { "payer_name": "UNITED HEALTHCARE", "plan_name": "SUTTER SELECT & SUTTER HEALTH PLAN HMO PLANS", "methodology": "per diem", "standard_charge_dollar": 28538.0, "standard_charge_algorithm": "Per diem ($28,538).", "count": "0", "additional_payer_notes": "Zero final payments for the item or service in the 15 months prior to posting the file." }, { "payer_name": "SUTTER", "plan_name": "SUTTER SELECT & SUTTER HEALTH PLAN HMO PLANS", "methodology": "per diem", "standard_charge_dollar": 28538.0, "standard_charge_algorithm": "Per diem ($28,538).", "count": "0", "additional_payer_notes": "Zero final payments for the item or service in the 15 months prior to posting the file." }, { "payer_name": "UNITED HEALTHCARE", "plan_name": "SUTTER SELECT & SUTTER HEALTH PLAN HMO PLANS", "methodology": "per diem", "standard_charge_dollar": 28538.0, "standard_charge_algorithm": "Per diem ($28,538).", "count": "0", "additional_payer_notes": "Zero final payments for the item or service in the 15 months prior to posting the file." }, { "payer_name": "UMR", "plan_name": "SUTTER SELECT & SUTTER HEALTH PLAN HMO PLANS", "methodology": "per diem", "standard_charge_dollar": 28538.0, "standard_charge_algorithm": "Per diem ($28,538).", "count": "0", "additional_payer_notes": "Zero final payments for the item or service in the 15 months prior to posting the file." } ] } ] }, { "description": "HC Drain Chest Gp006", "code_information": [ { "code": "PX-2120059006", "type": "CDM" }, { "code": "99999", "type": "CPT" }, { "code": "0272", "type": "RC" } ], "standard_charges": [ { "setting": "outpatient", "gross_charge": 293.0, "discounted_cash": 146.5, "minimum": 123.65, "maximum": 152.36, "additional_generic_notes": "Zero final payments for the item or service in the 15 months prior to posting the file.", "payers_information": [ { "payer_name": "AETNA", "plan_name": "AETNA ALL OTHER PLANS", "methodology": "percent of total billed charges", "standard_charge_dollar": 152.36, "standard_charge_percentage": 52.0, "count": "0", "additional_payer_notes": "Zero final payments for the item or service in the 15 months prior to posting the file." }, { "payer_name": "AETNA", "plan_name": "AETNA ALL OTHER PLANS", "methodology": "percent of total billed charges", "standard_charge_dollar": 152.36, "standard_charge_percentage": 52.0, "count": "0", "additional_payer_notes": "Zero final payments for the item or service in the 15 months prior to posting the file." }, { "payer_name": "MERITAIN HEALTH", "plan_name": "AETNA ALL OTHER PLANS", "methodology": "percent of total billed charges", "standard_charge_dollar": 152.36, "standard_charge_percentage": 52.0, "count": "0", "additional_payer_notes": "Zero final payments for the item or service in the 15 months prior to posting the file." }, { "payer_name": "BLUE SHIELD OUT OF STATE", "plan_name": "STANFORD HEALTHCARE ALLIANCE PLAN", "methodology": "percent of total billed charges", "standard_charge_dollar": 142.37, "standard_charge_percentage": 48.59, "count": "0", "additional_payer_notes": "Zero final payments for the item or service in the 15 months prior to posting the file." }, { "payer_name": "BLUE SHIELD", "plan_name": "STANFORD HEALTHCARE ALLIANCE PLAN", "methodology": "percent of total billed charges", "standard_charge_dollar": 142.37, "standard_charge_percentage": 48.59, "count": "0", "additional_payer_notes": "Zero final payments for the item or service in the 15 months prior to posting the file." }, { "payer_name": "BLUE SHIELD", "plan_name": "STANFORD HEALTHCARE ALLIANCE PLAN", "methodology": "percent of total billed charges", "standard_charge_dollar": 142.37, "standard_charge_percentage": 48.59, "count": "0", "additional_payer_notes": "Zero final payments for the item or service in the 15 months prior to posting the file." }, { "payer_name": "CIGNA", "plan_name": "CIGNA COM ALT HMO PLAN", "methodology": "percent of total billed charges", "standard_charge_dollar": 123.65, "standard_charge_percentage": 42.2, "count": "0", "additional_payer_notes": "Zero final payments for the item or service in the 15 months prior to posting the file." }, { "payer_name": "CIGNA", "plan_name": "CIGNA COM ALT HMO PLAN", "methodology": "percent of total billed charges", "standard_charge_dollar": 123.65, "standard_charge_percentage": 42.2, "count": "0", "additional_payer_notes": "Zero final payments for the item or service in the 15 months prior to posting the file." }, { "payer_name": "HEALTH NET", "plan_name": "HEALTHNET HMO, PPO, POS, EPO, CANOPY HEALTHNET HMO, OTHER-IN-NETWORK PLANS", "methodology": "per diem", "standard_charge_dollar": 8000.0, "standard_charge_algorithm": "Expected reimbursement is the lesser of Per diem ($8,000) for the length of stay and 70% of billed.", "count": "0", "additional_payer_notes": "Zero final payments for the item or service in the 15 months prior to posting the file." }, { "payer_name": "HEALTH NET", "plan_name": "HEALTHNET HMO, PPO, POS, EPO, CANOPY HEALTHNET HMO, OTHER-IN-NETWORK PLANS", "methodology": "per diem", "standard_charge_dollar": 8000.0, "standard_charge_algorithm": "Expected reimbursement is the lesser of Per diem ($8,000) for the length of stay and 70% of billed.", "count": "0", "additional_payer_notes": "Zero final payments for the item or service in the 15 months prior to posting the file." }, { "payer_name": "UNITED HEALTHCARE", "plan_name": "SUTTER SELECT & SUTTER HEALTH PLAN HMO PLANS", "methodology": "per diem", "standard_charge_dollar": 28538.0, "standard_charge_algorithm": "Per diem ($28,538).", "count": "0", "additional_payer_notes": "Zero final payments for the item or service in the 15 months prior to posting the file." }, { "payer_name": "UNITED HEALTHCARE", "plan_name": "SUTTER SELECT & SUTTER HEALTH PLAN HMO PLANS", "methodology": "per diem", "standard_charge_dollar": 28538.0, "standard_charge_algorithm": "Per diem ($28,538).", "count": "0", "additional_payer_notes": "Zero final payments for the item or service in the 15 months prior to posting the file." }, { "payer_name": "SUTTER", "plan_name": "SUTTER SELECT & SUTTER HEALTH PLAN HMO PLANS", "methodology": "per diem", "standard_charge_dollar": 28538.0, "standard_charge_algorithm": "Per diem ($28,538).", "count": "0", "additional_payer_notes": "Zero final payments for the item or service in the 15 months prior to posting the file." }, { "payer_name": "UNITED HEALTHCARE", "plan_name": "SUTTER SELECT & SUTTER HEALTH PLAN HMO PLANS", "methodology": "per diem", "standard_charge_dollar": 28538.0, "standard_charge_algorithm": "Per diem ($28,538).", "count": "0", "additional_payer_notes": "Zero final payments for the item or service in the 15 months prior to posting the file." }, { "payer_name": "UMR", "plan_name": "SUTTER SELECT & SUTTER HEALTH PLAN HMO PLANS", "methodology": "per diem", "standard_charge_dollar": 28538.0, "standard_charge_algorithm": "Per diem ($28,538).", "count": "0", "additional_payer_notes": "Zero final payments for the item or service in the 15 months prior to posting the file." } ] } ] }, { "description": "HC Drain Chest Gp007", "code_information": [ { "code": "PX-2120059007", "type": "CDM" }, { "code": "99999", "type": "CPT" }, { "code": "0272", "type": "RC" } ], "standard_charges": [ { "setting": "outpatient", "gross_charge": 380.0, "discounted_cash": 190.0, "minimum": 160.36, "maximum": 197.6, "additional_generic_notes": "Zero final payments for the item or service in the 15 months prior to posting the file.", "payers_information": [ { "payer_name": "AETNA", "plan_name": "AETNA ALL OTHER PLANS", "methodology": "percent of total billed charges", "standard_charge_dollar": 197.6, "standard_charge_percentage": 52.0, "count": "0", "additional_payer_notes": "Zero final payments for the item or service in the 15 months prior to posting the file." }, { "payer_name": "AETNA", "plan_name": "AETNA ALL OTHER PLANS", "methodology": "percent of total billed charges", "standard_charge_dollar": 197.6, "standard_charge_percentage": 52.0, "count": "0", "additional_payer_notes": "Zero final payments for the item or service in the 15 months prior to posting the file." }, { "payer_name": "MERITAIN HEALTH", "plan_name": "AETNA ALL OTHER PLANS", "methodology": "percent of total billed charges", "standard_charge_dollar": 197.6, "standard_charge_percentage": 52.0, "count": "0", "additional_payer_notes": "Zero final payments for the item or service in the 15 months prior to posting the file." }, { "payer_name": "BLUE SHIELD OUT OF STATE", "plan_name": "STANFORD HEALTHCARE ALLIANCE PLAN", "methodology": "percent of total billed charges", "standard_charge_dollar": 184.64, "standard_charge_percentage": 48.59, "count": "0", "additional_payer_notes": "Zero final payments for the item or service in the 15 months prior to posting the file." }, { "payer_name": "BLUE SHIELD", "plan_name": "STANFORD HEALTHCARE ALLIANCE PLAN", "methodology": "percent of total billed charges", "standard_charge_dollar": 184.64, "standard_charge_percentage": 48.59, "count": "0", "additional_payer_notes": "Zero final payments for the item or service in the 15 months prior to posting the file." }, { "payer_name": "BLUE SHIELD", "plan_name": "STANFORD HEALTHCARE ALLIANCE PLAN", "methodology": "percent of total billed charges", "standard_charge_dollar": 184.64, "standard_charge_percentage": 48.59, "count": "0", "additional_payer_notes": "Zero final payments for the item or service in the 15 months prior to posting the file." }, { "payer_name": "CIGNA", "plan_name": "CIGNA COM ALT HMO PLAN", "methodology": "percent of total billed charges", "standard_charge_dollar": 160.36, "standard_charge_percentage": 42.2, "count": "0", "additional_payer_notes": "Zero final payments for the item or service in the 15 months prior to posting the file." }, { "payer_name": "CIGNA", "plan_name": "CIGNA COM ALT HMO PLAN", "methodology": "percent of total billed charges", "standard_charge_dollar": 160.36, "standard_charge_percentage": 42.2, "count": "0", "additional_payer_notes": "Zero final payments for the item or service in the 15 months prior to posting the file." }, { "payer_name": "HEALTH NET", "plan_name": "HEALTHNET HMO, PPO, POS, EPO, CANOPY HEALTHNET HMO, OTHER-IN-NETWORK PLANS", "methodology": "per diem", "standard_charge_dollar": 8000.0, "standard_charge_algorithm": "Expected reimbursement is the lesser of Per diem ($8,000) for the length of stay and 70% of billed.", "count": "0", "additional_payer_notes": "Zero final payments for the item or service in the 15 months prior to posting the file." }, { "payer_name": "HEALTH NET", "plan_name": "HEALTHNET HMO, PPO, POS, EPO, CANOPY HEALTHNET HMO, OTHER-IN-NETWORK PLANS", "methodology": "per diem", "standard_charge_dollar": 8000.0, "standard_charge_algorithm": "Expected reimbursement is the lesser of Per diem ($8,000) for the length of stay and 70% of billed.", "count": "0", "additional_payer_notes": "Zero final payments for the item or service in the 15 months prior to posting the file." }, { "payer_name": "UNITED HEALTHCARE", "plan_name": "SUTTER SELECT & SUTTER HEALTH PLAN HMO PLANS", "methodology": "per diem", "standard_charge_dollar": 28538.0, "standard_charge_algorithm": "Per diem ($28,538).", "count": "0", "additional_payer_notes": "Zero final payments for the item or service in the 15 months prior to posting the file." }, { "payer_name": "UNITED HEALTHCARE", "plan_name": "SUTTER SELECT & SUTTER HEALTH PLAN HMO PLANS", "methodology": "per diem", "standard_charge_dollar": 28538.0, "standard_charge_algorithm": "Per diem ($28,538).", "count": "0", "additional_payer_notes": "Zero final payments for the item or service in the 15 months prior to posting the file." }, { "payer_name": "SUTTER", "plan_name": "SUTTER SELECT & SUTTER HEALTH PLAN HMO PLANS", "methodology": "per diem", "standard_charge_dollar": 28538.0, "standard_charge_algorithm": "Per diem ($28,538).", "count": "0", "additional_payer_notes": "Zero final payments for the item or service in the 15 months prior to posting the file." }, { "payer_name": "UNITED HEALTHCARE", "plan_name": "SUTTER SELECT & SUTTER HEALTH PLAN HMO PLANS", "methodology": "per diem", "standard_charge_dollar": 28538.0, "standard_charge_algorithm": "Per diem ($28,538).", "count": "0", "additional_payer_notes": "Zero final payments for the item or service in the 15 months prior to posting the file." }, { "payer_name": "UMR", "plan_name": "SUTTER SELECT & SUTTER HEALTH PLAN HMO PLANS", "methodology": "per diem", "standard_charge_dollar": 28538.0, "standard_charge_algorithm": "Per diem ($28,538).", "count": "0", "additional_payer_notes": "Zero final payments for the item or service in the 15 months prior to posting the file." } ] } ] }, { "description": "HC Drain Chest Gp008", "code_information": [ { "code": "PX-2120059008", "type": "CDM" }, { "code": "99999", "type": "CPT" }, { "code": "0272", "type": "RC" } ], "standard_charges": [ { "setting": "outpatient", "gross_charge": 475.0, "discounted_cash": 237.5, "minimum": 200.45, "maximum": 247.0, "additional_generic_notes": "Zero final payments for the item or service in the 15 months prior to posting the file.", "payers_information": [ { "payer_name": "AETNA", "plan_name": "AETNA ALL OTHER PLANS", "methodology": "percent of total billed charges", "standard_charge_dollar": 247.0, "standard_charge_percentage": 52.0, "count": "0", "additional_payer_notes": "Zero final payments for the item or service in the 15 months prior to posting the file." }, { "payer_name": "AETNA", "plan_name": "AETNA ALL OTHER PLANS", "methodology": "percent of total billed charges", "standard_charge_dollar": 247.0, "standard_charge_percentage": 52.0, "count": "0", "additional_payer_notes": "Zero final payments for the item or service in the 15 months prior to posting the file." }, { "payer_name": "MERITAIN HEALTH", "plan_name": "AETNA ALL OTHER PLANS", "methodology": "percent of total billed charges", "standard_charge_dollar": 247.0, "standard_charge_percentage": 52.0, "count": "0", "additional_payer_notes": "Zero final payments for the item or service in the 15 months prior to posting the file." }, { "payer_name": "BLUE SHIELD OUT OF STATE", "plan_name": "STANFORD HEALTHCARE ALLIANCE PLAN", "methodology": "percent of total billed charges", "standard_charge_dollar": 230.8, "standard_charge_percentage": 48.59, "count": "0", "additional_payer_notes": "Zero final payments for the item or service in the 15 months prior to posting the file." }, { "payer_name": "BLUE SHIELD", "plan_name": "STANFORD HEALTHCARE ALLIANCE PLAN", "methodology": "percent of total billed charges", "standard_charge_dollar": 230.8, "standard_charge_percentage": 48.59, "count": "0", "additional_payer_notes": "Zero final payments for the item or service in the 15 months prior to posting the file." }, { "payer_name": "BLUE SHIELD", "plan_name": "STANFORD HEALTHCARE ALLIANCE PLAN", "methodology": "percent of total billed charges", "standard_charge_dollar": 230.8, "standard_charge_percentage": 48.59, "count": "0", "additional_payer_notes": "Zero final payments for the item or service in the 15 months prior to posting the file." }, { "payer_name": "CIGNA", "plan_name": "CIGNA COM ALT HMO PLAN", "methodology": "percent of total billed charges", "standard_charge_dollar": 200.45, "standard_charge_percentage": 42.2, "count": "0", "additional_payer_notes": "Zero final payments for the item or service in the 15 months prior to posting the file." }, { "payer_name": "CIGNA", "plan_name": "CIGNA COM ALT HMO PLAN", "methodology": "percent of total billed charges", "standard_charge_dollar": 200.45, "standard_charge_percentage": 42.2, "count": "0", "additional_payer_notes": "Zero final payments for the item or service in the 15 months prior to posting the file." }, { "payer_name": "HEALTH NET", "plan_name": "HEALTHNET HMO, PPO, POS, EPO, CANOPY HEALTHNET HMO, OTHER-IN-NETWORK PLANS", "methodology": "per diem", "standard_charge_dollar": 8000.0, "standard_charge_algorithm": "Expected reimbursement is the lesser of Per diem ($8,000) for the length of stay and 70% of billed.", "count": "0", "additional_payer_notes": "Zero final payments for the item or service in the 15 months prior to posting the file." }, { "payer_name": "HEALTH NET", "plan_name": "HEALTHNET HMO, PPO, POS, EPO, CANOPY HEALTHNET HMO, OTHER-IN-NETWORK PLANS", "methodology": "per diem", "standard_charge_dollar": 8000.0, "standard_charge_algorithm": "Expected reimbursement is the lesser of Per diem ($8,000) for the length of stay and 70% of billed.", "count": "0", "additional_payer_notes": "Zero final payments for the item or service in the 15 months prior to posting the file." }, { "payer_name": "UNITED HEALTHCARE", "plan_name": "SUTTER SELECT & SUTTER HEALTH PLAN HMO PLANS", "methodology": "per diem", "standard_charge_dollar": 28538.0, "standard_charge_algorithm": "Per diem ($28,538).", "count": "0", "additional_payer_notes": "Zero final payments for the item or service in the 15 months prior to posting the file." }, { "payer_name": "UNITED HEALTHCARE", "plan_name": "SUTTER SELECT & SUTTER HEALTH PLAN HMO PLANS", "methodology": "per diem", "standard_charge_dollar": 28538.0, "standard_charge_algorithm": "Per diem ($28,538).", "count": "0", "additional_payer_notes": "Zero final payments for the item or service in the 15 months prior to posting the file." }, { "payer_name": "SUTTER", "plan_name": "SUTTER SELECT & SUTTER HEALTH PLAN HMO PLANS", "methodology": "per diem", "standard_charge_dollar": 28538.0, "standard_charge_algorithm": "Per diem ($28,538).", "count": "0", "additional_payer_notes": "Zero final payments for the item or service in the 15 months prior to posting the file." }, { "payer_name": "UNITED HEALTHCARE", "plan_name": "SUTTER SELECT & SUTTER HEALTH PLAN HMO PLANS", "methodology": "per diem", "standard_charge_dollar": 28538.0, "standard_charge_algorithm": "Per diem ($28,538).", "count": "0", "additional_payer_notes": "Zero final payments for the item or service in the 15 months prior to posting the file." }, { "payer_name": "UMR", "plan_name": "SUTTER SELECT & SUTTER HEALTH PLAN HMO PLANS", "methodology": "per diem", "standard_charge_dollar": 28538.0, "standard_charge_algorithm": "Per diem ($28,538).", "count": "0", "additional_payer_notes": "Zero final payments for the item or service in the 15 months prior to posting the file." } ] } ] }, { "description": "HC Drain Chest Gp011", "code_information": [ { "code": "PX-2120059011", "type": "CDM" }, { "code": "99999", "type": "CPT" }, { "code": "0272", "type": "RC" } ], "standard_charges": [ { "setting": "outpatient", "gross_charge": 740.0, "discounted_cash": 370.0, "minimum": 312.28, "maximum": 384.8, "additional_generic_notes": "Zero final payments for the item or service in the 15 months prior to posting the file.", "payers_information": [ { "payer_name": "AETNA", "plan_name": "AETNA ALL OTHER PLANS", "methodology": "percent of total billed charges", "standard_charge_dollar": 384.8, "standard_charge_percentage": 52.0, "count": "0", "additional_payer_notes": "Zero final payments for the item or service in the 15 months prior to posting the file." }, { "payer_name": "AETNA", "plan_name": "AETNA ALL OTHER PLANS", "methodology": "percent of total billed charges", "standard_charge_dollar": 384.8, "standard_charge_percentage": 52.0, "count": "0", "additional_payer_notes": "Zero final payments for the item or service in the 15 months prior to posting the file." }, { "payer_name": "MERITAIN HEALTH", "plan_name": "AETNA ALL OTHER PLANS", "methodology": "percent of total billed charges", "standard_charge_dollar": 384.8, "standard_charge_percentage": 52.0, "count": "0", "additional_payer_notes": "Zero final payments for the item or service in the 15 months prior to posting the file." }, { "payer_name": "BLUE SHIELD OUT OF STATE", "plan_name": "STANFORD HEALTHCARE ALLIANCE PLAN", "methodology": "percent of total billed charges", "standard_charge_dollar": 359.57, "standard_charge_percentage": 48.59, "count": "0", "additional_payer_notes": "Zero final payments for the item or service in the 15 months prior to posting the file." }, { "payer_name": "BLUE SHIELD", "plan_name": "STANFORD HEALTHCARE ALLIANCE PLAN", "methodology": "percent of total billed charges", "standard_charge_dollar": 359.57, "standard_charge_percentage": 48.59, "count": "0", "additional_payer_notes": "Zero final payments for the item or service in the 15 months prior to posting the file." }, { "payer_name": "BLUE SHIELD", "plan_name": "STANFORD HEALTHCARE ALLIANCE PLAN", "methodology": "percent of total billed charges", "standard_charge_dollar": 359.57, "standard_charge_percentage": 48.59, "count": "0", "additional_payer_notes": "Zero final payments for the item or service in the 15 months prior to posting the file." }, { "payer_name": "CIGNA", "plan_name": "CIGNA COM ALT HMO PLAN", "methodology": "percent of total billed charges", "standard_charge_dollar": 312.28, "standard_charge_percentage": 42.2, "count": "0", "additional_payer_notes": "Zero final payments for the item or service in the 15 months prior to posting the file." }, { "payer_name": "CIGNA", "plan_name": "CIGNA COM ALT HMO PLAN", "methodology": "percent of total billed charges", "standard_charge_dollar": 312.28, "standard_charge_percentage": 42.2, "count": "0", "additional_payer_notes": "Zero final payments for the item or service in the 15 months prior to posting the file." }, { "payer_name": "HEALTH NET", "plan_name": "HEALTHNET HMO, PPO, POS, EPO, CANOPY HEALTHNET HMO, OTHER-IN-NETWORK PLANS", "methodology": "per diem", "standard_charge_dollar": 8000.0, "standard_charge_algorithm": "Expected reimbursement is the lesser of Per diem ($8,000) for the length of stay and 70% of billed.", "count": "0", "additional_payer_notes": "Zero final payments for the item or service in the 15 months prior to posting the file." }, { "payer_name": "HEALTH NET", "plan_name": "HEALTHNET HMO, PPO, POS, EPO, CANOPY HEALTHNET HMO, OTHER-IN-NETWORK PLANS", "methodology": "per diem", "standard_charge_dollar": 8000.0, "standard_charge_algorithm": "Expected reimbursement is the lesser of Per diem ($8,000) for the length of stay and 70% of billed.", "count": "0", "additional_payer_notes": "Zero final payments for the item or service in the 15 months prior to posting the file." }, { "payer_name": "UNITED HEALTHCARE", "plan_name": "SUTTER SELECT & SUTTER HEALTH PLAN HMO PLANS", "methodology": "per diem", "standard_charge_dollar": 28538.0, "standard_charge_algorithm": "Per diem ($28,538).", "count": "0", "additional_payer_notes": "Zero final payments for the item or service in the 15 months prior to posting the file." }, { "payer_name": "UNITED HEALTHCARE", "plan_name": "SUTTER SELECT & SUTTER HEALTH PLAN HMO PLANS", "methodology": "per diem", "standard_charge_dollar": 28538.0, "standard_charge_algorithm": "Per diem ($28,538).", "count": "0", "additional_payer_notes": "Zero final payments for the item or service in the 15 months prior to posting the file." }, { "payer_name": "SUTTER", "plan_name": "SUTTER SELECT & SUTTER HEALTH PLAN HMO PLANS", "methodology": "per diem", "standard_charge_dollar": 28538.0, "standard_charge_algorithm": "Per diem ($28,538).", "count": "0", "additional_payer_notes": "Zero final payments for the item or service in the 15 months prior to posting the file." }, { "payer_name": "UNITED HEALTHCARE", "plan_name": "SUTTER SELECT & SUTTER HEALTH PLAN HMO PLANS", "methodology": "per diem", "standard_charge_dollar": 28538.0, "standard_charge_algorithm": "Per diem ($28,538).", "count": "0", "additional_payer_notes": "Zero final payments for the item or service in the 15 months prior to posting the file." }, { "payer_name": "UMR", "plan_name": "SUTTER SELECT & SUTTER HEALTH PLAN HMO PLANS", "methodology": "per diem", "standard_charge_dollar": 28538.0, "standard_charge_algorithm": "Per diem ($28,538).", "count": "0", "additional_payer_notes": "Zero final payments for the item or service in the 15 months prior to posting the file." } ] } ] }, { "description": "HC Drain Chest Gp014", "code_information": [ { "code": "PX-2120059014", "type": "CDM" }, { "code": "99999", "type": "CPT" }, { "code": "0272", "type": "RC" } ], "standard_charges": [ { "setting": "outpatient", "gross_charge": 1080.0, "discounted_cash": 540.0, "minimum": 455.76, "maximum": 561.6, "additional_generic_notes": "Zero final payments for the item or service in the 15 months prior to posting the file.", "payers_information": [ { "payer_name": "AETNA", "plan_name": "AETNA ALL OTHER PLANS", "methodology": "percent of total billed charges", "standard_charge_dollar": 561.6, "standard_charge_percentage": 52.0, "count": "0", "additional_payer_notes": "Zero final payments for the item or service in the 15 months prior to posting the file." }, { "payer_name": "AETNA", "plan_name": "AETNA ALL OTHER PLANS", "methodology": "percent of total billed charges", "standard_charge_dollar": 561.6, "standard_charge_percentage": 52.0, "count": "0", "additional_payer_notes": "Zero final payments for the item or service in the 15 months prior to posting the file." }, { "payer_name": "MERITAIN HEALTH", "plan_name": "AETNA ALL OTHER PLANS", "methodology": "percent of total billed charges", "standard_charge_dollar": 561.6, "standard_charge_percentage": 52.0, "count": "0", "additional_payer_notes": "Zero final payments for the item or service in the 15 months prior to posting the file." }, { "payer_name": "BLUE SHIELD OUT OF STATE", "plan_name": "STANFORD HEALTHCARE ALLIANCE PLAN", "methodology": "percent of total billed charges", "standard_charge_dollar": 524.77, "standard_charge_percentage": 48.59, "count": "0", "additional_payer_notes": "Zero final payments for the item or service in the 15 months prior to posting the file." }, { "payer_name": "BLUE SHIELD", "plan_name": "STANFORD HEALTHCARE ALLIANCE PLAN", "methodology": "percent of total billed charges", "standard_charge_dollar": 524.77, "standard_charge_percentage": 48.59, "median_amount": 68.24, "10th_percentile": 13.6, "90th_percentile": 1043.06, "count": "30" }, { "payer_name": "BLUE SHIELD", "plan_name": "STANFORD HEALTHCARE ALLIANCE PLAN", "methodology": "percent of total billed charges", "standard_charge_dollar": 524.77, "standard_charge_percentage": 48.59, "count": "0", "additional_payer_notes": "Zero final payments for the item or service in the 15 months prior to posting the file." }, { "payer_name": "BLUE SHIELD", "plan_name": "STANFORD HEALTHCARE ALLIANCE PLAN", "methodology": "percent of total billed charges", "standard_charge_dollar": 524.77, "standard_charge_percentage": 48.59, "count": "0", "additional_payer_notes": "Zero final payments for the item or service in the 15 months prior to posting the file." }, { "payer_name": "CIGNA", "plan_name": "CIGNA COM ALT HMO PLAN", "methodology": "percent of total billed charges", "standard_charge_dollar": 455.76, "standard_charge_percentage": 42.2, "count": "0", "additional_payer_notes": "Zero final payments for the item or service in the 15 months prior to posting the file." }, { "payer_name": "CIGNA", "plan_name": "CIGNA COM ALT HMO PLAN", "methodology": "percent of total billed charges", "standard_charge_dollar": 455.76, "standard_charge_percentage": 42.2, "count": "0", "additional_payer_notes": "Zero final payments for the item or service in the 15 months prior to posting the file." }, { "payer_name": "HEALTH NET", "plan_name": "HEALTHNET HMO, PPO, POS, EPO, CANOPY HEALTHNET HMO, OTHER-IN-NETWORK PLANS", "methodology": "per diem", "standard_charge_dollar": 8000.0, "standard_charge_algorithm": "Expected reimbursement is the lesser of Per diem ($8,000) for the length of stay and 70% of billed.", "count": "0", "additional_payer_notes": "Zero final payments for the item or service in the 15 months prior to posting the file." }, { "payer_name": "HEALTH NET", "plan_name": "HEALTHNET HMO, PPO, POS, EPO, CANOPY HEALTHNET HMO, OTHER-IN-NETWORK PLANS", "methodology": "per diem", "standard_charge_dollar": 8000.0, "standard_charge_algorithm": "Expected reimbursement is the lesser of Per diem ($8,000) for the length of stay and 70% of billed.", "count": "0", "additional_payer_notes": "Zero final payments for the item or service in the 15 months prior to posting the file." }, { "payer_name": "UNITED HEALTHCARE", "plan_name": "SUTTER SELECT & SUTTER HEALTH PLAN HMO PLANS", "methodology": "per diem", "standard_charge_dollar": 28538.0, "standard_charge_algorithm": "Per diem ($28,538).", "count": "0", "additional_payer_notes": "Zero final payments for the item or service in the 15 months prior to posting the file." }, { "payer_name": "UNITED HEALTHCARE", "plan_name": "SUTTER SELECT & SUTTER HEALTH PLAN HMO PLANS", "methodology": "per diem", "standard_charge_dollar": 28538.0, "standard_charge_algorithm": "Per diem ($28,538).", "count": "0", "additional_payer_notes": "Zero final payments for the item or service in the 15 months prior to posting the file." }, { "payer_name": "SUTTER", "plan_name": "SUTTER SELECT & SUTTER HEALTH PLAN HMO PLANS", "methodology": "per diem", "standard_charge_dollar": 28538.0, "standard_charge_algorithm": "Per diem ($28,538).", "count": "0", "additional_payer_notes": "Zero final payments for the item or service in the 15 months prior to posting the file." }, { "payer_name": "UNITED HEALTHCARE", "plan_name": "SUTTER SELECT & SUTTER HEALTH PLAN HMO PLANS", "methodology": "per diem", "standard_charge_dollar": 28538.0, "standard_charge_algorithm": "Per diem ($28,538).", "count": "0", "additional_payer_notes": "Zero final payments for the item or service in the 15 months prior to posting the file." }, { "payer_name": "UMR", "plan_name": "SUTTER SELECT & SUTTER HEALTH PLAN HMO PLANS", "methodology": "per diem", "standard_charge_dollar": 28538.0, "standard_charge_algorithm": "Per diem ($28,538).", "count": "0", "additional_payer_notes": "Zero final payments for the item or service in the 15 months prior to posting the file." } ] } ] }, { "description": "HC Drain Chest Gp015", "code_information": [ { "code": "PX-2120059015", "type": "CDM" }, { "code": "99999", "type": "CPT" }, { "code": "0272", "type": "RC" } ], "standard_charges": [ { "setting": "outpatient", "gross_charge": 1225.0, "discounted_cash": 612.5, "minimum": 516.95, "maximum": 637.0, "additional_generic_notes": "Zero final payments for the item or service in the 15 months prior to posting the file.", "payers_information": [ { "payer_name": "AETNA", "plan_name": "AETNA ALL OTHER PLANS", "methodology": "percent of total billed charges", "standard_charge_dollar": 637.0, "standard_charge_percentage": 52.0, "count": "0", "additional_payer_notes": "Zero final payments for the item or service in the 15 months prior to posting the file." }, { "payer_name": "AETNA", "plan_name": "AETNA ALL OTHER PLANS", "methodology": "percent of total billed charges", "standard_charge_dollar": 637.0, "standard_charge_percentage": 52.0, "count": "0", "additional_payer_notes": "Zero final payments for the item or service in the 15 months prior to posting the file." }, { "payer_name": "MERITAIN HEALTH", "plan_name": "AETNA ALL OTHER PLANS", "methodology": "percent of total billed charges", "standard_charge_dollar": 637.0, "standard_charge_percentage": 52.0, "count": "0", "additional_payer_notes": "Zero final payments for the item or service in the 15 months prior to posting the file." }, { "payer_name": "BLUE SHIELD OUT OF STATE", "plan_name": "STANFORD HEALTHCARE ALLIANCE PLAN", "methodology": "percent of total billed charges", "standard_charge_dollar": 595.23, "standard_charge_percentage": 48.59, "count": "0", "additional_payer_notes": "Zero final payments for the item or service in the 15 months prior to posting the file." }, { "payer_name": "BLUE SHIELD", "plan_name": "STANFORD HEALTHCARE ALLIANCE PLAN", "methodology": "percent of total billed charges", "standard_charge_dollar": 595.23, "standard_charge_percentage": 48.59, "median_amount": 68.24, "10th_percentile": 13.6, "90th_percentile": 1043.06, "count": "30" }, { "payer_name": "BLUE SHIELD", "plan_name": "STANFORD HEALTHCARE ALLIANCE PLAN", "methodology": "percent of total billed charges", "standard_charge_dollar": 595.23, "standard_charge_percentage": 48.59, "count": "0", "additional_payer_notes": "Zero final payments for the item or service in the 15 months prior to posting the file." }, { "payer_name": "BLUE SHIELD", "plan_name": "STANFORD HEALTHCARE ALLIANCE PLAN", "methodology": "percent of total billed charges", "standard_charge_dollar": 595.23, "standard_charge_percentage": 48.59, "count": "0", "additional_payer_notes": "Zero final payments for the item or service in the 15 months prior to posting the file." }, { "payer_name": "CIGNA", "plan_name": "CIGNA COM ALT HMO PLAN", "methodology": "percent of total billed charges", "standard_charge_dollar": 516.95, "standard_charge_percentage": 42.2, "count": "0", "additional_payer_notes": "Zero final payments for the item or service in the 15 months prior to posting the file." }, { "payer_name": "CIGNA", "plan_name": "CIGNA COM ALT HMO PLAN", "methodology": "percent of total billed charges", "standard_charge_dollar": 516.95, "standard_charge_percentage": 42.2, "count": "0", "additional_payer_notes": "Zero final payments for the item or service in the 15 months prior to posting the file." }, { "payer_name": "HEALTH NET", "plan_name": "HEALTHNET HMO, PPO, POS, EPO, CANOPY HEALTHNET HMO, OTHER-IN-NETWORK PLANS", "methodology": "per diem", "standard_charge_dollar": 8000.0, "standard_charge_algorithm": "Expected reimbursement is the lesser of Per diem ($8,000) for the length of stay and 70% of billed.", "count": "0", "additional_payer_notes": "Zero final payments for the item or service in the 15 months prior to posting the file." }, { "payer_name": "HEALTH NET", "plan_name": "HEALTHNET HMO, PPO, POS, EPO, CANOPY HEALTHNET HMO, OTHER-IN-NETWORK PLANS", "methodology": "per diem", "standard_charge_dollar": 8000.0, "standard_charge_algorithm": "Expected reimbursement is the lesser of Per diem ($8,000) for the length of stay and 70% of billed.", "count": "0", "additional_payer_notes": "Zero final payments for the item or service in the 15 months prior to posting the file." }, { "payer_name": "UNITED HEALTHCARE", "plan_name": "SUTTER SELECT & SUTTER HEALTH PLAN HMO PLANS", "methodology": "per diem", "standard_charge_dollar": 28538.0, "standard_charge_algorithm": "Per diem ($28,538).", "count": "0", "additional_payer_notes": "Zero final payments for the item or service in the 15 months prior to posting the file." }, { "payer_name": "UNITED HEALTHCARE", "plan_name": "SUTTER SELECT & SUTTER HEALTH PLAN HMO PLANS", "methodology": "per diem", "standard_charge_dollar": 28538.0, "standard_charge_algorithm": "Per diem ($28,538).", "count": "0", "additional_payer_notes": "Zero final payments for the item or service in the 15 months prior to posting the file." }, { "payer_name": "SUTTER", "plan_name": "SUTTER SELECT & SUTTER HEALTH PLAN HMO PLANS", "methodology": "per diem", "standard_charge_dollar": 28538.0, "standard_charge_algorithm": "Per diem ($28,538).", "count": "0", "additional_payer_notes": "Zero final payments for the item or service in the 15 months prior to posting the file." }, { "payer_name": "UNITED HEALTHCARE", "plan_name": "SUTTER SELECT & SUTTER HEALTH PLAN HMO PLANS", "methodology": "per diem", "standard_charge_dollar": 28538.0, "standard_charge_algorithm": "Per diem ($28,538).", "count": "0", "additional_payer_notes": "Zero final payments for the item or service in the 15 months prior to posting the file." }, { "payer_name": "UMR", "plan_name": "SUTTER SELECT & SUTTER HEALTH PLAN HMO PLANS", "methodology": "per diem", "standard_charge_dollar": 28538.0, "standard_charge_algorithm": "Per diem ($28,538).", "count": "0", "additional_payer_notes": "Zero final payments for the item or service in the 15 months prior to posting the file." } ] } ] }, { "description": "HC Drain Hemovac Gp002", "code_information": [ { "code": "PX-2120060002", "type": "CDM" }, { "code": "99999", "type": "CPT" }, { "code": "0272", "type": "RC" } ], "standard_charges": [ { "setting": "outpatient", "gross_charge": 50.0, "discounted_cash": 25.0, "minimum": 21.1, "maximum": 26.0, "additional_generic_notes": "Zero final payments for the item or service in the 15 months prior to posting the file.", "payers_information": [ { "payer_name": "AETNA", "plan_name": "AETNA ALL OTHER PLANS", "methodology": "percent of total billed charges", "standard_charge_dollar": 26.0, "standard_charge_percentage": 52.0, "count": "0", "additional_payer_notes": "Zero final payments for the item or service in the 15 months prior to posting the file." }, { "payer_name": "AETNA", "plan_name": "AETNA ALL OTHER PLANS", "methodology": "percent of total billed charges", "standard_charge_dollar": 26.0, "standard_charge_percentage": 52.0, "count": "0", "additional_payer_notes": "Zero final payments for the item or service in the 15 months prior to posting the file." }, { "payer_name": "MERITAIN HEALTH", "plan_name": "AETNA ALL OTHER PLANS", "methodology": "percent of total billed charges", "standard_charge_dollar": 26.0, "standard_charge_percentage": 52.0, "count": "0", "additional_payer_notes": "Zero final payments for the item or service in the 15 months prior to posting the file." }, { "payer_name": "BLUE SHIELD OUT OF STATE", "plan_name": "STANFORD HEALTHCARE ALLIANCE PLAN", "methodology": "percent of total billed charges", "standard_charge_dollar": 24.3, "standard_charge_percentage": 48.59, "count": "0", "additional_payer_notes": "Zero final payments for the item or service in the 15 months prior to posting the file." }, { "payer_name": "BLUE SHIELD", "plan_name": "STANFORD HEALTHCARE ALLIANCE PLAN", "methodology": "percent of total billed charges", "standard_charge_dollar": 24.3, "standard_charge_percentage": 48.59, "count": "0", "additional_payer_notes": "Zero final payments for the item or service in the 15 months prior to posting the file." }, { "payer_name": "BLUE SHIELD", "plan_name": "STANFORD HEALTHCARE ALLIANCE PLAN", "methodology": "percent of total billed charges", "standard_charge_dollar": 24.3, "standard_charge_percentage": 48.59, "count": "0", "additional_payer_notes": "Zero final payments for the item or service in the 15 months prior to posting the file." }, { "payer_name": "CIGNA", "plan_name": "CIGNA COM ALT HMO PLAN", "methodology": "percent of total billed charges", "standard_charge_dollar": 21.1, "standard_charge_percentage": 42.2, "count": "0", "additional_payer_notes": "Zero final payments for the item or service in the 15 months prior to posting the file." }, { "payer_name": "CIGNA", "plan_name": "CIGNA COM ALT HMO PLAN", "methodology": "percent of total billed charges", "standard_charge_dollar": 21.1, "standard_charge_percentage": 42.2, "count": "0", "additional_payer_notes": "Zero final payments for the item or service in the 15 months prior to posting the file." }, { "payer_name": "HEALTH NET", "plan_name": "HEALTHNET HMO, PPO, POS, EPO, CANOPY HEALTHNET HMO, OTHER-IN-NETWORK PLANS", "methodology": "per diem", "standard_charge_dollar": 8000.0, "standard_charge_algorithm": "Expected reimbursement is the lesser of Per diem ($8,000) for the length of stay and 70% of billed.", "count": "0", "additional_payer_notes": "Zero final payments for the item or service in the 15 months prior to posting the file." }, { "payer_name": "HEALTH NET", "plan_name": "HEALTHNET HMO, PPO, POS, EPO, CANOPY HEALTHNET HMO, OTHER-IN-NETWORK PLANS", "methodology": "per diem", "standard_charge_dollar": 8000.0, "standard_charge_algorithm": "Expected reimbursement is the lesser of Per diem ($8,000) for the length of stay and 70% of billed.", "count": "0", "additional_payer_notes": "Zero final payments for the item or service in the 15 months prior to posting the file." }, { "payer_name": "UNITED HEALTHCARE", "plan_name": "SUTTER SELECT & SUTTER HEALTH PLAN HMO PLANS", "methodology": "per diem", "standard_charge_dollar": 28538.0, "standard_charge_algorithm": "Per diem ($28,538).", "count": "0", "additional_payer_notes": "Zero final payments for the item or service in the 15 months prior to posting the file." }, { "payer_name": "UNITED HEALTHCARE", "plan_name": "SUTTER SELECT & SUTTER HEALTH PLAN HMO PLANS", "methodology": "per diem", "standard_charge_dollar": 28538.0, "standard_charge_algorithm": "Per diem ($28,538).", "count": "0", "additional_payer_notes": "Zero final payments for the item or service in the 15 months prior to posting the file." }, { "payer_name": "SUTTER", "plan_name": "SUTTER SELECT & SUTTER HEALTH PLAN HMO PLANS", "methodology": "per diem", "standard_charge_dollar": 28538.0, "standard_charge_algorithm": "Per diem ($28,538).", "count": "0", "additional_payer_notes": "Zero final payments for the item or service in the 15 months prior to posting the file." }, { "payer_name": "UNITED HEALTHCARE", "plan_name": "SUTTER SELECT & SUTTER HEALTH PLAN HMO PLANS", "methodology": "per diem", "standard_charge_dollar": 28538.0, "standard_charge_algorithm": "Per diem ($28,538).", "count": "0", "additional_payer_notes": "Zero final payments for the item or service in the 15 months prior to posting the file." }, { "payer_name": "UMR", "plan_name": "SUTTER SELECT & SUTTER HEALTH PLAN HMO PLANS", "methodology": "per diem", "standard_charge_dollar": 28538.0, "standard_charge_algorithm": "Per diem ($28,538).", "count": "0", "additional_payer_notes": "Zero final payments for the item or service in the 15 months prior to posting the file." } ] } ] }, { "description": "HC Drain Hemovac Gp003", "code_information": [ { "code": "PX-2120060003", "type": "CDM" }, { "code": "99999", "type": "CPT" }, { "code": "0272", "type": "RC" } ], "standard_charges": [ { "setting": "outpatient", "gross_charge": 100.0, "discounted_cash": 50.0, "minimum": 42.2, "maximum": 52.0, "additional_generic_notes": "Zero final payments for the item or service in the 15 months prior to posting the file.", "payers_information": [ { "payer_name": "AETNA", "plan_name": "AETNA ALL OTHER PLANS", "methodology": "percent of total billed charges", "standard_charge_dollar": 52.0, "standard_charge_percentage": 52.0, "count": "0", "additional_payer_notes": "Zero final payments for the item or service in the 15 months prior to posting the file." }, { "payer_name": "AETNA", "plan_name": "AETNA ALL OTHER PLANS", "methodology": "percent of total billed charges", "standard_charge_dollar": 52.0, "standard_charge_percentage": 52.0, "count": "0", "additional_payer_notes": "Zero final payments for the item or service in the 15 months prior to posting the file." }, { "payer_name": "MERITAIN HEALTH", "plan_name": "AETNA ALL OTHER PLANS", "methodology": "percent of total billed charges", "standard_charge_dollar": 52.0, "standard_charge_percentage": 52.0, "count": "0", "additional_payer_notes": "Zero final payments for the item or service in the 15 months prior to posting the file." }, { "payer_name": "BLUE SHIELD OUT OF STATE", "plan_name": "STANFORD HEALTHCARE ALLIANCE PLAN", "methodology": "percent of total billed charges", "standard_charge_dollar": 48.59, "standard_charge_percentage": 48.59, "count": "0", "additional_payer_notes": "Zero final payments for the item or service in the 15 months prior to posting the file." }, { "payer_name": "BLUE SHIELD", "plan_name": "STANFORD HEALTHCARE ALLIANCE PLAN", "methodology": "percent of total billed charges", "standard_charge_dollar": 48.59, "standard_charge_percentage": 48.59, "count": "0", "additional_payer_notes": "Zero final payments for the item or service in the 15 months prior to posting the file." }, { "payer_name": "BLUE SHIELD", "plan_name": "STANFORD HEALTHCARE ALLIANCE PLAN", "methodology": "percent of total billed charges", "standard_charge_dollar": 48.59, "standard_charge_percentage": 48.59, "count": "0", "additional_payer_notes": "Zero final payments for the item or service in the 15 months prior to posting the file." }, { "payer_name": "CIGNA", "plan_name": "CIGNA COM ALT HMO PLAN", "methodology": "percent of total billed charges", "standard_charge_dollar": 42.2, "standard_charge_percentage": 42.2, "count": "0", "additional_payer_notes": "Zero final payments for the item or service in the 15 months prior to posting the file." }, { "payer_name": "CIGNA", "plan_name": "CIGNA COM ALT HMO PLAN", "methodology": "percent of total billed charges", "standard_charge_dollar": 42.2, "standard_charge_percentage": 42.2, "count": "0", "additional_payer_notes": "Zero final payments for the item or service in the 15 months prior to posting the file." }, { "payer_name": "HEALTH NET", "plan_name": "HEALTHNET HMO, PPO, POS, EPO, CANOPY HEALTHNET HMO, OTHER-IN-NETWORK PLANS", "methodology": "per diem", "standard_charge_dollar": 8000.0, "standard_charge_algorithm": "Expected reimbursement is the lesser of Per diem ($8,000) for the length of stay and 70% of billed.", "count": "0", "additional_payer_notes": "Zero final payments for the item or service in the 15 months prior to posting the file." }, { "payer_name": "HEALTH NET", "plan_name": "HEALTHNET HMO, PPO, POS, EPO, CANOPY HEALTHNET HMO, OTHER-IN-NETWORK PLANS", "methodology": "per diem", "standard_charge_dollar": 8000.0, "standard_charge_algorithm": "Expected reimbursement is the lesser of Per diem ($8,000) for the length of stay and 70% of billed.", "count": "0", "additional_payer_notes": "Zero final payments for the item or service in the 15 months prior to posting the file." }, { "payer_name": "UNITED HEALTHCARE", "plan_name": "SUTTER SELECT & SUTTER HEALTH PLAN HMO PLANS", "methodology": "per diem", "standard_charge_dollar": 28538.0, "standard_charge_algorithm": "Per diem ($28,538).", "count": "0", "additional_payer_notes": "Zero final payments for the item or service in the 15 months prior to posting the file." }, { "payer_name": "UNITED HEALTHCARE", "plan_name": "SUTTER SELECT & SUTTER HEALTH PLAN HMO PLANS", "methodology": "per diem", "standard_charge_dollar": 28538.0, "standard_charge_algorithm": "Per diem ($28,538).", "count": "0", "additional_payer_notes": "Zero final payments for the item or service in the 15 months prior to posting the file." }, { "payer_name": "SUTTER", "plan_name": "SUTTER SELECT & SUTTER HEALTH PLAN HMO PLANS", "methodology": "per diem", "standard_charge_dollar": 28538.0, "standard_charge_algorithm": "Per diem ($28,538).", "count": "0", "additional_payer_notes": "Zero final payments for the item or service in the 15 months prior to posting the file." }, { "payer_name": "UNITED HEALTHCARE", "plan_name": "SUTTER SELECT & SUTTER HEALTH PLAN HMO PLANS", "methodology": "per diem", "standard_charge_dollar": 28538.0, "standard_charge_algorithm": "Per diem ($28,538).", "count": "0", "additional_payer_notes": "Zero final payments for the item or service in the 15 months prior to posting the file." }, { "payer_name": "UMR", "plan_name": "SUTTER SELECT & SUTTER HEALTH PLAN HMO PLANS", "methodology": "per diem", "standard_charge_dollar": 28538.0, "standard_charge_algorithm": "Per diem ($28,538).", "count": "0", "additional_payer_notes": "Zero final payments for the item or service in the 15 months prior to posting the file." } ] } ] }, { "description": "HC Drain Hemovac Gp005", "code_information": [ { "code": "PX-2120060005", "type": "CDM" }, { "code": "99999", "type": "CPT" }, { "code": "0272", "type": "RC" } ], "standard_charges": [ { "setting": "outpatient", "gross_charge": 195.0, "discounted_cash": 97.5, "minimum": 82.29, "maximum": 101.4, "additional_generic_notes": "Zero final payments for the item or service in the 15 months prior to posting the file.", "payers_information": [ { "payer_name": "AETNA", "plan_name": "AETNA ALL OTHER PLANS", "methodology": "percent of total billed charges", "standard_charge_dollar": 101.4, "standard_charge_percentage": 52.0, "count": "0", "additional_payer_notes": "Zero final payments for the item or service in the 15 months prior to posting the file." }, { "payer_name": "AETNA", "plan_name": "AETNA ALL OTHER PLANS", "methodology": "percent of total billed charges", "standard_charge_dollar": 101.4, "standard_charge_percentage": 52.0, "count": "0", "additional_payer_notes": "Zero final payments for the item or service in the 15 months prior to posting the file." }, { "payer_name": "MERITAIN HEALTH", "plan_name": "AETNA ALL OTHER PLANS", "methodology": "percent of total billed charges", "standard_charge_dollar": 101.4, "standard_charge_percentage": 52.0, "count": "0", "additional_payer_notes": "Zero final payments for the item or service in the 15 months prior to posting the file." }, { "payer_name": "BLUE SHIELD OUT OF STATE", "plan_name": "STANFORD HEALTHCARE ALLIANCE PLAN", "methodology": "percent of total billed charges", "standard_charge_dollar": 94.75, "standard_charge_percentage": 48.59, "count": "0", "additional_payer_notes": "Zero final payments for the item or service in the 15 months prior to posting the file." }, { "payer_name": "BLUE SHIELD", "plan_name": "STANFORD HEALTHCARE ALLIANCE PLAN", "methodology": "percent of total billed charges", "standard_charge_dollar": 94.75, "standard_charge_percentage": 48.59, "count": "0", "additional_payer_notes": "Zero final payments for the item or service in the 15 months prior to posting the file." }, { "payer_name": "BLUE SHIELD", "plan_name": "STANFORD HEALTHCARE ALLIANCE PLAN", "methodology": "percent of total billed charges", "standard_charge_dollar": 94.75, "standard_charge_percentage": 48.59, "count": "0", "additional_payer_notes": "Zero final payments for the item or service in the 15 months prior to posting the file." }, { "payer_name": "CIGNA", "plan_name": "CIGNA COM ALT HMO PLAN", "methodology": "percent of total billed charges", "standard_charge_dollar": 82.29, "standard_charge_percentage": 42.2, "count": "0", "additional_payer_notes": "Zero final payments for the item or service in the 15 months prior to posting the file." }, { "payer_name": "CIGNA", "plan_name": "CIGNA COM ALT HMO PLAN", "methodology": "percent of total billed charges", "standard_charge_dollar": 82.29, "standard_charge_percentage": 42.2, "count": "0", "additional_payer_notes": "Zero final payments for the item or service in the 15 months prior to posting the file." }, { "payer_name": "HEALTH NET", "plan_name": "HEALTHNET HMO, PPO, POS, EPO, CANOPY HEALTHNET HMO, OTHER-IN-NETWORK PLANS", "methodology": "per diem", "standard_charge_dollar": 8000.0, "standard_charge_algorithm": "Expected reimbursement is the lesser of Per diem ($8,000) for the length of stay and 70% of billed.", "count": "0", "additional_payer_notes": "Zero final payments for the item or service in the 15 months prior to posting the file." }, { "payer_name": "HEALTH NET", "plan_name": "HEALTHNET HMO, PPO, POS, EPO, CANOPY HEALTHNET HMO, OTHER-IN-NETWORK PLANS", "methodology": "per diem", "standard_charge_dollar": 8000.0, "standard_charge_algorithm": "Expected reimbursement is the lesser of Per diem ($8,000) for the length of stay and 70% of billed.", "count": "0", "additional_payer_notes": "Zero final payments for the item or service in the 15 months prior to posting the file." }, { "payer_name": "UNITED HEALTHCARE", "plan_name": "SUTTER SELECT & SUTTER HEALTH PLAN HMO PLANS", "methodology": "per diem", "standard_charge_dollar": 28538.0, "standard_charge_algorithm": "Per diem ($28,538).", "count": "0", "additional_payer_notes": "Zero final payments for the item or service in the 15 months prior to posting the file." }, { "payer_name": "UNITED HEALTHCARE", "plan_name": "SUTTER SELECT & SUTTER HEALTH PLAN HMO PLANS", "methodology": "per diem", "standard_charge_dollar": 28538.0, "standard_charge_algorithm": "Per diem ($28,538).", "count": "0", "additional_payer_notes": "Zero final payments for the item or service in the 15 months prior to posting the file." }, { "payer_name": "SUTTER", "plan_name": "SUTTER SELECT & SUTTER HEALTH PLAN HMO PLANS", "methodology": "per diem", "standard_charge_dollar": 28538.0, "standard_charge_algorithm": "Per diem ($28,538).", "count": "0", "additional_payer_notes": "Zero final payments for the item or service in the 15 months prior to posting the file." }, { "payer_name": "UNITED HEALTHCARE", "plan_name": "SUTTER SELECT & SUTTER HEALTH PLAN HMO PLANS", "methodology": "per diem", "standard_charge_dollar": 28538.0, "standard_charge_algorithm": "Per diem ($28,538).", "count": "0", "additional_payer_notes": "Zero final payments for the item or service in the 15 months prior to posting the file." }, { "payer_name": "UMR", "plan_name": "SUTTER SELECT & SUTTER HEALTH PLAN HMO PLANS", "methodology": "per diem", "standard_charge_dollar": 28538.0, "standard_charge_algorithm": "Per diem ($28,538).", "count": "0", "additional_payer_notes": "Zero final payments for the item or service in the 15 months prior to posting the file." } ] } ] }, { "description": "HC Drain Hemovac Gp012", "code_information": [ { "code": "PX-2120060012", "type": "CDM" }, { "code": "99999", "type": "CPT" }, { "code": "0272", "type": "RC" } ], "standard_charges": [ { "setting": "outpatient", "gross_charge": 810.0, "discounted_cash": 405.0, "minimum": 341.82, "maximum": 421.2, "additional_generic_notes": "Zero final payments for the item or service in the 15 months prior to posting the file.", "payers_information": [ { "payer_name": "AETNA", "plan_name": "AETNA ALL OTHER PLANS", "methodology": "percent of total billed charges", "standard_charge_dollar": 421.2, "standard_charge_percentage": 52.0, "count": "0", "additional_payer_notes": "Zero final payments for the item or service in the 15 months prior to posting the file." }, { "payer_name": "AETNA", "plan_name": "AETNA ALL OTHER PLANS", "methodology": "percent of total billed charges", "standard_charge_dollar": 421.2, "standard_charge_percentage": 52.0, "count": "0", "additional_payer_notes": "Zero final payments for the item or service in the 15 months prior to posting the file." }, { "payer_name": "MERITAIN HEALTH", "plan_name": "AETNA ALL OTHER PLANS", "methodology": "percent of total billed charges", "standard_charge_dollar": 421.2, "standard_charge_percentage": 52.0, "count": "0", "additional_payer_notes": "Zero final payments for the item or service in the 15 months prior to posting the file." }, { "payer_name": "BLUE SHIELD OUT OF STATE", "plan_name": "STANFORD HEALTHCARE ALLIANCE PLAN", "methodology": "percent of total billed charges", "standard_charge_dollar": 393.58, "standard_charge_percentage": 48.59, "count": "0", "additional_payer_notes": "Zero final payments for the item or service in the 15 months prior to posting the file." }, { "payer_name": "BLUE SHIELD", "plan_name": "STANFORD HEALTHCARE ALLIANCE PLAN", "methodology": "percent of total billed charges", "standard_charge_dollar": 393.58, "standard_charge_percentage": 48.59, "count": "0", "additional_payer_notes": "Zero final payments for the item or service in the 15 months prior to posting the file." }, { "payer_name": "BLUE SHIELD", "plan_name": "STANFORD HEALTHCARE ALLIANCE PLAN", "methodology": "percent of total billed charges", "standard_charge_dollar": 393.58, "standard_charge_percentage": 48.59, "count": "0", "additional_payer_notes": "Zero final payments for the item or service in the 15 months prior to posting the file." }, { "payer_name": "CIGNA", "plan_name": "CIGNA COM ALT HMO PLAN", "methodology": "percent of total billed charges", "standard_charge_dollar": 341.82, "standard_charge_percentage": 42.2, "count": "0", "additional_payer_notes": "Zero final payments for the item or service in the 15 months prior to posting the file." }, { "payer_name": "CIGNA", "plan_name": "CIGNA COM ALT HMO PLAN", "methodology": "percent of total billed charges", "standard_charge_dollar": 341.82, "standard_charge_percentage": 42.2, "count": "0", "additional_payer_notes": "Zero final payments for the item or service in the 15 months prior to posting the file." }, { "payer_name": "HEALTH NET", "plan_name": "HEALTHNET HMO, PPO, POS, EPO, CANOPY HEALTHNET HMO, OTHER-IN-NETWORK PLANS", "methodology": "per diem", "standard_charge_dollar": 8000.0, "standard_charge_algorithm": "Expected reimbursement is the lesser of Per diem ($8,000) for the length of stay and 70% of billed.", "count": "0", "additional_payer_notes": "Zero final payments for the item or service in the 15 months prior to posting the file." }, { "payer_name": "HEALTH NET", "plan_name": "HEALTHNET HMO, PPO, POS, EPO, CANOPY HEALTHNET HMO, OTHER-IN-NETWORK PLANS", "methodology": "per diem", "standard_charge_dollar": 8000.0, "standard_charge_algorithm": "Expected reimbursement is the lesser of Per diem ($8,000) for the length of stay and 70% of billed.", "count": "0", "additional_payer_notes": "Zero final payments for the item or service in the 15 months prior to posting the file." }, { "payer_name": "UNITED HEALTHCARE", "plan_name": "SUTTER SELECT & SUTTER HEALTH PLAN HMO PLANS", "methodology": "per diem", "standard_charge_dollar": 28538.0, "standard_charge_algorithm": "Per diem ($28,538).", "count": "0", "additional_payer_notes": "Zero final payments for the item or service in the 15 months prior to posting the file." }, { "payer_name": "UNITED HEALTHCARE", "plan_name": "SUTTER SELECT & SUTTER HEALTH PLAN HMO PLANS", "methodology": "per diem", "standard_charge_dollar": 28538.0, "standard_charge_algorithm": "Per diem ($28,538).", "count": "0", "additional_payer_notes": "Zero final payments for the item or service in the 15 months prior to posting the file." }, { "payer_name": "SUTTER", "plan_name": "SUTTER SELECT & SUTTER HEALTH PLAN HMO PLANS", "methodology": "per diem", "standard_charge_dollar": 28538.0, "standard_charge_algorithm": "Per diem ($28,538).", "count": "0", "additional_payer_notes": "Zero final payments for the item or service in the 15 months prior to posting the file." }, { "payer_name": "UNITED HEALTHCARE", "plan_name": "SUTTER SELECT & SUTTER HEALTH PLAN HMO PLANS", "methodology": "per diem", "standard_charge_dollar": 28538.0, "standard_charge_algorithm": "Per diem ($28,538).", "count": "0", "additional_payer_notes": "Zero final payments for the item or service in the 15 months prior to posting the file." }, { "payer_name": "UMR", "plan_name": "SUTTER SELECT & SUTTER HEALTH PLAN HMO PLANS", "methodology": "per diem", "standard_charge_dollar": 28538.0, "standard_charge_algorithm": "Per diem ($28,538).", "count": "0", "additional_payer_notes": "Zero final payments for the item or service in the 15 months prior to posting the file." } ] } ] }, { "description": "HC Drain Hemovac Gp018", "code_information": [ { "code": "PX-2120060018", "type": "CDM" }, { "code": "99999", "type": "CPT" }, { "code": "0272", "type": "RC" } ], "standard_charges": [ { "setting": "outpatient", "gross_charge": 1750.0, "discounted_cash": 875.0, "minimum": 738.5, "maximum": 910.0, "additional_generic_notes": "Zero final payments for the item or service in the 15 months prior to posting the file.", "payers_information": [ { "payer_name": "AETNA", "plan_name": "AETNA ALL OTHER PLANS", "methodology": "percent of total billed charges", "standard_charge_dollar": 910.0, "standard_charge_percentage": 52.0, "count": "0", "additional_payer_notes": "Zero final payments for the item or service in the 15 months prior to posting the file." }, { "payer_name": "AETNA", "plan_name": "AETNA ALL OTHER PLANS", "methodology": "percent of total billed charges", "standard_charge_dollar": 910.0, "standard_charge_percentage": 52.0, "count": "0", "additional_payer_notes": "Zero final payments for the item or service in the 15 months prior to posting the file." }, { "payer_name": "MERITAIN HEALTH", "plan_name": "AETNA ALL OTHER PLANS", "methodology": "percent of total billed charges", "standard_charge_dollar": 910.0, "standard_charge_percentage": 52.0, "count": "0", "additional_payer_notes": "Zero final payments for the item or service in the 15 months prior to posting the file." }, { "payer_name": "BLUE SHIELD OUT OF STATE", "plan_name": "STANFORD HEALTHCARE ALLIANCE PLAN", "methodology": "percent of total billed charges", "standard_charge_dollar": 850.33, "standard_charge_percentage": 48.59, "count": "0", "additional_payer_notes": "Zero final payments for the item or service in the 15 months prior to posting the file." }, { "payer_name": "BLUE SHIELD", "plan_name": "STANFORD HEALTHCARE ALLIANCE PLAN", "methodology": "percent of total billed charges", "standard_charge_dollar": 850.33, "standard_charge_percentage": 48.59, "median_amount": 68.24, "10th_percentile": 13.6, "90th_percentile": 1043.06, "count": "30" }, { "payer_name": "BLUE SHIELD", "plan_name": "STANFORD HEALTHCARE ALLIANCE PLAN", "methodology": "percent of total billed charges", "standard_charge_dollar": 850.33, "standard_charge_percentage": 48.59, "count": "0", "additional_payer_notes": "Zero final payments for the item or service in the 15 months prior to posting the file." }, { "payer_name": "BLUE SHIELD", "plan_name": "STANFORD HEALTHCARE ALLIANCE PLAN", "methodology": "percent of total billed charges", "standard_charge_dollar": 850.33, "standard_charge_percentage": 48.59, "count": "0", "additional_payer_notes": "Zero final payments for the item or service in the 15 months prior to posting the file." }, { "payer_name": "CIGNA", "plan_name": "CIGNA COM ALT HMO PLAN", "methodology": "percent of total billed charges", "standard_charge_dollar": 738.5, "standard_charge_percentage": 42.2, "count": "0", "additional_payer_notes": "Zero final payments for the item or service in the 15 months prior to posting the file." }, { "payer_name": "CIGNA", "plan_name": "CIGNA COM ALT HMO PLAN", "methodology": "percent of total billed charges", "standard_charge_dollar": 738.5, "standard_charge_percentage": 42.2, "count": "0", "additional_payer_notes": "Zero final payments for the item or service in the 15 months prior to posting the file." }, { "payer_name": "HEALTH NET", "plan_name": "HEALTHNET HMO, PPO, POS, EPO, CANOPY HEALTHNET HMO, OTHER-IN-NETWORK PLANS", "methodology": "per diem", "standard_charge_dollar": 8000.0, "standard_charge_algorithm": "Expected reimbursement is the lesser of Per diem ($8,000) for the length of stay and 70% of billed.", "count": "0", "additional_payer_notes": "Zero final payments for the item or service in the 15 months prior to posting the file." }, { "payer_name": "HEALTH NET", "plan_name": "HEALTHNET HMO, PPO, POS, EPO, CANOPY HEALTHNET HMO, OTHER-IN-NETWORK PLANS", "methodology": "per diem", "standard_charge_dollar": 8000.0, "standard_charge_algorithm": "Expected reimbursement is the lesser of Per diem ($8,000) for the length of stay and 70% of billed.", "count": "0", "additional_payer_notes": "Zero final payments for the item or service in the 15 months prior to posting the file." }, { "payer_name": "UNITED HEALTHCARE", "plan_name": "SUTTER SELECT & SUTTER HEALTH PLAN HMO PLANS", "methodology": "per diem", "standard_charge_dollar": 28538.0, "standard_charge_algorithm": "Per diem ($28,538).", "count": "0", "additional_payer_notes": "Zero final payments for the item or service in the 15 months prior to posting the file." }, { "payer_name": "UNITED HEALTHCARE", "plan_name": "SUTTER SELECT & SUTTER HEALTH PLAN HMO PLANS", "methodology": "per diem", "standard_charge_dollar": 28538.0, "standard_charge_algorithm": "Per diem ($28,538).", "count": "0", "additional_payer_notes": "Zero final payments for the item or service in the 15 months prior to posting the file." }, { "payer_name": "SUTTER", "plan_name": "SUTTER SELECT & SUTTER HEALTH PLAN HMO PLANS", "methodology": "per diem", "standard_charge_dollar": 28538.0, "standard_charge_algorithm": "Per diem ($28,538).", "count": "0", "additional_payer_notes": "Zero final payments for the item or service in the 15 months prior to posting the file." }, { "payer_name": "UNITED HEALTHCARE", "plan_name": "SUTTER SELECT & SUTTER HEALTH PLAN HMO PLANS", "methodology": "per diem", "standard_charge_dollar": 28538.0, "standard_charge_algorithm": "Per diem ($28,538).", "count": "0", "additional_payer_notes": "Zero final payments for the item or service in the 15 months prior to posting the file." }, { "payer_name": "UMR", "plan_name": "SUTTER SELECT & SUTTER HEALTH PLAN HMO PLANS", "methodology": "per diem", "standard_charge_dollar": 28538.0, "standard_charge_algorithm": "Per diem ($28,538).", "count": "0", "additional_payer_notes": "Zero final payments for the item or service in the 15 months prior to posting the file." } ] } ] }, { "description": "HC Drill Bit Gp002", "code_information": [ { "code": "PX-2120061002", "type": "CDM" }, { "code": "99999", "type": "CPT" }, { "code": "0272", "type": "RC" } ], "standard_charges": [ { "setting": "outpatient", "gross_charge": 50.0, "discounted_cash": 25.0, "minimum": 21.1, "maximum": 26.0, "additional_generic_notes": "Zero final payments for the item or service in the 15 months prior to posting the file.", "payers_information": [ { "payer_name": "AETNA", "plan_name": "AETNA ALL OTHER PLANS", "methodology": "percent of total billed charges", "standard_charge_dollar": 26.0, "standard_charge_percentage": 52.0, "count": "0", "additional_payer_notes": "Zero final payments for the item or service in the 15 months prior to posting the file." }, { "payer_name": "AETNA", "plan_name": "AETNA ALL OTHER PLANS", "methodology": "percent of total billed charges", "standard_charge_dollar": 26.0, "standard_charge_percentage": 52.0, "count": "0", "additional_payer_notes": "Zero final payments for the item or service in the 15 months prior to posting the file." }, { "payer_name": "MERITAIN HEALTH", "plan_name": "AETNA ALL OTHER PLANS", "methodology": "percent of total billed charges", "standard_charge_dollar": 26.0, "standard_charge_percentage": 52.0, "count": "0", "additional_payer_notes": "Zero final payments for the item or service in the 15 months prior to posting the file." }, { "payer_name": "BLUE SHIELD OUT OF STATE", "plan_name": "STANFORD HEALTHCARE ALLIANCE PLAN", "methodology": "percent of total billed charges", "standard_charge_dollar": 24.3, "standard_charge_percentage": 48.59, "count": "0", "additional_payer_notes": "Zero final payments for the item or service in the 15 months prior to posting the file." }, { "payer_name": "BLUE SHIELD", "plan_name": "STANFORD HEALTHCARE ALLIANCE PLAN", "methodology": "percent of total billed charges", "standard_charge_dollar": 24.3, "standard_charge_percentage": 48.59, "count": "0", "additional_payer_notes": "Zero final payments for the item or service in the 15 months prior to posting the file." }, { "payer_name": "BLUE SHIELD", "plan_name": "STANFORD HEALTHCARE ALLIANCE PLAN", "methodology": "percent of total billed charges", "standard_charge_dollar": 24.3, "standard_charge_percentage": 48.59, "count": "0", "additional_payer_notes": "Zero final payments for the item or service in the 15 months prior to posting the file." }, { "payer_name": "CIGNA", "plan_name": "CIGNA COM ALT HMO PLAN", "methodology": "percent of total billed charges", "standard_charge_dollar": 21.1, "standard_charge_percentage": 42.2, "count": "0", "additional_payer_notes": "Zero final payments for the item or service in the 15 months prior to posting the file." }, { "payer_name": "CIGNA", "plan_name": "CIGNA COM ALT HMO PLAN", "methodology": "percent of total billed charges", "standard_charge_dollar": 21.1, "standard_charge_percentage": 42.2, "count": "0", "additional_payer_notes": "Zero final payments for the item or service in the 15 months prior to posting the file." }, { "payer_name": "HEALTH NET", "plan_name": "HEALTHNET HMO, PPO, POS, EPO, CANOPY HEALTHNET HMO, OTHER-IN-NETWORK PLANS", "methodology": "per diem", "standard_charge_dollar": 8000.0, "standard_charge_algorithm": "Expected reimbursement is the lesser of Per diem ($8,000) for the length of stay and 70% of billed.", "count": "0", "additional_payer_notes": "Zero final payments for the item or service in the 15 months prior to posting the file." }, { "payer_name": "HEALTH NET", "plan_name": "HEALTHNET HMO, PPO, POS, EPO, CANOPY HEALTHNET HMO, OTHER-IN-NETWORK PLANS", "methodology": "per diem", "standard_charge_dollar": 8000.0, "standard_charge_algorithm": "Expected reimbursement is the lesser of Per diem ($8,000) for the length of stay and 70% of billed.", "count": "0", "additional_payer_notes": "Zero final payments for the item or service in the 15 months prior to posting the file." }, { "payer_name": "UNITED HEALTHCARE", "plan_name": "SUTTER SELECT & SUTTER HEALTH PLAN HMO PLANS", "methodology": "per diem", "standard_charge_dollar": 28538.0, "standard_charge_algorithm": "Per diem ($28,538).", "count": "0", "additional_payer_notes": "Zero final payments for the item or service in the 15 months prior to posting the file." }, { "payer_name": "UNITED HEALTHCARE", "plan_name": "SUTTER SELECT & SUTTER HEALTH PLAN HMO PLANS", "methodology": "per diem", "standard_charge_dollar": 28538.0, "standard_charge_algorithm": "Per diem ($28,538).", "count": "0", "additional_payer_notes": "Zero final payments for the item or service in the 15 months prior to posting the file." }, { "payer_name": "SUTTER", "plan_name": "SUTTER SELECT & SUTTER HEALTH PLAN HMO PLANS", "methodology": "per diem", "standard_charge_dollar": 28538.0, "standard_charge_algorithm": "Per diem ($28,538).", "count": "0", "additional_payer_notes": "Zero final payments for the item or service in the 15 months prior to posting the file." }, { "payer_name": "UNITED HEALTHCARE", "plan_name": "SUTTER SELECT & SUTTER HEALTH PLAN HMO PLANS", "methodology": "per diem", "standard_charge_dollar": 28538.0, "standard_charge_algorithm": "Per diem ($28,538).", "count": "0", "additional_payer_notes": "Zero final payments for the item or service in the 15 months prior to posting the file." }, { "payer_name": "UMR", "plan_name": "SUTTER SELECT & SUTTER HEALTH PLAN HMO PLANS", "methodology": "per diem", "standard_charge_dollar": 28538.0, "standard_charge_algorithm": "Per diem ($28,538).", "count": "0", "additional_payer_notes": "Zero final payments for the item or service in the 15 months prior to posting the file." } ] } ] }, { "description": "HC Drill Bit Gp003", "code_information": [ { "code": "PX-2120061003", "type": "CDM" }, { "code": "99999", "type": "CPT" }, { "code": "0272", "type": "RC" } ], "standard_charges": [ { "setting": "outpatient", "gross_charge": 100.0, "discounted_cash": 50.0, "minimum": 42.2, "maximum": 52.0, "additional_generic_notes": "Zero final payments for the item or service in the 15 months prior to posting the file.", "payers_information": [ { "payer_name": "AETNA", "plan_name": "AETNA ALL OTHER PLANS", "methodology": "percent of total billed charges", "standard_charge_dollar": 52.0, "standard_charge_percentage": 52.0, "count": "0", "additional_payer_notes": "Zero final payments for the item or service in the 15 months prior to posting the file." }, { "payer_name": "AETNA", "plan_name": "AETNA ALL OTHER PLANS", "methodology": "percent of total billed charges", "standard_charge_dollar": 52.0, "standard_charge_percentage": 52.0, "count": "0", "additional_payer_notes": "Zero final payments for the item or service in the 15 months prior to posting the file." }, { "payer_name": "MERITAIN HEALTH", "plan_name": "AETNA ALL OTHER PLANS", "methodology": "percent of total billed charges", "standard_charge_dollar": 52.0, "standard_charge_percentage": 52.0, "count": "0", "additional_payer_notes": "Zero final payments for the item or service in the 15 months prior to posting the file." }, { "payer_name": "BLUE SHIELD OUT OF STATE", "plan_name": "STANFORD HEALTHCARE ALLIANCE PLAN", "methodology": "percent of total billed charges", "standard_charge_dollar": 48.59, "standard_charge_percentage": 48.59, "count": "0", "additional_payer_notes": "Zero final payments for the item or service in the 15 months prior to posting the file." }, { "payer_name": "BLUE SHIELD", "plan_name": "STANFORD HEALTHCARE ALLIANCE PLAN", "methodology": "percent of total billed charges", "standard_charge_dollar": 48.59, "standard_charge_percentage": 48.59, "count": "0", "additional_payer_notes": "Zero final payments for the item or service in the 15 months prior to posting the file." }, { "payer_name": "BLUE SHIELD", "plan_name": "STANFORD HEALTHCARE ALLIANCE PLAN", "methodology": "percent of total billed charges", "standard_charge_dollar": 48.59, "standard_charge_percentage": 48.59, "count": "0", "additional_payer_notes": "Zero final payments for the item or service in the 15 months prior to posting the file." }, { "payer_name": "CIGNA", "plan_name": "CIGNA COM ALT HMO PLAN", "methodology": "percent of total billed charges", "standard_charge_dollar": 42.2, "standard_charge_percentage": 42.2, "count": "0", "additional_payer_notes": "Zero final payments for the item or service in the 15 months prior to posting the file." }, { "payer_name": "CIGNA", "plan_name": "CIGNA COM ALT HMO PLAN", "methodology": "percent of total billed charges", "standard_charge_dollar": 42.2, "standard_charge_percentage": 42.2, "count": "0", "additional_payer_notes": "Zero final payments for the item or service in the 15 months prior to posting the file." }, { "payer_name": "HEALTH NET", "plan_name": "HEALTHNET HMO, PPO, POS, EPO, CANOPY HEALTHNET HMO, OTHER-IN-NETWORK PLANS", "methodology": "per diem", "standard_charge_dollar": 8000.0, "standard_charge_algorithm": "Expected reimbursement is the lesser of Per diem ($8,000) for the length of stay and 70% of billed.", "count": "0", "additional_payer_notes": "Zero final payments for the item or service in the 15 months prior to posting the file." }, { "payer_name": "HEALTH NET", "plan_name": "HEALTHNET HMO, PPO, POS, EPO, CANOPY HEALTHNET HMO, OTHER-IN-NETWORK PLANS", "methodology": "per diem", "standard_charge_dollar": 8000.0, "standard_charge_algorithm": "Expected reimbursement is the lesser of Per diem ($8,000) for the length of stay and 70% of billed.", "count": "0", "additional_payer_notes": "Zero final payments for the item or service in the 15 months prior to posting the file." }, { "payer_name": "UNITED HEALTHCARE", "plan_name": "SUTTER SELECT & SUTTER HEALTH PLAN HMO PLANS", "methodology": "per diem", "standard_charge_dollar": 28538.0, "standard_charge_algorithm": "Per diem ($28,538).", "count": "0", "additional_payer_notes": "Zero final payments for the item or service in the 15 months prior to posting the file." }, { "payer_name": "UNITED HEALTHCARE", "plan_name": "SUTTER SELECT & SUTTER HEALTH PLAN HMO PLANS", "methodology": "per diem", "standard_charge_dollar": 28538.0, "standard_charge_algorithm": "Per diem ($28,538).", "count": "0", "additional_payer_notes": "Zero final payments for the item or service in the 15 months prior to posting the file." }, { "payer_name": "SUTTER", "plan_name": "SUTTER SELECT & SUTTER HEALTH PLAN HMO PLANS", "methodology": "per diem", "standard_charge_dollar": 28538.0, "standard_charge_algorithm": "Per diem ($28,538).", "count": "0", "additional_payer_notes": "Zero final payments for the item or service in the 15 months prior to posting the file." }, { "payer_name": "UNITED HEALTHCARE", "plan_name": "SUTTER SELECT & SUTTER HEALTH PLAN HMO PLANS", "methodology": "per diem", "standard_charge_dollar": 28538.0, "standard_charge_algorithm": "Per diem ($28,538).", "count": "0", "additional_payer_notes": "Zero final payments for the item or service in the 15 months prior to posting the file." }, { "payer_name": "UMR", "plan_name": "SUTTER SELECT & SUTTER HEALTH PLAN HMO PLANS", "methodology": "per diem", "standard_charge_dollar": 28538.0, "standard_charge_algorithm": "Per diem ($28,538).", "count": "0", "additional_payer_notes": "Zero final payments for the item or service in the 15 months prior to posting the file." } ] } ] }, { "description": "HC Drill Bit Gp004", "code_information": [ { "code": "PX-2120061004", "type": "CDM" }, { "code": "99999", "type": "CPT" }, { "code": "0272", "type": "RC" } ], "standard_charges": [ { "setting": "outpatient", "gross_charge": 146.0, "discounted_cash": 73.0, "minimum": 61.61, "maximum": 75.92, "additional_generic_notes": "Zero final payments for the item or service in the 15 months prior to posting the file.", "payers_information": [ { "payer_name": "AETNA", "plan_name": "AETNA ALL OTHER PLANS", "methodology": "percent of total billed charges", "standard_charge_dollar": 75.92, "standard_charge_percentage": 52.0, "count": "0", "additional_payer_notes": "Zero final payments for the item or service in the 15 months prior to posting the file." }, { "payer_name": "AETNA", "plan_name": "AETNA ALL OTHER PLANS", "methodology": "percent of total billed charges", "standard_charge_dollar": 75.92, "standard_charge_percentage": 52.0, "count": "0", "additional_payer_notes": "Zero final payments for the item or service in the 15 months prior to posting the file." }, { "payer_name": "MERITAIN HEALTH", "plan_name": "AETNA ALL OTHER PLANS", "methodology": "percent of total billed charges", "standard_charge_dollar": 75.92, "standard_charge_percentage": 52.0, "count": "0", "additional_payer_notes": "Zero final payments for the item or service in the 15 months prior to posting the file." }, { "payer_name": "BLUE SHIELD OUT OF STATE", "plan_name": "STANFORD HEALTHCARE ALLIANCE PLAN", "methodology": "percent of total billed charges", "standard_charge_dollar": 70.94, "standard_charge_percentage": 48.59, "count": "0", "additional_payer_notes": "Zero final payments for the item or service in the 15 months prior to posting the file." }, { "payer_name": "BLUE SHIELD", "plan_name": "STANFORD HEALTHCARE ALLIANCE PLAN", "methodology": "percent of total billed charges", "standard_charge_dollar": 70.94, "standard_charge_percentage": 48.59, "count": "0", "additional_payer_notes": "Zero final payments for the item or service in the 15 months prior to posting the file." }, { "payer_name": "BLUE SHIELD", "plan_name": "STANFORD HEALTHCARE ALLIANCE PLAN", "methodology": "percent of total billed charges", "standard_charge_dollar": 70.94, "standard_charge_percentage": 48.59, "count": "0", "additional_payer_notes": "Zero final payments for the item or service in the 15 months prior to posting the file." }, { "payer_name": "CIGNA", "plan_name": "CIGNA COM ALT HMO PLAN", "methodology": "percent of total billed charges", "standard_charge_dollar": 61.61, "standard_charge_percentage": 42.2, "count": "0", "additional_payer_notes": "Zero final payments for the item or service in the 15 months prior to posting the file." }, { "payer_name": "CIGNA", "plan_name": "CIGNA COM ALT HMO PLAN", "methodology": "percent of total billed charges", "standard_charge_dollar": 61.61, "standard_charge_percentage": 42.2, "count": "0", "additional_payer_notes": "Zero final payments for the item or service in the 15 months prior to posting the file." }, { "payer_name": "HEALTH NET", "plan_name": "HEALTHNET HMO, PPO, POS, EPO, CANOPY HEALTHNET HMO, OTHER-IN-NETWORK PLANS", "methodology": "per diem", "standard_charge_dollar": 8000.0, "standard_charge_algorithm": "Expected reimbursement is the lesser of Per diem ($8,000) for the length of stay and 70% of billed.", "count": "0", "additional_payer_notes": "Zero final payments for the item or service in the 15 months prior to posting the file." }, { "payer_name": "HEALTH NET", "plan_name": "HEALTHNET HMO, PPO, POS, EPO, CANOPY HEALTHNET HMO, OTHER-IN-NETWORK PLANS", "methodology": "per diem", "standard_charge_dollar": 8000.0, "standard_charge_algorithm": "Expected reimbursement is the lesser of Per diem ($8,000) for the length of stay and 70% of billed.", "count": "0", "additional_payer_notes": "Zero final payments for the item or service in the 15 months prior to posting the file." }, { "payer_name": "UNITED HEALTHCARE", "plan_name": "SUTTER SELECT & SUTTER HEALTH PLAN HMO PLANS", "methodology": "per diem", "standard_charge_dollar": 28538.0, "standard_charge_algorithm": "Per diem ($28,538).", "count": "0", "additional_payer_notes": "Zero final payments for the item or service in the 15 months prior to posting the file." }, { "payer_name": "UNITED HEALTHCARE", "plan_name": "SUTTER SELECT & SUTTER HEALTH PLAN HMO PLANS", "methodology": "per diem", "standard_charge_dollar": 28538.0, "standard_charge_algorithm": "Per diem ($28,538).", "count": "0", "additional_payer_notes": "Zero final payments for the item or service in the 15 months prior to posting the file." }, { "payer_name": "SUTTER", "plan_name": "SUTTER SELECT & SUTTER HEALTH PLAN HMO PLANS", "methodology": "per diem", "standard_charge_dollar": 28538.0, "standard_charge_algorithm": "Per diem ($28,538).", "count": "0", "additional_payer_notes": "Zero final payments for the item or service in the 15 months prior to posting the file." }, { "payer_name": "UNITED HEALTHCARE", "plan_name": "SUTTER SELECT & SUTTER HEALTH PLAN HMO PLANS", "methodology": "per diem", "standard_charge_dollar": 28538.0, "standard_charge_algorithm": "Per diem ($28,538).", "count": "0", "additional_payer_notes": "Zero final payments for the item or service in the 15 months prior to posting the file." }, { "payer_name": "UMR", "plan_name": "SUTTER SELECT & SUTTER HEALTH PLAN HMO PLANS", "methodology": "per diem", "standard_charge_dollar": 28538.0, "standard_charge_algorithm": "Per diem ($28,538).", "count": "0", "additional_payer_notes": "Zero final payments for the item or service in the 15 months prior to posting the file." } ] } ] }, { "description": "HC Drill Bit Gp006", "code_information": [ { "code": "PX-2120061006", "type": "CDM" }, { "code": "99999", "type": "CPT" }, { "code": "0272", "type": "RC" } ], "standard_charges": [ { "setting": "outpatient", "gross_charge": 293.0, "discounted_cash": 146.5, "minimum": 123.65, "maximum": 152.36, "additional_generic_notes": "Zero final payments for the item or service in the 15 months prior to posting the file.", "payers_information": [ { "payer_name": "AETNA", "plan_name": "AETNA ALL OTHER PLANS", "methodology": "percent of total billed charges", "standard_charge_dollar": 152.36, "standard_charge_percentage": 52.0, "count": "0", "additional_payer_notes": "Zero final payments for the item or service in the 15 months prior to posting the file." }, { "payer_name": "AETNA", "plan_name": "AETNA ALL OTHER PLANS", "methodology": "percent of total billed charges", "standard_charge_dollar": 152.36, "standard_charge_percentage": 52.0, "count": "0", "additional_payer_notes": "Zero final payments for the item or service in the 15 months prior to posting the file." }, { "payer_name": "MERITAIN HEALTH", "plan_name": "AETNA ALL OTHER PLANS", "methodology": "percent of total billed charges", "standard_charge_dollar": 152.36, "standard_charge_percentage": 52.0, "count": "0", "additional_payer_notes": "Zero final payments for the item or service in the 15 months prior to posting the file." }, { "payer_name": "BLUE SHIELD OUT OF STATE", "plan_name": "STANFORD HEALTHCARE ALLIANCE PLAN", "methodology": "percent of total billed charges", "standard_charge_dollar": 142.37, "standard_charge_percentage": 48.59, "count": "0", "additional_payer_notes": "Zero final payments for the item or service in the 15 months prior to posting the file." }, { "payer_name": "BLUE SHIELD", "plan_name": "STANFORD HEALTHCARE ALLIANCE PLAN", "methodology": "percent of total billed charges", "standard_charge_dollar": 142.37, "standard_charge_percentage": 48.59, "count": "0", "additional_payer_notes": "Zero final payments for the item or service in the 15 months prior to posting the file." }, { "payer_name": "BLUE SHIELD", "plan_name": "STANFORD HEALTHCARE ALLIANCE PLAN", "methodology": "percent of total billed charges", "standard_charge_dollar": 142.37, "standard_charge_percentage": 48.59, "count": "0", "additional_payer_notes": "Zero final payments for the item or service in the 15 months prior to posting the file." }, { "payer_name": "CIGNA", "plan_name": "CIGNA COM ALT HMO PLAN", "methodology": "percent of total billed charges", "standard_charge_dollar": 123.65, "standard_charge_percentage": 42.2, "count": "0", "additional_payer_notes": "Zero final payments for the item or service in the 15 months prior to posting the file." }, { "payer_name": "CIGNA", "plan_name": "CIGNA COM ALT HMO PLAN", "methodology": "percent of total billed charges", "standard_charge_dollar": 123.65, "standard_charge_percentage": 42.2, "count": "0", "additional_payer_notes": "Zero final payments for the item or service in the 15 months prior to posting the file." }, { "payer_name": "HEALTH NET", "plan_name": "HEALTHNET HMO, PPO, POS, EPO, CANOPY HEALTHNET HMO, OTHER-IN-NETWORK PLANS", "methodology": "per diem", "standard_charge_dollar": 8000.0, "standard_charge_algorithm": "Expected reimbursement is the lesser of Per diem ($8,000) for the length of stay and 70% of billed.", "count": "0", "additional_payer_notes": "Zero final payments for the item or service in the 15 months prior to posting the file." }, { "payer_name": "HEALTH NET", "plan_name": "HEALTHNET HMO, PPO, POS, EPO, CANOPY HEALTHNET HMO, OTHER-IN-NETWORK PLANS", "methodology": "per diem", "standard_charge_dollar": 8000.0, "standard_charge_algorithm": "Expected reimbursement is the lesser of Per diem ($8,000) for the length of stay and 70% of billed.", "count": "0", "additional_payer_notes": "Zero final payments for the item or service in the 15 months prior to posting the file." }, { "payer_name": "UNITED HEALTHCARE", "plan_name": "SUTTER SELECT & SUTTER HEALTH PLAN HMO PLANS", "methodology": "per diem", "standard_charge_dollar": 28538.0, "standard_charge_algorithm": "Per diem ($28,538).", "count": "0", "additional_payer_notes": "Zero final payments for the item or service in the 15 months prior to posting the file." }, { "payer_name": "UNITED HEALTHCARE", "plan_name": "SUTTER SELECT & SUTTER HEALTH PLAN HMO PLANS", "methodology": "per diem", "standard_charge_dollar": 28538.0, "standard_charge_algorithm": "Per diem ($28,538).", "count": "0", "additional_payer_notes": "Zero final payments for the item or service in the 15 months prior to posting the file." }, { "payer_name": "SUTTER", "plan_name": "SUTTER SELECT & SUTTER HEALTH PLAN HMO PLANS", "methodology": "per diem", "standard_charge_dollar": 28538.0, "standard_charge_algorithm": "Per diem ($28,538).", "count": "0", "additional_payer_notes": "Zero final payments for the item or service in the 15 months prior to posting the file." }, { "payer_name": "UNITED HEALTHCARE", "plan_name": "SUTTER SELECT & SUTTER HEALTH PLAN HMO PLANS", "methodology": "per diem", "standard_charge_dollar": 28538.0, "standard_charge_algorithm": "Per diem ($28,538).", "count": "0", "additional_payer_notes": "Zero final payments for the item or service in the 15 months prior to posting the file." }, { "payer_name": "UMR", "plan_name": "SUTTER SELECT & SUTTER HEALTH PLAN HMO PLANS", "methodology": "per diem", "standard_charge_dollar": 28538.0, "standard_charge_algorithm": "Per diem ($28,538).", "count": "0", "additional_payer_notes": "Zero final payments for the item or service in the 15 months prior to posting the file." } ] } ] }, { "description": "HC Drill Bit Gp007", "code_information": [ { "code": "PX-2120061007", "type": "CDM" }, { "code": "99999", "type": "CPT" }, { "code": "0272", "type": "RC" } ], "standard_charges": [ { "setting": "outpatient", "gross_charge": 380.0, "discounted_cash": 190.0, "minimum": 160.36, "maximum": 197.6, "additional_generic_notes": "Zero final payments for the item or service in the 15 months prior to posting the file.", "payers_information": [ { "payer_name": "AETNA", "plan_name": "AETNA ALL OTHER PLANS", "methodology": "percent of total billed charges", "standard_charge_dollar": 197.6, "standard_charge_percentage": 52.0, "count": "0", "additional_payer_notes": "Zero final payments for the item or service in the 15 months prior to posting the file." }, { "payer_name": "AETNA", "plan_name": "AETNA ALL OTHER PLANS", "methodology": "percent of total billed charges", "standard_charge_dollar": 197.6, "standard_charge_percentage": 52.0, "count": "0", "additional_payer_notes": "Zero final payments for the item or service in the 15 months prior to posting the file." }, { "payer_name": "MERITAIN HEALTH", "plan_name": "AETNA ALL OTHER PLANS", "methodology": "percent of total billed charges", "standard_charge_dollar": 197.6, "standard_charge_percentage": 52.0, "count": "0", "additional_payer_notes": "Zero final payments for the item or service in the 15 months prior to posting the file." }, { "payer_name": "BLUE SHIELD OUT OF STATE", "plan_name": "STANFORD HEALTHCARE ALLIANCE PLAN", "methodology": "percent of total billed charges", "standard_charge_dollar": 184.64, "standard_charge_percentage": 48.59, "count": "0", "additional_payer_notes": "Zero final payments for the item or service in the 15 months prior to posting the file." }, { "payer_name": "BLUE SHIELD", "plan_name": "STANFORD HEALTHCARE ALLIANCE PLAN", "methodology": "percent of total billed charges", "standard_charge_dollar": 184.64, "standard_charge_percentage": 48.59, "count": "0", "additional_payer_notes": "Zero final payments for the item or service in the 15 months prior to posting the file." }, { "payer_name": "BLUE SHIELD", "plan_name": "STANFORD HEALTHCARE ALLIANCE PLAN", "methodology": "percent of total billed charges", "standard_charge_dollar": 184.64, "standard_charge_percentage": 48.59, "count": "0", "additional_payer_notes": "Zero final payments for the item or service in the 15 months prior to posting the file." }, { "payer_name": "CIGNA", "plan_name": "CIGNA COM ALT HMO PLAN", "methodology": "percent of total billed charges", "standard_charge_dollar": 160.36, "standard_charge_percentage": 42.2, "count": "0", "additional_payer_notes": "Zero final payments for the item or service in the 15 months prior to posting the file." }, { "payer_name": "CIGNA", "plan_name": "CIGNA COM ALT HMO PLAN", "methodology": "percent of total billed charges", "standard_charge_dollar": 160.36, "standard_charge_percentage": 42.2, "count": "0", "additional_payer_notes": "Zero final payments for the item or service in the 15 months prior to posting the file." }, { "payer_name": "HEALTH NET", "plan_name": "HEALTHNET HMO, PPO, POS, EPO, CANOPY HEALTHNET HMO, OTHER-IN-NETWORK PLANS", "methodology": "per diem", "standard_charge_dollar": 8000.0, "standard_charge_algorithm": "Expected reimbursement is the lesser of Per diem ($8,000) for the length of stay and 70% of billed.", "count": "0", "additional_payer_notes": "Zero final payments for the item or service in the 15 months prior to posting the file." }, { "payer_name": "HEALTH NET", "plan_name": "HEALTHNET HMO, PPO, POS, EPO, CANOPY HEALTHNET HMO, OTHER-IN-NETWORK PLANS", "methodology": "per diem", "standard_charge_dollar": 8000.0, "standard_charge_algorithm": "Expected reimbursement is the lesser of Per diem ($8,000) for the length of stay and 70% of billed.", "count": "0", "additional_payer_notes": "Zero final payments for the item or service in the 15 months prior to posting the file." }, { "payer_name": "UNITED HEALTHCARE", "plan_name": "SUTTER SELECT & SUTTER HEALTH PLAN HMO PLANS", "methodology": "per diem", "standard_charge_dollar": 28538.0, "standard_charge_algorithm": "Per diem ($28,538).", "count": "0", "additional_payer_notes": "Zero final payments for the item or service in the 15 months prior to posting the file." }, { "payer_name": "UNITED HEALTHCARE", "plan_name": "SUTTER SELECT & SUTTER HEALTH PLAN HMO PLANS", "methodology": "per diem", "standard_charge_dollar": 28538.0, "standard_charge_algorithm": "Per diem ($28,538).", "count": "0", "additional_payer_notes": "Zero final payments for the item or service in the 15 months prior to posting the file." }, { "payer_name": "SUTTER", "plan_name": "SUTTER SELECT & SUTTER HEALTH PLAN HMO PLANS", "methodology": "per diem", "standard_charge_dollar": 28538.0, "standard_charge_algorithm": "Per diem ($28,538).", "count": "0", "additional_payer_notes": "Zero final payments for the item or service in the 15 months prior to posting the file." }, { "payer_name": "UNITED HEALTHCARE", "plan_name": "SUTTER SELECT & SUTTER HEALTH PLAN HMO PLANS", "methodology": "per diem", "standard_charge_dollar": 28538.0, "standard_charge_algorithm": "Per diem ($28,538).", "count": "0", "additional_payer_notes": "Zero final payments for the item or service in the 15 months prior to posting the file." }, { "payer_name": "UMR", "plan_name": "SUTTER SELECT & SUTTER HEALTH PLAN HMO PLANS", "methodology": "per diem", "standard_charge_dollar": 28538.0, "standard_charge_algorithm": "Per diem ($28,538).", "count": "0", "additional_payer_notes": "Zero final payments for the item or service in the 15 months prior to posting the file." } ] } ] }, { "description": "HC Drill Bit Gp008", "code_information": [ { "code": "PX-2120061008", "type": "CDM" }, { "code": "99999", "type": "CPT" }, { "code": "0272", "type": "RC" } ], "standard_charges": [ { "setting": "outpatient", "gross_charge": 475.0, "discounted_cash": 237.5, "minimum": 200.45, "maximum": 247.0, "additional_generic_notes": "Zero final payments for the item or service in the 15 months prior to posting the file.", "payers_information": [ { "payer_name": "AETNA", "plan_name": "AETNA ALL OTHER PLANS", "methodology": "percent of total billed charges", "standard_charge_dollar": 247.0, "standard_charge_percentage": 52.0, "count": "0", "additional_payer_notes": "Zero final payments for the item or service in the 15 months prior to posting the file." }, { "payer_name": "AETNA", "plan_name": "AETNA ALL OTHER PLANS", "methodology": "percent of total billed charges", "standard_charge_dollar": 247.0, "standard_charge_percentage": 52.0, "count": "0", "additional_payer_notes": "Zero final payments for the item or service in the 15 months prior to posting the file." }, { "payer_name": "MERITAIN HEALTH", "plan_name": "AETNA ALL OTHER PLANS", "methodology": "percent of total billed charges", "standard_charge_dollar": 247.0, "standard_charge_percentage": 52.0, "count": "0", "additional_payer_notes": "Zero final payments for the item or service in the 15 months prior to posting the file." }, { "payer_name": "BLUE SHIELD OUT OF STATE", "plan_name": "STANFORD HEALTHCARE ALLIANCE PLAN", "methodology": "percent of total billed charges", "standard_charge_dollar": 230.8, "standard_charge_percentage": 48.59, "count": "0", "additional_payer_notes": "Zero final payments for the item or service in the 15 months prior to posting the file." }, { "payer_name": "BLUE SHIELD", "plan_name": "STANFORD HEALTHCARE ALLIANCE PLAN", "methodology": "percent of total billed charges", "standard_charge_dollar": 230.8, "standard_charge_percentage": 48.59, "count": "0", "additional_payer_notes": "Zero final payments for the item or service in the 15 months prior to posting the file." }, { "payer_name": "BLUE SHIELD", "plan_name": "STANFORD HEALTHCARE ALLIANCE PLAN", "methodology": "percent of total billed charges", "standard_charge_dollar": 230.8, "standard_charge_percentage": 48.59, "count": "0", "additional_payer_notes": "Zero final payments for the item or service in the 15 months prior to posting the file." }, { "payer_name": "CIGNA", "plan_name": "CIGNA COM ALT HMO PLAN", "methodology": "percent of total billed charges", "standard_charge_dollar": 200.45, "standard_charge_percentage": 42.2, "count": "0", "additional_payer_notes": "Zero final payments for the item or service in the 15 months prior to posting the file." }, { "payer_name": "CIGNA", "plan_name": "CIGNA COM ALT HMO PLAN", "methodology": "percent of total billed charges", "standard_charge_dollar": 200.45, "standard_charge_percentage": 42.2, "count": "0", "additional_payer_notes": "Zero final payments for the item or service in the 15 months prior to posting the file." }, { "payer_name": "HEALTH NET", "plan_name": "HEALTHNET HMO, PPO, POS, EPO, CANOPY HEALTHNET HMO, OTHER-IN-NETWORK PLANS", "methodology": "per diem", "standard_charge_dollar": 8000.0, "standard_charge_algorithm": "Expected reimbursement is the lesser of Per diem ($8,000) for the length of stay and 70% of billed.", "count": "0", "additional_payer_notes": "Zero final payments for the item or service in the 15 months prior to posting the file." }, { "payer_name": "HEALTH NET", "plan_name": "HEALTHNET HMO, PPO, POS, EPO, CANOPY HEALTHNET HMO, OTHER-IN-NETWORK PLANS", "methodology": "per diem", "standard_charge_dollar": 8000.0, "standard_charge_algorithm": "Expected reimbursement is the lesser of Per diem ($8,000) for the length of stay and 70% of billed.", "count": "0", "additional_payer_notes": "Zero final payments for the item or service in the 15 months prior to posting the file." }, { "payer_name": "UNITED HEALTHCARE", "plan_name": "SUTTER SELECT & SUTTER HEALTH PLAN HMO PLANS", "methodology": "per diem", "standard_charge_dollar": 28538.0, "standard_charge_algorithm": "Per diem ($28,538).", "count": "0", "additional_payer_notes": "Zero final payments for the item or service in the 15 months prior to posting the file." }, { "payer_name": "UNITED HEALTHCARE", "plan_name": "SUTTER SELECT & SUTTER HEALTH PLAN HMO PLANS", "methodology": "per diem", "standard_charge_dollar": 28538.0, "standard_charge_algorithm": "Per diem ($28,538).", "count": "0", "additional_payer_notes": "Zero final payments for the item or service in the 15 months prior to posting the file." }, { "payer_name": "SUTTER", "plan_name": "SUTTER SELECT & SUTTER HEALTH PLAN HMO PLANS", "methodology": "per diem", "standard_charge_dollar": 28538.0, "standard_charge_algorithm": "Per diem ($28,538).", "count": "0", "additional_payer_notes": "Zero final payments for the item or service in the 15 months prior to posting the file." }, { "payer_name": "UNITED HEALTHCARE", "plan_name": "SUTTER SELECT & SUTTER HEALTH PLAN HMO PLANS", "methodology": "per diem", "standard_charge_dollar": 28538.0, "standard_charge_algorithm": "Per diem ($28,538).", "count": "0", "additional_payer_notes": "Zero final payments for the item or service in the 15 months prior to posting the file." }, { "payer_name": "UMR", "plan_name": "SUTTER SELECT & SUTTER HEALTH PLAN HMO PLANS", "methodology": "per diem", "standard_charge_dollar": 28538.0, "standard_charge_algorithm": "Per diem ($28,538).", "count": "0", "additional_payer_notes": "Zero final payments for the item or service in the 15 months prior to posting the file." } ] } ] }, { "description": "HC Drill Bit Gp009", "code_information": [ { "code": "PX-2120061009", "type": "CDM" }, { "code": "99999", "type": "CPT" }, { "code": "0272", "type": "RC" } ], "standard_charges": [ { "setting": "outpatient", "gross_charge": 570.0, "discounted_cash": 285.0, "minimum": 240.54, "maximum": 296.4, "additional_generic_notes": "Zero final payments for the item or service in the 15 months prior to posting the file.", "payers_information": [ { "payer_name": "AETNA", "plan_name": "AETNA ALL OTHER PLANS", "methodology": "percent of total billed charges", "standard_charge_dollar": 296.4, "standard_charge_percentage": 52.0, "count": "0", "additional_payer_notes": "Zero final payments for the item or service in the 15 months prior to posting the file." }, { "payer_name": "AETNA", "plan_name": "AETNA ALL OTHER PLANS", "methodology": "percent of total billed charges", "standard_charge_dollar": 296.4, "standard_charge_percentage": 52.0, "count": "0", "additional_payer_notes": "Zero final payments for the item or service in the 15 months prior to posting the file." }, { "payer_name": "MERITAIN HEALTH", "plan_name": "AETNA ALL OTHER PLANS", "methodology": "percent of total billed charges", "standard_charge_dollar": 296.4, "standard_charge_percentage": 52.0, "count": "0", "additional_payer_notes": "Zero final payments for the item or service in the 15 months prior to posting the file." }, { "payer_name": "BLUE SHIELD OUT OF STATE", "plan_name": "STANFORD HEALTHCARE ALLIANCE PLAN", "methodology": "percent of total billed charges", "standard_charge_dollar": 276.96, "standard_charge_percentage": 48.59, "count": "0", "additional_payer_notes": "Zero final payments for the item or service in the 15 months prior to posting the file." }, { "payer_name": "BLUE SHIELD", "plan_name": "STANFORD HEALTHCARE ALLIANCE PLAN", "methodology": "percent of total billed charges", "standard_charge_dollar": 276.96, "standard_charge_percentage": 48.59, "count": "0", "additional_payer_notes": "Zero final payments for the item or service in the 15 months prior to posting the file." }, { "payer_name": "BLUE SHIELD", "plan_name": "STANFORD HEALTHCARE ALLIANCE PLAN", "methodology": "percent of total billed charges", "standard_charge_dollar": 276.96, "standard_charge_percentage": 48.59, "count": "0", "additional_payer_notes": "Zero final payments for the item or service in the 15 months prior to posting the file." }, { "payer_name": "CIGNA", "plan_name": "CIGNA COM ALT HMO PLAN", "methodology": "percent of total billed charges", "standard_charge_dollar": 240.54, "standard_charge_percentage": 42.2, "count": "0", "additional_payer_notes": "Zero final payments for the item or service in the 15 months prior to posting the file." }, { "payer_name": "CIGNA", "plan_name": "CIGNA COM ALT HMO PLAN", "methodology": "percent of total billed charges", "standard_charge_dollar": 240.54, "standard_charge_percentage": 42.2, "count": "0", "additional_payer_notes": "Zero final payments for the item or service in the 15 months prior to posting the file." }, { "payer_name": "HEALTH NET", "plan_name": "HEALTHNET HMO, PPO, POS, EPO, CANOPY HEALTHNET HMO, OTHER-IN-NETWORK PLANS", "methodology": "per diem", "standard_charge_dollar": 8000.0, "standard_charge_algorithm": "Expected reimbursement is the lesser of Per diem ($8,000) for the length of stay and 70% of billed.", "count": "0", "additional_payer_notes": "Zero final payments for the item or service in the 15 months prior to posting the file." }, { "payer_name": "HEALTH NET", "plan_name": "HEALTHNET HMO, PPO, POS, EPO, CANOPY HEALTHNET HMO, OTHER-IN-NETWORK PLANS", "methodology": "per diem", "standard_charge_dollar": 8000.0, "standard_charge_algorithm": "Expected reimbursement is the lesser of Per diem ($8,000) for the length of stay and 70% of billed.", "count": "0", "additional_payer_notes": "Zero final payments for the item or service in the 15 months prior to posting the file." }, { "payer_name": "UNITED HEALTHCARE", "plan_name": "SUTTER SELECT & SUTTER HEALTH PLAN HMO PLANS", "methodology": "per diem", "standard_charge_dollar": 28538.0, "standard_charge_algorithm": "Per diem ($28,538).", "count": "0", "additional_payer_notes": "Zero final payments for the item or service in the 15 months prior to posting the file." }, { "payer_name": "UNITED HEALTHCARE", "plan_name": "SUTTER SELECT & SUTTER HEALTH PLAN HMO PLANS", "methodology": "per diem", "standard_charge_dollar": 28538.0, "standard_charge_algorithm": "Per diem ($28,538).", "count": "0", "additional_payer_notes": "Zero final payments for the item or service in the 15 months prior to posting the file." }, { "payer_name": "SUTTER", "plan_name": "SUTTER SELECT & SUTTER HEALTH PLAN HMO PLANS", "methodology": "per diem", "standard_charge_dollar": 28538.0, "standard_charge_algorithm": "Per diem ($28,538).", "count": "0", "additional_payer_notes": "Zero final payments for the item or service in the 15 months prior to posting the file." }, { "payer_name": "UNITED HEALTHCARE", "plan_name": "SUTTER SELECT & SUTTER HEALTH PLAN HMO PLANS", "methodology": "per diem", "standard_charge_dollar": 28538.0, "standard_charge_algorithm": "Per diem ($28,538).", "count": "0", "additional_payer_notes": "Zero final payments for the item or service in the 15 months prior to posting the file." }, { "payer_name": "UMR", "plan_name": "SUTTER SELECT & SUTTER HEALTH PLAN HMO PLANS", "methodology": "per diem", "standard_charge_dollar": 28538.0, "standard_charge_algorithm": "Per diem ($28,538).", "count": "0", "additional_payer_notes": "Zero final payments for the item or service in the 15 months prior to posting the file." } ] } ] }, { "description": "HC Drill Bit Gp010", "code_information": [ { "code": "PX-2120061010", "type": "CDM" }, { "code": "99999", "type": "CPT" }, { "code": "0272", "type": "RC" } ], "standard_charges": [ { "setting": "outpatient", "gross_charge": 665.0, "discounted_cash": 332.5, "minimum": 280.63, "maximum": 345.8, "additional_generic_notes": "Zero final payments for the item or service in the 15 months prior to posting the file.", "payers_information": [ { "payer_name": "AETNA", "plan_name": "AETNA ALL OTHER PLANS", "methodology": "percent of total billed charges", "standard_charge_dollar": 345.8, "standard_charge_percentage": 52.0, "count": "0", "additional_payer_notes": "Zero final payments for the item or service in the 15 months prior to posting the file." }, { "payer_name": "AETNA", "plan_name": "AETNA ALL OTHER PLANS", "methodology": "percent of total billed charges", "standard_charge_dollar": 345.8, "standard_charge_percentage": 52.0, "count": "0", "additional_payer_notes": "Zero final payments for the item or service in the 15 months prior to posting the file." }, { "payer_name": "MERITAIN HEALTH", "plan_name": "AETNA ALL OTHER PLANS", "methodology": "percent of total billed charges", "standard_charge_dollar": 345.8, "standard_charge_percentage": 52.0, "count": "0", "additional_payer_notes": "Zero final payments for the item or service in the 15 months prior to posting the file." }, { "payer_name": "BLUE SHIELD OUT OF STATE", "plan_name": "STANFORD HEALTHCARE ALLIANCE PLAN", "methodology": "percent of total billed charges", "standard_charge_dollar": 323.12, "standard_charge_percentage": 48.59, "count": "0", "additional_payer_notes": "Zero final payments for the item or service in the 15 months prior to posting the file." }, { "payer_name": "BLUE SHIELD", "plan_name": "STANFORD HEALTHCARE ALLIANCE PLAN", "methodology": "percent of total billed charges", "standard_charge_dollar": 323.12, "standard_charge_percentage": 48.59, "count": "0", "additional_payer_notes": "Zero final payments for the item or service in the 15 months prior to posting the file." }, { "payer_name": "BLUE SHIELD", "plan_name": "STANFORD HEALTHCARE ALLIANCE PLAN", "methodology": "percent of total billed charges", "standard_charge_dollar": 323.12, "standard_charge_percentage": 48.59, "count": "0", "additional_payer_notes": "Zero final payments for the item or service in the 15 months prior to posting the file." }, { "payer_name": "CIGNA", "plan_name": "CIGNA COM ALT HMO PLAN", "methodology": "percent of total billed charges", "standard_charge_dollar": 280.63, "standard_charge_percentage": 42.2, "count": "0", "additional_payer_notes": "Zero final payments for the item or service in the 15 months prior to posting the file." }, { "payer_name": "CIGNA", "plan_name": "CIGNA COM ALT HMO PLAN", "methodology": "percent of total billed charges", "standard_charge_dollar": 280.63, "standard_charge_percentage": 42.2, "count": "0", "additional_payer_notes": "Zero final payments for the item or service in the 15 months prior to posting the file." }, { "payer_name": "HEALTH NET", "plan_name": "HEALTHNET HMO, PPO, POS, EPO, CANOPY HEALTHNET HMO, OTHER-IN-NETWORK PLANS", "methodology": "per diem", "standard_charge_dollar": 8000.0, "standard_charge_algorithm": "Expected reimbursement is the lesser of Per diem ($8,000) for the length of stay and 70% of billed.", "count": "0", "additional_payer_notes": "Zero final payments for the item or service in the 15 months prior to posting the file." }, { "payer_name": "HEALTH NET", "plan_name": "HEALTHNET HMO, PPO, POS, EPO, CANOPY HEALTHNET HMO, OTHER-IN-NETWORK PLANS", "methodology": "per diem", "standard_charge_dollar": 8000.0, "standard_charge_algorithm": "Expected reimbursement is the lesser of Per diem ($8,000) for the length of stay and 70% of billed.", "count": "0", "additional_payer_notes": "Zero final payments for the item or service in the 15 months prior to posting the file." }, { "payer_name": "UNITED HEALTHCARE", "plan_name": "SUTTER SELECT & SUTTER HEALTH PLAN HMO PLANS", "methodology": "per diem", "standard_charge_dollar": 28538.0, "standard_charge_algorithm": "Per diem ($28,538).", "count": "0", "additional_payer_notes": "Zero final payments for the item or service in the 15 months prior to posting the file." }, { "payer_name": "UNITED HEALTHCARE", "plan_name": "SUTTER SELECT & SUTTER HEALTH PLAN HMO PLANS", "methodology": "per diem", "standard_charge_dollar": 28538.0, "standard_charge_algorithm": "Per diem ($28,538).", "count": "0", "additional_payer_notes": "Zero final payments for the item or service in the 15 months prior to posting the file." }, { "payer_name": "SUTTER", "plan_name": "SUTTER SELECT & SUTTER HEALTH PLAN HMO PLANS", "methodology": "per diem", "standard_charge_dollar": 28538.0, "standard_charge_algorithm": "Per diem ($28,538).", "count": "0", "additional_payer_notes": "Zero final payments for the item or service in the 15 months prior to posting the file." }, { "payer_name": "UNITED HEALTHCARE", "plan_name": "SUTTER SELECT & SUTTER HEALTH PLAN HMO PLANS", "methodology": "per diem", "standard_charge_dollar": 28538.0, "standard_charge_algorithm": "Per diem ($28,538).", "count": "0", "additional_payer_notes": "Zero final payments for the item or service in the 15 months prior to posting the file." }, { "payer_name": "UMR", "plan_name": "SUTTER SELECT & SUTTER HEALTH PLAN HMO PLANS", "methodology": "per diem", "standard_charge_dollar": 28538.0, "standard_charge_algorithm": "Per diem ($28,538).", "count": "0", "additional_payer_notes": "Zero final payments for the item or service in the 15 months prior to posting the file." } ] } ] }, { "description": "HC Drill Bit Gp011", "code_information": [ { "code": "PX-2120061011", "type": "CDM" }, { "code": "99999", "type": "CPT" }, { "code": "0272", "type": "RC" } ], "standard_charges": [ { "setting": "outpatient", "gross_charge": 740.0, "discounted_cash": 370.0, "minimum": 312.28, "maximum": 384.8, "additional_generic_notes": "Zero final payments for the item or service in the 15 months prior to posting the file.", "payers_information": [ { "payer_name": "AETNA", "plan_name": "AETNA ALL OTHER PLANS", "methodology": "percent of total billed charges", "standard_charge_dollar": 384.8, "standard_charge_percentage": 52.0, "count": "0", "additional_payer_notes": "Zero final payments for the item or service in the 15 months prior to posting the file." }, { "payer_name": "AETNA", "plan_name": "AETNA ALL OTHER PLANS", "methodology": "percent of total billed charges", "standard_charge_dollar": 384.8, "standard_charge_percentage": 52.0, "count": "0", "additional_payer_notes": "Zero final payments for the item or service in the 15 months prior to posting the file." }, { "payer_name": "MERITAIN HEALTH", "plan_name": "AETNA ALL OTHER PLANS", "methodology": "percent of total billed charges", "standard_charge_dollar": 384.8, "standard_charge_percentage": 52.0, "count": "0", "additional_payer_notes": "Zero final payments for the item or service in the 15 months prior to posting the file." }, { "payer_name": "BLUE SHIELD OUT OF STATE", "plan_name": "STANFORD HEALTHCARE ALLIANCE PLAN", "methodology": "percent of total billed charges", "standard_charge_dollar": 359.57, "standard_charge_percentage": 48.59, "count": "0", "additional_payer_notes": "Zero final payments for the item or service in the 15 months prior to posting the file." }, { "payer_name": "BLUE SHIELD", "plan_name": "STANFORD HEALTHCARE ALLIANCE PLAN", "methodology": "percent of total billed charges", "standard_charge_dollar": 359.57, "standard_charge_percentage": 48.59, "count": "0", "additional_payer_notes": "Zero final payments for the item or service in the 15 months prior to posting the file." }, { "payer_name": "BLUE SHIELD", "plan_name": "STANFORD HEALTHCARE ALLIANCE PLAN", "methodology": "percent of total billed charges", "standard_charge_dollar": 359.57, "standard_charge_percentage": 48.59, "count": "0", "additional_payer_notes": "Zero final payments for the item or service in the 15 months prior to posting the file." }, { "payer_name": "CIGNA", "plan_name": "CIGNA COM ALT HMO PLAN", "methodology": "percent of total billed charges", "standard_charge_dollar": 312.28, "standard_charge_percentage": 42.2, "count": "0", "additional_payer_notes": "Zero final payments for the item or service in the 15 months prior to posting the file." }, { "payer_name": "CIGNA", "plan_name": "CIGNA COM ALT HMO PLAN", "methodology": "percent of total billed charges", "standard_charge_dollar": 312.28, "standard_charge_percentage": 42.2, "count": "0", "additional_payer_notes": "Zero final payments for the item or service in the 15 months prior to posting the file." }, { "payer_name": "HEALTH NET", "plan_name": "HEALTHNET HMO, PPO, POS, EPO, CANOPY HEALTHNET HMO, OTHER-IN-NETWORK PLANS", "methodology": "per diem", "standard_charge_dollar": 8000.0, "standard_charge_algorithm": "Expected reimbursement is the lesser of Per diem ($8,000) for the length of stay and 70% of billed.", "count": "0", "additional_payer_notes": "Zero final payments for the item or service in the 15 months prior to posting the file." }, { "payer_name": "HEALTH NET", "plan_name": "HEALTHNET HMO, PPO, POS, EPO, CANOPY HEALTHNET HMO, OTHER-IN-NETWORK PLANS", "methodology": "per diem", "standard_charge_dollar": 8000.0, "standard_charge_algorithm": "Expected reimbursement is the lesser of Per diem ($8,000) for the length of stay and 70% of billed.", "count": "0", "additional_payer_notes": "Zero final payments for the item or service in the 15 months prior to posting the file." }, { "payer_name": "UNITED HEALTHCARE", "plan_name": "SUTTER SELECT & SUTTER HEALTH PLAN HMO PLANS", "methodology": "per diem", "standard_charge_dollar": 28538.0, "standard_charge_algorithm": "Per diem ($28,538).", "count": "0", "additional_payer_notes": "Zero final payments for the item or service in the 15 months prior to posting the file." }, { "payer_name": "UNITED HEALTHCARE", "plan_name": "SUTTER SELECT & SUTTER HEALTH PLAN HMO PLANS", "methodology": "per diem", "standard_charge_dollar": 28538.0, "standard_charge_algorithm": "Per diem ($28,538).", "count": "0", "additional_payer_notes": "Zero final payments for the item or service in the 15 months prior to posting the file." }, { "payer_name": "SUTTER", "plan_name": "SUTTER SELECT & SUTTER HEALTH PLAN HMO PLANS", "methodology": "per diem", "standard_charge_dollar": 28538.0, "standard_charge_algorithm": "Per diem ($28,538).", "count": "0", "additional_payer_notes": "Zero final payments for the item or service in the 15 months prior to posting the file." }, { "payer_name": "UNITED HEALTHCARE", "plan_name": "SUTTER SELECT & SUTTER HEALTH PLAN HMO PLANS", "methodology": "per diem", "standard_charge_dollar": 28538.0, "standard_charge_algorithm": "Per diem ($28,538).", "count": "0", "additional_payer_notes": "Zero final payments for the item or service in the 15 months prior to posting the file." }, { "payer_name": "UMR", "plan_name": "SUTTER SELECT & SUTTER HEALTH PLAN HMO PLANS", "methodology": "per diem", "standard_charge_dollar": 28538.0, "standard_charge_algorithm": "Per diem ($28,538).", "count": "0", "additional_payer_notes": "Zero final payments for the item or service in the 15 months prior to posting the file." } ] } ] }, { "description": "HC Drill Bit Gp012", "code_information": [ { "code": "PX-2120061012", "type": "CDM" }, { "code": "99999", "type": "CPT" }, { "code": "0272", "type": "RC" } ], "standard_charges": [ { "setting": "outpatient", "gross_charge": 810.0, "discounted_cash": 405.0, "minimum": 341.82, "maximum": 421.2, "additional_generic_notes": "Zero final payments for the item or service in the 15 months prior to posting the file.", "payers_information": [ { "payer_name": "AETNA", "plan_name": "AETNA ALL OTHER PLANS", "methodology": "percent of total billed charges", "standard_charge_dollar": 421.2, "standard_charge_percentage": 52.0, "count": "0", "additional_payer_notes": "Zero final payments for the item or service in the 15 months prior to posting the file." }, { "payer_name": "AETNA", "plan_name": "AETNA ALL OTHER PLANS", "methodology": "percent of total billed charges", "standard_charge_dollar": 421.2, "standard_charge_percentage": 52.0, "count": "0", "additional_payer_notes": "Zero final payments for the item or service in the 15 months prior to posting the file." }, { "payer_name": "MERITAIN HEALTH", "plan_name": "AETNA ALL OTHER PLANS", "methodology": "percent of total billed charges", "standard_charge_dollar": 421.2, "standard_charge_percentage": 52.0, "count": "0", "additional_payer_notes": "Zero final payments for the item or service in the 15 months prior to posting the file." }, { "payer_name": "BLUE SHIELD OUT OF STATE", "plan_name": "STANFORD HEALTHCARE ALLIANCE PLAN", "methodology": "percent of total billed charges", "standard_charge_dollar": 393.58, "standard_charge_percentage": 48.59, "count": "0", "additional_payer_notes": "Zero final payments for the item or service in the 15 months prior to posting the file." }, { "payer_name": "BLUE SHIELD", "plan_name": "STANFORD HEALTHCARE ALLIANCE PLAN", "methodology": "percent of total billed charges", "standard_charge_dollar": 393.58, "standard_charge_percentage": 48.59, "count": "0", "additional_payer_notes": "Zero final payments for the item or service in the 15 months prior to posting the file." }, { "payer_name": "BLUE SHIELD", "plan_name": "STANFORD HEALTHCARE ALLIANCE PLAN", "methodology": "percent of total billed charges", "standard_charge_dollar": 393.58, "standard_charge_percentage": 48.59, "count": "0", "additional_payer_notes": "Zero final payments for the item or service in the 15 months prior to posting the file." }, { "payer_name": "CIGNA", "plan_name": "CIGNA COM ALT HMO PLAN", "methodology": "percent of total billed charges", "standard_charge_dollar": 341.82, "standard_charge_percentage": 42.2, "count": "0", "additional_payer_notes": "Zero final payments for the item or service in the 15 months prior to posting the file." }, { "payer_name": "CIGNA", "plan_name": "CIGNA COM ALT HMO PLAN", "methodology": "percent of total billed charges", "standard_charge_dollar": 341.82, "standard_charge_percentage": 42.2, "count": "0", "additional_payer_notes": "Zero final payments for the item or service in the 15 months prior to posting the file." }, { "payer_name": "HEALTH NET", "plan_name": "HEALTHNET HMO, PPO, POS, EPO, CANOPY HEALTHNET HMO, OTHER-IN-NETWORK PLANS", "methodology": "per diem", "standard_charge_dollar": 8000.0, "standard_charge_algorithm": "Expected reimbursement is the lesser of Per diem ($8,000) for the length of stay and 70% of billed.", "count": "0", "additional_payer_notes": "Zero final payments for the item or service in the 15 months prior to posting the file." }, { "payer_name": "HEALTH NET", "plan_name": "HEALTHNET HMO, PPO, POS, EPO, CANOPY HEALTHNET HMO, OTHER-IN-NETWORK PLANS", "methodology": "per diem", "standard_charge_dollar": 8000.0, "standard_charge_algorithm": "Expected reimbursement is the lesser of Per diem ($8,000) for the length of stay and 70% of billed.", "count": "0", "additional_payer_notes": "Zero final payments for the item or service in the 15 months prior to posting the file." }, { "payer_name": "UNITED HEALTHCARE", "plan_name": "SUTTER SELECT & SUTTER HEALTH PLAN HMO PLANS", "methodology": "per diem", "standard_charge_dollar": 28538.0, "standard_charge_algorithm": "Per diem ($28,538).", "count": "0", "additional_payer_notes": "Zero final payments for the item or service in the 15 months prior to posting the file." }, { "payer_name": "UNITED HEALTHCARE", "plan_name": "SUTTER SELECT & SUTTER HEALTH PLAN HMO PLANS", "methodology": "per diem", "standard_charge_dollar": 28538.0, "standard_charge_algorithm": "Per diem ($28,538).", "count": "0", "additional_payer_notes": "Zero final payments for the item or service in the 15 months prior to posting the file." }, { "payer_name": "SUTTER", "plan_name": "SUTTER SELECT & SUTTER HEALTH PLAN HMO PLANS", "methodology": "per diem", "standard_charge_dollar": 28538.0, "standard_charge_algorithm": "Per diem ($28,538).", "count": "0", "additional_payer_notes": "Zero final payments for the item or service in the 15 months prior to posting the file." }, { "payer_name": "UNITED HEALTHCARE", "plan_name": "SUTTER SELECT & SUTTER HEALTH PLAN HMO PLANS", "methodology": "per diem", "standard_charge_dollar": 28538.0, "standard_charge_algorithm": "Per diem ($28,538).", "count": "0", "additional_payer_notes": "Zero final payments for the item or service in the 15 months prior to posting the file." }, { "payer_name": "UMR", "plan_name": "SUTTER SELECT & SUTTER HEALTH PLAN HMO PLANS", "methodology": "per diem", "standard_charge_dollar": 28538.0, "standard_charge_algorithm": "Per diem ($28,538).", "count": "0", "additional_payer_notes": "Zero final payments for the item or service in the 15 months prior to posting the file." } ] } ] }, { "description": "HC Drill Bit Gp013", "code_information": [ { "code": "PX-2120061013", "type": "CDM" }, { "code": "99999", "type": "CPT" }, { "code": "0272", "type": "RC" } ], "standard_charges": [ { "setting": "outpatient", "gross_charge": 900.0, "discounted_cash": 450.0, "minimum": 379.8, "maximum": 468.0, "additional_generic_notes": "Zero final payments for the item or service in the 15 months prior to posting the file.", "payers_information": [ { "payer_name": "AETNA", "plan_name": "AETNA ALL OTHER PLANS", "methodology": "percent of total billed charges", "standard_charge_dollar": 468.0, "standard_charge_percentage": 52.0, "count": "0", "additional_payer_notes": "Zero final payments for the item or service in the 15 months prior to posting the file." }, { "payer_name": "AETNA", "plan_name": "AETNA ALL OTHER PLANS", "methodology": "percent of total billed charges", "standard_charge_dollar": 468.0, "standard_charge_percentage": 52.0, "count": "0", "additional_payer_notes": "Zero final payments for the item or service in the 15 months prior to posting the file." }, { "payer_name": "MERITAIN HEALTH", "plan_name": "AETNA ALL OTHER PLANS", "methodology": "percent of total billed charges", "standard_charge_dollar": 468.0, "standard_charge_percentage": 52.0, "count": "0", "additional_payer_notes": "Zero final payments for the item or service in the 15 months prior to posting the file." }, { "payer_name": "BLUE SHIELD OUT OF STATE", "plan_name": "STANFORD HEALTHCARE ALLIANCE PLAN", "methodology": "percent of total billed charges", "standard_charge_dollar": 437.31, "standard_charge_percentage": 48.59, "count": "0", "additional_payer_notes": "Zero final payments for the item or service in the 15 months prior to posting the file." }, { "payer_name": "BLUE SHIELD", "plan_name": "STANFORD HEALTHCARE ALLIANCE PLAN", "methodology": "percent of total billed charges", "standard_charge_dollar": 437.31, "standard_charge_percentage": 48.59, "count": "0", "additional_payer_notes": "Zero final payments for the item or service in the 15 months prior to posting the file." }, { "payer_name": "BLUE SHIELD", "plan_name": "STANFORD HEALTHCARE ALLIANCE PLAN", "methodology": "percent of total billed charges", "standard_charge_dollar": 437.31, "standard_charge_percentage": 48.59, "count": "0", "additional_payer_notes": "Zero final payments for the item or service in the 15 months prior to posting the file." }, { "payer_name": "CIGNA", "plan_name": "CIGNA COM ALT HMO PLAN", "methodology": "percent of total billed charges", "standard_charge_dollar": 379.8, "standard_charge_percentage": 42.2, "count": "0", "additional_payer_notes": "Zero final payments for the item or service in the 15 months prior to posting the file." }, { "payer_name": "CIGNA", "plan_name": "CIGNA COM ALT HMO PLAN", "methodology": "percent of total billed charges", "standard_charge_dollar": 379.8, "standard_charge_percentage": 42.2, "count": "0", "additional_payer_notes": "Zero final payments for the item or service in the 15 months prior to posting the file." }, { "payer_name": "HEALTH NET", "plan_name": "HEALTHNET HMO, PPO, POS, EPO, CANOPY HEALTHNET HMO, OTHER-IN-NETWORK PLANS", "methodology": "per diem", "standard_charge_dollar": 8000.0, "standard_charge_algorithm": "Expected reimbursement is the lesser of Per diem ($8,000) for the length of stay and 70% of billed.", "count": "0", "additional_payer_notes": "Zero final payments for the item or service in the 15 months prior to posting the file." }, { "payer_name": "HEALTH NET", "plan_name": "HEALTHNET HMO, PPO, POS, EPO, CANOPY HEALTHNET HMO, OTHER-IN-NETWORK PLANS", "methodology": "per diem", "standard_charge_dollar": 8000.0, "standard_charge_algorithm": "Expected reimbursement is the lesser of Per diem ($8,000) for the length of stay and 70% of billed.", "count": "0", "additional_payer_notes": "Zero final payments for the item or service in the 15 months prior to posting the file." }, { "payer_name": "UNITED HEALTHCARE", "plan_name": "SUTTER SELECT & SUTTER HEALTH PLAN HMO PLANS", "methodology": "per diem", "standard_charge_dollar": 28538.0, "standard_charge_algorithm": "Per diem ($28,538).", "count": "0", "additional_payer_notes": "Zero final payments for the item or service in the 15 months prior to posting the file." }, { "payer_name": "UNITED HEALTHCARE", "plan_name": "SUTTER SELECT & SUTTER HEALTH PLAN HMO PLANS", "methodology": "per diem", "standard_charge_dollar": 28538.0, "standard_charge_algorithm": "Per diem ($28,538).", "count": "0", "additional_payer_notes": "Zero final payments for the item or service in the 15 months prior to posting the file." }, { "payer_name": "SUTTER", "plan_name": "SUTTER SELECT & SUTTER HEALTH PLAN HMO PLANS", "methodology": "per diem", "standard_charge_dollar": 28538.0, "standard_charge_algorithm": "Per diem ($28,538).", "count": "0", "additional_payer_notes": "Zero final payments for the item or service in the 15 months prior to posting the file." }, { "payer_name": "UNITED HEALTHCARE", "plan_name": "SUTTER SELECT & SUTTER HEALTH PLAN HMO PLANS", "methodology": "per diem", "standard_charge_dollar": 28538.0, "standard_charge_algorithm": "Per diem ($28,538).", "count": "0", "additional_payer_notes": "Zero final payments for the item or service in the 15 months prior to posting the file." }, { "payer_name": "UMR", "plan_name": "SUTTER SELECT & SUTTER HEALTH PLAN HMO PLANS", "methodology": "per diem", "standard_charge_dollar": 28538.0, "standard_charge_algorithm": "Per diem ($28,538).", "count": "0", "additional_payer_notes": "Zero final payments for the item or service in the 15 months prior to posting the file." } ] } ] }, { "description": "HC Drill Bit Gp014", "code_information": [ { "code": "PX-2120061014", "type": "CDM" }, { "code": "99999", "type": "CPT" }, { "code": "0272", "type": "RC" } ], "standard_charges": [ { "setting": "outpatient", "gross_charge": 1080.0, "discounted_cash": 540.0, "minimum": 455.76, "maximum": 561.6, "additional_generic_notes": "Zero final payments for the item or service in the 15 months prior to posting the file.", "payers_information": [ { "payer_name": "AETNA", "plan_name": "AETNA ALL OTHER PLANS", "methodology": "percent of total billed charges", "standard_charge_dollar": 561.6, "standard_charge_percentage": 52.0, "count": "0", "additional_payer_notes": "Zero final payments for the item or service in the 15 months prior to posting the file." }, { "payer_name": "AETNA", "plan_name": "AETNA ALL OTHER PLANS", "methodology": "percent of total billed charges", "standard_charge_dollar": 561.6, "standard_charge_percentage": 52.0, "count": "0", "additional_payer_notes": "Zero final payments for the item or service in the 15 months prior to posting the file." }, { "payer_name": "MERITAIN HEALTH", "plan_name": "AETNA ALL OTHER PLANS", "methodology": "percent of total billed charges", "standard_charge_dollar": 561.6, "standard_charge_percentage": 52.0, "count": "0", "additional_payer_notes": "Zero final payments for the item or service in the 15 months prior to posting the file." }, { "payer_name": "BLUE SHIELD OUT OF STATE", "plan_name": "STANFORD HEALTHCARE ALLIANCE PLAN", "methodology": "percent of total billed charges", "standard_charge_dollar": 524.77, "standard_charge_percentage": 48.59, "count": "0", "additional_payer_notes": "Zero final payments for the item or service in the 15 months prior to posting the file." }, { "payer_name": "BLUE SHIELD", "plan_name": "STANFORD HEALTHCARE ALLIANCE PLAN", "methodology": "percent of total billed charges", "standard_charge_dollar": 524.77, "standard_charge_percentage": 48.59, "median_amount": 68.24, "10th_percentile": 13.6, "90th_percentile": 1043.06, "count": "30" }, { "payer_name": "BLUE SHIELD", "plan_name": "STANFORD HEALTHCARE ALLIANCE PLAN", "methodology": "percent of total billed charges", "standard_charge_dollar": 524.77, "standard_charge_percentage": 48.59, "count": "0", "additional_payer_notes": "Zero final payments for the item or service in the 15 months prior to posting the file." }, { "payer_name": "BLUE SHIELD", "plan_name": "STANFORD HEALTHCARE ALLIANCE PLAN", "methodology": "percent of total billed charges", "standard_charge_dollar": 524.77, "standard_charge_percentage": 48.59, "count": "0", "additional_payer_notes": "Zero final payments for the item or service in the 15 months prior to posting the file." }, { "payer_name": "CIGNA", "plan_name": "CIGNA COM ALT HMO PLAN", "methodology": "percent of total billed charges", "standard_charge_dollar": 455.76, "standard_charge_percentage": 42.2, "count": "0", "additional_payer_notes": "Zero final payments for the item or service in the 15 months prior to posting the file." }, { "payer_name": "CIGNA", "plan_name": "CIGNA COM ALT HMO PLAN", "methodology": "percent of total billed charges", "standard_charge_dollar": 455.76, "standard_charge_percentage": 42.2, "count": "0", "additional_payer_notes": "Zero final payments for the item or service in the 15 months prior to posting the file." }, { "payer_name": "HEALTH NET", "plan_name": "HEALTHNET HMO, PPO, POS, EPO, CANOPY HEALTHNET HMO, OTHER-IN-NETWORK PLANS", "methodology": "per diem", "standard_charge_dollar": 8000.0, "standard_charge_algorithm": "Expected reimbursement is the lesser of Per diem ($8,000) for the length of stay and 70% of billed.", "count": "0", "additional_payer_notes": "Zero final payments for the item or service in the 15 months prior to posting the file." }, { "payer_name": "HEALTH NET", "plan_name": "HEALTHNET HMO, PPO, POS, EPO, CANOPY HEALTHNET HMO, OTHER-IN-NETWORK PLANS", "methodology": "per diem", "standard_charge_dollar": 8000.0, "standard_charge_algorithm": "Expected reimbursement is the lesser of Per diem ($8,000) for the length of stay and 70% of billed.", "count": "0", "additional_payer_notes": "Zero final payments for the item or service in the 15 months prior to posting the file." }, { "payer_name": "UNITED HEALTHCARE", "plan_name": "SUTTER SELECT & SUTTER HEALTH PLAN HMO PLANS", "methodology": "per diem", "standard_charge_dollar": 28538.0, "standard_charge_algorithm": "Per diem ($28,538).", "count": "0", "additional_payer_notes": "Zero final payments for the item or service in the 15 months prior to posting the file." }, { "payer_name": "UNITED HEALTHCARE", "plan_name": "SUTTER SELECT & SUTTER HEALTH PLAN HMO PLANS", "methodology": "per diem", "standard_charge_dollar": 28538.0, "standard_charge_algorithm": "Per diem ($28,538).", "count": "0", "additional_payer_notes": "Zero final payments for the item or service in the 15 months prior to posting the file." }, { "payer_name": "SUTTER", "plan_name": "SUTTER SELECT & SUTTER HEALTH PLAN HMO PLANS", "methodology": "per diem", "standard_charge_dollar": 28538.0, "standard_charge_algorithm": "Per diem ($28,538).", "count": "0", "additional_payer_notes": "Zero final payments for the item or service in the 15 months prior to posting the file." }, { "payer_name": "UNITED HEALTHCARE", "plan_name": "SUTTER SELECT & SUTTER HEALTH PLAN HMO PLANS", "methodology": "per diem", "standard_charge_dollar": 28538.0, "standard_charge_algorithm": "Per diem ($28,538).", "count": "0", "additional_payer_notes": "Zero final payments for the item or service in the 15 months prior to posting the file." }, { "payer_name": "UMR", "plan_name": "SUTTER SELECT & SUTTER HEALTH PLAN HMO PLANS", "methodology": "per diem", "standard_charge_dollar": 28538.0, "standard_charge_algorithm": "Per diem ($28,538).", "count": "0", "additional_payer_notes": "Zero final payments for the item or service in the 15 months prior to posting the file." } ] } ] }, { "description": "HC Drill Bit Gp015", "code_information": [ { "code": "PX-2120061015", "type": "CDM" }, { "code": "99999", "type": "CPT" }, { "code": "0272", "type": "RC" } ], "standard_charges": [ { "setting": "outpatient", "gross_charge": 1225.0, "discounted_cash": 612.5, "minimum": 516.95, "maximum": 637.0, "additional_generic_notes": "Zero final payments for the item or service in the 15 months prior to posting the file.", "payers_information": [ { "payer_name": "AETNA", "plan_name": "AETNA ALL OTHER PLANS", "methodology": "percent of total billed charges", "standard_charge_dollar": 637.0, "standard_charge_percentage": 52.0, "count": "0", "additional_payer_notes": "Zero final payments for the item or service in the 15 months prior to posting the file." }, { "payer_name": "AETNA", "plan_name": "AETNA ALL OTHER PLANS", "methodology": "percent of total billed charges", "standard_charge_dollar": 637.0, "standard_charge_percentage": 52.0, "count": "0", "additional_payer_notes": "Zero final payments for the item or service in the 15 months prior to posting the file." }, { "payer_name": "MERITAIN HEALTH", "plan_name": "AETNA ALL OTHER PLANS", "methodology": "percent of total billed charges", "standard_charge_dollar": 637.0, "standard_charge_percentage": 52.0, "count": "0", "additional_payer_notes": "Zero final payments for the item or service in the 15 months prior to posting the file." }, { "payer_name": "BLUE SHIELD OUT OF STATE", "plan_name": "STANFORD HEALTHCARE ALLIANCE PLAN", "methodology": "percent of total billed charges", "standard_charge_dollar": 595.23, "standard_charge_percentage": 48.59, "count": "0", "additional_payer_notes": "Zero final payments for the item or service in the 15 months prior to posting the file." }, { "payer_name": "BLUE SHIELD", "plan_name": "STANFORD HEALTHCARE ALLIANCE PLAN", "methodology": "percent of total billed charges", "standard_charge_dollar": 595.23, "standard_charge_percentage": 48.59, "median_amount": 68.24, "10th_percentile": 13.6, "90th_percentile": 1043.06, "count": "30" }, { "payer_name": "BLUE SHIELD", "plan_name": "STANFORD HEALTHCARE ALLIANCE PLAN", "methodology": "percent of total billed charges", "standard_charge_dollar": 595.23, "standard_charge_percentage": 48.59, "count": "0", "additional_payer_notes": "Zero final payments for the item or service in the 15 months prior to posting the file." }, { "payer_name": "BLUE SHIELD", "plan_name": "STANFORD HEALTHCARE ALLIANCE PLAN", "methodology": "percent of total billed charges", "standard_charge_dollar": 595.23, "standard_charge_percentage": 48.59, "count": "0", "additional_payer_notes": "Zero final payments for the item or service in the 15 months prior to posting the file." }, { "payer_name": "CIGNA", "plan_name": "CIGNA COM ALT HMO PLAN", "methodology": "percent of total billed charges", "standard_charge_dollar": 516.95, "standard_charge_percentage": 42.2, "count": "0", "additional_payer_notes": "Zero final payments for the item or service in the 15 months prior to posting the file." }, { "payer_name": "CIGNA", "plan_name": "CIGNA COM ALT HMO PLAN", "methodology": "percent of total billed charges", "standard_charge_dollar": 516.95, "standard_charge_percentage": 42.2, "count": "0", "additional_payer_notes": "Zero final payments for the item or service in the 15 months prior to posting the file." }, { "payer_name": "HEALTH NET", "plan_name": "HEALTHNET HMO, PPO, POS, EPO, CANOPY HEALTHNET HMO, OTHER-IN-NETWORK PLANS", "methodology": "per diem", "standard_charge_dollar": 8000.0, "standard_charge_algorithm": "Expected reimbursement is the lesser of Per diem ($8,000) for the length of stay and 70% of billed.", "count": "0", "additional_payer_notes": "Zero final payments for the item or service in the 15 months prior to posting the file." }, { "payer_name": "HEALTH NET", "plan_name": "HEALTHNET HMO, PPO, POS, EPO, CANOPY HEALTHNET HMO, OTHER-IN-NETWORK PLANS", "methodology": "per diem", "standard_charge_dollar": 8000.0, "standard_charge_algorithm": "Expected reimbursement is the lesser of Per diem ($8,000) for the length of stay and 70% of billed.", "count": "0", "additional_payer_notes": "Zero final payments for the item or service in the 15 months prior to posting the file." }, { "payer_name": "UNITED HEALTHCARE", "plan_name": "SUTTER SELECT & SUTTER HEALTH PLAN HMO PLANS", "methodology": "per diem", "standard_charge_dollar": 28538.0, "standard_charge_algorithm": "Per diem ($28,538).", "count": "0", "additional_payer_notes": "Zero final payments for the item or service in the 15 months prior to posting the file." }, { "payer_name": "UNITED HEALTHCARE", "plan_name": "SUTTER SELECT & SUTTER HEALTH PLAN HMO PLANS", "methodology": "per diem", "standard_charge_dollar": 28538.0, "standard_charge_algorithm": "Per diem ($28,538).", "count": "0", "additional_payer_notes": "Zero final payments for the item or service in the 15 months prior to posting the file." }, { "payer_name": "SUTTER", "plan_name": "SUTTER SELECT & SUTTER HEALTH PLAN HMO PLANS", "methodology": "per diem", "standard_charge_dollar": 28538.0, "standard_charge_algorithm": "Per diem ($28,538).", "count": "0", "additional_payer_notes": "Zero final payments for the item or service in the 15 months prior to posting the file." }, { "payer_name": "UNITED HEALTHCARE", "plan_name": "SUTTER SELECT & SUTTER HEALTH PLAN HMO PLANS", "methodology": "per diem", "standard_charge_dollar": 28538.0, "standard_charge_algorithm": "Per diem ($28,538).", "count": "0", "additional_payer_notes": "Zero final payments for the item or service in the 15 months prior to posting the file." }, { "payer_name": "UMR", "plan_name": "SUTTER SELECT & SUTTER HEALTH PLAN HMO PLANS", "methodology": "per diem", "standard_charge_dollar": 28538.0, "standard_charge_algorithm": "Per diem ($28,538).", "count": "0", "additional_payer_notes": "Zero final payments for the item or service in the 15 months prior to posting the file." } ] } ] }, { "description": "HC Drill Bit Gp016", "code_information": [ { "code": "PX-2120061016", "type": "CDM" }, { "code": "99999", "type": "CPT" }, { "code": "0272", "type": "RC" } ], "standard_charges": [ { "setting": "outpatient", "gross_charge": 1400.0, "discounted_cash": 700.0, "minimum": 590.8, "maximum": 728.0, "additional_generic_notes": "Zero final payments for the item or service in the 15 months prior to posting the file.", "payers_information": [ { "payer_name": "AETNA", "plan_name": "AETNA ALL OTHER PLANS", "methodology": "percent of total billed charges", "standard_charge_dollar": 728.0, "standard_charge_percentage": 52.0, "count": "0", "additional_payer_notes": "Zero final payments for the item or service in the 15 months prior to posting the file." }, { "payer_name": "AETNA", "plan_name": "AETNA ALL OTHER PLANS", "methodology": "percent of total billed charges", "standard_charge_dollar": 728.0, "standard_charge_percentage": 52.0, "count": "0", "additional_payer_notes": "Zero final payments for the item or service in the 15 months prior to posting the file." }, { "payer_name": "MERITAIN HEALTH", "plan_name": "AETNA ALL OTHER PLANS", "methodology": "percent of total billed charges", "standard_charge_dollar": 728.0, "standard_charge_percentage": 52.0, "count": "0", "additional_payer_notes": "Zero final payments for the item or service in the 15 months prior to posting the file." }, { "payer_name": "BLUE SHIELD OUT OF STATE", "plan_name": "STANFORD HEALTHCARE ALLIANCE PLAN", "methodology": "percent of total billed charges", "standard_charge_dollar": 680.26, "standard_charge_percentage": 48.59, "count": "0", "additional_payer_notes": "Zero final payments for the item or service in the 15 months prior to posting the file." }, { "payer_name": "BLUE SHIELD", "plan_name": "STANFORD HEALTHCARE ALLIANCE PLAN", "methodology": "percent of total billed charges", "standard_charge_dollar": 680.26, "standard_charge_percentage": 48.59, "median_amount": 68.24, "10th_percentile": 13.6, "90th_percentile": 1043.06, "count": "30" }, { "payer_name": "BLUE SHIELD", "plan_name": "STANFORD HEALTHCARE ALLIANCE PLAN", "methodology": "percent of total billed charges", "standard_charge_dollar": 680.26, "standard_charge_percentage": 48.59, "count": "0", "additional_payer_notes": "Zero final payments for the item or service in the 15 months prior to posting the file." }, { "payer_name": "BLUE SHIELD", "plan_name": "STANFORD HEALTHCARE ALLIANCE PLAN", "methodology": "percent of total billed charges", "standard_charge_dollar": 680.26, "standard_charge_percentage": 48.59, "count": "0", "additional_payer_notes": "Zero final payments for the item or service in the 15 months prior to posting the file." }, { "payer_name": "CIGNA", "plan_name": "CIGNA COM ALT HMO PLAN", "methodology": "percent of total billed charges", "standard_charge_dollar": 590.8, "standard_charge_percentage": 42.2, "count": "0", "additional_payer_notes": "Zero final payments for the item or service in the 15 months prior to posting the file." }, { "payer_name": "CIGNA", "plan_name": "CIGNA COM ALT HMO PLAN", "methodology": "percent of total billed charges", "standard_charge_dollar": 590.8, "standard_charge_percentage": 42.2, "count": "0", "additional_payer_notes": "Zero final payments for the item or service in the 15 months prior to posting the file." }, { "payer_name": "HEALTH NET", "plan_name": "HEALTHNET HMO, PPO, POS, EPO, CANOPY HEALTHNET HMO, OTHER-IN-NETWORK PLANS", "methodology": "per diem", "standard_charge_dollar": 8000.0, "standard_charge_algorithm": "Expected reimbursement is the lesser of Per diem ($8,000) for the length of stay and 70% of billed.", "count": "0", "additional_payer_notes": "Zero final payments for the item or service in the 15 months prior to posting the file." }, { "payer_name": "HEALTH NET", "plan_name": "HEALTHNET HMO, PPO, POS, EPO, CANOPY HEALTHNET HMO, OTHER-IN-NETWORK PLANS", "methodology": "per diem", "standard_charge_dollar": 8000.0, "standard_charge_algorithm": "Expected reimbursement is the lesser of Per diem ($8,000) for the length of stay and 70% of billed.", "count": "0", "additional_payer_notes": "Zero final payments for the item or service in the 15 months prior to posting the file." }, { "payer_name": "UNITED HEALTHCARE", "plan_name": "SUTTER SELECT & SUTTER HEALTH PLAN HMO PLANS", "methodology": "per diem", "standard_charge_dollar": 28538.0, "standard_charge_algorithm": "Per diem ($28,538).", "count": "0", "additional_payer_notes": "Zero final payments for the item or service in the 15 months prior to posting the file." }, { "payer_name": "UNITED HEALTHCARE", "plan_name": "SUTTER SELECT & SUTTER HEALTH PLAN HMO PLANS", "methodology": "per diem", "standard_charge_dollar": 28538.0, "standard_charge_algorithm": "Per diem ($28,538).", "count": "0", "additional_payer_notes": "Zero final payments for the item or service in the 15 months prior to posting the file." }, { "payer_name": "SUTTER", "plan_name": "SUTTER SELECT & SUTTER HEALTH PLAN HMO PLANS", "methodology": "per diem", "standard_charge_dollar": 28538.0, "standard_charge_algorithm": "Per diem ($28,538).", "count": "0", "additional_payer_notes": "Zero final payments for the item or service in the 15 months prior to posting the file." }, { "payer_name": "UNITED HEALTHCARE", "plan_name": "SUTTER SELECT & SUTTER HEALTH PLAN HMO PLANS", "methodology": "per diem", "standard_charge_dollar": 28538.0, "standard_charge_algorithm": "Per diem ($28,538).", "count": "0", "additional_payer_notes": "Zero final payments for the item or service in the 15 months prior to posting the file." }, { "payer_name": "UMR", "plan_name": "SUTTER SELECT & SUTTER HEALTH PLAN HMO PLANS", "methodology": "per diem", "standard_charge_dollar": 28538.0, "standard_charge_algorithm": "Per diem ($28,538).", "count": "0", "additional_payer_notes": "Zero final payments for the item or service in the 15 months prior to posting the file." } ] } ] }, { "description": "HC Drill Bit Gp017", "code_information": [ { "code": "PX-2120061017", "type": "CDM" }, { "code": "99999", "type": "CPT" }, { "code": "0272", "type": "RC" } ], "standard_charges": [ { "setting": "outpatient", "gross_charge": 1575.0, "discounted_cash": 787.5, "minimum": 664.65, "maximum": 819.0, "additional_generic_notes": "Zero final payments for the item or service in the 15 months prior to posting the file.", "payers_information": [ { "payer_name": "AETNA", "plan_name": "AETNA ALL OTHER PLANS", "methodology": "percent of total billed charges", "standard_charge_dollar": 819.0, "standard_charge_percentage": 52.0, "count": "0", "additional_payer_notes": "Zero final payments for the item or service in the 15 months prior to posting the file." }, { "payer_name": "AETNA", "plan_name": "AETNA ALL OTHER PLANS", "methodology": "percent of total billed charges", "standard_charge_dollar": 819.0, "standard_charge_percentage": 52.0, "count": "0", "additional_payer_notes": "Zero final payments for the item or service in the 15 months prior to posting the file." }, { "payer_name": "MERITAIN HEALTH", "plan_name": "AETNA ALL OTHER PLANS", "methodology": "percent of total billed charges", "standard_charge_dollar": 819.0, "standard_charge_percentage": 52.0, "count": "0", "additional_payer_notes": "Zero final payments for the item or service in the 15 months prior to posting the file." }, { "payer_name": "BLUE SHIELD OUT OF STATE", "plan_name": "STANFORD HEALTHCARE ALLIANCE PLAN", "methodology": "percent of total billed charges", "standard_charge_dollar": 765.29, "standard_charge_percentage": 48.59, "count": "0", "additional_payer_notes": "Zero final payments for the item or service in the 15 months prior to posting the file." }, { "payer_name": "BLUE SHIELD", "plan_name": "STANFORD HEALTHCARE ALLIANCE PLAN", "methodology": "percent of total billed charges", "standard_charge_dollar": 765.29, "standard_charge_percentage": 48.59, "median_amount": 68.24, "10th_percentile": 13.6, "90th_percentile": 1043.06, "count": "30" }, { "payer_name": "BLUE SHIELD", "plan_name": "STANFORD HEALTHCARE ALLIANCE PLAN", "methodology": "percent of total billed charges", "standard_charge_dollar": 765.29, "standard_charge_percentage": 48.59, "count": "0", "additional_payer_notes": "Zero final payments for the item or service in the 15 months prior to posting the file." }, { "payer_name": "BLUE SHIELD", "plan_name": "STANFORD HEALTHCARE ALLIANCE PLAN", "methodology": "percent of total billed charges", "standard_charge_dollar": 765.29, "standard_charge_percentage": 48.59, "count": "0", "additional_payer_notes": "Zero final payments for the item or service in the 15 months prior to posting the file." }, { "payer_name": "CIGNA", "plan_name": "CIGNA COM ALT HMO PLAN", "methodology": "percent of total billed charges", "standard_charge_dollar": 664.65, "standard_charge_percentage": 42.2, "count": "0", "additional_payer_notes": "Zero final payments for the item or service in the 15 months prior to posting the file." }, { "payer_name": "CIGNA", "plan_name": "CIGNA COM ALT HMO PLAN", "methodology": "percent of total billed charges", "standard_charge_dollar": 664.65, "standard_charge_percentage": 42.2, "count": "0", "additional_payer_notes": "Zero final payments for the item or service in the 15 months prior to posting the file." }, { "payer_name": "HEALTH NET", "plan_name": "HEALTHNET HMO, PPO, POS, EPO, CANOPY HEALTHNET HMO, OTHER-IN-NETWORK PLANS", "methodology": "per diem", "standard_charge_dollar": 8000.0, "standard_charge_algorithm": "Expected reimbursement is the lesser of Per diem ($8,000) for the length of stay and 70% of billed.", "count": "0", "additional_payer_notes": "Zero final payments for the item or service in the 15 months prior to posting the file." }, { "payer_name": "HEALTH NET", "plan_name": "HEALTHNET HMO, PPO, POS, EPO, CANOPY HEALTHNET HMO, OTHER-IN-NETWORK PLANS", "methodology": "per diem", "standard_charge_dollar": 8000.0, "standard_charge_algorithm": "Expected reimbursement is the lesser of Per diem ($8,000) for the length of stay and 70% of billed.", "count": "0", "additional_payer_notes": "Zero final payments for the item or service in the 15 months prior to posting the file." }, { "payer_name": "UNITED HEALTHCARE", "plan_name": "SUTTER SELECT & SUTTER HEALTH PLAN HMO PLANS", "methodology": "per diem", "standard_charge_dollar": 28538.0, "standard_charge_algorithm": "Per diem ($28,538).", "count": "0", "additional_payer_notes": "Zero final payments for the item or service in the 15 months prior to posting the file." }, { "payer_name": "UNITED HEALTHCARE", "plan_name": "SUTTER SELECT & SUTTER HEALTH PLAN HMO PLANS", "methodology": "per diem", "standard_charge_dollar": 28538.0, "standard_charge_algorithm": "Per diem ($28,538).", "count": "0", "additional_payer_notes": "Zero final payments for the item or service in the 15 months prior to posting the file." }, { "payer_name": "SUTTER", "plan_name": "SUTTER SELECT & SUTTER HEALTH PLAN HMO PLANS", "methodology": "per diem", "standard_charge_dollar": 28538.0, "standard_charge_algorithm": "Per diem ($28,538).", "count": "0", "additional_payer_notes": "Zero final payments for the item or service in the 15 months prior to posting the file." }, { "payer_name": "UNITED HEALTHCARE", "plan_name": "SUTTER SELECT & SUTTER HEALTH PLAN HMO PLANS", "methodology": "per diem", "standard_charge_dollar": 28538.0, "standard_charge_algorithm": "Per diem ($28,538).", "count": "0", "additional_payer_notes": "Zero final payments for the item or service in the 15 months prior to posting the file." }, { "payer_name": "UMR", "plan_name": "SUTTER SELECT & SUTTER HEALTH PLAN HMO PLANS", "methodology": "per diem", "standard_charge_dollar": 28538.0, "standard_charge_algorithm": "Per diem ($28,538).", "count": "0", "additional_payer_notes": "Zero final payments for the item or service in the 15 months prior to posting the file." } ] } ] }, { "description": "HC Drill Bit Gp018", "code_information": [ { "code": "PX-2120061018", "type": "CDM" }, { "code": "99999", "type": "CPT" }, { "code": "0272", "type": "RC" } ], "standard_charges": [ { "setting": "outpatient", "gross_charge": 1750.0, "discounted_cash": 875.0, "minimum": 738.5, "maximum": 910.0, "additional_generic_notes": "Zero final payments for the item or service in the 15 months prior to posting the file.", "payers_information": [ { "payer_name": "AETNA", "plan_name": "AETNA ALL OTHER PLANS", "methodology": "percent of total billed charges", "standard_charge_dollar": 910.0, "standard_charge_percentage": 52.0, "count": "0", "additional_payer_notes": "Zero final payments for the item or service in the 15 months prior to posting the file." }, { "payer_name": "AETNA", "plan_name": "AETNA ALL OTHER PLANS", "methodology": "percent of total billed charges", "standard_charge_dollar": 910.0, "standard_charge_percentage": 52.0, "count": "0", "additional_payer_notes": "Zero final payments for the item or service in the 15 months prior to posting the file." }, { "payer_name": "MERITAIN HEALTH", "plan_name": "AETNA ALL OTHER PLANS", "methodology": "percent of total billed charges", "standard_charge_dollar": 910.0, "standard_charge_percentage": 52.0, "count": "0", "additional_payer_notes": "Zero final payments for the item or service in the 15 months prior to posting the file." }, { "payer_name": "BLUE SHIELD OUT OF STATE", "plan_name": "STANFORD HEALTHCARE ALLIANCE PLAN", "methodology": "percent of total billed charges", "standard_charge_dollar": 850.33, "standard_charge_percentage": 48.59, "count": "0", "additional_payer_notes": "Zero final payments for the item or service in the 15 months prior to posting the file." }, { "payer_name": "BLUE SHIELD", "plan_name": "STANFORD HEALTHCARE ALLIANCE PLAN", "methodology": "percent of total billed charges", "standard_charge_dollar": 850.33, "standard_charge_percentage": 48.59, "median_amount": 68.24, "10th_percentile": 13.6, "90th_percentile": 1043.06, "count": "30" }, { "payer_name": "BLUE SHIELD", "plan_name": "STANFORD HEALTHCARE ALLIANCE PLAN", "methodology": "percent of total billed charges", "standard_charge_dollar": 850.33, "standard_charge_percentage": 48.59, "count": "0", "additional_payer_notes": "Zero final payments for the item or service in the 15 months prior to posting the file." }, { "payer_name": "BLUE SHIELD", "plan_name": "STANFORD HEALTHCARE ALLIANCE PLAN", "methodology": "percent of total billed charges", "standard_charge_dollar": 850.33, "standard_charge_percentage": 48.59, "count": "0", "additional_payer_notes": "Zero final payments for the item or service in the 15 months prior to posting the file." }, { "payer_name": "CIGNA", "plan_name": "CIGNA COM ALT HMO PLAN", "methodology": "percent of total billed charges", "standard_charge_dollar": 738.5, "standard_charge_percentage": 42.2, "count": "0", "additional_payer_notes": "Zero final payments for the item or service in the 15 months prior to posting the file." }, { "payer_name": "CIGNA", "plan_name": "CIGNA COM ALT HMO PLAN", "methodology": "percent of total billed charges", "standard_charge_dollar": 738.5, "standard_charge_percentage": 42.2, "count": "0", "additional_payer_notes": "Zero final payments for the item or service in the 15 months prior to posting the file." }, { "payer_name": "HEALTH NET", "plan_name": "HEALTHNET HMO, PPO, POS, EPO, CANOPY HEALTHNET HMO, OTHER-IN-NETWORK PLANS", "methodology": "per diem", "standard_charge_dollar": 8000.0, "standard_charge_algorithm": "Expected reimbursement is the lesser of Per diem ($8,000) for the length of stay and 70% of billed.", "count": "0", "additional_payer_notes": "Zero final payments for the item or service in the 15 months prior to posting the file." }, { "payer_name": "HEALTH NET", "plan_name": "HEALTHNET HMO, PPO, POS, EPO, CANOPY HEALTHNET HMO, OTHER-IN-NETWORK PLANS", "methodology": "per diem", "standard_charge_dollar": 8000.0, "standard_charge_algorithm": "Expected reimbursement is the lesser of Per diem ($8,000) for the length of stay and 70% of billed.", "count": "0", "additional_payer_notes": "Zero final payments for the item or service in the 15 months prior to posting the file." }, { "payer_name": "UNITED HEALTHCARE", "plan_name": "SUTTER SELECT & SUTTER HEALTH PLAN HMO PLANS", "methodology": "per diem", "standard_charge_dollar": 28538.0, "standard_charge_algorithm": "Per diem ($28,538).", "count": "0", "additional_payer_notes": "Zero final payments for the item or service in the 15 months prior to posting the file." }, { "payer_name": "UNITED HEALTHCARE", "plan_name": "SUTTER SELECT & SUTTER HEALTH PLAN HMO PLANS", "methodology": "per diem", "standard_charge_dollar": 28538.0, "standard_charge_algorithm": "Per diem ($28,538).", "count": "0", "additional_payer_notes": "Zero final payments for the item or service in the 15 months prior to posting the file." }, { "payer_name": "SUTTER", "plan_name": "SUTTER SELECT & SUTTER HEALTH PLAN HMO PLANS", "methodology": "per diem", "standard_charge_dollar": 28538.0, "standard_charge_algorithm": "Per diem ($28,538).", "count": "0", "additional_payer_notes": "Zero final payments for the item or service in the 15 months prior to posting the file." }, { "payer_name": "UNITED HEALTHCARE", "plan_name": "SUTTER SELECT & SUTTER HEALTH PLAN HMO PLANS", "methodology": "per diem", "standard_charge_dollar": 28538.0, "standard_charge_algorithm": "Per diem ($28,538).", "count": "0", "additional_payer_notes": "Zero final payments for the item or service in the 15 months prior to posting the file." }, { "payer_name": "UMR", "plan_name": "SUTTER SELECT & SUTTER HEALTH PLAN HMO PLANS", "methodology": "per diem", "standard_charge_dollar": 28538.0, "standard_charge_algorithm": "Per diem ($28,538).", "count": "0", "additional_payer_notes": "Zero final payments for the item or service in the 15 months prior to posting the file." } ] } ] }, { "description": "HC Drill Bit Gp019", "code_information": [ { "code": "PX-2120061019", "type": "CDM" }, { "code": "99999", "type": "CPT" }, { "code": "0272", "type": "RC" } ], "standard_charges": [ { "setting": "outpatient", "gross_charge": 2125.0, "discounted_cash": 1062.5, "minimum": 896.75, "maximum": 1105.0, "additional_generic_notes": "Zero final payments for the item or service in the 15 months prior to posting the file.", "payers_information": [ { "payer_name": "AETNA", "plan_name": "AETNA ALL OTHER PLANS", "methodology": "percent of total billed charges", "standard_charge_dollar": 1105.0, "standard_charge_percentage": 52.0, "count": "0", "additional_payer_notes": "Zero final payments for the item or service in the 15 months prior to posting the file." }, { "payer_name": "AETNA", "plan_name": "AETNA ALL OTHER PLANS", "methodology": "percent of total billed charges", "standard_charge_dollar": 1105.0, "standard_charge_percentage": 52.0, "count": "0", "additional_payer_notes": "Zero final payments for the item or service in the 15 months prior to posting the file." }, { "payer_name": "MERITAIN HEALTH", "plan_name": "AETNA ALL OTHER PLANS", "methodology": "percent of total billed charges", "standard_charge_dollar": 1105.0, "standard_charge_percentage": 52.0, "count": "0", "additional_payer_notes": "Zero final payments for the item or service in the 15 months prior to posting the file." }, { "payer_name": "BLUE SHIELD OUT OF STATE", "plan_name": "STANFORD HEALTHCARE ALLIANCE PLAN", "methodology": "percent of total billed charges", "standard_charge_dollar": 1032.54, "standard_charge_percentage": 48.59, "count": "0", "additional_payer_notes": "Zero final payments for the item or service in the 15 months prior to posting the file." }, { "payer_name": "BLUE SHIELD", "plan_name": "STANFORD HEALTHCARE ALLIANCE PLAN", "methodology": "percent of total billed charges", "standard_charge_dollar": 1032.54, "standard_charge_percentage": 48.59, "median_amount": 68.24, "10th_percentile": 13.6, "90th_percentile": 1043.06, "count": "30" }, { "payer_name": "BLUE SHIELD", "plan_name": "STANFORD HEALTHCARE ALLIANCE PLAN", "methodology": "percent of total billed charges", "standard_charge_dollar": 1032.54, "standard_charge_percentage": 48.59, "count": "0", "additional_payer_notes": "Zero final payments for the item or service in the 15 months prior to posting the file." }, { "payer_name": "BLUE SHIELD", "plan_name": "STANFORD HEALTHCARE ALLIANCE PLAN", "methodology": "percent of total billed charges", "standard_charge_dollar": 1032.54, "standard_charge_percentage": 48.59, "count": "0", "additional_payer_notes": "Zero final payments for the item or service in the 15 months prior to posting the file." }, { "payer_name": "CIGNA", "plan_name": "CIGNA COM ALT HMO PLAN", "methodology": "percent of total billed charges", "standard_charge_dollar": 896.75, "standard_charge_percentage": 42.2, "count": "0", "additional_payer_notes": "Zero final payments for the item or service in the 15 months prior to posting the file." }, { "payer_name": "CIGNA", "plan_name": "CIGNA COM ALT HMO PLAN", "methodology": "percent of total billed charges", "standard_charge_dollar": 896.75, "standard_charge_percentage": 42.2, "count": "0", "additional_payer_notes": "Zero final payments for the item or service in the 15 months prior to posting the file." }, { "payer_name": "HEALTH NET", "plan_name": "HEALTHNET HMO, PPO, POS, EPO, CANOPY HEALTHNET HMO, OTHER-IN-NETWORK PLANS", "methodology": "per diem", "standard_charge_dollar": 8000.0, "standard_charge_algorithm": "Expected reimbursement is the lesser of Per diem ($8,000) for the length of stay and 70% of billed.", "count": "0", "additional_payer_notes": "Zero final payments for the item or service in the 15 months prior to posting the file." }, { "payer_name": "HEALTH NET", "plan_name": "HEALTHNET HMO, PPO, POS, EPO, CANOPY HEALTHNET HMO, OTHER-IN-NETWORK PLANS", "methodology": "per diem", "standard_charge_dollar": 8000.0, "standard_charge_algorithm": "Expected reimbursement is the lesser of Per diem ($8,000) for the length of stay and 70% of billed.", "count": "0", "additional_payer_notes": "Zero final payments for the item or service in the 15 months prior to posting the file." }, { "payer_name": "UNITED HEALTHCARE", "plan_name": "SUTTER SELECT & SUTTER HEALTH PLAN HMO PLANS", "methodology": "per diem", "standard_charge_dollar": 28538.0, "standard_charge_algorithm": "Per diem ($28,538).", "count": "0", "additional_payer_notes": "Zero final payments for the item or service in the 15 months prior to posting the file." }, { "payer_name": "UNITED HEALTHCARE", "plan_name": "SUTTER SELECT & SUTTER HEALTH PLAN HMO PLANS", "methodology": "per diem", "standard_charge_dollar": 28538.0, "standard_charge_algorithm": "Per diem ($28,538).", "count": "0", "additional_payer_notes": "Zero final payments for the item or service in the 15 months prior to posting the file." }, { "payer_name": "SUTTER", "plan_name": "SUTTER SELECT & SUTTER HEALTH PLAN HMO PLANS", "methodology": "per diem", "standard_charge_dollar": 28538.0, "standard_charge_algorithm": "Per diem ($28,538).", "count": "0", "additional_payer_notes": "Zero final payments for the item or service in the 15 months prior to posting the file." }, { "payer_name": "UNITED HEALTHCARE", "plan_name": "SUTTER SELECT & SUTTER HEALTH PLAN HMO PLANS", "methodology": "per diem", "standard_charge_dollar": 28538.0, "standard_charge_algorithm": "Per diem ($28,538).", "count": "0", "additional_payer_notes": "Zero final payments for the item or service in the 15 months prior to posting the file." }, { "payer_name": "UMR", "plan_name": "SUTTER SELECT & SUTTER HEALTH PLAN HMO PLANS", "methodology": "per diem", "standard_charge_dollar": 28538.0, "standard_charge_algorithm": "Per diem ($28,538).", "count": "0", "additional_payer_notes": "Zero final payments for the item or service in the 15 months prior to posting the file." } ] } ] }, { "description": "HC Drill Bit Gp020", "code_information": [ { "code": "PX-2120061020", "type": "CDM" }, { "code": "99999", "type": "CPT" }, { "code": "0272", "type": "RC" } ], "standard_charges": [ { "setting": "outpatient", "gross_charge": 2550.0, "discounted_cash": 1275.0, "minimum": 1076.1, "maximum": 1326.0, "additional_generic_notes": "Zero final payments for the item or service in the 15 months prior to posting the file.", "payers_information": [ { "payer_name": "AETNA", "plan_name": "AETNA ALL OTHER PLANS", "methodology": "percent of total billed charges", "standard_charge_dollar": 1326.0, "standard_charge_percentage": 52.0, "count": "0", "additional_payer_notes": "Zero final payments for the item or service in the 15 months prior to posting the file." }, { "payer_name": "AETNA", "plan_name": "AETNA ALL OTHER PLANS", "methodology": "percent of total billed charges", "standard_charge_dollar": 1326.0, "standard_charge_percentage": 52.0, "count": "0", "additional_payer_notes": "Zero final payments for the item or service in the 15 months prior to posting the file." }, { "payer_name": "MERITAIN HEALTH", "plan_name": "AETNA ALL OTHER PLANS", "methodology": "percent of total billed charges", "standard_charge_dollar": 1326.0, "standard_charge_percentage": 52.0, "count": "0", "additional_payer_notes": "Zero final payments for the item or service in the 15 months prior to posting the file." }, { "payer_name": "BLUE SHIELD OUT OF STATE", "plan_name": "STANFORD HEALTHCARE ALLIANCE PLAN", "methodology": "percent of total billed charges", "standard_charge_dollar": 1239.05, "standard_charge_percentage": 48.59, "count": "0", "additional_payer_notes": "Zero final payments for the item or service in the 15 months prior to posting the file." }, { "payer_name": "BLUE SHIELD", "plan_name": "STANFORD HEALTHCARE ALLIANCE PLAN", "methodology": "percent of total billed charges", "standard_charge_dollar": 1239.05, "standard_charge_percentage": 48.59, "median_amount": 68.24, "10th_percentile": 13.6, "90th_percentile": 1043.06, "count": "30" }, { "payer_name": "BLUE SHIELD", "plan_name": "STANFORD HEALTHCARE ALLIANCE PLAN", "methodology": "percent of total billed charges", "standard_charge_dollar": 1239.05, "standard_charge_percentage": 48.59, "count": "0", "additional_payer_notes": "Zero final payments for the item or service in the 15 months prior to posting the file." }, { "payer_name": "BLUE SHIELD", "plan_name": "STANFORD HEALTHCARE ALLIANCE PLAN", "methodology": "percent of total billed charges", "standard_charge_dollar": 1239.05, "standard_charge_percentage": 48.59, "count": "0", "additional_payer_notes": "Zero final payments for the item or service in the 15 months prior to posting the file." }, { "payer_name": "CIGNA", "plan_name": "CIGNA COM ALT HMO PLAN", "methodology": "percent of total billed charges", "standard_charge_dollar": 1076.1, "standard_charge_percentage": 42.2, "count": "0", "additional_payer_notes": "Zero final payments for the item or service in the 15 months prior to posting the file." }, { "payer_name": "CIGNA", "plan_name": "CIGNA COM ALT HMO PLAN", "methodology": "percent of total billed charges", "standard_charge_dollar": 1076.1, "standard_charge_percentage": 42.2, "count": "0", "additional_payer_notes": "Zero final payments for the item or service in the 15 months prior to posting the file." }, { "payer_name": "HEALTH NET", "plan_name": "HEALTHNET HMO, PPO, POS, EPO, CANOPY HEALTHNET HMO, OTHER-IN-NETWORK PLANS", "methodology": "per diem", "standard_charge_dollar": 8000.0, "standard_charge_algorithm": "Expected reimbursement is the lesser of Per diem ($8,000) for the length of stay and 70% of billed.", "count": "0", "additional_payer_notes": "Zero final payments for the item or service in the 15 months prior to posting the file." }, { "payer_name": "HEALTH NET", "plan_name": "HEALTHNET HMO, PPO, POS, EPO, CANOPY HEALTHNET HMO, OTHER-IN-NETWORK PLANS", "methodology": "per diem", "standard_charge_dollar": 8000.0, "standard_charge_algorithm": "Expected reimbursement is the lesser of Per diem ($8,000) for the length of stay and 70% of billed.", "count": "0", "additional_payer_notes": "Zero final payments for the item or service in the 15 months prior to posting the file." }, { "payer_name": "UNITED HEALTHCARE", "plan_name": "SUTTER SELECT & SUTTER HEALTH PLAN HMO PLANS", "methodology": "per diem", "standard_charge_dollar": 28538.0, "standard_charge_algorithm": "Per diem ($28,538).", "count": "0", "additional_payer_notes": "Zero final payments for the item or service in the 15 months prior to posting the file." }, { "payer_name": "UNITED HEALTHCARE", "plan_name": "SUTTER SELECT & SUTTER HEALTH PLAN HMO PLANS", "methodology": "per diem", "standard_charge_dollar": 28538.0, "standard_charge_algorithm": "Per diem ($28,538).", "count": "0", "additional_payer_notes": "Zero final payments for the item or service in the 15 months prior to posting the file." }, { "payer_name": "SUTTER", "plan_name": "SUTTER SELECT & SUTTER HEALTH PLAN HMO PLANS", "methodology": "per diem", "standard_charge_dollar": 28538.0, "standard_charge_algorithm": "Per diem ($28,538).", "count": "0", "additional_payer_notes": "Zero final payments for the item or service in the 15 months prior to posting the file." }, { "payer_name": "UNITED HEALTHCARE", "plan_name": "SUTTER SELECT & SUTTER HEALTH PLAN HMO PLANS", "methodology": "per diem", "standard_charge_dollar": 28538.0, "standard_charge_algorithm": "Per diem ($28,538).", "count": "0", "additional_payer_notes": "Zero final payments for the item or service in the 15 months prior to posting the file." }, { "payer_name": "UMR", "plan_name": "SUTTER SELECT & SUTTER HEALTH PLAN HMO PLANS", "methodology": "per diem", "standard_charge_dollar": 28538.0, "standard_charge_algorithm": "Per diem ($28,538).", "count": "0", "additional_payer_notes": "Zero final payments for the item or service in the 15 months prior to posting the file." } ] } ] }, { "description": "HC Drill Bit Gp021", "code_information": [ { "code": "PX-2120061021", "type": "CDM" }, { "code": "99999", "type": "CPT" }, { "code": "0272", "type": "RC" } ], "standard_charges": [ { "setting": "outpatient", "gross_charge": 2888.0, "discounted_cash": 1444.0, "minimum": 1218.74, "maximum": 1501.76, "additional_generic_notes": "Zero final payments for the item or service in the 15 months prior to posting the file.", "payers_information": [ { "payer_name": "AETNA", "plan_name": "AETNA ALL OTHER PLANS", "methodology": "percent of total billed charges", "standard_charge_dollar": 1501.76, "standard_charge_percentage": 52.0, "count": "0", "additional_payer_notes": "Zero final payments for the item or service in the 15 months prior to posting the file." }, { "payer_name": "AETNA", "plan_name": "AETNA ALL OTHER PLANS", "methodology": "percent of total billed charges", "standard_charge_dollar": 1501.76, "standard_charge_percentage": 52.0, "count": "0", "additional_payer_notes": "Zero final payments for the item or service in the 15 months prior to posting the file." }, { "payer_name": "MERITAIN HEALTH", "plan_name": "AETNA ALL OTHER PLANS", "methodology": "percent of total billed charges", "standard_charge_dollar": 1501.76, "standard_charge_percentage": 52.0, "count": "0", "additional_payer_notes": "Zero final payments for the item or service in the 15 months prior to posting the file." }, { "payer_name": "BLUE SHIELD OUT OF STATE", "plan_name": "STANFORD HEALTHCARE ALLIANCE PLAN", "methodology": "percent of total billed charges", "standard_charge_dollar": 1403.28, "standard_charge_percentage": 48.59, "count": "0", "additional_payer_notes": "Zero final payments for the item or service in the 15 months prior to posting the file." }, { "payer_name": "BLUE SHIELD", "plan_name": "STANFORD HEALTHCARE ALLIANCE PLAN", "methodology": "percent of total billed charges", "standard_charge_dollar": 1403.28, "standard_charge_percentage": 48.59, "median_amount": 68.24, "10th_percentile": 13.6, "90th_percentile": 1043.06, "count": "30" }, { "payer_name": "BLUE SHIELD", "plan_name": "STANFORD HEALTHCARE ALLIANCE PLAN", "methodology": "percent of total billed charges", "standard_charge_dollar": 1403.28, "standard_charge_percentage": 48.59, "count": "0", "additional_payer_notes": "Zero final payments for the item or service in the 15 months prior to posting the file." }, { "payer_name": "BLUE SHIELD", "plan_name": "STANFORD HEALTHCARE ALLIANCE PLAN", "methodology": "percent of total billed charges", "standard_charge_dollar": 1403.28, "standard_charge_percentage": 48.59, "count": "0", "additional_payer_notes": "Zero final payments for the item or service in the 15 months prior to posting the file." }, { "payer_name": "CIGNA", "plan_name": "CIGNA COM ALT HMO PLAN", "methodology": "percent of total billed charges", "standard_charge_dollar": 1218.74, "standard_charge_percentage": 42.2, "count": "0", "additional_payer_notes": "Zero final payments for the item or service in the 15 months prior to posting the file." }, { "payer_name": "CIGNA", "plan_name": "CIGNA COM ALT HMO PLAN", "methodology": "percent of total billed charges", "standard_charge_dollar": 1218.74, "standard_charge_percentage": 42.2, "count": "0", "additional_payer_notes": "Zero final payments for the item or service in the 15 months prior to posting the file." }, { "payer_name": "HEALTH NET", "plan_name": "HEALTHNET HMO, PPO, POS, EPO, CANOPY HEALTHNET HMO, OTHER-IN-NETWORK PLANS", "methodology": "per diem", "standard_charge_dollar": 8000.0, "standard_charge_algorithm": "Expected reimbursement is the lesser of Per diem ($8,000) for the length of stay and 70% of billed.", "count": "0", "additional_payer_notes": "Zero final payments for the item or service in the 15 months prior to posting the file." }, { "payer_name": "HEALTH NET", "plan_name": "HEALTHNET HMO, PPO, POS, EPO, CANOPY HEALTHNET HMO, OTHER-IN-NETWORK PLANS", "methodology": "per diem", "standard_charge_dollar": 8000.0, "standard_charge_algorithm": "Expected reimbursement is the lesser of Per diem ($8,000) for the length of stay and 70% of billed.", "count": "0", "additional_payer_notes": "Zero final payments for the item or service in the 15 months prior to posting the file." }, { "payer_name": "UNITED HEALTHCARE", "plan_name": "SUTTER SELECT & SUTTER HEALTH PLAN HMO PLANS", "methodology": "per diem", "standard_charge_dollar": 28538.0, "standard_charge_algorithm": "Per diem ($28,538).", "count": "0", "additional_payer_notes": "Zero final payments for the item or service in the 15 months prior to posting the file." }, { "payer_name": "UNITED HEALTHCARE", "plan_name": "SUTTER SELECT & SUTTER HEALTH PLAN HMO PLANS", "methodology": "per diem", "standard_charge_dollar": 28538.0, "standard_charge_algorithm": "Per diem ($28,538).", "count": "0", "additional_payer_notes": "Zero final payments for the item or service in the 15 months prior to posting the file." }, { "payer_name": "SUTTER", "plan_name": "SUTTER SELECT & SUTTER HEALTH PLAN HMO PLANS", "methodology": "per diem", "standard_charge_dollar": 28538.0, "standard_charge_algorithm": "Per diem ($28,538).", "count": "0", "additional_payer_notes": "Zero final payments for the item or service in the 15 months prior to posting the file." }, { "payer_name": "UNITED HEALTHCARE", "plan_name": "SUTTER SELECT & SUTTER HEALTH PLAN HMO PLANS", "methodology": "per diem", "standard_charge_dollar": 28538.0, "standard_charge_algorithm": "Per diem ($28,538).", "count": "0", "additional_payer_notes": "Zero final payments for the item or service in the 15 months prior to posting the file." }, { "payer_name": "UMR", "plan_name": "SUTTER SELECT & SUTTER HEALTH PLAN HMO PLANS", "methodology": "per diem", "standard_charge_dollar": 28538.0, "standard_charge_algorithm": "Per diem ($28,538).", "count": "0", "additional_payer_notes": "Zero final payments for the item or service in the 15 months prior to posting the file." } ] } ] }, { "description": "HC Drill Bit Gp022", "code_information": [ { "code": "PX-2120061022", "type": "CDM" }, { "code": "99999", "type": "CPT" }, { "code": "0272", "type": "RC" } ], "standard_charges": [ { "setting": "outpatient", "gross_charge": 3300.0, "discounted_cash": 1650.0, "minimum": 1392.6, "maximum": 1716.0, "additional_generic_notes": "Zero final payments for the item or service in the 15 months prior to posting the file.", "payers_information": [ { "payer_name": "AETNA", "plan_name": "AETNA ALL OTHER PLANS", "methodology": "percent of total billed charges", "standard_charge_dollar": 1716.0, "standard_charge_percentage": 52.0, "count": "0", "additional_payer_notes": "Zero final payments for the item or service in the 15 months prior to posting the file." }, { "payer_name": "AETNA", "plan_name": "AETNA ALL OTHER PLANS", "methodology": "percent of total billed charges", "standard_charge_dollar": 1716.0, "standard_charge_percentage": 52.0, "count": "0", "additional_payer_notes": "Zero final payments for the item or service in the 15 months prior to posting the file." }, { "payer_name": "MERITAIN HEALTH", "plan_name": "AETNA ALL OTHER PLANS", "methodology": "percent of total billed charges", "standard_charge_dollar": 1716.0, "standard_charge_percentage": 52.0, "count": "0", "additional_payer_notes": "Zero final payments for the item or service in the 15 months prior to posting the file." }, { "payer_name": "BLUE SHIELD OUT OF STATE", "plan_name": "STANFORD HEALTHCARE ALLIANCE PLAN", "methodology": "percent of total billed charges", "standard_charge_dollar": 1603.47, "standard_charge_percentage": 48.59, "count": "0", "additional_payer_notes": "Zero final payments for the item or service in the 15 months prior to posting the file." }, { "payer_name": "BLUE SHIELD", "plan_name": "STANFORD HEALTHCARE ALLIANCE PLAN", "methodology": "percent of total billed charges", "standard_charge_dollar": 1603.47, "standard_charge_percentage": 48.59, "median_amount": 68.24, "10th_percentile": 13.6, "90th_percentile": 1043.06, "count": "30" }, { "payer_name": "BLUE SHIELD", "plan_name": "STANFORD HEALTHCARE ALLIANCE PLAN", "methodology": "percent of total billed charges", "standard_charge_dollar": 1603.47, "standard_charge_percentage": 48.59, "count": "0", "additional_payer_notes": "Zero final payments for the item or service in the 15 months prior to posting the file." }, { "payer_name": "BLUE SHIELD", "plan_name": "STANFORD HEALTHCARE ALLIANCE PLAN", "methodology": "percent of total billed charges", "standard_charge_dollar": 1603.47, "standard_charge_percentage": 48.59, "count": "0", "additional_payer_notes": "Zero final payments for the item or service in the 15 months prior to posting the file." }, { "payer_name": "CIGNA", "plan_name": "CIGNA COM ALT HMO PLAN", "methodology": "percent of total billed charges", "standard_charge_dollar": 1392.6, "standard_charge_percentage": 42.2, "count": "0", "additional_payer_notes": "Zero final payments for the item or service in the 15 months prior to posting the file." }, { "payer_name": "CIGNA", "plan_name": "CIGNA COM ALT HMO PLAN", "methodology": "percent of total billed charges", "standard_charge_dollar": 1392.6, "standard_charge_percentage": 42.2, "count": "0", "additional_payer_notes": "Zero final payments for the item or service in the 15 months prior to posting the file." }, { "payer_name": "HEALTH NET", "plan_name": "HEALTHNET HMO, PPO, POS, EPO, CANOPY HEALTHNET HMO, OTHER-IN-NETWORK PLANS", "methodology": "per diem", "standard_charge_dollar": 8000.0, "standard_charge_algorithm": "Expected reimbursement is the lesser of Per diem ($8,000) for the length of stay and 70% of billed.", "count": "0", "additional_payer_notes": "Zero final payments for the item or service in the 15 months prior to posting the file." }, { "payer_name": "HEALTH NET", "plan_name": "HEALTHNET HMO, PPO, POS, EPO, CANOPY HEALTHNET HMO, OTHER-IN-NETWORK PLANS", "methodology": "per diem", "standard_charge_dollar": 8000.0, "standard_charge_algorithm": "Expected reimbursement is the lesser of Per diem ($8,000) for the length of stay and 70% of billed.", "count": "0", "additional_payer_notes": "Zero final payments for the item or service in the 15 months prior to posting the file." }, { "payer_name": "UNITED HEALTHCARE", "plan_name": "SUTTER SELECT & SUTTER HEALTH PLAN HMO PLANS", "methodology": "per diem", "standard_charge_dollar": 28538.0, "standard_charge_algorithm": "Per diem ($28,538).", "count": "0", "additional_payer_notes": "Zero final payments for the item or service in the 15 months prior to posting the file." }, { "payer_name": "UNITED HEALTHCARE", "plan_name": "SUTTER SELECT & SUTTER HEALTH PLAN HMO PLANS", "methodology": "per diem", "standard_charge_dollar": 28538.0, "standard_charge_algorithm": "Per diem ($28,538).", "count": "0", "additional_payer_notes": "Zero final payments for the item or service in the 15 months prior to posting the file." }, { "payer_name": "SUTTER", "plan_name": "SUTTER SELECT & SUTTER HEALTH PLAN HMO PLANS", "methodology": "per diem", "standard_charge_dollar": 28538.0, "standard_charge_algorithm": "Per diem ($28,538).", "count": "0", "additional_payer_notes": "Zero final payments for the item or service in the 15 months prior to posting the file." }, { "payer_name": "UNITED HEALTHCARE", "plan_name": "SUTTER SELECT & SUTTER HEALTH PLAN HMO PLANS", "methodology": "per diem", "standard_charge_dollar": 28538.0, "standard_charge_algorithm": "Per diem ($28,538).", "count": "0", "additional_payer_notes": "Zero final payments for the item or service in the 15 months prior to posting the file." }, { "payer_name": "UMR", "plan_name": "SUTTER SELECT & SUTTER HEALTH PLAN HMO PLANS", "methodology": "per diem", "standard_charge_dollar": 28538.0, "standard_charge_algorithm": "Per diem ($28,538).", "count": "0", "additional_payer_notes": "Zero final payments for the item or service in the 15 months prior to posting the file." } ] } ] }, { "description": "HC Drill Bit Gp023", "code_information": [ { "code": "PX-2120061023", "type": "CDM" }, { "code": "99999", "type": "CPT" }, { "code": "0272", "type": "RC" } ], "standard_charges": [ { "setting": "outpatient", "gross_charge": 3600.0, "discounted_cash": 1800.0, "minimum": 1519.2, "maximum": 1872.0, "additional_generic_notes": "Zero final payments for the item or service in the 15 months prior to posting the file.", "payers_information": [ { "payer_name": "AETNA", "plan_name": "AETNA ALL OTHER PLANS", "methodology": "percent of total billed charges", "standard_charge_dollar": 1872.0, "standard_charge_percentage": 52.0, "count": "0", "additional_payer_notes": "Zero final payments for the item or service in the 15 months prior to posting the file." }, { "payer_name": "AETNA", "plan_name": "AETNA ALL OTHER PLANS", "methodology": "percent of total billed charges", "standard_charge_dollar": 1872.0, "standard_charge_percentage": 52.0, "count": "0", "additional_payer_notes": "Zero final payments for the item or service in the 15 months prior to posting the file." }, { "payer_name": "MERITAIN HEALTH", "plan_name": "AETNA ALL OTHER PLANS", "methodology": "percent of total billed charges", "standard_charge_dollar": 1872.0, "standard_charge_percentage": 52.0, "count": "0", "additional_payer_notes": "Zero final payments for the item or service in the 15 months prior to posting the file." }, { "payer_name": "BLUE SHIELD OUT OF STATE", "plan_name": "STANFORD HEALTHCARE ALLIANCE PLAN", "methodology": "percent of total billed charges", "standard_charge_dollar": 1749.24, "standard_charge_percentage": 48.59, "count": "0", "additional_payer_notes": "Zero final payments for the item or service in the 15 months prior to posting the file." }, { "payer_name": "BLUE SHIELD", "plan_name": "STANFORD HEALTHCARE ALLIANCE PLAN", "methodology": "percent of total billed charges", "standard_charge_dollar": 1749.24, "standard_charge_percentage": 48.59, "median_amount": 68.24, "10th_percentile": 13.6, "90th_percentile": 1043.06, "count": "30" }, { "payer_name": "BLUE SHIELD", "plan_name": "STANFORD HEALTHCARE ALLIANCE PLAN", "methodology": "percent of total billed charges", "standard_charge_dollar": 1749.24, "standard_charge_percentage": 48.59, "count": "0", "additional_payer_notes": "Zero final payments for the item or service in the 15 months prior to posting the file." }, { "payer_name": "BLUE SHIELD", "plan_name": "STANFORD HEALTHCARE ALLIANCE PLAN", "methodology": "percent of total billed charges", "standard_charge_dollar": 1749.24, "standard_charge_percentage": 48.59, "count": "0", "additional_payer_notes": "Zero final payments for the item or service in the 15 months prior to posting the file." }, { "payer_name": "CIGNA", "plan_name": "CIGNA COM ALT HMO PLAN", "methodology": "percent of total billed charges", "standard_charge_dollar": 1519.2, "standard_charge_percentage": 42.2, "count": "0", "additional_payer_notes": "Zero final payments for the item or service in the 15 months prior to posting the file." }, { "payer_name": "CIGNA", "plan_name": "CIGNA COM ALT HMO PLAN", "methodology": "percent of total billed charges", "standard_charge_dollar": 1519.2, "standard_charge_percentage": 42.2, "count": "0", "additional_payer_notes": "Zero final payments for the item or service in the 15 months prior to posting the file." }, { "payer_name": "HEALTH NET", "plan_name": "HEALTHNET HMO, PPO, POS, EPO, CANOPY HEALTHNET HMO, OTHER-IN-NETWORK PLANS", "methodology": "per diem", "standard_charge_dollar": 8000.0, "standard_charge_algorithm": "Expected reimbursement is the lesser of Per diem ($8,000) for the length of stay and 70% of billed.", "count": "0", "additional_payer_notes": "Zero final payments for the item or service in the 15 months prior to posting the file." }, { "payer_name": "HEALTH NET", "plan_name": "HEALTHNET HMO, PPO, POS, EPO, CANOPY HEALTHNET HMO, OTHER-IN-NETWORK PLANS", "methodology": "per diem", "standard_charge_dollar": 8000.0, "standard_charge_algorithm": "Expected reimbursement is the lesser of Per diem ($8,000) for the length of stay and 70% of billed.", "count": "0", "additional_payer_notes": "Zero final payments for the item or service in the 15 months prior to posting the file." }, { "payer_name": "UNITED HEALTHCARE", "plan_name": "SUTTER SELECT & SUTTER HEALTH PLAN HMO PLANS", "methodology": "per diem", "standard_charge_dollar": 28538.0, "standard_charge_algorithm": "Per diem ($28,538).", "count": "0", "additional_payer_notes": "Zero final payments for the item or service in the 15 months prior to posting the file." }, { "payer_name": "UNITED HEALTHCARE", "plan_name": "SUTTER SELECT & SUTTER HEALTH PLAN HMO PLANS", "methodology": "per diem", "standard_charge_dollar": 28538.0, "standard_charge_algorithm": "Per diem ($28,538).", "count": "0", "additional_payer_notes": "Zero final payments for the item or service in the 15 months prior to posting the file." }, { "payer_name": "SUTTER", "plan_name": "SUTTER SELECT & SUTTER HEALTH PLAN HMO PLANS", "methodology": "per diem", "standard_charge_dollar": 28538.0, "standard_charge_algorithm": "Per diem ($28,538).", "count": "0", "additional_payer_notes": "Zero final payments for the item or service in the 15 months prior to posting the file." }, { "payer_name": "UNITED HEALTHCARE", "plan_name": "SUTTER SELECT & SUTTER HEALTH PLAN HMO PLANS", "methodology": "per diem", "standard_charge_dollar": 28538.0, "standard_charge_algorithm": "Per diem ($28,538).", "count": "0", "additional_payer_notes": "Zero final payments for the item or service in the 15 months prior to posting the file." }, { "payer_name": "UMR", "plan_name": "SUTTER SELECT & SUTTER HEALTH PLAN HMO PLANS", "methodology": "per diem", "standard_charge_dollar": 28538.0, "standard_charge_algorithm": "Per diem ($28,538).", "count": "0", "additional_payer_notes": "Zero final payments for the item or service in the 15 months prior to posting the file." } ] } ] }, { "description": "HC Drill Bit Gp024", "code_information": [ { "code": "PX-2120061024", "type": "CDM" }, { "code": "99999", "type": "CPT" }, { "code": "0272", "type": "RC" } ], "standard_charges": [ { "setting": "outpatient", "gross_charge": 4000.0, "discounted_cash": 2000.0, "minimum": 1688.0, "maximum": 2080.0, "additional_generic_notes": "Zero final payments for the item or service in the 15 months prior to posting the file.", "payers_information": [ { "payer_name": "AETNA", "plan_name": "AETNA ALL OTHER PLANS", "methodology": "percent of total billed charges", "standard_charge_dollar": 2080.0, "standard_charge_percentage": 52.0, "count": "0", "additional_payer_notes": "Zero final payments for the item or service in the 15 months prior to posting the file." }, { "payer_name": "AETNA", "plan_name": "AETNA ALL OTHER PLANS", "methodology": "percent of total billed charges", "standard_charge_dollar": 2080.0, "standard_charge_percentage": 52.0, "count": "0", "additional_payer_notes": "Zero final payments for the item or service in the 15 months prior to posting the file." }, { "payer_name": "MERITAIN HEALTH", "plan_name": "AETNA ALL OTHER PLANS", "methodology": "percent of total billed charges", "standard_charge_dollar": 2080.0, "standard_charge_percentage": 52.0, "count": "0", "additional_payer_notes": "Zero final payments for the item or service in the 15 months prior to posting the file." }, { "payer_name": "BLUE SHIELD OUT OF STATE", "plan_name": "STANFORD HEALTHCARE ALLIANCE PLAN", "methodology": "percent of total billed charges", "standard_charge_dollar": 1943.6, "standard_charge_percentage": 48.59, "count": "0", "additional_payer_notes": "Zero final payments for the item or service in the 15 months prior to posting the file." }, { "payer_name": "BLUE SHIELD", "plan_name": "STANFORD HEALTHCARE ALLIANCE PLAN", "methodology": "percent of total billed charges", "standard_charge_dollar": 1943.6, "standard_charge_percentage": 48.59, "median_amount": 68.24, "10th_percentile": 13.6, "90th_percentile": 1043.06, "count": "30" }, { "payer_name": "BLUE SHIELD", "plan_name": "STANFORD HEALTHCARE ALLIANCE PLAN", "methodology": "percent of total billed charges", "standard_charge_dollar": 1943.6, "standard_charge_percentage": 48.59, "count": "0", "additional_payer_notes": "Zero final payments for the item or service in the 15 months prior to posting the file." }, { "payer_name": "BLUE SHIELD", "plan_name": "STANFORD HEALTHCARE ALLIANCE PLAN", "methodology": "percent of total billed charges", "standard_charge_dollar": 1943.6, "standard_charge_percentage": 48.59, "count": "0", "additional_payer_notes": "Zero final payments for the item or service in the 15 months prior to posting the file." }, { "payer_name": "CIGNA", "plan_name": "CIGNA COM ALT HMO PLAN", "methodology": "percent of total billed charges", "standard_charge_dollar": 1688.0, "standard_charge_percentage": 42.2, "count": "0", "additional_payer_notes": "Zero final payments for the item or service in the 15 months prior to posting the file." }, { "payer_name": "CIGNA", "plan_name": "CIGNA COM ALT HMO PLAN", "methodology": "percent of total billed charges", "standard_charge_dollar": 1688.0, "standard_charge_percentage": 42.2, "count": "0", "additional_payer_notes": "Zero final payments for the item or service in the 15 months prior to posting the file." }, { "payer_name": "HEALTH NET", "plan_name": "HEALTHNET HMO, PPO, POS, EPO, CANOPY HEALTHNET HMO, OTHER-IN-NETWORK PLANS", "methodology": "per diem", "standard_charge_dollar": 8000.0, "standard_charge_algorithm": "Expected reimbursement is the lesser of Per diem ($8,000) for the length of stay and 70% of billed.", "count": "0", "additional_payer_notes": "Zero final payments for the item or service in the 15 months prior to posting the file." }, { "payer_name": "HEALTH NET", "plan_name": "HEALTHNET HMO, PPO, POS, EPO, CANOPY HEALTHNET HMO, OTHER-IN-NETWORK PLANS", "methodology": "per diem", "standard_charge_dollar": 8000.0, "standard_charge_algorithm": "Expected reimbursement is the lesser of Per diem ($8,000) for the length of stay and 70% of billed.", "count": "0", "additional_payer_notes": "Zero final payments for the item or service in the 15 months prior to posting the file." }, { "payer_name": "UNITED HEALTHCARE", "plan_name": "SUTTER SELECT & SUTTER HEALTH PLAN HMO PLANS", "methodology": "per diem", "standard_charge_dollar": 28538.0, "standard_charge_algorithm": "Per diem ($28,538).", "count": "0", "additional_payer_notes": "Zero final payments for the item or service in the 15 months prior to posting the file." }, { "payer_name": "UNITED HEALTHCARE", "plan_name": "SUTTER SELECT & SUTTER HEALTH PLAN HMO PLANS", "methodology": "per diem", "standard_charge_dollar": 28538.0, "standard_charge_algorithm": "Per diem ($28,538).", "count": "0", "additional_payer_notes": "Zero final payments for the item or service in the 15 months prior to posting the file." }, { "payer_name": "SUTTER", "plan_name": "SUTTER SELECT & SUTTER HEALTH PLAN HMO PLANS", "methodology": "per diem", "standard_charge_dollar": 28538.0, "standard_charge_algorithm": "Per diem ($28,538).", "count": "0", "additional_payer_notes": "Zero final payments for the item or service in the 15 months prior to posting the file." }, { "payer_name": "UNITED HEALTHCARE", "plan_name": "SUTTER SELECT & SUTTER HEALTH PLAN HMO PLANS", "methodology": "per diem", "standard_charge_dollar": 28538.0, "standard_charge_algorithm": "Per diem ($28,538).", "count": "0", "additional_payer_notes": "Zero final payments for the item or service in the 15 months prior to posting the file." }, { "payer_name": "UMR", "plan_name": "SUTTER SELECT & SUTTER HEALTH PLAN HMO PLANS", "methodology": "per diem", "standard_charge_dollar": 28538.0, "standard_charge_algorithm": "Per diem ($28,538).", "count": "0", "additional_payer_notes": "Zero final payments for the item or service in the 15 months prior to posting the file." } ] } ] }, { "description": "HC Drill Bit Gp025", "code_information": [ { "code": "PX-2120061025", "type": "CDM" }, { "code": "99999", "type": "CPT" }, { "code": "0272", "type": "RC" } ], "standard_charges": [ { "setting": "outpatient", "gross_charge": 15300.0, "discounted_cash": 7650.0, "minimum": 6456.6, "maximum": 7956.0, "additional_generic_notes": "Zero final payments for the item or service in the 15 months prior to posting the file.", "payers_information": [ { "payer_name": "AETNA", "plan_name": "AETNA ALL OTHER PLANS", "methodology": "percent of total billed charges", "standard_charge_dollar": 7956.0, "standard_charge_percentage": 52.0, "count": "0", "additional_payer_notes": "Zero final payments for the item or service in the 15 months prior to posting the file." }, { "payer_name": "AETNA", "plan_name": "AETNA ALL OTHER PLANS", "methodology": "percent of total billed charges", "standard_charge_dollar": 7956.0, "standard_charge_percentage": 52.0, "count": "0", "additional_payer_notes": "Zero final payments for the item or service in the 15 months prior to posting the file." }, { "payer_name": "MERITAIN HEALTH", "plan_name": "AETNA ALL OTHER PLANS", "methodology": "percent of total billed charges", "standard_charge_dollar": 7956.0, "standard_charge_percentage": 52.0, "count": "0", "additional_payer_notes": "Zero final payments for the item or service in the 15 months prior to posting the file." }, { "payer_name": "BLUE SHIELD OUT OF STATE", "plan_name": "STANFORD HEALTHCARE ALLIANCE PLAN", "methodology": "percent of total billed charges", "standard_charge_dollar": 7434.27, "standard_charge_percentage": 48.59, "count": "0", "additional_payer_notes": "Zero final payments for the item or service in the 15 months prior to posting the file." }, { "payer_name": "BLUE SHIELD", "plan_name": "STANFORD HEALTHCARE ALLIANCE PLAN", "methodology": "percent of total billed charges", "standard_charge_dollar": 7434.27, "standard_charge_percentage": 48.59, "median_amount": 68.24, "10th_percentile": 13.6, "90th_percentile": 1043.06, "count": "30" }, { "payer_name": "BLUE SHIELD", "plan_name": "STANFORD HEALTHCARE ALLIANCE PLAN", "methodology": "percent of total billed charges", "standard_charge_dollar": 7434.27, "standard_charge_percentage": 48.59, "count": "0", "additional_payer_notes": "Zero final payments for the item or service in the 15 months prior to posting the file." }, { "payer_name": "BLUE SHIELD", "plan_name": "STANFORD HEALTHCARE ALLIANCE PLAN", "methodology": "percent of total billed charges", "standard_charge_dollar": 7434.27, "standard_charge_percentage": 48.59, "count": "0", "additional_payer_notes": "Zero final payments for the item or service in the 15 months prior to posting the file." }, { "payer_name": "CIGNA", "plan_name": "CIGNA COM ALT HMO PLAN", "methodology": "percent of total billed charges", "standard_charge_dollar": 6456.6, "standard_charge_percentage": 42.2, "count": "0", "additional_payer_notes": "Zero final payments for the item or service in the 15 months prior to posting the file." }, { "payer_name": "CIGNA", "plan_name": "CIGNA COM ALT HMO PLAN", "methodology": "percent of total billed charges", "standard_charge_dollar": 6456.6, "standard_charge_percentage": 42.2, "count": "0", "additional_payer_notes": "Zero final payments for the item or service in the 15 months prior to posting the file." }, { "payer_name": "HEALTH NET", "plan_name": "HEALTHNET HMO, PPO, POS, EPO, CANOPY HEALTHNET HMO, OTHER-IN-NETWORK PLANS", "methodology": "per diem", "standard_charge_dollar": 8000.0, "standard_charge_algorithm": "Expected reimbursement is the lesser of Per diem ($8,000) for the length of stay and 70% of billed.", "count": "0", "additional_payer_notes": "Zero final payments for the item or service in the 15 months prior to posting the file." }, { "payer_name": "HEALTH NET", "plan_name": "HEALTHNET HMO, PPO, POS, EPO, CANOPY HEALTHNET HMO, OTHER-IN-NETWORK PLANS", "methodology": "per diem", "standard_charge_dollar": 8000.0, "standard_charge_algorithm": "Expected reimbursement is the lesser of Per diem ($8,000) for the length of stay and 70% of billed.", "count": "0", "additional_payer_notes": "Zero final payments for the item or service in the 15 months prior to posting the file." }, { "payer_name": "UNITED HEALTHCARE", "plan_name": "SUTTER SELECT & SUTTER HEALTH PLAN HMO PLANS", "methodology": "per diem", "standard_charge_dollar": 28538.0, "standard_charge_algorithm": "Per diem ($28,538).", "count": "0", "additional_payer_notes": "Zero final payments for the item or service in the 15 months prior to posting the file." }, { "payer_name": "UNITED HEALTHCARE", "plan_name": "SUTTER SELECT & SUTTER HEALTH PLAN HMO PLANS", "methodology": "per diem", "standard_charge_dollar": 28538.0, "standard_charge_algorithm": "Per diem ($28,538).", "count": "0", "additional_payer_notes": "Zero final payments for the item or service in the 15 months prior to posting the file." }, { "payer_name": "SUTTER", "plan_name": "SUTTER SELECT & SUTTER HEALTH PLAN HMO PLANS", "methodology": "per diem", "standard_charge_dollar": 28538.0, "standard_charge_algorithm": "Per diem ($28,538).", "count": "0", "additional_payer_notes": "Zero final payments for the item or service in the 15 months prior to posting the file." }, { "payer_name": "UNITED HEALTHCARE", "plan_name": "SUTTER SELECT & SUTTER HEALTH PLAN HMO PLANS", "methodology": "per diem", "standard_charge_dollar": 28538.0, "standard_charge_algorithm": "Per diem ($28,538).", "count": "0", "additional_payer_notes": "Zero final payments for the item or service in the 15 months prior to posting the file." }, { "payer_name": "UMR", "plan_name": "SUTTER SELECT & SUTTER HEALTH PLAN HMO PLANS", "methodology": "per diem", "standard_charge_dollar": 28538.0, "standard_charge_algorithm": "Per diem ($28,538).", "count": "0", "additional_payer_notes": "Zero final payments for the item or service in the 15 months prior to posting the file." } ] } ] }, { "description": "HC Drill Bit Gp026", "code_information": [ { "code": "PX-2120061026", "type": "CDM" }, { "code": "99999", "type": "CPT" }, { "code": "0272", "type": "RC" } ], "standard_charges": [ { "setting": "outpatient", "gross_charge": 4650.0, "discounted_cash": 2325.0, "minimum": 1962.3, "maximum": 2418.0, "additional_generic_notes": "Zero final payments for the item or service in the 15 months prior to posting the file.", "payers_information": [ { "payer_name": "AETNA", "plan_name": "AETNA ALL OTHER PLANS", "methodology": "percent of total billed charges", "standard_charge_dollar": 2418.0, "standard_charge_percentage": 52.0, "count": "0", "additional_payer_notes": "Zero final payments for the item or service in the 15 months prior to posting the file." }, { "payer_name": "AETNA", "plan_name": "AETNA ALL OTHER PLANS", "methodology": "percent of total billed charges", "standard_charge_dollar": 2418.0, "standard_charge_percentage": 52.0, "count": "0", "additional_payer_notes": "Zero final payments for the item or service in the 15 months prior to posting the file." }, { "payer_name": "MERITAIN HEALTH", "plan_name": "AETNA ALL OTHER PLANS", "methodology": "percent of total billed charges", "standard_charge_dollar": 2418.0, "standard_charge_percentage": 52.0, "count": "0", "additional_payer_notes": "Zero final payments for the item or service in the 15 months prior to posting the file." }, { "payer_name": "BLUE SHIELD OUT OF STATE", "plan_name": "STANFORD HEALTHCARE ALLIANCE PLAN", "methodology": "percent of total billed charges", "standard_charge_dollar": 2259.44, "standard_charge_percentage": 48.59, "count": "0", "additional_payer_notes": "Zero final payments for the item or service in the 15 months prior to posting the file." }, { "payer_name": "BLUE SHIELD", "plan_name": "STANFORD HEALTHCARE ALLIANCE PLAN", "methodology": "percent of total billed charges", "standard_charge_dollar": 2259.44, "standard_charge_percentage": 48.59, "median_amount": 68.24, "10th_percentile": 13.6, "90th_percentile": 1043.06, "count": "30" }, { "payer_name": "BLUE SHIELD", "plan_name": "STANFORD HEALTHCARE ALLIANCE PLAN", "methodology": "percent of total billed charges", "standard_charge_dollar": 2259.44, "standard_charge_percentage": 48.59, "count": "0", "additional_payer_notes": "Zero final payments for the item or service in the 15 months prior to posting the file." }, { "payer_name": "BLUE SHIELD", "plan_name": "STANFORD HEALTHCARE ALLIANCE PLAN", "methodology": "percent of total billed charges", "standard_charge_dollar": 2259.44, "standard_charge_percentage": 48.59, "count": "0", "additional_payer_notes": "Zero final payments for the item or service in the 15 months prior to posting the file." }, { "payer_name": "CIGNA", "plan_name": "CIGNA COM ALT HMO PLAN", "methodology": "percent of total billed charges", "standard_charge_dollar": 1962.3, "standard_charge_percentage": 42.2, "count": "0", "additional_payer_notes": "Zero final payments for the item or service in the 15 months prior to posting the file." }, { "payer_name": "CIGNA", "plan_name": "CIGNA COM ALT HMO PLAN", "methodology": "percent of total billed charges", "standard_charge_dollar": 1962.3, "standard_charge_percentage": 42.2, "count": "0", "additional_payer_notes": "Zero final payments for the item or service in the 15 months prior to posting the file." }, { "payer_name": "HEALTH NET", "plan_name": "HEALTHNET HMO, PPO, POS, EPO, CANOPY HEALTHNET HMO, OTHER-IN-NETWORK PLANS", "methodology": "per diem", "standard_charge_dollar": 8000.0, "standard_charge_algorithm": "Expected reimbursement is the lesser of Per diem ($8,000) for the length of stay and 70% of billed.", "count": "0", "additional_payer_notes": "Zero final payments for the item or service in the 15 months prior to posting the file." }, { "payer_name": "HEALTH NET", "plan_name": "HEALTHNET HMO, PPO, POS, EPO, CANOPY HEALTHNET HMO, OTHER-IN-NETWORK PLANS", "methodology": "per diem", "standard_charge_dollar": 8000.0, "standard_charge_algorithm": "Expected reimbursement is the lesser of Per diem ($8,000) for the length of stay and 70% of billed.", "count": "0", "additional_payer_notes": "Zero final payments for the item or service in the 15 months prior to posting the file." }, { "payer_name": "UNITED HEALTHCARE", "plan_name": "SUTTER SELECT & SUTTER HEALTH PLAN HMO PLANS", "methodology": "per diem", "standard_charge_dollar": 28538.0, "standard_charge_algorithm": "Per diem ($28,538).", "count": "0", "additional_payer_notes": "Zero final payments for the item or service in the 15 months prior to posting the file." }, { "payer_name": "UNITED HEALTHCARE", "plan_name": "SUTTER SELECT & SUTTER HEALTH PLAN HMO PLANS", "methodology": "per diem", "standard_charge_dollar": 28538.0, "standard_charge_algorithm": "Per diem ($28,538).", "count": "0", "additional_payer_notes": "Zero final payments for the item or service in the 15 months prior to posting the file." }, { "payer_name": "SUTTER", "plan_name": "SUTTER SELECT & SUTTER HEALTH PLAN HMO PLANS", "methodology": "per diem", "standard_charge_dollar": 28538.0, "standard_charge_algorithm": "Per diem ($28,538).", "count": "0", "additional_payer_notes": "Zero final payments for the item or service in the 15 months prior to posting the file." }, { "payer_name": "UNITED HEALTHCARE", "plan_name": "SUTTER SELECT & SUTTER HEALTH PLAN HMO PLANS", "methodology": "per diem", "standard_charge_dollar": 28538.0, "standard_charge_algorithm": "Per diem ($28,538).", "count": "0", "additional_payer_notes": "Zero final payments for the item or service in the 15 months prior to posting the file." }, { "payer_name": "UMR", "plan_name": "SUTTER SELECT & SUTTER HEALTH PLAN HMO PLANS", "methodology": "per diem", "standard_charge_dollar": 28538.0, "standard_charge_algorithm": "Per diem ($28,538).", "count": "0", "additional_payer_notes": "Zero final payments for the item or service in the 15 months prior to posting the file." } ] } ] }, { "description": "HC Drill Bit Gp027", "code_information": [ { "code": "PX-2120061027", "type": "CDM" }, { "code": "99999", "type": "CPT" }, { "code": "0272", "type": "RC" } ], "standard_charges": [ { "setting": "outpatient", "gross_charge": 4875.0, "discounted_cash": 2437.5, "minimum": 2057.25, "maximum": 2535.0, "additional_generic_notes": "Zero final payments for the item or service in the 15 months prior to posting the file.", "payers_information": [ { "payer_name": "AETNA", "plan_name": "AETNA ALL OTHER PLANS", "methodology": "percent of total billed charges", "standard_charge_dollar": 2535.0, "standard_charge_percentage": 52.0, "count": "0", "additional_payer_notes": "Zero final payments for the item or service in the 15 months prior to posting the file." }, { "payer_name": "AETNA", "plan_name": "AETNA ALL OTHER PLANS", "methodology": "percent of total billed charges", "standard_charge_dollar": 2535.0, "standard_charge_percentage": 52.0, "count": "0", "additional_payer_notes": "Zero final payments for the item or service in the 15 months prior to posting the file." }, { "payer_name": "MERITAIN HEALTH", "plan_name": "AETNA ALL OTHER PLANS", "methodology": "percent of total billed charges", "standard_charge_dollar": 2535.0, "standard_charge_percentage": 52.0, "count": "0", "additional_payer_notes": "Zero final payments for the item or service in the 15 months prior to posting the file." }, { "payer_name": "BLUE SHIELD OUT OF STATE", "plan_name": "STANFORD HEALTHCARE ALLIANCE PLAN", "methodology": "percent of total billed charges", "standard_charge_dollar": 2368.76, "standard_charge_percentage": 48.59, "count": "0", "additional_payer_notes": "Zero final payments for the item or service in the 15 months prior to posting the file." }, { "payer_name": "BLUE SHIELD", "plan_name": "STANFORD HEALTHCARE ALLIANCE PLAN", "methodology": "percent of total billed charges", "standard_charge_dollar": 2368.76, "standard_charge_percentage": 48.59, "median_amount": 68.24, "10th_percentile": 13.6, "90th_percentile": 1043.06, "count": "30" }, { "payer_name": "BLUE SHIELD", "plan_name": "STANFORD HEALTHCARE ALLIANCE PLAN", "methodology": "percent of total billed charges", "standard_charge_dollar": 2368.76, "standard_charge_percentage": 48.59, "count": "0", "additional_payer_notes": "Zero final payments for the item or service in the 15 months prior to posting the file." }, { "payer_name": "BLUE SHIELD", "plan_name": "STANFORD HEALTHCARE ALLIANCE PLAN", "methodology": "percent of total billed charges", "standard_charge_dollar": 2368.76, "standard_charge_percentage": 48.59, "count": "0", "additional_payer_notes": "Zero final payments for the item or service in the 15 months prior to posting the file." }, { "payer_name": "CIGNA", "plan_name": "CIGNA COM ALT HMO PLAN", "methodology": "percent of total billed charges", "standard_charge_dollar": 2057.25, "standard_charge_percentage": 42.2, "count": "0", "additional_payer_notes": "Zero final payments for the item or service in the 15 months prior to posting the file." }, { "payer_name": "CIGNA", "plan_name": "CIGNA COM ALT HMO PLAN", "methodology": "percent of total billed charges", "standard_charge_dollar": 2057.25, "standard_charge_percentage": 42.2, "count": "0", "additional_payer_notes": "Zero final payments for the item or service in the 15 months prior to posting the file." }, { "payer_name": "HEALTH NET", "plan_name": "HEALTHNET HMO, PPO, POS, EPO, CANOPY HEALTHNET HMO, OTHER-IN-NETWORK PLANS", "methodology": "per diem", "standard_charge_dollar": 8000.0, "standard_charge_algorithm": "Expected reimbursement is the lesser of Per diem ($8,000) for the length of stay and 70% of billed.", "count": "0", "additional_payer_notes": "Zero final payments for the item or service in the 15 months prior to posting the file." }, { "payer_name": "HEALTH NET", "plan_name": "HEALTHNET HMO, PPO, POS, EPO, CANOPY HEALTHNET HMO, OTHER-IN-NETWORK PLANS", "methodology": "per diem", "standard_charge_dollar": 8000.0, "standard_charge_algorithm": "Expected reimbursement is the lesser of Per diem ($8,000) for the length of stay and 70% of billed.", "count": "0", "additional_payer_notes": "Zero final payments for the item or service in the 15 months prior to posting the file." }, { "payer_name": "UNITED HEALTHCARE", "plan_name": "SUTTER SELECT & SUTTER HEALTH PLAN HMO PLANS", "methodology": "per diem", "standard_charge_dollar": 28538.0, "standard_charge_algorithm": "Per diem ($28,538).", "count": "0", "additional_payer_notes": "Zero final payments for the item or service in the 15 months prior to posting the file." }, { "payer_name": "UNITED HEALTHCARE", "plan_name": "SUTTER SELECT & SUTTER HEALTH PLAN HMO PLANS", "methodology": "per diem", "standard_charge_dollar": 28538.0, "standard_charge_algorithm": "Per diem ($28,538).", "count": "0", "additional_payer_notes": "Zero final payments for the item or service in the 15 months prior to posting the file." }, { "payer_name": "SUTTER", "plan_name": "SUTTER SELECT & SUTTER HEALTH PLAN HMO PLANS", "methodology": "per diem", "standard_charge_dollar": 28538.0, "standard_charge_algorithm": "Per diem ($28,538).", "count": "0", "additional_payer_notes": "Zero final payments for the item or service in the 15 months prior to posting the file." }, { "payer_name": "UNITED HEALTHCARE", "plan_name": "SUTTER SELECT & SUTTER HEALTH PLAN HMO PLANS", "methodology": "per diem", "standard_charge_dollar": 28538.0, "standard_charge_algorithm": "Per diem ($28,538).", "count": "0", "additional_payer_notes": "Zero final payments for the item or service in the 15 months prior to posting the file." }, { "payer_name": "UMR", "plan_name": "SUTTER SELECT & SUTTER HEALTH PLAN HMO PLANS", "methodology": "per diem", "standard_charge_dollar": 28538.0, "standard_charge_algorithm": "Per diem ($28,538).", "count": "0", "additional_payer_notes": "Zero final payments for the item or service in the 15 months prior to posting the file." } ] } ] }, { "description": "HC Drill Bit Gp028", "code_information": [ { "code": "PX-2120061028", "type": "CDM" }, { "code": "99999", "type": "CPT" }, { "code": "0272", "type": "RC" } ], "standard_charges": [ { "setting": "outpatient", "gross_charge": 5250.0, "discounted_cash": 2625.0, "minimum": 2215.5, "maximum": 2730.0, "additional_generic_notes": "Zero final payments for the item or service in the 15 months prior to posting the file.", "payers_information": [ { "payer_name": "AETNA", "plan_name": "AETNA ALL OTHER PLANS", "methodology": "percent of total billed charges", "standard_charge_dollar": 2730.0, "standard_charge_percentage": 52.0, "count": "0", "additional_payer_notes": "Zero final payments for the item or service in the 15 months prior to posting the file." }, { "payer_name": "AETNA", "plan_name": "AETNA ALL OTHER PLANS", "methodology": "percent of total billed charges", "standard_charge_dollar": 2730.0, "standard_charge_percentage": 52.0, "count": "0", "additional_payer_notes": "Zero final payments for the item or service in the 15 months prior to posting the file." }, { "payer_name": "MERITAIN HEALTH", "plan_name": "AETNA ALL OTHER PLANS", "methodology": "percent of total billed charges", "standard_charge_dollar": 2730.0, "standard_charge_percentage": 52.0, "count": "0", "additional_payer_notes": "Zero final payments for the item or service in the 15 months prior to posting the file." }, { "payer_name": "BLUE SHIELD OUT OF STATE", "plan_name": "STANFORD HEALTHCARE ALLIANCE PLAN", "methodology": "percent of total billed charges", "standard_charge_dollar": 2550.98, "standard_charge_percentage": 48.59, "count": "0", "additional_payer_notes": "Zero final payments for the item or service in the 15 months prior to posting the file." }, { "payer_name": "BLUE SHIELD", "plan_name": "STANFORD HEALTHCARE ALLIANCE PLAN", "methodology": "percent of total billed charges", "standard_charge_dollar": 2550.98, "standard_charge_percentage": 48.59, "median_amount": 68.24, "10th_percentile": 13.6, "90th_percentile": 1043.06, "count": "30" }, { "payer_name": "BLUE SHIELD", "plan_name": "STANFORD HEALTHCARE ALLIANCE PLAN", "methodology": "percent of total billed charges", "standard_charge_dollar": 2550.98, "standard_charge_percentage": 48.59, "count": "0", "additional_payer_notes": "Zero final payments for the item or service in the 15 months prior to posting the file." }, { "payer_name": "BLUE SHIELD", "plan_name": "STANFORD HEALTHCARE ALLIANCE PLAN", "methodology": "percent of total billed charges", "standard_charge_dollar": 2550.98, "standard_charge_percentage": 48.59, "count": "0", "additional_payer_notes": "Zero final payments for the item or service in the 15 months prior to posting the file." }, { "payer_name": "CIGNA", "plan_name": "CIGNA COM ALT HMO PLAN", "methodology": "percent of total billed charges", "standard_charge_dollar": 2215.5, "standard_charge_percentage": 42.2, "count": "0", "additional_payer_notes": "Zero final payments for the item or service in the 15 months prior to posting the file." }, { "payer_name": "CIGNA", "plan_name": "CIGNA COM ALT HMO PLAN", "methodology": "percent of total billed charges", "standard_charge_dollar": 2215.5, "standard_charge_percentage": 42.2, "count": "0", "additional_payer_notes": "Zero final payments for the item or service in the 15 months prior to posting the file." }, { "payer_name": "HEALTH NET", "plan_name": "HEALTHNET HMO, PPO, POS, EPO, CANOPY HEALTHNET HMO, OTHER-IN-NETWORK PLANS", "methodology": "per diem", "standard_charge_dollar": 8000.0, "standard_charge_algorithm": "Expected reimbursement is the lesser of Per diem ($8,000) for the length of stay and 70% of billed.", "count": "0", "additional_payer_notes": "Zero final payments for the item or service in the 15 months prior to posting the file." }, { "payer_name": "HEALTH NET", "plan_name": "HEALTHNET HMO, PPO, POS, EPO, CANOPY HEALTHNET HMO, OTHER-IN-NETWORK PLANS", "methodology": "per diem", "standard_charge_dollar": 8000.0, "standard_charge_algorithm": "Expected reimbursement is the lesser of Per diem ($8,000) for the length of stay and 70% of billed.", "count": "0", "additional_payer_notes": "Zero final payments for the item or service in the 15 months prior to posting the file." }, { "payer_name": "UNITED HEALTHCARE", "plan_name": "SUTTER SELECT & SUTTER HEALTH PLAN HMO PLANS", "methodology": "per diem", "standard_charge_dollar": 28538.0, "standard_charge_algorithm": "Per diem ($28,538).", "count": "0", "additional_payer_notes": "Zero final payments for the item or service in the 15 months prior to posting the file." }, { "payer_name": "UNITED HEALTHCARE", "plan_name": "SUTTER SELECT & SUTTER HEALTH PLAN HMO PLANS", "methodology": "per diem", "standard_charge_dollar": 28538.0, "standard_charge_algorithm": "Per diem ($28,538).", "count": "0", "additional_payer_notes": "Zero final payments for the item or service in the 15 months prior to posting the file." }, { "payer_name": "SUTTER", "plan_name": "SUTTER SELECT & SUTTER HEALTH PLAN HMO PLANS", "methodology": "per diem", "standard_charge_dollar": 28538.0, "standard_charge_algorithm": "Per diem ($28,538).", "count": "0", "additional_payer_notes": "Zero final payments for the item or service in the 15 months prior to posting the file." }, { "payer_name": "UNITED HEALTHCARE", "plan_name": "SUTTER SELECT & SUTTER HEALTH PLAN HMO PLANS", "methodology": "per diem", "standard_charge_dollar": 28538.0, "standard_charge_algorithm": "Per diem ($28,538).", "count": "0", "additional_payer_notes": "Zero final payments for the item or service in the 15 months prior to posting the file." }, { "payer_name": "UMR", "plan_name": "SUTTER SELECT & SUTTER HEALTH PLAN HMO PLANS", "methodology": "per diem", "standard_charge_dollar": 28538.0, "standard_charge_algorithm": "Per diem ($28,538).", "count": "0", "additional_payer_notes": "Zero final payments for the item or service in the 15 months prior to posting the file." } ] } ] }, { "description": "HC Drill Bit Gp032", "code_information": [ { "code": "PX-2120061032", "type": "CDM" }, { "code": "99999", "type": "CPT" }, { "code": "0272", "type": "RC" } ], "standard_charges": [ { "setting": "outpatient", "gross_charge": 6300.0, "discounted_cash": 3150.0, "minimum": 2658.6, "maximum": 3276.0, "additional_generic_notes": "Zero final payments for the item or service in the 15 months prior to posting the file.", "payers_information": [ { "payer_name": "AETNA", "plan_name": "AETNA ALL OTHER PLANS", "methodology": "percent of total billed charges", "standard_charge_dollar": 3276.0, "standard_charge_percentage": 52.0, "count": "0", "additional_payer_notes": "Zero final payments for the item or service in the 15 months prior to posting the file." }, { "payer_name": "AETNA", "plan_name": "AETNA ALL OTHER PLANS", "methodology": "percent of total billed charges", "standard_charge_dollar": 3276.0, "standard_charge_percentage": 52.0, "count": "0", "additional_payer_notes": "Zero final payments for the item or service in the 15 months prior to posting the file." }, { "payer_name": "MERITAIN HEALTH", "plan_name": "AETNA ALL OTHER PLANS", "methodology": "percent of total billed charges", "standard_charge_dollar": 3276.0, "standard_charge_percentage": 52.0, "count": "0", "additional_payer_notes": "Zero final payments for the item or service in the 15 months prior to posting the file." }, { "payer_name": "BLUE SHIELD OUT OF STATE", "plan_name": "STANFORD HEALTHCARE ALLIANCE PLAN", "methodology": "percent of total billed charges", "standard_charge_dollar": 3061.17, "standard_charge_percentage": 48.59, "count": "0", "additional_payer_notes": "Zero final payments for the item or service in the 15 months prior to posting the file." }, { "payer_name": "BLUE SHIELD", "plan_name": "STANFORD HEALTHCARE ALLIANCE PLAN", "methodology": "percent of total billed charges", "standard_charge_dollar": 3061.17, "standard_charge_percentage": 48.59, "median_amount": 68.24, "10th_percentile": 13.6, "90th_percentile": 1043.06, "count": "30" }, { "payer_name": "BLUE SHIELD", "plan_name": "STANFORD HEALTHCARE ALLIANCE PLAN", "methodology": "percent of total billed charges", "standard_charge_dollar": 3061.17, "standard_charge_percentage": 48.59, "count": "0", "additional_payer_notes": "Zero final payments for the item or service in the 15 months prior to posting the file." }, { "payer_name": "BLUE SHIELD", "plan_name": "STANFORD HEALTHCARE ALLIANCE PLAN", "methodology": "percent of total billed charges", "standard_charge_dollar": 3061.17, "standard_charge_percentage": 48.59, "count": "0", "additional_payer_notes": "Zero final payments for the item or service in the 15 months prior to posting the file." }, { "payer_name": "CIGNA", "plan_name": "CIGNA COM ALT HMO PLAN", "methodology": "percent of total billed charges", "standard_charge_dollar": 2658.6, "standard_charge_percentage": 42.2, "count": "0", "additional_payer_notes": "Zero final payments for the item or service in the 15 months prior to posting the file." }, { "payer_name": "CIGNA", "plan_name": "CIGNA COM ALT HMO PLAN", "methodology": "percent of total billed charges", "standard_charge_dollar": 2658.6, "standard_charge_percentage": 42.2, "count": "0", "additional_payer_notes": "Zero final payments for the item or service in the 15 months prior to posting the file." }, { "payer_name": "HEALTH NET", "plan_name": "HEALTHNET HMO, PPO, POS, EPO, CANOPY HEALTHNET HMO, OTHER-IN-NETWORK PLANS", "methodology": "per diem", "standard_charge_dollar": 8000.0, "standard_charge_algorithm": "Expected reimbursement is the lesser of Per diem ($8,000) for the length of stay and 70% of billed.", "count": "0", "additional_payer_notes": "Zero final payments for the item or service in the 15 months prior to posting the file." }, { "payer_name": "HEALTH NET", "plan_name": "HEALTHNET HMO, PPO, POS, EPO, CANOPY HEALTHNET HMO, OTHER-IN-NETWORK PLANS", "methodology": "per diem", "standard_charge_dollar": 8000.0, "standard_charge_algorithm": "Expected reimbursement is the lesser of Per diem ($8,000) for the length of stay and 70% of billed.", "count": "0", "additional_payer_notes": "Zero final payments for the item or service in the 15 months prior to posting the file." }, { "payer_name": "UNITED HEALTHCARE", "plan_name": "SUTTER SELECT & SUTTER HEALTH PLAN HMO PLANS", "methodology": "per diem", "standard_charge_dollar": 28538.0, "standard_charge_algorithm": "Per diem ($28,538).", "count": "0", "additional_payer_notes": "Zero final payments for the item or service in the 15 months prior to posting the file." }, { "payer_name": "UNITED HEALTHCARE", "plan_name": "SUTTER SELECT & SUTTER HEALTH PLAN HMO PLANS", "methodology": "per diem", "standard_charge_dollar": 28538.0, "standard_charge_algorithm": "Per diem ($28,538).", "count": "0", "additional_payer_notes": "Zero final payments for the item or service in the 15 months prior to posting the file." }, { "payer_name": "SUTTER", "plan_name": "SUTTER SELECT & SUTTER HEALTH PLAN HMO PLANS", "methodology": "per diem", "standard_charge_dollar": 28538.0, "standard_charge_algorithm": "Per diem ($28,538).", "count": "0", "additional_payer_notes": "Zero final payments for the item or service in the 15 months prior to posting the file." }, { "payer_name": "UNITED HEALTHCARE", "plan_name": "SUTTER SELECT & SUTTER HEALTH PLAN HMO PLANS", "methodology": "per diem", "standard_charge_dollar": 28538.0, "standard_charge_algorithm": "Per diem ($28,538).", "count": "0", "additional_payer_notes": "Zero final payments for the item or service in the 15 months prior to posting the file." }, { "payer_name": "UMR", "plan_name": "SUTTER SELECT & SUTTER HEALTH PLAN HMO PLANS", "methodology": "per diem", "standard_charge_dollar": 28538.0, "standard_charge_algorithm": "Per diem ($28,538).", "count": "0", "additional_payer_notes": "Zero final payments for the item or service in the 15 months prior to posting the file." } ] } ] }, { "description": "HC Drill Bit Gp033", "code_information": [ { "code": "PX-2120061033", "type": "CDM" }, { "code": "99999", "type": "CPT" }, { "code": "0272", "type": "RC" } ], "standard_charges": [ { "setting": "outpatient", "gross_charge": 6413.0, "discounted_cash": 3206.5, "minimum": 2706.29, "maximum": 3334.76, "additional_generic_notes": "Zero final payments for the item or service in the 15 months prior to posting the file.", "payers_information": [ { "payer_name": "AETNA", "plan_name": "AETNA ALL OTHER PLANS", "methodology": "percent of total billed charges", "standard_charge_dollar": 3334.76, "standard_charge_percentage": 52.0, "count": "0", "additional_payer_notes": "Zero final payments for the item or service in the 15 months prior to posting the file." }, { "payer_name": "AETNA", "plan_name": "AETNA ALL OTHER PLANS", "methodology": "percent of total billed charges", "standard_charge_dollar": 3334.76, "standard_charge_percentage": 52.0, "count": "0", "additional_payer_notes": "Zero final payments for the item or service in the 15 months prior to posting the file." }, { "payer_name": "MERITAIN HEALTH", "plan_name": "AETNA ALL OTHER PLANS", "methodology": "percent of total billed charges", "standard_charge_dollar": 3334.76, "standard_charge_percentage": 52.0, "count": "0", "additional_payer_notes": "Zero final payments for the item or service in the 15 months prior to posting the file." }, { "payer_name": "BLUE SHIELD OUT OF STATE", "plan_name": "STANFORD HEALTHCARE ALLIANCE PLAN", "methodology": "percent of total billed charges", "standard_charge_dollar": 3116.08, "standard_charge_percentage": 48.59, "count": "0", "additional_payer_notes": "Zero final payments for the item or service in the 15 months prior to posting the file." }, { "payer_name": "BLUE SHIELD", "plan_name": "STANFORD HEALTHCARE ALLIANCE PLAN", "methodology": "percent of total billed charges", "standard_charge_dollar": 3116.08, "standard_charge_percentage": 48.59, "median_amount": 68.24, "10th_percentile": 13.6, "90th_percentile": 1043.06, "count": "30" }, { "payer_name": "BLUE SHIELD", "plan_name": "STANFORD HEALTHCARE ALLIANCE PLAN", "methodology": "percent of total billed charges", "standard_charge_dollar": 3116.08, "standard_charge_percentage": 48.59, "count": "0", "additional_payer_notes": "Zero final payments for the item or service in the 15 months prior to posting the file." }, { "payer_name": "BLUE SHIELD", "plan_name": "STANFORD HEALTHCARE ALLIANCE PLAN", "methodology": "percent of total billed charges", "standard_charge_dollar": 3116.08, "standard_charge_percentage": 48.59, "count": "0", "additional_payer_notes": "Zero final payments for the item or service in the 15 months prior to posting the file." }, { "payer_name": "CIGNA", "plan_name": "CIGNA COM ALT HMO PLAN", "methodology": "percent of total billed charges", "standard_charge_dollar": 2706.29, "standard_charge_percentage": 42.2, "count": "0", "additional_payer_notes": "Zero final payments for the item or service in the 15 months prior to posting the file." }, { "payer_name": "CIGNA", "plan_name": "CIGNA COM ALT HMO PLAN", "methodology": "percent of total billed charges", "standard_charge_dollar": 2706.29, "standard_charge_percentage": 42.2, "count": "0", "additional_payer_notes": "Zero final payments for the item or service in the 15 months prior to posting the file." }, { "payer_name": "HEALTH NET", "plan_name": "HEALTHNET HMO, PPO, POS, EPO, CANOPY HEALTHNET HMO, OTHER-IN-NETWORK PLANS", "methodology": "per diem", "standard_charge_dollar": 8000.0, "standard_charge_algorithm": "Expected reimbursement is the lesser of Per diem ($8,000) for the length of stay and 70% of billed.", "count": "0", "additional_payer_notes": "Zero final payments for the item or service in the 15 months prior to posting the file." }, { "payer_name": "HEALTH NET", "plan_name": "HEALTHNET HMO, PPO, POS, EPO, CANOPY HEALTHNET HMO, OTHER-IN-NETWORK PLANS", "methodology": "per diem", "standard_charge_dollar": 8000.0, "standard_charge_algorithm": "Expected reimbursement is the lesser of Per diem ($8,000) for the length of stay and 70% of billed.", "count": "0", "additional_payer_notes": "Zero final payments for the item or service in the 15 months prior to posting the file." }, { "payer_name": "UNITED HEALTHCARE", "plan_name": "SUTTER SELECT & SUTTER HEALTH PLAN HMO PLANS", "methodology": "per diem", "standard_charge_dollar": 28538.0, "standard_charge_algorithm": "Per diem ($28,538).", "count": "0", "additional_payer_notes": "Zero final payments for the item or service in the 15 months prior to posting the file." }, { "payer_name": "UNITED HEALTHCARE", "plan_name": "SUTTER SELECT & SUTTER HEALTH PLAN HMO PLANS", "methodology": "per diem", "standard_charge_dollar": 28538.0, "standard_charge_algorithm": "Per diem ($28,538).", "count": "0", "additional_payer_notes": "Zero final payments for the item or service in the 15 months prior to posting the file." }, { "payer_name": "SUTTER", "plan_name": "SUTTER SELECT & SUTTER HEALTH PLAN HMO PLANS", "methodology": "per diem", "standard_charge_dollar": 28538.0, "standard_charge_algorithm": "Per diem ($28,538).", "count": "0", "additional_payer_notes": "Zero final payments for the item or service in the 15 months prior to posting the file." }, { "payer_name": "UNITED HEALTHCARE", "plan_name": "SUTTER SELECT & SUTTER HEALTH PLAN HMO PLANS", "methodology": "per diem", "standard_charge_dollar": 28538.0, "standard_charge_algorithm": "Per diem ($28,538).", "count": "0", "additional_payer_notes": "Zero final payments for the item or service in the 15 months prior to posting the file." }, { "payer_name": "UMR", "plan_name": "SUTTER SELECT & SUTTER HEALTH PLAN HMO PLANS", "methodology": "per diem", "standard_charge_dollar": 28538.0, "standard_charge_algorithm": "Per diem ($28,538).", "count": "0", "additional_payer_notes": "Zero final payments for the item or service in the 15 months prior to posting the file." } ] } ] }, { "description": "HC Drill Bit Gp034", "code_information": [ { "code": "PX-2120061034", "type": "CDM" }, { "code": "99999", "type": "CPT" }, { "code": "0272", "type": "RC" } ], "standard_charges": [ { "setting": "outpatient", "gross_charge": 6750.0, "discounted_cash": 3375.0, "minimum": 2848.5, "maximum": 3510.0, "additional_generic_notes": "Zero final payments for the item or service in the 15 months prior to posting the file.", "payers_information": [ { "payer_name": "AETNA", "plan_name": "AETNA ALL OTHER PLANS", "methodology": "percent of total billed charges", "standard_charge_dollar": 3510.0, "standard_charge_percentage": 52.0, "count": "0", "additional_payer_notes": "Zero final payments for the item or service in the 15 months prior to posting the file." }, { "payer_name": "AETNA", "plan_name": "AETNA ALL OTHER PLANS", "methodology": "percent of total billed charges", "standard_charge_dollar": 3510.0, "standard_charge_percentage": 52.0, "count": "0", "additional_payer_notes": "Zero final payments for the item or service in the 15 months prior to posting the file." }, { "payer_name": "MERITAIN HEALTH", "plan_name": "AETNA ALL OTHER PLANS", "methodology": "percent of total billed charges", "standard_charge_dollar": 3510.0, "standard_charge_percentage": 52.0, "count": "0", "additional_payer_notes": "Zero final payments for the item or service in the 15 months prior to posting the file." }, { "payer_name": "BLUE SHIELD OUT OF STATE", "plan_name": "STANFORD HEALTHCARE ALLIANCE PLAN", "methodology": "percent of total billed charges", "standard_charge_dollar": 3279.83, "standard_charge_percentage": 48.59, "count": "0", "additional_payer_notes": "Zero final payments for the item or service in the 15 months prior to posting the file." }, { "payer_name": "BLUE SHIELD", "plan_name": "STANFORD HEALTHCARE ALLIANCE PLAN", "methodology": "percent of total billed charges", "standard_charge_dollar": 3279.83, "standard_charge_percentage": 48.59, "median_amount": 68.24, "10th_percentile": 13.6, "90th_percentile": 1043.06, "count": "30" }, { "payer_name": "BLUE SHIELD", "plan_name": "STANFORD HEALTHCARE ALLIANCE PLAN", "methodology": "percent of total billed charges", "standard_charge_dollar": 3279.83, "standard_charge_percentage": 48.59, "count": "0", "additional_payer_notes": "Zero final payments for the item or service in the 15 months prior to posting the file." }, { "payer_name": "BLUE SHIELD", "plan_name": "STANFORD HEALTHCARE ALLIANCE PLAN", "methodology": "percent of total billed charges", "standard_charge_dollar": 3279.83, "standard_charge_percentage": 48.59, "count": "0", "additional_payer_notes": "Zero final payments for the item or service in the 15 months prior to posting the file." }, { "payer_name": "CIGNA", "plan_name": "CIGNA COM ALT HMO PLAN", "methodology": "percent of total billed charges", "standard_charge_dollar": 2848.5, "standard_charge_percentage": 42.2, "count": "0", "additional_payer_notes": "Zero final payments for the item or service in the 15 months prior to posting the file." }, { "payer_name": "CIGNA", "plan_name": "CIGNA COM ALT HMO PLAN", "methodology": "percent of total billed charges", "standard_charge_dollar": 2848.5, "standard_charge_percentage": 42.2, "count": "0", "additional_payer_notes": "Zero final payments for the item or service in the 15 months prior to posting the file." }, { "payer_name": "HEALTH NET", "plan_name": "HEALTHNET HMO, PPO, POS, EPO, CANOPY HEALTHNET HMO, OTHER-IN-NETWORK PLANS", "methodology": "per diem", "standard_charge_dollar": 8000.0, "standard_charge_algorithm": "Expected reimbursement is the lesser of Per diem ($8,000) for the length of stay and 70% of billed.", "count": "0", "additional_payer_notes": "Zero final payments for the item or service in the 15 months prior to posting the file." }, { "payer_name": "HEALTH NET", "plan_name": "HEALTHNET HMO, PPO, POS, EPO, CANOPY HEALTHNET HMO, OTHER-IN-NETWORK PLANS", "methodology": "per diem", "standard_charge_dollar": 8000.0, "standard_charge_algorithm": "Expected reimbursement is the lesser of Per diem ($8,000) for the length of stay and 70% of billed.", "count": "0", "additional_payer_notes": "Zero final payments for the item or service in the 15 months prior to posting the file." }, { "payer_name": "UNITED HEALTHCARE", "plan_name": "SUTTER SELECT & SUTTER HEALTH PLAN HMO PLANS", "methodology": "per diem", "standard_charge_dollar": 28538.0, "standard_charge_algorithm": "Per diem ($28,538).", "count": "0", "additional_payer_notes": "Zero final payments for the item or service in the 15 months prior to posting the file." }, { "payer_name": "UNITED HEALTHCARE", "plan_name": "SUTTER SELECT & SUTTER HEALTH PLAN HMO PLANS", "methodology": "per diem", "standard_charge_dollar": 28538.0, "standard_charge_algorithm": "Per diem ($28,538).", "count": "0", "additional_payer_notes": "Zero final payments for the item or service in the 15 months prior to posting the file." }, { "payer_name": "SUTTER", "plan_name": "SUTTER SELECT & SUTTER HEALTH PLAN HMO PLANS", "methodology": "per diem", "standard_charge_dollar": 28538.0, "standard_charge_algorithm": "Per diem ($28,538).", "count": "0", "additional_payer_notes": "Zero final payments for the item or service in the 15 months prior to posting the file." }, { "payer_name": "UNITED HEALTHCARE", "plan_name": "SUTTER SELECT & SUTTER HEALTH PLAN HMO PLANS", "methodology": "per diem", "standard_charge_dollar": 28538.0, "standard_charge_algorithm": "Per diem ($28,538).", "count": "0", "additional_payer_notes": "Zero final payments for the item or service in the 15 months prior to posting the file." }, { "payer_name": "UMR", "plan_name": "SUTTER SELECT & SUTTER HEALTH PLAN HMO PLANS", "methodology": "per diem", "standard_charge_dollar": 28538.0, "standard_charge_algorithm": "Per diem ($28,538).", "count": "0", "additional_payer_notes": "Zero final payments for the item or service in the 15 months prior to posting the file." } ] } ] }, { "description": "HC Drill Bit Gp035", "code_information": [ { "code": "PX-2120061038", "type": "CDM" }, { "code": "99999", "type": "CPT" }, { "code": "0272", "type": "RC" } ], "standard_charges": [ { "setting": "outpatient", "gross_charge": 1750.0, "discounted_cash": 875.0, "minimum": 738.5, "maximum": 910.0, "additional_generic_notes": "Zero final payments for the item or service in the 15 months prior to posting the file.", "payers_information": [ { "payer_name": "AETNA", "plan_name": "AETNA ALL OTHER PLANS", "methodology": "percent of total billed charges", "standard_charge_dollar": 910.0, "standard_charge_percentage": 52.0, "count": "0", "additional_payer_notes": "Zero final payments for the item or service in the 15 months prior to posting the file." }, { "payer_name": "AETNA", "plan_name": "AETNA ALL OTHER PLANS", "methodology": "percent of total billed charges", "standard_charge_dollar": 910.0, "standard_charge_percentage": 52.0, "count": "0", "additional_payer_notes": "Zero final payments for the item or service in the 15 months prior to posting the file." }, { "payer_name": "MERITAIN HEALTH", "plan_name": "AETNA ALL OTHER PLANS", "methodology": "percent of total billed charges", "standard_charge_dollar": 910.0, "standard_charge_percentage": 52.0, "count": "0", "additional_payer_notes": "Zero final payments for the item or service in the 15 months prior to posting the file." }, { "payer_name": "BLUE SHIELD OUT OF STATE", "plan_name": "STANFORD HEALTHCARE ALLIANCE PLAN", "methodology": "percent of total billed charges", "standard_charge_dollar": 850.33, "standard_charge_percentage": 48.59, "count": "0", "additional_payer_notes": "Zero final payments for the item or service in the 15 months prior to posting the file." }, { "payer_name": "BLUE SHIELD", "plan_name": "STANFORD HEALTHCARE ALLIANCE PLAN", "methodology": "percent of total billed charges", "standard_charge_dollar": 850.33, "standard_charge_percentage": 48.59, "median_amount": 68.24, "10th_percentile": 13.6, "90th_percentile": 1043.06, "count": "30" }, { "payer_name": "BLUE SHIELD", "plan_name": "STANFORD HEALTHCARE ALLIANCE PLAN", "methodology": "percent of total billed charges", "standard_charge_dollar": 850.33, "standard_charge_percentage": 48.59, "count": "0", "additional_payer_notes": "Zero final payments for the item or service in the 15 months prior to posting the file." }, { "payer_name": "BLUE SHIELD", "plan_name": "STANFORD HEALTHCARE ALLIANCE PLAN", "methodology": "percent of total billed charges", "standard_charge_dollar": 850.33, "standard_charge_percentage": 48.59, "count": "0", "additional_payer_notes": "Zero final payments for the item or service in the 15 months prior to posting the file." }, { "payer_name": "CIGNA", "plan_name": "CIGNA COM ALT HMO PLAN", "methodology": "percent of total billed charges", "standard_charge_dollar": 738.5, "standard_charge_percentage": 42.2, "count": "0", "additional_payer_notes": "Zero final payments for the item or service in the 15 months prior to posting the file." }, { "payer_name": "CIGNA", "plan_name": "CIGNA COM ALT HMO PLAN", "methodology": "percent of total billed charges", "standard_charge_dollar": 738.5, "standard_charge_percentage": 42.2, "count": "0", "additional_payer_notes": "Zero final payments for the item or service in the 15 months prior to posting the file." }, { "payer_name": "HEALTH NET", "plan_name": "HEALTHNET HMO, PPO, POS, EPO, CANOPY HEALTHNET HMO, OTHER-IN-NETWORK PLANS", "methodology": "per diem", "standard_charge_dollar": 8000.0, "standard_charge_algorithm": "Expected reimbursement is the lesser of Per diem ($8,000) for the length of stay and 70% of billed.", "count": "0", "additional_payer_notes": "Zero final payments for the item or service in the 15 months prior to posting the file." }, { "payer_name": "HEALTH NET", "plan_name": "HEALTHNET HMO, PPO, POS, EPO, CANOPY HEALTHNET HMO, OTHER-IN-NETWORK PLANS", "methodology": "per diem", "standard_charge_dollar": 8000.0, "standard_charge_algorithm": "Expected reimbursement is the lesser of Per diem ($8,000) for the length of stay and 70% of billed.", "count": "0", "additional_payer_notes": "Zero final payments for the item or service in the 15 months prior to posting the file." }, { "payer_name": "UNITED HEALTHCARE", "plan_name": "SUTTER SELECT & SUTTER HEALTH PLAN HMO PLANS", "methodology": "per diem", "standard_charge_dollar": 28538.0, "standard_charge_algorithm": "Per diem ($28,538).", "count": "0", "additional_payer_notes": "Zero final payments for the item or service in the 15 months prior to posting the file." }, { "payer_name": "UNITED HEALTHCARE", "plan_name": "SUTTER SELECT & SUTTER HEALTH PLAN HMO PLANS", "methodology": "per diem", "standard_charge_dollar": 28538.0, "standard_charge_algorithm": "Per diem ($28,538).", "count": "0", "additional_payer_notes": "Zero final payments for the item or service in the 15 months prior to posting the file." }, { "payer_name": "SUTTER", "plan_name": "SUTTER SELECT & SUTTER HEALTH PLAN HMO PLANS", "methodology": "per diem", "standard_charge_dollar": 28538.0, "standard_charge_algorithm": "Per diem ($28,538).", "count": "0", "additional_payer_notes": "Zero final payments for the item or service in the 15 months prior to posting the file." }, { "payer_name": "UNITED HEALTHCARE", "plan_name": "SUTTER SELECT & SUTTER HEALTH PLAN HMO PLANS", "methodology": "per diem", "standard_charge_dollar": 28538.0, "standard_charge_algorithm": "Per diem ($28,538).", "count": "0", "additional_payer_notes": "Zero final payments for the item or service in the 15 months prior to posting the file." }, { "payer_name": "UMR", "plan_name": "SUTTER SELECT & SUTTER HEALTH PLAN HMO PLANS", "methodology": "per diem", "standard_charge_dollar": 28538.0, "standard_charge_algorithm": "Per diem ($28,538).", "count": "0", "additional_payer_notes": "Zero final payments for the item or service in the 15 months prior to posting the file." } ] } ] }, { "description": "HC Electrode Depth Gp014", "code_information": [ { "code": "PX-2120062014", "type": "CDM" }, { "code": "99999", "type": "CPT" }, { "code": "0272", "type": "RC" } ], "standard_charges": [ { "setting": "outpatient", "gross_charge": 1080.0, "discounted_cash": 540.0, "minimum": 455.76, "maximum": 561.6, "additional_generic_notes": "Zero final payments for the item or service in the 15 months prior to posting the file.", "payers_information": [ { "payer_name": "AETNA", "plan_name": "AETNA ALL OTHER PLANS", "methodology": "percent of total billed charges", "standard_charge_dollar": 561.6, "standard_charge_percentage": 52.0, "count": "0", "additional_payer_notes": "Zero final payments for the item or service in the 15 months prior to posting the file." }, { "payer_name": "AETNA", "plan_name": "AETNA ALL OTHER PLANS", "methodology": "percent of total billed charges", "standard_charge_dollar": 561.6, "standard_charge_percentage": 52.0, "count": "0", "additional_payer_notes": "Zero final payments for the item or service in the 15 months prior to posting the file." }, { "payer_name": "MERITAIN HEALTH", "plan_name": "AETNA ALL OTHER PLANS", "methodology": "percent of total billed charges", "standard_charge_dollar": 561.6, "standard_charge_percentage": 52.0, "count": "0", "additional_payer_notes": "Zero final payments for the item or service in the 15 months prior to posting the file." }, { "payer_name": "BLUE SHIELD OUT OF STATE", "plan_name": "STANFORD HEALTHCARE ALLIANCE PLAN", "methodology": "percent of total billed charges", "standard_charge_dollar": 524.77, "standard_charge_percentage": 48.59, "count": "0", "additional_payer_notes": "Zero final payments for the item or service in the 15 months prior to posting the file." }, { "payer_name": "BLUE SHIELD", "plan_name": "STANFORD HEALTHCARE ALLIANCE PLAN", "methodology": "percent of total billed charges", "standard_charge_dollar": 524.77, "standard_charge_percentage": 48.59, "median_amount": 68.24, "10th_percentile": 13.6, "90th_percentile": 1043.06, "count": "30" }, { "payer_name": "BLUE SHIELD", "plan_name": "STANFORD HEALTHCARE ALLIANCE PLAN", "methodology": "percent of total billed charges", "standard_charge_dollar": 524.77, "standard_charge_percentage": 48.59, "count": "0", "additional_payer_notes": "Zero final payments for the item or service in the 15 months prior to posting the file." }, { "payer_name": "BLUE SHIELD", "plan_name": "STANFORD HEALTHCARE ALLIANCE PLAN", "methodology": "percent of total billed charges", "standard_charge_dollar": 524.77, "standard_charge_percentage": 48.59, "count": "0", "additional_payer_notes": "Zero final payments for the item or service in the 15 months prior to posting the file." }, { "payer_name": "CIGNA", "plan_name": "CIGNA COM ALT HMO PLAN", "methodology": "percent of total billed charges", "standard_charge_dollar": 455.76, "standard_charge_percentage": 42.2, "count": "0", "additional_payer_notes": "Zero final payments for the item or service in the 15 months prior to posting the file." }, { "payer_name": "CIGNA", "plan_name": "CIGNA COM ALT HMO PLAN", "methodology": "percent of total billed charges", "standard_charge_dollar": 455.76, "standard_charge_percentage": 42.2, "count": "0", "additional_payer_notes": "Zero final payments for the item or service in the 15 months prior to posting the file." }, { "payer_name": "HEALTH NET", "plan_name": "HEALTHNET HMO, PPO, POS, EPO, CANOPY HEALTHNET HMO, OTHER-IN-NETWORK PLANS", "methodology": "per diem", "standard_charge_dollar": 8000.0, "standard_charge_algorithm": "Expected reimbursement is the lesser of Per diem ($8,000) for the length of stay and 70% of billed.", "count": "0", "additional_payer_notes": "Zero final payments for the item or service in the 15 months prior to posting the file." }, { "payer_name": "HEALTH NET", "plan_name": "HEALTHNET HMO, PPO, POS, EPO, CANOPY HEALTHNET HMO, OTHER-IN-NETWORK PLANS", "methodology": "per diem", "standard_charge_dollar": 8000.0, "standard_charge_algorithm": "Expected reimbursement is the lesser of Per diem ($8,000) for the length of stay and 70% of billed.", "count": "0", "additional_payer_notes": "Zero final payments for the item or service in the 15 months prior to posting the file." }, { "payer_name": "UNITED HEALTHCARE", "plan_name": "SUTTER SELECT & SUTTER HEALTH PLAN HMO PLANS", "methodology": "per diem", "standard_charge_dollar": 28538.0, "standard_charge_algorithm": "Per diem ($28,538).", "count": "0", "additional_payer_notes": "Zero final payments for the item or service in the 15 months prior to posting the file." }, { "payer_name": "UNITED HEALTHCARE", "plan_name": "SUTTER SELECT & SUTTER HEALTH PLAN HMO PLANS", "methodology": "per diem", "standard_charge_dollar": 28538.0, "standard_charge_algorithm": "Per diem ($28,538).", "count": "0", "additional_payer_notes": "Zero final payments for the item or service in the 15 months prior to posting the file." }, { "payer_name": "SUTTER", "plan_name": "SUTTER SELECT & SUTTER HEALTH PLAN HMO PLANS", "methodology": "per diem", "standard_charge_dollar": 28538.0, "standard_charge_algorithm": "Per diem ($28,538).", "count": "0", "additional_payer_notes": "Zero final payments for the item or service in the 15 months prior to posting the file." }, { "payer_name": "UNITED HEALTHCARE", "plan_name": "SUTTER SELECT & SUTTER HEALTH PLAN HMO PLANS", "methodology": "per diem", "standard_charge_dollar": 28538.0, "standard_charge_algorithm": "Per diem ($28,538).", "count": "0", "additional_payer_notes": "Zero final payments for the item or service in the 15 months prior to posting the file." }, { "payer_name": "UMR", "plan_name": "SUTTER SELECT & SUTTER HEALTH PLAN HMO PLANS", "methodology": "per diem", "standard_charge_dollar": 28538.0, "standard_charge_algorithm": "Per diem ($28,538).", "count": "0", "additional_payer_notes": "Zero final payments for the item or service in the 15 months prior to posting the file." } ] } ] }, { "description": "HC Electrode Depth Gp026", "code_information": [ { "code": "PX-2120062026", "type": "CDM" }, { "code": "99999", "type": "CPT" }, { "code": "0272", "type": "RC" } ], "standard_charges": [ { "setting": "outpatient", "gross_charge": 4650.0, "discounted_cash": 2325.0, "minimum": 1962.3, "maximum": 2418.0, "additional_generic_notes": "Zero final payments for the item or service in the 15 months prior to posting the file.", "payers_information": [ { "payer_name": "AETNA", "plan_name": "AETNA ALL OTHER PLANS", "methodology": "percent of total billed charges", "standard_charge_dollar": 2418.0, "standard_charge_percentage": 52.0, "count": "0", "additional_payer_notes": "Zero final payments for the item or service in the 15 months prior to posting the file." }, { "payer_name": "AETNA", "plan_name": "AETNA ALL OTHER PLANS", "methodology": "percent of total billed charges", "standard_charge_dollar": 2418.0, "standard_charge_percentage": 52.0, "count": "0", "additional_payer_notes": "Zero final payments for the item or service in the 15 months prior to posting the file." }, { "payer_name": "MERITAIN HEALTH", "plan_name": "AETNA ALL OTHER PLANS", "methodology": "percent of total billed charges", "standard_charge_dollar": 2418.0, "standard_charge_percentage": 52.0, "count": "0", "additional_payer_notes": "Zero final payments for the item or service in the 15 months prior to posting the file." }, { "payer_name": "BLUE SHIELD OUT OF STATE", "plan_name": "STANFORD HEALTHCARE ALLIANCE PLAN", "methodology": "percent of total billed charges", "standard_charge_dollar": 2259.44, "standard_charge_percentage": 48.59, "count": "0", "additional_payer_notes": "Zero final payments for the item or service in the 15 months prior to posting the file." }, { "payer_name": "BLUE SHIELD", "plan_name": "STANFORD HEALTHCARE ALLIANCE PLAN", "methodology": "percent of total billed charges", "standard_charge_dollar": 2259.44, "standard_charge_percentage": 48.59, "median_amount": 68.24, "10th_percentile": 13.6, "90th_percentile": 1043.06, "count": "30" }, { "payer_name": "BLUE SHIELD", "plan_name": "STANFORD HEALTHCARE ALLIANCE PLAN", "methodology": "percent of total billed charges", "standard_charge_dollar": 2259.44, "standard_charge_percentage": 48.59, "count": "0", "additional_payer_notes": "Zero final payments for the item or service in the 15 months prior to posting the file." }, { "payer_name": "BLUE SHIELD", "plan_name": "STANFORD HEALTHCARE ALLIANCE PLAN", "methodology": "percent of total billed charges", "standard_charge_dollar": 2259.44, "standard_charge_percentage": 48.59, "count": "0", "additional_payer_notes": "Zero final payments for the item or service in the 15 months prior to posting the file." }, { "payer_name": "CIGNA", "plan_name": "CIGNA COM ALT HMO PLAN", "methodology": "percent of total billed charges", "standard_charge_dollar": 1962.3, "standard_charge_percentage": 42.2, "count": "0", "additional_payer_notes": "Zero final payments for the item or service in the 15 months prior to posting the file." }, { "payer_name": "CIGNA", "plan_name": "CIGNA COM ALT HMO PLAN", "methodology": "percent of total billed charges", "standard_charge_dollar": 1962.3, "standard_charge_percentage": 42.2, "count": "0", "additional_payer_notes": "Zero final payments for the item or service in the 15 months prior to posting the file." }, { "payer_name": "HEALTH NET", "plan_name": "HEALTHNET HMO, PPO, POS, EPO, CANOPY HEALTHNET HMO, OTHER-IN-NETWORK PLANS", "methodology": "per diem", "standard_charge_dollar": 8000.0, "standard_charge_algorithm": "Expected reimbursement is the lesser of Per diem ($8,000) for the length of stay and 70% of billed.", "count": "0", "additional_payer_notes": "Zero final payments for the item or service in the 15 months prior to posting the file." }, { "payer_name": "HEALTH NET", "plan_name": "HEALTHNET HMO, PPO, POS, EPO, CANOPY HEALTHNET HMO, OTHER-IN-NETWORK PLANS", "methodology": "per diem", "standard_charge_dollar": 8000.0, "standard_charge_algorithm": "Expected reimbursement is the lesser of Per diem ($8,000) for the length of stay and 70% of billed.", "count": "0", "additional_payer_notes": "Zero final payments for the item or service in the 15 months prior to posting the file." }, { "payer_name": "UNITED HEALTHCARE", "plan_name": "SUTTER SELECT & SUTTER HEALTH PLAN HMO PLANS", "methodology": "per diem", "standard_charge_dollar": 28538.0, "standard_charge_algorithm": "Per diem ($28,538).", "count": "0", "additional_payer_notes": "Zero final payments for the item or service in the 15 months prior to posting the file." }, { "payer_name": "UNITED HEALTHCARE", "plan_name": "SUTTER SELECT & SUTTER HEALTH PLAN HMO PLANS", "methodology": "per diem", "standard_charge_dollar": 28538.0, "standard_charge_algorithm": "Per diem ($28,538).", "count": "0", "additional_payer_notes": "Zero final payments for the item or service in the 15 months prior to posting the file." }, { "payer_name": "SUTTER", "plan_name": "SUTTER SELECT & SUTTER HEALTH PLAN HMO PLANS", "methodology": "per diem", "standard_charge_dollar": 28538.0, "standard_charge_algorithm": "Per diem ($28,538).", "count": "0", "additional_payer_notes": "Zero final payments for the item or service in the 15 months prior to posting the file." }, { "payer_name": "UNITED HEALTHCARE", "plan_name": "SUTTER SELECT & SUTTER HEALTH PLAN HMO PLANS", "methodology": "per diem", "standard_charge_dollar": 28538.0, "standard_charge_algorithm": "Per diem ($28,538).", "count": "0", "additional_payer_notes": "Zero final payments for the item or service in the 15 months prior to posting the file." }, { "payer_name": "UMR", "plan_name": "SUTTER SELECT & SUTTER HEALTH PLAN HMO PLANS", "methodology": "per diem", "standard_charge_dollar": 28538.0, "standard_charge_algorithm": "Per diem ($28,538).", "count": "0", "additional_payer_notes": "Zero final payments for the item or service in the 15 months prior to posting the file." } ] } ] }, { "description": "HC Electrode Depth Gp027", "code_information": [ { "code": "PX-2120062027", "type": "CDM" }, { "code": "99999", "type": "CPT" }, { "code": "0272", "type": "RC" } ], "standard_charges": [ { "setting": "outpatient", "gross_charge": 4875.0, "discounted_cash": 2437.5, "minimum": 2057.25, "maximum": 2535.0, "additional_generic_notes": "Zero final payments for the item or service in the 15 months prior to posting the file.", "payers_information": [ { "payer_name": "AETNA", "plan_name": "AETNA ALL OTHER PLANS", "methodology": "percent of total billed charges", "standard_charge_dollar": 2535.0, "standard_charge_percentage": 52.0, "count": "0", "additional_payer_notes": "Zero final payments for the item or service in the 15 months prior to posting the file." }, { "payer_name": "AETNA", "plan_name": "AETNA ALL OTHER PLANS", "methodology": "percent of total billed charges", "standard_charge_dollar": 2535.0, "standard_charge_percentage": 52.0, "count": "0", "additional_payer_notes": "Zero final payments for the item or service in the 15 months prior to posting the file." }, { "payer_name": "MERITAIN HEALTH", "plan_name": "AETNA ALL OTHER PLANS", "methodology": "percent of total billed charges", "standard_charge_dollar": 2535.0, "standard_charge_percentage": 52.0, "count": "0", "additional_payer_notes": "Zero final payments for the item or service in the 15 months prior to posting the file." }, { "payer_name": "BLUE SHIELD OUT OF STATE", "plan_name": "STANFORD HEALTHCARE ALLIANCE PLAN", "methodology": "percent of total billed charges", "standard_charge_dollar": 2368.76, "standard_charge_percentage": 48.59, "count": "0", "additional_payer_notes": "Zero final payments for the item or service in the 15 months prior to posting the file." }, { "payer_name": "BLUE SHIELD", "plan_name": "STANFORD HEALTHCARE ALLIANCE PLAN", "methodology": "percent of total billed charges", "standard_charge_dollar": 2368.76, "standard_charge_percentage": 48.59, "median_amount": 68.24, "10th_percentile": 13.6, "90th_percentile": 1043.06, "count": "30" }, { "payer_name": "BLUE SHIELD", "plan_name": "STANFORD HEALTHCARE ALLIANCE PLAN", "methodology": "percent of total billed charges", "standard_charge_dollar": 2368.76, "standard_charge_percentage": 48.59, "count": "0", "additional_payer_notes": "Zero final payments for the item or service in the 15 months prior to posting the file." }, { "payer_name": "BLUE SHIELD", "plan_name": "STANFORD HEALTHCARE ALLIANCE PLAN", "methodology": "percent of total billed charges", "standard_charge_dollar": 2368.76, "standard_charge_percentage": 48.59, "count": "0", "additional_payer_notes": "Zero final payments for the item or service in the 15 months prior to posting the file." }, { "payer_name": "CIGNA", "plan_name": "CIGNA COM ALT HMO PLAN", "methodology": "percent of total billed charges", "standard_charge_dollar": 2057.25, "standard_charge_percentage": 42.2, "count": "0", "additional_payer_notes": "Zero final payments for the item or service in the 15 months prior to posting the file." }, { "payer_name": "CIGNA", "plan_name": "CIGNA COM ALT HMO PLAN", "methodology": "percent of total billed charges", "standard_charge_dollar": 2057.25, "standard_charge_percentage": 42.2, "count": "0", "additional_payer_notes": "Zero final payments for the item or service in the 15 months prior to posting the file." }, { "payer_name": "HEALTH NET", "plan_name": "HEALTHNET HMO, PPO, POS, EPO, CANOPY HEALTHNET HMO, OTHER-IN-NETWORK PLANS", "methodology": "per diem", "standard_charge_dollar": 8000.0, "standard_charge_algorithm": "Expected reimbursement is the lesser of Per diem ($8,000) for the length of stay and 70% of billed.", "count": "0", "additional_payer_notes": "Zero final payments for the item or service in the 15 months prior to posting the file." }, { "payer_name": "HEALTH NET", "plan_name": "HEALTHNET HMO, PPO, POS, EPO, CANOPY HEALTHNET HMO, OTHER-IN-NETWORK PLANS", "methodology": "per diem", "standard_charge_dollar": 8000.0, "standard_charge_algorithm": "Expected reimbursement is the lesser of Per diem ($8,000) for the length of stay and 70% of billed.", "count": "0", "additional_payer_notes": "Zero final payments for the item or service in the 15 months prior to posting the file." }, { "payer_name": "UNITED HEALTHCARE", "plan_name": "SUTTER SELECT & SUTTER HEALTH PLAN HMO PLANS", "methodology": "per diem", "standard_charge_dollar": 28538.0, "standard_charge_algorithm": "Per diem ($28,538).", "count": "0", "additional_payer_notes": "Zero final payments for the item or service in the 15 months prior to posting the file." }, { "payer_name": "UNITED HEALTHCARE", "plan_name": "SUTTER SELECT & SUTTER HEALTH PLAN HMO PLANS", "methodology": "per diem", "standard_charge_dollar": 28538.0, "standard_charge_algorithm": "Per diem ($28,538).", "count": "0", "additional_payer_notes": "Zero final payments for the item or service in the 15 months prior to posting the file." }, { "payer_name": "SUTTER", "plan_name": "SUTTER SELECT & SUTTER HEALTH PLAN HMO PLANS", "methodology": "per diem", "standard_charge_dollar": 28538.0, "standard_charge_algorithm": "Per diem ($28,538).", "count": "0", "additional_payer_notes": "Zero final payments for the item or service in the 15 months prior to posting the file." }, { "payer_name": "UNITED HEALTHCARE", "plan_name": "SUTTER SELECT & SUTTER HEALTH PLAN HMO PLANS", "methodology": "per diem", "standard_charge_dollar": 28538.0, "standard_charge_algorithm": "Per diem ($28,538).", "count": "0", "additional_payer_notes": "Zero final payments for the item or service in the 15 months prior to posting the file." }, { "payer_name": "UMR", "plan_name": "SUTTER SELECT & SUTTER HEALTH PLAN HMO PLANS", "methodology": "per diem", "standard_charge_dollar": 28538.0, "standard_charge_algorithm": "Per diem ($28,538).", "count": "0", "additional_payer_notes": "Zero final payments for the item or service in the 15 months prior to posting the file." } ] } ] }, { "description": "HC Electrode Depth Gp028", "code_information": [ { "code": "PX-2120062028", "type": "CDM" }, { "code": "99999", "type": "CPT" }, { "code": "0272", "type": "RC" } ], "standard_charges": [ { "setting": "outpatient", "gross_charge": 5250.0, "discounted_cash": 2625.0, "minimum": 2215.5, "maximum": 2730.0, "additional_generic_notes": "Zero final payments for the item or service in the 15 months prior to posting the file.", "payers_information": [ { "payer_name": "AETNA", "plan_name": "AETNA ALL OTHER PLANS", "methodology": "percent of total billed charges", "standard_charge_dollar": 2730.0, "standard_charge_percentage": 52.0, "count": "0", "additional_payer_notes": "Zero final payments for the item or service in the 15 months prior to posting the file." }, { "payer_name": "AETNA", "plan_name": "AETNA ALL OTHER PLANS", "methodology": "percent of total billed charges", "standard_charge_dollar": 2730.0, "standard_charge_percentage": 52.0, "count": "0", "additional_payer_notes": "Zero final payments for the item or service in the 15 months prior to posting the file." }, { "payer_name": "MERITAIN HEALTH", "plan_name": "AETNA ALL OTHER PLANS", "methodology": "percent of total billed charges", "standard_charge_dollar": 2730.0, "standard_charge_percentage": 52.0, "count": "0", "additional_payer_notes": "Zero final payments for the item or service in the 15 months prior to posting the file." }, { "payer_name": "BLUE SHIELD OUT OF STATE", "plan_name": "STANFORD HEALTHCARE ALLIANCE PLAN", "methodology": "percent of total billed charges", "standard_charge_dollar": 2550.98, "standard_charge_percentage": 48.59, "count": "0", "additional_payer_notes": "Zero final payments for the item or service in the 15 months prior to posting the file." }, { "payer_name": "BLUE SHIELD", "plan_name": "STANFORD HEALTHCARE ALLIANCE PLAN", "methodology": "percent of total billed charges", "standard_charge_dollar": 2550.98, "standard_charge_percentage": 48.59, "median_amount": 68.24, "10th_percentile": 13.6, "90th_percentile": 1043.06, "count": "30" }, { "payer_name": "BLUE SHIELD", "plan_name": "STANFORD HEALTHCARE ALLIANCE PLAN", "methodology": "percent of total billed charges", "standard_charge_dollar": 2550.98, "standard_charge_percentage": 48.59, "count": "0", "additional_payer_notes": "Zero final payments for the item or service in the 15 months prior to posting the file." }, { "payer_name": "BLUE SHIELD", "plan_name": "STANFORD HEALTHCARE ALLIANCE PLAN", "methodology": "percent of total billed charges", "standard_charge_dollar": 2550.98, "standard_charge_percentage": 48.59, "count": "0", "additional_payer_notes": "Zero final payments for the item or service in the 15 months prior to posting the file." }, { "payer_name": "CIGNA", "plan_name": "CIGNA COM ALT HMO PLAN", "methodology": "percent of total billed charges", "standard_charge_dollar": 2215.5, "standard_charge_percentage": 42.2, "count": "0", "additional_payer_notes": "Zero final payments for the item or service in the 15 months prior to posting the file." }, { "payer_name": "CIGNA", "plan_name": "CIGNA COM ALT HMO PLAN", "methodology": "percent of total billed charges", "standard_charge_dollar": 2215.5, "standard_charge_percentage": 42.2, "count": "0", "additional_payer_notes": "Zero final payments for the item or service in the 15 months prior to posting the file." }, { "payer_name": "HEALTH NET", "plan_name": "HEALTHNET HMO, PPO, POS, EPO, CANOPY HEALTHNET HMO, OTHER-IN-NETWORK PLANS", "methodology": "per diem", "standard_charge_dollar": 8000.0, "standard_charge_algorithm": "Expected reimbursement is the lesser of Per diem ($8,000) for the length of stay and 70% of billed.", "count": "0", "additional_payer_notes": "Zero final payments for the item or service in the 15 months prior to posting the file." }, { "payer_name": "HEALTH NET", "plan_name": "HEALTHNET HMO, PPO, POS, EPO, CANOPY HEALTHNET HMO, OTHER-IN-NETWORK PLANS", "methodology": "per diem", "standard_charge_dollar": 8000.0, "standard_charge_algorithm": "Expected reimbursement is the lesser of Per diem ($8,000) for the length of stay and 70% of billed.", "count": "0", "additional_payer_notes": "Zero final payments for the item or service in the 15 months prior to posting the file." }, { "payer_name": "UNITED HEALTHCARE", "plan_name": "SUTTER SELECT & SUTTER HEALTH PLAN HMO PLANS", "methodology": "per diem", "standard_charge_dollar": 28538.0, "standard_charge_algorithm": "Per diem ($28,538).", "count": "0", "additional_payer_notes": "Zero final payments for the item or service in the 15 months prior to posting the file." }, { "payer_name": "UNITED HEALTHCARE", "plan_name": "SUTTER SELECT & SUTTER HEALTH PLAN HMO PLANS", "methodology": "per diem", "standard_charge_dollar": 28538.0, "standard_charge_algorithm": "Per diem ($28,538).", "count": "0", "additional_payer_notes": "Zero final payments for the item or service in the 15 months prior to posting the file." }, { "payer_name": "SUTTER", "plan_name": "SUTTER SELECT & SUTTER HEALTH PLAN HMO PLANS", "methodology": "per diem", "standard_charge_dollar": 28538.0, "standard_charge_algorithm": "Per diem ($28,538).", "count": "0", "additional_payer_notes": "Zero final payments for the item or service in the 15 months prior to posting the file." }, { "payer_name": "UNITED HEALTHCARE", "plan_name": "SUTTER SELECT & SUTTER HEALTH PLAN HMO PLANS", "methodology": "per diem", "standard_charge_dollar": 28538.0, "standard_charge_algorithm": "Per diem ($28,538).", "count": "0", "additional_payer_notes": "Zero final payments for the item or service in the 15 months prior to posting the file." }, { "payer_name": "UMR", "plan_name": "SUTTER SELECT & SUTTER HEALTH PLAN HMO PLANS", "methodology": "per diem", "standard_charge_dollar": 28538.0, "standard_charge_algorithm": "Per diem ($28,538).", "count": "0", "additional_payer_notes": "Zero final payments for the item or service in the 15 months prior to posting the file." } ] } ] }, { "description": "HC Electrode Depth Gp028", "code_information": [ { "code": "PX-2120062030", "type": "CDM" }, { "code": "99999", "type": "CPT" }, { "code": "0272", "type": "RC" } ], "standard_charges": [ { "setting": "outpatient", "gross_charge": 5250.0, "discounted_cash": 2625.0, "minimum": 2215.5, "maximum": 2730.0, "additional_generic_notes": "Zero final payments for the item or service in the 15 months prior to posting the file.", "payers_information": [ { "payer_name": "AETNA", "plan_name": "AETNA ALL OTHER PLANS", "methodology": "percent of total billed charges", "standard_charge_dollar": 2730.0, "standard_charge_percentage": 52.0, "count": "0", "additional_payer_notes": "Zero final payments for the item or service in the 15 months prior to posting the file." }, { "payer_name": "AETNA", "plan_name": "AETNA ALL OTHER PLANS", "methodology": "percent of total billed charges", "standard_charge_dollar": 2730.0, "standard_charge_percentage": 52.0, "count": "0", "additional_payer_notes": "Zero final payments for the item or service in the 15 months prior to posting the file." }, { "payer_name": "MERITAIN HEALTH", "plan_name": "AETNA ALL OTHER PLANS", "methodology": "percent of total billed charges", "standard_charge_dollar": 2730.0, "standard_charge_percentage": 52.0, "count": "0", "additional_payer_notes": "Zero final payments for the item or service in the 15 months prior to posting the file." }, { "payer_name": "BLUE SHIELD OUT OF STATE", "plan_name": "STANFORD HEALTHCARE ALLIANCE PLAN", "methodology": "percent of total billed charges", "standard_charge_dollar": 2550.98, "standard_charge_percentage": 48.59, "count": "0", "additional_payer_notes": "Zero final payments for the item or service in the 15 months prior to posting the file." }, { "payer_name": "BLUE SHIELD", "plan_name": "STANFORD HEALTHCARE ALLIANCE PLAN", "methodology": "percent of total billed charges", "standard_charge_dollar": 2550.98, "standard_charge_percentage": 48.59, "median_amount": 68.24, "10th_percentile": 13.6, "90th_percentile": 1043.06, "count": "30" }, { "payer_name": "BLUE SHIELD", "plan_name": "STANFORD HEALTHCARE ALLIANCE PLAN", "methodology": "percent of total billed charges", "standard_charge_dollar": 2550.98, "standard_charge_percentage": 48.59, "count": "0", "additional_payer_notes": "Zero final payments for the item or service in the 15 months prior to posting the file." }, { "payer_name": "BLUE SHIELD", "plan_name": "STANFORD HEALTHCARE ALLIANCE PLAN", "methodology": "percent of total billed charges", "standard_charge_dollar": 2550.98, "standard_charge_percentage": 48.59, "count": "0", "additional_payer_notes": "Zero final payments for the item or service in the 15 months prior to posting the file." }, { "payer_name": "CIGNA", "plan_name": "CIGNA COM ALT HMO PLAN", "methodology": "percent of total billed charges", "standard_charge_dollar": 2215.5, "standard_charge_percentage": 42.2, "count": "0", "additional_payer_notes": "Zero final payments for the item or service in the 15 months prior to posting the file." }, { "payer_name": "CIGNA", "plan_name": "CIGNA COM ALT HMO PLAN", "methodology": "percent of total billed charges", "standard_charge_dollar": 2215.5, "standard_charge_percentage": 42.2, "count": "0", "additional_payer_notes": "Zero final payments for the item or service in the 15 months prior to posting the file." }, { "payer_name": "HEALTH NET", "plan_name": "HEALTHNET HMO, PPO, POS, EPO, CANOPY HEALTHNET HMO, OTHER-IN-NETWORK PLANS", "methodology": "per diem", "standard_charge_dollar": 8000.0, "standard_charge_algorithm": "Expected reimbursement is the lesser of Per diem ($8,000) for the length of stay and 70% of billed.", "count": "0", "additional_payer_notes": "Zero final payments for the item or service in the 15 months prior to posting the file." }, { "payer_name": "HEALTH NET", "plan_name": "HEALTHNET HMO, PPO, POS, EPO, CANOPY HEALTHNET HMO, OTHER-IN-NETWORK PLANS", "methodology": "per diem", "standard_charge_dollar": 8000.0, "standard_charge_algorithm": "Expected reimbursement is the lesser of Per diem ($8,000) for the length of stay and 70% of billed.", "count": "0", "additional_payer_notes": "Zero final payments for the item or service in the 15 months prior to posting the file." }, { "payer_name": "UNITED HEALTHCARE", "plan_name": "SUTTER SELECT & SUTTER HEALTH PLAN HMO PLANS", "methodology": "per diem", "standard_charge_dollar": 28538.0, "standard_charge_algorithm": "Per diem ($28,538).", "count": "0", "additional_payer_notes": "Zero final payments for the item or service in the 15 months prior to posting the file." }, { "payer_name": "UNITED HEALTHCARE", "plan_name": "SUTTER SELECT & SUTTER HEALTH PLAN HMO PLANS", "methodology": "per diem", "standard_charge_dollar": 28538.0, "standard_charge_algorithm": "Per diem ($28,538).", "count": "0", "additional_payer_notes": "Zero final payments for the item or service in the 15 months prior to posting the file." }, { "payer_name": "SUTTER", "plan_name": "SUTTER SELECT & SUTTER HEALTH PLAN HMO PLANS", "methodology": "per diem", "standard_charge_dollar": 28538.0, "standard_charge_algorithm": "Per diem ($28,538).", "count": "0", "additional_payer_notes": "Zero final payments for the item or service in the 15 months prior to posting the file." }, { "payer_name": "UNITED HEALTHCARE", "plan_name": "SUTTER SELECT & SUTTER HEALTH PLAN HMO PLANS", "methodology": "per diem", "standard_charge_dollar": 28538.0, "standard_charge_algorithm": "Per diem ($28,538).", "count": "0", "additional_payer_notes": "Zero final payments for the item or service in the 15 months prior to posting the file." }, { "payer_name": "UMR", "plan_name": "SUTTER SELECT & SUTTER HEALTH PLAN HMO PLANS", "methodology": "per diem", "standard_charge_dollar": 28538.0, "standard_charge_algorithm": "Per diem ($28,538).", "count": "0", "additional_payer_notes": "Zero final payments for the item or service in the 15 months prior to posting the file." } ] } ] }, { "description": "Hc Electrode Depth Gp034", "code_information": [ { "code": "PX-2120062034", "type": "CDM" }, { "code": "99999", "type": "CPT" }, { "code": "0272", "type": "RC" } ], "standard_charges": [ { "setting": "outpatient", "gross_charge": 6750.0, "discounted_cash": 3375.0, "minimum": 2848.5, "maximum": 3510.0, "additional_generic_notes": "Zero final payments for the item or service in the 15 months prior to posting the file.", "payers_information": [ { "payer_name": "AETNA", "plan_name": "AETNA ALL OTHER PLANS", "methodology": "percent of total billed charges", "standard_charge_dollar": 3510.0, "standard_charge_percentage": 52.0, "count": "0", "additional_payer_notes": "Zero final payments for the item or service in the 15 months prior to posting the file." }, { "payer_name": "AETNA", "plan_name": "AETNA ALL OTHER PLANS", "methodology": "percent of total billed charges", "standard_charge_dollar": 3510.0, "standard_charge_percentage": 52.0, "count": "0", "additional_payer_notes": "Zero final payments for the item or service in the 15 months prior to posting the file." }, { "payer_name": "MERITAIN HEALTH", "plan_name": "AETNA ALL OTHER PLANS", "methodology": "percent of total billed charges", "standard_charge_dollar": 3510.0, "standard_charge_percentage": 52.0, "count": "0", "additional_payer_notes": "Zero final payments for the item or service in the 15 months prior to posting the file." }, { "payer_name": "BLUE SHIELD OUT OF STATE", "plan_name": "STANFORD HEALTHCARE ALLIANCE PLAN", "methodology": "percent of total billed charges", "standard_charge_dollar": 3279.83, "standard_charge_percentage": 48.59, "count": "0", "additional_payer_notes": "Zero final payments for the item or service in the 15 months prior to posting the file." }, { "payer_name": "BLUE SHIELD", "plan_name": "STANFORD HEALTHCARE ALLIANCE PLAN", "methodology": "percent of total billed charges", "standard_charge_dollar": 3279.83, "standard_charge_percentage": 48.59, "median_amount": 68.24, "10th_percentile": 13.6, "90th_percentile": 1043.06, "count": "30" }, { "payer_name": "BLUE SHIELD", "plan_name": "STANFORD HEALTHCARE ALLIANCE PLAN", "methodology": "percent of total billed charges", "standard_charge_dollar": 3279.83, "standard_charge_percentage": 48.59, "count": "0", "additional_payer_notes": "Zero final payments for the item or service in the 15 months prior to posting the file." }, { "payer_name": "BLUE SHIELD", "plan_name": "STANFORD HEALTHCARE ALLIANCE PLAN", "methodology": "percent of total billed charges", "standard_charge_dollar": 3279.83, "standard_charge_percentage": 48.59, "count": "0", "additional_payer_notes": "Zero final payments for the item or service in the 15 months prior to posting the file." }, { "payer_name": "CIGNA", "plan_name": "CIGNA COM ALT HMO PLAN", "methodology": "percent of total billed charges", "standard_charge_dollar": 2848.5, "standard_charge_percentage": 42.2, "count": "0", "additional_payer_notes": "Zero final payments for the item or service in the 15 months prior to posting the file." }, { "payer_name": "CIGNA", "plan_name": "CIGNA COM ALT HMO PLAN", "methodology": "percent of total billed charges", "standard_charge_dollar": 2848.5, "standard_charge_percentage": 42.2, "count": "0", "additional_payer_notes": "Zero final payments for the item or service in the 15 months prior to posting the file." }, { "payer_name": "HEALTH NET", "plan_name": "HEALTHNET HMO, PPO, POS, EPO, CANOPY HEALTHNET HMO, OTHER-IN-NETWORK PLANS", "methodology": "per diem", "standard_charge_dollar": 8000.0, "standard_charge_algorithm": "Expected reimbursement is the lesser of Per diem ($8,000) for the length of stay and 70% of billed.", "count": "0", "additional_payer_notes": "Zero final payments for the item or service in the 15 months prior to posting the file." }, { "payer_name": "HEALTH NET", "plan_name": "HEALTHNET HMO, PPO, POS, EPO, CANOPY HEALTHNET HMO, OTHER-IN-NETWORK PLANS", "methodology": "per diem", "standard_charge_dollar": 8000.0, "standard_charge_algorithm": "Expected reimbursement is the lesser of Per diem ($8,000) for the length of stay and 70% of billed.", "count": "0", "additional_payer_notes": "Zero final payments for the item or service in the 15 months prior to posting the file." }, { "payer_name": "UNITED HEALTHCARE", "plan_name": "SUTTER SELECT & SUTTER HEALTH PLAN HMO PLANS", "methodology": "per diem", "standard_charge_dollar": 28538.0, "standard_charge_algorithm": "Per diem ($28,538).", "count": "0", "additional_payer_notes": "Zero final payments for the item or service in the 15 months prior to posting the file." }, { "payer_name": "UNITED HEALTHCARE", "plan_name": "SUTTER SELECT & SUTTER HEALTH PLAN HMO PLANS", "methodology": "per diem", "standard_charge_dollar": 28538.0, "standard_charge_algorithm": "Per diem ($28,538).", "count": "0", "additional_payer_notes": "Zero final payments for the item or service in the 15 months prior to posting the file." }, { "payer_name": "SUTTER", "plan_name": "SUTTER SELECT & SUTTER HEALTH PLAN HMO PLANS", "methodology": "per diem", "standard_charge_dollar": 28538.0, "standard_charge_algorithm": "Per diem ($28,538).", "count": "0", "additional_payer_notes": "Zero final payments for the item or service in the 15 months prior to posting the file." }, { "payer_name": "UNITED HEALTHCARE", "plan_name": "SUTTER SELECT & SUTTER HEALTH PLAN HMO PLANS", "methodology": "per diem", "standard_charge_dollar": 28538.0, "standard_charge_algorithm": "Per diem ($28,538).", "count": "0", "additional_payer_notes": "Zero final payments for the item or service in the 15 months prior to posting the file." }, { "payer_name": "UMR", "plan_name": "SUTTER SELECT & SUTTER HEALTH PLAN HMO PLANS", "methodology": "per diem", "standard_charge_dollar": 28538.0, "standard_charge_algorithm": "Per diem ($28,538).", "count": "0", "additional_payer_notes": "Zero final payments for the item or service in the 15 months prior to posting the file." } ] } ] }, { "description": "HC Gelfilm Gp022", "code_information": [ { "code": "PX-2120066022", "type": "CDM" }, { "code": "99999", "type": "CPT" }, { "code": "0272", "type": "RC" } ], "standard_charges": [ { "setting": "outpatient", "gross_charge": 3300.0, "discounted_cash": 1650.0, "minimum": 1392.6, "maximum": 1716.0, "additional_generic_notes": "Zero final payments for the item or service in the 15 months prior to posting the file.", "payers_information": [ { "payer_name": "AETNA", "plan_name": "AETNA ALL OTHER PLANS", "methodology": "percent of total billed charges", "standard_charge_dollar": 1716.0, "standard_charge_percentage": 52.0, "count": "0", "additional_payer_notes": "Zero final payments for the item or service in the 15 months prior to posting the file." }, { "payer_name": "AETNA", "plan_name": "AETNA ALL OTHER PLANS", "methodology": "percent of total billed charges", "standard_charge_dollar": 1716.0, "standard_charge_percentage": 52.0, "count": "0", "additional_payer_notes": "Zero final payments for the item or service in the 15 months prior to posting the file." }, { "payer_name": "MERITAIN HEALTH", "plan_name": "AETNA ALL OTHER PLANS", "methodology": "percent of total billed charges", "standard_charge_dollar": 1716.0, "standard_charge_percentage": 52.0, "count": "0", "additional_payer_notes": "Zero final payments for the item or service in the 15 months prior to posting the file." }, { "payer_name": "BLUE SHIELD OUT OF STATE", "plan_name": "STANFORD HEALTHCARE ALLIANCE PLAN", "methodology": "percent of total billed charges", "standard_charge_dollar": 1603.47, "standard_charge_percentage": 48.59, "count": "0", "additional_payer_notes": "Zero final payments for the item or service in the 15 months prior to posting the file." }, { "payer_name": "BLUE SHIELD", "plan_name": "STANFORD HEALTHCARE ALLIANCE PLAN", "methodology": "percent of total billed charges", "standard_charge_dollar": 1603.47, "standard_charge_percentage": 48.59, "median_amount": 68.24, "10th_percentile": 13.6, "90th_percentile": 1043.06, "count": "30" }, { "payer_name": "BLUE SHIELD", "plan_name": "STANFORD HEALTHCARE ALLIANCE PLAN", "methodology": "percent of total billed charges", "standard_charge_dollar": 1603.47, "standard_charge_percentage": 48.59, "count": "0", "additional_payer_notes": "Zero final payments for the item or service in the 15 months prior to posting the file." }, { "payer_name": "BLUE SHIELD", "plan_name": "STANFORD HEALTHCARE ALLIANCE PLAN", "methodology": "percent of total billed charges", "standard_charge_dollar": 1603.47, "standard_charge_percentage": 48.59, "count": "0", "additional_payer_notes": "Zero final payments for the item or service in the 15 months prior to posting the file." }, { "payer_name": "CIGNA", "plan_name": "CIGNA COM ALT HMO PLAN", "methodology": "percent of total billed charges", "standard_charge_dollar": 1392.6, "standard_charge_percentage": 42.2, "count": "0", "additional_payer_notes": "Zero final payments for the item or service in the 15 months prior to posting the file." }, { "payer_name": "CIGNA", "plan_name": "CIGNA COM ALT HMO PLAN", "methodology": "percent of total billed charges", "standard_charge_dollar": 1392.6, "standard_charge_percentage": 42.2, "count": "0", "additional_payer_notes": "Zero final payments for the item or service in the 15 months prior to posting the file." }, { "payer_name": "HEALTH NET", "plan_name": "HEALTHNET HMO, PPO, POS, EPO, CANOPY HEALTHNET HMO, OTHER-IN-NETWORK PLANS", "methodology": "per diem", "standard_charge_dollar": 8000.0, "standard_charge_algorithm": "Expected reimbursement is the lesser of Per diem ($8,000) for the length of stay and 70% of billed.", "count": "0", "additional_payer_notes": "Zero final payments for the item or service in the 15 months prior to posting the file." }, { "payer_name": "HEALTH NET", "plan_name": "HEALTHNET HMO, PPO, POS, EPO, CANOPY HEALTHNET HMO, OTHER-IN-NETWORK PLANS", "methodology": "per diem", "standard_charge_dollar": 8000.0, "standard_charge_algorithm": "Expected reimbursement is the lesser of Per diem ($8,000) for the length of stay and 70% of billed.", "count": "0", "additional_payer_notes": "Zero final payments for the item or service in the 15 months prior to posting the file." }, { "payer_name": "UNITED HEALTHCARE", "plan_name": "SUTTER SELECT & SUTTER HEALTH PLAN HMO PLANS", "methodology": "per diem", "standard_charge_dollar": 28538.0, "standard_charge_algorithm": "Per diem ($28,538).", "count": "0", "additional_payer_notes": "Zero final payments for the item or service in the 15 months prior to posting the file." }, { "payer_name": "UNITED HEALTHCARE", "plan_name": "SUTTER SELECT & SUTTER HEALTH PLAN HMO PLANS", "methodology": "per diem", "standard_charge_dollar": 28538.0, "standard_charge_algorithm": "Per diem ($28,538).", "count": "0", "additional_payer_notes": "Zero final payments for the item or service in the 15 months prior to posting the file." }, { "payer_name": "SUTTER", "plan_name": "SUTTER SELECT & SUTTER HEALTH PLAN HMO PLANS", "methodology": "per diem", "standard_charge_dollar": 28538.0, "standard_charge_algorithm": "Per diem ($28,538).", "count": "0", "additional_payer_notes": "Zero final payments for the item or service in the 15 months prior to posting the file." }, { "payer_name": "UNITED HEALTHCARE", "plan_name": "SUTTER SELECT & SUTTER HEALTH PLAN HMO PLANS", "methodology": "per diem", "standard_charge_dollar": 28538.0, "standard_charge_algorithm": "Per diem ($28,538).", "count": "0", "additional_payer_notes": "Zero final payments for the item or service in the 15 months prior to posting the file." }, { "payer_name": "UMR", "plan_name": "SUTTER SELECT & SUTTER HEALTH PLAN HMO PLANS", "methodology": "per diem", "standard_charge_dollar": 28538.0, "standard_charge_algorithm": "Per diem ($28,538).", "count": "0", "additional_payer_notes": "Zero final payments for the item or service in the 15 months prior to posting the file." } ] } ] }, { "description": "HC Gelfilm Gp010", "code_information": [ { "code": "PX-2120066023", "type": "CDM" }, { "code": "99999", "type": "CPT" }, { "code": "0272", "type": "RC" } ], "standard_charges": [ { "setting": "outpatient", "gross_charge": 3600.0, "discounted_cash": 1800.0, "minimum": 1519.2, "maximum": 1872.0, "additional_generic_notes": "Zero final payments for the item or service in the 15 months prior to posting the file.", "payers_information": [ { "payer_name": "AETNA", "plan_name": "AETNA ALL OTHER PLANS", "methodology": "percent of total billed charges", "standard_charge_dollar": 1872.0, "standard_charge_percentage": 52.0, "count": "0", "additional_payer_notes": "Zero final payments for the item or service in the 15 months prior to posting the file." }, { "payer_name": "AETNA", "plan_name": "AETNA ALL OTHER PLANS", "methodology": "percent of total billed charges", "standard_charge_dollar": 1872.0, "standard_charge_percentage": 52.0, "count": "0", "additional_payer_notes": "Zero final payments for the item or service in the 15 months prior to posting the file." }, { "payer_name": "MERITAIN HEALTH", "plan_name": "AETNA ALL OTHER PLANS", "methodology": "percent of total billed charges", "standard_charge_dollar": 1872.0, "standard_charge_percentage": 52.0, "count": "0", "additional_payer_notes": "Zero final payments for the item or service in the 15 months prior to posting the file." }, { "payer_name": "BLUE SHIELD OUT OF STATE", "plan_name": "STANFORD HEALTHCARE ALLIANCE PLAN", "methodology": "percent of total billed charges", "standard_charge_dollar": 1749.24, "standard_charge_percentage": 48.59, "count": "0", "additional_payer_notes": "Zero final payments for the item or service in the 15 months prior to posting the file." }, { "payer_name": "BLUE SHIELD", "plan_name": "STANFORD HEALTHCARE ALLIANCE PLAN", "methodology": "percent of total billed charges", "standard_charge_dollar": 1749.24, "standard_charge_percentage": 48.59, "median_amount": 68.24, "10th_percentile": 13.6, "90th_percentile": 1043.06, "count": "30" }, { "payer_name": "BLUE SHIELD", "plan_name": "STANFORD HEALTHCARE ALLIANCE PLAN", "methodology": "percent of total billed charges", "standard_charge_dollar": 1749.24, "standard_charge_percentage": 48.59, "count": "0", "additional_payer_notes": "Zero final payments for the item or service in the 15 months prior to posting the file." }, { "payer_name": "BLUE SHIELD", "plan_name": "STANFORD HEALTHCARE ALLIANCE PLAN", "methodology": "percent of total billed charges", "standard_charge_dollar": 1749.24, "standard_charge_percentage": 48.59, "count": "0", "additional_payer_notes": "Zero final payments for the item or service in the 15 months prior to posting the file." }, { "payer_name": "CIGNA", "plan_name": "CIGNA COM ALT HMO PLAN", "methodology": "percent of total billed charges", "standard_charge_dollar": 1519.2, "standard_charge_percentage": 42.2, "count": "0", "additional_payer_notes": "Zero final payments for the item or service in the 15 months prior to posting the file." }, { "payer_name": "CIGNA", "plan_name": "CIGNA COM ALT HMO PLAN", "methodology": "percent of total billed charges", "standard_charge_dollar": 1519.2, "standard_charge_percentage": 42.2, "count": "0", "additional_payer_notes": "Zero final payments for the item or service in the 15 months prior to posting the file." }, { "payer_name": "HEALTH NET", "plan_name": "HEALTHNET HMO, PPO, POS, EPO, CANOPY HEALTHNET HMO, OTHER-IN-NETWORK PLANS", "methodology": "per diem", "standard_charge_dollar": 8000.0, "standard_charge_algorithm": "Expected reimbursement is the lesser of Per diem ($8,000) for the length of stay and 70% of billed.", "count": "0", "additional_payer_notes": "Zero final payments for the item or service in the 15 months prior to posting the file." }, { "payer_name": "HEALTH NET", "plan_name": "HEALTHNET HMO, PPO, POS, EPO, CANOPY HEALTHNET HMO, OTHER-IN-NETWORK PLANS", "methodology": "per diem", "standard_charge_dollar": 8000.0, "standard_charge_algorithm": "Expected reimbursement is the lesser of Per diem ($8,000) for the length of stay and 70% of billed.", "count": "0", "additional_payer_notes": "Zero final payments for the item or service in the 15 months prior to posting the file." }, { "payer_name": "UNITED HEALTHCARE", "plan_name": "SUTTER SELECT & SUTTER HEALTH PLAN HMO PLANS", "methodology": "per diem", "standard_charge_dollar": 28538.0, "standard_charge_algorithm": "Per diem ($28,538).", "count": "0", "additional_payer_notes": "Zero final payments for the item or service in the 15 months prior to posting the file." }, { "payer_name": "UNITED HEALTHCARE", "plan_name": "SUTTER SELECT & SUTTER HEALTH PLAN HMO PLANS", "methodology": "per diem", "standard_charge_dollar": 28538.0, "standard_charge_algorithm": "Per diem ($28,538).", "count": "0", "additional_payer_notes": "Zero final payments for the item or service in the 15 months prior to posting the file." }, { "payer_name": "SUTTER", "plan_name": "SUTTER SELECT & SUTTER HEALTH PLAN HMO PLANS", "methodology": "per diem", "standard_charge_dollar": 28538.0, "standard_charge_algorithm": "Per diem ($28,538).", "count": "0", "additional_payer_notes": "Zero final payments for the item or service in the 15 months prior to posting the file." }, { "payer_name": "UNITED HEALTHCARE", "plan_name": "SUTTER SELECT & SUTTER HEALTH PLAN HMO PLANS", "methodology": "per diem", "standard_charge_dollar": 28538.0, "standard_charge_algorithm": "Per diem ($28,538).", "count": "0", "additional_payer_notes": "Zero final payments for the item or service in the 15 months prior to posting the file." }, { "payer_name": "UMR", "plan_name": "SUTTER SELECT & SUTTER HEALTH PLAN HMO PLANS", "methodology": "per diem", "standard_charge_dollar": 28538.0, "standard_charge_algorithm": "Per diem ($28,538).", "count": "0", "additional_payer_notes": "Zero final payments for the item or service in the 15 months prior to posting the file." } ] } ] }, { "description": "HC Gelport Gp025", "code_information": [ { "code": "PX-2120066025", "type": "CDM" }, { "code": "99999", "type": "CPT" }, { "code": "0272", "type": "RC" } ], "standard_charges": [ { "setting": "outpatient", "gross_charge": 4263.0, "discounted_cash": 2131.5, "minimum": 1798.99, "maximum": 2216.76, "additional_generic_notes": "Zero final payments for the item or service in the 15 months prior to posting the file.", "payers_information": [ { "payer_name": "AETNA", "plan_name": "AETNA ALL OTHER PLANS", "methodology": "percent of total billed charges", "standard_charge_dollar": 2216.76, "standard_charge_percentage": 52.0, "count": "0", "additional_payer_notes": "Zero final payments for the item or service in the 15 months prior to posting the file." }, { "payer_name": "AETNA", "plan_name": "AETNA ALL OTHER PLANS", "methodology": "percent of total billed charges", "standard_charge_dollar": 2216.76, "standard_charge_percentage": 52.0, "count": "0", "additional_payer_notes": "Zero final payments for the item or service in the 15 months prior to posting the file." }, { "payer_name": "MERITAIN HEALTH", "plan_name": "AETNA ALL OTHER PLANS", "methodology": "percent of total billed charges", "standard_charge_dollar": 2216.76, "standard_charge_percentage": 52.0, "count": "0", "additional_payer_notes": "Zero final payments for the item or service in the 15 months prior to posting the file." }, { "payer_name": "BLUE SHIELD OUT OF STATE", "plan_name": "STANFORD HEALTHCARE ALLIANCE PLAN", "methodology": "percent of total billed charges", "standard_charge_dollar": 2071.39, "standard_charge_percentage": 48.59, "count": "0", "additional_payer_notes": "Zero final payments for the item or service in the 15 months prior to posting the file." }, { "payer_name": "BLUE SHIELD", "plan_name": "STANFORD HEALTHCARE ALLIANCE PLAN", "methodology": "percent of total billed charges", "standard_charge_dollar": 2071.39, "standard_charge_percentage": 48.59, "median_amount": 68.24, "10th_percentile": 13.6, "90th_percentile": 1043.06, "count": "30" }, { "payer_name": "BLUE SHIELD", "plan_name": "STANFORD HEALTHCARE ALLIANCE PLAN", "methodology": "percent of total billed charges", "standard_charge_dollar": 2071.39, "standard_charge_percentage": 48.59, "count": "0", "additional_payer_notes": "Zero final payments for the item or service in the 15 months prior to posting the file." }, { "payer_name": "BLUE SHIELD", "plan_name": "STANFORD HEALTHCARE ALLIANCE PLAN", "methodology": "percent of total billed charges", "standard_charge_dollar": 2071.39, "standard_charge_percentage": 48.59, "count": "0", "additional_payer_notes": "Zero final payments for the item or service in the 15 months prior to posting the file." }, { "payer_name": "CIGNA", "plan_name": "CIGNA COM ALT HMO PLAN", "methodology": "percent of total billed charges", "standard_charge_dollar": 1798.99, "standard_charge_percentage": 42.2, "count": "0", "additional_payer_notes": "Zero final payments for the item or service in the 15 months prior to posting the file." }, { "payer_name": "CIGNA", "plan_name": "CIGNA COM ALT HMO PLAN", "methodology": "percent of total billed charges", "standard_charge_dollar": 1798.99, "standard_charge_percentage": 42.2, "count": "0", "additional_payer_notes": "Zero final payments for the item or service in the 15 months prior to posting the file." }, { "payer_name": "HEALTH NET", "plan_name": "HEALTHNET HMO, PPO, POS, EPO, CANOPY HEALTHNET HMO, OTHER-IN-NETWORK PLANS", "methodology": "per diem", "standard_charge_dollar": 8000.0, "standard_charge_algorithm": "Expected reimbursement is the lesser of Per diem ($8,000) for the length of stay and 70% of billed.", "count": "0", "additional_payer_notes": "Zero final payments for the item or service in the 15 months prior to posting the file." }, { "payer_name": "HEALTH NET", "plan_name": "HEALTHNET HMO, PPO, POS, EPO, CANOPY HEALTHNET HMO, OTHER-IN-NETWORK PLANS", "methodology": "per diem", "standard_charge_dollar": 8000.0, "standard_charge_algorithm": "Expected reimbursement is the lesser of Per diem ($8,000) for the length of stay and 70% of billed.", "count": "0", "additional_payer_notes": "Zero final payments for the item or service in the 15 months prior to posting the file." }, { "payer_name": "UNITED HEALTHCARE", "plan_name": "SUTTER SELECT & SUTTER HEALTH PLAN HMO PLANS", "methodology": "per diem", "standard_charge_dollar": 28538.0, "standard_charge_algorithm": "Per diem ($28,538).", "count": "0", "additional_payer_notes": "Zero final payments for the item or service in the 15 months prior to posting the file." }, { "payer_name": "UNITED HEALTHCARE", "plan_name": "SUTTER SELECT & SUTTER HEALTH PLAN HMO PLANS", "methodology": "per diem", "standard_charge_dollar": 28538.0, "standard_charge_algorithm": "Per diem ($28,538).", "count": "0", "additional_payer_notes": "Zero final payments for the item or service in the 15 months prior to posting the file." }, { "payer_name": "SUTTER", "plan_name": "SUTTER SELECT & SUTTER HEALTH PLAN HMO PLANS", "methodology": "per diem", "standard_charge_dollar": 28538.0, "standard_charge_algorithm": "Per diem ($28,538).", "count": "0", "additional_payer_notes": "Zero final payments for the item or service in the 15 months prior to posting the file." }, { "payer_name": "UNITED HEALTHCARE", "plan_name": "SUTTER SELECT & SUTTER HEALTH PLAN HMO PLANS", "methodology": "per diem", "standard_charge_dollar": 28538.0, "standard_charge_algorithm": "Per diem ($28,538).", "count": "0", "additional_payer_notes": "Zero final payments for the item or service in the 15 months prior to posting the file." }, { "payer_name": "UMR", "plan_name": "SUTTER SELECT & SUTTER HEALTH PLAN HMO PLANS", "methodology": "per diem", "standard_charge_dollar": 28538.0, "standard_charge_algorithm": "Per diem ($28,538).", "count": "0", "additional_payer_notes": "Zero final payments for the item or service in the 15 months prior to posting the file." } ] } ] }, { "description": "HC Impl Cannula Venous Gp019", "code_information": [ { "code": "PX-2120067019", "type": "CDM" }, { "code": "99999", "type": "CPT" }, { "code": "0272", "type": "RC" } ], "standard_charges": [ { "setting": "outpatient", "gross_charge": 2125.0, "discounted_cash": 1062.5, "minimum": 896.75, "maximum": 1105.0, "additional_generic_notes": "Zero final payments for the item or service in the 15 months prior to posting the file.", "payers_information": [ { "payer_name": "AETNA", "plan_name": "AETNA ALL OTHER PLANS", "methodology": "percent of total billed charges", "standard_charge_dollar": 1105.0, "standard_charge_percentage": 52.0, "count": "0", "additional_payer_notes": "Zero final payments for the item or service in the 15 months prior to posting the file." }, { "payer_name": "AETNA", "plan_name": "AETNA ALL OTHER PLANS", "methodology": "percent of total billed charges", "standard_charge_dollar": 1105.0, "standard_charge_percentage": 52.0, "count": "0", "additional_payer_notes": "Zero final payments for the item or service in the 15 months prior to posting the file." }, { "payer_name": "MERITAIN HEALTH", "plan_name": "AETNA ALL OTHER PLANS", "methodology": "percent of total billed charges", "standard_charge_dollar": 1105.0, "standard_charge_percentage": 52.0, "count": "0", "additional_payer_notes": "Zero final payments for the item or service in the 15 months prior to posting the file." }, { "payer_name": "BLUE SHIELD OUT OF STATE", "plan_name": "STANFORD HEALTHCARE ALLIANCE PLAN", "methodology": "percent of total billed charges", "standard_charge_dollar": 1032.54, "standard_charge_percentage": 48.59, "count": "0", "additional_payer_notes": "Zero final payments for the item or service in the 15 months prior to posting the file." }, { "payer_name": "BLUE SHIELD", "plan_name": "STANFORD HEALTHCARE ALLIANCE PLAN", "methodology": "percent of total billed charges", "standard_charge_dollar": 1032.54, "standard_charge_percentage": 48.59, "median_amount": 68.24, "10th_percentile": 13.6, "90th_percentile": 1043.06, "count": "30" }, { "payer_name": "BLUE SHIELD", "plan_name": "STANFORD HEALTHCARE ALLIANCE PLAN", "methodology": "percent of total billed charges", "standard_charge_dollar": 1032.54, "standard_charge_percentage": 48.59, "count": "0", "additional_payer_notes": "Zero final payments for the item or service in the 15 months prior to posting the file." }, { "payer_name": "BLUE SHIELD", "plan_name": "STANFORD HEALTHCARE ALLIANCE PLAN", "methodology": "percent of total billed charges", "standard_charge_dollar": 1032.54, "standard_charge_percentage": 48.59, "count": "0", "additional_payer_notes": "Zero final payments for the item or service in the 15 months prior to posting the file." }, { "payer_name": "CIGNA", "plan_name": "CIGNA COM ALT HMO PLAN", "methodology": "percent of total billed charges", "standard_charge_dollar": 896.75, "standard_charge_percentage": 42.2, "count": "0", "additional_payer_notes": "Zero final payments for the item or service in the 15 months prior to posting the file." }, { "payer_name": "CIGNA", "plan_name": "CIGNA COM ALT HMO PLAN", "methodology": "percent of total billed charges", "standard_charge_dollar": 896.75, "standard_charge_percentage": 42.2, "count": "0", "additional_payer_notes": "Zero final payments for the item or service in the 15 months prior to posting the file." }, { "payer_name": "HEALTH NET", "plan_name": "HEALTHNET HMO, PPO, POS, EPO, CANOPY HEALTHNET HMO, OTHER-IN-NETWORK PLANS", "methodology": "per diem", "standard_charge_dollar": 8000.0, "standard_charge_algorithm": "Expected reimbursement is the lesser of Per diem ($8,000) for the length of stay and 70% of billed.", "count": "0", "additional_payer_notes": "Zero final payments for the item or service in the 15 months prior to posting the file." }, { "payer_name": "HEALTH NET", "plan_name": "HEALTHNET HMO, PPO, POS, EPO, CANOPY HEALTHNET HMO, OTHER-IN-NETWORK PLANS", "methodology": "per diem", "standard_charge_dollar": 8000.0, "standard_charge_algorithm": "Expected reimbursement is the lesser of Per diem ($8,000) for the length of stay and 70% of billed.", "count": "0", "additional_payer_notes": "Zero final payments for the item or service in the 15 months prior to posting the file." }, { "payer_name": "UNITED HEALTHCARE", "plan_name": "SUTTER SELECT & SUTTER HEALTH PLAN HMO PLANS", "methodology": "per diem", "standard_charge_dollar": 28538.0, "standard_charge_algorithm": "Per diem ($28,538).", "count": "0", "additional_payer_notes": "Zero final payments for the item or service in the 15 months prior to posting the file." }, { "payer_name": "UNITED HEALTHCARE", "plan_name": "SUTTER SELECT & SUTTER HEALTH PLAN HMO PLANS", "methodology": "per diem", "standard_charge_dollar": 28538.0, "standard_charge_algorithm": "Per diem ($28,538).", "count": "0", "additional_payer_notes": "Zero final payments for the item or service in the 15 months prior to posting the file." }, { "payer_name": "SUTTER", "plan_name": "SUTTER SELECT & SUTTER HEALTH PLAN HMO PLANS", "methodology": "per diem", "standard_charge_dollar": 28538.0, "standard_charge_algorithm": "Per diem ($28,538).", "count": "0", "additional_payer_notes": "Zero final payments for the item or service in the 15 months prior to posting the file." }, { "payer_name": "UNITED HEALTHCARE", "plan_name": "SUTTER SELECT & SUTTER HEALTH PLAN HMO PLANS", "methodology": "per diem", "standard_charge_dollar": 28538.0, "standard_charge_algorithm": "Per diem ($28,538).", "count": "0", "additional_payer_notes": "Zero final payments for the item or service in the 15 months prior to posting the file." }, { "payer_name": "UMR", "plan_name": "SUTTER SELECT & SUTTER HEALTH PLAN HMO PLANS", "methodology": "per diem", "standard_charge_dollar": 28538.0, "standard_charge_algorithm": "Per diem ($28,538).", "count": "0", "additional_payer_notes": "Zero final payments for the item or service in the 15 months prior to posting the file." } ] } ] }, { "description": "HC Guidewire Gp002", "code_information": [ { "code": "PX-2120068002", "type": "CDM" }, { "code": "C1769", "type": "HCPCS" }, { "code": "0272", "type": "RC" } ], "standard_charges": [ { "setting": "outpatient", "gross_charge": 50.0, "discounted_cash": 25.0, "minimum": 21.1, "maximum": 26.0, "additional_generic_notes": "Zero final payments for the item or service in the 15 months prior to posting the file.", "payers_information": [ { "payer_name": "AETNA", "plan_name": "AETNA ALL OTHER PLANS", "methodology": "percent of total billed charges", "standard_charge_dollar": 26.0, "standard_charge_percentage": 52.0, "count": "0", "additional_payer_notes": "Zero final payments for the item or service in the 15 months prior to posting the file." }, { "payer_name": "AETNA", "plan_name": "AETNA ALL OTHER PLANS", "methodology": "percent of total billed charges", "standard_charge_dollar": 26.0, "standard_charge_percentage": 52.0, "count": "0", "additional_payer_notes": "Zero final payments for the item or service in the 15 months prior to posting the file." }, { "payer_name": "BLUE SHIELD", "plan_name": "STANFORD HEALTHCARE ALLIANCE PLAN", "methodology": "percent of total billed charges", "standard_charge_dollar": 24.3, "standard_charge_percentage": 48.59, "count": "0", "additional_payer_notes": "Zero final payments for the item or service in the 15 months prior to posting the file." }, { "payer_name": "CIGNA", "plan_name": "CIGNA COM ALT HMO PLAN", "methodology": "percent of total billed charges", "standard_charge_dollar": 21.1, "standard_charge_percentage": 42.2, "count": "0", "additional_payer_notes": "Zero final payments for the item or service in the 15 months prior to posting the file." }, { "payer_name": "CIGNA", "plan_name": "CIGNA COM ALT HMO PLAN", "methodology": "percent of total billed charges", "standard_charge_dollar": 21.1, "standard_charge_percentage": 42.2, "count": "0", "additional_payer_notes": "Zero final payments for the item or service in the 15 months prior to posting the file." }, { "payer_name": "HEALTH NET", "plan_name": "HEALTHNET HMO, PPO, POS, EPO, CANOPY HEALTHNET HMO, OTHER-IN-NETWORK PLANS", "methodology": "per diem", "standard_charge_dollar": 8000.0, "standard_charge_algorithm": "Expected reimbursement is the lesser of Per diem ($8,000) for the length of stay and 70% of billed.", "count": "0", "additional_payer_notes": "Zero final payments for the item or service in the 15 months prior to posting the file." }, { "payer_name": "UNITED HEALTHCARE", "plan_name": "SUTTER SELECT & SUTTER HEALTH PLAN HMO PLANS", "methodology": "per diem", "standard_charge_dollar": 28538.0, "standard_charge_algorithm": "Per diem ($28,538).", "count": "0", "additional_payer_notes": "Zero final payments for the item or service in the 15 months prior to posting the file." }, { "payer_name": "UNITED HEALTHCARE", "plan_name": "SUTTER SELECT & SUTTER HEALTH PLAN HMO PLANS", "methodology": "per diem", "standard_charge_dollar": 28538.0, "standard_charge_algorithm": "Per diem ($28,538).", "count": "0", "additional_payer_notes": "Zero final payments for the item or service in the 15 months prior to posting the file." }, { "payer_name": "UNITED HEALTHCARE", "plan_name": "SUTTER SELECT & SUTTER HEALTH PLAN HMO PLANS", "methodology": "per diem", "standard_charge_dollar": 28538.0, "standard_charge_algorithm": "Per diem ($28,538).", "count": "0", "additional_payer_notes": "Zero final payments for the item or service in the 15 months prior to posting the file." } ] } ] }, { "description": "HC Guidewire Gp003", "code_information": [ { "code": "PX-2120068003", "type": "CDM" }, { "code": "C1769", "type": "HCPCS" }, { "code": "0272", "type": "RC" } ], "standard_charges": [ { "setting": "outpatient", "gross_charge": 100.0, "discounted_cash": 50.0, "minimum": 42.2, "maximum": 52.0, "additional_generic_notes": "Zero final payments for the item or service in the 15 months prior to posting the file.", "payers_information": [ { "payer_name": "AETNA", "plan_name": "AETNA ALL OTHER PLANS", "methodology": "percent of total billed charges", "standard_charge_dollar": 52.0, "standard_charge_percentage": 52.0, "count": "0", "additional_payer_notes": "Zero final payments for the item or service in the 15 months prior to posting the file." }, { "payer_name": "AETNA", "plan_name": "AETNA ALL OTHER PLANS", "methodology": "percent of total billed charges", "standard_charge_dollar": 52.0, "standard_charge_percentage": 52.0, "count": "0", "additional_payer_notes": "Zero final payments for the item or service in the 15 months prior to posting the file." }, { "payer_name": "BLUE SHIELD", "plan_name": "STANFORD HEALTHCARE ALLIANCE PLAN", "methodology": "percent of total billed charges", "standard_charge_dollar": 48.59, "standard_charge_percentage": 48.59, "count": "0", "additional_payer_notes": "Zero final payments for the item or service in the 15 months prior to posting the file." }, { "payer_name": "CIGNA", "plan_name": "CIGNA COM ALT HMO PLAN", "methodology": "percent of total billed charges", "standard_charge_dollar": 42.2, "standard_charge_percentage": 42.2, "count": "0", "additional_payer_notes": "Zero final payments for the item or service in the 15 months prior to posting the file." }, { "payer_name": "CIGNA", "plan_name": "CIGNA COM ALT HMO PLAN", "methodology": "percent of total billed charges", "standard_charge_dollar": 42.2, "standard_charge_percentage": 42.2, "count": "0", "additional_payer_notes": "Zero final payments for the item or service in the 15 months prior to posting the file." }, { "payer_name": "HEALTH NET", "plan_name": "HEALTHNET HMO, PPO, POS, EPO, CANOPY HEALTHNET HMO, OTHER-IN-NETWORK PLANS", "methodology": "per diem", "standard_charge_dollar": 8000.0, "standard_charge_algorithm": "Expected reimbursement is the lesser of Per diem ($8,000) for the length of stay and 70% of billed.", "count": "0", "additional_payer_notes": "Zero final payments for the item or service in the 15 months prior to posting the file." }, { "payer_name": "UNITED HEALTHCARE", "plan_name": "SUTTER SELECT & SUTTER HEALTH PLAN HMO PLANS", "methodology": "per diem", "standard_charge_dollar": 28538.0, "standard_charge_algorithm": "Per diem ($28,538).", "count": "0", "additional_payer_notes": "Zero final payments for the item or service in the 15 months prior to posting the file." }, { "payer_name": "UNITED HEALTHCARE", "plan_name": "SUTTER SELECT & SUTTER HEALTH PLAN HMO PLANS", "methodology": "per diem", "standard_charge_dollar": 28538.0, "standard_charge_algorithm": "Per diem ($28,538).", "count": "0", "additional_payer_notes": "Zero final payments for the item or service in the 15 months prior to posting the file." }, { "payer_name": "UNITED HEALTHCARE", "plan_name": "SUTTER SELECT & SUTTER HEALTH PLAN HMO PLANS", "methodology": "per diem", "standard_charge_dollar": 28538.0, "standard_charge_algorithm": "Per diem ($28,538).", "count": "0", "additional_payer_notes": "Zero final payments for the item or service in the 15 months prior to posting the file." } ] } ] }, { "description": "HC Guidewire Gp004", "code_information": [ { "code": "PX-2120068004", "type": "CDM" }, { "code": "C1769", "type": "HCPCS" }, { "code": "0272", "type": "RC" } ], "standard_charges": [ { "setting": "outpatient", "gross_charge": 146.0, "discounted_cash": 73.0, "minimum": 61.61, "maximum": 75.92, "additional_generic_notes": "Zero final payments for the item or service in the 15 months prior to posting the file.", "payers_information": [ { "payer_name": "AETNA", "plan_name": "AETNA ALL OTHER PLANS", "methodology": "percent of total billed charges", "standard_charge_dollar": 75.92, "standard_charge_percentage": 52.0, "count": "0", "additional_payer_notes": "Zero final payments for the item or service in the 15 months prior to posting the file." }, { "payer_name": "AETNA", "plan_name": "AETNA ALL OTHER PLANS", "methodology": "percent of total billed charges", "standard_charge_dollar": 75.92, "standard_charge_percentage": 52.0, "count": "0", "additional_payer_notes": "Zero final payments for the item or service in the 15 months prior to posting the file." }, { "payer_name": "BLUE SHIELD", "plan_name": "STANFORD HEALTHCARE ALLIANCE PLAN", "methodology": "percent of total billed charges", "standard_charge_dollar": 70.94, "standard_charge_percentage": 48.59, "count": "0", "additional_payer_notes": "Zero final payments for the item or service in the 15 months prior to posting the file." }, { "payer_name": "CIGNA", "plan_name": "CIGNA COM ALT HMO PLAN", "methodology": "percent of total billed charges", "standard_charge_dollar": 61.61, "standard_charge_percentage": 42.2, "count": "0", "additional_payer_notes": "Zero final payments for the item or service in the 15 months prior to posting the file." }, { "payer_name": "CIGNA", "plan_name": "CIGNA COM ALT HMO PLAN", "methodology": "percent of total billed charges", "standard_charge_dollar": 61.61, "standard_charge_percentage": 42.2, "count": "0", "additional_payer_notes": "Zero final payments for the item or service in the 15 months prior to posting the file." }, { "payer_name": "HEALTH NET", "plan_name": "HEALTHNET HMO, PPO, POS, EPO, CANOPY HEALTHNET HMO, OTHER-IN-NETWORK PLANS", "methodology": "per diem", "standard_charge_dollar": 8000.0, "standard_charge_algorithm": "Expected reimbursement is the lesser of Per diem ($8,000) for the length of stay and 70% of billed.", "median_amount": 132.67, "10th_percentile": 132.67, "90th_percentile": 132.67, "count": "1 through 10" }, { "payer_name": "HEALTH NET", "plan_name": "HEALTHNET HMO, PPO, POS, EPO, CANOPY HEALTHNET HMO, OTHER-IN-NETWORK PLANS", "methodology": "per diem", "standard_charge_dollar": 8000.0, "standard_charge_algorithm": "Expected reimbursement is the lesser of Per diem ($8,000) for the length of stay and 70% of billed.", "count": "0", "additional_payer_notes": "Zero final payments for the item or service in the 15 months prior to posting the file." }, { "payer_name": "UNITED HEALTHCARE", "plan_name": "SUTTER SELECT & SUTTER HEALTH PLAN HMO PLANS", "methodology": "per diem", "standard_charge_dollar": 28538.0, "standard_charge_algorithm": "Per diem ($28,538).", "count": "0", "additional_payer_notes": "Zero final payments for the item or service in the 15 months prior to posting the file." }, { "payer_name": "UNITED HEALTHCARE", "plan_name": "SUTTER SELECT & SUTTER HEALTH PLAN HMO PLANS", "methodology": "per diem", "standard_charge_dollar": 28538.0, "standard_charge_algorithm": "Per diem ($28,538).", "count": "0", "additional_payer_notes": "Zero final payments for the item or service in the 15 months prior to posting the file." }, { "payer_name": "UNITED HEALTHCARE", "plan_name": "SUTTER SELECT & SUTTER HEALTH PLAN HMO PLANS", "methodology": "per diem", "standard_charge_dollar": 28538.0, "standard_charge_algorithm": "Per diem ($28,538).", "count": "0", "additional_payer_notes": "Zero final payments for the item or service in the 15 months prior to posting the file." } ] } ] }, { "description": "HC Guidewire Gp005", "code_information": [ { "code": "PX-2120068005", "type": "CDM" }, { "code": "C1769", "type": "HCPCS" }, { "code": "0272", "type": "RC" } ], "standard_charges": [ { "setting": "outpatient", "gross_charge": 195.0, "discounted_cash": 97.5, "minimum": 82.29, "maximum": 101.4, "additional_generic_notes": "Zero final payments for the item or service in the 15 months prior to posting the file.", "payers_information": [ { "payer_name": "AETNA", "plan_name": "AETNA ALL OTHER PLANS", "methodology": "percent of total billed charges", "standard_charge_dollar": 101.4, "standard_charge_percentage": 52.0, "count": "0", "additional_payer_notes": "Zero final payments for the item or service in the 15 months prior to posting the file." }, { "payer_name": "AETNA", "plan_name": "AETNA ALL OTHER PLANS", "methodology": "percent of total billed charges", "standard_charge_dollar": 101.4, "standard_charge_percentage": 52.0, "count": "0", "additional_payer_notes": "Zero final payments for the item or service in the 15 months prior to posting the file." }, { "payer_name": "BLUE SHIELD", "plan_name": "STANFORD HEALTHCARE ALLIANCE PLAN", "methodology": "percent of total billed charges", "standard_charge_dollar": 94.75, "standard_charge_percentage": 48.59, "count": "0", "additional_payer_notes": "Zero final payments for the item or service in the 15 months prior to posting the file." }, { "payer_name": "CIGNA", "plan_name": "CIGNA COM ALT HMO PLAN", "methodology": "percent of total billed charges", "standard_charge_dollar": 82.29, "standard_charge_percentage": 42.2, "count": "0", "additional_payer_notes": "Zero final payments for the item or service in the 15 months prior to posting the file." }, { "payer_name": "CIGNA", "plan_name": "CIGNA COM ALT HMO PLAN", "methodology": "percent of total billed charges", "standard_charge_dollar": 82.29, "standard_charge_percentage": 42.2, "count": "0", "additional_payer_notes": "Zero final payments for the item or service in the 15 months prior to posting the file." }, { "payer_name": "HEALTH NET", "plan_name": "HEALTHNET HMO, PPO, POS, EPO, CANOPY HEALTHNET HMO, OTHER-IN-NETWORK PLANS", "methodology": "per diem", "standard_charge_dollar": 8000.0, "standard_charge_algorithm": "Expected reimbursement is the lesser of Per diem ($8,000) for the length of stay and 70% of billed.", "median_amount": 132.67, "10th_percentile": 132.67, "90th_percentile": 132.67, "count": "1 through 10" }, { "payer_name": "HEALTH NET", "plan_name": "HEALTHNET HMO, PPO, POS, EPO, CANOPY HEALTHNET HMO, OTHER-IN-NETWORK PLANS", "methodology": "per diem", "standard_charge_dollar": 8000.0, "standard_charge_algorithm": "Expected reimbursement is the lesser of Per diem ($8,000) for the length of stay and 70% of billed.", "count": "0", "additional_payer_notes": "Zero final payments for the item or service in the 15 months prior to posting the file." }, { "payer_name": "UNITED HEALTHCARE", "plan_name": "SUTTER SELECT & SUTTER HEALTH PLAN HMO PLANS", "methodology": "per diem", "standard_charge_dollar": 28538.0, "standard_charge_algorithm": "Per diem ($28,538).", "count": "0", "additional_payer_notes": "Zero final payments for the item or service in the 15 months prior to posting the file." }, { "payer_name": "UNITED HEALTHCARE", "plan_name": "SUTTER SELECT & SUTTER HEALTH PLAN HMO PLANS", "methodology": "per diem", "standard_charge_dollar": 28538.0, "standard_charge_algorithm": "Per diem ($28,538).", "count": "0", "additional_payer_notes": "Zero final payments for the item or service in the 15 months prior to posting the file." }, { "payer_name": "UNITED HEALTHCARE", "plan_name": "SUTTER SELECT & SUTTER HEALTH PLAN HMO PLANS", "methodology": "per diem", "standard_charge_dollar": 28538.0, "standard_charge_algorithm": "Per diem ($28,538).", "count": "0", "additional_payer_notes": "Zero final payments for the item or service in the 15 months prior to posting the file." } ] } ] }, { "description": "HC Guidewire Gp006", "code_information": [ { "code": "PX-2120068006", "type": "CDM" }, { "code": "C1769", "type": "HCPCS" }, { "code": "0272", "type": "RC" } ], "standard_charges": [ { "setting": "outpatient", "gross_charge": 293.0, "discounted_cash": 146.5, "minimum": 123.65, "maximum": 152.36, "additional_generic_notes": "Zero final payments for the item or service in the 15 months prior to posting the file.", "payers_information": [ { "payer_name": "AETNA", "plan_name": "AETNA ALL OTHER PLANS", "methodology": "percent of total billed charges", "standard_charge_dollar": 152.36, "standard_charge_percentage": 52.0, "count": "0", "additional_payer_notes": "Zero final payments for the item or service in the 15 months prior to posting the file." }, { "payer_name": "AETNA", "plan_name": "AETNA ALL OTHER PLANS", "methodology": "percent of total billed charges", "standard_charge_dollar": 152.36, "standard_charge_percentage": 52.0, "count": "0", "additional_payer_notes": "Zero final payments for the item or service in the 15 months prior to posting the file." }, { "payer_name": "BLUE SHIELD", "plan_name": "STANFORD HEALTHCARE ALLIANCE PLAN", "methodology": "percent of total billed charges", "standard_charge_dollar": 142.37, "standard_charge_percentage": 48.59, "count": "0", "additional_payer_notes": "Zero final payments for the item or service in the 15 months prior to posting the file." }, { "payer_name": "CIGNA", "plan_name": "CIGNA COM ALT HMO PLAN", "methodology": "percent of total billed charges", "standard_charge_dollar": 123.65, "standard_charge_percentage": 42.2, "count": "0", "additional_payer_notes": "Zero final payments for the item or service in the 15 months prior to posting the file." }, { "payer_name": "CIGNA", "plan_name": "CIGNA COM ALT HMO PLAN", "methodology": "percent of total billed charges", "standard_charge_dollar": 123.65, "standard_charge_percentage": 42.2, "count": "0", "additional_payer_notes": "Zero final payments for the item or service in the 15 months prior to posting the file." }, { "payer_name": "HEALTH NET", "plan_name": "HEALTHNET HMO, PPO, POS, EPO, CANOPY HEALTHNET HMO, OTHER-IN-NETWORK PLANS", "methodology": "per diem", "standard_charge_dollar": 8000.0, "standard_charge_algorithm": "Expected reimbursement is the lesser of Per diem ($8,000) for the length of stay and 70% of billed.", "median_amount": 132.67, "10th_percentile": 132.67, "90th_percentile": 132.67, "count": "1 through 10" }, { "payer_name": "HEALTH NET", "plan_name": "HEALTHNET HMO, PPO, POS, EPO, CANOPY HEALTHNET HMO, OTHER-IN-NETWORK PLANS", "methodology": "per diem", "standard_charge_dollar": 8000.0, "standard_charge_algorithm": "Expected reimbursement is the lesser of Per diem ($8,000) for the length of stay and 70% of billed.", "count": "0", "additional_payer_notes": "Zero final payments for the item or service in the 15 months prior to posting the file." }, { "payer_name": "UNITED HEALTHCARE", "plan_name": "SUTTER SELECT & SUTTER HEALTH PLAN HMO PLANS", "methodology": "per diem", "standard_charge_dollar": 28538.0, "standard_charge_algorithm": "Per diem ($28,538).", "count": "0", "additional_payer_notes": "Zero final payments for the item or service in the 15 months prior to posting the file." }, { "payer_name": "UNITED HEALTHCARE", "plan_name": "SUTTER SELECT & SUTTER HEALTH PLAN HMO PLANS", "methodology": "per diem", "standard_charge_dollar": 28538.0, "standard_charge_algorithm": "Per diem ($28,538).", "count": "0", "additional_payer_notes": "Zero final payments for the item or service in the 15 months prior to posting the file." }, { "payer_name": "UNITED HEALTHCARE", "plan_name": "SUTTER SELECT & SUTTER HEALTH PLAN HMO PLANS", "methodology": "per diem", "standard_charge_dollar": 28538.0, "standard_charge_algorithm": "Per diem ($28,538).", "count": "0", "additional_payer_notes": "Zero final payments for the item or service in the 15 months prior to posting the file." } ] } ] }, { "description": "HC Guidewire Gp007", "code_information": [ { "code": "PX-2120068007", "type": "CDM" }, { "code": "C1769", "type": "HCPCS" }, { "code": "0272", "type": "RC" } ], "standard_charges": [ { "setting": "outpatient", "gross_charge": 380.0, "discounted_cash": 190.0, "minimum": 160.36, "maximum": 197.6, "additional_generic_notes": "Zero final payments for the item or service in the 15 months prior to posting the file.", "payers_information": [ { "payer_name": "AETNA", "plan_name": "AETNA ALL OTHER PLANS", "methodology": "percent of total billed charges", "standard_charge_dollar": 197.6, "standard_charge_percentage": 52.0, "count": "0", "additional_payer_notes": "Zero final payments for the item or service in the 15 months prior to posting the file." }, { "payer_name": "AETNA", "plan_name": "AETNA ALL OTHER PLANS", "methodology": "percent of total billed charges", "standard_charge_dollar": 197.6, "standard_charge_percentage": 52.0, "count": "0", "additional_payer_notes": "Zero final payments for the item or service in the 15 months prior to posting the file." }, { "payer_name": "BLUE SHIELD", "plan_name": "STANFORD HEALTHCARE ALLIANCE PLAN", "methodology": "percent of total billed charges", "standard_charge_dollar": 184.64, "standard_charge_percentage": 48.59, "count": "0", "additional_payer_notes": "Zero final payments for the item or service in the 15 months prior to posting the file." }, { "payer_name": "CIGNA", "plan_name": "CIGNA COM ALT HMO PLAN", "methodology": "percent of total billed charges", "standard_charge_dollar": 160.36, "standard_charge_percentage": 42.2, "count": "0", "additional_payer_notes": "Zero final payments for the item or service in the 15 months prior to posting the file." }, { "payer_name": "CIGNA", "plan_name": "CIGNA COM ALT HMO PLAN", "methodology": "percent of total billed charges", "standard_charge_dollar": 160.36, "standard_charge_percentage": 42.2, "count": "0", "additional_payer_notes": "Zero final payments for the item or service in the 15 months prior to posting the file." }, { "payer_name": "HEALTH NET", "plan_name": "HEALTHNET HMO, PPO, POS, EPO, CANOPY HEALTHNET HMO, OTHER-IN-NETWORK PLANS", "methodology": "per diem", "standard_charge_dollar": 8000.0, "standard_charge_algorithm": "Expected reimbursement is the lesser of Per diem ($8,000) for the length of stay and 70% of billed.", "median_amount": 132.67, "10th_percentile": 132.67, "90th_percentile": 132.67, "count": "1 through 10" }, { "payer_name": "HEALTH NET", "plan_name": "HEALTHNET HMO, PPO, POS, EPO, CANOPY HEALTHNET HMO, OTHER-IN-NETWORK PLANS", "methodology": "per diem", "standard_charge_dollar": 8000.0, "standard_charge_algorithm": "Expected reimbursement is the lesser of Per diem ($8,000) for the length of stay and 70% of billed.", "count": "0", "additional_payer_notes": "Zero final payments for the item or service in the 15 months prior to posting the file." }, { "payer_name": "UNITED HEALTHCARE", "plan_name": "SUTTER SELECT & SUTTER HEALTH PLAN HMO PLANS", "methodology": "per diem", "standard_charge_dollar": 28538.0, "standard_charge_algorithm": "Per diem ($28,538).", "count": "0", "additional_payer_notes": "Zero final payments for the item or service in the 15 months prior to posting the file." }, { "payer_name": "UNITED HEALTHCARE", "plan_name": "SUTTER SELECT & SUTTER HEALTH PLAN HMO PLANS", "methodology": "per diem", "standard_charge_dollar": 28538.0, "standard_charge_algorithm": "Per diem ($28,538).", "count": "0", "additional_payer_notes": "Zero final payments for the item or service in the 15 months prior to posting the file." }, { "payer_name": "UNITED HEALTHCARE", "plan_name": "SUTTER SELECT & SUTTER HEALTH PLAN HMO PLANS", "methodology": "per diem", "standard_charge_dollar": 28538.0, "standard_charge_algorithm": "Per diem ($28,538).", "count": "0", "additional_payer_notes": "Zero final payments for the item or service in the 15 months prior to posting the file." } ] } ] }, { "description": "HC Guidewire Gp008", "code_information": [ { "code": "PX-2120068008", "type": "CDM" }, { "code": "C1769", "type": "HCPCS" }, { "code": "0272", "type": "RC" } ], "standard_charges": [ { "setting": "outpatient", "gross_charge": 475.0, "discounted_cash": 237.5, "minimum": 200.45, "maximum": 247.0, "additional_generic_notes": "Zero final payments for the item or service in the 15 months prior to posting the file.", "payers_information": [ { "payer_name": "AETNA", "plan_name": "AETNA ALL OTHER PLANS", "methodology": "percent of total billed charges", "standard_charge_dollar": 247.0, "standard_charge_percentage": 52.0, "count": "0", "additional_payer_notes": "Zero final payments for the item or service in the 15 months prior to posting the file." }, { "payer_name": "AETNA", "plan_name": "AETNA ALL OTHER PLANS", "methodology": "percent of total billed charges", "standard_charge_dollar": 247.0, "standard_charge_percentage": 52.0, "count": "0", "additional_payer_notes": "Zero final payments for the item or service in the 15 months prior to posting the file." }, { "payer_name": "BLUE SHIELD", "plan_name": "STANFORD HEALTHCARE ALLIANCE PLAN", "methodology": "percent of total billed charges", "standard_charge_dollar": 230.8, "standard_charge_percentage": 48.59, "count": "0", "additional_payer_notes": "Zero final payments for the item or service in the 15 months prior to posting the file." }, { "payer_name": "CIGNA", "plan_name": "CIGNA COM ALT HMO PLAN", "methodology": "percent of total billed charges", "standard_charge_dollar": 200.45, "standard_charge_percentage": 42.2, "count": "0", "additional_payer_notes": "Zero final payments for the item or service in the 15 months prior to posting the file." }, { "payer_name": "CIGNA", "plan_name": "CIGNA COM ALT HMO PLAN", "methodology": "percent of total billed charges", "standard_charge_dollar": 200.45, "standard_charge_percentage": 42.2, "count": "0", "additional_payer_notes": "Zero final payments for the item or service in the 15 months prior to posting the file." }, { "payer_name": "HEALTH NET", "plan_name": "HEALTHNET HMO, PPO, POS, EPO, CANOPY HEALTHNET HMO, OTHER-IN-NETWORK PLANS", "methodology": "per diem", "standard_charge_dollar": 8000.0, "standard_charge_algorithm": "Expected reimbursement is the lesser of Per diem ($8,000) for the length of stay and 70% of billed.", "median_amount": 132.67, "10th_percentile": 132.67, "90th_percentile": 132.67, "count": "1 through 10" }, { "payer_name": "HEALTH NET", "plan_name": "HEALTHNET HMO, PPO, POS, EPO, CANOPY HEALTHNET HMO, OTHER-IN-NETWORK PLANS", "methodology": "per diem", "standard_charge_dollar": 8000.0, "standard_charge_algorithm": "Expected reimbursement is the lesser of Per diem ($8,000) for the length of stay and 70% of billed.", "count": "0", "additional_payer_notes": "Zero final payments for the item or service in the 15 months prior to posting the file." }, { "payer_name": "UNITED HEALTHCARE", "plan_name": "SUTTER SELECT & SUTTER HEALTH PLAN HMO PLANS", "methodology": "per diem", "standard_charge_dollar": 28538.0, "standard_charge_algorithm": "Per diem ($28,538).", "count": "0", "additional_payer_notes": "Zero final payments for the item or service in the 15 months prior to posting the file." }, { "payer_name": "UNITED HEALTHCARE", "plan_name": "SUTTER SELECT & SUTTER HEALTH PLAN HMO PLANS", "methodology": "per diem", "standard_charge_dollar": 28538.0, "standard_charge_algorithm": "Per diem ($28,538).", "count": "0", "additional_payer_notes": "Zero final payments for the item or service in the 15 months prior to posting the file." }, { "payer_name": "UNITED HEALTHCARE", "plan_name": "SUTTER SELECT & SUTTER HEALTH PLAN HMO PLANS", "methodology": "per diem", "standard_charge_dollar": 28538.0, "standard_charge_algorithm": "Per diem ($28,538).", "count": "0", "additional_payer_notes": "Zero final payments for the item or service in the 15 months prior to posting the file." } ] } ] }, { "description": "HC Guidewire Gp009", "code_information": [ { "code": "PX-2120068009", "type": "CDM" }, { "code": "C1769", "type": "HCPCS" }, { "code": "0272", "type": "RC" } ], "standard_charges": [ { "setting": "outpatient", "gross_charge": 570.0, "discounted_cash": 285.0, "minimum": 240.54, "maximum": 296.4, "additional_generic_notes": "Zero final payments for the item or service in the 15 months prior to posting the file.", "payers_information": [ { "payer_name": "AETNA", "plan_name": "AETNA ALL OTHER PLANS", "methodology": "percent of total billed charges", "standard_charge_dollar": 296.4, "standard_charge_percentage": 52.0, "count": "0", "additional_payer_notes": "Zero final payments for the item or service in the 15 months prior to posting the file." }, { "payer_name": "AETNA", "plan_name": "AETNA ALL OTHER PLANS", "methodology": "percent of total billed charges", "standard_charge_dollar": 296.4, "standard_charge_percentage": 52.0, "count": "0", "additional_payer_notes": "Zero final payments for the item or service in the 15 months prior to posting the file." }, { "payer_name": "BLUE SHIELD", "plan_name": "STANFORD HEALTHCARE ALLIANCE PLAN", "methodology": "percent of total billed charges", "standard_charge_dollar": 276.96, "standard_charge_percentage": 48.59, "count": "0", "additional_payer_notes": "Zero final payments for the item or service in the 15 months prior to posting the file." }, { "payer_name": "CIGNA", "plan_name": "CIGNA COM ALT HMO PLAN", "methodology": "percent of total billed charges", "standard_charge_dollar": 240.54, "standard_charge_percentage": 42.2, "count": "0", "additional_payer_notes": "Zero final payments for the item or service in the 15 months prior to posting the file." }, { "payer_name": "CIGNA", "plan_name": "CIGNA COM ALT HMO PLAN", "methodology": "percent of total billed charges", "standard_charge_dollar": 240.54, "standard_charge_percentage": 42.2, "count": "0", "additional_payer_notes": "Zero final payments for the item or service in the 15 months prior to posting the file." }, { "payer_name": "HEALTH NET", "plan_name": "HEALTHNET HMO, PPO, POS, EPO, CANOPY HEALTHNET HMO, OTHER-IN-NETWORK PLANS", "methodology": "per diem", "standard_charge_dollar": 8000.0, "standard_charge_algorithm": "Expected reimbursement is the lesser of Per diem ($8,000) for the length of stay and 70% of billed.", "median_amount": 132.67, "10th_percentile": 132.67, "90th_percentile": 132.67, "count": "1 through 10" }, { "payer_name": "HEALTH NET", "plan_name": "HEALTHNET HMO, PPO, POS, EPO, CANOPY HEALTHNET HMO, OTHER-IN-NETWORK PLANS", "methodology": "per diem", "standard_charge_dollar": 8000.0, "standard_charge_algorithm": "Expected reimbursement is the lesser of Per diem ($8,000) for the length of stay and 70% of billed.", "count": "0", "additional_payer_notes": "Zero final payments for the item or service in the 15 months prior to posting the file." }, { "payer_name": "UNITED HEALTHCARE", "plan_name": "SUTTER SELECT & SUTTER HEALTH PLAN HMO PLANS", "methodology": "per diem", "standard_charge_dollar": 28538.0, "standard_charge_algorithm": "Per diem ($28,538).", "count": "0", "additional_payer_notes": "Zero final payments for the item or service in the 15 months prior to posting the file." }, { "payer_name": "UNITED HEALTHCARE", "plan_name": "SUTTER SELECT & SUTTER HEALTH PLAN HMO PLANS", "methodology": "per diem", "standard_charge_dollar": 28538.0, "standard_charge_algorithm": "Per diem ($28,538).", "count": "0", "additional_payer_notes": "Zero final payments for the item or service in the 15 months prior to posting the file." }, { "payer_name": "UNITED HEALTHCARE", "plan_name": "SUTTER SELECT & SUTTER HEALTH PLAN HMO PLANS", "methodology": "per diem", "standard_charge_dollar": 28538.0, "standard_charge_algorithm": "Per diem ($28,538).", "count": "0", "additional_payer_notes": "Zero final payments for the item or service in the 15 months prior to posting the file." } ] } ] }, { "description": "HC Guidewire Gp010", "code_information": [ { "code": "PX-2120068010", "type": "CDM" }, { "code": "C1769", "type": "HCPCS" }, { "code": "0272", "type": "RC" } ], "standard_charges": [ { "setting": "outpatient", "gross_charge": 665.0, "discounted_cash": 332.5, "minimum": 280.63, "maximum": 345.8, "additional_generic_notes": "Zero final payments for the item or service in the 15 months prior to posting the file.", "payers_information": [ { "payer_name": "AETNA", "plan_name": "AETNA ALL OTHER PLANS", "methodology": "percent of total billed charges", "standard_charge_dollar": 345.8, "standard_charge_percentage": 52.0, "count": "0", "additional_payer_notes": "Zero final payments for the item or service in the 15 months prior to posting the file." }, { "payer_name": "AETNA", "plan_name": "AETNA ALL OTHER PLANS", "methodology": "percent of total billed charges", "standard_charge_dollar": 345.8, "standard_charge_percentage": 52.0, "count": "0", "additional_payer_notes": "Zero final payments for the item or service in the 15 months prior to posting the file." }, { "payer_name": "BLUE SHIELD", "plan_name": "STANFORD HEALTHCARE ALLIANCE PLAN", "methodology": "percent of total billed charges", "standard_charge_dollar": 323.12, "standard_charge_percentage": 48.59, "count": "0", "additional_payer_notes": "Zero final payments for the item or service in the 15 months prior to posting the file." }, { "payer_name": "CIGNA", "plan_name": "CIGNA COM ALT HMO PLAN", "methodology": "percent of total billed charges", "standard_charge_dollar": 280.63, "standard_charge_percentage": 42.2, "count": "0", "additional_payer_notes": "Zero final payments for the item or service in the 15 months prior to posting the file." }, { "payer_name": "CIGNA", "plan_name": "CIGNA COM ALT HMO PLAN", "methodology": "percent of total billed charges", "standard_charge_dollar": 280.63, "standard_charge_percentage": 42.2, "count": "0", "additional_payer_notes": "Zero final payments for the item or service in the 15 months prior to posting the file." }, { "payer_name": "HEALTH NET", "plan_name": "HEALTHNET HMO, PPO, POS, EPO, CANOPY HEALTHNET HMO, OTHER-IN-NETWORK PLANS", "methodology": "per diem", "standard_charge_dollar": 8000.0, "standard_charge_algorithm": "Expected reimbursement is the lesser of Per diem ($8,000) for the length of stay and 70% of billed.", "median_amount": 132.67, "10th_percentile": 132.67, "90th_percentile": 132.67, "count": "1 through 10" }, { "payer_name": "HEALTH NET", "plan_name": "HEALTHNET HMO, PPO, POS, EPO, CANOPY HEALTHNET HMO, OTHER-IN-NETWORK PLANS", "methodology": "per diem", "standard_charge_dollar": 8000.0, "standard_charge_algorithm": "Expected reimbursement is the lesser of Per diem ($8,000) for the length of stay and 70% of billed.", "count": "0", "additional_payer_notes": "Zero final payments for the item or service in the 15 months prior to posting the file." }, { "payer_name": "UNITED HEALTHCARE", "plan_name": "SUTTER SELECT & SUTTER HEALTH PLAN HMO PLANS", "methodology": "per diem", "standard_charge_dollar": 28538.0, "standard_charge_algorithm": "Per diem ($28,538).", "count": "0", "additional_payer_notes": "Zero final payments for the item or service in the 15 months prior to posting the file." }, { "payer_name": "UNITED HEALTHCARE", "plan_name": "SUTTER SELECT & SUTTER HEALTH PLAN HMO PLANS", "methodology": "per diem", "standard_charge_dollar": 28538.0, "standard_charge_algorithm": "Per diem ($28,538).", "count": "0", "additional_payer_notes": "Zero final payments for the item or service in the 15 months prior to posting the file." }, { "payer_name": "UNITED HEALTHCARE", "plan_name": "SUTTER SELECT & SUTTER HEALTH PLAN HMO PLANS", "methodology": "per diem", "standard_charge_dollar": 28538.0, "standard_charge_algorithm": "Per diem ($28,538).", "count": "0", "additional_payer_notes": "Zero final payments for the item or service in the 15 months prior to posting the file." } ] } ] }, { "description": "HC Guidewire Gp011", "code_information": [ { "code": "PX-2120068011", "type": "CDM" }, { "code": "C1769", "type": "HCPCS" }, { "code": "0272", "type": "RC" } ], "standard_charges": [ { "setting": "outpatient", "gross_charge": 740.0, "discounted_cash": 370.0, "minimum": 312.28, "maximum": 384.8, "additional_generic_notes": "Zero final payments for the item or service in the 15 months prior to posting the file.", "payers_information": [ { "payer_name": "AETNA", "plan_name": "AETNA ALL OTHER PLANS", "methodology": "percent of total billed charges", "standard_charge_dollar": 384.8, "standard_charge_percentage": 52.0, "count": "0", "additional_payer_notes": "Zero final payments for the item or service in the 15 months prior to posting the file." }, { "payer_name": "AETNA", "plan_name": "AETNA ALL OTHER PLANS", "methodology": "percent of total billed charges", "standard_charge_dollar": 384.8, "standard_charge_percentage": 52.0, "count": "0", "additional_payer_notes": "Zero final payments for the item or service in the 15 months prior to posting the file." }, { "payer_name": "BLUE SHIELD", "plan_name": "STANFORD HEALTHCARE ALLIANCE PLAN", "methodology": "percent of total billed charges", "standard_charge_dollar": 359.57, "standard_charge_percentage": 48.59, "count": "0", "additional_payer_notes": "Zero final payments for the item or service in the 15 months prior to posting the file." }, { "payer_name": "CIGNA", "plan_name": "CIGNA COM ALT HMO PLAN", "methodology": "percent of total billed charges", "standard_charge_dollar": 312.28, "standard_charge_percentage": 42.2, "count": "0", "additional_payer_notes": "Zero final payments for the item or service in the 15 months prior to posting the file." }, { "payer_name": "CIGNA", "plan_name": "CIGNA COM ALT HMO PLAN", "methodology": "percent of total billed charges", "standard_charge_dollar": 312.28, "standard_charge_percentage": 42.2, "count": "0", "additional_payer_notes": "Zero final payments for the item or service in the 15 months prior to posting the file." }, { "payer_name": "HEALTH NET", "plan_name": "HEALTHNET HMO, PPO, POS, EPO, CANOPY HEALTHNET HMO, OTHER-IN-NETWORK PLANS", "methodology": "per diem", "standard_charge_dollar": 8000.0, "standard_charge_algorithm": "Expected reimbursement is the lesser of Per diem ($8,000) for the length of stay and 70% of billed.", "median_amount": 132.67, "10th_percentile": 132.67, "90th_percentile": 132.67, "count": "1 through 10" }, { "payer_name": "HEALTH NET", "plan_name": "HEALTHNET HMO, PPO, POS, EPO, CANOPY HEALTHNET HMO, OTHER-IN-NETWORK PLANS", "methodology": "per diem", "standard_charge_dollar": 8000.0, "standard_charge_algorithm": "Expected reimbursement is the lesser of Per diem ($8,000) for the length of stay and 70% of billed.", "count": "0", "additional_payer_notes": "Zero final payments for the item or service in the 15 months prior to posting the file." }, { "payer_name": "UNITED HEALTHCARE", "plan_name": "SUTTER SELECT & SUTTER HEALTH PLAN HMO PLANS", "methodology": "per diem", "standard_charge_dollar": 28538.0, "standard_charge_algorithm": "Per diem ($28,538).", "count": "0", "additional_payer_notes": "Zero final payments for the item or service in the 15 months prior to posting the file." }, { "payer_name": "UNITED HEALTHCARE", "plan_name": "SUTTER SELECT & SUTTER HEALTH PLAN HMO PLANS", "methodology": "per diem", "standard_charge_dollar": 28538.0, "standard_charge_algorithm": "Per diem ($28,538).", "count": "0", "additional_payer_notes": "Zero final payments for the item or service in the 15 months prior to posting the file." }, { "payer_name": "UNITED HEALTHCARE", "plan_name": "SUTTER SELECT & SUTTER HEALTH PLAN HMO PLANS", "methodology": "per diem", "standard_charge_dollar": 28538.0, "standard_charge_algorithm": "Per diem ($28,538).", "count": "0", "additional_payer_notes": "Zero final payments for the item or service in the 15 months prior to posting the file." } ] } ] }, { "description": "HC Guidewire Gp012", "code_information": [ { "code": "PX-2120068012", "type": "CDM" }, { "code": "C1769", "type": "HCPCS" }, { "code": "0272", "type": "RC" } ], "standard_charges": [ { "setting": "outpatient", "gross_charge": 810.0, "discounted_cash": 405.0, "minimum": 341.82, "maximum": 421.2, "additional_generic_notes": "Zero final payments for the item or service in the 15 months prior to posting the file.", "payers_information": [ { "payer_name": "AETNA", "plan_name": "AETNA ALL OTHER PLANS", "methodology": "percent of total billed charges", "standard_charge_dollar": 421.2, "standard_charge_percentage": 52.0, "count": "0", "additional_payer_notes": "Zero final payments for the item or service in the 15 months prior to posting the file." }, { "payer_name": "AETNA", "plan_name": "AETNA ALL OTHER PLANS", "methodology": "percent of total billed charges", "standard_charge_dollar": 421.2, "standard_charge_percentage": 52.0, "count": "0", "additional_payer_notes": "Zero final payments for the item or service in the 15 months prior to posting the file." }, { "payer_name": "BLUE SHIELD", "plan_name": "STANFORD HEALTHCARE ALLIANCE PLAN", "methodology": "percent of total billed charges", "standard_charge_dollar": 393.58, "standard_charge_percentage": 48.59, "count": "0", "additional_payer_notes": "Zero final payments for the item or service in the 15 months prior to posting the file." }, { "payer_name": "CIGNA", "plan_name": "CIGNA COM ALT HMO PLAN", "methodology": "percent of total billed charges", "standard_charge_dollar": 341.82, "standard_charge_percentage": 42.2, "count": "0", "additional_payer_notes": "Zero final payments for the item or service in the 15 months prior to posting the file." }, { "payer_name": "CIGNA", "plan_name": "CIGNA COM ALT HMO PLAN", "methodology": "percent of total billed charges", "standard_charge_dollar": 341.82, "standard_charge_percentage": 42.2, "count": "0", "additional_payer_notes": "Zero final payments for the item or service in the 15 months prior to posting the file." }, { "payer_name": "HEALTH NET", "plan_name": "HEALTHNET HMO, PPO, POS, EPO, CANOPY HEALTHNET HMO, OTHER-IN-NETWORK PLANS", "methodology": "per diem", "standard_charge_dollar": 8000.0, "standard_charge_algorithm": "Expected reimbursement is the lesser of Per diem ($8,000) for the length of stay and 70% of billed.", "median_amount": 132.67, "10th_percentile": 132.67, "90th_percentile": 132.67, "count": "1 through 10" }, { "payer_name": "HEALTH NET", "plan_name": "HEALTHNET HMO, PPO, POS, EPO, CANOPY HEALTHNET HMO, OTHER-IN-NETWORK PLANS", "methodology": "per diem", "standard_charge_dollar": 8000.0, "standard_charge_algorithm": "Expected reimbursement is the lesser of Per diem ($8,000) for the length of stay and 70% of billed.", "count": "0", "additional_payer_notes": "Zero final payments for the item or service in the 15 months prior to posting the file." }, { "payer_name": "UNITED HEALTHCARE", "plan_name": "SUTTER SELECT & SUTTER HEALTH PLAN HMO PLANS", "methodology": "per diem", "standard_charge_dollar": 28538.0, "standard_charge_algorithm": "Per diem ($28,538).", "count": "0", "additional_payer_notes": "Zero final payments for the item or service in the 15 months prior to posting the file." }, { "payer_name": "UNITED HEALTHCARE", "plan_name": "SUTTER SELECT & SUTTER HEALTH PLAN HMO PLANS", "methodology": "per diem", "standard_charge_dollar": 28538.0, "standard_charge_algorithm": "Per diem ($28,538).", "count": "0", "additional_payer_notes": "Zero final payments for the item or service in the 15 months prior to posting the file." }, { "payer_name": "UNITED HEALTHCARE", "plan_name": "SUTTER SELECT & SUTTER HEALTH PLAN HMO PLANS", "methodology": "per diem", "standard_charge_dollar": 28538.0, "standard_charge_algorithm": "Per diem ($28,538).", "count": "0", "additional_payer_notes": "Zero final payments for the item or service in the 15 months prior to posting the file." } ] } ] }, { "description": "HC Guidewire Gp013", "code_information": [ { "code": "PX-2120068013", "type": "CDM" }, { "code": "C1769", "type": "HCPCS" }, { "code": "0272", "type": "RC" } ], "standard_charges": [ { "setting": "outpatient", "gross_charge": 900.0, "discounted_cash": 450.0, "minimum": 379.8, "maximum": 468.0, "additional_generic_notes": "Zero final payments for the item or service in the 15 months prior to posting the file.", "payers_information": [ { "payer_name": "AETNA", "plan_name": "AETNA ALL OTHER PLANS", "methodology": "percent of total billed charges", "standard_charge_dollar": 468.0, "standard_charge_percentage": 52.0, "count": "0", "additional_payer_notes": "Zero final payments for the item or service in the 15 months prior to posting the file." }, { "payer_name": "AETNA", "plan_name": "AETNA ALL OTHER PLANS", "methodology": "percent of total billed charges", "standard_charge_dollar": 468.0, "standard_charge_percentage": 52.0, "count": "0", "additional_payer_notes": "Zero final payments for the item or service in the 15 months prior to posting the file." }, { "payer_name": "BLUE SHIELD", "plan_name": "STANFORD HEALTHCARE ALLIANCE PLAN", "methodology": "percent of total billed charges", "standard_charge_dollar": 437.31, "standard_charge_percentage": 48.59, "count": "0", "additional_payer_notes": "Zero final payments for the item or service in the 15 months prior to posting the file." }, { "payer_name": "CIGNA", "plan_name": "CIGNA COM ALT HMO PLAN", "methodology": "percent of total billed charges", "standard_charge_dollar": 379.8, "standard_charge_percentage": 42.2, "count": "0", "additional_payer_notes": "Zero final payments for the item or service in the 15 months prior to posting the file." }, { "payer_name": "CIGNA", "plan_name": "CIGNA COM ALT HMO PLAN", "methodology": "percent of total billed charges", "standard_charge_dollar": 379.8, "standard_charge_percentage": 42.2, "count": "0", "additional_payer_notes": "Zero final payments for the item or service in the 15 months prior to posting the file." }, { "payer_name": "HEALTH NET", "plan_name": "HEALTHNET HMO, PPO, POS, EPO, CANOPY HEALTHNET HMO, OTHER-IN-NETWORK PLANS", "methodology": "per diem", "standard_charge_dollar": 8000.0, "standard_charge_algorithm": "Expected reimbursement is the lesser of Per diem ($8,000) for the length of stay and 70% of billed.", "median_amount": 132.67, "10th_percentile": 132.67, "90th_percentile": 132.67, "count": "1 through 10" }, { "payer_name": "HEALTH NET", "plan_name": "HEALTHNET HMO, PPO, POS, EPO, CANOPY HEALTHNET HMO, OTHER-IN-NETWORK PLANS", "methodology": "per diem", "standard_charge_dollar": 8000.0, "standard_charge_algorithm": "Expected reimbursement is the lesser of Per diem ($8,000) for the length of stay and 70% of billed.", "count": "0", "additional_payer_notes": "Zero final payments for the item or service in the 15 months prior to posting the file." }, { "payer_name": "UNITED HEALTHCARE", "plan_name": "SUTTER SELECT & SUTTER HEALTH PLAN HMO PLANS", "methodology": "per diem", "standard_charge_dollar": 28538.0, "standard_charge_algorithm": "Per diem ($28,538).", "count": "0", "additional_payer_notes": "Zero final payments for the item or service in the 15 months prior to posting the file." }, { "payer_name": "UNITED HEALTHCARE", "plan_name": "SUTTER SELECT & SUTTER HEALTH PLAN HMO PLANS", "methodology": "per diem", "standard_charge_dollar": 28538.0, "standard_charge_algorithm": "Per diem ($28,538).", "count": "0", "additional_payer_notes": "Zero final payments for the item or service in the 15 months prior to posting the file." }, { "payer_name": "UNITED HEALTHCARE", "plan_name": "SUTTER SELECT & SUTTER HEALTH PLAN HMO PLANS", "methodology": "per diem", "standard_charge_dollar": 28538.0, "standard_charge_algorithm": "Per diem ($28,538).", "count": "0", "additional_payer_notes": "Zero final payments for the item or service in the 15 months prior to posting the file." } ] } ] }, { "description": "HC Guidewire Gp014", "code_information": [ { "code": "PX-2120068014", "type": "CDM" }, { "code": "C1769", "type": "HCPCS" }, { "code": "0272", "type": "RC" } ], "standard_charges": [ { "setting": "outpatient", "gross_charge": 1080.0, "discounted_cash": 540.0, "minimum": 455.76, "maximum": 561.6, "additional_generic_notes": "Zero final payments for the item or service in the 15 months prior to posting the file.", "payers_information": [ { "payer_name": "AETNA", "plan_name": "AETNA ALL OTHER PLANS", "methodology": "percent of total billed charges", "standard_charge_dollar": 561.6, "standard_charge_percentage": 52.0, "count": "0", "additional_payer_notes": "Zero final payments for the item or service in the 15 months prior to posting the file." }, { "payer_name": "AETNA", "plan_name": "AETNA ALL OTHER PLANS", "methodology": "percent of total billed charges", "standard_charge_dollar": 561.6, "standard_charge_percentage": 52.0, "count": "0", "additional_payer_notes": "Zero final payments for the item or service in the 15 months prior to posting the file." }, { "payer_name": "BLUE SHIELD", "plan_name": "STANFORD HEALTHCARE ALLIANCE PLAN", "methodology": "percent of total billed charges", "standard_charge_dollar": 524.77, "standard_charge_percentage": 48.59, "count": "0", "additional_payer_notes": "Zero final payments for the item or service in the 15 months prior to posting the file." }, { "payer_name": "CIGNA", "plan_name": "CIGNA COM ALT HMO PLAN", "methodology": "percent of total billed charges", "standard_charge_dollar": 455.76, "standard_charge_percentage": 42.2, "count": "0", "additional_payer_notes": "Zero final payments for the item or service in the 15 months prior to posting the file." }, { "payer_name": "CIGNA", "plan_name": "CIGNA COM ALT HMO PLAN", "methodology": "percent of total billed charges", "standard_charge_dollar": 455.76, "standard_charge_percentage": 42.2, "count": "0", "additional_payer_notes": "Zero final payments for the item or service in the 15 months prior to posting the file." }, { "payer_name": "HEALTH NET", "plan_name": "HEALTHNET HMO, PPO, POS, EPO, CANOPY HEALTHNET HMO, OTHER-IN-NETWORK PLANS", "methodology": "per diem", "standard_charge_dollar": 8000.0, "standard_charge_algorithm": "Expected reimbursement is the lesser of Per diem ($8,000) for the length of stay and 70% of billed.", "median_amount": 132.67, "10th_percentile": 132.67, "90th_percentile": 132.67, "count": "1 through 10" }, { "payer_name": "HEALTH NET", "plan_name": "HEALTHNET HMO, PPO, POS, EPO, CANOPY HEALTHNET HMO, OTHER-IN-NETWORK PLANS", "methodology": "per diem", "standard_charge_dollar": 8000.0, "standard_charge_algorithm": "Expected reimbursement is the lesser of Per diem ($8,000) for the length of stay and 70% of billed.", "count": "0", "additional_payer_notes": "Zero final payments for the item or service in the 15 months prior to posting the file." }, { "payer_name": "UNITED HEALTHCARE", "plan_name": "SUTTER SELECT & SUTTER HEALTH PLAN HMO PLANS", "methodology": "per diem", "standard_charge_dollar": 28538.0, "standard_charge_algorithm": "Per diem ($28,538).", "count": "0", "additional_payer_notes": "Zero final payments for the item or service in the 15 months prior to posting the file." }, { "payer_name": "UNITED HEALTHCARE", "plan_name": "SUTTER SELECT & SUTTER HEALTH PLAN HMO PLANS", "methodology": "per diem", "standard_charge_dollar": 28538.0, "standard_charge_algorithm": "Per diem ($28,538).", "count": "0", "additional_payer_notes": "Zero final payments for the item or service in the 15 months prior to posting the file." }, { "payer_name": "UNITED HEALTHCARE", "plan_name": "SUTTER SELECT & SUTTER HEALTH PLAN HMO PLANS", "methodology": "per diem", "standard_charge_dollar": 28538.0, "standard_charge_algorithm": "Per diem ($28,538).", "count": "0", "additional_payer_notes": "Zero final payments for the item or service in the 15 months prior to posting the file." }, { "payer_name": "UMR", "plan_name": "SUTTER SELECT & SUTTER HEALTH PLAN HMO PLANS", "methodology": "per diem", "standard_charge_dollar": 28538.0, "standard_charge_algorithm": "Per diem ($28,538).", "median_amount": 985.09, "10th_percentile": 45.1, "90th_percentile": 985.09, "count": "1 through 10" } ] } ] }, { "description": "HC Guidewire Gp015", "code_information": [ { "code": "PX-2120068015", "type": "CDM" }, { "code": "C1769", "type": "HCPCS" }, { "code": "0272", "type": "RC" } ], "standard_charges": [ { "setting": "outpatient", "gross_charge": 1225.0, "discounted_cash": 612.5, "minimum": 516.95, "maximum": 637.0, "additional_generic_notes": "Zero final payments for the item or service in the 15 months prior to posting the file.", "payers_information": [ { "payer_name": "AETNA", "plan_name": "AETNA ALL OTHER PLANS", "methodology": "percent of total billed charges", "standard_charge_dollar": 637.0, "standard_charge_percentage": 52.0, "count": "0", "additional_payer_notes": "Zero final payments for the item or service in the 15 months prior to posting the file." }, { "payer_name": "AETNA", "plan_name": "AETNA ALL OTHER PLANS", "methodology": "percent of total billed charges", "standard_charge_dollar": 637.0, "standard_charge_percentage": 52.0, "count": "0", "additional_payer_notes": "Zero final payments for the item or service in the 15 months prior to posting the file." }, { "payer_name": "BLUE SHIELD", "plan_name": "STANFORD HEALTHCARE ALLIANCE PLAN", "methodology": "percent of total billed charges", "standard_charge_dollar": 595.23, "standard_charge_percentage": 48.59, "count": "0", "additional_payer_notes": "Zero final payments for the item or service in the 15 months prior to posting the file." }, { "payer_name": "CIGNA", "plan_name": "CIGNA COM ALT HMO PLAN", "methodology": "percent of total billed charges", "standard_charge_dollar": 516.95, "standard_charge_percentage": 42.2, "count": "0", "additional_payer_notes": "Zero final payments for the item or service in the 15 months prior to posting the file." }, { "payer_name": "CIGNA", "plan_name": "CIGNA COM ALT HMO PLAN", "methodology": "percent of total billed charges", "standard_charge_dollar": 516.95, "standard_charge_percentage": 42.2, "count": "0", "additional_payer_notes": "Zero final payments for the item or service in the 15 months prior to posting the file." }, { "payer_name": "HEALTH NET", "plan_name": "HEALTHNET HMO, PPO, POS, EPO, CANOPY HEALTHNET HMO, OTHER-IN-NETWORK PLANS", "methodology": "per diem", "standard_charge_dollar": 8000.0, "standard_charge_algorithm": "Expected reimbursement is the lesser of Per diem ($8,000) for the length of stay and 70% of billed.", "median_amount": 132.67, "10th_percentile": 132.67, "90th_percentile": 132.67, "count": "1 through 10" }, { "payer_name": "HEALTH NET", "plan_name": "HEALTHNET HMO, PPO, POS, EPO, CANOPY HEALTHNET HMO, OTHER-IN-NETWORK PLANS", "methodology": "per diem", "standard_charge_dollar": 8000.0, "standard_charge_algorithm": "Expected reimbursement is the lesser of Per diem ($8,000) for the length of stay and 70% of billed.", "count": "0", "additional_payer_notes": "Zero final payments for the item or service in the 15 months prior to posting the file." }, { "payer_name": "UNITED HEALTHCARE", "plan_name": "SUTTER SELECT & SUTTER HEALTH PLAN HMO PLANS", "methodology": "per diem", "standard_charge_dollar": 28538.0, "standard_charge_algorithm": "Per diem ($28,538).", "count": "0", "additional_payer_notes": "Zero final payments for the item or service in the 15 months prior to posting the file." }, { "payer_name": "UNITED HEALTHCARE", "plan_name": "SUTTER SELECT & SUTTER HEALTH PLAN HMO PLANS", "methodology": "per diem", "standard_charge_dollar": 28538.0, "standard_charge_algorithm": "Per diem ($28,538).", "count": "0", "additional_payer_notes": "Zero final payments for the item or service in the 15 months prior to posting the file." }, { "payer_name": "UNITED HEALTHCARE", "plan_name": "SUTTER SELECT & SUTTER HEALTH PLAN HMO PLANS", "methodology": "per diem", "standard_charge_dollar": 28538.0, "standard_charge_algorithm": "Per diem ($28,538).", "count": "0", "additional_payer_notes": "Zero final payments for the item or service in the 15 months prior to posting the file." }, { "payer_name": "UMR", "plan_name": "SUTTER SELECT & SUTTER HEALTH PLAN HMO PLANS", "methodology": "per diem", "standard_charge_dollar": 28538.0, "standard_charge_algorithm": "Per diem ($28,538).", "median_amount": 985.09, "10th_percentile": 45.1, "90th_percentile": 985.09, "count": "1 through 10" } ] } ] }, { "description": "HC Guidewire Gp016", "code_information": [ { "code": "PX-2120068016", "type": "CDM" }, { "code": "C1769", "type": "HCPCS" }, { "code": "0272", "type": "RC" } ], "standard_charges": [ { "setting": "outpatient", "gross_charge": 1400.0, "discounted_cash": 700.0, "minimum": 590.8, "maximum": 728.0, "additional_generic_notes": "Zero final payments for the item or service in the 15 months prior to posting the file.", "payers_information": [ { "payer_name": "AETNA", "plan_name": "AETNA ALL OTHER PLANS", "methodology": "percent of total billed charges", "standard_charge_dollar": 728.0, "standard_charge_percentage": 52.0, "count": "0", "additional_payer_notes": "Zero final payments for the item or service in the 15 months prior to posting the file." }, { "payer_name": "AETNA", "plan_name": "AETNA ALL OTHER PLANS", "methodology": "percent of total billed charges", "standard_charge_dollar": 728.0, "standard_charge_percentage": 52.0, "count": "0", "additional_payer_notes": "Zero final payments for the item or service in the 15 months prior to posting the file." }, { "payer_name": "MERITAIN HEALTH", "plan_name": "AETNA ALL OTHER PLANS", "methodology": "percent of total billed charges", "standard_charge_dollar": 728.0, "standard_charge_percentage": 52.0, "median_amount": 311.12, "10th_percentile": 311.12, "90th_percentile": 1281.22, "count": "1 through 10" }, { "payer_name": "BLUE SHIELD", "plan_name": "STANFORD HEALTHCARE ALLIANCE PLAN", "methodology": "percent of total billed charges", "standard_charge_dollar": 680.26, "standard_charge_percentage": 48.59, "count": "0", "additional_payer_notes": "Zero final payments for the item or service in the 15 months prior to posting the file." }, { "payer_name": "CIGNA", "plan_name": "CIGNA COM ALT HMO PLAN", "methodology": "percent of total billed charges", "standard_charge_dollar": 590.8, "standard_charge_percentage": 42.2, "count": "0", "additional_payer_notes": "Zero final payments for the item or service in the 15 months prior to posting the file." }, { "payer_name": "CIGNA", "plan_name": "CIGNA COM ALT HMO PLAN", "methodology": "percent of total billed charges", "standard_charge_dollar": 590.8, "standard_charge_percentage": 42.2, "count": "0", "additional_payer_notes": "Zero final payments for the item or service in the 15 months prior to posting the file." }, { "payer_name": "HEALTH NET", "plan_name": "HEALTHNET HMO, PPO, POS, EPO, CANOPY HEALTHNET HMO, OTHER-IN-NETWORK PLANS", "methodology": "per diem", "standard_charge_dollar": 8000.0, "standard_charge_algorithm": "Expected reimbursement is the lesser of Per diem ($8,000) for the length of stay and 70% of billed.", "median_amount": 132.67, "10th_percentile": 132.67, "90th_percentile": 132.67, "count": "1 through 10" }, { "payer_name": "HEALTH NET", "plan_name": "HEALTHNET HMO, PPO, POS, EPO, CANOPY HEALTHNET HMO, OTHER-IN-NETWORK PLANS", "methodology": "per diem", "standard_charge_dollar": 8000.0, "standard_charge_algorithm": "Expected reimbursement is the lesser of Per diem ($8,000) for the length of stay and 70% of billed.", "count": "0", "additional_payer_notes": "Zero final payments for the item or service in the 15 months prior to posting the file." }, { "payer_name": "UNITED HEALTHCARE", "plan_name": "SUTTER SELECT & SUTTER HEALTH PLAN HMO PLANS", "methodology": "per diem", "standard_charge_dollar": 28538.0, "standard_charge_algorithm": "Per diem ($28,538).", "count": "0", "additional_payer_notes": "Zero final payments for the item or service in the 15 months prior to posting the file." }, { "payer_name": "UNITED HEALTHCARE", "plan_name": "SUTTER SELECT & SUTTER HEALTH PLAN HMO PLANS", "methodology": "per diem", "standard_charge_dollar": 28538.0, "standard_charge_algorithm": "Per diem ($28,538).", "count": "0", "additional_payer_notes": "Zero final payments for the item or service in the 15 months prior to posting the file." }, { "payer_name": "SUTTER", "plan_name": "SUTTER SELECT & SUTTER HEALTH PLAN HMO PLANS", "methodology": "per diem", "standard_charge_dollar": 28538.0, "standard_charge_algorithm": "Per diem ($28,538).", "median_amount": 422.89, "10th_percentile": 228.42, "90th_percentile": 1353.56, "count": "40" }, { "payer_name": "UNITED HEALTHCARE", "plan_name": "SUTTER SELECT & SUTTER HEALTH PLAN HMO PLANS", "methodology": "per diem", "standard_charge_dollar": 28538.0, "standard_charge_algorithm": "Per diem ($28,538).", "count": "0", "additional_payer_notes": "Zero final payments for the item or service in the 15 months prior to posting the file." }, { "payer_name": "UMR", "plan_name": "SUTTER SELECT & SUTTER HEALTH PLAN HMO PLANS", "methodology": "per diem", "standard_charge_dollar": 28538.0, "standard_charge_algorithm": "Per diem ($28,538).", "median_amount": 985.09, "10th_percentile": 45.1, "90th_percentile": 985.09, "count": "1 through 10" } ] } ] }, { "description": "HC Guidewire Gp017", "code_information": [ { "code": "PX-2120068017", "type": "CDM" }, { "code": "C1769", "type": "HCPCS" }, { "code": "0272", "type": "RC" } ], "standard_charges": [ { "setting": "outpatient", "gross_charge": 1575.0, "discounted_cash": 787.5, "minimum": 664.65, "maximum": 819.0, "additional_generic_notes": "Zero final payments for the item or service in the 15 months prior to posting the file.", "payers_information": [ { "payer_name": "AETNA", "plan_name": "AETNA ALL OTHER PLANS", "methodology": "percent of total billed charges", "standard_charge_dollar": 819.0, "standard_charge_percentage": 52.0, "count": "0", "additional_payer_notes": "Zero final payments for the item or service in the 15 months prior to posting the file." }, { "payer_name": "AETNA", "plan_name": "AETNA ALL OTHER PLANS", "methodology": "percent of total billed charges", "standard_charge_dollar": 819.0, "standard_charge_percentage": 52.0, "count": "0", "additional_payer_notes": "Zero final payments for the item or service in the 15 months prior to posting the file." }, { "payer_name": "MERITAIN HEALTH", "plan_name": "AETNA ALL OTHER PLANS", "methodology": "percent of total billed charges", "standard_charge_dollar": 819.0, "standard_charge_percentage": 52.0, "median_amount": 311.12, "10th_percentile": 311.12, "90th_percentile": 1281.22, "count": "1 through 10" }, { "payer_name": "BLUE SHIELD", "plan_name": "STANFORD HEALTHCARE ALLIANCE PLAN", "methodology": "percent of total billed charges", "standard_charge_dollar": 765.29, "standard_charge_percentage": 48.59, "count": "0", "additional_payer_notes": "Zero final payments for the item or service in the 15 months prior to posting the file." }, { "payer_name": "CIGNA", "plan_name": "CIGNA COM ALT HMO PLAN", "methodology": "percent of total billed charges", "standard_charge_dollar": 664.65, "standard_charge_percentage": 42.2, "count": "0", "additional_payer_notes": "Zero final payments for the item or service in the 15 months prior to posting the file." }, { "payer_name": "CIGNA", "plan_name": "CIGNA COM ALT HMO PLAN", "methodology": "percent of total billed charges", "standard_charge_dollar": 664.65, "standard_charge_percentage": 42.2, "count": "0", "additional_payer_notes": "Zero final payments for the item or service in the 15 months prior to posting the file." }, { "payer_name": "HEALTH NET", "plan_name": "HEALTHNET HMO, PPO, POS, EPO, CANOPY HEALTHNET HMO, OTHER-IN-NETWORK PLANS", "methodology": "per diem", "standard_charge_dollar": 8000.0, "standard_charge_algorithm": "Expected reimbursement is the lesser of Per diem ($8,000) for the length of stay and 70% of billed.", "median_amount": 132.67, "10th_percentile": 132.67, "90th_percentile": 132.67, "count": "1 through 10" }, { "payer_name": "HEALTH NET", "plan_name": "HEALTHNET HMO, PPO, POS, EPO, CANOPY HEALTHNET HMO, OTHER-IN-NETWORK PLANS", "methodology": "per diem", "standard_charge_dollar": 8000.0, "standard_charge_algorithm": "Expected reimbursement is the lesser of Per diem ($8,000) for the length of stay and 70% of billed.", "count": "0", "additional_payer_notes": "Zero final payments for the item or service in the 15 months prior to posting the file." }, { "payer_name": "UNITED HEALTHCARE", "plan_name": "SUTTER SELECT & SUTTER HEALTH PLAN HMO PLANS", "methodology": "per diem", "standard_charge_dollar": 28538.0, "standard_charge_algorithm": "Per diem ($28,538).", "count": "0", "additional_payer_notes": "Zero final payments for the item or service in the 15 months prior to posting the file." }, { "payer_name": "UNITED HEALTHCARE", "plan_name": "SUTTER SELECT & SUTTER HEALTH PLAN HMO PLANS", "methodology": "per diem", "standard_charge_dollar": 28538.0, "standard_charge_algorithm": "Per diem ($28,538).", "count": "0", "additional_payer_notes": "Zero final payments for the item or service in the 15 months prior to posting the file." }, { "payer_name": "SUTTER", "plan_name": "SUTTER SELECT & SUTTER HEALTH PLAN HMO PLANS", "methodology": "per diem", "standard_charge_dollar": 28538.0, "standard_charge_algorithm": "Per diem ($28,538).", "median_amount": 422.89, "10th_percentile": 228.42, "90th_percentile": 1353.56, "count": "40" }, { "payer_name": "UNITED HEALTHCARE", "plan_name": "SUTTER SELECT & SUTTER HEALTH PLAN HMO PLANS", "methodology": "per diem", "standard_charge_dollar": 28538.0, "standard_charge_algorithm": "Per diem ($28,538).", "count": "0", "additional_payer_notes": "Zero final payments for the item or service in the 15 months prior to posting the file." }, { "payer_name": "UMR", "plan_name": "SUTTER SELECT & SUTTER HEALTH PLAN HMO PLANS", "methodology": "per diem", "standard_charge_dollar": 28538.0, "standard_charge_algorithm": "Per diem ($28,538).", "median_amount": 985.09, "10th_percentile": 45.1, "90th_percentile": 985.09, "count": "1 through 10" }, { "payer_name": "UNITED HEALTHCARE", "plan_name": "SUTTER SELECT & SUTTER HEALTH PLAN HMO PLANS", "methodology": "per diem", "standard_charge_dollar": 28538.0, "standard_charge_algorithm": "Per diem ($28,538).", "median_amount": 823.68, "10th_percentile": 594.01, "90th_percentile": 1518.0, "count": "13" } ] } ] }, { "description": "HC Guidewire Gp018", "code_information": [ { "code": "PX-2120068018", "type": "CDM" }, { "code": "C1769", "type": "HCPCS" }, { "code": "0272", "type": "RC" } ], "standard_charges": [ { "setting": "outpatient", "gross_charge": 1750.0, "discounted_cash": 875.0, "minimum": 738.5, "maximum": 910.0, "additional_generic_notes": "Zero final payments for the item or service in the 15 months prior to posting the file.", "payers_information": [ { "payer_name": "AETNA", "plan_name": "AETNA ALL OTHER PLANS", "methodology": "percent of total billed charges", "standard_charge_dollar": 910.0, "standard_charge_percentage": 52.0, "count": "0", "additional_payer_notes": "Zero final payments for the item or service in the 15 months prior to posting the file." }, { "payer_name": "AETNA", "plan_name": "AETNA ALL OTHER PLANS", "methodology": "percent of total billed charges", "standard_charge_dollar": 910.0, "standard_charge_percentage": 52.0, "count": "0", "additional_payer_notes": "Zero final payments for the item or service in the 15 months prior to posting the file." }, { "payer_name": "MERITAIN HEALTH", "plan_name": "AETNA ALL OTHER PLANS", "methodology": "percent of total billed charges", "standard_charge_dollar": 910.0, "standard_charge_percentage": 52.0, "median_amount": 311.12, "10th_percentile": 311.12, "90th_percentile": 1281.22, "count": "1 through 10" }, { "payer_name": "BLUE SHIELD", "plan_name": "STANFORD HEALTHCARE ALLIANCE PLAN", "methodology": "percent of total billed charges", "standard_charge_dollar": 850.33, "standard_charge_percentage": 48.59, "count": "0", "additional_payer_notes": "Zero final payments for the item or service in the 15 months prior to posting the file." }, { "payer_name": "CIGNA", "plan_name": "CIGNA COM ALT HMO PLAN", "methodology": "percent of total billed charges", "standard_charge_dollar": 738.5, "standard_charge_percentage": 42.2, "count": "0", "additional_payer_notes": "Zero final payments for the item or service in the 15 months prior to posting the file." }, { "payer_name": "CIGNA", "plan_name": "CIGNA COM ALT HMO PLAN", "methodology": "percent of total billed charges", "standard_charge_dollar": 738.5, "standard_charge_percentage": 42.2, "count": "0", "additional_payer_notes": "Zero final payments for the item or service in the 15 months prior to posting the file." }, { "payer_name": "HEALTH NET", "plan_name": "HEALTHNET HMO, PPO, POS, EPO, CANOPY HEALTHNET HMO, OTHER-IN-NETWORK PLANS", "methodology": "per diem", "standard_charge_dollar": 8000.0, "standard_charge_algorithm": "Expected reimbursement is the lesser of Per diem ($8,000) for the length of stay and 70% of billed.", "median_amount": 132.67, "10th_percentile": 132.67, "90th_percentile": 132.67, "count": "1 through 10" }, { "payer_name": "HEALTH NET", "plan_name": "HEALTHNET HMO, PPO, POS, EPO, CANOPY HEALTHNET HMO, OTHER-IN-NETWORK PLANS", "methodology": "per diem", "standard_charge_dollar": 8000.0, "standard_charge_algorithm": "Expected reimbursement is the lesser of Per diem ($8,000) for the length of stay and 70% of billed.", "count": "0", "additional_payer_notes": "Zero final payments for the item or service in the 15 months prior to posting the file." }, { "payer_name": "UNITED HEALTHCARE", "plan_name": "SUTTER SELECT & SUTTER HEALTH PLAN HMO PLANS", "methodology": "per diem", "standard_charge_dollar": 28538.0, "standard_charge_algorithm": "Per diem ($28,538).", "count": "0", "additional_payer_notes": "Zero final payments for the item or service in the 15 months prior to posting the file." }, { "payer_name": "UNITED HEALTHCARE", "plan_name": "SUTTER SELECT & SUTTER HEALTH PLAN HMO PLANS", "methodology": "per diem", "standard_charge_dollar": 28538.0, "standard_charge_algorithm": "Per diem ($28,538).", "count": "0", "additional_payer_notes": "Zero final payments for the item or service in the 15 months prior to posting the file." }, { "payer_name": "SUTTER", "plan_name": "SUTTER SELECT & SUTTER HEALTH PLAN HMO PLANS", "methodology": "per diem", "standard_charge_dollar": 28538.0, "standard_charge_algorithm": "Per diem ($28,538).", "median_amount": 422.89, "10th_percentile": 228.42, "90th_percentile": 1353.56, "count": "40" }, { "payer_name": "UNITED HEALTHCARE", "plan_name": "SUTTER SELECT & SUTTER HEALTH PLAN HMO PLANS", "methodology": "per diem", "standard_charge_dollar": 28538.0, "standard_charge_algorithm": "Per diem ($28,538).", "count": "0", "additional_payer_notes": "Zero final payments for the item or service in the 15 months prior to posting the file." }, { "payer_name": "UMR", "plan_name": "SUTTER SELECT & SUTTER HEALTH PLAN HMO PLANS", "methodology": "per diem", "standard_charge_dollar": 28538.0, "standard_charge_algorithm": "Per diem ($28,538).", "median_amount": 985.09, "10th_percentile": 45.1, "90th_percentile": 985.09, "count": "1 through 10" }, { "payer_name": "UNITED HEALTHCARE", "plan_name": "SUTTER SELECT & SUTTER HEALTH PLAN HMO PLANS", "methodology": "per diem", "standard_charge_dollar": 28538.0, "standard_charge_algorithm": "Per diem ($28,538).", "median_amount": 823.68, "10th_percentile": 594.01, "90th_percentile": 1518.0, "count": "13" } ] } ] }, { "description": "HC Guidewire Gp019", "code_information": [ { "code": "PX-2120068019", "type": "CDM" }, { "code": "C1769", "type": "HCPCS" }, { "code": "0272", "type": "RC" } ], "standard_charges": [ { "setting": "outpatient", "gross_charge": 2125.0, "discounted_cash": 1062.5, "minimum": 896.75, "maximum": 1105.0, "additional_generic_notes": "Zero final payments for the item or service in the 15 months prior to posting the file.", "payers_information": [ { "payer_name": "AETNA", "plan_name": "AETNA ALL OTHER PLANS", "methodology": "percent of total billed charges", "standard_charge_dollar": 1105.0, "standard_charge_percentage": 52.0, "count": "0", "additional_payer_notes": "Zero final payments for the item or service in the 15 months prior to posting the file." }, { "payer_name": "AETNA", "plan_name": "AETNA ALL OTHER PLANS", "methodology": "percent of total billed charges", "standard_charge_dollar": 1105.0, "standard_charge_percentage": 52.0, "count": "0", "additional_payer_notes": "Zero final payments for the item or service in the 15 months prior to posting the file." }, { "payer_name": "MERITAIN HEALTH", "plan_name": "AETNA ALL OTHER PLANS", "methodology": "percent of total billed charges", "standard_charge_dollar": 1105.0, "standard_charge_percentage": 52.0, "median_amount": 311.12, "10th_percentile": 311.12, "90th_percentile": 1281.22, "count": "1 through 10" }, { "payer_name": "BLUE SHIELD", "plan_name": "STANFORD HEALTHCARE ALLIANCE PLAN", "methodology": "percent of total billed charges", "standard_charge_dollar": 1032.54, "standard_charge_percentage": 48.59, "median_amount": 772.96, "10th_percentile": 276.79, "90th_percentile": 2049.03, "count": "29" }, { "payer_name": "BLUE SHIELD", "plan_name": "STANFORD HEALTHCARE ALLIANCE PLAN", "methodology": "percent of total billed charges", "standard_charge_dollar": 1032.54, "standard_charge_percentage": 48.59, "count": "0", "additional_payer_notes": "Zero final payments for the item or service in the 15 months prior to posting the file." }, { "payer_name": "CIGNA", "plan_name": "CIGNA COM ALT HMO PLAN", "methodology": "percent of total billed charges", "standard_charge_dollar": 896.75, "standard_charge_percentage": 42.2, "count": "0", "additional_payer_notes": "Zero final payments for the item or service in the 15 months prior to posting the file." }, { "payer_name": "CIGNA", "plan_name": "CIGNA COM ALT HMO PLAN", "methodology": "percent of total billed charges", "standard_charge_dollar": 896.75, "standard_charge_percentage": 42.2, "count": "0", "additional_payer_notes": "Zero final payments for the item or service in the 15 months prior to posting the file." }, { "payer_name": "HEALTH NET", "plan_name": "HEALTHNET HMO, PPO, POS, EPO, CANOPY HEALTHNET HMO, OTHER-IN-NETWORK PLANS", "methodology": "per diem", "standard_charge_dollar": 8000.0, "standard_charge_algorithm": "Expected reimbursement is the lesser of Per diem ($8,000) for the length of stay and 70% of billed.", "median_amount": 132.67, "10th_percentile": 132.67, "90th_percentile": 132.67, "count": "1 through 10" }, { "payer_name": "HEALTH NET", "plan_name": "HEALTHNET HMO, PPO, POS, EPO, CANOPY HEALTHNET HMO, OTHER-IN-NETWORK PLANS", "methodology": "per diem", "standard_charge_dollar": 8000.0, "standard_charge_algorithm": "Expected reimbursement is the lesser of Per diem ($8,000) for the length of stay and 70% of billed.", "count": "0", "additional_payer_notes": "Zero final payments for the item or service in the 15 months prior to posting the file." }, { "payer_name": "UNITED HEALTHCARE", "plan_name": "SUTTER SELECT & SUTTER HEALTH PLAN HMO PLANS", "methodology": "per diem", "standard_charge_dollar": 28538.0, "standard_charge_algorithm": "Per diem ($28,538).", "count": "0", "additional_payer_notes": "Zero final payments for the item or service in the 15 months prior to posting the file." }, { "payer_name": "UNITED HEALTHCARE", "plan_name": "SUTTER SELECT & SUTTER HEALTH PLAN HMO PLANS", "methodology": "per diem", "standard_charge_dollar": 28538.0, "standard_charge_algorithm": "Per diem ($28,538).", "count": "0", "additional_payer_notes": "Zero final payments for the item or service in the 15 months prior to posting the file." }, { "payer_name": "SUTTER", "plan_name": "SUTTER SELECT & SUTTER HEALTH PLAN HMO PLANS", "methodology": "per diem", "standard_charge_dollar": 28538.0, "standard_charge_algorithm": "Per diem ($28,538).", "median_amount": 422.89, "10th_percentile": 228.42, "90th_percentile": 1353.56, "count": "40" }, { "payer_name": "UNITED HEALTHCARE", "plan_name": "SUTTER SELECT & SUTTER HEALTH PLAN HMO PLANS", "methodology": "per diem", "standard_charge_dollar": 28538.0, "standard_charge_algorithm": "Per diem ($28,538).", "count": "0", "additional_payer_notes": "Zero final payments for the item or service in the 15 months prior to posting the file." }, { "payer_name": "UMR", "plan_name": "SUTTER SELECT & SUTTER HEALTH PLAN HMO PLANS", "methodology": "per diem", "standard_charge_dollar": 28538.0, "standard_charge_algorithm": "Per diem ($28,538).", "median_amount": 985.09, "10th_percentile": 45.1, "90th_percentile": 985.09, "count": "1 through 10" }, { "payer_name": "UNITED HEALTHCARE", "plan_name": "SUTTER SELECT & SUTTER HEALTH PLAN HMO PLANS", "methodology": "per diem", "standard_charge_dollar": 28538.0, "standard_charge_algorithm": "Per diem ($28,538).", "median_amount": 823.68, "10th_percentile": 594.01, "90th_percentile": 1518.0, "count": "13" } ] } ] }, { "description": "HC Guidewire Gp020", "code_information": [ { "code": "PX-2120068020", "type": "CDM" }, { "code": "C1769", "type": "HCPCS" }, { "code": "0272", "type": "RC" } ], "standard_charges": [ { "setting": "outpatient", "gross_charge": 2550.0, "discounted_cash": 1275.0, "minimum": 1076.1, "maximum": 1326.0, "additional_generic_notes": "Zero final payments for the item or service in the 15 months prior to posting the file.", "payers_information": [ { "payer_name": "AETNA", "plan_name": "AETNA ALL OTHER PLANS", "methodology": "percent of total billed charges", "standard_charge_dollar": 1326.0, "standard_charge_percentage": 52.0, "count": "0", "additional_payer_notes": "Zero final payments for the item or service in the 15 months prior to posting the file." }, { "payer_name": "AETNA", "plan_name": "AETNA ALL OTHER PLANS", "methodology": "percent of total billed charges", "standard_charge_dollar": 1326.0, "standard_charge_percentage": 52.0, "count": "0", "additional_payer_notes": "Zero final payments for the item or service in the 15 months prior to posting the file." }, { "payer_name": "MERITAIN HEALTH", "plan_name": "AETNA ALL OTHER PLANS", "methodology": "percent of total billed charges", "standard_charge_dollar": 1326.0, "standard_charge_percentage": 52.0, "median_amount": 311.12, "10th_percentile": 311.12, "90th_percentile": 1281.22, "count": "1 through 10" }, { "payer_name": "BLUE SHIELD", "plan_name": "STANFORD HEALTHCARE ALLIANCE PLAN", "methodology": "percent of total billed charges", "standard_charge_dollar": 1239.05, "standard_charge_percentage": 48.59, "median_amount": 900.78, "10th_percentile": 312.72, "90th_percentile": 2440.68, "count": "80" }, { "payer_name": "BLUE SHIELD", "plan_name": "STANFORD HEALTHCARE ALLIANCE PLAN", "methodology": "percent of total billed charges", "standard_charge_dollar": 1239.05, "standard_charge_percentage": 48.59, "median_amount": 772.96, "10th_percentile": 276.79, "90th_percentile": 2049.03, "count": "29" }, { "payer_name": "BLUE SHIELD", "plan_name": "STANFORD HEALTHCARE ALLIANCE PLAN", "methodology": "percent of total billed charges", "standard_charge_dollar": 1239.05, "standard_charge_percentage": 48.59, "count": "0", "additional_payer_notes": "Zero final payments for the item or service in the 15 months prior to posting the file." }, { "payer_name": "CIGNA", "plan_name": "CIGNA COM ALT HMO PLAN", "methodology": "percent of total billed charges", "standard_charge_dollar": 1076.1, "standard_charge_percentage": 42.2, "count": "0", "additional_payer_notes": "Zero final payments for the item or service in the 15 months prior to posting the file." }, { "payer_name": "CIGNA", "plan_name": "CIGNA COM ALT HMO PLAN", "methodology": "percent of total billed charges", "standard_charge_dollar": 1076.1, "standard_charge_percentage": 42.2, "count": "0", "additional_payer_notes": "Zero final payments for the item or service in the 15 months prior to posting the file." }, { "payer_name": "HEALTH NET", "plan_name": "HEALTHNET HMO, PPO, POS, EPO, CANOPY HEALTHNET HMO, OTHER-IN-NETWORK PLANS", "methodology": "per diem", "standard_charge_dollar": 8000.0, "standard_charge_algorithm": "Expected reimbursement is the lesser of Per diem ($8,000) for the length of stay and 70% of billed.", "median_amount": 132.67, "10th_percentile": 132.67, "90th_percentile": 132.67, "count": "1 through 10" }, { "payer_name": "HEALTH NET", "plan_name": "HEALTHNET HMO, PPO, POS, EPO, CANOPY HEALTHNET HMO, OTHER-IN-NETWORK PLANS", "methodology": "per diem", "standard_charge_dollar": 8000.0, "standard_charge_algorithm": "Expected reimbursement is the lesser of Per diem ($8,000) for the length of stay and 70% of billed.", "count": "0", "additional_payer_notes": "Zero final payments for the item or service in the 15 months prior to posting the file." }, { "payer_name": "UNITED HEALTHCARE", "plan_name": "SUTTER SELECT & SUTTER HEALTH PLAN HMO PLANS", "methodology": "per diem", "standard_charge_dollar": 28538.0, "standard_charge_algorithm": "Per diem ($28,538).", "count": "0", "additional_payer_notes": "Zero final payments for the item or service in the 15 months prior to posting the file." }, { "payer_name": "UNITED HEALTHCARE", "plan_name": "SUTTER SELECT & SUTTER HEALTH PLAN HMO PLANS", "methodology": "per diem", "standard_charge_dollar": 28538.0, "standard_charge_algorithm": "Per diem ($28,538).", "count": "0", "additional_payer_notes": "Zero final payments for the item or service in the 15 months prior to posting the file." }, { "payer_name": "SUTTER", "plan_name": "SUTTER SELECT & SUTTER HEALTH PLAN HMO PLANS", "methodology": "per diem", "standard_charge_dollar": 28538.0, "standard_charge_algorithm": "Per diem ($28,538).", "median_amount": 422.89, "10th_percentile": 228.42, "90th_percentile": 1353.56, "count": "40" }, { "payer_name": "UNITED HEALTHCARE", "plan_name": "SUTTER SELECT & SUTTER HEALTH PLAN HMO PLANS", "methodology": "per diem", "standard_charge_dollar": 28538.0, "standard_charge_algorithm": "Per diem ($28,538).", "count": "0", "additional_payer_notes": "Zero final payments for the item or service in the 15 months prior to posting the file." }, { "payer_name": "UMR", "plan_name": "SUTTER SELECT & SUTTER HEALTH PLAN HMO PLANS", "methodology": "per diem", "standard_charge_dollar": 28538.0, "standard_charge_algorithm": "Per diem ($28,538).", "median_amount": 985.09, "10th_percentile": 45.1, "90th_percentile": 985.09, "count": "1 through 10" }, { "payer_name": "UNITED HEALTHCARE", "plan_name": "SUTTER SELECT & SUTTER HEALTH PLAN HMO PLANS", "methodology": "per diem", "standard_charge_dollar": 28538.0, "standard_charge_algorithm": "Per diem ($28,538).", "median_amount": 823.68, "10th_percentile": 594.01, "90th_percentile": 1518.0, "count": "13" } ] } ] }, { "description": "HC Guidewire Gp021", "code_information": [ { "code": "PX-2120068021", "type": "CDM" }, { "code": "C1769", "type": "HCPCS" }, { "code": "0272", "type": "RC" } ], "standard_charges": [ { "setting": "outpatient", "gross_charge": 2888.0, "discounted_cash": 1444.0, "minimum": 1218.74, "maximum": 1501.76, "additional_generic_notes": "Zero final payments for the item or service in the 15 months prior to posting the file.", "payers_information": [ { "payer_name": "AETNA", "plan_name": "AETNA ALL OTHER PLANS", "methodology": "percent of total billed charges", "standard_charge_dollar": 1501.76, "standard_charge_percentage": 52.0, "count": "0", "additional_payer_notes": "Zero final payments for the item or service in the 15 months prior to posting the file." }, { "payer_name": "AETNA", "plan_name": "AETNA ALL OTHER PLANS", "methodology": "percent of total billed charges", "standard_charge_dollar": 1501.76, "standard_charge_percentage": 52.0, "count": "0", "additional_payer_notes": "Zero final payments for the item or service in the 15 months prior to posting the file." }, { "payer_name": "MERITAIN HEALTH", "plan_name": "AETNA ALL OTHER PLANS", "methodology": "percent of total billed charges", "standard_charge_dollar": 1501.76, "standard_charge_percentage": 52.0, "median_amount": 311.12, "10th_percentile": 311.12, "90th_percentile": 1281.22, "count": "1 through 10" }, { "payer_name": "BLUE SHIELD", "plan_name": "STANFORD HEALTHCARE ALLIANCE PLAN", "methodology": "percent of total billed charges", "standard_charge_dollar": 1403.28, "standard_charge_percentage": 48.59, "median_amount": 900.78, "10th_percentile": 312.72, "90th_percentile": 2440.68, "count": "80" }, { "payer_name": "BLUE SHIELD", "plan_name": "STANFORD HEALTHCARE ALLIANCE PLAN", "methodology": "percent of total billed charges", "standard_charge_dollar": 1403.28, "standard_charge_percentage": 48.59, "median_amount": 772.96, "10th_percentile": 276.79, "90th_percentile": 2049.03, "count": "29" }, { "payer_name": "BLUE SHIELD", "plan_name": "STANFORD HEALTHCARE ALLIANCE PLAN", "methodology": "percent of total billed charges", "standard_charge_dollar": 1403.28, "standard_charge_percentage": 48.59, "count": "0", "additional_payer_notes": "Zero final payments for the item or service in the 15 months prior to posting the file." }, { "payer_name": "CIGNA", "plan_name": "CIGNA COM ALT HMO PLAN", "methodology": "percent of total billed charges", "standard_charge_dollar": 1218.74, "standard_charge_percentage": 42.2, "count": "0", "additional_payer_notes": "Zero final payments for the item or service in the 15 months prior to posting the file." }, { "payer_name": "CIGNA", "plan_name": "CIGNA COM ALT HMO PLAN", "methodology": "percent of total billed charges", "standard_charge_dollar": 1218.74, "standard_charge_percentage": 42.2, "count": "0", "additional_payer_notes": "Zero final payments for the item or service in the 15 months prior to posting the file." }, { "payer_name": "HEALTH NET", "plan_name": "HEALTHNET HMO, PPO, POS, EPO, CANOPY HEALTHNET HMO, OTHER-IN-NETWORK PLANS", "methodology": "per diem", "standard_charge_dollar": 8000.0, "standard_charge_algorithm": "Expected reimbursement is the lesser of Per diem ($8,000) for the length of stay and 70% of billed.", "median_amount": 132.67, "10th_percentile": 132.67, "90th_percentile": 132.67, "count": "1 through 10" }, { "payer_name": "HEALTH NET", "plan_name": "HEALTHNET HMO, PPO, POS, EPO, CANOPY HEALTHNET HMO, OTHER-IN-NETWORK PLANS", "methodology": "per diem", "standard_charge_dollar": 8000.0, "standard_charge_algorithm": "Expected reimbursement is the lesser of Per diem ($8,000) for the length of stay and 70% of billed.", "count": "0", "additional_payer_notes": "Zero final payments for the item or service in the 15 months prior to posting the file." }, { "payer_name": "UNITED HEALTHCARE", "plan_name": "SUTTER SELECT & SUTTER HEALTH PLAN HMO PLANS", "methodology": "per diem", "standard_charge_dollar": 28538.0, "standard_charge_algorithm": "Per diem ($28,538).", "count": "0", "additional_payer_notes": "Zero final payments for the item or service in the 15 months prior to posting the file." }, { "payer_name": "UNITED HEALTHCARE", "plan_name": "SUTTER SELECT & SUTTER HEALTH PLAN HMO PLANS", "methodology": "per diem", "standard_charge_dollar": 28538.0, "standard_charge_algorithm": "Per diem ($28,538).", "count": "0", "additional_payer_notes": "Zero final payments for the item or service in the 15 months prior to posting the file." }, { "payer_name": "SUTTER", "plan_name": "SUTTER SELECT & SUTTER HEALTH PLAN HMO PLANS", "methodology": "per diem", "standard_charge_dollar": 28538.0, "standard_charge_algorithm": "Per diem ($28,538).", "median_amount": 422.89, "10th_percentile": 228.42, "90th_percentile": 1353.56, "count": "40" }, { "payer_name": "UNITED HEALTHCARE", "plan_name": "SUTTER SELECT & SUTTER HEALTH PLAN HMO PLANS", "methodology": "per diem", "standard_charge_dollar": 28538.0, "standard_charge_algorithm": "Per diem ($28,538).", "count": "0", "additional_payer_notes": "Zero final payments for the item or service in the 15 months prior to posting the file." }, { "payer_name": "UMR", "plan_name": "SUTTER SELECT & SUTTER HEALTH PLAN HMO PLANS", "methodology": "per diem", "standard_charge_dollar": 28538.0, "standard_charge_algorithm": "Per diem ($28,538).", "median_amount": 985.09, "10th_percentile": 45.1, "90th_percentile": 985.09, "count": "1 through 10" }, { "payer_name": "UNITED HEALTHCARE", "plan_name": "SUTTER SELECT & SUTTER HEALTH PLAN HMO PLANS", "methodology": "per diem", "standard_charge_dollar": 28538.0, "standard_charge_algorithm": "Per diem ($28,538).", "median_amount": 823.68, "10th_percentile": 594.01, "90th_percentile": 1518.0, "count": "13" } ] } ] }, { "description": "HC Guidewire Gp022", "code_information": [ { "code": "PX-2120068022", "type": "CDM" }, { "code": "C1769", "type": "HCPCS" }, { "code": "0272", "type": "RC" } ], "standard_charges": [ { "setting": "outpatient", "gross_charge": 3300.0, "discounted_cash": 1650.0, "minimum": 1392.6, "maximum": 1716.0, "additional_generic_notes": "Zero final payments for the item or service in the 15 months prior to posting the file.", "payers_information": [ { "payer_name": "AETNA", "plan_name": "AETNA ALL OTHER PLANS", "methodology": "percent of total billed charges", "standard_charge_dollar": 1716.0, "standard_charge_percentage": 52.0, "count": "0", "additional_payer_notes": "Zero final payments for the item or service in the 15 months prior to posting the file." }, { "payer_name": "AETNA", "plan_name": "AETNA ALL OTHER PLANS", "methodology": "percent of total billed charges", "standard_charge_dollar": 1716.0, "standard_charge_percentage": 52.0, "count": "0", "additional_payer_notes": "Zero final payments for the item or service in the 15 months prior to posting the file." }, { "payer_name": "MERITAIN HEALTH", "plan_name": "AETNA ALL OTHER PLANS", "methodology": "percent of total billed charges", "standard_charge_dollar": 1716.0, "standard_charge_percentage": 52.0, "median_amount": 311.12, "10th_percentile": 311.12, "90th_percentile": 1281.22, "count": "1 through 10" }, { "payer_name": "BLUE SHIELD", "plan_name": "STANFORD HEALTHCARE ALLIANCE PLAN", "methodology": "percent of total billed charges", "standard_charge_dollar": 1603.47, "standard_charge_percentage": 48.59, "median_amount": 900.78, "10th_percentile": 312.72, "90th_percentile": 2440.68, "count": "80" }, { "payer_name": "BLUE SHIELD", "plan_name": "STANFORD HEALTHCARE ALLIANCE PLAN", "methodology": "percent of total billed charges", "standard_charge_dollar": 1603.47, "standard_charge_percentage": 48.59, "median_amount": 772.96, "10th_percentile": 276.79, "90th_percentile": 2049.03, "count": "29" }, { "payer_name": "BLUE SHIELD", "plan_name": "STANFORD HEALTHCARE ALLIANCE PLAN", "methodology": "percent of total billed charges", "standard_charge_dollar": 1603.47, "standard_charge_percentage": 48.59, "count": "0", "additional_payer_notes": "Zero final payments for the item or service in the 15 months prior to posting the file." }, { "payer_name": "CIGNA", "plan_name": "CIGNA COM ALT HMO PLAN", "methodology": "percent of total billed charges", "standard_charge_dollar": 1392.6, "standard_charge_percentage": 42.2, "count": "0", "additional_payer_notes": "Zero final payments for the item or service in the 15 months prior to posting the file." }, { "payer_name": "CIGNA", "plan_name": "CIGNA COM ALT HMO PLAN", "methodology": "percent of total billed charges", "standard_charge_dollar": 1392.6, "standard_charge_percentage": 42.2, "count": "0", "additional_payer_notes": "Zero final payments for the item or service in the 15 months prior to posting the file." }, { "payer_name": "HEALTH NET", "plan_name": "HEALTHNET HMO, PPO, POS, EPO, CANOPY HEALTHNET HMO, OTHER-IN-NETWORK PLANS", "methodology": "per diem", "standard_charge_dollar": 8000.0, "standard_charge_algorithm": "Expected reimbursement is the lesser of Per diem ($8,000) for the length of stay and 70% of billed.", "median_amount": 132.67, "10th_percentile": 132.67, "90th_percentile": 132.67, "count": "1 through 10" }, { "payer_name": "HEALTH NET", "plan_name": "HEALTHNET HMO, PPO, POS, EPO, CANOPY HEALTHNET HMO, OTHER-IN-NETWORK PLANS", "methodology": "per diem", "standard_charge_dollar": 8000.0, "standard_charge_algorithm": "Expected reimbursement is the lesser of Per diem ($8,000) for the length of stay and 70% of billed.", "count": "0", "additional_payer_notes": "Zero final payments for the item or service in the 15 months prior to posting the file." }, { "payer_name": "UNITED HEALTHCARE", "plan_name": "SUTTER SELECT & SUTTER HEALTH PLAN HMO PLANS", "methodology": "per diem", "standard_charge_dollar": 28538.0, "standard_charge_algorithm": "Per diem ($28,538).", "count": "0", "additional_payer_notes": "Zero final payments for the item or service in the 15 months prior to posting the file." }, { "payer_name": "UNITED HEALTHCARE", "plan_name": "SUTTER SELECT & SUTTER HEALTH PLAN HMO PLANS", "methodology": "per diem", "standard_charge_dollar": 28538.0, "standard_charge_algorithm": "Per diem ($28,538).", "count": "0", "additional_payer_notes": "Zero final payments for the item or service in the 15 months prior to posting the file." }, { "payer_name": "SUTTER", "plan_name": "SUTTER SELECT & SUTTER HEALTH PLAN HMO PLANS", "methodology": "per diem", "standard_charge_dollar": 28538.0, "standard_charge_algorithm": "Per diem ($28,538).", "median_amount": 422.89, "10th_percentile": 228.42, "90th_percentile": 1353.56, "count": "40" }, { "payer_name": "UNITED HEALTHCARE", "plan_name": "SUTTER SELECT & SUTTER HEALTH PLAN HMO PLANS", "methodology": "per diem", "standard_charge_dollar": 28538.0, "standard_charge_algorithm": "Per diem ($28,538).", "count": "0", "additional_payer_notes": "Zero final payments for the item or service in the 15 months prior to posting the file." }, { "payer_name": "UMR", "plan_name": "SUTTER SELECT & SUTTER HEALTH PLAN HMO PLANS", "methodology": "per diem", "standard_charge_dollar": 28538.0, "standard_charge_algorithm": "Per diem ($28,538).", "median_amount": 985.09, "10th_percentile": 45.1, "90th_percentile": 985.09, "count": "1 through 10" }, { "payer_name": "UNITED HEALTHCARE", "plan_name": "SUTTER SELECT & SUTTER HEALTH PLAN HMO PLANS", "methodology": "per diem", "standard_charge_dollar": 28538.0, "standard_charge_algorithm": "Per diem ($28,538).", "median_amount": 823.68, "10th_percentile": 594.01, "90th_percentile": 1518.0, "count": "13" } ] } ] }, { "description": "HC Guidewire Gp023", "code_information": [ { "code": "PX-2120068023", "type": "CDM" }, { "code": "C1769", "type": "HCPCS" }, { "code": "0272", "type": "RC" } ], "standard_charges": [ { "setting": "outpatient", "gross_charge": 3600.0, "discounted_cash": 1800.0, "minimum": 1519.2, "maximum": 1872.0, "additional_generic_notes": "Zero final payments for the item or service in the 15 months prior to posting the file.", "payers_information": [ { "payer_name": "AETNA", "plan_name": "AETNA ALL OTHER PLANS", "methodology": "percent of total billed charges", "standard_charge_dollar": 1872.0, "standard_charge_percentage": 52.0, "count": "0", "additional_payer_notes": "Zero final payments for the item or service in the 15 months prior to posting the file." }, { "payer_name": "AETNA", "plan_name": "AETNA ALL OTHER PLANS", "methodology": "percent of total billed charges", "standard_charge_dollar": 1872.0, "standard_charge_percentage": 52.0, "count": "0", "additional_payer_notes": "Zero final payments for the item or service in the 15 months prior to posting the file." }, { "payer_name": "MERITAIN HEALTH", "plan_name": "AETNA ALL OTHER PLANS", "methodology": "percent of total billed charges", "standard_charge_dollar": 1872.0, "standard_charge_percentage": 52.0, "median_amount": 311.12, "10th_percentile": 311.12, "90th_percentile": 1281.22, "count": "1 through 10" }, { "payer_name": "BLUE SHIELD", "plan_name": "STANFORD HEALTHCARE ALLIANCE PLAN", "methodology": "percent of total billed charges", "standard_charge_dollar": 1749.24, "standard_charge_percentage": 48.59, "median_amount": 900.78, "10th_percentile": 312.72, "90th_percentile": 2440.68, "count": "80" }, { "payer_name": "BLUE SHIELD", "plan_name": "STANFORD HEALTHCARE ALLIANCE PLAN", "methodology": "percent of total billed charges", "standard_charge_dollar": 1749.24, "standard_charge_percentage": 48.59, "median_amount": 772.96, "10th_percentile": 276.79, "90th_percentile": 2049.03, "count": "29" }, { "payer_name": "BLUE SHIELD", "plan_name": "STANFORD HEALTHCARE ALLIANCE PLAN", "methodology": "percent of total billed charges", "standard_charge_dollar": 1749.24, "standard_charge_percentage": 48.59, "count": "0", "additional_payer_notes": "Zero final payments for the item or service in the 15 months prior to posting the file." }, { "payer_name": "CIGNA", "plan_name": "CIGNA COM ALT HMO PLAN", "methodology": "percent of total billed charges", "standard_charge_dollar": 1519.2, "standard_charge_percentage": 42.2, "count": "0", "additional_payer_notes": "Zero final payments for the item or service in the 15 months prior to posting the file." }, { "payer_name": "CIGNA", "plan_name": "CIGNA COM ALT HMO PLAN", "methodology": "percent of total billed charges", "standard_charge_dollar": 1519.2, "standard_charge_percentage": 42.2, "count": "0", "additional_payer_notes": "Zero final payments for the item or service in the 15 months prior to posting the file." }, { "payer_name": "HEALTH NET", "plan_name": "HEALTHNET HMO, PPO, POS, EPO, CANOPY HEALTHNET HMO, OTHER-IN-NETWORK PLANS", "methodology": "per diem", "standard_charge_dollar": 8000.0, "standard_charge_algorithm": "Expected reimbursement is the lesser of Per diem ($8,000) for the length of stay and 70% of billed.", "median_amount": 132.67, "10th_percentile": 132.67, "90th_percentile": 132.67, "count": "1 through 10" }, { "payer_name": "HEALTH NET", "plan_name": "HEALTHNET HMO, PPO, POS, EPO, CANOPY HEALTHNET HMO, OTHER-IN-NETWORK PLANS", "methodology": "per diem", "standard_charge_dollar": 8000.0, "standard_charge_algorithm": "Expected reimbursement is the lesser of Per diem ($8,000) for the length of stay and 70% of billed.", "count": "0", "additional_payer_notes": "Zero final payments for the item or service in the 15 months prior to posting the file." }, { "payer_name": "UNITED HEALTHCARE", "plan_name": "SUTTER SELECT & SUTTER HEALTH PLAN HMO PLANS", "methodology": "per diem", "standard_charge_dollar": 28538.0, "standard_charge_algorithm": "Per diem ($28,538).", "count": "0", "additional_payer_notes": "Zero final payments for the item or service in the 15 months prior to posting the file." }, { "payer_name": "UNITED HEALTHCARE", "plan_name": "SUTTER SELECT & SUTTER HEALTH PLAN HMO PLANS", "methodology": "per diem", "standard_charge_dollar": 28538.0, "standard_charge_algorithm": "Per diem ($28,538).", "count": "0", "additional_payer_notes": "Zero final payments for the item or service in the 15 months prior to posting the file." }, { "payer_name": "SUTTER", "plan_name": "SUTTER SELECT & SUTTER HEALTH PLAN HMO PLANS", "methodology": "per diem", "standard_charge_dollar": 28538.0, "standard_charge_algorithm": "Per diem ($28,538).", "median_amount": 422.89, "10th_percentile": 228.42, "90th_percentile": 1353.56, "count": "40" }, { "payer_name": "UNITED HEALTHCARE", "plan_name": "SUTTER SELECT & SUTTER HEALTH PLAN HMO PLANS", "methodology": "per diem", "standard_charge_dollar": 28538.0, "standard_charge_algorithm": "Per diem ($28,538).", "count": "0", "additional_payer_notes": "Zero final payments for the item or service in the 15 months prior to posting the file." }, { "payer_name": "UMR", "plan_name": "SUTTER SELECT & SUTTER HEALTH PLAN HMO PLANS", "methodology": "per diem", "standard_charge_dollar": 28538.0, "standard_charge_algorithm": "Per diem ($28,538).", "median_amount": 985.09, "10th_percentile": 45.1, "90th_percentile": 985.09, "count": "1 through 10" }, { "payer_name": "UNITED HEALTHCARE", "plan_name": "SUTTER SELECT & SUTTER HEALTH PLAN HMO PLANS", "methodology": "per diem", "standard_charge_dollar": 28538.0, "standard_charge_algorithm": "Per diem ($28,538).", "median_amount": 823.68, "10th_percentile": 594.01, "90th_percentile": 1518.0, "count": "13" } ] } ] }, { "description": "HC Guidewire Gp024", "code_information": [ { "code": "PX-2120068024", "type": "CDM" }, { "code": "C1769", "type": "HCPCS" }, { "code": "0272", "type": "RC" } ], "standard_charges": [ { "setting": "outpatient", "gross_charge": 4000.0, "discounted_cash": 2000.0, "minimum": 1688.0, "maximum": 2080.0, "additional_generic_notes": "Zero final payments for the item or service in the 15 months prior to posting the file.", "payers_information": [ { "payer_name": "AETNA", "plan_name": "AETNA ALL OTHER PLANS", "methodology": "percent of total billed charges", "standard_charge_dollar": 2080.0, "standard_charge_percentage": 52.0, "count": "0", "additional_payer_notes": "Zero final payments for the item or service in the 15 months prior to posting the file." }, { "payer_name": "AETNA", "plan_name": "AETNA ALL OTHER PLANS", "methodology": "percent of total billed charges", "standard_charge_dollar": 2080.0, "standard_charge_percentage": 52.0, "count": "0", "additional_payer_notes": "Zero final payments for the item or service in the 15 months prior to posting the file." }, { "payer_name": "MERITAIN HEALTH", "plan_name": "AETNA ALL OTHER PLANS", "methodology": "percent of total billed charges", "standard_charge_dollar": 2080.0, "standard_charge_percentage": 52.0, "median_amount": 311.12, "10th_percentile": 311.12, "90th_percentile": 1281.22, "count": "1 through 10" }, { "payer_name": "BLUE SHIELD OUT OF STATE", "plan_name": "STANFORD HEALTHCARE ALLIANCE PLAN", "methodology": "percent of total billed charges", "standard_charge_dollar": 1943.6, "standard_charge_percentage": 48.59, "median_amount": 805.51, "10th_percentile": 335.63, "90th_percentile": 3832.59, "count": "286" }, { "payer_name": "BLUE SHIELD", "plan_name": "STANFORD HEALTHCARE ALLIANCE PLAN", "methodology": "percent of total billed charges", "standard_charge_dollar": 1943.6, "standard_charge_percentage": 48.59, "median_amount": 900.78, "10th_percentile": 312.72, "90th_percentile": 2440.68, "count": "80" }, { "payer_name": "BLUE SHIELD", "plan_name": "STANFORD HEALTHCARE ALLIANCE PLAN", "methodology": "percent of total billed charges", "standard_charge_dollar": 1943.6, "standard_charge_percentage": 48.59, "median_amount": 772.96, "10th_percentile": 276.79, "90th_percentile": 2049.03, "count": "29" }, { "payer_name": "BLUE SHIELD", "plan_name": "STANFORD HEALTHCARE ALLIANCE PLAN", "methodology": "percent of total billed charges", "standard_charge_dollar": 1943.6, "standard_charge_percentage": 48.59, "count": "0", "additional_payer_notes": "Zero final payments for the item or service in the 15 months prior to posting the file." }, { "payer_name": "CIGNA", "plan_name": "CIGNA COM ALT HMO PLAN", "methodology": "percent of total billed charges", "standard_charge_dollar": 1688.0, "standard_charge_percentage": 42.2, "count": "0", "additional_payer_notes": "Zero final payments for the item or service in the 15 months prior to posting the file." }, { "payer_name": "CIGNA", "plan_name": "CIGNA COM ALT HMO PLAN", "methodology": "percent of total billed charges", "standard_charge_dollar": 1688.0, "standard_charge_percentage": 42.2, "count": "0", "additional_payer_notes": "Zero final payments for the item or service in the 15 months prior to posting the file." }, { "payer_name": "HEALTH NET", "plan_name": "HEALTHNET HMO, PPO, POS, EPO, CANOPY HEALTHNET HMO, OTHER-IN-NETWORK PLANS", "methodology": "per diem", "standard_charge_dollar": 8000.0, "standard_charge_algorithm": "Expected reimbursement is the lesser of Per diem ($8,000) for the length of stay and 70% of billed.", "median_amount": 132.67, "10th_percentile": 132.67, "90th_percentile": 132.67, "count": "1 through 10" }, { "payer_name": "HEALTH NET", "plan_name": "HEALTHNET HMO, PPO, POS, EPO, CANOPY HEALTHNET HMO, OTHER-IN-NETWORK PLANS", "methodology": "per diem", "standard_charge_dollar": 8000.0, "standard_charge_algorithm": "Expected reimbursement is the lesser of Per diem ($8,000) for the length of stay and 70% of billed.", "count": "0", "additional_payer_notes": "Zero final payments for the item or service in the 15 months prior to posting the file." }, { "payer_name": "UNITED HEALTHCARE", "plan_name": "SUTTER SELECT & SUTTER HEALTH PLAN HMO PLANS", "methodology": "per diem", "standard_charge_dollar": 28538.0, "standard_charge_algorithm": "Per diem ($28,538).", "count": "0", "additional_payer_notes": "Zero final payments for the item or service in the 15 months prior to posting the file." }, { "payer_name": "UNITED HEALTHCARE", "plan_name": "SUTTER SELECT & SUTTER HEALTH PLAN HMO PLANS", "methodology": "per diem", "standard_charge_dollar": 28538.0, "standard_charge_algorithm": "Per diem ($28,538).", "count": "0", "additional_payer_notes": "Zero final payments for the item or service in the 15 months prior to posting the file." }, { "payer_name": "SUTTER", "plan_name": "SUTTER SELECT & SUTTER HEALTH PLAN HMO PLANS", "methodology": "per diem", "standard_charge_dollar": 28538.0, "standard_charge_algorithm": "Per diem ($28,538).", "median_amount": 422.89, "10th_percentile": 228.42, "90th_percentile": 1353.56, "count": "40" }, { "payer_name": "UNITED HEALTHCARE", "plan_name": "SUTTER SELECT & SUTTER HEALTH PLAN HMO PLANS", "methodology": "per diem", "standard_charge_dollar": 28538.0, "standard_charge_algorithm": "Per diem ($28,538).", "count": "0", "additional_payer_notes": "Zero final payments for the item or service in the 15 months prior to posting the file." }, { "payer_name": "UMR", "plan_name": "SUTTER SELECT & SUTTER HEALTH PLAN HMO PLANS", "methodology": "per diem", "standard_charge_dollar": 28538.0, "standard_charge_algorithm": "Per diem ($28,538).", "median_amount": 985.09, "10th_percentile": 45.1, "90th_percentile": 985.09, "count": "1 through 10" }, { "payer_name": "UNITED HEALTHCARE", "plan_name": "SUTTER SELECT & SUTTER HEALTH PLAN HMO PLANS", "methodology": "per diem", "standard_charge_dollar": 28538.0, "standard_charge_algorithm": "Per diem ($28,538).", "median_amount": 823.68, "10th_percentile": 594.01, "90th_percentile": 1518.0, "count": "13" } ] } ] }, { "description": "HC Guidewire Gp025", "code_information": [ { "code": "PX-2120068025", "type": "CDM" }, { "code": "C1769", "type": "HCPCS" }, { "code": "0272", "type": "RC" } ], "standard_charges": [ { "setting": "outpatient", "gross_charge": 4263.0, "discounted_cash": 2131.5, "minimum": 1798.99, "maximum": 2216.76, "additional_generic_notes": "Zero final payments for the item or service in the 15 months prior to posting the file.", "payers_information": [ { "payer_name": "AETNA", "plan_name": "AETNA ALL OTHER PLANS", "methodology": "percent of total billed charges", "standard_charge_dollar": 2216.76, "standard_charge_percentage": 52.0, "count": "0", "additional_payer_notes": "Zero final payments for the item or service in the 15 months prior to posting the file." }, { "payer_name": "AETNA", "plan_name": "AETNA ALL OTHER PLANS", "methodology": "percent of total billed charges", "standard_charge_dollar": 2216.76, "standard_charge_percentage": 52.0, "count": "0", "additional_payer_notes": "Zero final payments for the item or service in the 15 months prior to posting the file." }, { "payer_name": "MERITAIN HEALTH", "plan_name": "AETNA ALL OTHER PLANS", "methodology": "percent of total billed charges", "standard_charge_dollar": 2216.76, "standard_charge_percentage": 52.0, "median_amount": 311.12, "10th_percentile": 311.12, "90th_percentile": 1281.22, "count": "1 through 10" }, { "payer_name": "BLUE SHIELD OUT OF STATE", "plan_name": "STANFORD HEALTHCARE ALLIANCE PLAN", "methodology": "percent of total billed charges", "standard_charge_dollar": 2071.39, "standard_charge_percentage": 48.59, "median_amount": 805.51, "10th_percentile": 335.63, "90th_percentile": 3832.59, "count": "286" }, { "payer_name": "BLUE SHIELD", "plan_name": "STANFORD HEALTHCARE ALLIANCE PLAN", "methodology": "percent of total billed charges", "standard_charge_dollar": 2071.39, "standard_charge_percentage": 48.59, "median_amount": 900.78, "10th_percentile": 312.72, "90th_percentile": 2440.68, "count": "80" }, { "payer_name": "BLUE SHIELD", "plan_name": "STANFORD HEALTHCARE ALLIANCE PLAN", "methodology": "percent of total billed charges", "standard_charge_dollar": 2071.39, "standard_charge_percentage": 48.59, "median_amount": 772.96, "10th_percentile": 276.79, "90th_percentile": 2049.03, "count": "29" }, { "payer_name": "BLUE SHIELD", "plan_name": "STANFORD HEALTHCARE ALLIANCE PLAN", "methodology": "percent of total billed charges", "standard_charge_dollar": 2071.39, "standard_charge_percentage": 48.59, "count": "0", "additional_payer_notes": "Zero final payments for the item or service in the 15 months prior to posting the file." }, { "payer_name": "CIGNA", "plan_name": "CIGNA COM ALT HMO PLAN", "methodology": "percent of total billed charges", "standard_charge_dollar": 1798.99, "standard_charge_percentage": 42.2, "count": "0", "additional_payer_notes": "Zero final payments for the item or service in the 15 months prior to posting the file." }, { "payer_name": "CIGNA", "plan_name": "CIGNA COM ALT HMO PLAN", "methodology": "percent of total billed charges", "standard_charge_dollar": 1798.99, "standard_charge_percentage": 42.2, "count": "0", "additional_payer_notes": "Zero final payments for the item or service in the 15 months prior to posting the file." }, { "payer_name": "HEALTH NET", "plan_name": "HEALTHNET HMO, PPO, POS, EPO, CANOPY HEALTHNET HMO, OTHER-IN-NETWORK PLANS", "methodology": "per diem", "standard_charge_dollar": 8000.0, "standard_charge_algorithm": "Expected reimbursement is the lesser of Per diem ($8,000) for the length of stay and 70% of billed.", "median_amount": 132.67, "10th_percentile": 132.67, "90th_percentile": 132.67, "count": "1 through 10" }, { "payer_name": "HEALTH NET", "plan_name": "HEALTHNET HMO, PPO, POS, EPO, CANOPY HEALTHNET HMO, OTHER-IN-NETWORK PLANS", "methodology": "per diem", "standard_charge_dollar": 8000.0, "standard_charge_algorithm": "Expected reimbursement is the lesser of Per diem ($8,000) for the length of stay and 70% of billed.", "count": "0", "additional_payer_notes": "Zero final payments for the item or service in the 15 months prior to posting the file." }, { "payer_name": "UNITED HEALTHCARE", "plan_name": "SUTTER SELECT & SUTTER HEALTH PLAN HMO PLANS", "methodology": "per diem", "standard_charge_dollar": 28538.0, "standard_charge_algorithm": "Per diem ($28,538).", "count": "0", "additional_payer_notes": "Zero final payments for the item or service in the 15 months prior to posting the file." }, { "payer_name": "UNITED HEALTHCARE", "plan_name": "SUTTER SELECT & SUTTER HEALTH PLAN HMO PLANS", "methodology": "per diem", "standard_charge_dollar": 28538.0, "standard_charge_algorithm": "Per diem ($28,538).", "count": "0", "additional_payer_notes": "Zero final payments for the item or service in the 15 months prior to posting the file." }, { "payer_name": "SUTTER", "plan_name": "SUTTER SELECT & SUTTER HEALTH PLAN HMO PLANS", "methodology": "per diem", "standard_charge_dollar": 28538.0, "standard_charge_algorithm": "Per diem ($28,538).", "median_amount": 422.89, "10th_percentile": 228.42, "90th_percentile": 1353.56, "count": "40" }, { "payer_name": "UNITED HEALTHCARE", "plan_name": "SUTTER SELECT & SUTTER HEALTH PLAN HMO PLANS", "methodology": "per diem", "standard_charge_dollar": 28538.0, "standard_charge_algorithm": "Per diem ($28,538).", "count": "0", "additional_payer_notes": "Zero final payments for the item or service in the 15 months prior to posting the file." }, { "payer_name": "UMR", "plan_name": "SUTTER SELECT & SUTTER HEALTH PLAN HMO PLANS", "methodology": "per diem", "standard_charge_dollar": 28538.0, "standard_charge_algorithm": "Per diem ($28,538).", "median_amount": 985.09, "10th_percentile": 45.1, "90th_percentile": 985.09, "count": "1 through 10" }, { "payer_name": "UNITED HEALTHCARE", "plan_name": "SUTTER SELECT & SUTTER HEALTH PLAN HMO PLANS", "methodology": "per diem", "standard_charge_dollar": 28538.0, "standard_charge_algorithm": "Per diem ($28,538).", "median_amount": 823.68, "10th_percentile": 594.01, "90th_percentile": 1518.0, "count": "13" } ] } ] }, { "description": "HC Guidewire Gp026", "code_information": [ { "code": "PX-2120068026", "type": "CDM" }, { "code": "C1769", "type": "HCPCS" }, { "code": "0272", "type": "RC" } ], "standard_charges": [ { "setting": "outpatient", "gross_charge": 4650.0, "discounted_cash": 2325.0, "minimum": 1962.3, "maximum": 2418.0, "additional_generic_notes": "Zero final payments for the item or service in the 15 months prior to posting the file.", "payers_information": [ { "payer_name": "AETNA", "plan_name": "AETNA ALL OTHER PLANS", "methodology": "percent of total billed charges", "standard_charge_dollar": 2418.0, "standard_charge_percentage": 52.0, "count": "0", "additional_payer_notes": "Zero final payments for the item or service in the 15 months prior to posting the file." }, { "payer_name": "AETNA", "plan_name": "AETNA ALL OTHER PLANS", "methodology": "percent of total billed charges", "standard_charge_dollar": 2418.0, "standard_charge_percentage": 52.0, "count": "0", "additional_payer_notes": "Zero final payments for the item or service in the 15 months prior to posting the file." }, { "payer_name": "MERITAIN HEALTH", "plan_name": "AETNA ALL OTHER PLANS", "methodology": "percent of total billed charges", "standard_charge_dollar": 2418.0, "standard_charge_percentage": 52.0, "median_amount": 311.12, "10th_percentile": 311.12, "90th_percentile": 1281.22, "count": "1 through 10" }, { "payer_name": "BLUE SHIELD OUT OF STATE", "plan_name": "STANFORD HEALTHCARE ALLIANCE PLAN", "methodology": "percent of total billed charges", "standard_charge_dollar": 2259.44, "standard_charge_percentage": 48.59, "median_amount": 805.51, "10th_percentile": 335.63, "90th_percentile": 3832.59, "count": "286" }, { "payer_name": "BLUE SHIELD", "plan_name": "STANFORD HEALTHCARE ALLIANCE PLAN", "methodology": "percent of total billed charges", "standard_charge_dollar": 2259.44, "standard_charge_percentage": 48.59, "median_amount": 900.78, "10th_percentile": 312.72, "90th_percentile": 2440.68, "count": "80" }, { "payer_name": "BLUE SHIELD", "plan_name": "STANFORD HEALTHCARE ALLIANCE PLAN", "methodology": "percent of total billed charges", "standard_charge_dollar": 2259.44, "standard_charge_percentage": 48.59, "median_amount": 772.96, "10th_percentile": 276.79, "90th_percentile": 2049.03, "count": "29" }, { "payer_name": "BLUE SHIELD", "plan_name": "STANFORD HEALTHCARE ALLIANCE PLAN", "methodology": "percent of total billed charges", "standard_charge_dollar": 2259.44, "standard_charge_percentage": 48.59, "count": "0", "additional_payer_notes": "Zero final payments for the item or service in the 15 months prior to posting the file." }, { "payer_name": "CIGNA", "plan_name": "CIGNA COM ALT HMO PLAN", "methodology": "percent of total billed charges", "standard_charge_dollar": 1962.3, "standard_charge_percentage": 42.2, "count": "0", "additional_payer_notes": "Zero final payments for the item or service in the 15 months prior to posting the file." }, { "payer_name": "CIGNA", "plan_name": "CIGNA COM ALT HMO PLAN", "methodology": "percent of total billed charges", "standard_charge_dollar": 1962.3, "standard_charge_percentage": 42.2, "count": "0", "additional_payer_notes": "Zero final payments for the item or service in the 15 months prior to posting the file." }, { "payer_name": "HEALTH NET", "plan_name": "HEALTHNET HMO, PPO, POS, EPO, CANOPY HEALTHNET HMO, OTHER-IN-NETWORK PLANS", "methodology": "per diem", "standard_charge_dollar": 8000.0, "standard_charge_algorithm": "Expected reimbursement is the lesser of Per diem ($8,000) for the length of stay and 70% of billed.", "median_amount": 132.67, "10th_percentile": 132.67, "90th_percentile": 132.67, "count": "1 through 10" }, { "payer_name": "HEALTH NET", "plan_name": "HEALTHNET HMO, PPO, POS, EPO, CANOPY HEALTHNET HMO, OTHER-IN-NETWORK PLANS", "methodology": "per diem", "standard_charge_dollar": 8000.0, "standard_charge_algorithm": "Expected reimbursement is the lesser of Per diem ($8,000) for the length of stay and 70% of billed.", "count": "0", "additional_payer_notes": "Zero final payments for the item or service in the 15 months prior to posting the file." }, { "payer_name": "UNITED HEALTHCARE", "plan_name": "SUTTER SELECT & SUTTER HEALTH PLAN HMO PLANS", "methodology": "per diem", "standard_charge_dollar": 28538.0, "standard_charge_algorithm": "Per diem ($28,538).", "count": "0", "additional_payer_notes": "Zero final payments for the item or service in the 15 months prior to posting the file." }, { "payer_name": "UNITED HEALTHCARE", "plan_name": "SUTTER SELECT & SUTTER HEALTH PLAN HMO PLANS", "methodology": "per diem", "standard_charge_dollar": 28538.0, "standard_charge_algorithm": "Per diem ($28,538).", "count": "0", "additional_payer_notes": "Zero final payments for the item or service in the 15 months prior to posting the file." }, { "payer_name": "SUTTER", "plan_name": "SUTTER SELECT & SUTTER HEALTH PLAN HMO PLANS", "methodology": "per diem", "standard_charge_dollar": 28538.0, "standard_charge_algorithm": "Per diem ($28,538).", "median_amount": 422.89, "10th_percentile": 228.42, "90th_percentile": 1353.56, "count": "40" }, { "payer_name": "UNITED HEALTHCARE", "plan_name": "SUTTER SELECT & SUTTER HEALTH PLAN HMO PLANS", "methodology": "per diem", "standard_charge_dollar": 28538.0, "standard_charge_algorithm": "Per diem ($28,538).", "count": "0", "additional_payer_notes": "Zero final payments for the item or service in the 15 months prior to posting the file." }, { "payer_name": "UMR", "plan_name": "SUTTER SELECT & SUTTER HEALTH PLAN HMO PLANS", "methodology": "per diem", "standard_charge_dollar": 28538.0, "standard_charge_algorithm": "Per diem ($28,538).", "median_amount": 985.09, "10th_percentile": 45.1, "90th_percentile": 985.09, "count": "1 through 10" }, { "payer_name": "UNITED HEALTHCARE", "plan_name": "SUTTER SELECT & SUTTER HEALTH PLAN HMO PLANS", "methodology": "per diem", "standard_charge_dollar": 28538.0, "standard_charge_algorithm": "Per diem ($28,538).", "median_amount": 823.68, "10th_percentile": 594.01, "90th_percentile": 1518.0, "count": "13" } ] } ] }, { "description": "HC Guidewire Gp027", "code_information": [ { "code": "PX-2120068027", "type": "CDM" }, { "code": "C1769", "type": "HCPCS" }, { "code": "0272", "type": "RC" } ], "standard_charges": [ { "setting": "outpatient", "gross_charge": 4875.0, "discounted_cash": 2437.5, "minimum": 2057.25, "maximum": 2535.0, "additional_generic_notes": "Zero final payments for the item or service in the 15 months prior to posting the file.", "payers_information": [ { "payer_name": "AETNA", "plan_name": "AETNA ALL OTHER PLANS", "methodology": "percent of total billed charges", "standard_charge_dollar": 2535.0, "standard_charge_percentage": 52.0, "count": "0", "additional_payer_notes": "Zero final payments for the item or service in the 15 months prior to posting the file." }, { "payer_name": "AETNA", "plan_name": "AETNA ALL OTHER PLANS", "methodology": "percent of total billed charges", "standard_charge_dollar": 2535.0, "standard_charge_percentage": 52.0, "count": "0", "additional_payer_notes": "Zero final payments for the item or service in the 15 months prior to posting the file." }, { "payer_name": "MERITAIN HEALTH", "plan_name": "AETNA ALL OTHER PLANS", "methodology": "percent of total billed charges", "standard_charge_dollar": 2535.0, "standard_charge_percentage": 52.0, "median_amount": 311.12, "10th_percentile": 311.12, "90th_percentile": 1281.22, "count": "1 through 10" }, { "payer_name": "BLUE SHIELD OUT OF STATE", "plan_name": "STANFORD HEALTHCARE ALLIANCE PLAN", "methodology": "percent of total billed charges", "standard_charge_dollar": 2368.76, "standard_charge_percentage": 48.59, "median_amount": 805.51, "10th_percentile": 335.63, "90th_percentile": 3832.59, "count": "286" }, { "payer_name": "BLUE SHIELD", "plan_name": "STANFORD HEALTHCARE ALLIANCE PLAN", "methodology": "percent of total billed charges", "standard_charge_dollar": 2368.76, "standard_charge_percentage": 48.59, "median_amount": 900.78, "10th_percentile": 312.72, "90th_percentile": 2440.68, "count": "80" }, { "payer_name": "BLUE SHIELD", "plan_name": "STANFORD HEALTHCARE ALLIANCE PLAN", "methodology": "percent of total billed charges", "standard_charge_dollar": 2368.76, "standard_charge_percentage": 48.59, "median_amount": 772.96, "10th_percentile": 276.79, "90th_percentile": 2049.03, "count": "29" }, { "payer_name": "BLUE SHIELD", "plan_name": "STANFORD HEALTHCARE ALLIANCE PLAN", "methodology": "percent of total billed charges", "standard_charge_dollar": 2368.76, "standard_charge_percentage": 48.59, "count": "0", "additional_payer_notes": "Zero final payments for the item or service in the 15 months prior to posting the file." }, { "payer_name": "CIGNA", "plan_name": "CIGNA COM ALT HMO PLAN", "methodology": "percent of total billed charges", "standard_charge_dollar": 2057.25, "standard_charge_percentage": 42.2, "count": "0", "additional_payer_notes": "Zero final payments for the item or service in the 15 months prior to posting the file." }, { "payer_name": "CIGNA", "plan_name": "CIGNA COM ALT HMO PLAN", "methodology": "percent of total billed charges", "standard_charge_dollar": 2057.25, "standard_charge_percentage": 42.2, "count": "0", "additional_payer_notes": "Zero final payments for the item or service in the 15 months prior to posting the file." }, { "payer_name": "HEALTH NET", "plan_name": "HEALTHNET HMO, PPO, POS, EPO, CANOPY HEALTHNET HMO, OTHER-IN-NETWORK PLANS", "methodology": "per diem", "standard_charge_dollar": 8000.0, "standard_charge_algorithm": "Expected reimbursement is the lesser of Per diem ($8,000) for the length of stay and 70% of billed.", "median_amount": 132.67, "10th_percentile": 132.67, "90th_percentile": 132.67, "count": "1 through 10" }, { "payer_name": "HEALTH NET", "plan_name": "HEALTHNET HMO, PPO, POS, EPO, CANOPY HEALTHNET HMO, OTHER-IN-NETWORK PLANS", "methodology": "per diem", "standard_charge_dollar": 8000.0, "standard_charge_algorithm": "Expected reimbursement is the lesser of Per diem ($8,000) for the length of stay and 70% of billed.", "count": "0", "additional_payer_notes": "Zero final payments for the item or service in the 15 months prior to posting the file." }, { "payer_name": "UNITED HEALTHCARE", "plan_name": "SUTTER SELECT & SUTTER HEALTH PLAN HMO PLANS", "methodology": "per diem", "standard_charge_dollar": 28538.0, "standard_charge_algorithm": "Per diem ($28,538).", "count": "0", "additional_payer_notes": "Zero final payments for the item or service in the 15 months prior to posting the file." }, { "payer_name": "UNITED HEALTHCARE", "plan_name": "SUTTER SELECT & SUTTER HEALTH PLAN HMO PLANS", "methodology": "per diem", "standard_charge_dollar": 28538.0, "standard_charge_algorithm": "Per diem ($28,538).", "count": "0", "additional_payer_notes": "Zero final payments for the item or service in the 15 months prior to posting the file." }, { "payer_name": "SUTTER", "plan_name": "SUTTER SELECT & SUTTER HEALTH PLAN HMO PLANS", "methodology": "per diem", "standard_charge_dollar": 28538.0, "standard_charge_algorithm": "Per diem ($28,538).", "median_amount": 422.89, "10th_percentile": 228.42, "90th_percentile": 1353.56, "count": "40" }, { "payer_name": "UNITED HEALTHCARE", "plan_name": "SUTTER SELECT & SUTTER HEALTH PLAN HMO PLANS", "methodology": "per diem", "standard_charge_dollar": 28538.0, "standard_charge_algorithm": "Per diem ($28,538).", "count": "0", "additional_payer_notes": "Zero final payments for the item or service in the 15 months prior to posting the file." }, { "payer_name": "UMR", "plan_name": "SUTTER SELECT & SUTTER HEALTH PLAN HMO PLANS", "methodology": "per diem", "standard_charge_dollar": 28538.0, "standard_charge_algorithm": "Per diem ($28,538).", "median_amount": 985.09, "10th_percentile": 45.1, "90th_percentile": 985.09, "count": "1 through 10" }, { "payer_name": "UNITED HEALTHCARE", "plan_name": "SUTTER SELECT & SUTTER HEALTH PLAN HMO PLANS", "methodology": "per diem", "standard_charge_dollar": 28538.0, "standard_charge_algorithm": "Per diem ($28,538).", "median_amount": 823.68, "10th_percentile": 594.01, "90th_percentile": 1518.0, "count": "13" } ] } ] }, { "description": "HC Guidewire Gp028", "code_information": [ { "code": "PX-2120068028", "type": "CDM" }, { "code": "C1769", "type": "HCPCS" }, { "code": "0272", "type": "RC" } ], "standard_charges": [ { "setting": "outpatient", "gross_charge": 5250.0, "discounted_cash": 2625.0, "minimum": 2215.5, "maximum": 2730.0, "additional_generic_notes": "Zero final payments for the item or service in the 15 months prior to posting the file.", "payers_information": [ { "payer_name": "AETNA", "plan_name": "AETNA ALL OTHER PLANS", "methodology": "percent of total billed charges", "standard_charge_dollar": 2730.0, "standard_charge_percentage": 52.0, "count": "0", "additional_payer_notes": "Zero final payments for the item or service in the 15 months prior to posting the file." }, { "payer_name": "AETNA", "plan_name": "AETNA ALL OTHER PLANS", "methodology": "percent of total billed charges", "standard_charge_dollar": 2730.0, "standard_charge_percentage": 52.0, "count": "0", "additional_payer_notes": "Zero final payments for the item or service in the 15 months prior to posting the file." }, { "payer_name": "MERITAIN HEALTH", "plan_name": "AETNA ALL OTHER PLANS", "methodology": "percent of total billed charges", "standard_charge_dollar": 2730.0, "standard_charge_percentage": 52.0, "median_amount": 311.12, "10th_percentile": 311.12, "90th_percentile": 1281.22, "count": "1 through 10" }, { "payer_name": "BLUE SHIELD OUT OF STATE", "plan_name": "STANFORD HEALTHCARE ALLIANCE PLAN", "methodology": "percent of total billed charges", "standard_charge_dollar": 2550.98, "standard_charge_percentage": 48.59, "median_amount": 805.51, "10th_percentile": 335.63, "90th_percentile": 3832.59, "count": "286" }, { "payer_name": "BLUE SHIELD", "plan_name": "STANFORD HEALTHCARE ALLIANCE PLAN", "methodology": "percent of total billed charges", "standard_charge_dollar": 2550.98, "standard_charge_percentage": 48.59, "median_amount": 900.78, "10th_percentile": 312.72, "90th_percentile": 2440.68, "count": "80" }, { "payer_name": "BLUE SHIELD", "plan_name": "STANFORD HEALTHCARE ALLIANCE PLAN", "methodology": "percent of total billed charges", "standard_charge_dollar": 2550.98, "standard_charge_percentage": 48.59, "median_amount": 772.96, "10th_percentile": 276.79, "90th_percentile": 2049.03, "count": "29" }, { "payer_name": "BLUE SHIELD", "plan_name": "STANFORD HEALTHCARE ALLIANCE PLAN", "methodology": "percent of total billed charges", "standard_charge_dollar": 2550.98, "standard_charge_percentage": 48.59, "count": "0", "additional_payer_notes": "Zero final payments for the item or service in the 15 months prior to posting the file." }, { "payer_name": "CIGNA", "plan_name": "CIGNA COM ALT HMO PLAN", "methodology": "percent of total billed charges", "standard_charge_dollar": 2215.5, "standard_charge_percentage": 42.2, "count": "0", "additional_payer_notes": "Zero final payments for the item or service in the 15 months prior to posting the file." }, { "payer_name": "CIGNA", "plan_name": "CIGNA COM ALT HMO PLAN", "methodology": "percent of total billed charges", "standard_charge_dollar": 2215.5, "standard_charge_percentage": 42.2, "count": "0", "additional_payer_notes": "Zero final payments for the item or service in the 15 months prior to posting the file." }, { "payer_name": "HEALTH NET", "plan_name": "HEALTHNET HMO, PPO, POS, EPO, CANOPY HEALTHNET HMO, OTHER-IN-NETWORK PLANS", "methodology": "per diem", "standard_charge_dollar": 8000.0, "standard_charge_algorithm": "Expected reimbursement is the lesser of Per diem ($8,000) for the length of stay and 70% of billed.", "median_amount": 132.67, "10th_percentile": 132.67, "90th_percentile": 132.67, "count": "1 through 10" }, { "payer_name": "HEALTH NET", "plan_name": "HEALTHNET HMO, PPO, POS, EPO, CANOPY HEALTHNET HMO, OTHER-IN-NETWORK PLANS", "methodology": "per diem", "standard_charge_dollar": 8000.0, "standard_charge_algorithm": "Expected reimbursement is the lesser of Per diem ($8,000) for the length of stay and 70% of billed.", "count": "0", "additional_payer_notes": "Zero final payments for the item or service in the 15 months prior to posting the file." }, { "payer_name": "UNITED HEALTHCARE", "plan_name": "SUTTER SELECT & SUTTER HEALTH PLAN HMO PLANS", "methodology": "per diem", "standard_charge_dollar": 28538.0, "standard_charge_algorithm": "Per diem ($28,538).", "count": "0", "additional_payer_notes": "Zero final payments for the item or service in the 15 months prior to posting the file." }, { "payer_name": "UNITED HEALTHCARE", "plan_name": "SUTTER SELECT & SUTTER HEALTH PLAN HMO PLANS", "methodology": "per diem", "standard_charge_dollar": 28538.0, "standard_charge_algorithm": "Per diem ($28,538).", "count": "0", "additional_payer_notes": "Zero final payments for the item or service in the 15 months prior to posting the file." }, { "payer_name": "SUTTER", "plan_name": "SUTTER SELECT & SUTTER HEALTH PLAN HMO PLANS", "methodology": "per diem", "standard_charge_dollar": 28538.0, "standard_charge_algorithm": "Per diem ($28,538).", "median_amount": 422.89, "10th_percentile": 228.42, "90th_percentile": 1353.56, "count": "40" }, { "payer_name": "UNITED HEALTHCARE", "plan_name": "SUTTER SELECT & SUTTER HEALTH PLAN HMO PLANS", "methodology": "per diem", "standard_charge_dollar": 28538.0, "standard_charge_algorithm": "Per diem ($28,538).", "count": "0", "additional_payer_notes": "Zero final payments for the item or service in the 15 months prior to posting the file." }, { "payer_name": "UMR", "plan_name": "SUTTER SELECT & SUTTER HEALTH PLAN HMO PLANS", "methodology": "per diem", "standard_charge_dollar": 28538.0, "standard_charge_algorithm": "Per diem ($28,538).", "median_amount": 985.09, "10th_percentile": 45.1, "90th_percentile": 985.09, "count": "1 through 10" }, { "payer_name": "UNITED HEALTHCARE", "plan_name": "SUTTER SELECT & SUTTER HEALTH PLAN HMO PLANS", "methodology": "per diem", "standard_charge_dollar": 28538.0, "standard_charge_algorithm": "Per diem ($28,538).", "median_amount": 823.68, "10th_percentile": 594.01, "90th_percentile": 1518.0, "count": "13" } ] } ] }, { "description": "HC Guidewire Gp029", "code_information": [ { "code": "PX-2120068029", "type": "CDM" }, { "code": "C1769", "type": "HCPCS" }, { "code": "0272", "type": "RC" } ], "standard_charges": [ { "setting": "outpatient", "gross_charge": 5438.0, "discounted_cash": 2719.0, "minimum": 2294.84, "maximum": 2827.76, "additional_generic_notes": "Zero final payments for the item or service in the 15 months prior to posting the file.", "payers_information": [ { "payer_name": "AETNA", "plan_name": "AETNA ALL OTHER PLANS", "methodology": "percent of total billed charges", "standard_charge_dollar": 2827.76, "standard_charge_percentage": 52.0, "count": "0", "additional_payer_notes": "Zero final payments for the item or service in the 15 months prior to posting the file." }, { "payer_name": "AETNA", "plan_name": "AETNA ALL OTHER PLANS", "methodology": "percent of total billed charges", "standard_charge_dollar": 2827.76, "standard_charge_percentage": 52.0, "count": "0", "additional_payer_notes": "Zero final payments for the item or service in the 15 months prior to posting the file." }, { "payer_name": "MERITAIN HEALTH", "plan_name": "AETNA ALL OTHER PLANS", "methodology": "percent of total billed charges", "standard_charge_dollar": 2827.76, "standard_charge_percentage": 52.0, "median_amount": 311.12, "10th_percentile": 311.12, "90th_percentile": 1281.22, "count": "1 through 10" }, { "payer_name": "BLUE SHIELD OUT OF STATE", "plan_name": "STANFORD HEALTHCARE ALLIANCE PLAN", "methodology": "percent of total billed charges", "standard_charge_dollar": 2642.32, "standard_charge_percentage": 48.59, "median_amount": 805.51, "10th_percentile": 335.63, "90th_percentile": 3832.59, "count": "286" }, { "payer_name": "BLUE SHIELD", "plan_name": "STANFORD HEALTHCARE ALLIANCE PLAN", "methodology": "percent of total billed charges", "standard_charge_dollar": 2642.32, "standard_charge_percentage": 48.59, "median_amount": 900.78, "10th_percentile": 312.72, "90th_percentile": 2440.68, "count": "80" }, { "payer_name": "BLUE SHIELD", "plan_name": "STANFORD HEALTHCARE ALLIANCE PLAN", "methodology": "percent of total billed charges", "standard_charge_dollar": 2642.32, "standard_charge_percentage": 48.59, "median_amount": 772.96, "10th_percentile": 276.79, "90th_percentile": 2049.03, "count": "29" }, { "payer_name": "BLUE SHIELD", "plan_name": "STANFORD HEALTHCARE ALLIANCE PLAN", "methodology": "percent of total billed charges", "standard_charge_dollar": 2642.32, "standard_charge_percentage": 48.59, "count": "0", "additional_payer_notes": "Zero final payments for the item or service in the 15 months prior to posting the file." }, { "payer_name": "CIGNA", "plan_name": "CIGNA COM ALT HMO PLAN", "methodology": "percent of total billed charges", "standard_charge_dollar": 2294.84, "standard_charge_percentage": 42.2, "count": "0", "additional_payer_notes": "Zero final payments for the item or service in the 15 months prior to posting the file." }, { "payer_name": "CIGNA", "plan_name": "CIGNA COM ALT HMO PLAN", "methodology": "percent of total billed charges", "standard_charge_dollar": 2294.84, "standard_charge_percentage": 42.2, "count": "0", "additional_payer_notes": "Zero final payments for the item or service in the 15 months prior to posting the file." }, { "payer_name": "HEALTH NET", "plan_name": "HEALTHNET HMO, PPO, POS, EPO, CANOPY HEALTHNET HMO, OTHER-IN-NETWORK PLANS", "methodology": "per diem", "standard_charge_dollar": 8000.0, "standard_charge_algorithm": "Expected reimbursement is the lesser of Per diem ($8,000) for the length of stay and 70% of billed.", "median_amount": 132.67, "10th_percentile": 132.67, "90th_percentile": 132.67, "count": "1 through 10" }, { "payer_name": "HEALTH NET", "plan_name": "HEALTHNET HMO, PPO, POS, EPO, CANOPY HEALTHNET HMO, OTHER-IN-NETWORK PLANS", "methodology": "per diem", "standard_charge_dollar": 8000.0, "standard_charge_algorithm": "Expected reimbursement is the lesser of Per diem ($8,000) for the length of stay and 70% of billed.", "count": "0", "additional_payer_notes": "Zero final payments for the item or service in the 15 months prior to posting the file." }, { "payer_name": "UNITED HEALTHCARE", "plan_name": "SUTTER SELECT & SUTTER HEALTH PLAN HMO PLANS", "methodology": "per diem", "standard_charge_dollar": 28538.0, "standard_charge_algorithm": "Per diem ($28,538).", "count": "0", "additional_payer_notes": "Zero final payments for the item or service in the 15 months prior to posting the file." }, { "payer_name": "UNITED HEALTHCARE", "plan_name": "SUTTER SELECT & SUTTER HEALTH PLAN HMO PLANS", "methodology": "per diem", "standard_charge_dollar": 28538.0, "standard_charge_algorithm": "Per diem ($28,538).", "count": "0", "additional_payer_notes": "Zero final payments for the item or service in the 15 months prior to posting the file." }, { "payer_name": "SUTTER", "plan_name": "SUTTER SELECT & SUTTER HEALTH PLAN HMO PLANS", "methodology": "per diem", "standard_charge_dollar": 28538.0, "standard_charge_algorithm": "Per diem ($28,538).", "median_amount": 422.89, "10th_percentile": 228.42, "90th_percentile": 1353.56, "count": "40" }, { "payer_name": "UNITED HEALTHCARE", "plan_name": "SUTTER SELECT & SUTTER HEALTH PLAN HMO PLANS", "methodology": "per diem", "standard_charge_dollar": 28538.0, "standard_charge_algorithm": "Per diem ($28,538).", "count": "0", "additional_payer_notes": "Zero final payments for the item or service in the 15 months prior to posting the file." }, { "payer_name": "UMR", "plan_name": "SUTTER SELECT & SUTTER HEALTH PLAN HMO PLANS", "methodology": "per diem", "standard_charge_dollar": 28538.0, "standard_charge_algorithm": "Per diem ($28,538).", "median_amount": 985.09, "10th_percentile": 45.1, "90th_percentile": 985.09, "count": "1 through 10" }, { "payer_name": "UNITED HEALTHCARE", "plan_name": "SUTTER SELECT & SUTTER HEALTH PLAN HMO PLANS", "methodology": "per diem", "standard_charge_dollar": 28538.0, "standard_charge_algorithm": "Per diem ($28,538).", "median_amount": 823.68, "10th_percentile": 594.01, "90th_percentile": 1518.0, "count": "13" } ] } ] }, { "description": "Hc Guidewire Gp030", "code_information": [ { "code": "PX-2120068030", "type": "CDM" }, { "code": "C1769", "type": "HCPCS" }, { "code": "0272", "type": "RC" } ], "standard_charges": [ { "setting": "outpatient", "gross_charge": 5800.0, "discounted_cash": 2900.0, "minimum": 2447.6, "maximum": 3016.0, "additional_generic_notes": "Zero final payments for the item or service in the 15 months prior to posting the file.", "payers_information": [ { "payer_name": "AETNA", "plan_name": "AETNA ALL OTHER PLANS", "methodology": "percent of total billed charges", "standard_charge_dollar": 3016.0, "standard_charge_percentage": 52.0, "count": "0", "additional_payer_notes": "Zero final payments for the item or service in the 15 months prior to posting the file." }, { "payer_name": "AETNA", "plan_name": "AETNA ALL OTHER PLANS", "methodology": "percent of total billed charges", "standard_charge_dollar": 3016.0, "standard_charge_percentage": 52.0, "count": "0", "additional_payer_notes": "Zero final payments for the item or service in the 15 months prior to posting the file." }, { "payer_name": "MERITAIN HEALTH", "plan_name": "AETNA ALL OTHER PLANS", "methodology": "percent of total billed charges", "standard_charge_dollar": 3016.0, "standard_charge_percentage": 52.0, "median_amount": 311.12, "10th_percentile": 311.12, "90th_percentile": 1281.22, "count": "1 through 10" }, { "payer_name": "BLUE SHIELD OUT OF STATE", "plan_name": "STANFORD HEALTHCARE ALLIANCE PLAN", "methodology": "percent of total billed charges", "standard_charge_dollar": 2818.22, "standard_charge_percentage": 48.59, "median_amount": 805.51, "10th_percentile": 335.63, "90th_percentile": 3832.59, "count": "286" }, { "payer_name": "BLUE SHIELD", "plan_name": "STANFORD HEALTHCARE ALLIANCE PLAN", "methodology": "percent of total billed charges", "standard_charge_dollar": 2818.22, "standard_charge_percentage": 48.59, "median_amount": 900.78, "10th_percentile": 312.72, "90th_percentile": 2440.68, "count": "80" }, { "payer_name": "BLUE SHIELD", "plan_name": "STANFORD HEALTHCARE ALLIANCE PLAN", "methodology": "percent of total billed charges", "standard_charge_dollar": 2818.22, "standard_charge_percentage": 48.59, "median_amount": 772.96, "10th_percentile": 276.79, "90th_percentile": 2049.03, "count": "29" }, { "payer_name": "BLUE SHIELD", "plan_name": "STANFORD HEALTHCARE ALLIANCE PLAN", "methodology": "percent of total billed charges", "standard_charge_dollar": 2818.22, "standard_charge_percentage": 48.59, "count": "0", "additional_payer_notes": "Zero final payments for the item or service in the 15 months prior to posting the file." }, { "payer_name": "CIGNA", "plan_name": "CIGNA COM ALT HMO PLAN", "methodology": "percent of total billed charges", "standard_charge_dollar": 2447.6, "standard_charge_percentage": 42.2, "count": "0", "additional_payer_notes": "Zero final payments for the item or service in the 15 months prior to posting the file." }, { "payer_name": "CIGNA", "plan_name": "CIGNA COM ALT HMO PLAN", "methodology": "percent of total billed charges", "standard_charge_dollar": 2447.6, "standard_charge_percentage": 42.2, "count": "0", "additional_payer_notes": "Zero final payments for the item or service in the 15 months prior to posting the file." }, { "payer_name": "HEALTH NET", "plan_name": "HEALTHNET HMO, PPO, POS, EPO, CANOPY HEALTHNET HMO, OTHER-IN-NETWORK PLANS", "methodology": "per diem", "standard_charge_dollar": 8000.0, "standard_charge_algorithm": "Expected reimbursement is the lesser of Per diem ($8,000) for the length of stay and 70% of billed.", "median_amount": 132.67, "10th_percentile": 132.67, "90th_percentile": 132.67, "count": "1 through 10" }, { "payer_name": "HEALTH NET", "plan_name": "HEALTHNET HMO, PPO, POS, EPO, CANOPY HEALTHNET HMO, OTHER-IN-NETWORK PLANS", "methodology": "per diem", "standard_charge_dollar": 8000.0, "standard_charge_algorithm": "Expected reimbursement is the lesser of Per diem ($8,000) for the length of stay and 70% of billed.", "count": "0", "additional_payer_notes": "Zero final payments for the item or service in the 15 months prior to posting the file." }, { "payer_name": "UNITED HEALTHCARE", "plan_name": "SUTTER SELECT & SUTTER HEALTH PLAN HMO PLANS", "methodology": "per diem", "standard_charge_dollar": 28538.0, "standard_charge_algorithm": "Per diem ($28,538).", "count": "0", "additional_payer_notes": "Zero final payments for the item or service in the 15 months prior to posting the file." }, { "payer_name": "UNITED HEALTHCARE", "plan_name": "SUTTER SELECT & SUTTER HEALTH PLAN HMO PLANS", "methodology": "per diem", "standard_charge_dollar": 28538.0, "standard_charge_algorithm": "Per diem ($28,538).", "count": "0", "additional_payer_notes": "Zero final payments for the item or service in the 15 months prior to posting the file." }, { "payer_name": "SUTTER", "plan_name": "SUTTER SELECT & SUTTER HEALTH PLAN HMO PLANS", "methodology": "per diem", "standard_charge_dollar": 28538.0, "standard_charge_algorithm": "Per diem ($28,538).", "median_amount": 422.89, "10th_percentile": 228.42, "90th_percentile": 1353.56, "count": "40" }, { "payer_name": "UNITED HEALTHCARE", "plan_name": "SUTTER SELECT & SUTTER HEALTH PLAN HMO PLANS", "methodology": "per diem", "standard_charge_dollar": 28538.0, "standard_charge_algorithm": "Per diem ($28,538).", "count": "0", "additional_payer_notes": "Zero final payments for the item or service in the 15 months prior to posting the file." }, { "payer_name": "UMR", "plan_name": "SUTTER SELECT & SUTTER HEALTH PLAN HMO PLANS", "methodology": "per diem", "standard_charge_dollar": 28538.0, "standard_charge_algorithm": "Per diem ($28,538).", "median_amount": 985.09, "10th_percentile": 45.1, "90th_percentile": 985.09, "count": "1 through 10" }, { "payer_name": "UNITED HEALTHCARE", "plan_name": "SUTTER SELECT & SUTTER HEALTH PLAN HMO PLANS", "methodology": "per diem", "standard_charge_dollar": 28538.0, "standard_charge_algorithm": "Per diem ($28,538).", "median_amount": 823.68, "10th_percentile": 594.01, "90th_percentile": 1518.0, "count": "13" } ] } ] }, { "description": "HC Guidewire Gp031", "code_information": [ { "code": "PX-2120068031", "type": "CDM" }, { "code": "C1769", "type": "HCPCS" }, { "code": "0272", "type": "RC" } ], "standard_charges": [ { "setting": "outpatient", "gross_charge": 5950.0, "discounted_cash": 2975.0, "minimum": 2510.9, "maximum": 3094.0, "additional_generic_notes": "Zero final payments for the item or service in the 15 months prior to posting the file.", "payers_information": [ { "payer_name": "AETNA", "plan_name": "AETNA ALL OTHER PLANS", "methodology": "percent of total billed charges", "standard_charge_dollar": 3094.0, "standard_charge_percentage": 52.0, "count": "0", "additional_payer_notes": "Zero final payments for the item or service in the 15 months prior to posting the file." }, { "payer_name": "AETNA", "plan_name": "AETNA ALL OTHER PLANS", "methodology": "percent of total billed charges", "standard_charge_dollar": 3094.0, "standard_charge_percentage": 52.0, "count": "0", "additional_payer_notes": "Zero final payments for the item or service in the 15 months prior to posting the file." }, { "payer_name": "MERITAIN HEALTH", "plan_name": "AETNA ALL OTHER PLANS", "methodology": "percent of total billed charges", "standard_charge_dollar": 3094.0, "standard_charge_percentage": 52.0, "median_amount": 311.12, "10th_percentile": 311.12, "90th_percentile": 1281.22, "count": "1 through 10" }, { "payer_name": "BLUE SHIELD OUT OF STATE", "plan_name": "STANFORD HEALTHCARE ALLIANCE PLAN", "methodology": "percent of total billed charges", "standard_charge_dollar": 2891.11, "standard_charge_percentage": 48.59, "median_amount": 805.51, "10th_percentile": 335.63, "90th_percentile": 3832.59, "count": "286" }, { "payer_name": "BLUE SHIELD", "plan_name": "STANFORD HEALTHCARE ALLIANCE PLAN", "methodology": "percent of total billed charges", "standard_charge_dollar": 2891.11, "standard_charge_percentage": 48.59, "median_amount": 900.78, "10th_percentile": 312.72, "90th_percentile": 2440.68, "count": "80" }, { "payer_name": "BLUE SHIELD", "plan_name": "STANFORD HEALTHCARE ALLIANCE PLAN", "methodology": "percent of total billed charges", "standard_charge_dollar": 2891.11, "standard_charge_percentage": 48.59, "median_amount": 772.96, "10th_percentile": 276.79, "90th_percentile": 2049.03, "count": "29" }, { "payer_name": "BLUE SHIELD", "plan_name": "STANFORD HEALTHCARE ALLIANCE PLAN", "methodology": "percent of total billed charges", "standard_charge_dollar": 2891.11, "standard_charge_percentage": 48.59, "count": "0", "additional_payer_notes": "Zero final payments for the item or service in the 15 months prior to posting the file." }, { "payer_name": "CIGNA", "plan_name": "CIGNA COM ALT HMO PLAN", "methodology": "percent of total billed charges", "standard_charge_dollar": 2510.9, "standard_charge_percentage": 42.2, "count": "0", "additional_payer_notes": "Zero final payments for the item or service in the 15 months prior to posting the file." }, { "payer_name": "CIGNA", "plan_name": "CIGNA COM ALT HMO PLAN", "methodology": "percent of total billed charges", "standard_charge_dollar": 2510.9, "standard_charge_percentage": 42.2, "count": "0", "additional_payer_notes": "Zero final payments for the item or service in the 15 months prior to posting the file." }, { "payer_name": "HEALTH NET", "plan_name": "HEALTHNET HMO, PPO, POS, EPO, CANOPY HEALTHNET HMO, OTHER-IN-NETWORK PLANS", "methodology": "per diem", "standard_charge_dollar": 8000.0, "standard_charge_algorithm": "Expected reimbursement is the lesser of Per diem ($8,000) for the length of stay and 70% of billed.", "median_amount": 132.67, "10th_percentile": 132.67, "90th_percentile": 132.67, "count": "1 through 10" }, { "payer_name": "HEALTH NET", "plan_name": "HEALTHNET HMO, PPO, POS, EPO, CANOPY HEALTHNET HMO, OTHER-IN-NETWORK PLANS", "methodology": "per diem", "standard_charge_dollar": 8000.0, "standard_charge_algorithm": "Expected reimbursement is the lesser of Per diem ($8,000) for the length of stay and 70% of billed.", "count": "0", "additional_payer_notes": "Zero final payments for the item or service in the 15 months prior to posting the file." }, { "payer_name": "UNITED HEALTHCARE", "plan_name": "SUTTER SELECT & SUTTER HEALTH PLAN HMO PLANS", "methodology": "per diem", "standard_charge_dollar": 28538.0, "standard_charge_algorithm": "Per diem ($28,538).", "count": "0", "additional_payer_notes": "Zero final payments for the item or service in the 15 months prior to posting the file." }, { "payer_name": "UNITED HEALTHCARE", "plan_name": "SUTTER SELECT & SUTTER HEALTH PLAN HMO PLANS", "methodology": "per diem", "standard_charge_dollar": 28538.0, "standard_charge_algorithm": "Per diem ($28,538).", "count": "0", "additional_payer_notes": "Zero final payments for the item or service in the 15 months prior to posting the file." }, { "payer_name": "SUTTER", "plan_name": "SUTTER SELECT & SUTTER HEALTH PLAN HMO PLANS", "methodology": "per diem", "standard_charge_dollar": 28538.0, "standard_charge_algorithm": "Per diem ($28,538).", "median_amount": 422.89, "10th_percentile": 228.42, "90th_percentile": 1353.56, "count": "40" }, { "payer_name": "UNITED HEALTHCARE", "plan_name": "SUTTER SELECT & SUTTER HEALTH PLAN HMO PLANS", "methodology": "per diem", "standard_charge_dollar": 28538.0, "standard_charge_algorithm": "Per diem ($28,538).", "count": "0", "additional_payer_notes": "Zero final payments for the item or service in the 15 months prior to posting the file." }, { "payer_name": "UMR", "plan_name": "SUTTER SELECT & SUTTER HEALTH PLAN HMO PLANS", "methodology": "per diem", "standard_charge_dollar": 28538.0, "standard_charge_algorithm": "Per diem ($28,538).", "median_amount": 985.09, "10th_percentile": 45.1, "90th_percentile": 985.09, "count": "1 through 10" }, { "payer_name": "UNITED HEALTHCARE", "plan_name": "SUTTER SELECT & SUTTER HEALTH PLAN HMO PLANS", "methodology": "per diem", "standard_charge_dollar": 28538.0, "standard_charge_algorithm": "Per diem ($28,538).", "median_amount": 823.68, "10th_percentile": 594.01, "90th_percentile": 1518.0, "count": "13" } ] } ] }, { "description": "HC Guidewire Gp032", "code_information": [ { "code": "PX-2120068032", "type": "CDM" }, { "code": "C1769", "type": "HCPCS" }, { "code": "0272", "type": "RC" } ], "standard_charges": [ { "setting": "outpatient", "gross_charge": 6300.0, "discounted_cash": 3150.0, "minimum": 2658.6, "maximum": 3276.0, "additional_generic_notes": "Zero final payments for the item or service in the 15 months prior to posting the file.", "payers_information": [ { "payer_name": "AETNA", "plan_name": "AETNA ALL OTHER PLANS", "methodology": "percent of total billed charges", "standard_charge_dollar": 3276.0, "standard_charge_percentage": 52.0, "count": "0", "additional_payer_notes": "Zero final payments for the item or service in the 15 months prior to posting the file." }, { "payer_name": "AETNA", "plan_name": "AETNA ALL OTHER PLANS", "methodology": "percent of total billed charges", "standard_charge_dollar": 3276.0, "standard_charge_percentage": 52.0, "count": "0", "additional_payer_notes": "Zero final payments for the item or service in the 15 months prior to posting the file." }, { "payer_name": "MERITAIN HEALTH", "plan_name": "AETNA ALL OTHER PLANS", "methodology": "percent of total billed charges", "standard_charge_dollar": 3276.0, "standard_charge_percentage": 52.0, "median_amount": 311.12, "10th_percentile": 311.12, "90th_percentile": 1281.22, "count": "1 through 10" }, { "payer_name": "BLUE SHIELD OUT OF STATE", "plan_name": "STANFORD HEALTHCARE ALLIANCE PLAN", "methodology": "percent of total billed charges", "standard_charge_dollar": 3061.17, "standard_charge_percentage": 48.59, "median_amount": 805.51, "10th_percentile": 335.63, "90th_percentile": 3832.59, "count": "286" }, { "payer_name": "BLUE SHIELD", "plan_name": "STANFORD HEALTHCARE ALLIANCE PLAN", "methodology": "percent of total billed charges", "standard_charge_dollar": 3061.17, "standard_charge_percentage": 48.59, "median_amount": 900.78, "10th_percentile": 312.72, "90th_percentile": 2440.68, "count": "80" }, { "payer_name": "BLUE SHIELD", "plan_name": "STANFORD HEALTHCARE ALLIANCE PLAN", "methodology": "percent of total billed charges", "standard_charge_dollar": 3061.17, "standard_charge_percentage": 48.59, "median_amount": 772.96, "10th_percentile": 276.79, "90th_percentile": 2049.03, "count": "29" }, { "payer_name": "BLUE SHIELD", "plan_name": "STANFORD HEALTHCARE ALLIANCE PLAN", "methodology": "percent of total billed charges", "standard_charge_dollar": 3061.17, "standard_charge_percentage": 48.59, "count": "0", "additional_payer_notes": "Zero final payments for the item or service in the 15 months prior to posting the file." }, { "payer_name": "CIGNA", "plan_name": "CIGNA COM ALT HMO PLAN", "methodology": "percent of total billed charges", "standard_charge_dollar": 2658.6, "standard_charge_percentage": 42.2, "count": "0", "additional_payer_notes": "Zero final payments for the item or service in the 15 months prior to posting the file." }, { "payer_name": "CIGNA", "plan_name": "CIGNA COM ALT HMO PLAN", "methodology": "percent of total billed charges", "standard_charge_dollar": 2658.6, "standard_charge_percentage": 42.2, "count": "0", "additional_payer_notes": "Zero final payments for the item or service in the 15 months prior to posting the file." }, { "payer_name": "HEALTH NET", "plan_name": "HEALTHNET HMO, PPO, POS, EPO, CANOPY HEALTHNET HMO, OTHER-IN-NETWORK PLANS", "methodology": "per diem", "standard_charge_dollar": 8000.0, "standard_charge_algorithm": "Expected reimbursement is the lesser of Per diem ($8,000) for the length of stay and 70% of billed.", "median_amount": 132.67, "10th_percentile": 132.67, "90th_percentile": 132.67, "count": "1 through 10" }, { "payer_name": "HEALTH NET", "plan_name": "HEALTHNET HMO, PPO, POS, EPO, CANOPY HEALTHNET HMO, OTHER-IN-NETWORK PLANS", "methodology": "per diem", "standard_charge_dollar": 8000.0, "standard_charge_algorithm": "Expected reimbursement is the lesser of Per diem ($8,000) for the length of stay and 70% of billed.", "count": "0", "additional_payer_notes": "Zero final payments for the item or service in the 15 months prior to posting the file." }, { "payer_name": "UNITED HEALTHCARE", "plan_name": "SUTTER SELECT & SUTTER HEALTH PLAN HMO PLANS", "methodology": "per diem", "standard_charge_dollar": 28538.0, "standard_charge_algorithm": "Per diem ($28,538).", "count": "0", "additional_payer_notes": "Zero final payments for the item or service in the 15 months prior to posting the file." }, { "payer_name": "UNITED HEALTHCARE", "plan_name": "SUTTER SELECT & SUTTER HEALTH PLAN HMO PLANS", "methodology": "per diem", "standard_charge_dollar": 28538.0, "standard_charge_algorithm": "Per diem ($28,538).", "count": "0", "additional_payer_notes": "Zero final payments for the item or service in the 15 months prior to posting the file." }, { "payer_name": "SUTTER", "plan_name": "SUTTER SELECT & SUTTER HEALTH PLAN HMO PLANS", "methodology": "per diem", "standard_charge_dollar": 28538.0, "standard_charge_algorithm": "Per diem ($28,538).", "median_amount": 422.89, "10th_percentile": 228.42, "90th_percentile": 1353.56, "count": "40" }, { "payer_name": "UNITED HEALTHCARE", "plan_name": "SUTTER SELECT & SUTTER HEALTH PLAN HMO PLANS", "methodology": "per diem", "standard_charge_dollar": 28538.0, "standard_charge_algorithm": "Per diem ($28,538).", "count": "0", "additional_payer_notes": "Zero final payments for the item or service in the 15 months prior to posting the file." }, { "payer_name": "UMR", "plan_name": "SUTTER SELECT & SUTTER HEALTH PLAN HMO PLANS", "methodology": "per diem", "standard_charge_dollar": 28538.0, "standard_charge_algorithm": "Per diem ($28,538).", "median_amount": 985.09, "10th_percentile": 45.1, "90th_percentile": 985.09, "count": "1 through 10" }, { "payer_name": "UNITED HEALTHCARE", "plan_name": "SUTTER SELECT & SUTTER HEALTH PLAN HMO PLANS", "methodology": "per diem", "standard_charge_dollar": 28538.0, "standard_charge_algorithm": "Per diem ($28,538).", "median_amount": 823.68, "10th_percentile": 594.01, "90th_percentile": 1518.0, "count": "13" } ] } ] }, { "description": "HC Guidewire Gp035", "code_information": [ { "code": "PX-2120068035", "type": "CDM" }, { "code": "C1769", "type": "HCPCS" }, { "code": "0272", "type": "RC" } ], "standard_charges": [ { "setting": "outpatient", "gross_charge": 7150.0, "discounted_cash": 3575.0, "minimum": 3017.3, "maximum": 3718.0, "additional_generic_notes": "Zero final payments for the item or service in the 15 months prior to posting the file.", "payers_information": [ { "payer_name": "AETNA", "plan_name": "AETNA ALL OTHER PLANS", "methodology": "percent of total billed charges", "standard_charge_dollar": 3718.0, "standard_charge_percentage": 52.0, "count": "0", "additional_payer_notes": "Zero final payments for the item or service in the 15 months prior to posting the file." }, { "payer_name": "AETNA", "plan_name": "AETNA ALL OTHER PLANS", "methodology": "percent of total billed charges", "standard_charge_dollar": 3718.0, "standard_charge_percentage": 52.0, "count": "0", "additional_payer_notes": "Zero final payments for the item or service in the 15 months prior to posting the file." }, { "payer_name": "MERITAIN HEALTH", "plan_name": "AETNA ALL OTHER PLANS", "methodology": "percent of total billed charges", "standard_charge_dollar": 3718.0, "standard_charge_percentage": 52.0, "median_amount": 311.12, "10th_percentile": 311.12, "90th_percentile": 1281.22, "count": "1 through 10" }, { "payer_name": "BLUE SHIELD OUT OF STATE", "plan_name": "STANFORD HEALTHCARE ALLIANCE PLAN", "methodology": "percent of total billed charges", "standard_charge_dollar": 3474.19, "standard_charge_percentage": 48.59, "median_amount": 805.51, "10th_percentile": 335.63, "90th_percentile": 3832.59, "count": "286" }, { "payer_name": "BLUE SHIELD", "plan_name": "STANFORD HEALTHCARE ALLIANCE PLAN", "methodology": "percent of total billed charges", "standard_charge_dollar": 3474.19, "standard_charge_percentage": 48.59, "median_amount": 900.78, "10th_percentile": 312.72, "90th_percentile": 2440.68, "count": "80" }, { "payer_name": "BLUE SHIELD", "plan_name": "STANFORD HEALTHCARE ALLIANCE PLAN", "methodology": "percent of total billed charges", "standard_charge_dollar": 3474.19, "standard_charge_percentage": 48.59, "median_amount": 772.96, "10th_percentile": 276.79, "90th_percentile": 2049.03, "count": "29" }, { "payer_name": "BLUE SHIELD", "plan_name": "STANFORD HEALTHCARE ALLIANCE PLAN", "methodology": "percent of total billed charges", "standard_charge_dollar": 3474.19, "standard_charge_percentage": 48.59, "count": "0", "additional_payer_notes": "Zero final payments for the item or service in the 15 months prior to posting the file." }, { "payer_name": "CIGNA", "plan_name": "CIGNA COM ALT HMO PLAN", "methodology": "percent of total billed charges", "standard_charge_dollar": 3017.3, "standard_charge_percentage": 42.2, "count": "0", "additional_payer_notes": "Zero final payments for the item or service in the 15 months prior to posting the file." }, { "payer_name": "CIGNA", "plan_name": "CIGNA COM ALT HMO PLAN", "methodology": "percent of total billed charges", "standard_charge_dollar": 3017.3, "standard_charge_percentage": 42.2, "count": "0", "additional_payer_notes": "Zero final payments for the item or service in the 15 months prior to posting the file." }, { "payer_name": "HEALTH NET", "plan_name": "HEALTHNET HMO, PPO, POS, EPO, CANOPY HEALTHNET HMO, OTHER-IN-NETWORK PLANS", "methodology": "per diem", "standard_charge_dollar": 8000.0, "standard_charge_algorithm": "Expected reimbursement is the lesser of Per diem ($8,000) for the length of stay and 70% of billed.", "median_amount": 132.67, "10th_percentile": 132.67, "90th_percentile": 132.67, "count": "1 through 10" }, { "payer_name": "HEALTH NET", "plan_name": "HEALTHNET HMO, PPO, POS, EPO, CANOPY HEALTHNET HMO, OTHER-IN-NETWORK PLANS", "methodology": "per diem", "standard_charge_dollar": 8000.0, "standard_charge_algorithm": "Expected reimbursement is the lesser of Per diem ($8,000) for the length of stay and 70% of billed.", "count": "0", "additional_payer_notes": "Zero final payments for the item or service in the 15 months prior to posting the file." }, { "payer_name": "UNITED HEALTHCARE", "plan_name": "SUTTER SELECT & SUTTER HEALTH PLAN HMO PLANS", "methodology": "per diem", "standard_charge_dollar": 28538.0, "standard_charge_algorithm": "Per diem ($28,538).", "count": "0", "additional_payer_notes": "Zero final payments for the item or service in the 15 months prior to posting the file." }, { "payer_name": "UNITED HEALTHCARE", "plan_name": "SUTTER SELECT & SUTTER HEALTH PLAN HMO PLANS", "methodology": "per diem", "standard_charge_dollar": 28538.0, "standard_charge_algorithm": "Per diem ($28,538).", "count": "0", "additional_payer_notes": "Zero final payments for the item or service in the 15 months prior to posting the file." }, { "payer_name": "SUTTER", "plan_name": "SUTTER SELECT & SUTTER HEALTH PLAN HMO PLANS", "methodology": "per diem", "standard_charge_dollar": 28538.0, "standard_charge_algorithm": "Per diem ($28,538).", "median_amount": 422.89, "10th_percentile": 228.42, "90th_percentile": 1353.56, "count": "40" }, { "payer_name": "UNITED HEALTHCARE", "plan_name": "SUTTER SELECT & SUTTER HEALTH PLAN HMO PLANS", "methodology": "per diem", "standard_charge_dollar": 28538.0, "standard_charge_algorithm": "Per diem ($28,538).", "count": "0", "additional_payer_notes": "Zero final payments for the item or service in the 15 months prior to posting the file." }, { "payer_name": "UMR", "plan_name": "SUTTER SELECT & SUTTER HEALTH PLAN HMO PLANS", "methodology": "per diem", "standard_charge_dollar": 28538.0, "standard_charge_algorithm": "Per diem ($28,538).", "median_amount": 985.09, "10th_percentile": 45.1, "90th_percentile": 985.09, "count": "1 through 10" }, { "payer_name": "UNITED HEALTHCARE", "plan_name": "SUTTER SELECT & SUTTER HEALTH PLAN HMO PLANS", "methodology": "per diem", "standard_charge_dollar": 28538.0, "standard_charge_algorithm": "Per diem ($28,538).", "median_amount": 823.68, "10th_percentile": 594.01, "90th_percentile": 1518.0, "count": "13" } ] } ] }, { "description": "HC Guidewire Gp038", "code_information": [ { "code": "PX-2120068038", "type": "CDM" }, { "code": "C1769", "type": "HCPCS" }, { "code": "0272", "type": "RC" } ], "standard_charges": [ { "setting": "outpatient", "gross_charge": 8750.0, "discounted_cash": 4375.0, "minimum": 3692.5, "maximum": 4550.0, "additional_generic_notes": "Zero final payments for the item or service in the 15 months prior to posting the file.", "payers_information": [ { "payer_name": "AETNA", "plan_name": "AETNA ALL OTHER PLANS", "methodology": "percent of total billed charges", "standard_charge_dollar": 4550.0, "standard_charge_percentage": 52.0, "count": "0", "additional_payer_notes": "Zero final payments for the item or service in the 15 months prior to posting the file." }, { "payer_name": "AETNA", "plan_name": "AETNA ALL OTHER PLANS", "methodology": "percent of total billed charges", "standard_charge_dollar": 4550.0, "standard_charge_percentage": 52.0, "count": "0", "additional_payer_notes": "Zero final payments for the item or service in the 15 months prior to posting the file." }, { "payer_name": "MERITAIN HEALTH", "plan_name": "AETNA ALL OTHER PLANS", "methodology": "percent of total billed charges", "standard_charge_dollar": 4550.0, "standard_charge_percentage": 52.0, "median_amount": 311.12, "10th_percentile": 311.12, "90th_percentile": 1281.22, "count": "1 through 10" }, { "payer_name": "BLUE SHIELD OUT OF STATE", "plan_name": "STANFORD HEALTHCARE ALLIANCE PLAN", "methodology": "percent of total billed charges", "standard_charge_dollar": 4251.63, "standard_charge_percentage": 48.59, "median_amount": 805.51, "10th_percentile": 335.63, "90th_percentile": 3832.59, "count": "286" }, { "payer_name": "BLUE SHIELD", "plan_name": "STANFORD HEALTHCARE ALLIANCE PLAN", "methodology": "percent of total billed charges", "standard_charge_dollar": 4251.63, "standard_charge_percentage": 48.59, "median_amount": 900.78, "10th_percentile": 312.72, "90th_percentile": 2440.68, "count": "80" }, { "payer_name": "BLUE SHIELD", "plan_name": "STANFORD HEALTHCARE ALLIANCE PLAN", "methodology": "percent of total billed charges", "standard_charge_dollar": 4251.63, "standard_charge_percentage": 48.59, "median_amount": 772.96, "10th_percentile": 276.79, "90th_percentile": 2049.03, "count": "29" }, { "payer_name": "BLUE SHIELD", "plan_name": "STANFORD HEALTHCARE ALLIANCE PLAN", "methodology": "percent of total billed charges", "standard_charge_dollar": 4251.63, "standard_charge_percentage": 48.59, "count": "0", "additional_payer_notes": "Zero final payments for the item or service in the 15 months prior to posting the file." }, { "payer_name": "CIGNA", "plan_name": "CIGNA COM ALT HMO PLAN", "methodology": "percent of total billed charges", "standard_charge_dollar": 3692.5, "standard_charge_percentage": 42.2, "count": "0", "additional_payer_notes": "Zero final payments for the item or service in the 15 months prior to posting the file." }, { "payer_name": "CIGNA", "plan_name": "CIGNA COM ALT HMO PLAN", "methodology": "percent of total billed charges", "standard_charge_dollar": 3692.5, "standard_charge_percentage": 42.2, "count": "0", "additional_payer_notes": "Zero final payments for the item or service in the 15 months prior to posting the file." }, { "payer_name": "HEALTH NET", "plan_name": "HEALTHNET HMO, PPO, POS, EPO, CANOPY HEALTHNET HMO, OTHER-IN-NETWORK PLANS", "methodology": "per diem", "standard_charge_dollar": 8000.0, "standard_charge_algorithm": "Expected reimbursement is the lesser of Per diem ($8,000) for the length of stay and 70% of billed.", "median_amount": 132.67, "10th_percentile": 132.67, "90th_percentile": 132.67, "count": "1 through 10" }, { "payer_name": "HEALTH NET", "plan_name": "HEALTHNET HMO, PPO, POS, EPO, CANOPY HEALTHNET HMO, OTHER-IN-NETWORK PLANS", "methodology": "per diem", "standard_charge_dollar": 8000.0, "standard_charge_algorithm": "Expected reimbursement is the lesser of Per diem ($8,000) for the length of stay and 70% of billed.", "count": "0", "additional_payer_notes": "Zero final payments for the item or service in the 15 months prior to posting the file." }, { "payer_name": "UNITED HEALTHCARE", "plan_name": "SUTTER SELECT & SUTTER HEALTH PLAN HMO PLANS", "methodology": "per diem", "standard_charge_dollar": 28538.0, "standard_charge_algorithm": "Per diem ($28,538).", "count": "0", "additional_payer_notes": "Zero final payments for the item or service in the 15 months prior to posting the file." }, { "payer_name": "UNITED HEALTHCARE", "plan_name": "SUTTER SELECT & SUTTER HEALTH PLAN HMO PLANS", "methodology": "per diem", "standard_charge_dollar": 28538.0, "standard_charge_algorithm": "Per diem ($28,538).", "count": "0", "additional_payer_notes": "Zero final payments for the item or service in the 15 months prior to posting the file." }, { "payer_name": "SUTTER", "plan_name": "SUTTER SELECT & SUTTER HEALTH PLAN HMO PLANS", "methodology": "per diem", "standard_charge_dollar": 28538.0, "standard_charge_algorithm": "Per diem ($28,538).", "median_amount": 422.89, "10th_percentile": 228.42, "90th_percentile": 1353.56, "count": "40" }, { "payer_name": "UNITED HEALTHCARE", "plan_name": "SUTTER SELECT & SUTTER HEALTH PLAN HMO PLANS", "methodology": "per diem", "standard_charge_dollar": 28538.0, "standard_charge_algorithm": "Per diem ($28,538).", "count": "0", "additional_payer_notes": "Zero final payments for the item or service in the 15 months prior to posting the file." }, { "payer_name": "UMR", "plan_name": "SUTTER SELECT & SUTTER HEALTH PLAN HMO PLANS", "methodology": "per diem", "standard_charge_dollar": 28538.0, "standard_charge_algorithm": "Per diem ($28,538).", "median_amount": 985.09, "10th_percentile": 45.1, "90th_percentile": 985.09, "count": "1 through 10" }, { "payer_name": "UNITED HEALTHCARE", "plan_name": "SUTTER SELECT & SUTTER HEALTH PLAN HMO PLANS", "methodology": "per diem", "standard_charge_dollar": 28538.0, "standard_charge_algorithm": "Per diem ($28,538).", "median_amount": 823.68, "10th_percentile": 594.01, "90th_percentile": 1518.0, "count": "13" } ] } ] }, { "description": "HC Hemostatic Collagen Gp002", "code_information": [ { "code": "PX-2120069002", "type": "CDM" }, { "code": "99999", "type": "CPT" }, { "code": "0272", "type": "RC" } ], "standard_charges": [ { "setting": "outpatient", "gross_charge": 50.0, "discounted_cash": 25.0, "minimum": 21.1, "maximum": 26.0, "additional_generic_notes": "Zero final payments for the item or service in the 15 months prior to posting the file.", "payers_information": [ { "payer_name": "AETNA", "plan_name": "AETNA ALL OTHER PLANS", "methodology": "percent of total billed charges", "standard_charge_dollar": 26.0, "standard_charge_percentage": 52.0, "count": "0", "additional_payer_notes": "Zero final payments for the item or service in the 15 months prior to posting the file." }, { "payer_name": "AETNA", "plan_name": "AETNA ALL OTHER PLANS", "methodology": "percent of total billed charges", "standard_charge_dollar": 26.0, "standard_charge_percentage": 52.0, "count": "0", "additional_payer_notes": "Zero final payments for the item or service in the 15 months prior to posting the file." }, { "payer_name": "MERITAIN HEALTH", "plan_name": "AETNA ALL OTHER PLANS", "methodology": "percent of total billed charges", "standard_charge_dollar": 26.0, "standard_charge_percentage": 52.0, "count": "0", "additional_payer_notes": "Zero final payments for the item or service in the 15 months prior to posting the file." }, { "payer_name": "BLUE SHIELD OUT OF STATE", "plan_name": "STANFORD HEALTHCARE ALLIANCE PLAN", "methodology": "percent of total billed charges", "standard_charge_dollar": 24.3, "standard_charge_percentage": 48.59, "count": "0", "additional_payer_notes": "Zero final payments for the item or service in the 15 months prior to posting the file." }, { "payer_name": "BLUE SHIELD", "plan_name": "STANFORD HEALTHCARE ALLIANCE PLAN", "methodology": "percent of total billed charges", "standard_charge_dollar": 24.3, "standard_charge_percentage": 48.59, "count": "0", "additional_payer_notes": "Zero final payments for the item or service in the 15 months prior to posting the file." }, { "payer_name": "BLUE SHIELD", "plan_name": "STANFORD HEALTHCARE ALLIANCE PLAN", "methodology": "percent of total billed charges", "standard_charge_dollar": 24.3, "standard_charge_percentage": 48.59, "count": "0", "additional_payer_notes": "Zero final payments for the item or service in the 15 months prior to posting the file." }, { "payer_name": "CIGNA", "plan_name": "CIGNA COM ALT HMO PLAN", "methodology": "percent of total billed charges", "standard_charge_dollar": 21.1, "standard_charge_percentage": 42.2, "count": "0", "additional_payer_notes": "Zero final payments for the item or service in the 15 months prior to posting the file." }, { "payer_name": "CIGNA", "plan_name": "CIGNA COM ALT HMO PLAN", "methodology": "percent of total billed charges", "standard_charge_dollar": 21.1, "standard_charge_percentage": 42.2, "count": "0", "additional_payer_notes": "Zero final payments for the item or service in the 15 months prior to posting the file." }, { "payer_name": "HEALTH NET", "plan_name": "HEALTHNET HMO, PPO, POS, EPO, CANOPY HEALTHNET HMO, OTHER-IN-NETWORK PLANS", "methodology": "per diem", "standard_charge_dollar": 8000.0, "standard_charge_algorithm": "Expected reimbursement is the lesser of Per diem ($8,000) for the length of stay and 70% of billed.", "count": "0", "additional_payer_notes": "Zero final payments for the item or service in the 15 months prior to posting the file." }, { "payer_name": "HEALTH NET", "plan_name": "HEALTHNET HMO, PPO, POS, EPO, CANOPY HEALTHNET HMO, OTHER-IN-NETWORK PLANS", "methodology": "per diem", "standard_charge_dollar": 8000.0, "standard_charge_algorithm": "Expected reimbursement is the lesser of Per diem ($8,000) for the length of stay and 70% of billed.", "count": "0", "additional_payer_notes": "Zero final payments for the item or service in the 15 months prior to posting the file." }, { "payer_name": "UNITED HEALTHCARE", "plan_name": "SUTTER SELECT & SUTTER HEALTH PLAN HMO PLANS", "methodology": "per diem", "standard_charge_dollar": 28538.0, "standard_charge_algorithm": "Per diem ($28,538).", "count": "0", "additional_payer_notes": "Zero final payments for the item or service in the 15 months prior to posting the file." }, { "payer_name": "UNITED HEALTHCARE", "plan_name": "SUTTER SELECT & SUTTER HEALTH PLAN HMO PLANS", "methodology": "per diem", "standard_charge_dollar": 28538.0, "standard_charge_algorithm": "Per diem ($28,538).", "count": "0", "additional_payer_notes": "Zero final payments for the item or service in the 15 months prior to posting the file." }, { "payer_name": "SUTTER", "plan_name": "SUTTER SELECT & SUTTER HEALTH PLAN HMO PLANS", "methodology": "per diem", "standard_charge_dollar": 28538.0, "standard_charge_algorithm": "Per diem ($28,538).", "count": "0", "additional_payer_notes": "Zero final payments for the item or service in the 15 months prior to posting the file." }, { "payer_name": "UNITED HEALTHCARE", "plan_name": "SUTTER SELECT & SUTTER HEALTH PLAN HMO PLANS", "methodology": "per diem", "standard_charge_dollar": 28538.0, "standard_charge_algorithm": "Per diem ($28,538).", "count": "0", "additional_payer_notes": "Zero final payments for the item or service in the 15 months prior to posting the file." }, { "payer_name": "UMR", "plan_name": "SUTTER SELECT & SUTTER HEALTH PLAN HMO PLANS", "methodology": "per diem", "standard_charge_dollar": 28538.0, "standard_charge_algorithm": "Per diem ($28,538).", "count": "0", "additional_payer_notes": "Zero final payments for the item or service in the 15 months prior to posting the file." } ] } ] }, { "description": "HC Hemostatic Collagen Gp006", "code_information": [ { "code": "PX-2120069006", "type": "CDM" }, { "code": "99999", "type": "CPT" }, { "code": "0272", "type": "RC" } ], "standard_charges": [ { "setting": "outpatient", "gross_charge": 293.0, "discounted_cash": 146.5, "minimum": 123.65, "maximum": 152.36, "additional_generic_notes": "Zero final payments for the item or service in the 15 months prior to posting the file.", "payers_information": [ { "payer_name": "AETNA", "plan_name": "AETNA ALL OTHER PLANS", "methodology": "percent of total billed charges", "standard_charge_dollar": 152.36, "standard_charge_percentage": 52.0, "count": "0", "additional_payer_notes": "Zero final payments for the item or service in the 15 months prior to posting the file." }, { "payer_name": "AETNA", "plan_name": "AETNA ALL OTHER PLANS", "methodology": "percent of total billed charges", "standard_charge_dollar": 152.36, "standard_charge_percentage": 52.0, "count": "0", "additional_payer_notes": "Zero final payments for the item or service in the 15 months prior to posting the file." }, { "payer_name": "MERITAIN HEALTH", "plan_name": "AETNA ALL OTHER PLANS", "methodology": "percent of total billed charges", "standard_charge_dollar": 152.36, "standard_charge_percentage": 52.0, "count": "0", "additional_payer_notes": "Zero final payments for the item or service in the 15 months prior to posting the file." }, { "payer_name": "BLUE SHIELD OUT OF STATE", "plan_name": "STANFORD HEALTHCARE ALLIANCE PLAN", "methodology": "percent of total billed charges", "standard_charge_dollar": 142.37, "standard_charge_percentage": 48.59, "count": "0", "additional_payer_notes": "Zero final payments for the item or service in the 15 months prior to posting the file." }, { "payer_name": "BLUE SHIELD", "plan_name": "STANFORD HEALTHCARE ALLIANCE PLAN", "methodology": "percent of total billed charges", "standard_charge_dollar": 142.37, "standard_charge_percentage": 48.59, "count": "0", "additional_payer_notes": "Zero final payments for the item or service in the 15 months prior to posting the file." }, { "payer_name": "BLUE SHIELD", "plan_name": "STANFORD HEALTHCARE ALLIANCE PLAN", "methodology": "percent of total billed charges", "standard_charge_dollar": 142.37, "standard_charge_percentage": 48.59, "count": "0", "additional_payer_notes": "Zero final payments for the item or service in the 15 months prior to posting the file." }, { "payer_name": "CIGNA", "plan_name": "CIGNA COM ALT HMO PLAN", "methodology": "percent of total billed charges", "standard_charge_dollar": 123.65, "standard_charge_percentage": 42.2, "count": "0", "additional_payer_notes": "Zero final payments for the item or service in the 15 months prior to posting the file." }, { "payer_name": "CIGNA", "plan_name": "CIGNA COM ALT HMO PLAN", "methodology": "percent of total billed charges", "standard_charge_dollar": 123.65, "standard_charge_percentage": 42.2, "count": "0", "additional_payer_notes": "Zero final payments for the item or service in the 15 months prior to posting the file." }, { "payer_name": "HEALTH NET", "plan_name": "HEALTHNET HMO, PPO, POS, EPO, CANOPY HEALTHNET HMO, OTHER-IN-NETWORK PLANS", "methodology": "per diem", "standard_charge_dollar": 8000.0, "standard_charge_algorithm": "Expected reimbursement is the lesser of Per diem ($8,000) for the length of stay and 70% of billed.", "count": "0", "additional_payer_notes": "Zero final payments for the item or service in the 15 months prior to posting the file." }, { "payer_name": "HEALTH NET", "plan_name": "HEALTHNET HMO, PPO, POS, EPO, CANOPY HEALTHNET HMO, OTHER-IN-NETWORK PLANS", "methodology": "per diem", "standard_charge_dollar": 8000.0, "standard_charge_algorithm": "Expected reimbursement is the lesser of Per diem ($8,000) for the length of stay and 70% of billed.", "count": "0", "additional_payer_notes": "Zero final payments for the item or service in the 15 months prior to posting the file." }, { "payer_name": "UNITED HEALTHCARE", "plan_name": "SUTTER SELECT & SUTTER HEALTH PLAN HMO PLANS", "methodology": "per diem", "standard_charge_dollar": 28538.0, "standard_charge_algorithm": "Per diem ($28,538).", "count": "0", "additional_payer_notes": "Zero final payments for the item or service in the 15 months prior to posting the file." }, { "payer_name": "UNITED HEALTHCARE", "plan_name": "SUTTER SELECT & SUTTER HEALTH PLAN HMO PLANS", "methodology": "per diem", "standard_charge_dollar": 28538.0, "standard_charge_algorithm": "Per diem ($28,538).", "count": "0", "additional_payer_notes": "Zero final payments for the item or service in the 15 months prior to posting the file." }, { "payer_name": "SUTTER", "plan_name": "SUTTER SELECT & SUTTER HEALTH PLAN HMO PLANS", "methodology": "per diem", "standard_charge_dollar": 28538.0, "standard_charge_algorithm": "Per diem ($28,538).", "count": "0", "additional_payer_notes": "Zero final payments for the item or service in the 15 months prior to posting the file." }, { "payer_name": "UNITED HEALTHCARE", "plan_name": "SUTTER SELECT & SUTTER HEALTH PLAN HMO PLANS", "methodology": "per diem", "standard_charge_dollar": 28538.0, "standard_charge_algorithm": "Per diem ($28,538).", "count": "0", "additional_payer_notes": "Zero final payments for the item or service in the 15 months prior to posting the file." }, { "payer_name": "UMR", "plan_name": "SUTTER SELECT & SUTTER HEALTH PLAN HMO PLANS", "methodology": "per diem", "standard_charge_dollar": 28538.0, "standard_charge_algorithm": "Per diem ($28,538).", "count": "0", "additional_payer_notes": "Zero final payments for the item or service in the 15 months prior to posting the file." } ] } ] }, { "description": "HC Hemostatic Collagen Gp008", "code_information": [ { "code": "PX-2120069008", "type": "CDM" }, { "code": "99999", "type": "CPT" }, { "code": "0272", "type": "RC" } ], "standard_charges": [ { "setting": "outpatient", "gross_charge": 475.0, "discounted_cash": 237.5, "minimum": 200.45, "maximum": 247.0, "additional_generic_notes": "Zero final payments for the item or service in the 15 months prior to posting the file.", "payers_information": [ { "payer_name": "AETNA", "plan_name": "AETNA ALL OTHER PLANS", "methodology": "percent of total billed charges", "standard_charge_dollar": 247.0, "standard_charge_percentage": 52.0, "count": "0", "additional_payer_notes": "Zero final payments for the item or service in the 15 months prior to posting the file." }, { "payer_name": "AETNA", "plan_name": "AETNA ALL OTHER PLANS", "methodology": "percent of total billed charges", "standard_charge_dollar": 247.0, "standard_charge_percentage": 52.0, "count": "0", "additional_payer_notes": "Zero final payments for the item or service in the 15 months prior to posting the file." }, { "payer_name": "MERITAIN HEALTH", "plan_name": "AETNA ALL OTHER PLANS", "methodology": "percent of total billed charges", "standard_charge_dollar": 247.0, "standard_charge_percentage": 52.0, "count": "0", "additional_payer_notes": "Zero final payments for the item or service in the 15 months prior to posting the file." }, { "payer_name": "BLUE SHIELD OUT OF STATE", "plan_name": "STANFORD HEALTHCARE ALLIANCE PLAN", "methodology": "percent of total billed charges", "standard_charge_dollar": 230.8, "standard_charge_percentage": 48.59, "count": "0", "additional_payer_notes": "Zero final payments for the item or service in the 15 months prior to posting the file." }, { "payer_name": "BLUE SHIELD", "plan_name": "STANFORD HEALTHCARE ALLIANCE PLAN", "methodology": "percent of total billed charges", "standard_charge_dollar": 230.8, "standard_charge_percentage": 48.59, "count": "0", "additional_payer_notes": "Zero final payments for the item or service in the 15 months prior to posting the file." }, { "payer_name": "BLUE SHIELD", "plan_name": "STANFORD HEALTHCARE ALLIANCE PLAN", "methodology": "percent of total billed charges", "standard_charge_dollar": 230.8, "standard_charge_percentage": 48.59, "count": "0", "additional_payer_notes": "Zero final payments for the item or service in the 15 months prior to posting the file." }, { "payer_name": "CIGNA", "plan_name": "CIGNA COM ALT HMO PLAN", "methodology": "percent of total billed charges", "standard_charge_dollar": 200.45, "standard_charge_percentage": 42.2, "count": "0", "additional_payer_notes": "Zero final payments for the item or service in the 15 months prior to posting the file." }, { "payer_name": "CIGNA", "plan_name": "CIGNA COM ALT HMO PLAN", "methodology": "percent of total billed charges", "standard_charge_dollar": 200.45, "standard_charge_percentage": 42.2, "count": "0", "additional_payer_notes": "Zero final payments for the item or service in the 15 months prior to posting the file." }, { "payer_name": "HEALTH NET", "plan_name": "HEALTHNET HMO, PPO, POS, EPO, CANOPY HEALTHNET HMO, OTHER-IN-NETWORK PLANS", "methodology": "per diem", "standard_charge_dollar": 8000.0, "standard_charge_algorithm": "Expected reimbursement is the lesser of Per diem ($8,000) for the length of stay and 70% of billed.", "count": "0", "additional_payer_notes": "Zero final payments for the item or service in the 15 months prior to posting the file." }, { "payer_name": "HEALTH NET", "plan_name": "HEALTHNET HMO, PPO, POS, EPO, CANOPY HEALTHNET HMO, OTHER-IN-NETWORK PLANS", "methodology": "per diem", "standard_charge_dollar": 8000.0, "standard_charge_algorithm": "Expected reimbursement is the lesser of Per diem ($8,000) for the length of stay and 70% of billed.", "count": "0", "additional_payer_notes": "Zero final payments for the item or service in the 15 months prior to posting the file." }, { "payer_name": "UNITED HEALTHCARE", "plan_name": "SUTTER SELECT & SUTTER HEALTH PLAN HMO PLANS", "methodology": "per diem", "standard_charge_dollar": 28538.0, "standard_charge_algorithm": "Per diem ($28,538).", "count": "0", "additional_payer_notes": "Zero final payments for the item or service in the 15 months prior to posting the file." }, { "payer_name": "UNITED HEALTHCARE", "plan_name": "SUTTER SELECT & SUTTER HEALTH PLAN HMO PLANS", "methodology": "per diem", "standard_charge_dollar": 28538.0, "standard_charge_algorithm": "Per diem ($28,538).", "count": "0", "additional_payer_notes": "Zero final payments for the item or service in the 15 months prior to posting the file." }, { "payer_name": "SUTTER", "plan_name": "SUTTER SELECT & SUTTER HEALTH PLAN HMO PLANS", "methodology": "per diem", "standard_charge_dollar": 28538.0, "standard_charge_algorithm": "Per diem ($28,538).", "count": "0", "additional_payer_notes": "Zero final payments for the item or service in the 15 months prior to posting the file." }, { "payer_name": "UNITED HEALTHCARE", "plan_name": "SUTTER SELECT & SUTTER HEALTH PLAN HMO PLANS", "methodology": "per diem", "standard_charge_dollar": 28538.0, "standard_charge_algorithm": "Per diem ($28,538).", "count": "0", "additional_payer_notes": "Zero final payments for the item or service in the 15 months prior to posting the file." }, { "payer_name": "UMR", "plan_name": "SUTTER SELECT & SUTTER HEALTH PLAN HMO PLANS", "methodology": "per diem", "standard_charge_dollar": 28538.0, "standard_charge_algorithm": "Per diem ($28,538).", "count": "0", "additional_payer_notes": "Zero final payments for the item or service in the 15 months prior to posting the file." } ] } ] }, { "description": "HC Hemostatic Collagen Gp009", "code_information": [ { "code": "PX-2120069009", "type": "CDM" }, { "code": "99999", "type": "CPT" }, { "code": "0272", "type": "RC" } ], "standard_charges": [ { "setting": "outpatient", "gross_charge": 570.0, "discounted_cash": 285.0, "minimum": 240.54, "maximum": 296.4, "additional_generic_notes": "Zero final payments for the item or service in the 15 months prior to posting the file.", "payers_information": [ { "payer_name": "AETNA", "plan_name": "AETNA ALL OTHER PLANS", "methodology": "percent of total billed charges", "standard_charge_dollar": 296.4, "standard_charge_percentage": 52.0, "count": "0", "additional_payer_notes": "Zero final payments for the item or service in the 15 months prior to posting the file." }, { "payer_name": "AETNA", "plan_name": "AETNA ALL OTHER PLANS", "methodology": "percent of total billed charges", "standard_charge_dollar": 296.4, "standard_charge_percentage": 52.0, "count": "0", "additional_payer_notes": "Zero final payments for the item or service in the 15 months prior to posting the file." }, { "payer_name": "MERITAIN HEALTH", "plan_name": "AETNA ALL OTHER PLANS", "methodology": "percent of total billed charges", "standard_charge_dollar": 296.4, "standard_charge_percentage": 52.0, "count": "0", "additional_payer_notes": "Zero final payments for the item or service in the 15 months prior to posting the file." }, { "payer_name": "BLUE SHIELD OUT OF STATE", "plan_name": "STANFORD HEALTHCARE ALLIANCE PLAN", "methodology": "percent of total billed charges", "standard_charge_dollar": 276.96, "standard_charge_percentage": 48.59, "count": "0", "additional_payer_notes": "Zero final payments for the item or service in the 15 months prior to posting the file." }, { "payer_name": "BLUE SHIELD", "plan_name": "STANFORD HEALTHCARE ALLIANCE PLAN", "methodology": "percent of total billed charges", "standard_charge_dollar": 276.96, "standard_charge_percentage": 48.59, "count": "0", "additional_payer_notes": "Zero final payments for the item or service in the 15 months prior to posting the file." }, { "payer_name": "BLUE SHIELD", "plan_name": "STANFORD HEALTHCARE ALLIANCE PLAN", "methodology": "percent of total billed charges", "standard_charge_dollar": 276.96, "standard_charge_percentage": 48.59, "count": "0", "additional_payer_notes": "Zero final payments for the item or service in the 15 months prior to posting the file." }, { "payer_name": "CIGNA", "plan_name": "CIGNA COM ALT HMO PLAN", "methodology": "percent of total billed charges", "standard_charge_dollar": 240.54, "standard_charge_percentage": 42.2, "count": "0", "additional_payer_notes": "Zero final payments for the item or service in the 15 months prior to posting the file." }, { "payer_name": "CIGNA", "plan_name": "CIGNA COM ALT HMO PLAN", "methodology": "percent of total billed charges", "standard_charge_dollar": 240.54, "standard_charge_percentage": 42.2, "count": "0", "additional_payer_notes": "Zero final payments for the item or service in the 15 months prior to posting the file." }, { "payer_name": "HEALTH NET", "plan_name": "HEALTHNET HMO, PPO, POS, EPO, CANOPY HEALTHNET HMO, OTHER-IN-NETWORK PLANS", "methodology": "per diem", "standard_charge_dollar": 8000.0, "standard_charge_algorithm": "Expected reimbursement is the lesser of Per diem ($8,000) for the length of stay and 70% of billed.", "count": "0", "additional_payer_notes": "Zero final payments for the item or service in the 15 months prior to posting the file." }, { "payer_name": "HEALTH NET", "plan_name": "HEALTHNET HMO, PPO, POS, EPO, CANOPY HEALTHNET HMO, OTHER-IN-NETWORK PLANS", "methodology": "per diem", "standard_charge_dollar": 8000.0, "standard_charge_algorithm": "Expected reimbursement is the lesser of Per diem ($8,000) for the length of stay and 70% of billed.", "count": "0", "additional_payer_notes": "Zero final payments for the item or service in the 15 months prior to posting the file." }, { "payer_name": "UNITED HEALTHCARE", "plan_name": "SUTTER SELECT & SUTTER HEALTH PLAN HMO PLANS", "methodology": "per diem", "standard_charge_dollar": 28538.0, "standard_charge_algorithm": "Per diem ($28,538).", "count": "0", "additional_payer_notes": "Zero final payments for the item or service in the 15 months prior to posting the file." }, { "payer_name": "UNITED HEALTHCARE", "plan_name": "SUTTER SELECT & SUTTER HEALTH PLAN HMO PLANS", "methodology": "per diem", "standard_charge_dollar": 28538.0, "standard_charge_algorithm": "Per diem ($28,538).", "count": "0", "additional_payer_notes": "Zero final payments for the item or service in the 15 months prior to posting the file." }, { "payer_name": "SUTTER", "plan_name": "SUTTER SELECT & SUTTER HEALTH PLAN HMO PLANS", "methodology": "per diem", "standard_charge_dollar": 28538.0, "standard_charge_algorithm": "Per diem ($28,538).", "count": "0", "additional_payer_notes": "Zero final payments for the item or service in the 15 months prior to posting the file." }, { "payer_name": "UNITED HEALTHCARE", "plan_name": "SUTTER SELECT & SUTTER HEALTH PLAN HMO PLANS", "methodology": "per diem", "standard_charge_dollar": 28538.0, "standard_charge_algorithm": "Per diem ($28,538).", "count": "0", "additional_payer_notes": "Zero final payments for the item or service in the 15 months prior to posting the file." }, { "payer_name": "UMR", "plan_name": "SUTTER SELECT & SUTTER HEALTH PLAN HMO PLANS", "methodology": "per diem", "standard_charge_dollar": 28538.0, "standard_charge_algorithm": "Per diem ($28,538).", "count": "0", "additional_payer_notes": "Zero final payments for the item or service in the 15 months prior to posting the file." } ] } ] }, { "description": "HC Hemostatic Collagen Gp013", "code_information": [ { "code": "PX-2120069013", "type": "CDM" }, { "code": "99999", "type": "CPT" }, { "code": "0272", "type": "RC" } ], "standard_charges": [ { "setting": "outpatient", "gross_charge": 900.0, "discounted_cash": 450.0, "minimum": 379.8, "maximum": 468.0, "additional_generic_notes": "Zero final payments for the item or service in the 15 months prior to posting the file.", "payers_information": [ { "payer_name": "AETNA", "plan_name": "AETNA ALL OTHER PLANS", "methodology": "percent of total billed charges", "standard_charge_dollar": 468.0, "standard_charge_percentage": 52.0, "count": "0", "additional_payer_notes": "Zero final payments for the item or service in the 15 months prior to posting the file." }, { "payer_name": "AETNA", "plan_name": "AETNA ALL OTHER PLANS", "methodology": "percent of total billed charges", "standard_charge_dollar": 468.0, "standard_charge_percentage": 52.0, "count": "0", "additional_payer_notes": "Zero final payments for the item or service in the 15 months prior to posting the file." }, { "payer_name": "MERITAIN HEALTH", "plan_name": "AETNA ALL OTHER PLANS", "methodology": "percent of total billed charges", "standard_charge_dollar": 468.0, "standard_charge_percentage": 52.0, "count": "0", "additional_payer_notes": "Zero final payments for the item or service in the 15 months prior to posting the file." }, { "payer_name": "BLUE SHIELD OUT OF STATE", "plan_name": "STANFORD HEALTHCARE ALLIANCE PLAN", "methodology": "percent of total billed charges", "standard_charge_dollar": 437.31, "standard_charge_percentage": 48.59, "count": "0", "additional_payer_notes": "Zero final payments for the item or service in the 15 months prior to posting the file." }, { "payer_name": "BLUE SHIELD", "plan_name": "STANFORD HEALTHCARE ALLIANCE PLAN", "methodology": "percent of total billed charges", "standard_charge_dollar": 437.31, "standard_charge_percentage": 48.59, "count": "0", "additional_payer_notes": "Zero final payments for the item or service in the 15 months prior to posting the file." }, { "payer_name": "BLUE SHIELD", "plan_name": "STANFORD HEALTHCARE ALLIANCE PLAN", "methodology": "percent of total billed charges", "standard_charge_dollar": 437.31, "standard_charge_percentage": 48.59, "count": "0", "additional_payer_notes": "Zero final payments for the item or service in the 15 months prior to posting the file." }, { "payer_name": "CIGNA", "plan_name": "CIGNA COM ALT HMO PLAN", "methodology": "percent of total billed charges", "standard_charge_dollar": 379.8, "standard_charge_percentage": 42.2, "count": "0", "additional_payer_notes": "Zero final payments for the item or service in the 15 months prior to posting the file." }, { "payer_name": "CIGNA", "plan_name": "CIGNA COM ALT HMO PLAN", "methodology": "percent of total billed charges", "standard_charge_dollar": 379.8, "standard_charge_percentage": 42.2, "count": "0", "additional_payer_notes": "Zero final payments for the item or service in the 15 months prior to posting the file." }, { "payer_name": "HEALTH NET", "plan_name": "HEALTHNET HMO, PPO, POS, EPO, CANOPY HEALTHNET HMO, OTHER-IN-NETWORK PLANS", "methodology": "per diem", "standard_charge_dollar": 8000.0, "standard_charge_algorithm": "Expected reimbursement is the lesser of Per diem ($8,000) for the length of stay and 70% of billed.", "count": "0", "additional_payer_notes": "Zero final payments for the item or service in the 15 months prior to posting the file." }, { "payer_name": "HEALTH NET", "plan_name": "HEALTHNET HMO, PPO, POS, EPO, CANOPY HEALTHNET HMO, OTHER-IN-NETWORK PLANS", "methodology": "per diem", "standard_charge_dollar": 8000.0, "standard_charge_algorithm": "Expected reimbursement is the lesser of Per diem ($8,000) for the length of stay and 70% of billed.", "count": "0", "additional_payer_notes": "Zero final payments for the item or service in the 15 months prior to posting the file." }, { "payer_name": "UNITED HEALTHCARE", "plan_name": "SUTTER SELECT & SUTTER HEALTH PLAN HMO PLANS", "methodology": "per diem", "standard_charge_dollar": 28538.0, "standard_charge_algorithm": "Per diem ($28,538).", "count": "0", "additional_payer_notes": "Zero final payments for the item or service in the 15 months prior to posting the file." }, { "payer_name": "UNITED HEALTHCARE", "plan_name": "SUTTER SELECT & SUTTER HEALTH PLAN HMO PLANS", "methodology": "per diem", "standard_charge_dollar": 28538.0, "standard_charge_algorithm": "Per diem ($28,538).", "count": "0", "additional_payer_notes": "Zero final payments for the item or service in the 15 months prior to posting the file." }, { "payer_name": "SUTTER", "plan_name": "SUTTER SELECT & SUTTER HEALTH PLAN HMO PLANS", "methodology": "per diem", "standard_charge_dollar": 28538.0, "standard_charge_algorithm": "Per diem ($28,538).", "count": "0", "additional_payer_notes": "Zero final payments for the item or service in the 15 months prior to posting the file." }, { "payer_name": "UNITED HEALTHCARE", "plan_name": "SUTTER SELECT & SUTTER HEALTH PLAN HMO PLANS", "methodology": "per diem", "standard_charge_dollar": 28538.0, "standard_charge_algorithm": "Per diem ($28,538).", "count": "0", "additional_payer_notes": "Zero final payments for the item or service in the 15 months prior to posting the file." }, { "payer_name": "UMR", "plan_name": "SUTTER SELECT & SUTTER HEALTH PLAN HMO PLANS", "methodology": "per diem", "standard_charge_dollar": 28538.0, "standard_charge_algorithm": "Per diem ($28,538).", "count": "0", "additional_payer_notes": "Zero final payments for the item or service in the 15 months prior to posting the file." } ] } ] }, { "description": "HC Hemostatic Collagen Gp014", "code_information": [ { "code": "PX-2120069014", "type": "CDM" }, { "code": "99999", "type": "CPT" }, { "code": "0272", "type": "RC" } ], "standard_charges": [ { "setting": "outpatient", "gross_charge": 1080.0, "discounted_cash": 540.0, "minimum": 455.76, "maximum": 561.6, "additional_generic_notes": "Zero final payments for the item or service in the 15 months prior to posting the file.", "payers_information": [ { "payer_name": "AETNA", "plan_name": "AETNA ALL OTHER PLANS", "methodology": "percent of total billed charges", "standard_charge_dollar": 561.6, "standard_charge_percentage": 52.0, "count": "0", "additional_payer_notes": "Zero final payments for the item or service in the 15 months prior to posting the file." }, { "payer_name": "AETNA", "plan_name": "AETNA ALL OTHER PLANS", "methodology": "percent of total billed charges", "standard_charge_dollar": 561.6, "standard_charge_percentage": 52.0, "count": "0", "additional_payer_notes": "Zero final payments for the item or service in the 15 months prior to posting the file." }, { "payer_name": "MERITAIN HEALTH", "plan_name": "AETNA ALL OTHER PLANS", "methodology": "percent of total billed charges", "standard_charge_dollar": 561.6, "standard_charge_percentage": 52.0, "count": "0", "additional_payer_notes": "Zero final payments for the item or service in the 15 months prior to posting the file." }, { "payer_name": "BLUE SHIELD OUT OF STATE", "plan_name": "STANFORD HEALTHCARE ALLIANCE PLAN", "methodology": "percent of total billed charges", "standard_charge_dollar": 524.77, "standard_charge_percentage": 48.59, "count": "0", "additional_payer_notes": "Zero final payments for the item or service in the 15 months prior to posting the file." }, { "payer_name": "BLUE SHIELD", "plan_name": "STANFORD HEALTHCARE ALLIANCE PLAN", "methodology": "percent of total billed charges", "standard_charge_dollar": 524.77, "standard_charge_percentage": 48.59, "median_amount": 68.24, "10th_percentile": 13.6, "90th_percentile": 1043.06, "count": "30" }, { "payer_name": "BLUE SHIELD", "plan_name": "STANFORD HEALTHCARE ALLIANCE PLAN", "methodology": "percent of total billed charges", "standard_charge_dollar": 524.77, "standard_charge_percentage": 48.59, "count": "0", "additional_payer_notes": "Zero final payments for the item or service in the 15 months prior to posting the file." }, { "payer_name": "BLUE SHIELD", "plan_name": "STANFORD HEALTHCARE ALLIANCE PLAN", "methodology": "percent of total billed charges", "standard_charge_dollar": 524.77, "standard_charge_percentage": 48.59, "count": "0", "additional_payer_notes": "Zero final payments for the item or service in the 15 months prior to posting the file." }, { "payer_name": "CIGNA", "plan_name": "CIGNA COM ALT HMO PLAN", "methodology": "percent of total billed charges", "standard_charge_dollar": 455.76, "standard_charge_percentage": 42.2, "count": "0", "additional_payer_notes": "Zero final payments for the item or service in the 15 months prior to posting the file." }, { "payer_name": "CIGNA", "plan_name": "CIGNA COM ALT HMO PLAN", "methodology": "percent of total billed charges", "standard_charge_dollar": 455.76, "standard_charge_percentage": 42.2, "count": "0", "additional_payer_notes": "Zero final payments for the item or service in the 15 months prior to posting the file." }, { "payer_name": "HEALTH NET", "plan_name": "HEALTHNET HMO, PPO, POS, EPO, CANOPY HEALTHNET HMO, OTHER-IN-NETWORK PLANS", "methodology": "per diem", "standard_charge_dollar": 8000.0, "standard_charge_algorithm": "Expected reimbursement is the lesser of Per diem ($8,000) for the length of stay and 70% of billed.", "count": "0", "additional_payer_notes": "Zero final payments for the item or service in the 15 months prior to posting the file." }, { "payer_name": "HEALTH NET", "plan_name": "HEALTHNET HMO, PPO, POS, EPO, CANOPY HEALTHNET HMO, OTHER-IN-NETWORK PLANS", "methodology": "per diem", "standard_charge_dollar": 8000.0, "standard_charge_algorithm": "Expected reimbursement is the lesser of Per diem ($8,000) for the length of stay and 70% of billed.", "count": "0", "additional_payer_notes": "Zero final payments for the item or service in the 15 months prior to posting the file." }, { "payer_name": "UNITED HEALTHCARE", "plan_name": "SUTTER SELECT & SUTTER HEALTH PLAN HMO PLANS", "methodology": "per diem", "standard_charge_dollar": 28538.0, "standard_charge_algorithm": "Per diem ($28,538).", "count": "0", "additional_payer_notes": "Zero final payments for the item or service in the 15 months prior to posting the file." }, { "payer_name": "UNITED HEALTHCARE", "plan_name": "SUTTER SELECT & SUTTER HEALTH PLAN HMO PLANS", "methodology": "per diem", "standard_charge_dollar": 28538.0, "standard_charge_algorithm": "Per diem ($28,538).", "count": "0", "additional_payer_notes": "Zero final payments for the item or service in the 15 months prior to posting the file." }, { "payer_name": "SUTTER", "plan_name": "SUTTER SELECT & SUTTER HEALTH PLAN HMO PLANS", "methodology": "per diem", "standard_charge_dollar": 28538.0, "standard_charge_algorithm": "Per diem ($28,538).", "count": "0", "additional_payer_notes": "Zero final payments for the item or service in the 15 months prior to posting the file." }, { "payer_name": "UNITED HEALTHCARE", "plan_name": "SUTTER SELECT & SUTTER HEALTH PLAN HMO PLANS", "methodology": "per diem", "standard_charge_dollar": 28538.0, "standard_charge_algorithm": "Per diem ($28,538).", "count": "0", "additional_payer_notes": "Zero final payments for the item or service in the 15 months prior to posting the file." }, { "payer_name": "UMR", "plan_name": "SUTTER SELECT & SUTTER HEALTH PLAN HMO PLANS", "methodology": "per diem", "standard_charge_dollar": 28538.0, "standard_charge_algorithm": "Per diem ($28,538).", "count": "0", "additional_payer_notes": "Zero final payments for the item or service in the 15 months prior to posting the file." } ] } ] }, { "description": "HC Hemostatic Collagen Gp018", "code_information": [ { "code": "PX-2120069018", "type": "CDM" }, { "code": "99999", "type": "CPT" }, { "code": "0272", "type": "RC" } ], "standard_charges": [ { "setting": "outpatient", "gross_charge": 1750.0, "discounted_cash": 875.0, "minimum": 738.5, "maximum": 910.0, "additional_generic_notes": "Zero final payments for the item or service in the 15 months prior to posting the file.", "payers_information": [ { "payer_name": "AETNA", "plan_name": "AETNA ALL OTHER PLANS", "methodology": "percent of total billed charges", "standard_charge_dollar": 910.0, "standard_charge_percentage": 52.0, "count": "0", "additional_payer_notes": "Zero final payments for the item or service in the 15 months prior to posting the file." }, { "payer_name": "AETNA", "plan_name": "AETNA ALL OTHER PLANS", "methodology": "percent of total billed charges", "standard_charge_dollar": 910.0, "standard_charge_percentage": 52.0, "count": "0", "additional_payer_notes": "Zero final payments for the item or service in the 15 months prior to posting the file." }, { "payer_name": "MERITAIN HEALTH", "plan_name": "AETNA ALL OTHER PLANS", "methodology": "percent of total billed charges", "standard_charge_dollar": 910.0, "standard_charge_percentage": 52.0, "count": "0", "additional_payer_notes": "Zero final payments for the item or service in the 15 months prior to posting the file." }, { "payer_name": "BLUE SHIELD OUT OF STATE", "plan_name": "STANFORD HEALTHCARE ALLIANCE PLAN", "methodology": "percent of total billed charges", "standard_charge_dollar": 850.33, "standard_charge_percentage": 48.59, "count": "0", "additional_payer_notes": "Zero final payments for the item or service in the 15 months prior to posting the file." }, { "payer_name": "BLUE SHIELD", "plan_name": "STANFORD HEALTHCARE ALLIANCE PLAN", "methodology": "percent of total billed charges", "standard_charge_dollar": 850.33, "standard_charge_percentage": 48.59, "median_amount": 68.24, "10th_percentile": 13.6, "90th_percentile": 1043.06, "count": "30" }, { "payer_name": "BLUE SHIELD", "plan_name": "STANFORD HEALTHCARE ALLIANCE PLAN", "methodology": "percent of total billed charges", "standard_charge_dollar": 850.33, "standard_charge_percentage": 48.59, "count": "0", "additional_payer_notes": "Zero final payments for the item or service in the 15 months prior to posting the file." }, { "payer_name": "BLUE SHIELD", "plan_name": "STANFORD HEALTHCARE ALLIANCE PLAN", "methodology": "percent of total billed charges", "standard_charge_dollar": 850.33, "standard_charge_percentage": 48.59, "count": "0", "additional_payer_notes": "Zero final payments for the item or service in the 15 months prior to posting the file." }, { "payer_name": "CIGNA", "plan_name": "CIGNA COM ALT HMO PLAN", "methodology": "percent of total billed charges", "standard_charge_dollar": 738.5, "standard_charge_percentage": 42.2, "count": "0", "additional_payer_notes": "Zero final payments for the item or service in the 15 months prior to posting the file." }, { "payer_name": "CIGNA", "plan_name": "CIGNA COM ALT HMO PLAN", "methodology": "percent of total billed charges", "standard_charge_dollar": 738.5, "standard_charge_percentage": 42.2, "count": "0", "additional_payer_notes": "Zero final payments for the item or service in the 15 months prior to posting the file." }, { "payer_name": "HEALTH NET", "plan_name": "HEALTHNET HMO, PPO, POS, EPO, CANOPY HEALTHNET HMO, OTHER-IN-NETWORK PLANS", "methodology": "per diem", "standard_charge_dollar": 8000.0, "standard_charge_algorithm": "Expected reimbursement is the lesser of Per diem ($8,000) for the length of stay and 70% of billed.", "count": "0", "additional_payer_notes": "Zero final payments for the item or service in the 15 months prior to posting the file." }, { "payer_name": "HEALTH NET", "plan_name": "HEALTHNET HMO, PPO, POS, EPO, CANOPY HEALTHNET HMO, OTHER-IN-NETWORK PLANS", "methodology": "per diem", "standard_charge_dollar": 8000.0, "standard_charge_algorithm": "Expected reimbursement is the lesser of Per diem ($8,000) for the length of stay and 70% of billed.", "count": "0", "additional_payer_notes": "Zero final payments for the item or service in the 15 months prior to posting the file." }, { "payer_name": "UNITED HEALTHCARE", "plan_name": "SUTTER SELECT & SUTTER HEALTH PLAN HMO PLANS", "methodology": "per diem", "standard_charge_dollar": 28538.0, "standard_charge_algorithm": "Per diem ($28,538).", "count": "0", "additional_payer_notes": "Zero final payments for the item or service in the 15 months prior to posting the file." }, { "payer_name": "UNITED HEALTHCARE", "plan_name": "SUTTER SELECT & SUTTER HEALTH PLAN HMO PLANS", "methodology": "per diem", "standard_charge_dollar": 28538.0, "standard_charge_algorithm": "Per diem ($28,538).", "count": "0", "additional_payer_notes": "Zero final payments for the item or service in the 15 months prior to posting the file." }, { "payer_name": "SUTTER", "plan_name": "SUTTER SELECT & SUTTER HEALTH PLAN HMO PLANS", "methodology": "per diem", "standard_charge_dollar": 28538.0, "standard_charge_algorithm": "Per diem ($28,538).", "count": "0", "additional_payer_notes": "Zero final payments for the item or service in the 15 months prior to posting the file." }, { "payer_name": "UNITED HEALTHCARE", "plan_name": "SUTTER SELECT & SUTTER HEALTH PLAN HMO PLANS", "methodology": "per diem", "standard_charge_dollar": 28538.0, "standard_charge_algorithm": "Per diem ($28,538).", "count": "0", "additional_payer_notes": "Zero final payments for the item or service in the 15 months prior to posting the file." }, { "payer_name": "UMR", "plan_name": "SUTTER SELECT & SUTTER HEALTH PLAN HMO PLANS", "methodology": "per diem", "standard_charge_dollar": 28538.0, "standard_charge_algorithm": "Per diem ($28,538).", "count": "0", "additional_payer_notes": "Zero final payments for the item or service in the 15 months prior to posting the file." } ] } ] }, { "description": "HC Floseal Hemostatic Gp014", "code_information": [ { "code": "PX-2120070014", "type": "CDM" }, { "code": "99999", "type": "CPT" }, { "code": "0272", "type": "RC" } ], "standard_charges": [ { "setting": "outpatient", "gross_charge": 1080.0, "discounted_cash": 540.0, "minimum": 455.76, "maximum": 561.6, "additional_generic_notes": "Zero final payments for the item or service in the 15 months prior to posting the file.", "payers_information": [ { "payer_name": "AETNA", "plan_name": "AETNA ALL OTHER PLANS", "methodology": "percent of total billed charges", "standard_charge_dollar": 561.6, "standard_charge_percentage": 52.0, "count": "0", "additional_payer_notes": "Zero final payments for the item or service in the 15 months prior to posting the file." }, { "payer_name": "AETNA", "plan_name": "AETNA ALL OTHER PLANS", "methodology": "percent of total billed charges", "standard_charge_dollar": 561.6, "standard_charge_percentage": 52.0, "count": "0", "additional_payer_notes": "Zero final payments for the item or service in the 15 months prior to posting the file." }, { "payer_name": "MERITAIN HEALTH", "plan_name": "AETNA ALL OTHER PLANS", "methodology": "percent of total billed charges", "standard_charge_dollar": 561.6, "standard_charge_percentage": 52.0, "count": "0", "additional_payer_notes": "Zero final payments for the item or service in the 15 months prior to posting the file." }, { "payer_name": "BLUE SHIELD OUT OF STATE", "plan_name": "STANFORD HEALTHCARE ALLIANCE PLAN", "methodology": "percent of total billed charges", "standard_charge_dollar": 524.77, "standard_charge_percentage": 48.59, "count": "0", "additional_payer_notes": "Zero final payments for the item or service in the 15 months prior to posting the file." }, { "payer_name": "BLUE SHIELD", "plan_name": "STANFORD HEALTHCARE ALLIANCE PLAN", "methodology": "percent of total billed charges", "standard_charge_dollar": 524.77, "standard_charge_percentage": 48.59, "median_amount": 68.24, "10th_percentile": 13.6, "90th_percentile": 1043.06, "count": "30" }, { "payer_name": "BLUE SHIELD", "plan_name": "STANFORD HEALTHCARE ALLIANCE PLAN", "methodology": "percent of total billed charges", "standard_charge_dollar": 524.77, "standard_charge_percentage": 48.59, "count": "0", "additional_payer_notes": "Zero final payments for the item or service in the 15 months prior to posting the file." }, { "payer_name": "BLUE SHIELD", "plan_name": "STANFORD HEALTHCARE ALLIANCE PLAN", "methodology": "percent of total billed charges", "standard_charge_dollar": 524.77, "standard_charge_percentage": 48.59, "count": "0", "additional_payer_notes": "Zero final payments for the item or service in the 15 months prior to posting the file." }, { "payer_name": "CIGNA", "plan_name": "CIGNA COM ALT HMO PLAN", "methodology": "percent of total billed charges", "standard_charge_dollar": 455.76, "standard_charge_percentage": 42.2, "count": "0", "additional_payer_notes": "Zero final payments for the item or service in the 15 months prior to posting the file." }, { "payer_name": "CIGNA", "plan_name": "CIGNA COM ALT HMO PLAN", "methodology": "percent of total billed charges", "standard_charge_dollar": 455.76, "standard_charge_percentage": 42.2, "count": "0", "additional_payer_notes": "Zero final payments for the item or service in the 15 months prior to posting the file." }, { "payer_name": "HEALTH NET", "plan_name": "HEALTHNET HMO, PPO, POS, EPO, CANOPY HEALTHNET HMO, OTHER-IN-NETWORK PLANS", "methodology": "per diem", "standard_charge_dollar": 8000.0, "standard_charge_algorithm": "Expected reimbursement is the lesser of Per diem ($8,000) for the length of stay and 70% of billed.", "count": "0", "additional_payer_notes": "Zero final payments for the item or service in the 15 months prior to posting the file." }, { "payer_name": "HEALTH NET", "plan_name": "HEALTHNET HMO, PPO, POS, EPO, CANOPY HEALTHNET HMO, OTHER-IN-NETWORK PLANS", "methodology": "per diem", "standard_charge_dollar": 8000.0, "standard_charge_algorithm": "Expected reimbursement is the lesser of Per diem ($8,000) for the length of stay and 70% of billed.", "count": "0", "additional_payer_notes": "Zero final payments for the item or service in the 15 months prior to posting the file." }, { "payer_name": "UNITED HEALTHCARE", "plan_name": "SUTTER SELECT & SUTTER HEALTH PLAN HMO PLANS", "methodology": "per diem", "standard_charge_dollar": 28538.0, "standard_charge_algorithm": "Per diem ($28,538).", "count": "0", "additional_payer_notes": "Zero final payments for the item or service in the 15 months prior to posting the file." }, { "payer_name": "UNITED HEALTHCARE", "plan_name": "SUTTER SELECT & SUTTER HEALTH PLAN HMO PLANS", "methodology": "per diem", "standard_charge_dollar": 28538.0, "standard_charge_algorithm": "Per diem ($28,538).", "count": "0", "additional_payer_notes": "Zero final payments for the item or service in the 15 months prior to posting the file." }, { "payer_name": "SUTTER", "plan_name": "SUTTER SELECT & SUTTER HEALTH PLAN HMO PLANS", "methodology": "per diem", "standard_charge_dollar": 28538.0, "standard_charge_algorithm": "Per diem ($28,538).", "count": "0", "additional_payer_notes": "Zero final payments for the item or service in the 15 months prior to posting the file." }, { "payer_name": "UNITED HEALTHCARE", "plan_name": "SUTTER SELECT & SUTTER HEALTH PLAN HMO PLANS", "methodology": "per diem", "standard_charge_dollar": 28538.0, "standard_charge_algorithm": "Per diem ($28,538).", "count": "0", "additional_payer_notes": "Zero final payments for the item or service in the 15 months prior to posting the file." }, { "payer_name": "UMR", "plan_name": "SUTTER SELECT & SUTTER HEALTH PLAN HMO PLANS", "methodology": "per diem", "standard_charge_dollar": 28538.0, "standard_charge_algorithm": "Per diem ($28,538).", "count": "0", "additional_payer_notes": "Zero final payments for the item or service in the 15 months prior to posting the file." } ] } ] }, { "description": "HC Floseal Hemostatic Gp015", "code_information": [ { "code": "PX-2120070015", "type": "CDM" }, { "code": "99999", "type": "CPT" }, { "code": "0272", "type": "RC" } ], "standard_charges": [ { "setting": "outpatient", "gross_charge": 1225.0, "discounted_cash": 612.5, "minimum": 516.95, "maximum": 637.0, "additional_generic_notes": "Zero final payments for the item or service in the 15 months prior to posting the file.", "payers_information": [ { "payer_name": "AETNA", "plan_name": "AETNA ALL OTHER PLANS", "methodology": "percent of total billed charges", "standard_charge_dollar": 637.0, "standard_charge_percentage": 52.0, "count": "0", "additional_payer_notes": "Zero final payments for the item or service in the 15 months prior to posting the file." }, { "payer_name": "AETNA", "plan_name": "AETNA ALL OTHER PLANS", "methodology": "percent of total billed charges", "standard_charge_dollar": 637.0, "standard_charge_percentage": 52.0, "count": "0", "additional_payer_notes": "Zero final payments for the item or service in the 15 months prior to posting the file." }, { "payer_name": "MERITAIN HEALTH", "plan_name": "AETNA ALL OTHER PLANS", "methodology": "percent of total billed charges", "standard_charge_dollar": 637.0, "standard_charge_percentage": 52.0, "count": "0", "additional_payer_notes": "Zero final payments for the item or service in the 15 months prior to posting the file." }, { "payer_name": "BLUE SHIELD OUT OF STATE", "plan_name": "STANFORD HEALTHCARE ALLIANCE PLAN", "methodology": "percent of total billed charges", "standard_charge_dollar": 595.23, "standard_charge_percentage": 48.59, "count": "0", "additional_payer_notes": "Zero final payments for the item or service in the 15 months prior to posting the file." }, { "payer_name": "BLUE SHIELD", "plan_name": "STANFORD HEALTHCARE ALLIANCE PLAN", "methodology": "percent of total billed charges", "standard_charge_dollar": 595.23, "standard_charge_percentage": 48.59, "median_amount": 68.24, "10th_percentile": 13.6, "90th_percentile": 1043.06, "count": "30" }, { "payer_name": "BLUE SHIELD", "plan_name": "STANFORD HEALTHCARE ALLIANCE PLAN", "methodology": "percent of total billed charges", "standard_charge_dollar": 595.23, "standard_charge_percentage": 48.59, "count": "0", "additional_payer_notes": "Zero final payments for the item or service in the 15 months prior to posting the file." }, { "payer_name": "BLUE SHIELD", "plan_name": "STANFORD HEALTHCARE ALLIANCE PLAN", "methodology": "percent of total billed charges", "standard_charge_dollar": 595.23, "standard_charge_percentage": 48.59, "count": "0", "additional_payer_notes": "Zero final payments for the item or service in the 15 months prior to posting the file." }, { "payer_name": "CIGNA", "plan_name": "CIGNA COM ALT HMO PLAN", "methodology": "percent of total billed charges", "standard_charge_dollar": 516.95, "standard_charge_percentage": 42.2, "count": "0", "additional_payer_notes": "Zero final payments for the item or service in the 15 months prior to posting the file." }, { "payer_name": "CIGNA", "plan_name": "CIGNA COM ALT HMO PLAN", "methodology": "percent of total billed charges", "standard_charge_dollar": 516.95, "standard_charge_percentage": 42.2, "count": "0", "additional_payer_notes": "Zero final payments for the item or service in the 15 months prior to posting the file." }, { "payer_name": "HEALTH NET", "plan_name": "HEALTHNET HMO, PPO, POS, EPO, CANOPY HEALTHNET HMO, OTHER-IN-NETWORK PLANS", "methodology": "per diem", "standard_charge_dollar": 8000.0, "standard_charge_algorithm": "Expected reimbursement is the lesser of Per diem ($8,000) for the length of stay and 70% of billed.", "count": "0", "additional_payer_notes": "Zero final payments for the item or service in the 15 months prior to posting the file." }, { "payer_name": "HEALTH NET", "plan_name": "HEALTHNET HMO, PPO, POS, EPO, CANOPY HEALTHNET HMO, OTHER-IN-NETWORK PLANS", "methodology": "per diem", "standard_charge_dollar": 8000.0, "standard_charge_algorithm": "Expected reimbursement is the lesser of Per diem ($8,000) for the length of stay and 70% of billed.", "count": "0", "additional_payer_notes": "Zero final payments for the item or service in the 15 months prior to posting the file." }, { "payer_name": "UNITED HEALTHCARE", "plan_name": "SUTTER SELECT & SUTTER HEALTH PLAN HMO PLANS", "methodology": "per diem", "standard_charge_dollar": 28538.0, "standard_charge_algorithm": "Per diem ($28,538).", "count": "0", "additional_payer_notes": "Zero final payments for the item or service in the 15 months prior to posting the file." }, { "payer_name": "UNITED HEALTHCARE", "plan_name": "SUTTER SELECT & SUTTER HEALTH PLAN HMO PLANS", "methodology": "per diem", "standard_charge_dollar": 28538.0, "standard_charge_algorithm": "Per diem ($28,538).", "count": "0", "additional_payer_notes": "Zero final payments for the item or service in the 15 months prior to posting the file." }, { "payer_name": "SUTTER", "plan_name": "SUTTER SELECT & SUTTER HEALTH PLAN HMO PLANS", "methodology": "per diem", "standard_charge_dollar": 28538.0, "standard_charge_algorithm": "Per diem ($28,538).", "count": "0", "additional_payer_notes": "Zero final payments for the item or service in the 15 months prior to posting the file." }, { "payer_name": "UNITED HEALTHCARE", "plan_name": "SUTTER SELECT & SUTTER HEALTH PLAN HMO PLANS", "methodology": "per diem", "standard_charge_dollar": 28538.0, "standard_charge_algorithm": "Per diem ($28,538).", "count": "0", "additional_payer_notes": "Zero final payments for the item or service in the 15 months prior to posting the file." }, { "payer_name": "UMR", "plan_name": "SUTTER SELECT & SUTTER HEALTH PLAN HMO PLANS", "methodology": "per diem", "standard_charge_dollar": 28538.0, "standard_charge_algorithm": "Per diem ($28,538).", "count": "0", "additional_payer_notes": "Zero final payments for the item or service in the 15 months prior to posting the file." } ] } ] }, { "description": "HC Floseal Hemostatic Gp016", "code_information": [ { "code": "PX-2120070016", "type": "CDM" }, { "code": "99999", "type": "CPT" }, { "code": "0272", "type": "RC" } ], "standard_charges": [ { "setting": "outpatient", "gross_charge": 1400.0, "discounted_cash": 700.0, "minimum": 590.8, "maximum": 728.0, "additional_generic_notes": "Zero final payments for the item or service in the 15 months prior to posting the file.", "payers_information": [ { "payer_name": "AETNA", "plan_name": "AETNA ALL OTHER PLANS", "methodology": "percent of total billed charges", "standard_charge_dollar": 728.0, "standard_charge_percentage": 52.0, "count": "0", "additional_payer_notes": "Zero final payments for the item or service in the 15 months prior to posting the file." }, { "payer_name": "AETNA", "plan_name": "AETNA ALL OTHER PLANS", "methodology": "percent of total billed charges", "standard_charge_dollar": 728.0, "standard_charge_percentage": 52.0, "count": "0", "additional_payer_notes": "Zero final payments for the item or service in the 15 months prior to posting the file." }, { "payer_name": "MERITAIN HEALTH", "plan_name": "AETNA ALL OTHER PLANS", "methodology": "percent of total billed charges", "standard_charge_dollar": 728.0, "standard_charge_percentage": 52.0, "count": "0", "additional_payer_notes": "Zero final payments for the item or service in the 15 months prior to posting the file." }, { "payer_name": "BLUE SHIELD OUT OF STATE", "plan_name": "STANFORD HEALTHCARE ALLIANCE PLAN", "methodology": "percent of total billed charges", "standard_charge_dollar": 680.26, "standard_charge_percentage": 48.59, "count": "0", "additional_payer_notes": "Zero final payments for the item or service in the 15 months prior to posting the file." }, { "payer_name": "BLUE SHIELD", "plan_name": "STANFORD HEALTHCARE ALLIANCE PLAN", "methodology": "percent of total billed charges", "standard_charge_dollar": 680.26, "standard_charge_percentage": 48.59, "median_amount": 68.24, "10th_percentile": 13.6, "90th_percentile": 1043.06, "count": "30" }, { "payer_name": "BLUE SHIELD", "plan_name": "STANFORD HEALTHCARE ALLIANCE PLAN", "methodology": "percent of total billed charges", "standard_charge_dollar": 680.26, "standard_charge_percentage": 48.59, "count": "0", "additional_payer_notes": "Zero final payments for the item or service in the 15 months prior to posting the file." }, { "payer_name": "BLUE SHIELD", "plan_name": "STANFORD HEALTHCARE ALLIANCE PLAN", "methodology": "percent of total billed charges", "standard_charge_dollar": 680.26, "standard_charge_percentage": 48.59, "count": "0", "additional_payer_notes": "Zero final payments for the item or service in the 15 months prior to posting the file." }, { "payer_name": "CIGNA", "plan_name": "CIGNA COM ALT HMO PLAN", "methodology": "percent of total billed charges", "standard_charge_dollar": 590.8, "standard_charge_percentage": 42.2, "count": "0", "additional_payer_notes": "Zero final payments for the item or service in the 15 months prior to posting the file." }, { "payer_name": "CIGNA", "plan_name": "CIGNA COM ALT HMO PLAN", "methodology": "percent of total billed charges", "standard_charge_dollar": 590.8, "standard_charge_percentage": 42.2, "count": "0", "additional_payer_notes": "Zero final payments for the item or service in the 15 months prior to posting the file." }, { "payer_name": "HEALTH NET", "plan_name": "HEALTHNET HMO, PPO, POS, EPO, CANOPY HEALTHNET HMO, OTHER-IN-NETWORK PLANS", "methodology": "per diem", "standard_charge_dollar": 8000.0, "standard_charge_algorithm": "Expected reimbursement is the lesser of Per diem ($8,000) for the length of stay and 70% of billed.", "count": "0", "additional_payer_notes": "Zero final payments for the item or service in the 15 months prior to posting the file." }, { "payer_name": "HEALTH NET", "plan_name": "HEALTHNET HMO, PPO, POS, EPO, CANOPY HEALTHNET HMO, OTHER-IN-NETWORK PLANS", "methodology": "per diem", "standard_charge_dollar": 8000.0, "standard_charge_algorithm": "Expected reimbursement is the lesser of Per diem ($8,000) for the length of stay and 70% of billed.", "count": "0", "additional_payer_notes": "Zero final payments for the item or service in the 15 months prior to posting the file." }, { "payer_name": "UNITED HEALTHCARE", "plan_name": "SUTTER SELECT & SUTTER HEALTH PLAN HMO PLANS", "methodology": "per diem", "standard_charge_dollar": 28538.0, "standard_charge_algorithm": "Per diem ($28,538).", "count": "0", "additional_payer_notes": "Zero final payments for the item or service in the 15 months prior to posting the file." }, { "payer_name": "UNITED HEALTHCARE", "plan_name": "SUTTER SELECT & SUTTER HEALTH PLAN HMO PLANS", "methodology": "per diem", "standard_charge_dollar": 28538.0, "standard_charge_algorithm": "Per diem ($28,538).", "count": "0", "additional_payer_notes": "Zero final payments for the item or service in the 15 months prior to posting the file." }, { "payer_name": "SUTTER", "plan_name": "SUTTER SELECT & SUTTER HEALTH PLAN HMO PLANS", "methodology": "per diem", "standard_charge_dollar": 28538.0, "standard_charge_algorithm": "Per diem ($28,538).", "count": "0", "additional_payer_notes": "Zero final payments for the item or service in the 15 months prior to posting the file." }, { "payer_name": "UNITED HEALTHCARE", "plan_name": "SUTTER SELECT & SUTTER HEALTH PLAN HMO PLANS", "methodology": "per diem", "standard_charge_dollar": 28538.0, "standard_charge_algorithm": "Per diem ($28,538).", "count": "0", "additional_payer_notes": "Zero final payments for the item or service in the 15 months prior to posting the file." }, { "payer_name": "UMR", "plan_name": "SUTTER SELECT & SUTTER HEALTH PLAN HMO PLANS", "methodology": "per diem", "standard_charge_dollar": 28538.0, "standard_charge_algorithm": "Per diem ($28,538).", "count": "0", "additional_payer_notes": "Zero final payments for the item or service in the 15 months prior to posting the file." } ] } ] }, { "description": "HC Floseal Hemostatic Gp017", "code_information": [ { "code": "PX-2120070017", "type": "CDM" }, { "code": "99999", "type": "CPT" }, { "code": "0272", "type": "RC" } ], "standard_charges": [ { "setting": "outpatient", "gross_charge": 1575.0, "discounted_cash": 787.5, "minimum": 664.65, "maximum": 819.0, "additional_generic_notes": "Zero final payments for the item or service in the 15 months prior to posting the file.", "payers_information": [ { "payer_name": "AETNA", "plan_name": "AETNA ALL OTHER PLANS", "methodology": "percent of total billed charges", "standard_charge_dollar": 819.0, "standard_charge_percentage": 52.0, "count": "0", "additional_payer_notes": "Zero final payments for the item or service in the 15 months prior to posting the file." }, { "payer_name": "AETNA", "plan_name": "AETNA ALL OTHER PLANS", "methodology": "percent of total billed charges", "standard_charge_dollar": 819.0, "standard_charge_percentage": 52.0, "count": "0", "additional_payer_notes": "Zero final payments for the item or service in the 15 months prior to posting the file." }, { "payer_name": "MERITAIN HEALTH", "plan_name": "AETNA ALL OTHER PLANS", "methodology": "percent of total billed charges", "standard_charge_dollar": 819.0, "standard_charge_percentage": 52.0, "count": "0", "additional_payer_notes": "Zero final payments for the item or service in the 15 months prior to posting the file." }, { "payer_name": "BLUE SHIELD OUT OF STATE", "plan_name": "STANFORD HEALTHCARE ALLIANCE PLAN", "methodology": "percent of total billed charges", "standard_charge_dollar": 765.29, "standard_charge_percentage": 48.59, "count": "0", "additional_payer_notes": "Zero final payments for the item or service in the 15 months prior to posting the file." }, { "payer_name": "BLUE SHIELD", "plan_name": "STANFORD HEALTHCARE ALLIANCE PLAN", "methodology": "percent of total billed charges", "standard_charge_dollar": 765.29, "standard_charge_percentage": 48.59, "median_amount": 68.24, "10th_percentile": 13.6, "90th_percentile": 1043.06, "count": "30" }, { "payer_name": "BLUE SHIELD", "plan_name": "STANFORD HEALTHCARE ALLIANCE PLAN", "methodology": "percent of total billed charges", "standard_charge_dollar": 765.29, "standard_charge_percentage": 48.59, "count": "0", "additional_payer_notes": "Zero final payments for the item or service in the 15 months prior to posting the file." }, { "payer_name": "BLUE SHIELD", "plan_name": "STANFORD HEALTHCARE ALLIANCE PLAN", "methodology": "percent of total billed charges", "standard_charge_dollar": 765.29, "standard_charge_percentage": 48.59, "count": "0", "additional_payer_notes": "Zero final payments for the item or service in the 15 months prior to posting the file." }, { "payer_name": "CIGNA", "plan_name": "CIGNA COM ALT HMO PLAN", "methodology": "percent of total billed charges", "standard_charge_dollar": 664.65, "standard_charge_percentage": 42.2, "count": "0", "additional_payer_notes": "Zero final payments for the item or service in the 15 months prior to posting the file." }, { "payer_name": "CIGNA", "plan_name": "CIGNA COM ALT HMO PLAN", "methodology": "percent of total billed charges", "standard_charge_dollar": 664.65, "standard_charge_percentage": 42.2, "count": "0", "additional_payer_notes": "Zero final payments for the item or service in the 15 months prior to posting the file." }, { "payer_name": "HEALTH NET", "plan_name": "HEALTHNET HMO, PPO, POS, EPO, CANOPY HEALTHNET HMO, OTHER-IN-NETWORK PLANS", "methodology": "per diem", "standard_charge_dollar": 8000.0, "standard_charge_algorithm": "Expected reimbursement is the lesser of Per diem ($8,000) for the length of stay and 70% of billed.", "count": "0", "additional_payer_notes": "Zero final payments for the item or service in the 15 months prior to posting the file." }, { "payer_name": "HEALTH NET", "plan_name": "HEALTHNET HMO, PPO, POS, EPO, CANOPY HEALTHNET HMO, OTHER-IN-NETWORK PLANS", "methodology": "per diem", "standard_charge_dollar": 8000.0, "standard_charge_algorithm": "Expected reimbursement is the lesser of Per diem ($8,000) for the length of stay and 70% of billed.", "count": "0", "additional_payer_notes": "Zero final payments for the item or service in the 15 months prior to posting the file." }, { "payer_name": "UNITED HEALTHCARE", "plan_name": "SUTTER SELECT & SUTTER HEALTH PLAN HMO PLANS", "methodology": "per diem", "standard_charge_dollar": 28538.0, "standard_charge_algorithm": "Per diem ($28,538).", "count": "0", "additional_payer_notes": "Zero final payments for the item or service in the 15 months prior to posting the file." }, { "payer_name": "UNITED HEALTHCARE", "plan_name": "SUTTER SELECT & SUTTER HEALTH PLAN HMO PLANS", "methodology": "per diem", "standard_charge_dollar": 28538.0, "standard_charge_algorithm": "Per diem ($28,538).", "count": "0", "additional_payer_notes": "Zero final payments for the item or service in the 15 months prior to posting the file." }, { "payer_name": "SUTTER", "plan_name": "SUTTER SELECT & SUTTER HEALTH PLAN HMO PLANS", "methodology": "per diem", "standard_charge_dollar": 28538.0, "standard_charge_algorithm": "Per diem ($28,538).", "count": "0", "additional_payer_notes": "Zero final payments for the item or service in the 15 months prior to posting the file." }, { "payer_name": "UNITED HEALTHCARE", "plan_name": "SUTTER SELECT & SUTTER HEALTH PLAN HMO PLANS", "methodology": "per diem", "standard_charge_dollar": 28538.0, "standard_charge_algorithm": "Per diem ($28,538).", "count": "0", "additional_payer_notes": "Zero final payments for the item or service in the 15 months prior to posting the file." }, { "payer_name": "UMR", "plan_name": "SUTTER SELECT & SUTTER HEALTH PLAN HMO PLANS", "methodology": "per diem", "standard_charge_dollar": 28538.0, "standard_charge_algorithm": "Per diem ($28,538).", "count": "0", "additional_payer_notes": "Zero final payments for the item or service in the 15 months prior to posting the file." } ] } ] }, { "description": "HC Floseal Hemostatic Gp018", "code_information": [ { "code": "PX-2120070018", "type": "CDM" }, { "code": "99999", "type": "CPT" }, { "code": "0272", "type": "RC" } ], "standard_charges": [ { "setting": "outpatient", "gross_charge": 1750.0, "discounted_cash": 875.0, "minimum": 738.5, "maximum": 910.0, "additional_generic_notes": "Zero final payments for the item or service in the 15 months prior to posting the file.", "payers_information": [ { "payer_name": "AETNA", "plan_name": "AETNA ALL OTHER PLANS", "methodology": "percent of total billed charges", "standard_charge_dollar": 910.0, "standard_charge_percentage": 52.0, "count": "0", "additional_payer_notes": "Zero final payments for the item or service in the 15 months prior to posting the file." }, { "payer_name": "AETNA", "plan_name": "AETNA ALL OTHER PLANS", "methodology": "percent of total billed charges", "standard_charge_dollar": 910.0, "standard_charge_percentage": 52.0, "count": "0", "additional_payer_notes": "Zero final payments for the item or service in the 15 months prior to posting the file." }, { "payer_name": "MERITAIN HEALTH", "plan_name": "AETNA ALL OTHER PLANS", "methodology": "percent of total billed charges", "standard_charge_dollar": 910.0, "standard_charge_percentage": 52.0, "count": "0", "additional_payer_notes": "Zero final payments for the item or service in the 15 months prior to posting the file." }, { "payer_name": "BLUE SHIELD OUT OF STATE", "plan_name": "STANFORD HEALTHCARE ALLIANCE PLAN", "methodology": "percent of total billed charges", "standard_charge_dollar": 850.33, "standard_charge_percentage": 48.59, "count": "0", "additional_payer_notes": "Zero final payments for the item or service in the 15 months prior to posting the file." }, { "payer_name": "BLUE SHIELD", "plan_name": "STANFORD HEALTHCARE ALLIANCE PLAN", "methodology": "percent of total billed charges", "standard_charge_dollar": 850.33, "standard_charge_percentage": 48.59, "median_amount": 68.24, "10th_percentile": 13.6, "90th_percentile": 1043.06, "count": "30" }, { "payer_name": "BLUE SHIELD", "plan_name": "STANFORD HEALTHCARE ALLIANCE PLAN", "methodology": "percent of total billed charges", "standard_charge_dollar": 850.33, "standard_charge_percentage": 48.59, "count": "0", "additional_payer_notes": "Zero final payments for the item or service in the 15 months prior to posting the file." }, { "payer_name": "BLUE SHIELD", "plan_name": "STANFORD HEALTHCARE ALLIANCE PLAN", "methodology": "percent of total billed charges", "standard_charge_dollar": 850.33, "standard_charge_percentage": 48.59, "count": "0", "additional_payer_notes": "Zero final payments for the item or service in the 15 months prior to posting the file." }, { "payer_name": "CIGNA", "plan_name": "CIGNA COM ALT HMO PLAN", "methodology": "percent of total billed charges", "standard_charge_dollar": 738.5, "standard_charge_percentage": 42.2, "count": "0", "additional_payer_notes": "Zero final payments for the item or service in the 15 months prior to posting the file." }, { "payer_name": "CIGNA", "plan_name": "CIGNA COM ALT HMO PLAN", "methodology": "percent of total billed charges", "standard_charge_dollar": 738.5, "standard_charge_percentage": 42.2, "count": "0", "additional_payer_notes": "Zero final payments for the item or service in the 15 months prior to posting the file." }, { "payer_name": "HEALTH NET", "plan_name": "HEALTHNET HMO, PPO, POS, EPO, CANOPY HEALTHNET HMO, OTHER-IN-NETWORK PLANS", "methodology": "per diem", "standard_charge_dollar": 8000.0, "standard_charge_algorithm": "Expected reimbursement is the lesser of Per diem ($8,000) for the length of stay and 70% of billed.", "count": "0", "additional_payer_notes": "Zero final payments for the item or service in the 15 months prior to posting the file." }, { "payer_name": "HEALTH NET", "plan_name": "HEALTHNET HMO, PPO, POS, EPO, CANOPY HEALTHNET HMO, OTHER-IN-NETWORK PLANS", "methodology": "per diem", "standard_charge_dollar": 8000.0, "standard_charge_algorithm": "Expected reimbursement is the lesser of Per diem ($8,000) for the length of stay and 70% of billed.", "count": "0", "additional_payer_notes": "Zero final payments for the item or service in the 15 months prior to posting the file." }, { "payer_name": "UNITED HEALTHCARE", "plan_name": "SUTTER SELECT & SUTTER HEALTH PLAN HMO PLANS", "methodology": "per diem", "standard_charge_dollar": 28538.0, "standard_charge_algorithm": "Per diem ($28,538).", "count": "0", "additional_payer_notes": "Zero final payments for the item or service in the 15 months prior to posting the file." }, { "payer_name": "UNITED HEALTHCARE", "plan_name": "SUTTER SELECT & SUTTER HEALTH PLAN HMO PLANS", "methodology": "per diem", "standard_charge_dollar": 28538.0, "standard_charge_algorithm": "Per diem ($28,538).", "count": "0", "additional_payer_notes": "Zero final payments for the item or service in the 15 months prior to posting the file." }, { "payer_name": "SUTTER", "plan_name": "SUTTER SELECT & SUTTER HEALTH PLAN HMO PLANS", "methodology": "per diem", "standard_charge_dollar": 28538.0, "standard_charge_algorithm": "Per diem ($28,538).", "count": "0", "additional_payer_notes": "Zero final payments for the item or service in the 15 months prior to posting the file." }, { "payer_name": "UNITED HEALTHCARE", "plan_name": "SUTTER SELECT & SUTTER HEALTH PLAN HMO PLANS", "methodology": "per diem", "standard_charge_dollar": 28538.0, "standard_charge_algorithm": "Per diem ($28,538).", "count": "0", "additional_payer_notes": "Zero final payments for the item or service in the 15 months prior to posting the file." }, { "payer_name": "UMR", "plan_name": "SUTTER SELECT & SUTTER HEALTH PLAN HMO PLANS", "methodology": "per diem", "standard_charge_dollar": 28538.0, "standard_charge_algorithm": "Per diem ($28,538).", "count": "0", "additional_payer_notes": "Zero final payments for the item or service in the 15 months prior to posting the file." } ] } ] }, { "description": "HC Floseal Hemostatic Gp019", "code_information": [ { "code": "PX-2120070019", "type": "CDM" }, { "code": "99999", "type": "CPT" }, { "code": "0272", "type": "RC" } ], "standard_charges": [ { "setting": "outpatient", "gross_charge": 2125.0, "discounted_cash": 1062.5, "minimum": 896.75, "maximum": 1105.0, "additional_generic_notes": "Zero final payments for the item or service in the 15 months prior to posting the file.", "payers_information": [ { "payer_name": "AETNA", "plan_name": "AETNA ALL OTHER PLANS", "methodology": "percent of total billed charges", "standard_charge_dollar": 1105.0, "standard_charge_percentage": 52.0, "count": "0", "additional_payer_notes": "Zero final payments for the item or service in the 15 months prior to posting the file." }, { "payer_name": "AETNA", "plan_name": "AETNA ALL OTHER PLANS", "methodology": "percent of total billed charges", "standard_charge_dollar": 1105.0, "standard_charge_percentage": 52.0, "count": "0", "additional_payer_notes": "Zero final payments for the item or service in the 15 months prior to posting the file." }, { "payer_name": "MERITAIN HEALTH", "plan_name": "AETNA ALL OTHER PLANS", "methodology": "percent of total billed charges", "standard_charge_dollar": 1105.0, "standard_charge_percentage": 52.0, "count": "0", "additional_payer_notes": "Zero final payments for the item or service in the 15 months prior to posting the file." }, { "payer_name": "BLUE SHIELD OUT OF STATE", "plan_name": "STANFORD HEALTHCARE ALLIANCE PLAN", "methodology": "percent of total billed charges", "standard_charge_dollar": 1032.54, "standard_charge_percentage": 48.59, "count": "0", "additional_payer_notes": "Zero final payments for the item or service in the 15 months prior to posting the file." }, { "payer_name": "BLUE SHIELD", "plan_name": "STANFORD HEALTHCARE ALLIANCE PLAN", "methodology": "percent of total billed charges", "standard_charge_dollar": 1032.54, "standard_charge_percentage": 48.59, "median_amount": 68.24, "10th_percentile": 13.6, "90th_percentile": 1043.06, "count": "30" }, { "payer_name": "BLUE SHIELD", "plan_name": "STANFORD HEALTHCARE ALLIANCE PLAN", "methodology": "percent of total billed charges", "standard_charge_dollar": 1032.54, "standard_charge_percentage": 48.59, "count": "0", "additional_payer_notes": "Zero final payments for the item or service in the 15 months prior to posting the file." }, { "payer_name": "BLUE SHIELD", "plan_name": "STANFORD HEALTHCARE ALLIANCE PLAN", "methodology": "percent of total billed charges", "standard_charge_dollar": 1032.54, "standard_charge_percentage": 48.59, "count": "0", "additional_payer_notes": "Zero final payments for the item or service in the 15 months prior to posting the file." }, { "payer_name": "CIGNA", "plan_name": "CIGNA COM ALT HMO PLAN", "methodology": "percent of total billed charges", "standard_charge_dollar": 896.75, "standard_charge_percentage": 42.2, "count": "0", "additional_payer_notes": "Zero final payments for the item or service in the 15 months prior to posting the file." }, { "payer_name": "CIGNA", "plan_name": "CIGNA COM ALT HMO PLAN", "methodology": "percent of total billed charges", "standard_charge_dollar": 896.75, "standard_charge_percentage": 42.2, "count": "0", "additional_payer_notes": "Zero final payments for the item or service in the 15 months prior to posting the file." }, { "payer_name": "HEALTH NET", "plan_name": "HEALTHNET HMO, PPO, POS, EPO, CANOPY HEALTHNET HMO, OTHER-IN-NETWORK PLANS", "methodology": "per diem", "standard_charge_dollar": 8000.0, "standard_charge_algorithm": "Expected reimbursement is the lesser of Per diem ($8,000) for the length of stay and 70% of billed.", "count": "0", "additional_payer_notes": "Zero final payments for the item or service in the 15 months prior to posting the file." }, { "payer_name": "HEALTH NET", "plan_name": "HEALTHNET HMO, PPO, POS, EPO, CANOPY HEALTHNET HMO, OTHER-IN-NETWORK PLANS", "methodology": "per diem", "standard_charge_dollar": 8000.0, "standard_charge_algorithm": "Expected reimbursement is the lesser of Per diem ($8,000) for the length of stay and 70% of billed.", "count": "0", "additional_payer_notes": "Zero final payments for the item or service in the 15 months prior to posting the file." }, { "payer_name": "UNITED HEALTHCARE", "plan_name": "SUTTER SELECT & SUTTER HEALTH PLAN HMO PLANS", "methodology": "per diem", "standard_charge_dollar": 28538.0, "standard_charge_algorithm": "Per diem ($28,538).", "count": "0", "additional_payer_notes": "Zero final payments for the item or service in the 15 months prior to posting the file." }, { "payer_name": "UNITED HEALTHCARE", "plan_name": "SUTTER SELECT & SUTTER HEALTH PLAN HMO PLANS", "methodology": "per diem", "standard_charge_dollar": 28538.0, "standard_charge_algorithm": "Per diem ($28,538).", "count": "0", "additional_payer_notes": "Zero final payments for the item or service in the 15 months prior to posting the file." }, { "payer_name": "SUTTER", "plan_name": "SUTTER SELECT & SUTTER HEALTH PLAN HMO PLANS", "methodology": "per diem", "standard_charge_dollar": 28538.0, "standard_charge_algorithm": "Per diem ($28,538).", "count": "0", "additional_payer_notes": "Zero final payments for the item or service in the 15 months prior to posting the file." }, { "payer_name": "UNITED HEALTHCARE", "plan_name": "SUTTER SELECT & SUTTER HEALTH PLAN HMO PLANS", "methodology": "per diem", "standard_charge_dollar": 28538.0, "standard_charge_algorithm": "Per diem ($28,538).", "count": "0", "additional_payer_notes": "Zero final payments for the item or service in the 15 months prior to posting the file." }, { "payer_name": "UMR", "plan_name": "SUTTER SELECT & SUTTER HEALTH PLAN HMO PLANS", "methodology": "per diem", "standard_charge_dollar": 28538.0, "standard_charge_algorithm": "Per diem ($28,538).", "count": "0", "additional_payer_notes": "Zero final payments for the item or service in the 15 months prior to posting the file." } ] } ] }, { "description": "HC Impl Cochlear Gp074", "code_information": [ { "code": "PX-2120091074", "type": "CDM" }, { "code": "L8614", "type": "HCPCS" }, { "code": "0278", "type": "RC" } ], "standard_charges": [ { "setting": "outpatient", "gross_charge": 32000.0, "discounted_cash": 16000.0, "minimum": 13504.0, "maximum": 16640.0, "additional_generic_notes": "Zero final payments for the item or service in the 15 months prior to posting the file.", "payers_information": [ { "payer_name": "AETNA", "plan_name": "AETNA ALL OTHER PLANS", "methodology": "percent of total billed charges", "standard_charge_dollar": 16640.0, "standard_charge_percentage": 52.0, "median_amount": 29521.8, "10th_percentile": 24684.0, "90th_percentile": 29521.8, "count": "1 through 10" }, { "payer_name": "AETNA", "plan_name": "AETNA ALL OTHER PLANS", "methodology": "percent of total billed charges", "standard_charge_dollar": 16640.0, "standard_charge_percentage": 52.0, "count": "0", "additional_payer_notes": "Zero final payments for the item or service in the 15 months prior to posting the file." }, { "payer_name": "MERITAIN HEALTH", "plan_name": "AETNA ALL OTHER PLANS", "methodology": "percent of total billed charges", "standard_charge_dollar": 16640.0, "standard_charge_percentage": 52.0, "median_amount": 30738.0, "10th_percentile": 30738.0, "90th_percentile": 30738.0, "count": "1 through 10" }, { "payer_name": "BLUE SHIELD OUT OF STATE", "plan_name": "STANFORD HEALTHCARE ALLIANCE PLAN", "methodology": "percent of total billed charges", "standard_charge_dollar": 15548.8, "standard_charge_percentage": 48.59, "median_amount": 19521.66, "10th_percentile": 19521.66, "90th_percentile": 19521.66, "count": "1 through 10" }, { "payer_name": "BLUE SHIELD", "plan_name": "STANFORD HEALTHCARE ALLIANCE PLAN", "methodology": "percent of total billed charges", "standard_charge_dollar": 15548.8, "standard_charge_percentage": 48.59, "count": "0", "additional_payer_notes": "Zero final payments for the item or service in the 15 months prior to posting the file." }, { "payer_name": "BLUE SHIELD", "plan_name": "STANFORD HEALTHCARE ALLIANCE PLAN", "methodology": "percent of total billed charges", "standard_charge_dollar": 15548.8, "standard_charge_percentage": 48.59, "count": "0", "additional_payer_notes": "Zero final payments for the item or service in the 15 months prior to posting the file." }, { "payer_name": "BLUE SHIELD", "plan_name": "STANFORD HEALTHCARE ALLIANCE PLAN", "methodology": "percent of total billed charges", "standard_charge_dollar": 15548.8, "standard_charge_percentage": 48.59, "count": "0", "additional_payer_notes": "Zero final payments for the item or service in the 15 months prior to posting the file." }, { "payer_name": "CIGNA", "plan_name": "CIGNA COM ALT HMO PLAN", "methodology": "percent of total billed charges", "standard_charge_dollar": 13504.0, "standard_charge_percentage": 42.2, "count": "0", "additional_payer_notes": "Zero final payments for the item or service in the 15 months prior to posting the file." }, { "payer_name": "CIGNA", "plan_name": "CIGNA COM ALT HMO PLAN", "methodology": "percent of total billed charges", "standard_charge_dollar": 13504.0, "standard_charge_percentage": 42.2, "count": "0", "additional_payer_notes": "Zero final payments for the item or service in the 15 months prior to posting the file." } ] } ] }, { "description": "HC Impl Cochlear Gp090", "code_information": [ { "code": "PX-2120091090", "type": "CDM" }, { "code": "L8614", "type": "HCPCS" }, { "code": "0278", "type": "RC" } ], "standard_charges": [ { "setting": "outpatient", "gross_charge": 44800.0, "discounted_cash": 22400.0, "minimum": 18905.6, "maximum": 23296.0, "additional_generic_notes": "Zero final payments for the item or service in the 15 months prior to posting the file.", "payers_information": [ { "payer_name": "AETNA", "plan_name": "AETNA ALL OTHER PLANS", "methodology": "percent of total billed charges", "standard_charge_dollar": 23296.0, "standard_charge_percentage": 52.0, "median_amount": 29521.8, "10th_percentile": 24684.0, "90th_percentile": 29521.8, "count": "1 through 10" }, { "payer_name": "AETNA", "plan_name": "AETNA ALL OTHER PLANS", "methodology": "percent of total billed charges", "standard_charge_dollar": 23296.0, "standard_charge_percentage": 52.0, "count": "0", "additional_payer_notes": "Zero final payments for the item or service in the 15 months prior to posting the file." }, { "payer_name": "MERITAIN HEALTH", "plan_name": "AETNA ALL OTHER PLANS", "methodology": "percent of total billed charges", "standard_charge_dollar": 23296.0, "standard_charge_percentage": 52.0, "median_amount": 30738.0, "10th_percentile": 30738.0, "90th_percentile": 30738.0, "count": "1 through 10" }, { "payer_name": "BLUE SHIELD OUT OF STATE", "plan_name": "STANFORD HEALTHCARE ALLIANCE PLAN", "methodology": "percent of total billed charges", "standard_charge_dollar": 21768.32, "standard_charge_percentage": 48.59, "median_amount": 19521.66, "10th_percentile": 19521.66, "90th_percentile": 19521.66, "count": "1 through 10" }, { "payer_name": "BLUE SHIELD", "plan_name": "STANFORD HEALTHCARE ALLIANCE PLAN", "methodology": "percent of total billed charges", "standard_charge_dollar": 21768.32, "standard_charge_percentage": 48.59, "count": "0", "additional_payer_notes": "Zero final payments for the item or service in the 15 months prior to posting the file." }, { "payer_name": "BLUE SHIELD", "plan_name": "STANFORD HEALTHCARE ALLIANCE PLAN", "methodology": "percent of total billed charges", "standard_charge_dollar": 21768.32, "standard_charge_percentage": 48.59, "count": "0", "additional_payer_notes": "Zero final payments for the item or service in the 15 months prior to posting the file." }, { "payer_name": "BLUE SHIELD", "plan_name": "STANFORD HEALTHCARE ALLIANCE PLAN", "methodology": "percent of total billed charges", "standard_charge_dollar": 21768.32, "standard_charge_percentage": 48.59, "count": "0", "additional_payer_notes": "Zero final payments for the item or service in the 15 months prior to posting the file." }, { "payer_name": "CIGNA", "plan_name": "CIGNA COM ALT HMO PLAN", "methodology": "percent of total billed charges", "standard_charge_dollar": 18905.6, "standard_charge_percentage": 42.2, "count": "0", "additional_payer_notes": "Zero final payments for the item or service in the 15 months prior to posting the file." }, { "payer_name": "CIGNA", "plan_name": "CIGNA COM ALT HMO PLAN", "methodology": "percent of total billed charges", "standard_charge_dollar": 18905.6, "standard_charge_percentage": 42.2, "count": "0", "additional_payer_notes": "Zero final payments for the item or service in the 15 months prior to posting the file." } ] } ] }, { "description": "HC Impl Cochlear Gp093", "code_information": [ { "code": "PX-2120091093", "type": "CDM" }, { "code": "L8614", "type": "HCPCS" }, { "code": "0278", "type": "RC" } ], "standard_charges": [ { "setting": "outpatient", "gross_charge": 47200.0, "discounted_cash": 23600.0, "minimum": 19918.4, "maximum": 24544.0, "additional_generic_notes": "Zero final payments for the item or service in the 15 months prior to posting the file.", "payers_information": [ { "payer_name": "AETNA", "plan_name": "AETNA ALL OTHER PLANS", "methodology": "percent of total billed charges", "standard_charge_dollar": 24544.0, "standard_charge_percentage": 52.0, "median_amount": 29521.8, "10th_percentile": 24684.0, "90th_percentile": 29521.8, "count": "1 through 10" }, { "payer_name": "AETNA", "plan_name": "AETNA ALL OTHER PLANS", "methodology": "percent of total billed charges", "standard_charge_dollar": 24544.0, "standard_charge_percentage": 52.0, "count": "0", "additional_payer_notes": "Zero final payments for the item or service in the 15 months prior to posting the file." }, { "payer_name": "MERITAIN HEALTH", "plan_name": "AETNA ALL OTHER PLANS", "methodology": "percent of total billed charges", "standard_charge_dollar": 24544.0, "standard_charge_percentage": 52.0, "median_amount": 30738.0, "10th_percentile": 30738.0, "90th_percentile": 30738.0, "count": "1 through 10" }, { "payer_name": "BLUE SHIELD OUT OF STATE", "plan_name": "STANFORD HEALTHCARE ALLIANCE PLAN", "methodology": "percent of total billed charges", "standard_charge_dollar": 22934.48, "standard_charge_percentage": 48.59, "median_amount": 19521.66, "10th_percentile": 19521.66, "90th_percentile": 19521.66, "count": "1 through 10" }, { "payer_name": "BLUE SHIELD", "plan_name": "STANFORD HEALTHCARE ALLIANCE PLAN", "methodology": "percent of total billed charges", "standard_charge_dollar": 22934.48, "standard_charge_percentage": 48.59, "count": "0", "additional_payer_notes": "Zero final payments for the item or service in the 15 months prior to posting the file." }, { "payer_name": "BLUE SHIELD", "plan_name": "STANFORD HEALTHCARE ALLIANCE PLAN", "methodology": "percent of total billed charges", "standard_charge_dollar": 22934.48, "standard_charge_percentage": 48.59, "count": "0", "additional_payer_notes": "Zero final payments for the item or service in the 15 months prior to posting the file." }, { "payer_name": "BLUE SHIELD", "plan_name": "STANFORD HEALTHCARE ALLIANCE PLAN", "methodology": "percent of total billed charges", "standard_charge_dollar": 22934.48, "standard_charge_percentage": 48.59, "count": "0", "additional_payer_notes": "Zero final payments for the item or service in the 15 months prior to posting the file." }, { "payer_name": "CIGNA", "plan_name": "CIGNA COM ALT HMO PLAN", "methodology": "percent of total billed charges", "standard_charge_dollar": 19918.4, "standard_charge_percentage": 42.2, "count": "0", "additional_payer_notes": "Zero final payments for the item or service in the 15 months prior to posting the file." }, { "payer_name": "CIGNA", "plan_name": "CIGNA COM ALT HMO PLAN", "methodology": "percent of total billed charges", "standard_charge_dollar": 19918.4, "standard_charge_percentage": 42.2, "count": "0", "additional_payer_notes": "Zero final payments for the item or service in the 15 months prior to posting the file." } ] } ] }, { "description": "HC Impl Cochlear Gp105", "code_information": [ { "code": "PX-2120091105", "type": "CDM" }, { "code": "L8614", "type": "HCPCS" }, { "code": "0278", "type": "RC" } ], "standard_charges": [ { "setting": "outpatient", "gross_charge": 50410.0, "discounted_cash": 25205.0, "minimum": 21273.02, "maximum": 26213.2, "additional_generic_notes": "Zero final payments for the item or service in the 15 months prior to posting the file.", "payers_information": [ { "payer_name": "AETNA", "plan_name": "AETNA ALL OTHER PLANS", "methodology": "percent of total billed charges", "standard_charge_dollar": 26213.2, "standard_charge_percentage": 52.0, "median_amount": 29521.8, "10th_percentile": 24684.0, "90th_percentile": 29521.8, "count": "1 through 10" }, { "payer_name": "AETNA", "plan_name": "AETNA ALL OTHER PLANS", "methodology": "percent of total billed charges", "standard_charge_dollar": 26213.2, "standard_charge_percentage": 52.0, "count": "0", "additional_payer_notes": "Zero final payments for the item or service in the 15 months prior to posting the file." }, { "payer_name": "MERITAIN HEALTH", "plan_name": "AETNA ALL OTHER PLANS", "methodology": "percent of total billed charges", "standard_charge_dollar": 26213.2, "standard_charge_percentage": 52.0, "median_amount": 30738.0, "10th_percentile": 30738.0, "90th_percentile": 30738.0, "count": "1 through 10" }, { "payer_name": "BLUE SHIELD OUT OF STATE", "plan_name": "STANFORD HEALTHCARE ALLIANCE PLAN", "methodology": "percent of total billed charges", "standard_charge_dollar": 24494.22, "standard_charge_percentage": 48.59, "median_amount": 19521.66, "10th_percentile": 19521.66, "90th_percentile": 19521.66, "count": "1 through 10" }, { "payer_name": "BLUE SHIELD", "plan_name": "STANFORD HEALTHCARE ALLIANCE PLAN", "methodology": "percent of total billed charges", "standard_charge_dollar": 24494.22, "standard_charge_percentage": 48.59, "count": "0", "additional_payer_notes": "Zero final payments for the item or service in the 15 months prior to posting the file." }, { "payer_name": "BLUE SHIELD", "plan_name": "STANFORD HEALTHCARE ALLIANCE PLAN", "methodology": "percent of total billed charges", "standard_charge_dollar": 24494.22, "standard_charge_percentage": 48.59, "count": "0", "additional_payer_notes": "Zero final payments for the item or service in the 15 months prior to posting the file." }, { "payer_name": "BLUE SHIELD", "plan_name": "STANFORD HEALTHCARE ALLIANCE PLAN", "methodology": "percent of total billed charges", "standard_charge_dollar": 24494.22, "standard_charge_percentage": 48.59, "count": "0", "additional_payer_notes": "Zero final payments for the item or service in the 15 months prior to posting the file." }, { "payer_name": "CIGNA", "plan_name": "CIGNA COM ALT HMO PLAN", "methodology": "percent of total billed charges", "standard_charge_dollar": 21273.02, "standard_charge_percentage": 42.2, "count": "0", "additional_payer_notes": "Zero final payments for the item or service in the 15 months prior to posting the file." }, { "payer_name": "CIGNA", "plan_name": "CIGNA COM ALT HMO PLAN", "methodology": "percent of total billed charges", "standard_charge_dollar": 21273.02, "standard_charge_percentage": 42.2, "count": "0", "additional_payer_notes": "Zero final payments for the item or service in the 15 months prior to posting the file." } ] } ] }, { "description": "HC Impl Cochlear Gp107", "code_information": [ { "code": "PX-2120091107", "type": "CDM" }, { "code": "L8614", "type": "HCPCS" }, { "code": "0278", "type": "RC" } ], "standard_charges": [ { "setting": "outpatient", "gross_charge": 50516.0, "discounted_cash": 25258.0, "minimum": 21317.75, "maximum": 26268.32, "additional_generic_notes": "Zero final payments for the item or service in the 15 months prior to posting the file.", "payers_information": [ { "payer_name": "AETNA", "plan_name": "AETNA ALL OTHER PLANS", "methodology": "percent of total billed charges", "standard_charge_dollar": 26268.32, "standard_charge_percentage": 52.0, "median_amount": 29521.8, "10th_percentile": 24684.0, "90th_percentile": 29521.8, "count": "1 through 10" }, { "payer_name": "AETNA", "plan_name": "AETNA ALL OTHER PLANS", "methodology": "percent of total billed charges", "standard_charge_dollar": 26268.32, "standard_charge_percentage": 52.0, "count": "0", "additional_payer_notes": "Zero final payments for the item or service in the 15 months prior to posting the file." }, { "payer_name": "MERITAIN HEALTH", "plan_name": "AETNA ALL OTHER PLANS", "methodology": "percent of total billed charges", "standard_charge_dollar": 26268.32, "standard_charge_percentage": 52.0, "median_amount": 30738.0, "10th_percentile": 30738.0, "90th_percentile": 30738.0, "count": "1 through 10" }, { "payer_name": "BLUE SHIELD OUT OF STATE", "plan_name": "STANFORD HEALTHCARE ALLIANCE PLAN", "methodology": "percent of total billed charges", "standard_charge_dollar": 24545.72, "standard_charge_percentage": 48.59, "median_amount": 19521.66, "10th_percentile": 19521.66, "90th_percentile": 19521.66, "count": "1 through 10" }, { "payer_name": "BLUE SHIELD", "plan_name": "STANFORD HEALTHCARE ALLIANCE PLAN", "methodology": "percent of total billed charges", "standard_charge_dollar": 24545.72, "standard_charge_percentage": 48.59, "count": "0", "additional_payer_notes": "Zero final payments for the item or service in the 15 months prior to posting the file." }, { "payer_name": "BLUE SHIELD", "plan_name": "STANFORD HEALTHCARE ALLIANCE PLAN", "methodology": "percent of total billed charges", "standard_charge_dollar": 24545.72, "standard_charge_percentage": 48.59, "count": "0", "additional_payer_notes": "Zero final payments for the item or service in the 15 months prior to posting the file." }, { "payer_name": "BLUE SHIELD", "plan_name": "STANFORD HEALTHCARE ALLIANCE PLAN", "methodology": "percent of total billed charges", "standard_charge_dollar": 24545.72, "standard_charge_percentage": 48.59, "count": "0", "additional_payer_notes": "Zero final payments for the item or service in the 15 months prior to posting the file." }, { "payer_name": "CIGNA", "plan_name": "CIGNA COM ALT HMO PLAN", "methodology": "percent of total billed charges", "standard_charge_dollar": 21317.75, "standard_charge_percentage": 42.2, "count": "0", "additional_payer_notes": "Zero final payments for the item or service in the 15 months prior to posting the file." }, { "payer_name": "CIGNA", "plan_name": "CIGNA COM ALT HMO PLAN", "methodology": "percent of total billed charges", "standard_charge_dollar": 21317.75, "standard_charge_percentage": 42.2, "count": "0", "additional_payer_notes": "Zero final payments for the item or service in the 15 months prior to posting the file." } ] } ] }, { "description": "HC Impl Cochlear Gp109", "code_information": [ { "code": "PX-2120091109", "type": "CDM" }, { "code": "L8614", "type": "HCPCS" }, { "code": "0278", "type": "RC" } ], "standard_charges": [ { "setting": "outpatient", "gross_charge": 51000.0, "discounted_cash": 25500.0, "minimum": 21522.0, "maximum": 26520.0, "additional_generic_notes": "Zero final payments for the item or service in the 15 months prior to posting the file.", "payers_information": [ { "payer_name": "AETNA", "plan_name": "AETNA ALL OTHER PLANS", "methodology": "percent of total billed charges", "standard_charge_dollar": 26520.0, "standard_charge_percentage": 52.0, "median_amount": 29521.8, "10th_percentile": 24684.0, "90th_percentile": 29521.8, "count": "1 through 10" }, { "payer_name": "AETNA", "plan_name": "AETNA ALL OTHER PLANS", "methodology": "percent of total billed charges", "standard_charge_dollar": 26520.0, "standard_charge_percentage": 52.0, "count": "0", "additional_payer_notes": "Zero final payments for the item or service in the 15 months prior to posting the file." }, { "payer_name": "MERITAIN HEALTH", "plan_name": "AETNA ALL OTHER PLANS", "methodology": "percent of total billed charges", "standard_charge_dollar": 26520.0, "standard_charge_percentage": 52.0, "median_amount": 30738.0, "10th_percentile": 30738.0, "90th_percentile": 30738.0, "count": "1 through 10" }, { "payer_name": "BLUE SHIELD OUT OF STATE", "plan_name": "STANFORD HEALTHCARE ALLIANCE PLAN", "methodology": "percent of total billed charges", "standard_charge_dollar": 24780.9, "standard_charge_percentage": 48.59, "median_amount": 19521.66, "10th_percentile": 19521.66, "90th_percentile": 19521.66, "count": "1 through 10" }, { "payer_name": "BLUE SHIELD", "plan_name": "STANFORD HEALTHCARE ALLIANCE PLAN", "methodology": "percent of total billed charges", "standard_charge_dollar": 24780.9, "standard_charge_percentage": 48.59, "count": "0", "additional_payer_notes": "Zero final payments for the item or service in the 15 months prior to posting the file." }, { "payer_name": "BLUE SHIELD", "plan_name": "STANFORD HEALTHCARE ALLIANCE PLAN", "methodology": "percent of total billed charges", "standard_charge_dollar": 24780.9, "standard_charge_percentage": 48.59, "count": "0", "additional_payer_notes": "Zero final payments for the item or service in the 15 months prior to posting the file." }, { "payer_name": "BLUE SHIELD", "plan_name": "STANFORD HEALTHCARE ALLIANCE PLAN", "methodology": "percent of total billed charges", "standard_charge_dollar": 24780.9, "standard_charge_percentage": 48.59, "count": "0", "additional_payer_notes": "Zero final payments for the item or service in the 15 months prior to posting the file." }, { "payer_name": "CIGNA", "plan_name": "CIGNA COM ALT HMO PLAN", "methodology": "percent of total billed charges", "standard_charge_dollar": 21522.0, "standard_charge_percentage": 42.2, "count": "0", "additional_payer_notes": "Zero final payments for the item or service in the 15 months prior to posting the file." }, { "payer_name": "CIGNA", "plan_name": "CIGNA COM ALT HMO PLAN", "methodology": "percent of total billed charges", "standard_charge_dollar": 21522.0, "standard_charge_percentage": 42.2, "count": "0", "additional_payer_notes": "Zero final payments for the item or service in the 15 months prior to posting the file." } ] } ] }, { "description": "HC Impl Cochlear Gp111", "code_information": [ { "code": "PX-2120091111", "type": "CDM" }, { "code": "L8614", "type": "HCPCS" }, { "code": "0278", "type": "RC" } ], "standard_charges": [ { "setting": "outpatient", "gross_charge": 51590.0, "discounted_cash": 25795.0, "minimum": 21770.98, "maximum": 26826.8, "additional_generic_notes": "Zero final payments for the item or service in the 15 months prior to posting the file.", "payers_information": [ { "payer_name": "AETNA", "plan_name": "AETNA ALL OTHER PLANS", "methodology": "percent of total billed charges", "standard_charge_dollar": 26826.8, "standard_charge_percentage": 52.0, "median_amount": 29521.8, "10th_percentile": 24684.0, "90th_percentile": 29521.8, "count": "1 through 10" }, { "payer_name": "AETNA", "plan_name": "AETNA ALL OTHER PLANS", "methodology": "percent of total billed charges", "standard_charge_dollar": 26826.8, "standard_charge_percentage": 52.0, "count": "0", "additional_payer_notes": "Zero final payments for the item or service in the 15 months prior to posting the file." }, { "payer_name": "MERITAIN HEALTH", "plan_name": "AETNA ALL OTHER PLANS", "methodology": "percent of total billed charges", "standard_charge_dollar": 26826.8, "standard_charge_percentage": 52.0, "median_amount": 30738.0, "10th_percentile": 30738.0, "90th_percentile": 30738.0, "count": "1 through 10" }, { "payer_name": "BLUE SHIELD OUT OF STATE", "plan_name": "STANFORD HEALTHCARE ALLIANCE PLAN", "methodology": "percent of total billed charges", "standard_charge_dollar": 25067.58, "standard_charge_percentage": 48.59, "median_amount": 19521.66, "10th_percentile": 19521.66, "90th_percentile": 19521.66, "count": "1 through 10" }, { "payer_name": "BLUE SHIELD", "plan_name": "STANFORD HEALTHCARE ALLIANCE PLAN", "methodology": "percent of total billed charges", "standard_charge_dollar": 25067.58, "standard_charge_percentage": 48.59, "count": "0", "additional_payer_notes": "Zero final payments for the item or service in the 15 months prior to posting the file." }, { "payer_name": "BLUE SHIELD", "plan_name": "STANFORD HEALTHCARE ALLIANCE PLAN", "methodology": "percent of total billed charges", "standard_charge_dollar": 25067.58, "standard_charge_percentage": 48.59, "count": "0", "additional_payer_notes": "Zero final payments for the item or service in the 15 months prior to posting the file." }, { "payer_name": "BLUE SHIELD", "plan_name": "STANFORD HEALTHCARE ALLIANCE PLAN", "methodology": "percent of total billed charges", "standard_charge_dollar": 25067.58, "standard_charge_percentage": 48.59, "count": "0", "additional_payer_notes": "Zero final payments for the item or service in the 15 months prior to posting the file." }, { "payer_name": "CIGNA", "plan_name": "CIGNA COM ALT HMO PLAN", "methodology": "percent of total billed charges", "standard_charge_dollar": 21770.98, "standard_charge_percentage": 42.2, "count": "0", "additional_payer_notes": "Zero final payments for the item or service in the 15 months prior to posting the file." }, { "payer_name": "CIGNA", "plan_name": "CIGNA COM ALT HMO PLAN", "methodology": "percent of total billed charges", "standard_charge_dollar": 21770.98, "standard_charge_percentage": 42.2, "count": "0", "additional_payer_notes": "Zero final payments for the item or service in the 15 months prior to posting the file." } ] } ] }, { "description": "HC Impl Cochlear Gp112", "code_information": [ { "code": "PX-2120091112", "type": "CDM" }, { "code": "L8614", "type": "HCPCS" }, { "code": "0278", "type": "RC" } ], "standard_charges": [ { "setting": "outpatient", "gross_charge": 53120.0, "discounted_cash": 26560.0, "minimum": 22416.64, "maximum": 27622.4, "additional_generic_notes": "Zero final payments for the item or service in the 15 months prior to posting the file.", "payers_information": [ { "payer_name": "AETNA", "plan_name": "AETNA ALL OTHER PLANS", "methodology": "percent of total billed charges", "standard_charge_dollar": 27622.4, "standard_charge_percentage": 52.0, "median_amount": 29521.8, "10th_percentile": 24684.0, "90th_percentile": 29521.8, "count": "1 through 10" }, { "payer_name": "AETNA", "plan_name": "AETNA ALL OTHER PLANS", "methodology": "percent of total billed charges", "standard_charge_dollar": 27622.4, "standard_charge_percentage": 52.0, "count": "0", "additional_payer_notes": "Zero final payments for the item or service in the 15 months prior to posting the file." }, { "payer_name": "MERITAIN HEALTH", "plan_name": "AETNA ALL OTHER PLANS", "methodology": "percent of total billed charges", "standard_charge_dollar": 27622.4, "standard_charge_percentage": 52.0, "median_amount": 30738.0, "10th_percentile": 30738.0, "90th_percentile": 30738.0, "count": "1 through 10" }, { "payer_name": "BLUE SHIELD OUT OF STATE", "plan_name": "STANFORD HEALTHCARE ALLIANCE PLAN", "methodology": "percent of total billed charges", "standard_charge_dollar": 25811.01, "standard_charge_percentage": 48.59, "median_amount": 19521.66, "10th_percentile": 19521.66, "90th_percentile": 19521.66, "count": "1 through 10" }, { "payer_name": "BLUE SHIELD", "plan_name": "STANFORD HEALTHCARE ALLIANCE PLAN", "methodology": "percent of total billed charges", "standard_charge_dollar": 25811.01, "standard_charge_percentage": 48.59, "count": "0", "additional_payer_notes": "Zero final payments for the item or service in the 15 months prior to posting the file." }, { "payer_name": "BLUE SHIELD", "plan_name": "STANFORD HEALTHCARE ALLIANCE PLAN", "methodology": "percent of total billed charges", "standard_charge_dollar": 25811.01, "standard_charge_percentage": 48.59, "count": "0", "additional_payer_notes": "Zero final payments for the item or service in the 15 months prior to posting the file." }, { "payer_name": "BLUE SHIELD", "plan_name": "STANFORD HEALTHCARE ALLIANCE PLAN", "methodology": "percent of total billed charges", "standard_charge_dollar": 25811.01, "standard_charge_percentage": 48.59, "count": "0", "additional_payer_notes": "Zero final payments for the item or service in the 15 months prior to posting the file." }, { "payer_name": "CIGNA", "plan_name": "CIGNA COM ALT HMO PLAN", "methodology": "percent of total billed charges", "standard_charge_dollar": 22416.64, "standard_charge_percentage": 42.2, "count": "0", "additional_payer_notes": "Zero final payments for the item or service in the 15 months prior to posting the file." }, { "payer_name": "CIGNA", "plan_name": "CIGNA COM ALT HMO PLAN", "methodology": "percent of total billed charges", "standard_charge_dollar": 22416.64, "standard_charge_percentage": 42.2, "count": "0", "additional_payer_notes": "Zero final payments for the item or service in the 15 months prior to posting the file." } ] } ] }, { "description": "HC Impl Cochlear Gp113", "code_information": [ { "code": "PX-2120091113", "type": "CDM" }, { "code": "L8614", "type": "HCPCS" }, { "code": "0278", "type": "RC" } ], "standard_charges": [ { "setting": "outpatient", "gross_charge": 59400.0, "discounted_cash": 29700.0, "minimum": 25066.8, "maximum": 30888.0, "additional_generic_notes": "Zero final payments for the item or service in the 15 months prior to posting the file.", "payers_information": [ { "payer_name": "AETNA", "plan_name": "AETNA ALL OTHER PLANS", "methodology": "percent of total billed charges", "standard_charge_dollar": 30888.0, "standard_charge_percentage": 52.0, "median_amount": 29521.8, "10th_percentile": 24684.0, "90th_percentile": 29521.8, "count": "1 through 10" }, { "payer_name": "AETNA", "plan_name": "AETNA ALL OTHER PLANS", "methodology": "percent of total billed charges", "standard_charge_dollar": 30888.0, "standard_charge_percentage": 52.0, "count": "0", "additional_payer_notes": "Zero final payments for the item or service in the 15 months prior to posting the file." }, { "payer_name": "MERITAIN HEALTH", "plan_name": "AETNA ALL OTHER PLANS", "methodology": "percent of total billed charges", "standard_charge_dollar": 30888.0, "standard_charge_percentage": 52.0, "median_amount": 30738.0, "10th_percentile": 30738.0, "90th_percentile": 30738.0, "count": "1 through 10" }, { "payer_name": "BLUE SHIELD OUT OF STATE", "plan_name": "STANFORD HEALTHCARE ALLIANCE PLAN", "methodology": "percent of total billed charges", "standard_charge_dollar": 28862.46, "standard_charge_percentage": 48.59, "median_amount": 19521.66, "10th_percentile": 19521.66, "90th_percentile": 19521.66, "count": "1 through 10" }, { "payer_name": "BLUE SHIELD", "plan_name": "STANFORD HEALTHCARE ALLIANCE PLAN", "methodology": "percent of total billed charges", "standard_charge_dollar": 28862.46, "standard_charge_percentage": 48.59, "count": "0", "additional_payer_notes": "Zero final payments for the item or service in the 15 months prior to posting the file." }, { "payer_name": "BLUE SHIELD", "plan_name": "STANFORD HEALTHCARE ALLIANCE PLAN", "methodology": "percent of total billed charges", "standard_charge_dollar": 28862.46, "standard_charge_percentage": 48.59, "count": "0", "additional_payer_notes": "Zero final payments for the item or service in the 15 months prior to posting the file." }, { "payer_name": "BLUE SHIELD", "plan_name": "STANFORD HEALTHCARE ALLIANCE PLAN", "methodology": "percent of total billed charges", "standard_charge_dollar": 28862.46, "standard_charge_percentage": 48.59, "count": "0", "additional_payer_notes": "Zero final payments for the item or service in the 15 months prior to posting the file." }, { "payer_name": "CIGNA", "plan_name": "CIGNA COM ALT HMO PLAN", "methodology": "percent of total billed charges", "standard_charge_dollar": 25066.8, "standard_charge_percentage": 42.2, "count": "0", "additional_payer_notes": "Zero final payments for the item or service in the 15 months prior to posting the file." }, { "payer_name": "CIGNA", "plan_name": "CIGNA COM ALT HMO PLAN", "methodology": "percent of total billed charges", "standard_charge_dollar": 25066.8, "standard_charge_percentage": 42.2, "count": "0", "additional_payer_notes": "Zero final payments for the item or service in the 15 months prior to posting the file." } ] } ] }, { "description": "HC Impl Cochlear Gp114", "code_information": [ { "code": "PX-2120091114", "type": "CDM" }, { "code": "L8614", "type": "HCPCS" }, { "code": "0278", "type": "RC" } ], "standard_charges": [ { "setting": "outpatient", "gross_charge": 65400.0, "discounted_cash": 32700.0, "minimum": 27598.8, "maximum": 34008.0, "additional_generic_notes": "Zero final payments for the item or service in the 15 months prior to posting the file.", "payers_information": [ { "payer_name": "AETNA", "plan_name": "AETNA ALL OTHER PLANS", "methodology": "percent of total billed charges", "standard_charge_dollar": 34008.0, "standard_charge_percentage": 52.0, "median_amount": 29521.8, "10th_percentile": 24684.0, "90th_percentile": 29521.8, "count": "1 through 10" }, { "payer_name": "AETNA", "plan_name": "AETNA ALL OTHER PLANS", "methodology": "percent of total billed charges", "standard_charge_dollar": 34008.0, "standard_charge_percentage": 52.0, "count": "0", "additional_payer_notes": "Zero final payments for the item or service in the 15 months prior to posting the file." }, { "payer_name": "MERITAIN HEALTH", "plan_name": "AETNA ALL OTHER PLANS", "methodology": "percent of total billed charges", "standard_charge_dollar": 34008.0, "standard_charge_percentage": 52.0, "median_amount": 30738.0, "10th_percentile": 30738.0, "90th_percentile": 30738.0, "count": "1 through 10" }, { "payer_name": "BLUE SHIELD OUT OF STATE", "plan_name": "STANFORD HEALTHCARE ALLIANCE PLAN", "methodology": "percent of total billed charges", "standard_charge_dollar": 31777.86, "standard_charge_percentage": 48.59, "median_amount": 19521.66, "10th_percentile": 19521.66, "90th_percentile": 19521.66, "count": "1 through 10" }, { "payer_name": "BLUE SHIELD", "plan_name": "STANFORD HEALTHCARE ALLIANCE PLAN", "methodology": "percent of total billed charges", "standard_charge_dollar": 31777.86, "standard_charge_percentage": 48.59, "count": "0", "additional_payer_notes": "Zero final payments for the item or service in the 15 months prior to posting the file." }, { "payer_name": "BLUE SHIELD", "plan_name": "STANFORD HEALTHCARE ALLIANCE PLAN", "methodology": "percent of total billed charges", "standard_charge_dollar": 31777.86, "standard_charge_percentage": 48.59, "count": "0", "additional_payer_notes": "Zero final payments for the item or service in the 15 months prior to posting the file." }, { "payer_name": "BLUE SHIELD", "plan_name": "STANFORD HEALTHCARE ALLIANCE PLAN", "methodology": "percent of total billed charges", "standard_charge_dollar": 31777.86, "standard_charge_percentage": 48.59, "count": "0", "additional_payer_notes": "Zero final payments for the item or service in the 15 months prior to posting the file." }, { "payer_name": "CIGNA", "plan_name": "CIGNA COM ALT HMO PLAN", "methodology": "percent of total billed charges", "standard_charge_dollar": 27598.8, "standard_charge_percentage": 42.2, "count": "0", "additional_payer_notes": "Zero final payments for the item or service in the 15 months prior to posting the file." }, { "payer_name": "CIGNA", "plan_name": "CIGNA COM ALT HMO PLAN", "methodology": "percent of total billed charges", "standard_charge_dollar": 27598.8, "standard_charge_percentage": 42.2, "count": "0", "additional_payer_notes": "Zero final payments for the item or service in the 15 months prior to posting the file." } ] } ] }, { "description": "HC Impl Cochlear Gp115", "code_information": [ { "code": "PX-2120091115", "type": "CDM" }, { "code": "L8614", "type": "HCPCS" }, { "code": "0278", "type": "RC" } ], "standard_charges": [ { "setting": "outpatient", "gross_charge": 71500.0, "discounted_cash": 35750.0, "minimum": 30173.0, "maximum": 37180.0, "additional_generic_notes": "Zero final payments for the item or service in the 15 months prior to posting the file.", "payers_information": [ { "payer_name": "AETNA", "plan_name": "AETNA ALL OTHER PLANS", "methodology": "percent of total billed charges", "standard_charge_dollar": 37180.0, "standard_charge_percentage": 52.0, "median_amount": 29521.8, "10th_percentile": 24684.0, "90th_percentile": 29521.8, "count": "1 through 10" }, { "payer_name": "AETNA", "plan_name": "AETNA ALL OTHER PLANS", "methodology": "percent of total billed charges", "standard_charge_dollar": 37180.0, "standard_charge_percentage": 52.0, "count": "0", "additional_payer_notes": "Zero final payments for the item or service in the 15 months prior to posting the file." }, { "payer_name": "MERITAIN HEALTH", "plan_name": "AETNA ALL OTHER PLANS", "methodology": "percent of total billed charges", "standard_charge_dollar": 37180.0, "standard_charge_percentage": 52.0, "median_amount": 30738.0, "10th_percentile": 30738.0, "90th_percentile": 30738.0, "count": "1 through 10" }, { "payer_name": "BLUE SHIELD OUT OF STATE", "plan_name": "STANFORD HEALTHCARE ALLIANCE PLAN", "methodology": "percent of total billed charges", "standard_charge_dollar": 34741.85, "standard_charge_percentage": 48.59, "median_amount": 19521.66, "10th_percentile": 19521.66, "90th_percentile": 19521.66, "count": "1 through 10" }, { "payer_name": "BLUE SHIELD", "plan_name": "STANFORD HEALTHCARE ALLIANCE PLAN", "methodology": "percent of total billed charges", "standard_charge_dollar": 34741.85, "standard_charge_percentage": 48.59, "count": "0", "additional_payer_notes": "Zero final payments for the item or service in the 15 months prior to posting the file." }, { "payer_name": "BLUE SHIELD", "plan_name": "STANFORD HEALTHCARE ALLIANCE PLAN", "methodology": "percent of total billed charges", "standard_charge_dollar": 34741.85, "standard_charge_percentage": 48.59, "count": "0", "additional_payer_notes": "Zero final payments for the item or service in the 15 months prior to posting the file." }, { "payer_name": "BLUE SHIELD", "plan_name": "STANFORD HEALTHCARE ALLIANCE PLAN", "methodology": "percent of total billed charges", "standard_charge_dollar": 34741.85, "standard_charge_percentage": 48.59, "count": "0", "additional_payer_notes": "Zero final payments for the item or service in the 15 months prior to posting the file." }, { "payer_name": "CIGNA", "plan_name": "CIGNA COM ALT HMO PLAN", "methodology": "percent of total billed charges", "standard_charge_dollar": 30173.0, "standard_charge_percentage": 42.2, "count": "0", "additional_payer_notes": "Zero final payments for the item or service in the 15 months prior to posting the file." }, { "payer_name": "CIGNA", "plan_name": "CIGNA COM ALT HMO PLAN", "methodology": "percent of total billed charges", "standard_charge_dollar": 30173.0, "standard_charge_percentage": 42.2, "count": "0", "additional_payer_notes": "Zero final payments for the item or service in the 15 months prior to posting the file." } ] } ] }, { "description": "HC Impl Cochlear Gp116", "code_information": [ { "code": "PX-2120091116", "type": "CDM" }, { "code": "L8614", "type": "HCPCS" }, { "code": "0278", "type": "RC" } ], "standard_charges": [ { "setting": "outpatient", "gross_charge": 72000.0, "discounted_cash": 36000.0, "minimum": 30384.0, "maximum": 37440.0, "additional_generic_notes": "Zero final payments for the item or service in the 15 months prior to posting the file.", "payers_information": [ { "payer_name": "AETNA", "plan_name": "AETNA ALL OTHER PLANS", "methodology": "percent of total billed charges", "standard_charge_dollar": 37440.0, "standard_charge_percentage": 52.0, "median_amount": 29521.8, "10th_percentile": 24684.0, "90th_percentile": 29521.8, "count": "1 through 10" }, { "payer_name": "AETNA", "plan_name": "AETNA ALL OTHER PLANS", "methodology": "percent of total billed charges", "standard_charge_dollar": 37440.0, "standard_charge_percentage": 52.0, "count": "0", "additional_payer_notes": "Zero final payments for the item or service in the 15 months prior to posting the file." }, { "payer_name": "MERITAIN HEALTH", "plan_name": "AETNA ALL OTHER PLANS", "methodology": "percent of total billed charges", "standard_charge_dollar": 37440.0, "standard_charge_percentage": 52.0, "median_amount": 30738.0, "10th_percentile": 30738.0, "90th_percentile": 30738.0, "count": "1 through 10" }, { "payer_name": "BLUE SHIELD OUT OF STATE", "plan_name": "STANFORD HEALTHCARE ALLIANCE PLAN", "methodology": "percent of total billed charges", "standard_charge_dollar": 34984.8, "standard_charge_percentage": 48.59, "median_amount": 19521.66, "10th_percentile": 19521.66, "90th_percentile": 19521.66, "count": "1 through 10" }, { "payer_name": "BLUE SHIELD", "plan_name": "STANFORD HEALTHCARE ALLIANCE PLAN", "methodology": "percent of total billed charges", "standard_charge_dollar": 34984.8, "standard_charge_percentage": 48.59, "count": "0", "additional_payer_notes": "Zero final payments for the item or service in the 15 months prior to posting the file." }, { "payer_name": "BLUE SHIELD", "plan_name": "STANFORD HEALTHCARE ALLIANCE PLAN", "methodology": "percent of total billed charges", "standard_charge_dollar": 34984.8, "standard_charge_percentage": 48.59, "count": "0", "additional_payer_notes": "Zero final payments for the item or service in the 15 months prior to posting the file." }, { "payer_name": "BLUE SHIELD", "plan_name": "STANFORD HEALTHCARE ALLIANCE PLAN", "methodology": "percent of total billed charges", "standard_charge_dollar": 34984.8, "standard_charge_percentage": 48.59, "count": "0", "additional_payer_notes": "Zero final payments for the item or service in the 15 months prior to posting the file." }, { "payer_name": "CIGNA", "plan_name": "CIGNA COM ALT HMO PLAN", "methodology": "percent of total billed charges", "standard_charge_dollar": 30384.0, "standard_charge_percentage": 42.2, "count": "0", "additional_payer_notes": "Zero final payments for the item or service in the 15 months prior to posting the file." }, { "payer_name": "CIGNA", "plan_name": "CIGNA COM ALT HMO PLAN", "methodology": "percent of total billed charges", "standard_charge_dollar": 30384.0, "standard_charge_percentage": 42.2, "count": "0", "additional_payer_notes": "Zero final payments for the item or service in the 15 months prior to posting the file." } ] } ] }, { "description": "HC Impl Cochlear Gp117", "code_information": [ { "code": "PX-2120091117", "type": "CDM" }, { "code": "L8614", "type": "HCPCS" }, { "code": "0278", "type": "RC" } ], "standard_charges": [ { "setting": "outpatient", "gross_charge": 78000.0, "discounted_cash": 39000.0, "minimum": 32916.0, "maximum": 40560.0, "additional_generic_notes": "Zero final payments for the item or service in the 15 months prior to posting the file.", "payers_information": [ { "payer_name": "AETNA", "plan_name": "AETNA ALL OTHER PLANS", "methodology": "percent of total billed charges", "standard_charge_dollar": 40560.0, "standard_charge_percentage": 52.0, "median_amount": 29521.8, "10th_percentile": 24684.0, "90th_percentile": 29521.8, "count": "1 through 10" }, { "payer_name": "AETNA", "plan_name": "AETNA ALL OTHER PLANS", "methodology": "percent of total billed charges", "standard_charge_dollar": 40560.0, "standard_charge_percentage": 52.0, "count": "0", "additional_payer_notes": "Zero final payments for the item or service in the 15 months prior to posting the file." }, { "payer_name": "MERITAIN HEALTH", "plan_name": "AETNA ALL OTHER PLANS", "methodology": "percent of total billed charges", "standard_charge_dollar": 40560.0, "standard_charge_percentage": 52.0, "median_amount": 30738.0, "10th_percentile": 30738.0, "90th_percentile": 30738.0, "count": "1 through 10" }, { "payer_name": "BLUE SHIELD OUT OF STATE", "plan_name": "STANFORD HEALTHCARE ALLIANCE PLAN", "methodology": "percent of total billed charges", "standard_charge_dollar": 37900.2, "standard_charge_percentage": 48.59, "median_amount": 19521.66, "10th_percentile": 19521.66, "90th_percentile": 19521.66, "count": "1 through 10" }, { "payer_name": "BLUE SHIELD", "plan_name": "STANFORD HEALTHCARE ALLIANCE PLAN", "methodology": "percent of total billed charges", "standard_charge_dollar": 37900.2, "standard_charge_percentage": 48.59, "count": "0", "additional_payer_notes": "Zero final payments for the item or service in the 15 months prior to posting the file." }, { "payer_name": "BLUE SHIELD", "plan_name": "STANFORD HEALTHCARE ALLIANCE PLAN", "methodology": "percent of total billed charges", "standard_charge_dollar": 37900.2, "standard_charge_percentage": 48.59, "count": "0", "additional_payer_notes": "Zero final payments for the item or service in the 15 months prior to posting the file." }, { "payer_name": "BLUE SHIELD", "plan_name": "STANFORD HEALTHCARE ALLIANCE PLAN", "methodology": "percent of total billed charges", "standard_charge_dollar": 37900.2, "standard_charge_percentage": 48.59, "count": "0", "additional_payer_notes": "Zero final payments for the item or service in the 15 months prior to posting the file." }, { "payer_name": "CIGNA", "plan_name": "CIGNA COM ALT HMO PLAN", "methodology": "percent of total billed charges", "standard_charge_dollar": 32916.0, "standard_charge_percentage": 42.2, "count": "0", "additional_payer_notes": "Zero final payments for the item or service in the 15 months prior to posting the file." }, { "payer_name": "CIGNA", "plan_name": "CIGNA COM ALT HMO PLAN", "methodology": "percent of total billed charges", "standard_charge_dollar": 32916.0, "standard_charge_percentage": 42.2, "count": "0", "additional_payer_notes": "Zero final payments for the item or service in the 15 months prior to posting the file." } ] } ] }, { "description": "HC Impl Cochlear Gp118", "code_information": [ { "code": "PX-2120091118", "type": "CDM" }, { "code": "L8614", "type": "HCPCS" }, { "code": "0278", "type": "RC" } ], "standard_charges": [ { "setting": "outpatient", "gross_charge": 84000.0, "discounted_cash": 42000.0, "minimum": 35448.0, "maximum": 43680.0, "additional_generic_notes": "Zero final payments for the item or service in the 15 months prior to posting the file.", "payers_information": [ { "payer_name": "AETNA", "plan_name": "AETNA ALL OTHER PLANS", "methodology": "percent of total billed charges", "standard_charge_dollar": 43680.0, "standard_charge_percentage": 52.0, "median_amount": 29521.8, "10th_percentile": 24684.0, "90th_percentile": 29521.8, "count": "1 through 10" }, { "payer_name": "AETNA", "plan_name": "AETNA ALL OTHER PLANS", "methodology": "percent of total billed charges", "standard_charge_dollar": 43680.0, "standard_charge_percentage": 52.0, "count": "0", "additional_payer_notes": "Zero final payments for the item or service in the 15 months prior to posting the file." }, { "payer_name": "MERITAIN HEALTH", "plan_name": "AETNA ALL OTHER PLANS", "methodology": "percent of total billed charges", "standard_charge_dollar": 43680.0, "standard_charge_percentage": 52.0, "median_amount": 30738.0, "10th_percentile": 30738.0, "90th_percentile": 30738.0, "count": "1 through 10" }, { "payer_name": "BLUE SHIELD OUT OF STATE", "plan_name": "STANFORD HEALTHCARE ALLIANCE PLAN", "methodology": "percent of total billed charges", "standard_charge_dollar": 40815.6, "standard_charge_percentage": 48.59, "median_amount": 19521.66, "10th_percentile": 19521.66, "90th_percentile": 19521.66, "count": "1 through 10" }, { "payer_name": "BLUE SHIELD", "plan_name": "STANFORD HEALTHCARE ALLIANCE PLAN", "methodology": "percent of total billed charges", "standard_charge_dollar": 40815.6, "standard_charge_percentage": 48.59, "count": "0", "additional_payer_notes": "Zero final payments for the item or service in the 15 months prior to posting the file." }, { "payer_name": "BLUE SHIELD", "plan_name": "STANFORD HEALTHCARE ALLIANCE PLAN", "methodology": "percent of total billed charges", "standard_charge_dollar": 40815.6, "standard_charge_percentage": 48.59, "count": "0", "additional_payer_notes": "Zero final payments for the item or service in the 15 months prior to posting the file." }, { "payer_name": "BLUE SHIELD", "plan_name": "STANFORD HEALTHCARE ALLIANCE PLAN", "methodology": "percent of total billed charges", "standard_charge_dollar": 40815.6, "standard_charge_percentage": 48.59, "count": "0", "additional_payer_notes": "Zero final payments for the item or service in the 15 months prior to posting the file." }, { "payer_name": "CIGNA", "plan_name": "CIGNA COM ALT HMO PLAN", "methodology": "percent of total billed charges", "standard_charge_dollar": 35448.0, "standard_charge_percentage": 42.2, "count": "0", "additional_payer_notes": "Zero final payments for the item or service in the 15 months prior to posting the file." }, { "payer_name": "CIGNA", "plan_name": "CIGNA COM ALT HMO PLAN", "methodology": "percent of total billed charges", "standard_charge_dollar": 35448.0, "standard_charge_percentage": 42.2, "count": "0", "additional_payer_notes": "Zero final payments for the item or service in the 15 months prior to posting the file." } ] } ] }, { "description": "HC Impl Cochlear Gp121", "code_information": [ { "code": "PX-2120091121", "type": "CDM" }, { "code": "L8614", "type": "HCPCS" }, { "code": "0278", "type": "RC" } ], "standard_charges": [ { "setting": "outpatient", "gross_charge": 102000.0, "discounted_cash": 51000.0, "minimum": 43044.0, "maximum": 53040.0, "additional_generic_notes": "Zero final payments for the item or service in the 15 months prior to posting the file.", "payers_information": [ { "payer_name": "AETNA", "plan_name": "AETNA ALL OTHER PLANS", "methodology": "percent of total billed charges", "standard_charge_dollar": 53040.0, "standard_charge_percentage": 52.0, "median_amount": 29521.8, "10th_percentile": 24684.0, "90th_percentile": 29521.8, "count": "1 through 10" }, { "payer_name": "AETNA", "plan_name": "AETNA ALL OTHER PLANS", "methodology": "percent of total billed charges", "standard_charge_dollar": 53040.0, "standard_charge_percentage": 52.0, "count": "0", "additional_payer_notes": "Zero final payments for the item or service in the 15 months prior to posting the file." }, { "payer_name": "MERITAIN HEALTH", "plan_name": "AETNA ALL OTHER PLANS", "methodology": "percent of total billed charges", "standard_charge_dollar": 53040.0, "standard_charge_percentage": 52.0, "median_amount": 30738.0, "10th_percentile": 30738.0, "90th_percentile": 30738.0, "count": "1 through 10" }, { "payer_name": "BLUE SHIELD OUT OF STATE", "plan_name": "STANFORD HEALTHCARE ALLIANCE PLAN", "methodology": "percent of total billed charges", "standard_charge_dollar": 49561.8, "standard_charge_percentage": 48.59, "median_amount": 19521.66, "10th_percentile": 19521.66, "90th_percentile": 19521.66, "count": "1 through 10" }, { "payer_name": "BLUE SHIELD", "plan_name": "STANFORD HEALTHCARE ALLIANCE PLAN", "methodology": "percent of total billed charges", "standard_charge_dollar": 49561.8, "standard_charge_percentage": 48.59, "count": "0", "additional_payer_notes": "Zero final payments for the item or service in the 15 months prior to posting the file." }, { "payer_name": "BLUE SHIELD", "plan_name": "STANFORD HEALTHCARE ALLIANCE PLAN", "methodology": "percent of total billed charges", "standard_charge_dollar": 49561.8, "standard_charge_percentage": 48.59, "count": "0", "additional_payer_notes": "Zero final payments for the item or service in the 15 months prior to posting the file." }, { "payer_name": "BLUE SHIELD", "plan_name": "STANFORD HEALTHCARE ALLIANCE PLAN", "methodology": "percent of total billed charges", "standard_charge_dollar": 49561.8, "standard_charge_percentage": 48.59, "count": "0", "additional_payer_notes": "Zero final payments for the item or service in the 15 months prior to posting the file." }, { "payer_name": "CIGNA", "plan_name": "CIGNA COM ALT HMO PLAN", "methodology": "percent of total billed charges", "standard_charge_dollar": 43044.0, "standard_charge_percentage": 42.2, "count": "0", "additional_payer_notes": "Zero final payments for the item or service in the 15 months prior to posting the file." }, { "payer_name": "CIGNA", "plan_name": "CIGNA COM ALT HMO PLAN", "methodology": "percent of total billed charges", "standard_charge_dollar": 43044.0, "standard_charge_percentage": 42.2, "count": "0", "additional_payer_notes": "Zero final payments for the item or service in the 15 months prior to posting the file." } ] } ] }, { "description": "Hc Bolt Anchor Gp010", "code_information": [ { "code": "PX-2120094010", "type": "CDM" }, { "code": "99999", "type": "CPT" }, { "code": "0272", "type": "RC" } ], "standard_charges": [ { "setting": "outpatient", "gross_charge": 665.0, "discounted_cash": 332.5, "minimum": 280.63, "maximum": 345.8, "additional_generic_notes": "Zero final payments for the item or service in the 15 months prior to posting the file.", "payers_information": [ { "payer_name": "AETNA", "plan_name": "AETNA ALL OTHER PLANS", "methodology": "percent of total billed charges", "standard_charge_dollar": 345.8, "standard_charge_percentage": 52.0, "count": "0", "additional_payer_notes": "Zero final payments for the item or service in the 15 months prior to posting the file." }, { "payer_name": "AETNA", "plan_name": "AETNA ALL OTHER PLANS", "methodology": "percent of total billed charges", "standard_charge_dollar": 345.8, "standard_charge_percentage": 52.0, "count": "0", "additional_payer_notes": "Zero final payments for the item or service in the 15 months prior to posting the file." }, { "payer_name": "MERITAIN HEALTH", "plan_name": "AETNA ALL OTHER PLANS", "methodology": "percent of total billed charges", "standard_charge_dollar": 345.8, "standard_charge_percentage": 52.0, "count": "0", "additional_payer_notes": "Zero final payments for the item or service in the 15 months prior to posting the file." }, { "payer_name": "BLUE SHIELD OUT OF STATE", "plan_name": "STANFORD HEALTHCARE ALLIANCE PLAN", "methodology": "percent of total billed charges", "standard_charge_dollar": 323.12, "standard_charge_percentage": 48.59, "count": "0", "additional_payer_notes": "Zero final payments for the item or service in the 15 months prior to posting the file." }, { "payer_name": "BLUE SHIELD", "plan_name": "STANFORD HEALTHCARE ALLIANCE PLAN", "methodology": "percent of total billed charges", "standard_charge_dollar": 323.12, "standard_charge_percentage": 48.59, "count": "0", "additional_payer_notes": "Zero final payments for the item or service in the 15 months prior to posting the file." }, { "payer_name": "BLUE SHIELD", "plan_name": "STANFORD HEALTHCARE ALLIANCE PLAN", "methodology": "percent of total billed charges", "standard_charge_dollar": 323.12, "standard_charge_percentage": 48.59, "count": "0", "additional_payer_notes": "Zero final payments for the item or service in the 15 months prior to posting the file." }, { "payer_name": "CIGNA", "plan_name": "CIGNA COM ALT HMO PLAN", "methodology": "percent of total billed charges", "standard_charge_dollar": 280.63, "standard_charge_percentage": 42.2, "count": "0", "additional_payer_notes": "Zero final payments for the item or service in the 15 months prior to posting the file." }, { "payer_name": "CIGNA", "plan_name": "CIGNA COM ALT HMO PLAN", "methodology": "percent of total billed charges", "standard_charge_dollar": 280.63, "standard_charge_percentage": 42.2, "count": "0", "additional_payer_notes": "Zero final payments for the item or service in the 15 months prior to posting the file." }, { "payer_name": "HEALTH NET", "plan_name": "HEALTHNET HMO, PPO, POS, EPO, CANOPY HEALTHNET HMO, OTHER-IN-NETWORK PLANS", "methodology": "per diem", "standard_charge_dollar": 8000.0, "standard_charge_algorithm": "Expected reimbursement is the lesser of Per diem ($8,000) for the length of stay and 70% of billed.", "count": "0", "additional_payer_notes": "Zero final payments for the item or service in the 15 months prior to posting the file." }, { "payer_name": "HEALTH NET", "plan_name": "HEALTHNET HMO, PPO, POS, EPO, CANOPY HEALTHNET HMO, OTHER-IN-NETWORK PLANS", "methodology": "per diem", "standard_charge_dollar": 8000.0, "standard_charge_algorithm": "Expected reimbursement is the lesser of Per diem ($8,000) for the length of stay and 70% of billed.", "count": "0", "additional_payer_notes": "Zero final payments for the item or service in the 15 months prior to posting the file." }, { "payer_name": "UNITED HEALTHCARE", "plan_name": "SUTTER SELECT & SUTTER HEALTH PLAN HMO PLANS", "methodology": "per diem", "standard_charge_dollar": 28538.0, "standard_charge_algorithm": "Per diem ($28,538).", "count": "0", "additional_payer_notes": "Zero final payments for the item or service in the 15 months prior to posting the file." }, { "payer_name": "UNITED HEALTHCARE", "plan_name": "SUTTER SELECT & SUTTER HEALTH PLAN HMO PLANS", "methodology": "per diem", "standard_charge_dollar": 28538.0, "standard_charge_algorithm": "Per diem ($28,538).", "count": "0", "additional_payer_notes": "Zero final payments for the item or service in the 15 months prior to posting the file." }, { "payer_name": "SUTTER", "plan_name": "SUTTER SELECT & SUTTER HEALTH PLAN HMO PLANS", "methodology": "per diem", "standard_charge_dollar": 28538.0, "standard_charge_algorithm": "Per diem ($28,538).", "count": "0", "additional_payer_notes": "Zero final payments for the item or service in the 15 months prior to posting the file." }, { "payer_name": "UNITED HEALTHCARE", "plan_name": "SUTTER SELECT & SUTTER HEALTH PLAN HMO PLANS", "methodology": "per diem", "standard_charge_dollar": 28538.0, "standard_charge_algorithm": "Per diem ($28,538).", "count": "0", "additional_payer_notes": "Zero final payments for the item or service in the 15 months prior to posting the file." }, { "payer_name": "UMR", "plan_name": "SUTTER SELECT & SUTTER HEALTH PLAN HMO PLANS", "methodology": "per diem", "standard_charge_dollar": 28538.0, "standard_charge_algorithm": "Per diem ($28,538).", "count": "0", "additional_payer_notes": "Zero final payments for the item or service in the 15 months prior to posting the file." } ] } ] }, { "description": "HC Bolt Anchor Gp012", "code_information": [ { "code": "PX-2120094012", "type": "CDM" }, { "code": "99999", "type": "CPT" }, { "code": "0272", "type": "RC" } ], "standard_charges": [ { "setting": "outpatient", "gross_charge": 810.0, "discounted_cash": 405.0, "minimum": 341.82, "maximum": 421.2, "additional_generic_notes": "Zero final payments for the item or service in the 15 months prior to posting the file.", "payers_information": [ { "payer_name": "AETNA", "plan_name": "AETNA ALL OTHER PLANS", "methodology": "percent of total billed charges", "standard_charge_dollar": 421.2, "standard_charge_percentage": 52.0, "count": "0", "additional_payer_notes": "Zero final payments for the item or service in the 15 months prior to posting the file." }, { "payer_name": "AETNA", "plan_name": "AETNA ALL OTHER PLANS", "methodology": "percent of total billed charges", "standard_charge_dollar": 421.2, "standard_charge_percentage": 52.0, "count": "0", "additional_payer_notes": "Zero final payments for the item or service in the 15 months prior to posting the file." }, { "payer_name": "MERITAIN HEALTH", "plan_name": "AETNA ALL OTHER PLANS", "methodology": "percent of total billed charges", "standard_charge_dollar": 421.2, "standard_charge_percentage": 52.0, "count": "0", "additional_payer_notes": "Zero final payments for the item or service in the 15 months prior to posting the file." }, { "payer_name": "BLUE SHIELD OUT OF STATE", "plan_name": "STANFORD HEALTHCARE ALLIANCE PLAN", "methodology": "percent of total billed charges", "standard_charge_dollar": 393.58, "standard_charge_percentage": 48.59, "count": "0", "additional_payer_notes": "Zero final payments for the item or service in the 15 months prior to posting the file." }, { "payer_name": "BLUE SHIELD", "plan_name": "STANFORD HEALTHCARE ALLIANCE PLAN", "methodology": "percent of total billed charges", "standard_charge_dollar": 393.58, "standard_charge_percentage": 48.59, "count": "0", "additional_payer_notes": "Zero final payments for the item or service in the 15 months prior to posting the file." }, { "payer_name": "BLUE SHIELD", "plan_name": "STANFORD HEALTHCARE ALLIANCE PLAN", "methodology": "percent of total billed charges", "standard_charge_dollar": 393.58, "standard_charge_percentage": 48.59, "count": "0", "additional_payer_notes": "Zero final payments for the item or service in the 15 months prior to posting the file." }, { "payer_name": "CIGNA", "plan_name": "CIGNA COM ALT HMO PLAN", "methodology": "percent of total billed charges", "standard_charge_dollar": 341.82, "standard_charge_percentage": 42.2, "count": "0", "additional_payer_notes": "Zero final payments for the item or service in the 15 months prior to posting the file." }, { "payer_name": "CIGNA", "plan_name": "CIGNA COM ALT HMO PLAN", "methodology": "percent of total billed charges", "standard_charge_dollar": 341.82, "standard_charge_percentage": 42.2, "count": "0", "additional_payer_notes": "Zero final payments for the item or service in the 15 months prior to posting the file." }, { "payer_name": "HEALTH NET", "plan_name": "HEALTHNET HMO, PPO, POS, EPO, CANOPY HEALTHNET HMO, OTHER-IN-NETWORK PLANS", "methodology": "per diem", "standard_charge_dollar": 8000.0, "standard_charge_algorithm": "Expected reimbursement is the lesser of Per diem ($8,000) for the length of stay and 70% of billed.", "count": "0", "additional_payer_notes": "Zero final payments for the item or service in the 15 months prior to posting the file." }, { "payer_name": "HEALTH NET", "plan_name": "HEALTHNET HMO, PPO, POS, EPO, CANOPY HEALTHNET HMO, OTHER-IN-NETWORK PLANS", "methodology": "per diem", "standard_charge_dollar": 8000.0, "standard_charge_algorithm": "Expected reimbursement is the lesser of Per diem ($8,000) for the length of stay and 70% of billed.", "count": "0", "additional_payer_notes": "Zero final payments for the item or service in the 15 months prior to posting the file." }, { "payer_name": "UNITED HEALTHCARE", "plan_name": "SUTTER SELECT & SUTTER HEALTH PLAN HMO PLANS", "methodology": "per diem", "standard_charge_dollar": 28538.0, "standard_charge_algorithm": "Per diem ($28,538).", "count": "0", "additional_payer_notes": "Zero final payments for the item or service in the 15 months prior to posting the file." }, { "payer_name": "UNITED HEALTHCARE", "plan_name": "SUTTER SELECT & SUTTER HEALTH PLAN HMO PLANS", "methodology": "per diem", "standard_charge_dollar": 28538.0, "standard_charge_algorithm": "Per diem ($28,538).", "count": "0", "additional_payer_notes": "Zero final payments for the item or service in the 15 months prior to posting the file." }, { "payer_name": "SUTTER", "plan_name": "SUTTER SELECT & SUTTER HEALTH PLAN HMO PLANS", "methodology": "per diem", "standard_charge_dollar": 28538.0, "standard_charge_algorithm": "Per diem ($28,538).", "count": "0", "additional_payer_notes": "Zero final payments for the item or service in the 15 months prior to posting the file." }, { "payer_name": "UNITED HEALTHCARE", "plan_name": "SUTTER SELECT & SUTTER HEALTH PLAN HMO PLANS", "methodology": "per diem", "standard_charge_dollar": 28538.0, "standard_charge_algorithm": "Per diem ($28,538).", "count": "0", "additional_payer_notes": "Zero final payments for the item or service in the 15 months prior to posting the file." }, { "payer_name": "UMR", "plan_name": "SUTTER SELECT & SUTTER HEALTH PLAN HMO PLANS", "methodology": "per diem", "standard_charge_dollar": 28538.0, "standard_charge_algorithm": "Per diem ($28,538).", "count": "0", "additional_payer_notes": "Zero final payments for the item or service in the 15 months prior to posting the file." } ] } ] }, { "description": "HC Bolt Anchor Gp014", "code_information": [ { "code": "PX-2120094014", "type": "CDM" }, { "code": "99999", "type": "CPT" }, { "code": "0272", "type": "RC" } ], "standard_charges": [ { "setting": "outpatient", "gross_charge": 1080.0, "discounted_cash": 540.0, "minimum": 455.76, "maximum": 561.6, "additional_generic_notes": "Zero final payments for the item or service in the 15 months prior to posting the file.", "payers_information": [ { "payer_name": "AETNA", "plan_name": "AETNA ALL OTHER PLANS", "methodology": "percent of total billed charges", "standard_charge_dollar": 561.6, "standard_charge_percentage": 52.0, "count": "0", "additional_payer_notes": "Zero final payments for the item or service in the 15 months prior to posting the file." }, { "payer_name": "AETNA", "plan_name": "AETNA ALL OTHER PLANS", "methodology": "percent of total billed charges", "standard_charge_dollar": 561.6, "standard_charge_percentage": 52.0, "count": "0", "additional_payer_notes": "Zero final payments for the item or service in the 15 months prior to posting the file." }, { "payer_name": "MERITAIN HEALTH", "plan_name": "AETNA ALL OTHER PLANS", "methodology": "percent of total billed charges", "standard_charge_dollar": 561.6, "standard_charge_percentage": 52.0, "count": "0", "additional_payer_notes": "Zero final payments for the item or service in the 15 months prior to posting the file." }, { "payer_name": "BLUE SHIELD OUT OF STATE", "plan_name": "STANFORD HEALTHCARE ALLIANCE PLAN", "methodology": "percent of total billed charges", "standard_charge_dollar": 524.77, "standard_charge_percentage": 48.59, "count": "0", "additional_payer_notes": "Zero final payments for the item or service in the 15 months prior to posting the file." }, { "payer_name": "BLUE SHIELD", "plan_name": "STANFORD HEALTHCARE ALLIANCE PLAN", "methodology": "percent of total billed charges", "standard_charge_dollar": 524.77, "standard_charge_percentage": 48.59, "median_amount": 68.24, "10th_percentile": 13.6, "90th_percentile": 1043.06, "count": "30" }, { "payer_name": "BLUE SHIELD", "plan_name": "STANFORD HEALTHCARE ALLIANCE PLAN", "methodology": "percent of total billed charges", "standard_charge_dollar": 524.77, "standard_charge_percentage": 48.59, "count": "0", "additional_payer_notes": "Zero final payments for the item or service in the 15 months prior to posting the file." }, { "payer_name": "BLUE SHIELD", "plan_name": "STANFORD HEALTHCARE ALLIANCE PLAN", "methodology": "percent of total billed charges", "standard_charge_dollar": 524.77, "standard_charge_percentage": 48.59, "count": "0", "additional_payer_notes": "Zero final payments for the item or service in the 15 months prior to posting the file." }, { "payer_name": "CIGNA", "plan_name": "CIGNA COM ALT HMO PLAN", "methodology": "percent of total billed charges", "standard_charge_dollar": 455.76, "standard_charge_percentage": 42.2, "count": "0", "additional_payer_notes": "Zero final payments for the item or service in the 15 months prior to posting the file." }, { "payer_name": "CIGNA", "plan_name": "CIGNA COM ALT HMO PLAN", "methodology": "percent of total billed charges", "standard_charge_dollar": 455.76, "standard_charge_percentage": 42.2, "count": "0", "additional_payer_notes": "Zero final payments for the item or service in the 15 months prior to posting the file." }, { "payer_name": "HEALTH NET", "plan_name": "HEALTHNET HMO, PPO, POS, EPO, CANOPY HEALTHNET HMO, OTHER-IN-NETWORK PLANS", "methodology": "per diem", "standard_charge_dollar": 8000.0, "standard_charge_algorithm": "Expected reimbursement is the lesser of Per diem ($8,000) for the length of stay and 70% of billed.", "count": "0", "additional_payer_notes": "Zero final payments for the item or service in the 15 months prior to posting the file." }, { "payer_name": "HEALTH NET", "plan_name": "HEALTHNET HMO, PPO, POS, EPO, CANOPY HEALTHNET HMO, OTHER-IN-NETWORK PLANS", "methodology": "per diem", "standard_charge_dollar": 8000.0, "standard_charge_algorithm": "Expected reimbursement is the lesser of Per diem ($8,000) for the length of stay and 70% of billed.", "count": "0", "additional_payer_notes": "Zero final payments for the item or service in the 15 months prior to posting the file." }, { "payer_name": "UNITED HEALTHCARE", "plan_name": "SUTTER SELECT & SUTTER HEALTH PLAN HMO PLANS", "methodology": "per diem", "standard_charge_dollar": 28538.0, "standard_charge_algorithm": "Per diem ($28,538).", "count": "0", "additional_payer_notes": "Zero final payments for the item or service in the 15 months prior to posting the file." }, { "payer_name": "UNITED HEALTHCARE", "plan_name": "SUTTER SELECT & SUTTER HEALTH PLAN HMO PLANS", "methodology": "per diem", "standard_charge_dollar": 28538.0, "standard_charge_algorithm": "Per diem ($28,538).", "count": "0", "additional_payer_notes": "Zero final payments for the item or service in the 15 months prior to posting the file." }, { "payer_name": "SUTTER", "plan_name": "SUTTER SELECT & SUTTER HEALTH PLAN HMO PLANS", "methodology": "per diem", "standard_charge_dollar": 28538.0, "standard_charge_algorithm": "Per diem ($28,538).", "count": "0", "additional_payer_notes": "Zero final payments for the item or service in the 15 months prior to posting the file." }, { "payer_name": "UNITED HEALTHCARE", "plan_name": "SUTTER SELECT & SUTTER HEALTH PLAN HMO PLANS", "methodology": "per diem", "standard_charge_dollar": 28538.0, "standard_charge_algorithm": "Per diem ($28,538).", "count": "0", "additional_payer_notes": "Zero final payments for the item or service in the 15 months prior to posting the file." }, { "payer_name": "UMR", "plan_name": "SUTTER SELECT & SUTTER HEALTH PLAN HMO PLANS", "methodology": "per diem", "standard_charge_dollar": 28538.0, "standard_charge_algorithm": "Per diem ($28,538).", "count": "0", "additional_payer_notes": "Zero final payments for the item or service in the 15 months prior to posting the file." } ] } ] }, { "description": "HC Bolt Anchor Gp015", "code_information": [ { "code": "PX-2120094015", "type": "CDM" }, { "code": "99999", "type": "CPT" }, { "code": "0272", "type": "RC" } ], "standard_charges": [ { "setting": "outpatient", "gross_charge": 1225.0, "discounted_cash": 612.5, "minimum": 516.95, "maximum": 637.0, "additional_generic_notes": "Zero final payments for the item or service in the 15 months prior to posting the file.", "payers_information": [ { "payer_name": "AETNA", "plan_name": "AETNA ALL OTHER PLANS", "methodology": "percent of total billed charges", "standard_charge_dollar": 637.0, "standard_charge_percentage": 52.0, "count": "0", "additional_payer_notes": "Zero final payments for the item or service in the 15 months prior to posting the file." }, { "payer_name": "AETNA", "plan_name": "AETNA ALL OTHER PLANS", "methodology": "percent of total billed charges", "standard_charge_dollar": 637.0, "standard_charge_percentage": 52.0, "count": "0", "additional_payer_notes": "Zero final payments for the item or service in the 15 months prior to posting the file." }, { "payer_name": "MERITAIN HEALTH", "plan_name": "AETNA ALL OTHER PLANS", "methodology": "percent of total billed charges", "standard_charge_dollar": 637.0, "standard_charge_percentage": 52.0, "count": "0", "additional_payer_notes": "Zero final payments for the item or service in the 15 months prior to posting the file." }, { "payer_name": "BLUE SHIELD OUT OF STATE", "plan_name": "STANFORD HEALTHCARE ALLIANCE PLAN", "methodology": "percent of total billed charges", "standard_charge_dollar": 595.23, "standard_charge_percentage": 48.59, "count": "0", "additional_payer_notes": "Zero final payments for the item or service in the 15 months prior to posting the file." }, { "payer_name": "BLUE SHIELD", "plan_name": "STANFORD HEALTHCARE ALLIANCE PLAN", "methodology": "percent of total billed charges", "standard_charge_dollar": 595.23, "standard_charge_percentage": 48.59, "median_amount": 68.24, "10th_percentile": 13.6, "90th_percentile": 1043.06, "count": "30" }, { "payer_name": "BLUE SHIELD", "plan_name": "STANFORD HEALTHCARE ALLIANCE PLAN", "methodology": "percent of total billed charges", "standard_charge_dollar": 595.23, "standard_charge_percentage": 48.59, "count": "0", "additional_payer_notes": "Zero final payments for the item or service in the 15 months prior to posting the file." }, { "payer_name": "BLUE SHIELD", "plan_name": "STANFORD HEALTHCARE ALLIANCE PLAN", "methodology": "percent of total billed charges", "standard_charge_dollar": 595.23, "standard_charge_percentage": 48.59, "count": "0", "additional_payer_notes": "Zero final payments for the item or service in the 15 months prior to posting the file." }, { "payer_name": "CIGNA", "plan_name": "CIGNA COM ALT HMO PLAN", "methodology": "percent of total billed charges", "standard_charge_dollar": 516.95, "standard_charge_percentage": 42.2, "count": "0", "additional_payer_notes": "Zero final payments for the item or service in the 15 months prior to posting the file." }, { "payer_name": "CIGNA", "plan_name": "CIGNA COM ALT HMO PLAN", "methodology": "percent of total billed charges", "standard_charge_dollar": 516.95, "standard_charge_percentage": 42.2, "count": "0", "additional_payer_notes": "Zero final payments for the item or service in the 15 months prior to posting the file." }, { "payer_name": "HEALTH NET", "plan_name": "HEALTHNET HMO, PPO, POS, EPO, CANOPY HEALTHNET HMO, OTHER-IN-NETWORK PLANS", "methodology": "per diem", "standard_charge_dollar": 8000.0, "standard_charge_algorithm": "Expected reimbursement is the lesser of Per diem ($8,000) for the length of stay and 70% of billed.", "count": "0", "additional_payer_notes": "Zero final payments for the item or service in the 15 months prior to posting the file." }, { "payer_name": "HEALTH NET", "plan_name": "HEALTHNET HMO, PPO, POS, EPO, CANOPY HEALTHNET HMO, OTHER-IN-NETWORK PLANS", "methodology": "per diem", "standard_charge_dollar": 8000.0, "standard_charge_algorithm": "Expected reimbursement is the lesser of Per diem ($8,000) for the length of stay and 70% of billed.", "count": "0", "additional_payer_notes": "Zero final payments for the item or service in the 15 months prior to posting the file." }, { "payer_name": "UNITED HEALTHCARE", "plan_name": "SUTTER SELECT & SUTTER HEALTH PLAN HMO PLANS", "methodology": "per diem", "standard_charge_dollar": 28538.0, "standard_charge_algorithm": "Per diem ($28,538).", "count": "0", "additional_payer_notes": "Zero final payments for the item or service in the 15 months prior to posting the file." }, { "payer_name": "UNITED HEALTHCARE", "plan_name": "SUTTER SELECT & SUTTER HEALTH PLAN HMO PLANS", "methodology": "per diem", "standard_charge_dollar": 28538.0, "standard_charge_algorithm": "Per diem ($28,538).", "count": "0", "additional_payer_notes": "Zero final payments for the item or service in the 15 months prior to posting the file." }, { "payer_name": "SUTTER", "plan_name": "SUTTER SELECT & SUTTER HEALTH PLAN HMO PLANS", "methodology": "per diem", "standard_charge_dollar": 28538.0, "standard_charge_algorithm": "Per diem ($28,538).", "count": "0", "additional_payer_notes": "Zero final payments for the item or service in the 15 months prior to posting the file." }, { "payer_name": "UNITED HEALTHCARE", "plan_name": "SUTTER SELECT & SUTTER HEALTH PLAN HMO PLANS", "methodology": "per diem", "standard_charge_dollar": 28538.0, "standard_charge_algorithm": "Per diem ($28,538).", "count": "0", "additional_payer_notes": "Zero final payments for the item or service in the 15 months prior to posting the file." }, { "payer_name": "UMR", "plan_name": "SUTTER SELECT & SUTTER HEALTH PLAN HMO PLANS", "methodology": "per diem", "standard_charge_dollar": 28538.0, "standard_charge_algorithm": "Per diem ($28,538).", "count": "0", "additional_payer_notes": "Zero final payments for the item or service in the 15 months prior to posting the file." } ] } ] }, { "description": "HC Bolt Anchor Gp030", "code_information": [ { "code": "PX-2120094030", "type": "CDM" }, { "code": "99999", "type": "CPT" }, { "code": "0272", "type": "RC" } ], "standard_charges": [ { "setting": "outpatient", "gross_charge": 5800.0, "discounted_cash": 2900.0, "minimum": 2447.6, "maximum": 3016.0, "additional_generic_notes": "Zero final payments for the item or service in the 15 months prior to posting the file.", "payers_information": [ { "payer_name": "AETNA", "plan_name": "AETNA ALL OTHER PLANS", "methodology": "percent of total billed charges", "standard_charge_dollar": 3016.0, "standard_charge_percentage": 52.0, "count": "0", "additional_payer_notes": "Zero final payments for the item or service in the 15 months prior to posting the file." }, { "payer_name": "AETNA", "plan_name": "AETNA ALL OTHER PLANS", "methodology": "percent of total billed charges", "standard_charge_dollar": 3016.0, "standard_charge_percentage": 52.0, "count": "0", "additional_payer_notes": "Zero final payments for the item or service in the 15 months prior to posting the file." }, { "payer_name": "MERITAIN HEALTH", "plan_name": "AETNA ALL OTHER PLANS", "methodology": "percent of total billed charges", "standard_charge_dollar": 3016.0, "standard_charge_percentage": 52.0, "count": "0", "additional_payer_notes": "Zero final payments for the item or service in the 15 months prior to posting the file." }, { "payer_name": "BLUE SHIELD OUT OF STATE", "plan_name": "STANFORD HEALTHCARE ALLIANCE PLAN", "methodology": "percent of total billed charges", "standard_charge_dollar": 2818.22, "standard_charge_percentage": 48.59, "count": "0", "additional_payer_notes": "Zero final payments for the item or service in the 15 months prior to posting the file." }, { "payer_name": "BLUE SHIELD", "plan_name": "STANFORD HEALTHCARE ALLIANCE PLAN", "methodology": "percent of total billed charges", "standard_charge_dollar": 2818.22, "standard_charge_percentage": 48.59, "median_amount": 68.24, "10th_percentile": 13.6, "90th_percentile": 1043.06, "count": "30" }, { "payer_name": "BLUE SHIELD", "plan_name": "STANFORD HEALTHCARE ALLIANCE PLAN", "methodology": "percent of total billed charges", "standard_charge_dollar": 2818.22, "standard_charge_percentage": 48.59, "count": "0", "additional_payer_notes": "Zero final payments for the item or service in the 15 months prior to posting the file." }, { "payer_name": "BLUE SHIELD", "plan_name": "STANFORD HEALTHCARE ALLIANCE PLAN", "methodology": "percent of total billed charges", "standard_charge_dollar": 2818.22, "standard_charge_percentage": 48.59, "count": "0", "additional_payer_notes": "Zero final payments for the item or service in the 15 months prior to posting the file." }, { "payer_name": "CIGNA", "plan_name": "CIGNA COM ALT HMO PLAN", "methodology": "percent of total billed charges", "standard_charge_dollar": 2447.6, "standard_charge_percentage": 42.2, "count": "0", "additional_payer_notes": "Zero final payments for the item or service in the 15 months prior to posting the file." }, { "payer_name": "CIGNA", "plan_name": "CIGNA COM ALT HMO PLAN", "methodology": "percent of total billed charges", "standard_charge_dollar": 2447.6, "standard_charge_percentage": 42.2, "count": "0", "additional_payer_notes": "Zero final payments for the item or service in the 15 months prior to posting the file." }, { "payer_name": "HEALTH NET", "plan_name": "HEALTHNET HMO, PPO, POS, EPO, CANOPY HEALTHNET HMO, OTHER-IN-NETWORK PLANS", "methodology": "per diem", "standard_charge_dollar": 8000.0, "standard_charge_algorithm": "Expected reimbursement is the lesser of Per diem ($8,000) for the length of stay and 70% of billed.", "count": "0", "additional_payer_notes": "Zero final payments for the item or service in the 15 months prior to posting the file." }, { "payer_name": "HEALTH NET", "plan_name": "HEALTHNET HMO, PPO, POS, EPO, CANOPY HEALTHNET HMO, OTHER-IN-NETWORK PLANS", "methodology": "per diem", "standard_charge_dollar": 8000.0, "standard_charge_algorithm": "Expected reimbursement is the lesser of Per diem ($8,000) for the length of stay and 70% of billed.", "count": "0", "additional_payer_notes": "Zero final payments for the item or service in the 15 months prior to posting the file." }, { "payer_name": "UNITED HEALTHCARE", "plan_name": "SUTTER SELECT & SUTTER HEALTH PLAN HMO PLANS", "methodology": "per diem", "standard_charge_dollar": 28538.0, "standard_charge_algorithm": "Per diem ($28,538).", "count": "0", "additional_payer_notes": "Zero final payments for the item or service in the 15 months prior to posting the file." }, { "payer_name": "UNITED HEALTHCARE", "plan_name": "SUTTER SELECT & SUTTER HEALTH PLAN HMO PLANS", "methodology": "per diem", "standard_charge_dollar": 28538.0, "standard_charge_algorithm": "Per diem ($28,538).", "count": "0", "additional_payer_notes": "Zero final payments for the item or service in the 15 months prior to posting the file." }, { "payer_name": "SUTTER", "plan_name": "SUTTER SELECT & SUTTER HEALTH PLAN HMO PLANS", "methodology": "per diem", "standard_charge_dollar": 28538.0, "standard_charge_algorithm": "Per diem ($28,538).", "count": "0", "additional_payer_notes": "Zero final payments for the item or service in the 15 months prior to posting the file." }, { "payer_name": "UNITED HEALTHCARE", "plan_name": "SUTTER SELECT & SUTTER HEALTH PLAN HMO PLANS", "methodology": "per diem", "standard_charge_dollar": 28538.0, "standard_charge_algorithm": "Per diem ($28,538).", "count": "0", "additional_payer_notes": "Zero final payments for the item or service in the 15 months prior to posting the file." }, { "payer_name": "UMR", "plan_name": "SUTTER SELECT & SUTTER HEALTH PLAN HMO PLANS", "methodology": "per diem", "standard_charge_dollar": 28538.0, "standard_charge_algorithm": "Per diem ($28,538).", "count": "0", "additional_payer_notes": "Zero final payments for the item or service in the 15 months prior to posting the file." } ] } ] }, { "description": "HC Impl Corneal Tissue Gp049", "code_information": [ { "code": "PX-2120095049", "type": "CDM" }, { "code": "V2785", "type": "HCPCS" }, { "code": "0278", "type": "RC" } ], "standard_charges": [ { "setting": "outpatient", "gross_charge": 14250.0, "discounted_cash": 7125.0, "minimum": 6013.5, "maximum": 7410.0, "additional_generic_notes": "Zero final payments for the item or service in the 15 months prior to posting the file.", "payers_information": [ { "payer_name": "AETNA", "plan_name": "AETNA ALL OTHER PLANS", "methodology": "percent of total billed charges", "standard_charge_dollar": 7410.0, "standard_charge_percentage": 52.0, "count": "0", "additional_payer_notes": "Zero final payments for the item or service in the 15 months prior to posting the file." }, { "payer_name": "AETNA", "plan_name": "AETNA ALL OTHER PLANS", "methodology": "percent of total billed charges", "standard_charge_dollar": 7410.0, "standard_charge_percentage": 52.0, "count": "0", "additional_payer_notes": "Zero final payments for the item or service in the 15 months prior to posting the file." }, { "payer_name": "MERITAIN HEALTH", "plan_name": "AETNA ALL OTHER PLANS", "methodology": "percent of total billed charges", "standard_charge_dollar": 7410.0, "standard_charge_percentage": 52.0, "count": "0", "additional_payer_notes": "Zero final payments for the item or service in the 15 months prior to posting the file." }, { "payer_name": "BLUE SHIELD OUT OF STATE", "plan_name": "STANFORD HEALTHCARE ALLIANCE PLAN", "methodology": "percent of total billed charges", "standard_charge_dollar": 6924.08, "standard_charge_percentage": 48.59, "count": "0", "additional_payer_notes": "Zero final payments for the item or service in the 15 months prior to posting the file." }, { "payer_name": "BLUE SHIELD", "plan_name": "STANFORD HEALTHCARE ALLIANCE PLAN", "methodology": "percent of total billed charges", "standard_charge_dollar": 6924.08, "standard_charge_percentage": 48.59, "count": "0", "additional_payer_notes": "Zero final payments for the item or service in the 15 months prior to posting the file." }, { "payer_name": "BLUE SHIELD", "plan_name": "STANFORD HEALTHCARE ALLIANCE PLAN", "methodology": "percent of total billed charges", "standard_charge_dollar": 6924.08, "standard_charge_percentage": 48.59, "count": "0", "additional_payer_notes": "Zero final payments for the item or service in the 15 months prior to posting the file." }, { "payer_name": "BLUE SHIELD", "plan_name": "STANFORD HEALTHCARE ALLIANCE PLAN", "methodology": "percent of total billed charges", "standard_charge_dollar": 6924.08, "standard_charge_percentage": 48.59, "count": "0", "additional_payer_notes": "Zero final payments for the item or service in the 15 months prior to posting the file." }, { "payer_name": "CIGNA", "plan_name": "CIGNA COM ALT HMO PLAN", "methodology": "percent of total billed charges", "standard_charge_dollar": 6013.5, "standard_charge_percentage": 42.2, "count": "0", "additional_payer_notes": "Zero final payments for the item or service in the 15 months prior to posting the file." }, { "payer_name": "CIGNA", "plan_name": "CIGNA COM ALT HMO PLAN", "methodology": "percent of total billed charges", "standard_charge_dollar": 6013.5, "standard_charge_percentage": 42.2, "count": "0", "additional_payer_notes": "Zero final payments for the item or service in the 15 months prior to posting the file." }, { "payer_name": "UNITED HEALTHCARE", "plan_name": "SUTTER SELECT & SUTTER HEALTH PLAN HMO PLANS", "methodology": "per diem", "standard_charge_dollar": 28538.0, "standard_charge_algorithm": "Per diem ($28,538).", "count": "0", "additional_payer_notes": "Zero final payments for the item or service in the 15 months prior to posting the file." }, { "payer_name": "UNITED HEALTHCARE", "plan_name": "SUTTER SELECT & SUTTER HEALTH PLAN HMO PLANS", "methodology": "per diem", "standard_charge_dollar": 28538.0, "standard_charge_algorithm": "Per diem ($28,538).", "count": "0", "additional_payer_notes": "Zero final payments for the item or service in the 15 months prior to posting the file." }, { "payer_name": "SUTTER", "plan_name": "SUTTER SELECT & SUTTER HEALTH PLAN HMO PLANS", "methodology": "per diem", "standard_charge_dollar": 28538.0, "standard_charge_algorithm": "Per diem ($28,538).", "count": "0", "additional_payer_notes": "Zero final payments for the item or service in the 15 months prior to posting the file." }, { "payer_name": "UNITED HEALTHCARE", "plan_name": "SUTTER SELECT & SUTTER HEALTH PLAN HMO PLANS", "methodology": "per diem", "standard_charge_dollar": 28538.0, "standard_charge_algorithm": "Per diem ($28,538).", "count": "0", "additional_payer_notes": "Zero final payments for the item or service in the 15 months prior to posting the file." }, { "payer_name": "UMR", "plan_name": "SUTTER SELECT & SUTTER HEALTH PLAN HMO PLANS", "methodology": "per diem", "standard_charge_dollar": 28538.0, "standard_charge_algorithm": "Per diem ($28,538).", "count": "0", "additional_payer_notes": "Zero final payments for the item or service in the 15 months prior to posting the file." }, { "payer_name": "UNITED HEALTHCARE", "plan_name": "SUTTER SELECT & SUTTER HEALTH PLAN HMO PLANS", "methodology": "per diem", "standard_charge_dollar": 28538.0, "standard_charge_algorithm": "Per diem ($28,538).", "count": "0", "additional_payer_notes": "Zero final payments for the item or service in the 15 months prior to posting the file." } ] } ] }, { "description": "Hc Impl Corneal Tissue Gp052", "code_information": [ { "code": "PX-2120095052", "type": "CDM" }, { "code": "V2785", "type": "HCPCS" }, { "code": "0278", "type": "RC" } ], "standard_charges": [ { "setting": "outpatient", "gross_charge": 16200.0, "discounted_cash": 8100.0, "minimum": 6836.4, "maximum": 8424.0, "additional_generic_notes": "Zero final payments for the item or service in the 15 months prior to posting the file.", "payers_information": [ { "payer_name": "AETNA", "plan_name": "AETNA ALL OTHER PLANS", "methodology": "percent of total billed charges", "standard_charge_dollar": 8424.0, "standard_charge_percentage": 52.0, "count": "0", "additional_payer_notes": "Zero final payments for the item or service in the 15 months prior to posting the file." }, { "payer_name": "AETNA", "plan_name": "AETNA ALL OTHER PLANS", "methodology": "percent of total billed charges", "standard_charge_dollar": 8424.0, "standard_charge_percentage": 52.0, "count": "0", "additional_payer_notes": "Zero final payments for the item or service in the 15 months prior to posting the file." }, { "payer_name": "MERITAIN HEALTH", "plan_name": "AETNA ALL OTHER PLANS", "methodology": "percent of total billed charges", "standard_charge_dollar": 8424.0, "standard_charge_percentage": 52.0, "count": "0", "additional_payer_notes": "Zero final payments for the item or service in the 15 months prior to posting the file." }, { "payer_name": "BLUE SHIELD OUT OF STATE", "plan_name": "STANFORD HEALTHCARE ALLIANCE PLAN", "methodology": "percent of total billed charges", "standard_charge_dollar": 7871.58, "standard_charge_percentage": 48.59, "count": "0", "additional_payer_notes": "Zero final payments for the item or service in the 15 months prior to posting the file." }, { "payer_name": "BLUE SHIELD", "plan_name": "STANFORD HEALTHCARE ALLIANCE PLAN", "methodology": "percent of total billed charges", "standard_charge_dollar": 7871.58, "standard_charge_percentage": 48.59, "count": "0", "additional_payer_notes": "Zero final payments for the item or service in the 15 months prior to posting the file." }, { "payer_name": "BLUE SHIELD", "plan_name": "STANFORD HEALTHCARE ALLIANCE PLAN", "methodology": "percent of total billed charges", "standard_charge_dollar": 7871.58, "standard_charge_percentage": 48.59, "count": "0", "additional_payer_notes": "Zero final payments for the item or service in the 15 months prior to posting the file." }, { "payer_name": "BLUE SHIELD", "plan_name": "STANFORD HEALTHCARE ALLIANCE PLAN", "methodology": "percent of total billed charges", "standard_charge_dollar": 7871.58, "standard_charge_percentage": 48.59, "count": "0", "additional_payer_notes": "Zero final payments for the item or service in the 15 months prior to posting the file." }, { "payer_name": "CIGNA", "plan_name": "CIGNA COM ALT HMO PLAN", "methodology": "percent of total billed charges", "standard_charge_dollar": 6836.4, "standard_charge_percentage": 42.2, "count": "0", "additional_payer_notes": "Zero final payments for the item or service in the 15 months prior to posting the file." }, { "payer_name": "CIGNA", "plan_name": "CIGNA COM ALT HMO PLAN", "methodology": "percent of total billed charges", "standard_charge_dollar": 6836.4, "standard_charge_percentage": 42.2, "count": "0", "additional_payer_notes": "Zero final payments for the item or service in the 15 months prior to posting the file." }, { "payer_name": "UNITED HEALTHCARE", "plan_name": "SUTTER SELECT & SUTTER HEALTH PLAN HMO PLANS", "methodology": "per diem", "standard_charge_dollar": 28538.0, "standard_charge_algorithm": "Per diem ($28,538).", "count": "0", "additional_payer_notes": "Zero final payments for the item or service in the 15 months prior to posting the file." }, { "payer_name": "UNITED HEALTHCARE", "plan_name": "SUTTER SELECT & SUTTER HEALTH PLAN HMO PLANS", "methodology": "per diem", "standard_charge_dollar": 28538.0, "standard_charge_algorithm": "Per diem ($28,538).", "count": "0", "additional_payer_notes": "Zero final payments for the item or service in the 15 months prior to posting the file." }, { "payer_name": "SUTTER", "plan_name": "SUTTER SELECT & SUTTER HEALTH PLAN HMO PLANS", "methodology": "per diem", "standard_charge_dollar": 28538.0, "standard_charge_algorithm": "Per diem ($28,538).", "count": "0", "additional_payer_notes": "Zero final payments for the item or service in the 15 months prior to posting the file." }, { "payer_name": "UNITED HEALTHCARE", "plan_name": "SUTTER SELECT & SUTTER HEALTH PLAN HMO PLANS", "methodology": "per diem", "standard_charge_dollar": 28538.0, "standard_charge_algorithm": "Per diem ($28,538).", "count": "0", "additional_payer_notes": "Zero final payments for the item or service in the 15 months prior to posting the file." }, { "payer_name": "UMR", "plan_name": "SUTTER SELECT & SUTTER HEALTH PLAN HMO PLANS", "methodology": "per diem", "standard_charge_dollar": 28538.0, "standard_charge_algorithm": "Per diem ($28,538).", "count": "0", "additional_payer_notes": "Zero final payments for the item or service in the 15 months prior to posting the file." }, { "payer_name": "UNITED HEALTHCARE", "plan_name": "SUTTER SELECT & SUTTER HEALTH PLAN HMO PLANS", "methodology": "per diem", "standard_charge_dollar": 28538.0, "standard_charge_algorithm": "Per diem ($28,538).", "count": "0", "additional_payer_notes": "Zero final payments for the item or service in the 15 months prior to posting the file." } ] } ] }, { "description": "HC Impl Defibrillator Gp113", "code_information": [ { "code": "PX-2120102113", "type": "CDM" }, { "code": "C1722", "type": "HCPCS" }, { "code": "0275", "type": "RC" } ], "standard_charges": [ { "setting": "outpatient", "gross_charge": 59400.0, "discounted_cash": 29700.0, "minimum": 25066.8, "maximum": 30888.0, "additional_generic_notes": "Zero final payments for the item or service in the 15 months prior to posting the file.", "payers_information": [ { "payer_name": "AETNA", "plan_name": "AETNA ALL OTHER PLANS", "methodology": "percent of total billed charges", "standard_charge_dollar": 30888.0, "standard_charge_percentage": 52.0, "count": "0", "additional_payer_notes": "Zero final payments for the item or service in the 15 months prior to posting the file." }, { "payer_name": "AETNA", "plan_name": "AETNA ALL OTHER PLANS", "methodology": "percent of total billed charges", "standard_charge_dollar": 30888.0, "standard_charge_percentage": 52.0, "count": "0", "additional_payer_notes": "Zero final payments for the item or service in the 15 months prior to posting the file." }, { "payer_name": "MERITAIN HEALTH", "plan_name": "AETNA ALL OTHER PLANS", "methodology": "percent of total billed charges", "standard_charge_dollar": 30888.0, "standard_charge_percentage": 52.0, "count": "0", "additional_payer_notes": "Zero final payments for the item or service in the 15 months prior to posting the file." }, { "payer_name": "BLUE SHIELD OUT OF STATE", "plan_name": "STANFORD HEALTHCARE ALLIANCE PLAN", "methodology": "percent of total billed charges", "standard_charge_dollar": 28862.46, "standard_charge_percentage": 48.59, "count": "0", "additional_payer_notes": "Zero final payments for the item or service in the 15 months prior to posting the file." }, { "payer_name": "BLUE SHIELD", "plan_name": "STANFORD HEALTHCARE ALLIANCE PLAN", "methodology": "percent of total billed charges", "standard_charge_dollar": 28862.46, "standard_charge_percentage": 48.59, "count": "0", "additional_payer_notes": "Zero final payments for the item or service in the 15 months prior to posting the file." }, { "payer_name": "BLUE SHIELD", "plan_name": "STANFORD HEALTHCARE ALLIANCE PLAN", "methodology": "percent of total billed charges", "standard_charge_dollar": 28862.46, "standard_charge_percentage": 48.59, "count": "0", "additional_payer_notes": "Zero final payments for the item or service in the 15 months prior to posting the file." }, { "payer_name": "BLUE SHIELD", "plan_name": "STANFORD HEALTHCARE ALLIANCE PLAN", "methodology": "percent of total billed charges", "standard_charge_dollar": 28862.46, "standard_charge_percentage": 48.59, "count": "0", "additional_payer_notes": "Zero final payments for the item or service in the 15 months prior to posting the file." }, { "payer_name": "CIGNA", "plan_name": "CIGNA COM ALT HMO PLAN", "methodology": "percent of total billed charges", "standard_charge_dollar": 25066.8, "standard_charge_percentage": 42.2, "count": "0", "additional_payer_notes": "Zero final payments for the item or service in the 15 months prior to posting the file." }, { "payer_name": "CIGNA", "plan_name": "CIGNA COM ALT HMO PLAN", "methodology": "percent of total billed charges", "standard_charge_dollar": 25066.8, "standard_charge_percentage": 42.2, "count": "0", "additional_payer_notes": "Zero final payments for the item or service in the 15 months prior to posting the file." }, { "payer_name": "UNITED HEALTHCARE", "plan_name": "SUTTER SELECT & SUTTER HEALTH PLAN HMO PLANS", "methodology": "per diem", "standard_charge_dollar": 28538.0, "standard_charge_algorithm": "Per diem ($28,538).", "count": "0", "additional_payer_notes": "Zero final payments for the item or service in the 15 months prior to posting the file." }, { "payer_name": "UNITED HEALTHCARE", "plan_name": "SUTTER SELECT & SUTTER HEALTH PLAN HMO PLANS", "methodology": "per diem", "standard_charge_dollar": 28538.0, "standard_charge_algorithm": "Per diem ($28,538).", "count": "0", "additional_payer_notes": "Zero final payments for the item or service in the 15 months prior to posting the file." }, { "payer_name": "SUTTER", "plan_name": "SUTTER SELECT & SUTTER HEALTH PLAN HMO PLANS", "methodology": "per diem", "standard_charge_dollar": 28538.0, "standard_charge_algorithm": "Per diem ($28,538).", "count": "0", "additional_payer_notes": "Zero final payments for the item or service in the 15 months prior to posting the file." }, { "payer_name": "UNITED HEALTHCARE", "plan_name": "SUTTER SELECT & SUTTER HEALTH PLAN HMO PLANS", "methodology": "per diem", "standard_charge_dollar": 28538.0, "standard_charge_algorithm": "Per diem ($28,538).", "count": "0", "additional_payer_notes": "Zero final payments for the item or service in the 15 months prior to posting the file." }, { "payer_name": "UMR", "plan_name": "SUTTER SELECT & SUTTER HEALTH PLAN HMO PLANS", "methodology": "per diem", "standard_charge_dollar": 28538.0, "standard_charge_algorithm": "Per diem ($28,538).", "count": "0", "additional_payer_notes": "Zero final payments for the item or service in the 15 months prior to posting the file." }, { "payer_name": "UNITED HEALTHCARE", "plan_name": "SUTTER SELECT & SUTTER HEALTH PLAN HMO PLANS", "methodology": "per diem", "standard_charge_dollar": 28538.0, "standard_charge_algorithm": "Per diem ($28,538).", "count": "0", "additional_payer_notes": "Zero final payments for the item or service in the 15 months prior to posting the file." } ] } ] }, { "description": "HC Duraseal Gp027", "code_information": [ { "code": "PX-2120105027", "type": "CDM" }, { "code": "C1763", "type": "HCPCS" }, { "code": "0272", "type": "RC" } ], "standard_charges": [ { "setting": "outpatient", "gross_charge": 4875.0, "discounted_cash": 2437.5, "minimum": 2057.25, "maximum": 2535.0, "additional_generic_notes": "Zero final payments for the item or service in the 15 months prior to posting the file.", "payers_information": [ { "payer_name": "AETNA", "plan_name": "AETNA ALL OTHER PLANS", "methodology": "percent of total billed charges", "standard_charge_dollar": 2535.0, "standard_charge_percentage": 52.0, "count": "0", "additional_payer_notes": "Zero final payments for the item or service in the 15 months prior to posting the file." }, { "payer_name": "AETNA", "plan_name": "AETNA ALL OTHER PLANS", "methodology": "percent of total billed charges", "standard_charge_dollar": 2535.0, "standard_charge_percentage": 52.0, "count": "0", "additional_payer_notes": "Zero final payments for the item or service in the 15 months prior to posting the file." }, { "payer_name": "MERITAIN HEALTH", "plan_name": "AETNA ALL OTHER PLANS", "methodology": "percent of total billed charges", "standard_charge_dollar": 2535.0, "standard_charge_percentage": 52.0, "count": "0", "additional_payer_notes": "Zero final payments for the item or service in the 15 months prior to posting the file." }, { "payer_name": "BLUE SHIELD OUT OF STATE", "plan_name": "STANFORD HEALTHCARE ALLIANCE PLAN", "methodology": "percent of total billed charges", "standard_charge_dollar": 2368.76, "standard_charge_percentage": 48.59, "median_amount": 1163.82, "10th_percentile": 595.98, "90th_percentile": 1163.82, "count": "1 through 10" }, { "payer_name": "BLUE SHIELD", "plan_name": "STANFORD HEALTHCARE ALLIANCE PLAN", "methodology": "percent of total billed charges", "standard_charge_dollar": 2368.76, "standard_charge_percentage": 48.59, "median_amount": 414.28, "10th_percentile": 414.28, "90th_percentile": 414.28, "count": "1 through 10" }, { "payer_name": "BLUE SHIELD", "plan_name": "STANFORD HEALTHCARE ALLIANCE PLAN", "methodology": "percent of total billed charges", "standard_charge_dollar": 2368.76, "standard_charge_percentage": 48.59, "median_amount": 595.98, "10th_percentile": 595.98, "90th_percentile": 595.98, "count": "1 through 10" }, { "payer_name": "BLUE SHIELD", "plan_name": "STANFORD HEALTHCARE ALLIANCE PLAN", "methodology": "percent of total billed charges", "standard_charge_dollar": 2368.76, "standard_charge_percentage": 48.59, "count": "0", "additional_payer_notes": "Zero final payments for the item or service in the 15 months prior to posting the file." }, { "payer_name": "CIGNA", "plan_name": "CIGNA COM ALT HMO PLAN", "methodology": "percent of total billed charges", "standard_charge_dollar": 2057.25, "standard_charge_percentage": 42.2, "median_amount": 784.66, "10th_percentile": 784.66, "90th_percentile": 784.66, "count": "1 through 10" }, { "payer_name": "CIGNA", "plan_name": "CIGNA COM ALT HMO PLAN", "methodology": "percent of total billed charges", "standard_charge_dollar": 2057.25, "standard_charge_percentage": 42.2, "count": "0", "additional_payer_notes": "Zero final payments for the item or service in the 15 months prior to posting the file." }, { "payer_name": "HEALTH NET", "plan_name": "HEALTHNET HMO, PPO, POS, EPO, CANOPY HEALTHNET HMO, OTHER-IN-NETWORK PLANS", "methodology": "per diem", "standard_charge_dollar": 8000.0, "standard_charge_algorithm": "Expected reimbursement is the lesser of Per diem ($8,000) for the length of stay and 70% of billed.", "count": "0", "additional_payer_notes": "Zero final payments for the item or service in the 15 months prior to posting the file." }, { "payer_name": "HEALTH NET", "plan_name": "HEALTHNET HMO, PPO, POS, EPO, CANOPY HEALTHNET HMO, OTHER-IN-NETWORK PLANS", "methodology": "per diem", "standard_charge_dollar": 8000.0, "standard_charge_algorithm": "Expected reimbursement is the lesser of Per diem ($8,000) for the length of stay and 70% of billed.", "count": "0", "additional_payer_notes": "Zero final payments for the item or service in the 15 months prior to posting the file." }, { "payer_name": "UNITED HEALTHCARE", "plan_name": "SUTTER SELECT & SUTTER HEALTH PLAN HMO PLANS", "methodology": "per diem", "standard_charge_dollar": 28538.0, "standard_charge_algorithm": "Per diem ($28,538).", "count": "0", "additional_payer_notes": "Zero final payments for the item or service in the 15 months prior to posting the file." }, { "payer_name": "UNITED HEALTHCARE", "plan_name": "SUTTER SELECT & SUTTER HEALTH PLAN HMO PLANS", "methodology": "per diem", "standard_charge_dollar": 28538.0, "standard_charge_algorithm": "Per diem ($28,538).", "count": "0", "additional_payer_notes": "Zero final payments for the item or service in the 15 months prior to posting the file." }, { "payer_name": "SUTTER", "plan_name": "SUTTER SELECT & SUTTER HEALTH PLAN HMO PLANS", "methodology": "per diem", "standard_charge_dollar": 28538.0, "standard_charge_algorithm": "Per diem ($28,538).", "count": "0", "additional_payer_notes": "Zero final payments for the item or service in the 15 months prior to posting the file." }, { "payer_name": "UNITED HEALTHCARE", "plan_name": "SUTTER SELECT & SUTTER HEALTH PLAN HMO PLANS", "methodology": "per diem", "standard_charge_dollar": 28538.0, "standard_charge_algorithm": "Per diem ($28,538).", "count": "0", "additional_payer_notes": "Zero final payments for the item or service in the 15 months prior to posting the file." }, { "payer_name": "UMR", "plan_name": "SUTTER SELECT & SUTTER HEALTH PLAN HMO PLANS", "methodology": "per diem", "standard_charge_dollar": 28538.0, "standard_charge_algorithm": "Per diem ($28,538).", "count": "0", "additional_payer_notes": "Zero final payments for the item or service in the 15 months prior to posting the file." }, { "payer_name": "UNITED HEALTHCARE", "plan_name": "SUTTER SELECT & SUTTER HEALTH PLAN HMO PLANS", "methodology": "per diem", "standard_charge_dollar": 28538.0, "standard_charge_algorithm": "Per diem ($28,538).", "count": "0", "additional_payer_notes": "Zero final payments for the item or service in the 15 months prior to posting the file." } ] } ] }, { "description": "HC Impl Ear Gp063", "code_information": [ { "code": "PX-2120106063", "type": "CDM" }, { "code": "L8619", "type": "HCPCS" }, { "code": "0278", "type": "RC" } ], "standard_charges": [ { "setting": "outpatient", "gross_charge": 23200.0, "discounted_cash": 11600.0, "minimum": 9790.4, "maximum": 12064.0, "additional_generic_notes": "Zero final payments for the item or service in the 15 months prior to posting the file.", "payers_information": [ { "payer_name": "AETNA", "plan_name": "AETNA ALL OTHER PLANS", "methodology": "percent of total billed charges", "standard_charge_dollar": 12064.0, "standard_charge_percentage": 52.0, "count": "0", "additional_payer_notes": "Zero final payments for the item or service in the 15 months prior to posting the file." }, { "payer_name": "AETNA", "plan_name": "AETNA ALL OTHER PLANS", "methodology": "percent of total billed charges", "standard_charge_dollar": 12064.0, "standard_charge_percentage": 52.0, "count": "0", "additional_payer_notes": "Zero final payments for the item or service in the 15 months prior to posting the file." }, { "payer_name": "MERITAIN HEALTH", "plan_name": "AETNA ALL OTHER PLANS", "methodology": "percent of total billed charges", "standard_charge_dollar": 12064.0, "standard_charge_percentage": 52.0, "count": "0", "additional_payer_notes": "Zero final payments for the item or service in the 15 months prior to posting the file." }, { "payer_name": "BLUE SHIELD OUT OF STATE", "plan_name": "STANFORD HEALTHCARE ALLIANCE PLAN", "methodology": "percent of total billed charges", "standard_charge_dollar": 11272.88, "standard_charge_percentage": 48.59, "count": "0", "additional_payer_notes": "Zero final payments for the item or service in the 15 months prior to posting the file." }, { "payer_name": "BLUE SHIELD", "plan_name": "STANFORD HEALTHCARE ALLIANCE PLAN", "methodology": "percent of total billed charges", "standard_charge_dollar": 11272.88, "standard_charge_percentage": 48.59, "count": "0", "additional_payer_notes": "Zero final payments for the item or service in the 15 months prior to posting the file." }, { "payer_name": "BLUE SHIELD", "plan_name": "STANFORD HEALTHCARE ALLIANCE PLAN", "methodology": "percent of total billed charges", "standard_charge_dollar": 11272.88, "standard_charge_percentage": 48.59, "count": "0", "additional_payer_notes": "Zero final payments for the item or service in the 15 months prior to posting the file." }, { "payer_name": "BLUE SHIELD", "plan_name": "STANFORD HEALTHCARE ALLIANCE PLAN", "methodology": "percent of total billed charges", "standard_charge_dollar": 11272.88, "standard_charge_percentage": 48.59, "count": "0", "additional_payer_notes": "Zero final payments for the item or service in the 15 months prior to posting the file." }, { "payer_name": "CIGNA", "plan_name": "CIGNA COM ALT HMO PLAN", "methodology": "percent of total billed charges", "standard_charge_dollar": 9790.4, "standard_charge_percentage": 42.2, "count": "0", "additional_payer_notes": "Zero final payments for the item or service in the 15 months prior to posting the file." }, { "payer_name": "CIGNA", "plan_name": "CIGNA COM ALT HMO PLAN", "methodology": "percent of total billed charges", "standard_charge_dollar": 9790.4, "standard_charge_percentage": 42.2, "count": "0", "additional_payer_notes": "Zero final payments for the item or service in the 15 months prior to posting the file." }, { "payer_name": "UNITED HEALTHCARE", "plan_name": "SUTTER SELECT & SUTTER HEALTH PLAN HMO PLANS", "methodology": "per diem", "standard_charge_dollar": 28538.0, "standard_charge_algorithm": "Per diem ($28,538).", "count": "0", "additional_payer_notes": "Zero final payments for the item or service in the 15 months prior to posting the file." }, { "payer_name": "UNITED HEALTHCARE", "plan_name": "SUTTER SELECT & SUTTER HEALTH PLAN HMO PLANS", "methodology": "per diem", "standard_charge_dollar": 28538.0, "standard_charge_algorithm": "Per diem ($28,538).", "count": "0", "additional_payer_notes": "Zero final payments for the item or service in the 15 months prior to posting the file." }, { "payer_name": "SUTTER", "plan_name": "SUTTER SELECT & SUTTER HEALTH PLAN HMO PLANS", "methodology": "per diem", "standard_charge_dollar": 28538.0, "standard_charge_algorithm": "Per diem ($28,538).", "count": "0", "additional_payer_notes": "Zero final payments for the item or service in the 15 months prior to posting the file." }, { "payer_name": "UNITED HEALTHCARE", "plan_name": "SUTTER SELECT & SUTTER HEALTH PLAN HMO PLANS", "methodology": "per diem", "standard_charge_dollar": 28538.0, "standard_charge_algorithm": "Per diem ($28,538).", "count": "0", "additional_payer_notes": "Zero final payments for the item or service in the 15 months prior to posting the file." }, { "payer_name": "UMR", "plan_name": "SUTTER SELECT & SUTTER HEALTH PLAN HMO PLANS", "methodology": "per diem", "standard_charge_dollar": 28538.0, "standard_charge_algorithm": "Per diem ($28,538).", "count": "0", "additional_payer_notes": "Zero final payments for the item or service in the 15 months prior to posting the file." }, { "payer_name": "UNITED HEALTHCARE", "plan_name": "SUTTER SELECT & SUTTER HEALTH PLAN HMO PLANS", "methodology": "per diem", "standard_charge_dollar": 28538.0, "standard_charge_algorithm": "Per diem ($28,538).", "count": "0", "additional_payer_notes": "Zero final payments for the item or service in the 15 months prior to posting the file." } ] } ] }, { "description": "HC Impl Ear Tube Gp006", "code_information": [ { "code": "PX-2120107006", "type": "CDM" }, { "code": "99999", "type": "CPT" }, { "code": "0272", "type": "RC" } ], "standard_charges": [ { "setting": "outpatient", "gross_charge": 293.0, "discounted_cash": 146.5, "minimum": 123.65, "maximum": 152.36, "additional_generic_notes": "Zero final payments for the item or service in the 15 months prior to posting the file.", "payers_information": [ { "payer_name": "AETNA", "plan_name": "AETNA ALL OTHER PLANS", "methodology": "percent of total billed charges", "standard_charge_dollar": 152.36, "standard_charge_percentage": 52.0, "count": "0", "additional_payer_notes": "Zero final payments for the item or service in the 15 months prior to posting the file." }, { "payer_name": "AETNA", "plan_name": "AETNA ALL OTHER PLANS", "methodology": "percent of total billed charges", "standard_charge_dollar": 152.36, "standard_charge_percentage": 52.0, "count": "0", "additional_payer_notes": "Zero final payments for the item or service in the 15 months prior to posting the file." }, { "payer_name": "MERITAIN HEALTH", "plan_name": "AETNA ALL OTHER PLANS", "methodology": "percent of total billed charges", "standard_charge_dollar": 152.36, "standard_charge_percentage": 52.0, "count": "0", "additional_payer_notes": "Zero final payments for the item or service in the 15 months prior to posting the file." }, { "payer_name": "BLUE SHIELD OUT OF STATE", "plan_name": "STANFORD HEALTHCARE ALLIANCE PLAN", "methodology": "percent of total billed charges", "standard_charge_dollar": 142.37, "standard_charge_percentage": 48.59, "count": "0", "additional_payer_notes": "Zero final payments for the item or service in the 15 months prior to posting the file." }, { "payer_name": "BLUE SHIELD", "plan_name": "STANFORD HEALTHCARE ALLIANCE PLAN", "methodology": "percent of total billed charges", "standard_charge_dollar": 142.37, "standard_charge_percentage": 48.59, "count": "0", "additional_payer_notes": "Zero final payments for the item or service in the 15 months prior to posting the file." }, { "payer_name": "BLUE SHIELD", "plan_name": "STANFORD HEALTHCARE ALLIANCE PLAN", "methodology": "percent of total billed charges", "standard_charge_dollar": 142.37, "standard_charge_percentage": 48.59, "count": "0", "additional_payer_notes": "Zero final payments for the item or service in the 15 months prior to posting the file." }, { "payer_name": "CIGNA", "plan_name": "CIGNA COM ALT HMO PLAN", "methodology": "percent of total billed charges", "standard_charge_dollar": 123.65, "standard_charge_percentage": 42.2, "count": "0", "additional_payer_notes": "Zero final payments for the item or service in the 15 months prior to posting the file." }, { "payer_name": "CIGNA", "plan_name": "CIGNA COM ALT HMO PLAN", "methodology": "percent of total billed charges", "standard_charge_dollar": 123.65, "standard_charge_percentage": 42.2, "count": "0", "additional_payer_notes": "Zero final payments for the item or service in the 15 months prior to posting the file." }, { "payer_name": "HEALTH NET", "plan_name": "HEALTHNET HMO, PPO, POS, EPO, CANOPY HEALTHNET HMO, OTHER-IN-NETWORK PLANS", "methodology": "per diem", "standard_charge_dollar": 8000.0, "standard_charge_algorithm": "Expected reimbursement is the lesser of Per diem ($8,000) for the length of stay and 70% of billed.", "count": "0", "additional_payer_notes": "Zero final payments for the item or service in the 15 months prior to posting the file." }, { "payer_name": "HEALTH NET", "plan_name": "HEALTHNET HMO, PPO, POS, EPO, CANOPY HEALTHNET HMO, OTHER-IN-NETWORK PLANS", "methodology": "per diem", "standard_charge_dollar": 8000.0, "standard_charge_algorithm": "Expected reimbursement is the lesser of Per diem ($8,000) for the length of stay and 70% of billed.", "count": "0", "additional_payer_notes": "Zero final payments for the item or service in the 15 months prior to posting the file." }, { "payer_name": "UNITED HEALTHCARE", "plan_name": "SUTTER SELECT & SUTTER HEALTH PLAN HMO PLANS", "methodology": "per diem", "standard_charge_dollar": 28538.0, "standard_charge_algorithm": "Per diem ($28,538).", "count": "0", "additional_payer_notes": "Zero final payments for the item or service in the 15 months prior to posting the file." }, { "payer_name": "UNITED HEALTHCARE", "plan_name": "SUTTER SELECT & SUTTER HEALTH PLAN HMO PLANS", "methodology": "per diem", "standard_charge_dollar": 28538.0, "standard_charge_algorithm": "Per diem ($28,538).", "count": "0", "additional_payer_notes": "Zero final payments for the item or service in the 15 months prior to posting the file." }, { "payer_name": "SUTTER", "plan_name": "SUTTER SELECT & SUTTER HEALTH PLAN HMO PLANS", "methodology": "per diem", "standard_charge_dollar": 28538.0, "standard_charge_algorithm": "Per diem ($28,538).", "count": "0", "additional_payer_notes": "Zero final payments for the item or service in the 15 months prior to posting the file." }, { "payer_name": "UNITED HEALTHCARE", "plan_name": "SUTTER SELECT & SUTTER HEALTH PLAN HMO PLANS", "methodology": "per diem", "standard_charge_dollar": 28538.0, "standard_charge_algorithm": "Per diem ($28,538).", "count": "0", "additional_payer_notes": "Zero final payments for the item or service in the 15 months prior to posting the file." }, { "payer_name": "UMR", "plan_name": "SUTTER SELECT & SUTTER HEALTH PLAN HMO PLANS", "methodology": "per diem", "standard_charge_dollar": 28538.0, "standard_charge_algorithm": "Per diem ($28,538).", "count": "0", "additional_payer_notes": "Zero final payments for the item or service in the 15 months prior to posting the file." } ] } ] }, { "description": "HC Cable Seeg Electrode Gp017", "code_information": [ { "code": "PX-2120115017", "type": "CDM" }, { "code": "99999", "type": "CPT" }, { "code": "0272", "type": "RC" } ], "standard_charges": [ { "setting": "outpatient", "gross_charge": 1575.0, "discounted_cash": 787.5, "minimum": 664.65, "maximum": 819.0, "additional_generic_notes": "Zero final payments for the item or service in the 15 months prior to posting the file.", "payers_information": [ { "payer_name": "AETNA", "plan_name": "AETNA ALL OTHER PLANS", "methodology": "percent of total billed charges", "standard_charge_dollar": 819.0, "standard_charge_percentage": 52.0, "count": "0", "additional_payer_notes": "Zero final payments for the item or service in the 15 months prior to posting the file." }, { "payer_name": "AETNA", "plan_name": "AETNA ALL OTHER PLANS", "methodology": "percent of total billed charges", "standard_charge_dollar": 819.0, "standard_charge_percentage": 52.0, "count": "0", "additional_payer_notes": "Zero final payments for the item or service in the 15 months prior to posting the file." }, { "payer_name": "MERITAIN HEALTH", "plan_name": "AETNA ALL OTHER PLANS", "methodology": "percent of total billed charges", "standard_charge_dollar": 819.0, "standard_charge_percentage": 52.0, "count": "0", "additional_payer_notes": "Zero final payments for the item or service in the 15 months prior to posting the file." }, { "payer_name": "BLUE SHIELD OUT OF STATE", "plan_name": "STANFORD HEALTHCARE ALLIANCE PLAN", "methodology": "percent of total billed charges", "standard_charge_dollar": 765.29, "standard_charge_percentage": 48.59, "count": "0", "additional_payer_notes": "Zero final payments for the item or service in the 15 months prior to posting the file." }, { "payer_name": "BLUE SHIELD", "plan_name": "STANFORD HEALTHCARE ALLIANCE PLAN", "methodology": "percent of total billed charges", "standard_charge_dollar": 765.29, "standard_charge_percentage": 48.59, "median_amount": 68.24, "10th_percentile": 13.6, "90th_percentile": 1043.06, "count": "30" }, { "payer_name": "BLUE SHIELD", "plan_name": "STANFORD HEALTHCARE ALLIANCE PLAN", "methodology": "percent of total billed charges", "standard_charge_dollar": 765.29, "standard_charge_percentage": 48.59, "count": "0", "additional_payer_notes": "Zero final payments for the item or service in the 15 months prior to posting the file." }, { "payer_name": "BLUE SHIELD", "plan_name": "STANFORD HEALTHCARE ALLIANCE PLAN", "methodology": "percent of total billed charges", "standard_charge_dollar": 765.29, "standard_charge_percentage": 48.59, "count": "0", "additional_payer_notes": "Zero final payments for the item or service in the 15 months prior to posting the file." }, { "payer_name": "CIGNA", "plan_name": "CIGNA COM ALT HMO PLAN", "methodology": "percent of total billed charges", "standard_charge_dollar": 664.65, "standard_charge_percentage": 42.2, "count": "0", "additional_payer_notes": "Zero final payments for the item or service in the 15 months prior to posting the file." }, { "payer_name": "CIGNA", "plan_name": "CIGNA COM ALT HMO PLAN", "methodology": "percent of total billed charges", "standard_charge_dollar": 664.65, "standard_charge_percentage": 42.2, "count": "0", "additional_payer_notes": "Zero final payments for the item or service in the 15 months prior to posting the file." }, { "payer_name": "HEALTH NET", "plan_name": "HEALTHNET HMO, PPO, POS, EPO, CANOPY HEALTHNET HMO, OTHER-IN-NETWORK PLANS", "methodology": "per diem", "standard_charge_dollar": 8000.0, "standard_charge_algorithm": "Expected reimbursement is the lesser of Per diem ($8,000) for the length of stay and 70% of billed.", "count": "0", "additional_payer_notes": "Zero final payments for the item or service in the 15 months prior to posting the file." }, { "payer_name": "HEALTH NET", "plan_name": "HEALTHNET HMO, PPO, POS, EPO, CANOPY HEALTHNET HMO, OTHER-IN-NETWORK PLANS", "methodology": "per diem", "standard_charge_dollar": 8000.0, "standard_charge_algorithm": "Expected reimbursement is the lesser of Per diem ($8,000) for the length of stay and 70% of billed.", "count": "0", "additional_payer_notes": "Zero final payments for the item or service in the 15 months prior to posting the file." }, { "payer_name": "UNITED HEALTHCARE", "plan_name": "SUTTER SELECT & SUTTER HEALTH PLAN HMO PLANS", "methodology": "per diem", "standard_charge_dollar": 28538.0, "standard_charge_algorithm": "Per diem ($28,538).", "count": "0", "additional_payer_notes": "Zero final payments for the item or service in the 15 months prior to posting the file." }, { "payer_name": "UNITED HEALTHCARE", "plan_name": "SUTTER SELECT & SUTTER HEALTH PLAN HMO PLANS", "methodology": "per diem", "standard_charge_dollar": 28538.0, "standard_charge_algorithm": "Per diem ($28,538).", "count": "0", "additional_payer_notes": "Zero final payments for the item or service in the 15 months prior to posting the file." }, { "payer_name": "SUTTER", "plan_name": "SUTTER SELECT & SUTTER HEALTH PLAN HMO PLANS", "methodology": "per diem", "standard_charge_dollar": 28538.0, "standard_charge_algorithm": "Per diem ($28,538).", "count": "0", "additional_payer_notes": "Zero final payments for the item or service in the 15 months prior to posting the file." }, { "payer_name": "UNITED HEALTHCARE", "plan_name": "SUTTER SELECT & SUTTER HEALTH PLAN HMO PLANS", "methodology": "per diem", "standard_charge_dollar": 28538.0, "standard_charge_algorithm": "Per diem ($28,538).", "count": "0", "additional_payer_notes": "Zero final payments for the item or service in the 15 months prior to posting the file." }, { "payer_name": "UMR", "plan_name": "SUTTER SELECT & SUTTER HEALTH PLAN HMO PLANS", "methodology": "per diem", "standard_charge_dollar": 28538.0, "standard_charge_algorithm": "Per diem ($28,538).", "count": "0", "additional_payer_notes": "Zero final payments for the item or service in the 15 months prior to posting the file." } ] } ] }, { "description": "HC Cable Seeg Electrode Gp018", "code_information": [ { "code": "PX-2120115018", "type": "CDM" }, { "code": "99999", "type": "CPT" }, { "code": "0272", "type": "RC" } ], "standard_charges": [ { "setting": "outpatient", "gross_charge": 1750.0, "discounted_cash": 875.0, "minimum": 738.5, "maximum": 910.0, "additional_generic_notes": "Zero final payments for the item or service in the 15 months prior to posting the file.", "payers_information": [ { "payer_name": "AETNA", "plan_name": "AETNA ALL OTHER PLANS", "methodology": "percent of total billed charges", "standard_charge_dollar": 910.0, "standard_charge_percentage": 52.0, "count": "0", "additional_payer_notes": "Zero final payments for the item or service in the 15 months prior to posting the file." }, { "payer_name": "AETNA", "plan_name": "AETNA ALL OTHER PLANS", "methodology": "percent of total billed charges", "standard_charge_dollar": 910.0, "standard_charge_percentage": 52.0, "count": "0", "additional_payer_notes": "Zero final payments for the item or service in the 15 months prior to posting the file." }, { "payer_name": "MERITAIN HEALTH", "plan_name": "AETNA ALL OTHER PLANS", "methodology": "percent of total billed charges", "standard_charge_dollar": 910.0, "standard_charge_percentage": 52.0, "count": "0", "additional_payer_notes": "Zero final payments for the item or service in the 15 months prior to posting the file." }, { "payer_name": "BLUE SHIELD OUT OF STATE", "plan_name": "STANFORD HEALTHCARE ALLIANCE PLAN", "methodology": "percent of total billed charges", "standard_charge_dollar": 850.33, "standard_charge_percentage": 48.59, "count": "0", "additional_payer_notes": "Zero final payments for the item or service in the 15 months prior to posting the file." }, { "payer_name": "BLUE SHIELD", "plan_name": "STANFORD HEALTHCARE ALLIANCE PLAN", "methodology": "percent of total billed charges", "standard_charge_dollar": 850.33, "standard_charge_percentage": 48.59, "median_amount": 68.24, "10th_percentile": 13.6, "90th_percentile": 1043.06, "count": "30" }, { "payer_name": "BLUE SHIELD", "plan_name": "STANFORD HEALTHCARE ALLIANCE PLAN", "methodology": "percent of total billed charges", "standard_charge_dollar": 850.33, "standard_charge_percentage": 48.59, "count": "0", "additional_payer_notes": "Zero final payments for the item or service in the 15 months prior to posting the file." }, { "payer_name": "BLUE SHIELD", "plan_name": "STANFORD HEALTHCARE ALLIANCE PLAN", "methodology": "percent of total billed charges", "standard_charge_dollar": 850.33, "standard_charge_percentage": 48.59, "count": "0", "additional_payer_notes": "Zero final payments for the item or service in the 15 months prior to posting the file." }, { "payer_name": "CIGNA", "plan_name": "CIGNA COM ALT HMO PLAN", "methodology": "percent of total billed charges", "standard_charge_dollar": 738.5, "standard_charge_percentage": 42.2, "count": "0", "additional_payer_notes": "Zero final payments for the item or service in the 15 months prior to posting the file." }, { "payer_name": "CIGNA", "plan_name": "CIGNA COM ALT HMO PLAN", "methodology": "percent of total billed charges", "standard_charge_dollar": 738.5, "standard_charge_percentage": 42.2, "count": "0", "additional_payer_notes": "Zero final payments for the item or service in the 15 months prior to posting the file." }, { "payer_name": "HEALTH NET", "plan_name": "HEALTHNET HMO, PPO, POS, EPO, CANOPY HEALTHNET HMO, OTHER-IN-NETWORK PLANS", "methodology": "per diem", "standard_charge_dollar": 8000.0, "standard_charge_algorithm": "Expected reimbursement is the lesser of Per diem ($8,000) for the length of stay and 70% of billed.", "count": "0", "additional_payer_notes": "Zero final payments for the item or service in the 15 months prior to posting the file." }, { "payer_name": "HEALTH NET", "plan_name": "HEALTHNET HMO, PPO, POS, EPO, CANOPY HEALTHNET HMO, OTHER-IN-NETWORK PLANS", "methodology": "per diem", "standard_charge_dollar": 8000.0, "standard_charge_algorithm": "Expected reimbursement is the lesser of Per diem ($8,000) for the length of stay and 70% of billed.", "count": "0", "additional_payer_notes": "Zero final payments for the item or service in the 15 months prior to posting the file." }, { "payer_name": "UNITED HEALTHCARE", "plan_name": "SUTTER SELECT & SUTTER HEALTH PLAN HMO PLANS", "methodology": "per diem", "standard_charge_dollar": 28538.0, "standard_charge_algorithm": "Per diem ($28,538).", "count": "0", "additional_payer_notes": "Zero final payments for the item or service in the 15 months prior to posting the file." }, { "payer_name": "UNITED HEALTHCARE", "plan_name": "SUTTER SELECT & SUTTER HEALTH PLAN HMO PLANS", "methodology": "per diem", "standard_charge_dollar": 28538.0, "standard_charge_algorithm": "Per diem ($28,538).", "count": "0", "additional_payer_notes": "Zero final payments for the item or service in the 15 months prior to posting the file." }, { "payer_name": "SUTTER", "plan_name": "SUTTER SELECT & SUTTER HEALTH PLAN HMO PLANS", "methodology": "per diem", "standard_charge_dollar": 28538.0, "standard_charge_algorithm": "Per diem ($28,538).", "count": "0", "additional_payer_notes": "Zero final payments for the item or service in the 15 months prior to posting the file." }, { "payer_name": "UNITED HEALTHCARE", "plan_name": "SUTTER SELECT & SUTTER HEALTH PLAN HMO PLANS", "methodology": "per diem", "standard_charge_dollar": 28538.0, "standard_charge_algorithm": "Per diem ($28,538).", "count": "0", "additional_payer_notes": "Zero final payments for the item or service in the 15 months prior to posting the file." }, { "payer_name": "UMR", "plan_name": "SUTTER SELECT & SUTTER HEALTH PLAN HMO PLANS", "methodology": "per diem", "standard_charge_dollar": 28538.0, "standard_charge_algorithm": "Per diem ($28,538).", "count": "0", "additional_payer_notes": "Zero final payments for the item or service in the 15 months prior to posting the file." } ] } ] }, { "description": "Hc Cable Seeg Electrode Gp019", "code_information": [ { "code": "PX-2120115019", "type": "CDM" }, { "code": "99999", "type": "CPT" }, { "code": "0272", "type": "RC" } ], "standard_charges": [ { "setting": "outpatient", "gross_charge": 2125.0, "discounted_cash": 1062.5, "minimum": 896.75, "maximum": 1105.0, "additional_generic_notes": "Zero final payments for the item or service in the 15 months prior to posting the file.", "payers_information": [ { "payer_name": "AETNA", "plan_name": "AETNA ALL OTHER PLANS", "methodology": "percent of total billed charges", "standard_charge_dollar": 1105.0, "standard_charge_percentage": 52.0, "count": "0", "additional_payer_notes": "Zero final payments for the item or service in the 15 months prior to posting the file." }, { "payer_name": "AETNA", "plan_name": "AETNA ALL OTHER PLANS", "methodology": "percent of total billed charges", "standard_charge_dollar": 1105.0, "standard_charge_percentage": 52.0, "count": "0", "additional_payer_notes": "Zero final payments for the item or service in the 15 months prior to posting the file." }, { "payer_name": "MERITAIN HEALTH", "plan_name": "AETNA ALL OTHER PLANS", "methodology": "percent of total billed charges", "standard_charge_dollar": 1105.0, "standard_charge_percentage": 52.0, "count": "0", "additional_payer_notes": "Zero final payments for the item or service in the 15 months prior to posting the file." }, { "payer_name": "BLUE SHIELD OUT OF STATE", "plan_name": "STANFORD HEALTHCARE ALLIANCE PLAN", "methodology": "percent of total billed charges", "standard_charge_dollar": 1032.54, "standard_charge_percentage": 48.59, "count": "0", "additional_payer_notes": "Zero final payments for the item or service in the 15 months prior to posting the file." }, { "payer_name": "BLUE SHIELD", "plan_name": "STANFORD HEALTHCARE ALLIANCE PLAN", "methodology": "percent of total billed charges", "standard_charge_dollar": 1032.54, "standard_charge_percentage": 48.59, "median_amount": 68.24, "10th_percentile": 13.6, "90th_percentile": 1043.06, "count": "30" }, { "payer_name": "BLUE SHIELD", "plan_name": "STANFORD HEALTHCARE ALLIANCE PLAN", "methodology": "percent of total billed charges", "standard_charge_dollar": 1032.54, "standard_charge_percentage": 48.59, "count": "0", "additional_payer_notes": "Zero final payments for the item or service in the 15 months prior to posting the file." }, { "payer_name": "BLUE SHIELD", "plan_name": "STANFORD HEALTHCARE ALLIANCE PLAN", "methodology": "percent of total billed charges", "standard_charge_dollar": 1032.54, "standard_charge_percentage": 48.59, "count": "0", "additional_payer_notes": "Zero final payments for the item or service in the 15 months prior to posting the file." }, { "payer_name": "CIGNA", "plan_name": "CIGNA COM ALT HMO PLAN", "methodology": "percent of total billed charges", "standard_charge_dollar": 896.75, "standard_charge_percentage": 42.2, "count": "0", "additional_payer_notes": "Zero final payments for the item or service in the 15 months prior to posting the file." }, { "payer_name": "CIGNA", "plan_name": "CIGNA COM ALT HMO PLAN", "methodology": "percent of total billed charges", "standard_charge_dollar": 896.75, "standard_charge_percentage": 42.2, "count": "0", "additional_payer_notes": "Zero final payments for the item or service in the 15 months prior to posting the file." }, { "payer_name": "HEALTH NET", "plan_name": "HEALTHNET HMO, PPO, POS, EPO, CANOPY HEALTHNET HMO, OTHER-IN-NETWORK PLANS", "methodology": "per diem", "standard_charge_dollar": 8000.0, "standard_charge_algorithm": "Expected reimbursement is the lesser of Per diem ($8,000) for the length of stay and 70% of billed.", "count": "0", "additional_payer_notes": "Zero final payments for the item or service in the 15 months prior to posting the file." }, { "payer_name": "HEALTH NET", "plan_name": "HEALTHNET HMO, PPO, POS, EPO, CANOPY HEALTHNET HMO, OTHER-IN-NETWORK PLANS", "methodology": "per diem", "standard_charge_dollar": 8000.0, "standard_charge_algorithm": "Expected reimbursement is the lesser of Per diem ($8,000) for the length of stay and 70% of billed.", "count": "0", "additional_payer_notes": "Zero final payments for the item or service in the 15 months prior to posting the file." }, { "payer_name": "UNITED HEALTHCARE", "plan_name": "SUTTER SELECT & SUTTER HEALTH PLAN HMO PLANS", "methodology": "per diem", "standard_charge_dollar": 28538.0, "standard_charge_algorithm": "Per diem ($28,538).", "count": "0", "additional_payer_notes": "Zero final payments for the item or service in the 15 months prior to posting the file." }, { "payer_name": "UNITED HEALTHCARE", "plan_name": "SUTTER SELECT & SUTTER HEALTH PLAN HMO PLANS", "methodology": "per diem", "standard_charge_dollar": 28538.0, "standard_charge_algorithm": "Per diem ($28,538).", "count": "0", "additional_payer_notes": "Zero final payments for the item or service in the 15 months prior to posting the file." }, { "payer_name": "SUTTER", "plan_name": "SUTTER SELECT & SUTTER HEALTH PLAN HMO PLANS", "methodology": "per diem", "standard_charge_dollar": 28538.0, "standard_charge_algorithm": "Per diem ($28,538).", "count": "0", "additional_payer_notes": "Zero final payments for the item or service in the 15 months prior to posting the file." }, { "payer_name": "UNITED HEALTHCARE", "plan_name": "SUTTER SELECT & SUTTER HEALTH PLAN HMO PLANS", "methodology": "per diem", "standard_charge_dollar": 28538.0, "standard_charge_algorithm": "Per diem ($28,538).", "count": "0", "additional_payer_notes": "Zero final payments for the item or service in the 15 months prior to posting the file." }, { "payer_name": "UMR", "plan_name": "SUTTER SELECT & SUTTER HEALTH PLAN HMO PLANS", "methodology": "per diem", "standard_charge_dollar": 28538.0, "standard_charge_algorithm": "Per diem ($28,538).", "count": "0", "additional_payer_notes": "Zero final payments for the item or service in the 15 months prior to posting the file." } ] } ] }, { "description": "HC Cable Seeg Electrode Gp027", "code_information": [ { "code": "PX-2120115027", "type": "CDM" }, { "code": "99999", "type": "CPT" }, { "code": "0272", "type": "RC" } ], "standard_charges": [ { "setting": "outpatient", "gross_charge": 4875.0, "discounted_cash": 2437.5, "minimum": 2057.25, "maximum": 2535.0, "additional_generic_notes": "Zero final payments for the item or service in the 15 months prior to posting the file.", "payers_information": [ { "payer_name": "AETNA", "plan_name": "AETNA ALL OTHER PLANS", "methodology": "percent of total billed charges", "standard_charge_dollar": 2535.0, "standard_charge_percentage": 52.0, "count": "0", "additional_payer_notes": "Zero final payments for the item or service in the 15 months prior to posting the file." }, { "payer_name": "AETNA", "plan_name": "AETNA ALL OTHER PLANS", "methodology": "percent of total billed charges", "standard_charge_dollar": 2535.0, "standard_charge_percentage": 52.0, "count": "0", "additional_payer_notes": "Zero final payments for the item or service in the 15 months prior to posting the file." }, { "payer_name": "MERITAIN HEALTH", "plan_name": "AETNA ALL OTHER PLANS", "methodology": "percent of total billed charges", "standard_charge_dollar": 2535.0, "standard_charge_percentage": 52.0, "count": "0", "additional_payer_notes": "Zero final payments for the item or service in the 15 months prior to posting the file." }, { "payer_name": "BLUE SHIELD OUT OF STATE", "plan_name": "STANFORD HEALTHCARE ALLIANCE PLAN", "methodology": "percent of total billed charges", "standard_charge_dollar": 2368.76, "standard_charge_percentage": 48.59, "count": "0", "additional_payer_notes": "Zero final payments for the item or service in the 15 months prior to posting the file." }, { "payer_name": "BLUE SHIELD", "plan_name": "STANFORD HEALTHCARE ALLIANCE PLAN", "methodology": "percent of total billed charges", "standard_charge_dollar": 2368.76, "standard_charge_percentage": 48.59, "median_amount": 68.24, "10th_percentile": 13.6, "90th_percentile": 1043.06, "count": "30" }, { "payer_name": "BLUE SHIELD", "plan_name": "STANFORD HEALTHCARE ALLIANCE PLAN", "methodology": "percent of total billed charges", "standard_charge_dollar": 2368.76, "standard_charge_percentage": 48.59, "count": "0", "additional_payer_notes": "Zero final payments for the item or service in the 15 months prior to posting the file." }, { "payer_name": "BLUE SHIELD", "plan_name": "STANFORD HEALTHCARE ALLIANCE PLAN", "methodology": "percent of total billed charges", "standard_charge_dollar": 2368.76, "standard_charge_percentage": 48.59, "count": "0", "additional_payer_notes": "Zero final payments for the item or service in the 15 months prior to posting the file." }, { "payer_name": "CIGNA", "plan_name": "CIGNA COM ALT HMO PLAN", "methodology": "percent of total billed charges", "standard_charge_dollar": 2057.25, "standard_charge_percentage": 42.2, "count": "0", "additional_payer_notes": "Zero final payments for the item or service in the 15 months prior to posting the file." }, { "payer_name": "CIGNA", "plan_name": "CIGNA COM ALT HMO PLAN", "methodology": "percent of total billed charges", "standard_charge_dollar": 2057.25, "standard_charge_percentage": 42.2, "count": "0", "additional_payer_notes": "Zero final payments for the item or service in the 15 months prior to posting the file." }, { "payer_name": "HEALTH NET", "plan_name": "HEALTHNET HMO, PPO, POS, EPO, CANOPY HEALTHNET HMO, OTHER-IN-NETWORK PLANS", "methodology": "per diem", "standard_charge_dollar": 8000.0, "standard_charge_algorithm": "Expected reimbursement is the lesser of Per diem ($8,000) for the length of stay and 70% of billed.", "count": "0", "additional_payer_notes": "Zero final payments for the item or service in the 15 months prior to posting the file." }, { "payer_name": "HEALTH NET", "plan_name": "HEALTHNET HMO, PPO, POS, EPO, CANOPY HEALTHNET HMO, OTHER-IN-NETWORK PLANS", "methodology": "per diem", "standard_charge_dollar": 8000.0, "standard_charge_algorithm": "Expected reimbursement is the lesser of Per diem ($8,000) for the length of stay and 70% of billed.", "count": "0", "additional_payer_notes": "Zero final payments for the item or service in the 15 months prior to posting the file." }, { "payer_name": "UNITED HEALTHCARE", "plan_name": "SUTTER SELECT & SUTTER HEALTH PLAN HMO PLANS", "methodology": "per diem", "standard_charge_dollar": 28538.0, "standard_charge_algorithm": "Per diem ($28,538).", "count": "0", "additional_payer_notes": "Zero final payments for the item or service in the 15 months prior to posting the file." }, { "payer_name": "UNITED HEALTHCARE", "plan_name": "SUTTER SELECT & SUTTER HEALTH PLAN HMO PLANS", "methodology": "per diem", "standard_charge_dollar": 28538.0, "standard_charge_algorithm": "Per diem ($28,538).", "count": "0", "additional_payer_notes": "Zero final payments for the item or service in the 15 months prior to posting the file." }, { "payer_name": "SUTTER", "plan_name": "SUTTER SELECT & SUTTER HEALTH PLAN HMO PLANS", "methodology": "per diem", "standard_charge_dollar": 28538.0, "standard_charge_algorithm": "Per diem ($28,538).", "count": "0", "additional_payer_notes": "Zero final payments for the item or service in the 15 months prior to posting the file." }, { "payer_name": "UNITED HEALTHCARE", "plan_name": "SUTTER SELECT & SUTTER HEALTH PLAN HMO PLANS", "methodology": "per diem", "standard_charge_dollar": 28538.0, "standard_charge_algorithm": "Per diem ($28,538).", "count": "0", "additional_payer_notes": "Zero final payments for the item or service in the 15 months prior to posting the file." }, { "payer_name": "UMR", "plan_name": "SUTTER SELECT & SUTTER HEALTH PLAN HMO PLANS", "methodology": "per diem", "standard_charge_dollar": 28538.0, "standard_charge_algorithm": "Per diem ($28,538).", "count": "0", "additional_payer_notes": "Zero final payments for the item or service in the 15 months prior to posting the file." } ] } ] }, { "description": "HC Cable Seeg Electrode Gp033", "code_information": [ { "code": "PX-2120115033", "type": "CDM" }, { "code": "99999", "type": "CPT" }, { "code": "0272", "type": "RC" } ], "standard_charges": [ { "setting": "outpatient", "gross_charge": 6413.0, "discounted_cash": 3206.5, "minimum": 2706.29, "maximum": 3334.76, "additional_generic_notes": "Zero final payments for the item or service in the 15 months prior to posting the file.", "payers_information": [ { "payer_name": "AETNA", "plan_name": "AETNA ALL OTHER PLANS", "methodology": "percent of total billed charges", "standard_charge_dollar": 3334.76, "standard_charge_percentage": 52.0, "count": "0", "additional_payer_notes": "Zero final payments for the item or service in the 15 months prior to posting the file." }, { "payer_name": "AETNA", "plan_name": "AETNA ALL OTHER PLANS", "methodology": "percent of total billed charges", "standard_charge_dollar": 3334.76, "standard_charge_percentage": 52.0, "count": "0", "additional_payer_notes": "Zero final payments for the item or service in the 15 months prior to posting the file." }, { "payer_name": "MERITAIN HEALTH", "plan_name": "AETNA ALL OTHER PLANS", "methodology": "percent of total billed charges", "standard_charge_dollar": 3334.76, "standard_charge_percentage": 52.0, "count": "0", "additional_payer_notes": "Zero final payments for the item or service in the 15 months prior to posting the file." }, { "payer_name": "BLUE SHIELD OUT OF STATE", "plan_name": "STANFORD HEALTHCARE ALLIANCE PLAN", "methodology": "percent of total billed charges", "standard_charge_dollar": 3116.08, "standard_charge_percentage": 48.59, "count": "0", "additional_payer_notes": "Zero final payments for the item or service in the 15 months prior to posting the file." }, { "payer_name": "BLUE SHIELD", "plan_name": "STANFORD HEALTHCARE ALLIANCE PLAN", "methodology": "percent of total billed charges", "standard_charge_dollar": 3116.08, "standard_charge_percentage": 48.59, "median_amount": 68.24, "10th_percentile": 13.6, "90th_percentile": 1043.06, "count": "30" }, { "payer_name": "BLUE SHIELD", "plan_name": "STANFORD HEALTHCARE ALLIANCE PLAN", "methodology": "percent of total billed charges", "standard_charge_dollar": 3116.08, "standard_charge_percentage": 48.59, "count": "0", "additional_payer_notes": "Zero final payments for the item or service in the 15 months prior to posting the file." }, { "payer_name": "BLUE SHIELD", "plan_name": "STANFORD HEALTHCARE ALLIANCE PLAN", "methodology": "percent of total billed charges", "standard_charge_dollar": 3116.08, "standard_charge_percentage": 48.59, "count": "0", "additional_payer_notes": "Zero final payments for the item or service in the 15 months prior to posting the file." }, { "payer_name": "CIGNA", "plan_name": "CIGNA COM ALT HMO PLAN", "methodology": "percent of total billed charges", "standard_charge_dollar": 2706.29, "standard_charge_percentage": 42.2, "count": "0", "additional_payer_notes": "Zero final payments for the item or service in the 15 months prior to posting the file." }, { "payer_name": "CIGNA", "plan_name": "CIGNA COM ALT HMO PLAN", "methodology": "percent of total billed charges", "standard_charge_dollar": 2706.29, "standard_charge_percentage": 42.2, "count": "0", "additional_payer_notes": "Zero final payments for the item or service in the 15 months prior to posting the file." }, { "payer_name": "HEALTH NET", "plan_name": "HEALTHNET HMO, PPO, POS, EPO, CANOPY HEALTHNET HMO, OTHER-IN-NETWORK PLANS", "methodology": "per diem", "standard_charge_dollar": 8000.0, "standard_charge_algorithm": "Expected reimbursement is the lesser of Per diem ($8,000) for the length of stay and 70% of billed.", "count": "0", "additional_payer_notes": "Zero final payments for the item or service in the 15 months prior to posting the file." }, { "payer_name": "HEALTH NET", "plan_name": "HEALTHNET HMO, PPO, POS, EPO, CANOPY HEALTHNET HMO, OTHER-IN-NETWORK PLANS", "methodology": "per diem", "standard_charge_dollar": 8000.0, "standard_charge_algorithm": "Expected reimbursement is the lesser of Per diem ($8,000) for the length of stay and 70% of billed.", "count": "0", "additional_payer_notes": "Zero final payments for the item or service in the 15 months prior to posting the file." }, { "payer_name": "UNITED HEALTHCARE", "plan_name": "SUTTER SELECT & SUTTER HEALTH PLAN HMO PLANS", "methodology": "per diem", "standard_charge_dollar": 28538.0, "standard_charge_algorithm": "Per diem ($28,538).", "count": "0", "additional_payer_notes": "Zero final payments for the item or service in the 15 months prior to posting the file." }, { "payer_name": "UNITED HEALTHCARE", "plan_name": "SUTTER SELECT & SUTTER HEALTH PLAN HMO PLANS", "methodology": "per diem", "standard_charge_dollar": 28538.0, "standard_charge_algorithm": "Per diem ($28,538).", "count": "0", "additional_payer_notes": "Zero final payments for the item or service in the 15 months prior to posting the file." }, { "payer_name": "SUTTER", "plan_name": "SUTTER SELECT & SUTTER HEALTH PLAN HMO PLANS", "methodology": "per diem", "standard_charge_dollar": 28538.0, "standard_charge_algorithm": "Per diem ($28,538).", "count": "0", "additional_payer_notes": "Zero final payments for the item or service in the 15 months prior to posting the file." }, { "payer_name": "UNITED HEALTHCARE", "plan_name": "SUTTER SELECT & SUTTER HEALTH PLAN HMO PLANS", "methodology": "per diem", "standard_charge_dollar": 28538.0, "standard_charge_algorithm": "Per diem ($28,538).", "count": "0", "additional_payer_notes": "Zero final payments for the item or service in the 15 months prior to posting the file." }, { "payer_name": "UMR", "plan_name": "SUTTER SELECT & SUTTER HEALTH PLAN HMO PLANS", "methodology": "per diem", "standard_charge_dollar": 28538.0, "standard_charge_algorithm": "Per diem ($28,538).", "count": "0", "additional_payer_notes": "Zero final payments for the item or service in the 15 months prior to posting the file." } ] } ] }, { "description": "HC Ndl Cryoablation Gp037", "code_information": [ { "code": "PX-2120119037", "type": "CDM" }, { "code": "99999", "type": "CPT" }, { "code": "0272", "type": "RC" } ], "standard_charges": [ { "setting": "outpatient", "gross_charge": 8125.0, "discounted_cash": 4062.5, "minimum": 3428.75, "maximum": 4225.0, "additional_generic_notes": "Zero final payments for the item or service in the 15 months prior to posting the file.", "payers_information": [ { "payer_name": "AETNA", "plan_name": "AETNA ALL OTHER PLANS", "methodology": "percent of total billed charges", "standard_charge_dollar": 4225.0, "standard_charge_percentage": 52.0, "count": "0", "additional_payer_notes": "Zero final payments for the item or service in the 15 months prior to posting the file." }, { "payer_name": "AETNA", "plan_name": "AETNA ALL OTHER PLANS", "methodology": "percent of total billed charges", "standard_charge_dollar": 4225.0, "standard_charge_percentage": 52.0, "count": "0", "additional_payer_notes": "Zero final payments for the item or service in the 15 months prior to posting the file." }, { "payer_name": "MERITAIN HEALTH", "plan_name": "AETNA ALL OTHER PLANS", "methodology": "percent of total billed charges", "standard_charge_dollar": 4225.0, "standard_charge_percentage": 52.0, "count": "0", "additional_payer_notes": "Zero final payments for the item or service in the 15 months prior to posting the file." }, { "payer_name": "BLUE SHIELD OUT OF STATE", "plan_name": "STANFORD HEALTHCARE ALLIANCE PLAN", "methodology": "percent of total billed charges", "standard_charge_dollar": 3947.94, "standard_charge_percentage": 48.59, "count": "0", "additional_payer_notes": "Zero final payments for the item or service in the 15 months prior to posting the file." }, { "payer_name": "BLUE SHIELD", "plan_name": "STANFORD HEALTHCARE ALLIANCE PLAN", "methodology": "percent of total billed charges", "standard_charge_dollar": 3947.94, "standard_charge_percentage": 48.59, "median_amount": 68.24, "10th_percentile": 13.6, "90th_percentile": 1043.06, "count": "30" }, { "payer_name": "BLUE SHIELD", "plan_name": "STANFORD HEALTHCARE ALLIANCE PLAN", "methodology": "percent of total billed charges", "standard_charge_dollar": 3947.94, "standard_charge_percentage": 48.59, "count": "0", "additional_payer_notes": "Zero final payments for the item or service in the 15 months prior to posting the file." }, { "payer_name": "BLUE SHIELD", "plan_name": "STANFORD HEALTHCARE ALLIANCE PLAN", "methodology": "percent of total billed charges", "standard_charge_dollar": 3947.94, "standard_charge_percentage": 48.59, "count": "0", "additional_payer_notes": "Zero final payments for the item or service in the 15 months prior to posting the file." }, { "payer_name": "CIGNA", "plan_name": "CIGNA COM ALT HMO PLAN", "methodology": "percent of total billed charges", "standard_charge_dollar": 3428.75, "standard_charge_percentage": 42.2, "count": "0", "additional_payer_notes": "Zero final payments for the item or service in the 15 months prior to posting the file." }, { "payer_name": "CIGNA", "plan_name": "CIGNA COM ALT HMO PLAN", "methodology": "percent of total billed charges", "standard_charge_dollar": 3428.75, "standard_charge_percentage": 42.2, "count": "0", "additional_payer_notes": "Zero final payments for the item or service in the 15 months prior to posting the file." }, { "payer_name": "HEALTH NET", "plan_name": "HEALTHNET HMO, PPO, POS, EPO, CANOPY HEALTHNET HMO, OTHER-IN-NETWORK PLANS", "methodology": "per diem", "standard_charge_dollar": 8000.0, "standard_charge_algorithm": "Expected reimbursement is the lesser of Per diem ($8,000) for the length of stay and 70% of billed.", "count": "0", "additional_payer_notes": "Zero final payments for the item or service in the 15 months prior to posting the file." }, { "payer_name": "HEALTH NET", "plan_name": "HEALTHNET HMO, PPO, POS, EPO, CANOPY HEALTHNET HMO, OTHER-IN-NETWORK PLANS", "methodology": "per diem", "standard_charge_dollar": 8000.0, "standard_charge_algorithm": "Expected reimbursement is the lesser of Per diem ($8,000) for the length of stay and 70% of billed.", "count": "0", "additional_payer_notes": "Zero final payments for the item or service in the 15 months prior to posting the file." }, { "payer_name": "UNITED HEALTHCARE", "plan_name": "SUTTER SELECT & SUTTER HEALTH PLAN HMO PLANS", "methodology": "per diem", "standard_charge_dollar": 28538.0, "standard_charge_algorithm": "Per diem ($28,538).", "count": "0", "additional_payer_notes": "Zero final payments for the item or service in the 15 months prior to posting the file." }, { "payer_name": "UNITED HEALTHCARE", "plan_name": "SUTTER SELECT & SUTTER HEALTH PLAN HMO PLANS", "methodology": "per diem", "standard_charge_dollar": 28538.0, "standard_charge_algorithm": "Per diem ($28,538).", "count": "0", "additional_payer_notes": "Zero final payments for the item or service in the 15 months prior to posting the file." }, { "payer_name": "SUTTER", "plan_name": "SUTTER SELECT & SUTTER HEALTH PLAN HMO PLANS", "methodology": "per diem", "standard_charge_dollar": 28538.0, "standard_charge_algorithm": "Per diem ($28,538).", "count": "0", "additional_payer_notes": "Zero final payments for the item or service in the 15 months prior to posting the file." }, { "payer_name": "UNITED HEALTHCARE", "plan_name": "SUTTER SELECT & SUTTER HEALTH PLAN HMO PLANS", "methodology": "per diem", "standard_charge_dollar": 28538.0, "standard_charge_algorithm": "Per diem ($28,538).", "count": "0", "additional_payer_notes": "Zero final payments for the item or service in the 15 months prior to posting the file." }, { "payer_name": "UMR", "plan_name": "SUTTER SELECT & SUTTER HEALTH PLAN HMO PLANS", "methodology": "per diem", "standard_charge_dollar": 28538.0, "standard_charge_algorithm": "Per diem ($28,538).", "count": "0", "additional_payer_notes": "Zero final payments for the item or service in the 15 months prior to posting the file." } ] } ] }, { "description": "HC System Surg Omni Gp038", "code_information": [ { "code": "PX-2120135038", "type": "CDM" }, { "code": "99999", "type": "CPT" }, { "code": "0272", "type": "RC" } ], "standard_charges": [ { "setting": "outpatient", "gross_charge": 8750.0, "discounted_cash": 4375.0, "minimum": 3692.5, "maximum": 4550.0, "additional_generic_notes": "Zero final payments for the item or service in the 15 months prior to posting the file.", "payers_information": [ { "payer_name": "AETNA", "plan_name": "AETNA ALL OTHER PLANS", "methodology": "percent of total billed charges", "standard_charge_dollar": 4550.0, "standard_charge_percentage": 52.0, "count": "0", "additional_payer_notes": "Zero final payments for the item or service in the 15 months prior to posting the file." }, { "payer_name": "AETNA", "plan_name": "AETNA ALL OTHER PLANS", "methodology": "percent of total billed charges", "standard_charge_dollar": 4550.0, "standard_charge_percentage": 52.0, "count": "0", "additional_payer_notes": "Zero final payments for the item or service in the 15 months prior to posting the file." }, { "payer_name": "MERITAIN HEALTH", "plan_name": "AETNA ALL OTHER PLANS", "methodology": "percent of total billed charges", "standard_charge_dollar": 4550.0, "standard_charge_percentage": 52.0, "count": "0", "additional_payer_notes": "Zero final payments for the item or service in the 15 months prior to posting the file." }, { "payer_name": "BLUE SHIELD OUT OF STATE", "plan_name": "STANFORD HEALTHCARE ALLIANCE PLAN", "methodology": "percent of total billed charges", "standard_charge_dollar": 4251.63, "standard_charge_percentage": 48.59, "count": "0", "additional_payer_notes": "Zero final payments for the item or service in the 15 months prior to posting the file." }, { "payer_name": "BLUE SHIELD", "plan_name": "STANFORD HEALTHCARE ALLIANCE PLAN", "methodology": "percent of total billed charges", "standard_charge_dollar": 4251.63, "standard_charge_percentage": 48.59, "median_amount": 68.24, "10th_percentile": 13.6, "90th_percentile": 1043.06, "count": "30" }, { "payer_name": "BLUE SHIELD", "plan_name": "STANFORD HEALTHCARE ALLIANCE PLAN", "methodology": "percent of total billed charges", "standard_charge_dollar": 4251.63, "standard_charge_percentage": 48.59, "count": "0", "additional_payer_notes": "Zero final payments for the item or service in the 15 months prior to posting the file." }, { "payer_name": "BLUE SHIELD", "plan_name": "STANFORD HEALTHCARE ALLIANCE PLAN", "methodology": "percent of total billed charges", "standard_charge_dollar": 4251.63, "standard_charge_percentage": 48.59, "count": "0", "additional_payer_notes": "Zero final payments for the item or service in the 15 months prior to posting the file." }, { "payer_name": "CIGNA", "plan_name": "CIGNA COM ALT HMO PLAN", "methodology": "percent of total billed charges", "standard_charge_dollar": 3692.5, "standard_charge_percentage": 42.2, "count": "0", "additional_payer_notes": "Zero final payments for the item or service in the 15 months prior to posting the file." }, { "payer_name": "CIGNA", "plan_name": "CIGNA COM ALT HMO PLAN", "methodology": "percent of total billed charges", "standard_charge_dollar": 3692.5, "standard_charge_percentage": 42.2, "count": "0", "additional_payer_notes": "Zero final payments for the item or service in the 15 months prior to posting the file." }, { "payer_name": "HEALTH NET", "plan_name": "HEALTHNET HMO, PPO, POS, EPO, CANOPY HEALTHNET HMO, OTHER-IN-NETWORK PLANS", "methodology": "per diem", "standard_charge_dollar": 8000.0, "standard_charge_algorithm": "Expected reimbursement is the lesser of Per diem ($8,000) for the length of stay and 70% of billed.", "count": "0", "additional_payer_notes": "Zero final payments for the item or service in the 15 months prior to posting the file." }, { "payer_name": "HEALTH NET", "plan_name": "HEALTHNET HMO, PPO, POS, EPO, CANOPY HEALTHNET HMO, OTHER-IN-NETWORK PLANS", "methodology": "per diem", "standard_charge_dollar": 8000.0, "standard_charge_algorithm": "Expected reimbursement is the lesser of Per diem ($8,000) for the length of stay and 70% of billed.", "count": "0", "additional_payer_notes": "Zero final payments for the item or service in the 15 months prior to posting the file." }, { "payer_name": "UNITED HEALTHCARE", "plan_name": "SUTTER SELECT & SUTTER HEALTH PLAN HMO PLANS", "methodology": "per diem", "standard_charge_dollar": 28538.0, "standard_charge_algorithm": "Per diem ($28,538).", "count": "0", "additional_payer_notes": "Zero final payments for the item or service in the 15 months prior to posting the file." }, { "payer_name": "UNITED HEALTHCARE", "plan_name": "SUTTER SELECT & SUTTER HEALTH PLAN HMO PLANS", "methodology": "per diem", "standard_charge_dollar": 28538.0, "standard_charge_algorithm": "Per diem ($28,538).", "count": "0", "additional_payer_notes": "Zero final payments for the item or service in the 15 months prior to posting the file." }, { "payer_name": "SUTTER", "plan_name": "SUTTER SELECT & SUTTER HEALTH PLAN HMO PLANS", "methodology": "per diem", "standard_charge_dollar": 28538.0, "standard_charge_algorithm": "Per diem ($28,538).", "count": "0", "additional_payer_notes": "Zero final payments for the item or service in the 15 months prior to posting the file." }, { "payer_name": "UNITED HEALTHCARE", "plan_name": "SUTTER SELECT & SUTTER HEALTH PLAN HMO PLANS", "methodology": "per diem", "standard_charge_dollar": 28538.0, "standard_charge_algorithm": "Per diem ($28,538).", "count": "0", "additional_payer_notes": "Zero final payments for the item or service in the 15 months prior to posting the file." }, { "payer_name": "UMR", "plan_name": "SUTTER SELECT & SUTTER HEALTH PLAN HMO PLANS", "methodology": "per diem", "standard_charge_dollar": 28538.0, "standard_charge_algorithm": "Per diem ($28,538).", "count": "0", "additional_payer_notes": "Zero final payments for the item or service in the 15 months prior to posting the file." } ] } ] }, { "description": "HC System Surg Omni Gp040", "code_information": [ { "code": "PX-2120135040", "type": "CDM" }, { "code": "99999", "type": "CPT" }, { "code": "0272", "type": "RC" } ], "standard_charges": [ { "setting": "outpatient", "gross_charge": 9600.0, "discounted_cash": 4800.0, "minimum": 4051.2, "maximum": 4992.0, "additional_generic_notes": "Zero final payments for the item or service in the 15 months prior to posting the file.", "payers_information": [ { "payer_name": "AETNA", "plan_name": "AETNA ALL OTHER PLANS", "methodology": "percent of total billed charges", "standard_charge_dollar": 4992.0, "standard_charge_percentage": 52.0, "count": "0", "additional_payer_notes": "Zero final payments for the item or service in the 15 months prior to posting the file." }, { "payer_name": "AETNA", "plan_name": "AETNA ALL OTHER PLANS", "methodology": "percent of total billed charges", "standard_charge_dollar": 4992.0, "standard_charge_percentage": 52.0, "count": "0", "additional_payer_notes": "Zero final payments for the item or service in the 15 months prior to posting the file." }, { "payer_name": "MERITAIN HEALTH", "plan_name": "AETNA ALL OTHER PLANS", "methodology": "percent of total billed charges", "standard_charge_dollar": 4992.0, "standard_charge_percentage": 52.0, "count": "0", "additional_payer_notes": "Zero final payments for the item or service in the 15 months prior to posting the file." }, { "payer_name": "BLUE SHIELD OUT OF STATE", "plan_name": "STANFORD HEALTHCARE ALLIANCE PLAN", "methodology": "percent of total billed charges", "standard_charge_dollar": 4664.64, "standard_charge_percentage": 48.59, "count": "0", "additional_payer_notes": "Zero final payments for the item or service in the 15 months prior to posting the file." }, { "payer_name": "BLUE SHIELD", "plan_name": "STANFORD HEALTHCARE ALLIANCE PLAN", "methodology": "percent of total billed charges", "standard_charge_dollar": 4664.64, "standard_charge_percentage": 48.59, "median_amount": 68.24, "10th_percentile": 13.6, "90th_percentile": 1043.06, "count": "30" }, { "payer_name": "BLUE SHIELD", "plan_name": "STANFORD HEALTHCARE ALLIANCE PLAN", "methodology": "percent of total billed charges", "standard_charge_dollar": 4664.64, "standard_charge_percentage": 48.59, "count": "0", "additional_payer_notes": "Zero final payments for the item or service in the 15 months prior to posting the file." }, { "payer_name": "BLUE SHIELD", "plan_name": "STANFORD HEALTHCARE ALLIANCE PLAN", "methodology": "percent of total billed charges", "standard_charge_dollar": 4664.64, "standard_charge_percentage": 48.59, "count": "0", "additional_payer_notes": "Zero final payments for the item or service in the 15 months prior to posting the file." }, { "payer_name": "CIGNA", "plan_name": "CIGNA COM ALT HMO PLAN", "methodology": "percent of total billed charges", "standard_charge_dollar": 4051.2, "standard_charge_percentage": 42.2, "count": "0", "additional_payer_notes": "Zero final payments for the item or service in the 15 months prior to posting the file." }, { "payer_name": "CIGNA", "plan_name": "CIGNA COM ALT HMO PLAN", "methodology": "percent of total billed charges", "standard_charge_dollar": 4051.2, "standard_charge_percentage": 42.2, "count": "0", "additional_payer_notes": "Zero final payments for the item or service in the 15 months prior to posting the file." }, { "payer_name": "HEALTH NET", "plan_name": "HEALTHNET HMO, PPO, POS, EPO, CANOPY HEALTHNET HMO, OTHER-IN-NETWORK PLANS", "methodology": "per diem", "standard_charge_dollar": 8000.0, "standard_charge_algorithm": "Expected reimbursement is the lesser of Per diem ($8,000) for the length of stay and 70% of billed.", "count": "0", "additional_payer_notes": "Zero final payments for the item or service in the 15 months prior to posting the file." }, { "payer_name": "HEALTH NET", "plan_name": "HEALTHNET HMO, PPO, POS, EPO, CANOPY HEALTHNET HMO, OTHER-IN-NETWORK PLANS", "methodology": "per diem", "standard_charge_dollar": 8000.0, "standard_charge_algorithm": "Expected reimbursement is the lesser of Per diem ($8,000) for the length of stay and 70% of billed.", "count": "0", "additional_payer_notes": "Zero final payments for the item or service in the 15 months prior to posting the file." }, { "payer_name": "UNITED HEALTHCARE", "plan_name": "SUTTER SELECT & SUTTER HEALTH PLAN HMO PLANS", "methodology": "per diem", "standard_charge_dollar": 28538.0, "standard_charge_algorithm": "Per diem ($28,538).", "count": "0", "additional_payer_notes": "Zero final payments for the item or service in the 15 months prior to posting the file." }, { "payer_name": "UNITED HEALTHCARE", "plan_name": "SUTTER SELECT & SUTTER HEALTH PLAN HMO PLANS", "methodology": "per diem", "standard_charge_dollar": 28538.0, "standard_charge_algorithm": "Per diem ($28,538).", "count": "0", "additional_payer_notes": "Zero final payments for the item or service in the 15 months prior to posting the file." }, { "payer_name": "SUTTER", "plan_name": "SUTTER SELECT & SUTTER HEALTH PLAN HMO PLANS", "methodology": "per diem", "standard_charge_dollar": 28538.0, "standard_charge_algorithm": "Per diem ($28,538).", "count": "0", "additional_payer_notes": "Zero final payments for the item or service in the 15 months prior to posting the file." }, { "payer_name": "UNITED HEALTHCARE", "plan_name": "SUTTER SELECT & SUTTER HEALTH PLAN HMO PLANS", "methodology": "per diem", "standard_charge_dollar": 28538.0, "standard_charge_algorithm": "Per diem ($28,538).", "count": "0", "additional_payer_notes": "Zero final payments for the item or service in the 15 months prior to posting the file." }, { "payer_name": "UMR", "plan_name": "SUTTER SELECT & SUTTER HEALTH PLAN HMO PLANS", "methodology": "per diem", "standard_charge_dollar": 28538.0, "standard_charge_algorithm": "Per diem ($28,538).", "count": "0", "additional_payer_notes": "Zero final payments for the item or service in the 15 months prior to posting the file." } ] } ] }, { "description": "HC Distractor Kit Gp076", "code_information": [ { "code": "PX-2120137076", "type": "CDM" }, { "code": "99999", "type": "CPT" }, { "code": "0272", "type": "RC" } ], "standard_charges": [ { "setting": "outpatient", "gross_charge": 33600.0, "discounted_cash": 16800.0, "minimum": 14179.2, "maximum": 17472.0, "additional_generic_notes": "Zero final payments for the item or service in the 15 months prior to posting the file.", "payers_information": [ { "payer_name": "AETNA", "plan_name": "AETNA ALL OTHER PLANS", "methodology": "percent of total billed charges", "standard_charge_dollar": 17472.0, "standard_charge_percentage": 52.0, "count": "0", "additional_payer_notes": "Zero final payments for the item or service in the 15 months prior to posting the file." }, { "payer_name": "AETNA", "plan_name": "AETNA ALL OTHER PLANS", "methodology": "percent of total billed charges", "standard_charge_dollar": 17472.0, "standard_charge_percentage": 52.0, "count": "0", "additional_payer_notes": "Zero final payments for the item or service in the 15 months prior to posting the file." }, { "payer_name": "MERITAIN HEALTH", "plan_name": "AETNA ALL OTHER PLANS", "methodology": "percent of total billed charges", "standard_charge_dollar": 17472.0, "standard_charge_percentage": 52.0, "count": "0", "additional_payer_notes": "Zero final payments for the item or service in the 15 months prior to posting the file." }, { "payer_name": "BLUE SHIELD OUT OF STATE", "plan_name": "STANFORD HEALTHCARE ALLIANCE PLAN", "methodology": "percent of total billed charges", "standard_charge_dollar": 16326.24, "standard_charge_percentage": 48.59, "count": "0", "additional_payer_notes": "Zero final payments for the item or service in the 15 months prior to posting the file." }, { "payer_name": "BLUE SHIELD", "plan_name": "STANFORD HEALTHCARE ALLIANCE PLAN", "methodology": "percent of total billed charges", "standard_charge_dollar": 16326.24, "standard_charge_percentage": 48.59, "median_amount": 68.24, "10th_percentile": 13.6, "90th_percentile": 1043.06, "count": "30" }, { "payer_name": "BLUE SHIELD", "plan_name": "STANFORD HEALTHCARE ALLIANCE PLAN", "methodology": "percent of total billed charges", "standard_charge_dollar": 16326.24, "standard_charge_percentage": 48.59, "count": "0", "additional_payer_notes": "Zero final payments for the item or service in the 15 months prior to posting the file." }, { "payer_name": "BLUE SHIELD", "plan_name": "STANFORD HEALTHCARE ALLIANCE PLAN", "methodology": "percent of total billed charges", "standard_charge_dollar": 16326.24, "standard_charge_percentage": 48.59, "count": "0", "additional_payer_notes": "Zero final payments for the item or service in the 15 months prior to posting the file." }, { "payer_name": "CIGNA", "plan_name": "CIGNA COM ALT HMO PLAN", "methodology": "percent of total billed charges", "standard_charge_dollar": 14179.2, "standard_charge_percentage": 42.2, "count": "0", "additional_payer_notes": "Zero final payments for the item or service in the 15 months prior to posting the file." }, { "payer_name": "CIGNA", "plan_name": "CIGNA COM ALT HMO PLAN", "methodology": "percent of total billed charges", "standard_charge_dollar": 14179.2, "standard_charge_percentage": 42.2, "count": "0", "additional_payer_notes": "Zero final payments for the item or service in the 15 months prior to posting the file." }, { "payer_name": "HEALTH NET", "plan_name": "HEALTHNET HMO, PPO, POS, EPO, CANOPY HEALTHNET HMO, OTHER-IN-NETWORK PLANS", "methodology": "per diem", "standard_charge_dollar": 8000.0, "standard_charge_algorithm": "Expected reimbursement is the lesser of Per diem ($8,000) for the length of stay and 70% of billed.", "count": "0", "additional_payer_notes": "Zero final payments for the item or service in the 15 months prior to posting the file." }, { "payer_name": "HEALTH NET", "plan_name": "HEALTHNET HMO, PPO, POS, EPO, CANOPY HEALTHNET HMO, OTHER-IN-NETWORK PLANS", "methodology": "per diem", "standard_charge_dollar": 8000.0, "standard_charge_algorithm": "Expected reimbursement is the lesser of Per diem ($8,000) for the length of stay and 70% of billed.", "count": "0", "additional_payer_notes": "Zero final payments for the item or service in the 15 months prior to posting the file." }, { "payer_name": "UNITED HEALTHCARE", "plan_name": "SUTTER SELECT & SUTTER HEALTH PLAN HMO PLANS", "methodology": "per diem", "standard_charge_dollar": 28538.0, "standard_charge_algorithm": "Per diem ($28,538).", "count": "0", "additional_payer_notes": "Zero final payments for the item or service in the 15 months prior to posting the file." }, { "payer_name": "UNITED HEALTHCARE", "plan_name": "SUTTER SELECT & SUTTER HEALTH PLAN HMO PLANS", "methodology": "per diem", "standard_charge_dollar": 28538.0, "standard_charge_algorithm": "Per diem ($28,538).", "count": "0", "additional_payer_notes": "Zero final payments for the item or service in the 15 months prior to posting the file." }, { "payer_name": "SUTTER", "plan_name": "SUTTER SELECT & SUTTER HEALTH PLAN HMO PLANS", "methodology": "per diem", "standard_charge_dollar": 28538.0, "standard_charge_algorithm": "Per diem ($28,538).", "count": "0", "additional_payer_notes": "Zero final payments for the item or service in the 15 months prior to posting the file." }, { "payer_name": "UNITED HEALTHCARE", "plan_name": "SUTTER SELECT & SUTTER HEALTH PLAN HMO PLANS", "methodology": "per diem", "standard_charge_dollar": 28538.0, "standard_charge_algorithm": "Per diem ($28,538).", "count": "0", "additional_payer_notes": "Zero final payments for the item or service in the 15 months prior to posting the file." }, { "payer_name": "UMR", "plan_name": "SUTTER SELECT & SUTTER HEALTH PLAN HMO PLANS", "methodology": "per diem", "standard_charge_dollar": 28538.0, "standard_charge_algorithm": "Per diem ($28,538).", "count": "0", "additional_payer_notes": "Zero final payments for the item or service in the 15 months prior to posting the file." }, { "payer_name": "UNITED HEALTHCARE", "plan_name": "SUTTER SELECT & SUTTER HEALTH PLAN HMO PLANS", "methodology": "per diem", "standard_charge_dollar": 28538.0, "standard_charge_algorithm": "Per diem ($28,538).", "median_amount": 21329.69, "10th_percentile": 21329.69, "90th_percentile": 21329.69, "count": "1 through 10" } ] } ] }, { "description": "HC Distractor Kit Gp089", "code_information": [ { "code": "PX-2120137089", "type": "CDM" }, { "code": "99999", "type": "CPT" }, { "code": "0272", "type": "RC" } ], "standard_charges": [ { "setting": "outpatient", "gross_charge": 44000.0, "discounted_cash": 22000.0, "minimum": 18568.0, "maximum": 22880.0, "additional_generic_notes": "Zero final payments for the item or service in the 15 months prior to posting the file.", "payers_information": [ { "payer_name": "AETNA", "plan_name": "AETNA ALL OTHER PLANS", "methodology": "percent of total billed charges", "standard_charge_dollar": 22880.0, "standard_charge_percentage": 52.0, "count": "0", "additional_payer_notes": "Zero final payments for the item or service in the 15 months prior to posting the file." }, { "payer_name": "AETNA", "plan_name": "AETNA ALL OTHER PLANS", "methodology": "percent of total billed charges", "standard_charge_dollar": 22880.0, "standard_charge_percentage": 52.0, "count": "0", "additional_payer_notes": "Zero final payments for the item or service in the 15 months prior to posting the file." }, { "payer_name": "MERITAIN HEALTH", "plan_name": "AETNA ALL OTHER PLANS", "methodology": "percent of total billed charges", "standard_charge_dollar": 22880.0, "standard_charge_percentage": 52.0, "count": "0", "additional_payer_notes": "Zero final payments for the item or service in the 15 months prior to posting the file." }, { "payer_name": "BLUE SHIELD OUT OF STATE", "plan_name": "STANFORD HEALTHCARE ALLIANCE PLAN", "methodology": "percent of total billed charges", "standard_charge_dollar": 21379.6, "standard_charge_percentage": 48.59, "count": "0", "additional_payer_notes": "Zero final payments for the item or service in the 15 months prior to posting the file." }, { "payer_name": "BLUE SHIELD", "plan_name": "STANFORD HEALTHCARE ALLIANCE PLAN", "methodology": "percent of total billed charges", "standard_charge_dollar": 21379.6, "standard_charge_percentage": 48.59, "median_amount": 68.24, "10th_percentile": 13.6, "90th_percentile": 1043.06, "count": "30" }, { "payer_name": "BLUE SHIELD", "plan_name": "STANFORD HEALTHCARE ALLIANCE PLAN", "methodology": "percent of total billed charges", "standard_charge_dollar": 21379.6, "standard_charge_percentage": 48.59, "count": "0", "additional_payer_notes": "Zero final payments for the item or service in the 15 months prior to posting the file." }, { "payer_name": "BLUE SHIELD", "plan_name": "STANFORD HEALTHCARE ALLIANCE PLAN", "methodology": "percent of total billed charges", "standard_charge_dollar": 21379.6, "standard_charge_percentage": 48.59, "count": "0", "additional_payer_notes": "Zero final payments for the item or service in the 15 months prior to posting the file." }, { "payer_name": "CIGNA", "plan_name": "CIGNA COM ALT HMO PLAN", "methodology": "percent of total billed charges", "standard_charge_dollar": 18568.0, "standard_charge_percentage": 42.2, "count": "0", "additional_payer_notes": "Zero final payments for the item or service in the 15 months prior to posting the file." }, { "payer_name": "CIGNA", "plan_name": "CIGNA COM ALT HMO PLAN", "methodology": "percent of total billed charges", "standard_charge_dollar": 18568.0, "standard_charge_percentage": 42.2, "count": "0", "additional_payer_notes": "Zero final payments for the item or service in the 15 months prior to posting the file." }, { "payer_name": "HEALTH NET", "plan_name": "HEALTHNET HMO, PPO, POS, EPO, CANOPY HEALTHNET HMO, OTHER-IN-NETWORK PLANS", "methodology": "per diem", "standard_charge_dollar": 8000.0, "standard_charge_algorithm": "Expected reimbursement is the lesser of Per diem ($8,000) for the length of stay and 70% of billed.", "count": "0", "additional_payer_notes": "Zero final payments for the item or service in the 15 months prior to posting the file." }, { "payer_name": "HEALTH NET", "plan_name": "HEALTHNET HMO, PPO, POS, EPO, CANOPY HEALTHNET HMO, OTHER-IN-NETWORK PLANS", "methodology": "per diem", "standard_charge_dollar": 8000.0, "standard_charge_algorithm": "Expected reimbursement is the lesser of Per diem ($8,000) for the length of stay and 70% of billed.", "count": "0", "additional_payer_notes": "Zero final payments for the item or service in the 15 months prior to posting the file." }, { "payer_name": "UNITED HEALTHCARE", "plan_name": "SUTTER SELECT & SUTTER HEALTH PLAN HMO PLANS", "methodology": "per diem", "standard_charge_dollar": 28538.0, "standard_charge_algorithm": "Per diem ($28,538).", "count": "0", "additional_payer_notes": "Zero final payments for the item or service in the 15 months prior to posting the file." }, { "payer_name": "UNITED HEALTHCARE", "plan_name": "SUTTER SELECT & SUTTER HEALTH PLAN HMO PLANS", "methodology": "per diem", "standard_charge_dollar": 28538.0, "standard_charge_algorithm": "Per diem ($28,538).", "count": "0", "additional_payer_notes": "Zero final payments for the item or service in the 15 months prior to posting the file." }, { "payer_name": "SUTTER", "plan_name": "SUTTER SELECT & SUTTER HEALTH PLAN HMO PLANS", "methodology": "per diem", "standard_charge_dollar": 28538.0, "standard_charge_algorithm": "Per diem ($28,538).", "count": "0", "additional_payer_notes": "Zero final payments for the item or service in the 15 months prior to posting the file." }, { "payer_name": "UNITED HEALTHCARE", "plan_name": "SUTTER SELECT & SUTTER HEALTH PLAN HMO PLANS", "methodology": "per diem", "standard_charge_dollar": 28538.0, "standard_charge_algorithm": "Per diem ($28,538).", "count": "0", "additional_payer_notes": "Zero final payments for the item or service in the 15 months prior to posting the file." }, { "payer_name": "UMR", "plan_name": "SUTTER SELECT & SUTTER HEALTH PLAN HMO PLANS", "methodology": "per diem", "standard_charge_dollar": 28538.0, "standard_charge_algorithm": "Per diem ($28,538).", "count": "0", "additional_payer_notes": "Zero final payments for the item or service in the 15 months prior to posting the file." }, { "payer_name": "UNITED HEALTHCARE", "plan_name": "SUTTER SELECT & SUTTER HEALTH PLAN HMO PLANS", "methodology": "per diem", "standard_charge_dollar": 28538.0, "standard_charge_algorithm": "Per diem ($28,538).", "median_amount": 21329.69, "10th_percentile": 21329.69, "90th_percentile": 21329.69, "count": "1 through 10" } ] } ] }, { "description": "HC Connector Ext Fixtr Gp049", "code_information": [ { "code": "PX-2120143049", "type": "CDM" }, { "code": "99999", "type": "CPT" }, { "code": "0272", "type": "RC" } ], "standard_charges": [ { "setting": "outpatient", "gross_charge": 14250.0, "discounted_cash": 7125.0, "minimum": 6013.5, "maximum": 7410.0, "additional_generic_notes": "Zero final payments for the item or service in the 15 months prior to posting the file.", "payers_information": [ { "payer_name": "AETNA", "plan_name": "AETNA ALL OTHER PLANS", "methodology": "percent of total billed charges", "standard_charge_dollar": 7410.0, "standard_charge_percentage": 52.0, "count": "0", "additional_payer_notes": "Zero final payments for the item or service in the 15 months prior to posting the file." }, { "payer_name": "AETNA", "plan_name": "AETNA ALL OTHER PLANS", "methodology": "percent of total billed charges", "standard_charge_dollar": 7410.0, "standard_charge_percentage": 52.0, "count": "0", "additional_payer_notes": "Zero final payments for the item or service in the 15 months prior to posting the file." }, { "payer_name": "MERITAIN HEALTH", "plan_name": "AETNA ALL OTHER PLANS", "methodology": "percent of total billed charges", "standard_charge_dollar": 7410.0, "standard_charge_percentage": 52.0, "count": "0", "additional_payer_notes": "Zero final payments for the item or service in the 15 months prior to posting the file." }, { "payer_name": "BLUE SHIELD OUT OF STATE", "plan_name": "STANFORD HEALTHCARE ALLIANCE PLAN", "methodology": "percent of total billed charges", "standard_charge_dollar": 6924.08, "standard_charge_percentage": 48.59, "count": "0", "additional_payer_notes": "Zero final payments for the item or service in the 15 months prior to posting the file." }, { "payer_name": "BLUE SHIELD", "plan_name": "STANFORD HEALTHCARE ALLIANCE PLAN", "methodology": "percent of total billed charges", "standard_charge_dollar": 6924.08, "standard_charge_percentage": 48.59, "median_amount": 68.24, "10th_percentile": 13.6, "90th_percentile": 1043.06, "count": "30" }, { "payer_name": "BLUE SHIELD", "plan_name": "STANFORD HEALTHCARE ALLIANCE PLAN", "methodology": "percent of total billed charges", "standard_charge_dollar": 6924.08, "standard_charge_percentage": 48.59, "count": "0", "additional_payer_notes": "Zero final payments for the item or service in the 15 months prior to posting the file." }, { "payer_name": "BLUE SHIELD", "plan_name": "STANFORD HEALTHCARE ALLIANCE PLAN", "methodology": "percent of total billed charges", "standard_charge_dollar": 6924.08, "standard_charge_percentage": 48.59, "count": "0", "additional_payer_notes": "Zero final payments for the item or service in the 15 months prior to posting the file." }, { "payer_name": "CIGNA", "plan_name": "CIGNA COM ALT HMO PLAN", "methodology": "percent of total billed charges", "standard_charge_dollar": 6013.5, "standard_charge_percentage": 42.2, "count": "0", "additional_payer_notes": "Zero final payments for the item or service in the 15 months prior to posting the file." }, { "payer_name": "CIGNA", "plan_name": "CIGNA COM ALT HMO PLAN", "methodology": "percent of total billed charges", "standard_charge_dollar": 6013.5, "standard_charge_percentage": 42.2, "count": "0", "additional_payer_notes": "Zero final payments for the item or service in the 15 months prior to posting the file." }, { "payer_name": "HEALTH NET", "plan_name": "HEALTHNET HMO, PPO, POS, EPO, CANOPY HEALTHNET HMO, OTHER-IN-NETWORK PLANS", "methodology": "per diem", "standard_charge_dollar": 8000.0, "standard_charge_algorithm": "Expected reimbursement is the lesser of Per diem ($8,000) for the length of stay and 70% of billed.", "count": "0", "additional_payer_notes": "Zero final payments for the item or service in the 15 months prior to posting the file." }, { "payer_name": "HEALTH NET", "plan_name": "HEALTHNET HMO, PPO, POS, EPO, CANOPY HEALTHNET HMO, OTHER-IN-NETWORK PLANS", "methodology": "per diem", "standard_charge_dollar": 8000.0, "standard_charge_algorithm": "Expected reimbursement is the lesser of Per diem ($8,000) for the length of stay and 70% of billed.", "count": "0", "additional_payer_notes": "Zero final payments for the item or service in the 15 months prior to posting the file." }, { "payer_name": "UNITED HEALTHCARE", "plan_name": "SUTTER SELECT & SUTTER HEALTH PLAN HMO PLANS", "methodology": "per diem", "standard_charge_dollar": 28538.0, "standard_charge_algorithm": "Per diem ($28,538).", "count": "0", "additional_payer_notes": "Zero final payments for the item or service in the 15 months prior to posting the file." }, { "payer_name": "UNITED HEALTHCARE", "plan_name": "SUTTER SELECT & SUTTER HEALTH PLAN HMO PLANS", "methodology": "per diem", "standard_charge_dollar": 28538.0, "standard_charge_algorithm": "Per diem ($28,538).", "count": "0", "additional_payer_notes": "Zero final payments for the item or service in the 15 months prior to posting the file." }, { "payer_name": "SUTTER", "plan_name": "SUTTER SELECT & SUTTER HEALTH PLAN HMO PLANS", "methodology": "per diem", "standard_charge_dollar": 28538.0, "standard_charge_algorithm": "Per diem ($28,538).", "count": "0", "additional_payer_notes": "Zero final payments for the item or service in the 15 months prior to posting the file." }, { "payer_name": "UNITED HEALTHCARE", "plan_name": "SUTTER SELECT & SUTTER HEALTH PLAN HMO PLANS", "methodology": "per diem", "standard_charge_dollar": 28538.0, "standard_charge_algorithm": "Per diem ($28,538).", "count": "0", "additional_payer_notes": "Zero final payments for the item or service in the 15 months prior to posting the file." }, { "payer_name": "UMR", "plan_name": "SUTTER SELECT & SUTTER HEALTH PLAN HMO PLANS", "methodology": "per diem", "standard_charge_dollar": 28538.0, "standard_charge_algorithm": "Per diem ($28,538).", "count": "0", "additional_payer_notes": "Zero final payments for the item or service in the 15 months prior to posting the file." } ] } ] }, { "description": "HC Impl Mesh Gp079", "code_information": [ { "code": "PX-2120146079", "type": "CDM" }, { "code": "Q4130", "type": "HCPCS" }, { "code": "0278", "type": "RC" } ], "standard_charges": [ { "setting": "outpatient", "gross_charge": 36000.0, "discounted_cash": 18000.0, "minimum": 15192.0, "maximum": 18720.0, "additional_generic_notes": "Zero final payments for the item or service in the 15 months prior to posting the file.", "payers_information": [ { "payer_name": "AETNA", "plan_name": "AETNA ALL OTHER PLANS", "methodology": "percent of total billed charges", "standard_charge_dollar": 18720.0, "standard_charge_percentage": 52.0, "count": "0", "additional_payer_notes": "Zero final payments for the item or service in the 15 months prior to posting the file." }, { "payer_name": "AETNA", "plan_name": "AETNA ALL OTHER PLANS", "methodology": "percent of total billed charges", "standard_charge_dollar": 18720.0, "standard_charge_percentage": 52.0, "count": "0", "additional_payer_notes": "Zero final payments for the item or service in the 15 months prior to posting the file." }, { "payer_name": "MERITAIN HEALTH", "plan_name": "AETNA ALL OTHER PLANS", "methodology": "percent of total billed charges", "standard_charge_dollar": 18720.0, "standard_charge_percentage": 52.0, "count": "0", "additional_payer_notes": "Zero final payments for the item or service in the 15 months prior to posting the file." }, { "payer_name": "BLUE SHIELD OUT OF STATE", "plan_name": "STANFORD HEALTHCARE ALLIANCE PLAN", "methodology": "percent of total billed charges", "standard_charge_dollar": 17492.4, "standard_charge_percentage": 48.59, "count": "0", "additional_payer_notes": "Zero final payments for the item or service in the 15 months prior to posting the file." }, { "payer_name": "BLUE SHIELD", "plan_name": "STANFORD HEALTHCARE ALLIANCE PLAN", "methodology": "percent of total billed charges", "standard_charge_dollar": 17492.4, "standard_charge_percentage": 48.59, "count": "0", "additional_payer_notes": "Zero final payments for the item or service in the 15 months prior to posting the file." }, { "payer_name": "BLUE SHIELD", "plan_name": "STANFORD HEALTHCARE ALLIANCE PLAN", "methodology": "percent of total billed charges", "standard_charge_dollar": 17492.4, "standard_charge_percentage": 48.59, "count": "0", "additional_payer_notes": "Zero final payments for the item or service in the 15 months prior to posting the file." }, { "payer_name": "BLUE SHIELD", "plan_name": "STANFORD HEALTHCARE ALLIANCE PLAN", "methodology": "percent of total billed charges", "standard_charge_dollar": 17492.4, "standard_charge_percentage": 48.59, "count": "0", "additional_payer_notes": "Zero final payments for the item or service in the 15 months prior to posting the file." }, { "payer_name": "CIGNA", "plan_name": "CIGNA COM ALT HMO PLAN", "methodology": "percent of total billed charges", "standard_charge_dollar": 15192.0, "standard_charge_percentage": 42.2, "count": "0", "additional_payer_notes": "Zero final payments for the item or service in the 15 months prior to posting the file." }, { "payer_name": "CIGNA", "plan_name": "CIGNA COM ALT HMO PLAN", "methodology": "percent of total billed charges", "standard_charge_dollar": 15192.0, "standard_charge_percentage": 42.2, "count": "0", "additional_payer_notes": "Zero final payments for the item or service in the 15 months prior to posting the file." }, { "payer_name": "UNITED HEALTHCARE", "plan_name": "SUTTER SELECT & SUTTER HEALTH PLAN HMO PLANS", "methodology": "per diem", "standard_charge_dollar": 28538.0, "standard_charge_algorithm": "Per diem ($28,538).", "count": "0", "additional_payer_notes": "Zero final payments for the item or service in the 15 months prior to posting the file." }, { "payer_name": "UNITED HEALTHCARE", "plan_name": "SUTTER SELECT & SUTTER HEALTH PLAN HMO PLANS", "methodology": "per diem", "standard_charge_dollar": 28538.0, "standard_charge_algorithm": "Per diem ($28,538).", "count": "0", "additional_payer_notes": "Zero final payments for the item or service in the 15 months prior to posting the file." }, { "payer_name": "SUTTER", "plan_name": "SUTTER SELECT & SUTTER HEALTH PLAN HMO PLANS", "methodology": "per diem", "standard_charge_dollar": 28538.0, "standard_charge_algorithm": "Per diem ($28,538).", "count": "0", "additional_payer_notes": "Zero final payments for the item or service in the 15 months prior to posting the file." }, { "payer_name": "UNITED HEALTHCARE", "plan_name": "SUTTER SELECT & SUTTER HEALTH PLAN HMO PLANS", "methodology": "per diem", "standard_charge_dollar": 28538.0, "standard_charge_algorithm": "Per diem ($28,538).", "count": "0", "additional_payer_notes": "Zero final payments for the item or service in the 15 months prior to posting the file." }, { "payer_name": "UMR", "plan_name": "SUTTER SELECT & SUTTER HEALTH PLAN HMO PLANS", "methodology": "per diem", "standard_charge_dollar": 28538.0, "standard_charge_algorithm": "Per diem ($28,538).", "count": "0", "additional_payer_notes": "Zero final payments for the item or service in the 15 months prior to posting the file." }, { "payer_name": "UNITED HEALTHCARE", "plan_name": "SUTTER SELECT & SUTTER HEALTH PLAN HMO PLANS", "methodology": "per diem", "standard_charge_dollar": 28538.0, "standard_charge_algorithm": "Per diem ($28,538).", "count": "0", "additional_payer_notes": "Zero final payments for the item or service in the 15 months prior to posting the file." } ] } ] }, { "description": "HC Impl Penile Infl Gp053", "code_information": [ { "code": "PX-2120160053", "type": "CDM" }, { "code": "C1813", "type": "HCPCS" }, { "code": "0278", "type": "RC" } ], "standard_charges": [ { "setting": "outpatient", "gross_charge": 16300.0, "discounted_cash": 8150.0, "minimum": 6878.6, "maximum": 8476.0, "additional_generic_notes": "Zero final payments for the item or service in the 15 months prior to posting the file.", "payers_information": [ { "payer_name": "AETNA", "plan_name": "AETNA ALL OTHER PLANS", "methodology": "percent of total billed charges", "standard_charge_dollar": 8476.0, "standard_charge_percentage": 52.0, "count": "0", "additional_payer_notes": "Zero final payments for the item or service in the 15 months prior to posting the file." }, { "payer_name": "AETNA", "plan_name": "AETNA ALL OTHER PLANS", "methodology": "percent of total billed charges", "standard_charge_dollar": 8476.0, "standard_charge_percentage": 52.0, "count": "0", "additional_payer_notes": "Zero final payments for the item or service in the 15 months prior to posting the file." }, { "payer_name": "MERITAIN HEALTH", "plan_name": "AETNA ALL OTHER PLANS", "methodology": "percent of total billed charges", "standard_charge_dollar": 8476.0, "standard_charge_percentage": 52.0, "count": "0", "additional_payer_notes": "Zero final payments for the item or service in the 15 months prior to posting the file." }, { "payer_name": "BLUE SHIELD OUT OF STATE", "plan_name": "STANFORD HEALTHCARE ALLIANCE PLAN", "methodology": "percent of total billed charges", "standard_charge_dollar": 7920.17, "standard_charge_percentage": 48.59, "count": "0", "additional_payer_notes": "Zero final payments for the item or service in the 15 months prior to posting the file." }, { "payer_name": "BLUE SHIELD", "plan_name": "STANFORD HEALTHCARE ALLIANCE PLAN", "methodology": "percent of total billed charges", "standard_charge_dollar": 7920.17, "standard_charge_percentage": 48.59, "count": "0", "additional_payer_notes": "Zero final payments for the item or service in the 15 months prior to posting the file." }, { "payer_name": "BLUE SHIELD", "plan_name": "STANFORD HEALTHCARE ALLIANCE PLAN", "methodology": "percent of total billed charges", "standard_charge_dollar": 7920.17, "standard_charge_percentage": 48.59, "count": "0", "additional_payer_notes": "Zero final payments for the item or service in the 15 months prior to posting the file." }, { "payer_name": "BLUE SHIELD", "plan_name": "STANFORD HEALTHCARE ALLIANCE PLAN", "methodology": "percent of total billed charges", "standard_charge_dollar": 7920.17, "standard_charge_percentage": 48.59, "count": "0", "additional_payer_notes": "Zero final payments for the item or service in the 15 months prior to posting the file." }, { "payer_name": "CIGNA", "plan_name": "CIGNA COM ALT HMO PLAN", "methodology": "percent of total billed charges", "standard_charge_dollar": 6878.6, "standard_charge_percentage": 42.2, "count": "0", "additional_payer_notes": "Zero final payments for the item or service in the 15 months prior to posting the file." }, { "payer_name": "CIGNA", "plan_name": "CIGNA COM ALT HMO PLAN", "methodology": "percent of total billed charges", "standard_charge_dollar": 6878.6, "standard_charge_percentage": 42.2, "count": "0", "additional_payer_notes": "Zero final payments for the item or service in the 15 months prior to posting the file." }, { "payer_name": "UNITED HEALTHCARE", "plan_name": "SUTTER SELECT & SUTTER HEALTH PLAN HMO PLANS", "methodology": "per diem", "standard_charge_dollar": 28538.0, "standard_charge_algorithm": "Per diem ($28,538).", "count": "0", "additional_payer_notes": "Zero final payments for the item or service in the 15 months prior to posting the file." }, { "payer_name": "UNITED HEALTHCARE", "plan_name": "SUTTER SELECT & SUTTER HEALTH PLAN HMO PLANS", "methodology": "per diem", "standard_charge_dollar": 28538.0, "standard_charge_algorithm": "Per diem ($28,538).", "count": "0", "additional_payer_notes": "Zero final payments for the item or service in the 15 months prior to posting the file." }, { "payer_name": "SUTTER", "plan_name": "SUTTER SELECT & SUTTER HEALTH PLAN HMO PLANS", "methodology": "per diem", "standard_charge_dollar": 28538.0, "standard_charge_algorithm": "Per diem ($28,538).", "count": "0", "additional_payer_notes": "Zero final payments for the item or service in the 15 months prior to posting the file." }, { "payer_name": "UNITED HEALTHCARE", "plan_name": "SUTTER SELECT & SUTTER HEALTH PLAN HMO PLANS", "methodology": "per diem", "standard_charge_dollar": 28538.0, "standard_charge_algorithm": "Per diem ($28,538).", "count": "0", "additional_payer_notes": "Zero final payments for the item or service in the 15 months prior to posting the file." }, { "payer_name": "UMR", "plan_name": "SUTTER SELECT & SUTTER HEALTH PLAN HMO PLANS", "methodology": "per diem", "standard_charge_dollar": 28538.0, "standard_charge_algorithm": "Per diem ($28,538).", "count": "0", "additional_payer_notes": "Zero final payments for the item or service in the 15 months prior to posting the file." }, { "payer_name": "UNITED HEALTHCARE", "plan_name": "SUTTER SELECT & SUTTER HEALTH PLAN HMO PLANS", "methodology": "per diem", "standard_charge_dollar": 28538.0, "standard_charge_algorithm": "Per diem ($28,538).", "count": "0", "additional_payer_notes": "Zero final payments for the item or service in the 15 months prior to posting the file." } ] } ] }, { "description": "HC Impl Penile Infl Gp067", "code_information": [ { "code": "PX-2120160067", "type": "CDM" }, { "code": "C1813", "type": "HCPCS" }, { "code": "0278", "type": "RC" } ], "standard_charges": [ { "setting": "outpatient", "gross_charge": 26400.0, "discounted_cash": 13200.0, "minimum": 11140.8, "maximum": 13728.0, "additional_generic_notes": "Zero final payments for the item or service in the 15 months prior to posting the file.", "payers_information": [ { "payer_name": "AETNA", "plan_name": "AETNA ALL OTHER PLANS", "methodology": "percent of total billed charges", "standard_charge_dollar": 13728.0, "standard_charge_percentage": 52.0, "count": "0", "additional_payer_notes": "Zero final payments for the item or service in the 15 months prior to posting the file." }, { "payer_name": "AETNA", "plan_name": "AETNA ALL OTHER PLANS", "methodology": "percent of total billed charges", "standard_charge_dollar": 13728.0, "standard_charge_percentage": 52.0, "count": "0", "additional_payer_notes": "Zero final payments for the item or service in the 15 months prior to posting the file." }, { "payer_name": "MERITAIN HEALTH", "plan_name": "AETNA ALL OTHER PLANS", "methodology": "percent of total billed charges", "standard_charge_dollar": 13728.0, "standard_charge_percentage": 52.0, "count": "0", "additional_payer_notes": "Zero final payments for the item or service in the 15 months prior to posting the file." }, { "payer_name": "BLUE SHIELD OUT OF STATE", "plan_name": "STANFORD HEALTHCARE ALLIANCE PLAN", "methodology": "percent of total billed charges", "standard_charge_dollar": 12827.76, "standard_charge_percentage": 48.59, "count": "0", "additional_payer_notes": "Zero final payments for the item or service in the 15 months prior to posting the file." }, { "payer_name": "BLUE SHIELD", "plan_name": "STANFORD HEALTHCARE ALLIANCE PLAN", "methodology": "percent of total billed charges", "standard_charge_dollar": 12827.76, "standard_charge_percentage": 48.59, "count": "0", "additional_payer_notes": "Zero final payments for the item or service in the 15 months prior to posting the file." }, { "payer_name": "BLUE SHIELD", "plan_name": "STANFORD HEALTHCARE ALLIANCE PLAN", "methodology": "percent of total billed charges", "standard_charge_dollar": 12827.76, "standard_charge_percentage": 48.59, "count": "0", "additional_payer_notes": "Zero final payments for the item or service in the 15 months prior to posting the file." }, { "payer_name": "BLUE SHIELD", "plan_name": "STANFORD HEALTHCARE ALLIANCE PLAN", "methodology": "percent of total billed charges", "standard_charge_dollar": 12827.76, "standard_charge_percentage": 48.59, "count": "0", "additional_payer_notes": "Zero final payments for the item or service in the 15 months prior to posting the file." }, { "payer_name": "CIGNA", "plan_name": "CIGNA COM ALT HMO PLAN", "methodology": "percent of total billed charges", "standard_charge_dollar": 11140.8, "standard_charge_percentage": 42.2, "count": "0", "additional_payer_notes": "Zero final payments for the item or service in the 15 months prior to posting the file." }, { "payer_name": "CIGNA", "plan_name": "CIGNA COM ALT HMO PLAN", "methodology": "percent of total billed charges", "standard_charge_dollar": 11140.8, "standard_charge_percentage": 42.2, "count": "0", "additional_payer_notes": "Zero final payments for the item or service in the 15 months prior to posting the file." }, { "payer_name": "UNITED HEALTHCARE", "plan_name": "SUTTER SELECT & SUTTER HEALTH PLAN HMO PLANS", "methodology": "per diem", "standard_charge_dollar": 28538.0, "standard_charge_algorithm": "Per diem ($28,538).", "count": "0", "additional_payer_notes": "Zero final payments for the item or service in the 15 months prior to posting the file." }, { "payer_name": "UNITED HEALTHCARE", "plan_name": "SUTTER SELECT & SUTTER HEALTH PLAN HMO PLANS", "methodology": "per diem", "standard_charge_dollar": 28538.0, "standard_charge_algorithm": "Per diem ($28,538).", "count": "0", "additional_payer_notes": "Zero final payments for the item or service in the 15 months prior to posting the file." }, { "payer_name": "SUTTER", "plan_name": "SUTTER SELECT & SUTTER HEALTH PLAN HMO PLANS", "methodology": "per diem", "standard_charge_dollar": 28538.0, "standard_charge_algorithm": "Per diem ($28,538).", "count": "0", "additional_payer_notes": "Zero final payments for the item or service in the 15 months prior to posting the file." }, { "payer_name": "UNITED HEALTHCARE", "plan_name": "SUTTER SELECT & SUTTER HEALTH PLAN HMO PLANS", "methodology": "per diem", "standard_charge_dollar": 28538.0, "standard_charge_algorithm": "Per diem ($28,538).", "count": "0", "additional_payer_notes": "Zero final payments for the item or service in the 15 months prior to posting the file." }, { "payer_name": "UMR", "plan_name": "SUTTER SELECT & SUTTER HEALTH PLAN HMO PLANS", "methodology": "per diem", "standard_charge_dollar": 28538.0, "standard_charge_algorithm": "Per diem ($28,538).", "count": "0", "additional_payer_notes": "Zero final payments for the item or service in the 15 months prior to posting the file." }, { "payer_name": "UNITED HEALTHCARE", "plan_name": "SUTTER SELECT & SUTTER HEALTH PLAN HMO PLANS", "methodology": "per diem", "standard_charge_dollar": 28538.0, "standard_charge_algorithm": "Per diem ($28,538).", "count": "0", "additional_payer_notes": "Zero final payments for the item or service in the 15 months prior to posting the file." } ] } ] }, { "description": "HC Impl Penile Infl Gp068", "code_information": [ { "code": "PX-2120160068", "type": "CDM" }, { "code": "C1813", "type": "HCPCS" }, { "code": "0278", "type": "RC" } ], "standard_charges": [ { "setting": "outpatient", "gross_charge": 27200.0, "discounted_cash": 13600.0, "minimum": 11478.4, "maximum": 14144.0, "additional_generic_notes": "Zero final payments for the item or service in the 15 months prior to posting the file.", "payers_information": [ { "payer_name": "AETNA", "plan_name": "AETNA ALL OTHER PLANS", "methodology": "percent of total billed charges", "standard_charge_dollar": 14144.0, "standard_charge_percentage": 52.0, "count": "0", "additional_payer_notes": "Zero final payments for the item or service in the 15 months prior to posting the file." }, { "payer_name": "AETNA", "plan_name": "AETNA ALL OTHER PLANS", "methodology": "percent of total billed charges", "standard_charge_dollar": 14144.0, "standard_charge_percentage": 52.0, "count": "0", "additional_payer_notes": "Zero final payments for the item or service in the 15 months prior to posting the file." }, { "payer_name": "MERITAIN HEALTH", "plan_name": "AETNA ALL OTHER PLANS", "methodology": "percent of total billed charges", "standard_charge_dollar": 14144.0, "standard_charge_percentage": 52.0, "count": "0", "additional_payer_notes": "Zero final payments for the item or service in the 15 months prior to posting the file." }, { "payer_name": "BLUE SHIELD OUT OF STATE", "plan_name": "STANFORD HEALTHCARE ALLIANCE PLAN", "methodology": "percent of total billed charges", "standard_charge_dollar": 13216.48, "standard_charge_percentage": 48.59, "count": "0", "additional_payer_notes": "Zero final payments for the item or service in the 15 months prior to posting the file." }, { "payer_name": "BLUE SHIELD", "plan_name": "STANFORD HEALTHCARE ALLIANCE PLAN", "methodology": "percent of total billed charges", "standard_charge_dollar": 13216.48, "standard_charge_percentage": 48.59, "count": "0", "additional_payer_notes": "Zero final payments for the item or service in the 15 months prior to posting the file." }, { "payer_name": "BLUE SHIELD", "plan_name": "STANFORD HEALTHCARE ALLIANCE PLAN", "methodology": "percent of total billed charges", "standard_charge_dollar": 13216.48, "standard_charge_percentage": 48.59, "count": "0", "additional_payer_notes": "Zero final payments for the item or service in the 15 months prior to posting the file." }, { "payer_name": "BLUE SHIELD", "plan_name": "STANFORD HEALTHCARE ALLIANCE PLAN", "methodology": "percent of total billed charges", "standard_charge_dollar": 13216.48, "standard_charge_percentage": 48.59, "count": "0", "additional_payer_notes": "Zero final payments for the item or service in the 15 months prior to posting the file." }, { "payer_name": "CIGNA", "plan_name": "CIGNA COM ALT HMO PLAN", "methodology": "percent of total billed charges", "standard_charge_dollar": 11478.4, "standard_charge_percentage": 42.2, "count": "0", "additional_payer_notes": "Zero final payments for the item or service in the 15 months prior to posting the file." }, { "payer_name": "CIGNA", "plan_name": "CIGNA COM ALT HMO PLAN", "methodology": "percent of total billed charges", "standard_charge_dollar": 11478.4, "standard_charge_percentage": 42.2, "count": "0", "additional_payer_notes": "Zero final payments for the item or service in the 15 months prior to posting the file." }, { "payer_name": "UNITED HEALTHCARE", "plan_name": "SUTTER SELECT & SUTTER HEALTH PLAN HMO PLANS", "methodology": "per diem", "standard_charge_dollar": 28538.0, "standard_charge_algorithm": "Per diem ($28,538).", "count": "0", "additional_payer_notes": "Zero final payments for the item or service in the 15 months prior to posting the file." }, { "payer_name": "UNITED HEALTHCARE", "plan_name": "SUTTER SELECT & SUTTER HEALTH PLAN HMO PLANS", "methodology": "per diem", "standard_charge_dollar": 28538.0, "standard_charge_algorithm": "Per diem ($28,538).", "count": "0", "additional_payer_notes": "Zero final payments for the item or service in the 15 months prior to posting the file." }, { "payer_name": "SUTTER", "plan_name": "SUTTER SELECT & SUTTER HEALTH PLAN HMO PLANS", "methodology": "per diem", "standard_charge_dollar": 28538.0, "standard_charge_algorithm": "Per diem ($28,538).", "count": "0", "additional_payer_notes": "Zero final payments for the item or service in the 15 months prior to posting the file." }, { "payer_name": "UNITED HEALTHCARE", "plan_name": "SUTTER SELECT & SUTTER HEALTH PLAN HMO PLANS", "methodology": "per diem", "standard_charge_dollar": 28538.0, "standard_charge_algorithm": "Per diem ($28,538).", "count": "0", "additional_payer_notes": "Zero final payments for the item or service in the 15 months prior to posting the file." }, { "payer_name": "UMR", "plan_name": "SUTTER SELECT & SUTTER HEALTH PLAN HMO PLANS", "methodology": "per diem", "standard_charge_dollar": 28538.0, "standard_charge_algorithm": "Per diem ($28,538).", "count": "0", "additional_payer_notes": "Zero final payments for the item or service in the 15 months prior to posting the file." }, { "payer_name": "UNITED HEALTHCARE", "plan_name": "SUTTER SELECT & SUTTER HEALTH PLAN HMO PLANS", "methodology": "per diem", "standard_charge_dollar": 28538.0, "standard_charge_algorithm": "Per diem ($28,538).", "count": "0", "additional_payer_notes": "Zero final payments for the item or service in the 15 months prior to posting the file." } ] } ] }, { "description": "HC Impl Penile Non Infl Gp049", "code_information": [ { "code": "PX-2120161049", "type": "CDM" }, { "code": "C2622", "type": "HCPCS" }, { "code": "0278", "type": "RC" } ], "standard_charges": [ { "setting": "outpatient", "gross_charge": 14250.0, "discounted_cash": 7125.0, "minimum": 6013.5, "maximum": 7410.0, "additional_generic_notes": "Zero final payments for the item or service in the 15 months prior to posting the file.", "payers_information": [ { "payer_name": "AETNA", "plan_name": "AETNA ALL OTHER PLANS", "methodology": "percent of total billed charges", "standard_charge_dollar": 7410.0, "standard_charge_percentage": 52.0, "count": "0", "additional_payer_notes": "Zero final payments for the item or service in the 15 months prior to posting the file." }, { "payer_name": "AETNA", "plan_name": "AETNA ALL OTHER PLANS", "methodology": "percent of total billed charges", "standard_charge_dollar": 7410.0, "standard_charge_percentage": 52.0, "count": "0", "additional_payer_notes": "Zero final payments for the item or service in the 15 months prior to posting the file." }, { "payer_name": "MERITAIN HEALTH", "plan_name": "AETNA ALL OTHER PLANS", "methodology": "percent of total billed charges", "standard_charge_dollar": 7410.0, "standard_charge_percentage": 52.0, "count": "0", "additional_payer_notes": "Zero final payments for the item or service in the 15 months prior to posting the file." }, { "payer_name": "BLUE SHIELD OUT OF STATE", "plan_name": "STANFORD HEALTHCARE ALLIANCE PLAN", "methodology": "percent of total billed charges", "standard_charge_dollar": 6924.08, "standard_charge_percentage": 48.59, "count": "0", "additional_payer_notes": "Zero final payments for the item or service in the 15 months prior to posting the file." }, { "payer_name": "BLUE SHIELD", "plan_name": "STANFORD HEALTHCARE ALLIANCE PLAN", "methodology": "percent of total billed charges", "standard_charge_dollar": 6924.08, "standard_charge_percentage": 48.59, "count": "0", "additional_payer_notes": "Zero final payments for the item or service in the 15 months prior to posting the file." }, { "payer_name": "BLUE SHIELD", "plan_name": "STANFORD HEALTHCARE ALLIANCE PLAN", "methodology": "percent of total billed charges", "standard_charge_dollar": 6924.08, "standard_charge_percentage": 48.59, "count": "0", "additional_payer_notes": "Zero final payments for the item or service in the 15 months prior to posting the file." }, { "payer_name": "BLUE SHIELD", "plan_name": "STANFORD HEALTHCARE ALLIANCE PLAN", "methodology": "percent of total billed charges", "standard_charge_dollar": 6924.08, "standard_charge_percentage": 48.59, "count": "0", "additional_payer_notes": "Zero final payments for the item or service in the 15 months prior to posting the file." }, { "payer_name": "CIGNA", "plan_name": "CIGNA COM ALT HMO PLAN", "methodology": "percent of total billed charges", "standard_charge_dollar": 6013.5, "standard_charge_percentage": 42.2, "count": "0", "additional_payer_notes": "Zero final payments for the item or service in the 15 months prior to posting the file." }, { "payer_name": "CIGNA", "plan_name": "CIGNA COM ALT HMO PLAN", "methodology": "percent of total billed charges", "standard_charge_dollar": 6013.5, "standard_charge_percentage": 42.2, "count": "0", "additional_payer_notes": "Zero final payments for the item or service in the 15 months prior to posting the file." }, { "payer_name": "UNITED HEALTHCARE", "plan_name": "SUTTER SELECT & SUTTER HEALTH PLAN HMO PLANS", "methodology": "per diem", "standard_charge_dollar": 28538.0, "standard_charge_algorithm": "Per diem ($28,538).", "count": "0", "additional_payer_notes": "Zero final payments for the item or service in the 15 months prior to posting the file." }, { "payer_name": "UNITED HEALTHCARE", "plan_name": "SUTTER SELECT & SUTTER HEALTH PLAN HMO PLANS", "methodology": "per diem", "standard_charge_dollar": 28538.0, "standard_charge_algorithm": "Per diem ($28,538).", "count": "0", "additional_payer_notes": "Zero final payments for the item or service in the 15 months prior to posting the file." }, { "payer_name": "SUTTER", "plan_name": "SUTTER SELECT & SUTTER HEALTH PLAN HMO PLANS", "methodology": "per diem", "standard_charge_dollar": 28538.0, "standard_charge_algorithm": "Per diem ($28,538).", "count": "0", "additional_payer_notes": "Zero final payments for the item or service in the 15 months prior to posting the file." }, { "payer_name": "UNITED HEALTHCARE", "plan_name": "SUTTER SELECT & SUTTER HEALTH PLAN HMO PLANS", "methodology": "per diem", "standard_charge_dollar": 28538.0, "standard_charge_algorithm": "Per diem ($28,538).", "count": "0", "additional_payer_notes": "Zero final payments for the item or service in the 15 months prior to posting the file." }, { "payer_name": "UMR", "plan_name": "SUTTER SELECT & SUTTER HEALTH PLAN HMO PLANS", "methodology": "per diem", "standard_charge_dollar": 28538.0, "standard_charge_algorithm": "Per diem ($28,538).", "count": "0", "additional_payer_notes": "Zero final payments for the item or service in the 15 months prior to posting the file." }, { "payer_name": "UNITED HEALTHCARE", "plan_name": "SUTTER SELECT & SUTTER HEALTH PLAN HMO PLANS", "methodology": "per diem", "standard_charge_dollar": 28538.0, "standard_charge_algorithm": "Per diem ($28,538).", "count": "0", "additional_payer_notes": "Zero final payments for the item or service in the 15 months prior to posting the file." } ] } ] }, { "description": "HC Cap Anchor Bolt Gp012", "code_information": [ { "code": "PX-2120164012", "type": "CDM" }, { "code": "99999", "type": "CPT" }, { "code": "0272", "type": "RC" } ], "standard_charges": [ { "setting": "outpatient", "gross_charge": 810.0, "discounted_cash": 405.0, "minimum": 341.82, "maximum": 421.2, "additional_generic_notes": "Zero final payments for the item or service in the 15 months prior to posting the file.", "payers_information": [ { "payer_name": "AETNA", "plan_name": "AETNA ALL OTHER PLANS", "methodology": "percent of total billed charges", "standard_charge_dollar": 421.2, "standard_charge_percentage": 52.0, "count": "0", "additional_payer_notes": "Zero final payments for the item or service in the 15 months prior to posting the file." }, { "payer_name": "AETNA", "plan_name": "AETNA ALL OTHER PLANS", "methodology": "percent of total billed charges", "standard_charge_dollar": 421.2, "standard_charge_percentage": 52.0, "count": "0", "additional_payer_notes": "Zero final payments for the item or service in the 15 months prior to posting the file." }, { "payer_name": "MERITAIN HEALTH", "plan_name": "AETNA ALL OTHER PLANS", "methodology": "percent of total billed charges", "standard_charge_dollar": 421.2, "standard_charge_percentage": 52.0, "count": "0", "additional_payer_notes": "Zero final payments for the item or service in the 15 months prior to posting the file." }, { "payer_name": "BLUE SHIELD OUT OF STATE", "plan_name": "STANFORD HEALTHCARE ALLIANCE PLAN", "methodology": "percent of total billed charges", "standard_charge_dollar": 393.58, "standard_charge_percentage": 48.59, "count": "0", "additional_payer_notes": "Zero final payments for the item or service in the 15 months prior to posting the file." }, { "payer_name": "BLUE SHIELD", "plan_name": "STANFORD HEALTHCARE ALLIANCE PLAN", "methodology": "percent of total billed charges", "standard_charge_dollar": 393.58, "standard_charge_percentage": 48.59, "count": "0", "additional_payer_notes": "Zero final payments for the item or service in the 15 months prior to posting the file." }, { "payer_name": "BLUE SHIELD", "plan_name": "STANFORD HEALTHCARE ALLIANCE PLAN", "methodology": "percent of total billed charges", "standard_charge_dollar": 393.58, "standard_charge_percentage": 48.59, "count": "0", "additional_payer_notes": "Zero final payments for the item or service in the 15 months prior to posting the file." }, { "payer_name": "CIGNA", "plan_name": "CIGNA COM ALT HMO PLAN", "methodology": "percent of total billed charges", "standard_charge_dollar": 341.82, "standard_charge_percentage": 42.2, "count": "0", "additional_payer_notes": "Zero final payments for the item or service in the 15 months prior to posting the file." }, { "payer_name": "CIGNA", "plan_name": "CIGNA COM ALT HMO PLAN", "methodology": "percent of total billed charges", "standard_charge_dollar": 341.82, "standard_charge_percentage": 42.2, "count": "0", "additional_payer_notes": "Zero final payments for the item or service in the 15 months prior to posting the file." }, { "payer_name": "HEALTH NET", "plan_name": "HEALTHNET HMO, PPO, POS, EPO, CANOPY HEALTHNET HMO, OTHER-IN-NETWORK PLANS", "methodology": "per diem", "standard_charge_dollar": 8000.0, "standard_charge_algorithm": "Expected reimbursement is the lesser of Per diem ($8,000) for the length of stay and 70% of billed.", "count": "0", "additional_payer_notes": "Zero final payments for the item or service in the 15 months prior to posting the file." }, { "payer_name": "HEALTH NET", "plan_name": "HEALTHNET HMO, PPO, POS, EPO, CANOPY HEALTHNET HMO, OTHER-IN-NETWORK PLANS", "methodology": "per diem", "standard_charge_dollar": 8000.0, "standard_charge_algorithm": "Expected reimbursement is the lesser of Per diem ($8,000) for the length of stay and 70% of billed.", "count": "0", "additional_payer_notes": "Zero final payments for the item or service in the 15 months prior to posting the file." }, { "payer_name": "UNITED HEALTHCARE", "plan_name": "SUTTER SELECT & SUTTER HEALTH PLAN HMO PLANS", "methodology": "per diem", "standard_charge_dollar": 28538.0, "standard_charge_algorithm": "Per diem ($28,538).", "count": "0", "additional_payer_notes": "Zero final payments for the item or service in the 15 months prior to posting the file." }, { "payer_name": "UNITED HEALTHCARE", "plan_name": "SUTTER SELECT & SUTTER HEALTH PLAN HMO PLANS", "methodology": "per diem", "standard_charge_dollar": 28538.0, "standard_charge_algorithm": "Per diem ($28,538).", "count": "0", "additional_payer_notes": "Zero final payments for the item or service in the 15 months prior to posting the file." }, { "payer_name": "SUTTER", "plan_name": "SUTTER SELECT & SUTTER HEALTH PLAN HMO PLANS", "methodology": "per diem", "standard_charge_dollar": 28538.0, "standard_charge_algorithm": "Per diem ($28,538).", "count": "0", "additional_payer_notes": "Zero final payments for the item or service in the 15 months prior to posting the file." }, { "payer_name": "UNITED HEALTHCARE", "plan_name": "SUTTER SELECT & SUTTER HEALTH PLAN HMO PLANS", "methodology": "per diem", "standard_charge_dollar": 28538.0, "standard_charge_algorithm": "Per diem ($28,538).", "count": "0", "additional_payer_notes": "Zero final payments for the item or service in the 15 months prior to posting the file." }, { "payer_name": "UMR", "plan_name": "SUTTER SELECT & SUTTER HEALTH PLAN HMO PLANS", "methodology": "per diem", "standard_charge_dollar": 28538.0, "standard_charge_algorithm": "Per diem ($28,538).", "count": "0", "additional_payer_notes": "Zero final payments for the item or service in the 15 months prior to posting the file." } ] } ] }, { "description": "HC Cap Anchor Bolt Gp013", "code_information": [ { "code": "PX-2120164013", "type": "CDM" }, { "code": "99999", "type": "CPT" }, { "code": "0272", "type": "RC" } ], "standard_charges": [ { "setting": "outpatient", "gross_charge": 900.0, "discounted_cash": 450.0, "minimum": 379.8, "maximum": 468.0, "additional_generic_notes": "Zero final payments for the item or service in the 15 months prior to posting the file.", "payers_information": [ { "payer_name": "AETNA", "plan_name": "AETNA ALL OTHER PLANS", "methodology": "percent of total billed charges", "standard_charge_dollar": 468.0, "standard_charge_percentage": 52.0, "count": "0", "additional_payer_notes": "Zero final payments for the item or service in the 15 months prior to posting the file." }, { "payer_name": "AETNA", "plan_name": "AETNA ALL OTHER PLANS", "methodology": "percent of total billed charges", "standard_charge_dollar": 468.0, "standard_charge_percentage": 52.0, "count": "0", "additional_payer_notes": "Zero final payments for the item or service in the 15 months prior to posting the file." }, { "payer_name": "MERITAIN HEALTH", "plan_name": "AETNA ALL OTHER PLANS", "methodology": "percent of total billed charges", "standard_charge_dollar": 468.0, "standard_charge_percentage": 52.0, "count": "0", "additional_payer_notes": "Zero final payments for the item or service in the 15 months prior to posting the file." }, { "payer_name": "BLUE SHIELD OUT OF STATE", "plan_name": "STANFORD HEALTHCARE ALLIANCE PLAN", "methodology": "percent of total billed charges", "standard_charge_dollar": 437.31, "standard_charge_percentage": 48.59, "count": "0", "additional_payer_notes": "Zero final payments for the item or service in the 15 months prior to posting the file." }, { "payer_name": "BLUE SHIELD", "plan_name": "STANFORD HEALTHCARE ALLIANCE PLAN", "methodology": "percent of total billed charges", "standard_charge_dollar": 437.31, "standard_charge_percentage": 48.59, "count": "0", "additional_payer_notes": "Zero final payments for the item or service in the 15 months prior to posting the file." }, { "payer_name": "BLUE SHIELD", "plan_name": "STANFORD HEALTHCARE ALLIANCE PLAN", "methodology": "percent of total billed charges", "standard_charge_dollar": 437.31, "standard_charge_percentage": 48.59, "count": "0", "additional_payer_notes": "Zero final payments for the item or service in the 15 months prior to posting the file." }, { "payer_name": "CIGNA", "plan_name": "CIGNA COM ALT HMO PLAN", "methodology": "percent of total billed charges", "standard_charge_dollar": 379.8, "standard_charge_percentage": 42.2, "count": "0", "additional_payer_notes": "Zero final payments for the item or service in the 15 months prior to posting the file." }, { "payer_name": "CIGNA", "plan_name": "CIGNA COM ALT HMO PLAN", "methodology": "percent of total billed charges", "standard_charge_dollar": 379.8, "standard_charge_percentage": 42.2, "count": "0", "additional_payer_notes": "Zero final payments for the item or service in the 15 months prior to posting the file." }, { "payer_name": "HEALTH NET", "plan_name": "HEALTHNET HMO, PPO, POS, EPO, CANOPY HEALTHNET HMO, OTHER-IN-NETWORK PLANS", "methodology": "per diem", "standard_charge_dollar": 8000.0, "standard_charge_algorithm": "Expected reimbursement is the lesser of Per diem ($8,000) for the length of stay and 70% of billed.", "count": "0", "additional_payer_notes": "Zero final payments for the item or service in the 15 months prior to posting the file." }, { "payer_name": "HEALTH NET", "plan_name": "HEALTHNET HMO, PPO, POS, EPO, CANOPY HEALTHNET HMO, OTHER-IN-NETWORK PLANS", "methodology": "per diem", "standard_charge_dollar": 8000.0, "standard_charge_algorithm": "Expected reimbursement is the lesser of Per diem ($8,000) for the length of stay and 70% of billed.", "count": "0", "additional_payer_notes": "Zero final payments for the item or service in the 15 months prior to posting the file." }, { "payer_name": "UNITED HEALTHCARE", "plan_name": "SUTTER SELECT & SUTTER HEALTH PLAN HMO PLANS", "methodology": "per diem", "standard_charge_dollar": 28538.0, "standard_charge_algorithm": "Per diem ($28,538).", "count": "0", "additional_payer_notes": "Zero final payments for the item or service in the 15 months prior to posting the file." }, { "payer_name": "UNITED HEALTHCARE", "plan_name": "SUTTER SELECT & SUTTER HEALTH PLAN HMO PLANS", "methodology": "per diem", "standard_charge_dollar": 28538.0, "standard_charge_algorithm": "Per diem ($28,538).", "count": "0", "additional_payer_notes": "Zero final payments for the item or service in the 15 months prior to posting the file." }, { "payer_name": "SUTTER", "plan_name": "SUTTER SELECT & SUTTER HEALTH PLAN HMO PLANS", "methodology": "per diem", "standard_charge_dollar": 28538.0, "standard_charge_algorithm": "Per diem ($28,538).", "count": "0", "additional_payer_notes": "Zero final payments for the item or service in the 15 months prior to posting the file." }, { "payer_name": "UNITED HEALTHCARE", "plan_name": "SUTTER SELECT & SUTTER HEALTH PLAN HMO PLANS", "methodology": "per diem", "standard_charge_dollar": 28538.0, "standard_charge_algorithm": "Per diem ($28,538).", "count": "0", "additional_payer_notes": "Zero final payments for the item or service in the 15 months prior to posting the file." }, { "payer_name": "UMR", "plan_name": "SUTTER SELECT & SUTTER HEALTH PLAN HMO PLANS", "methodology": "per diem", "standard_charge_dollar": 28538.0, "standard_charge_algorithm": "Per diem ($28,538).", "count": "0", "additional_payer_notes": "Zero final payments for the item or service in the 15 months prior to posting the file." } ] } ] }, { "description": "HC Impl Pump Penile Infl Gp049", "code_information": [ { "code": "PX-2120170049", "type": "CDM" }, { "code": "C1813", "type": "HCPCS" }, { "code": "0278", "type": "RC" } ], "standard_charges": [ { "setting": "outpatient", "gross_charge": 14250.0, "discounted_cash": 7125.0, "minimum": 6013.5, "maximum": 7410.0, "additional_generic_notes": "Zero final payments for the item or service in the 15 months prior to posting the file.", "payers_information": [ { "payer_name": "AETNA", "plan_name": "AETNA ALL OTHER PLANS", "methodology": "percent of total billed charges", "standard_charge_dollar": 7410.0, "standard_charge_percentage": 52.0, "count": "0", "additional_payer_notes": "Zero final payments for the item or service in the 15 months prior to posting the file." }, { "payer_name": "AETNA", "plan_name": "AETNA ALL OTHER PLANS", "methodology": "percent of total billed charges", "standard_charge_dollar": 7410.0, "standard_charge_percentage": 52.0, "count": "0", "additional_payer_notes": "Zero final payments for the item or service in the 15 months prior to posting the file." }, { "payer_name": "MERITAIN HEALTH", "plan_name": "AETNA ALL OTHER PLANS", "methodology": "percent of total billed charges", "standard_charge_dollar": 7410.0, "standard_charge_percentage": 52.0, "count": "0", "additional_payer_notes": "Zero final payments for the item or service in the 15 months prior to posting the file." }, { "payer_name": "BLUE SHIELD OUT OF STATE", "plan_name": "STANFORD HEALTHCARE ALLIANCE PLAN", "methodology": "percent of total billed charges", "standard_charge_dollar": 6924.08, "standard_charge_percentage": 48.59, "count": "0", "additional_payer_notes": "Zero final payments for the item or service in the 15 months prior to posting the file." }, { "payer_name": "BLUE SHIELD", "plan_name": "STANFORD HEALTHCARE ALLIANCE PLAN", "methodology": "percent of total billed charges", "standard_charge_dollar": 6924.08, "standard_charge_percentage": 48.59, "count": "0", "additional_payer_notes": "Zero final payments for the item or service in the 15 months prior to posting the file." }, { "payer_name": "BLUE SHIELD", "plan_name": "STANFORD HEALTHCARE ALLIANCE PLAN", "methodology": "percent of total billed charges", "standard_charge_dollar": 6924.08, "standard_charge_percentage": 48.59, "count": "0", "additional_payer_notes": "Zero final payments for the item or service in the 15 months prior to posting the file." }, { "payer_name": "BLUE SHIELD", "plan_name": "STANFORD HEALTHCARE ALLIANCE PLAN", "methodology": "percent of total billed charges", "standard_charge_dollar": 6924.08, "standard_charge_percentage": 48.59, "count": "0", "additional_payer_notes": "Zero final payments for the item or service in the 15 months prior to posting the file." }, { "payer_name": "CIGNA", "plan_name": "CIGNA COM ALT HMO PLAN", "methodology": "percent of total billed charges", "standard_charge_dollar": 6013.5, "standard_charge_percentage": 42.2, "count": "0", "additional_payer_notes": "Zero final payments for the item or service in the 15 months prior to posting the file." }, { "payer_name": "CIGNA", "plan_name": "CIGNA COM ALT HMO PLAN", "methodology": "percent of total billed charges", "standard_charge_dollar": 6013.5, "standard_charge_percentage": 42.2, "count": "0", "additional_payer_notes": "Zero final payments for the item or service in the 15 months prior to posting the file." }, { "payer_name": "UNITED HEALTHCARE", "plan_name": "SUTTER SELECT & SUTTER HEALTH PLAN HMO PLANS", "methodology": "per diem", "standard_charge_dollar": 28538.0, "standard_charge_algorithm": "Per diem ($28,538).", "count": "0", "additional_payer_notes": "Zero final payments for the item or service in the 15 months prior to posting the file." }, { "payer_name": "UNITED HEALTHCARE", "plan_name": "SUTTER SELECT & SUTTER HEALTH PLAN HMO PLANS", "methodology": "per diem", "standard_charge_dollar": 28538.0, "standard_charge_algorithm": "Per diem ($28,538).", "count": "0", "additional_payer_notes": "Zero final payments for the item or service in the 15 months prior to posting the file." }, { "payer_name": "SUTTER", "plan_name": "SUTTER SELECT & SUTTER HEALTH PLAN HMO PLANS", "methodology": "per diem", "standard_charge_dollar": 28538.0, "standard_charge_algorithm": "Per diem ($28,538).", "count": "0", "additional_payer_notes": "Zero final payments for the item or service in the 15 months prior to posting the file." }, { "payer_name": "UNITED HEALTHCARE", "plan_name": "SUTTER SELECT & SUTTER HEALTH PLAN HMO PLANS", "methodology": "per diem", "standard_charge_dollar": 28538.0, "standard_charge_algorithm": "Per diem ($28,538).", "count": "0", "additional_payer_notes": "Zero final payments for the item or service in the 15 months prior to posting the file." }, { "payer_name": "UMR", "plan_name": "SUTTER SELECT & SUTTER HEALTH PLAN HMO PLANS", "methodology": "per diem", "standard_charge_dollar": 28538.0, "standard_charge_algorithm": "Per diem ($28,538).", "count": "0", "additional_payer_notes": "Zero final payments for the item or service in the 15 months prior to posting the file." }, { "payer_name": "UNITED HEALTHCARE", "plan_name": "SUTTER SELECT & SUTTER HEALTH PLAN HMO PLANS", "methodology": "per diem", "standard_charge_dollar": 28538.0, "standard_charge_algorithm": "Per diem ($28,538).", "count": "0", "additional_payer_notes": "Zero final payments for the item or service in the 15 months prior to posting the file." } ] } ] }, { "description": "HC Impl Pump Penile Infl Gp051", "code_information": [ { "code": "PX-2120170051", "type": "CDM" }, { "code": "C1813", "type": "HCPCS" }, { "code": "0278", "type": "RC" } ], "standard_charges": [ { "setting": "outpatient", "gross_charge": 15300.0, "discounted_cash": 7650.0, "minimum": 6456.6, "maximum": 7956.0, "additional_generic_notes": "Zero final payments for the item or service in the 15 months prior to posting the file.", "payers_information": [ { "payer_name": "AETNA", "plan_name": "AETNA ALL OTHER PLANS", "methodology": "percent of total billed charges", "standard_charge_dollar": 7956.0, "standard_charge_percentage": 52.0, "count": "0", "additional_payer_notes": "Zero final payments for the item or service in the 15 months prior to posting the file." }, { "payer_name": "AETNA", "plan_name": "AETNA ALL OTHER PLANS", "methodology": "percent of total billed charges", "standard_charge_dollar": 7956.0, "standard_charge_percentage": 52.0, "count": "0", "additional_payer_notes": "Zero final payments for the item or service in the 15 months prior to posting the file." }, { "payer_name": "MERITAIN HEALTH", "plan_name": "AETNA ALL OTHER PLANS", "methodology": "percent of total billed charges", "standard_charge_dollar": 7956.0, "standard_charge_percentage": 52.0, "count": "0", "additional_payer_notes": "Zero final payments for the item or service in the 15 months prior to posting the file." }, { "payer_name": "BLUE SHIELD OUT OF STATE", "plan_name": "STANFORD HEALTHCARE ALLIANCE PLAN", "methodology": "percent of total billed charges", "standard_charge_dollar": 7434.27, "standard_charge_percentage": 48.59, "count": "0", "additional_payer_notes": "Zero final payments for the item or service in the 15 months prior to posting the file." }, { "payer_name": "BLUE SHIELD", "plan_name": "STANFORD HEALTHCARE ALLIANCE PLAN", "methodology": "percent of total billed charges", "standard_charge_dollar": 7434.27, "standard_charge_percentage": 48.59, "count": "0", "additional_payer_notes": "Zero final payments for the item or service in the 15 months prior to posting the file." }, { "payer_name": "BLUE SHIELD", "plan_name": "STANFORD HEALTHCARE ALLIANCE PLAN", "methodology": "percent of total billed charges", "standard_charge_dollar": 7434.27, "standard_charge_percentage": 48.59, "count": "0", "additional_payer_notes": "Zero final payments for the item or service in the 15 months prior to posting the file." }, { "payer_name": "BLUE SHIELD", "plan_name": "STANFORD HEALTHCARE ALLIANCE PLAN", "methodology": "percent of total billed charges", "standard_charge_dollar": 7434.27, "standard_charge_percentage": 48.59, "count": "0", "additional_payer_notes": "Zero final payments for the item or service in the 15 months prior to posting the file." }, { "payer_name": "CIGNA", "plan_name": "CIGNA COM ALT HMO PLAN", "methodology": "percent of total billed charges", "standard_charge_dollar": 6456.6, "standard_charge_percentage": 42.2, "count": "0", "additional_payer_notes": "Zero final payments for the item or service in the 15 months prior to posting the file." }, { "payer_name": "CIGNA", "plan_name": "CIGNA COM ALT HMO PLAN", "methodology": "percent of total billed charges", "standard_charge_dollar": 6456.6, "standard_charge_percentage": 42.2, "count": "0", "additional_payer_notes": "Zero final payments for the item or service in the 15 months prior to posting the file." }, { "payer_name": "UNITED HEALTHCARE", "plan_name": "SUTTER SELECT & SUTTER HEALTH PLAN HMO PLANS", "methodology": "per diem", "standard_charge_dollar": 28538.0, "standard_charge_algorithm": "Per diem ($28,538).", "count": "0", "additional_payer_notes": "Zero final payments for the item or service in the 15 months prior to posting the file." }, { "payer_name": "UNITED HEALTHCARE", "plan_name": "SUTTER SELECT & SUTTER HEALTH PLAN HMO PLANS", "methodology": "per diem", "standard_charge_dollar": 28538.0, "standard_charge_algorithm": "Per diem ($28,538).", "count": "0", "additional_payer_notes": "Zero final payments for the item or service in the 15 months prior to posting the file." }, { "payer_name": "SUTTER", "plan_name": "SUTTER SELECT & SUTTER HEALTH PLAN HMO PLANS", "methodology": "per diem", "standard_charge_dollar": 28538.0, "standard_charge_algorithm": "Per diem ($28,538).", "count": "0", "additional_payer_notes": "Zero final payments for the item or service in the 15 months prior to posting the file." }, { "payer_name": "UNITED HEALTHCARE", "plan_name": "SUTTER SELECT & SUTTER HEALTH PLAN HMO PLANS", "methodology": "per diem", "standard_charge_dollar": 28538.0, "standard_charge_algorithm": "Per diem ($28,538).", "count": "0", "additional_payer_notes": "Zero final payments for the item or service in the 15 months prior to posting the file." }, { "payer_name": "UMR", "plan_name": "SUTTER SELECT & SUTTER HEALTH PLAN HMO PLANS", "methodology": "per diem", "standard_charge_dollar": 28538.0, "standard_charge_algorithm": "Per diem ($28,538).", "count": "0", "additional_payer_notes": "Zero final payments for the item or service in the 15 months prior to posting the file." }, { "payer_name": "UNITED HEALTHCARE", "plan_name": "SUTTER SELECT & SUTTER HEALTH PLAN HMO PLANS", "methodology": "per diem", "standard_charge_dollar": 28538.0, "standard_charge_algorithm": "Per diem ($28,538).", "count": "0", "additional_payer_notes": "Zero final payments for the item or service in the 15 months prior to posting the file." } ] } ] }, { "description": "HC Impl Putty Bone Gp051", "code_information": [ { "code": "PX-2120171051", "type": "CDM" }, { "code": "C9359", "type": "HCPCS" }, { "code": "0278", "type": "RC" } ], "standard_charges": [ { "setting": "outpatient", "gross_charge": 15300.0, "discounted_cash": 7650.0, "minimum": 6456.6, "maximum": 7956.0, "additional_generic_notes": "Zero final payments for the item or service in the 15 months prior to posting the file.", "payers_information": [ { "payer_name": "AETNA", "plan_name": "AETNA ALL OTHER PLANS", "methodology": "percent of total billed charges", "standard_charge_dollar": 7956.0, "standard_charge_percentage": 52.0, "count": "0", "additional_payer_notes": "Zero final payments for the item or service in the 15 months prior to posting the file." }, { "payer_name": "AETNA", "plan_name": "AETNA ALL OTHER PLANS", "methodology": "percent of total billed charges", "standard_charge_dollar": 7956.0, "standard_charge_percentage": 52.0, "count": "0", "additional_payer_notes": "Zero final payments for the item or service in the 15 months prior to posting the file." }, { "payer_name": "MERITAIN HEALTH", "plan_name": "AETNA ALL OTHER PLANS", "methodology": "percent of total billed charges", "standard_charge_dollar": 7956.0, "standard_charge_percentage": 52.0, "count": "0", "additional_payer_notes": "Zero final payments for the item or service in the 15 months prior to posting the file." }, { "payer_name": "BLUE SHIELD OUT OF STATE", "plan_name": "STANFORD HEALTHCARE ALLIANCE PLAN", "methodology": "percent of total billed charges", "standard_charge_dollar": 7434.27, "standard_charge_percentage": 48.59, "count": "0", "additional_payer_notes": "Zero final payments for the item or service in the 15 months prior to posting the file." }, { "payer_name": "BLUE SHIELD", "plan_name": "STANFORD HEALTHCARE ALLIANCE PLAN", "methodology": "percent of total billed charges", "standard_charge_dollar": 7434.27, "standard_charge_percentage": 48.59, "count": "0", "additional_payer_notes": "Zero final payments for the item or service in the 15 months prior to posting the file." }, { "payer_name": "BLUE SHIELD", "plan_name": "STANFORD HEALTHCARE ALLIANCE PLAN", "methodology": "percent of total billed charges", "standard_charge_dollar": 7434.27, "standard_charge_percentage": 48.59, "count": "0", "additional_payer_notes": "Zero final payments for the item or service in the 15 months prior to posting the file." }, { "payer_name": "BLUE SHIELD", "plan_name": "STANFORD HEALTHCARE ALLIANCE PLAN", "methodology": "percent of total billed charges", "standard_charge_dollar": 7434.27, "standard_charge_percentage": 48.59, "count": "0", "additional_payer_notes": "Zero final payments for the item or service in the 15 months prior to posting the file." }, { "payer_name": "CIGNA", "plan_name": "CIGNA COM ALT HMO PLAN", "methodology": "percent of total billed charges", "standard_charge_dollar": 6456.6, "standard_charge_percentage": 42.2, "count": "0", "additional_payer_notes": "Zero final payments for the item or service in the 15 months prior to posting the file." }, { "payer_name": "CIGNA", "plan_name": "CIGNA COM ALT HMO PLAN", "methodology": "percent of total billed charges", "standard_charge_dollar": 6456.6, "standard_charge_percentage": 42.2, "count": "0", "additional_payer_notes": "Zero final payments for the item or service in the 15 months prior to posting the file." }, { "payer_name": "UNITED HEALTHCARE", "plan_name": "SUTTER SELECT & SUTTER HEALTH PLAN HMO PLANS", "methodology": "per diem", "standard_charge_dollar": 28538.0, "standard_charge_algorithm": "Per diem ($28,538).", "count": "0", "additional_payer_notes": "Zero final payments for the item or service in the 15 months prior to posting the file." }, { "payer_name": "UNITED HEALTHCARE", "plan_name": "SUTTER SELECT & SUTTER HEALTH PLAN HMO PLANS", "methodology": "per diem", "standard_charge_dollar": 28538.0, "standard_charge_algorithm": "Per diem ($28,538).", "count": "0", "additional_payer_notes": "Zero final payments for the item or service in the 15 months prior to posting the file." }, { "payer_name": "SUTTER", "plan_name": "SUTTER SELECT & SUTTER HEALTH PLAN HMO PLANS", "methodology": "per diem", "standard_charge_dollar": 28538.0, "standard_charge_algorithm": "Per diem ($28,538).", "count": "0", "additional_payer_notes": "Zero final payments for the item or service in the 15 months prior to posting the file." }, { "payer_name": "UNITED HEALTHCARE", "plan_name": "SUTTER SELECT & SUTTER HEALTH PLAN HMO PLANS", "methodology": "per diem", "standard_charge_dollar": 28538.0, "standard_charge_algorithm": "Per diem ($28,538).", "count": "0", "additional_payer_notes": "Zero final payments for the item or service in the 15 months prior to posting the file." }, { "payer_name": "UMR", "plan_name": "SUTTER SELECT & SUTTER HEALTH PLAN HMO PLANS", "methodology": "per diem", "standard_charge_dollar": 28538.0, "standard_charge_algorithm": "Per diem ($28,538).", "count": "0", "additional_payer_notes": "Zero final payments for the item or service in the 15 months prior to posting the file." }, { "payer_name": "UNITED HEALTHCARE", "plan_name": "SUTTER SELECT & SUTTER HEALTH PLAN HMO PLANS", "methodology": "per diem", "standard_charge_dollar": 28538.0, "standard_charge_algorithm": "Per diem ($28,538).", "count": "0", "additional_payer_notes": "Zero final payments for the item or service in the 15 months prior to posting the file." } ] } ] }, { "description": "HC Impl Putty Bone Gp052", "code_information": [ { "code": "PX-2120171052", "type": "CDM" }, { "code": "C9359", "type": "HCPCS" }, { "code": "0278", "type": "RC" } ], "standard_charges": [ { "setting": "outpatient", "gross_charge": 16200.0, "discounted_cash": 8100.0, "minimum": 6836.4, "maximum": 8424.0, "additional_generic_notes": "Zero final payments for the item or service in the 15 months prior to posting the file.", "payers_information": [ { "payer_name": "AETNA", "plan_name": "AETNA ALL OTHER PLANS", "methodology": "percent of total billed charges", "standard_charge_dollar": 8424.0, "standard_charge_percentage": 52.0, "count": "0", "additional_payer_notes": "Zero final payments for the item or service in the 15 months prior to posting the file." }, { "payer_name": "AETNA", "plan_name": "AETNA ALL OTHER PLANS", "methodology": "percent of total billed charges", "standard_charge_dollar": 8424.0, "standard_charge_percentage": 52.0, "count": "0", "additional_payer_notes": "Zero final payments for the item or service in the 15 months prior to posting the file." }, { "payer_name": "MERITAIN HEALTH", "plan_name": "AETNA ALL OTHER PLANS", "methodology": "percent of total billed charges", "standard_charge_dollar": 8424.0, "standard_charge_percentage": 52.0, "count": "0", "additional_payer_notes": "Zero final payments for the item or service in the 15 months prior to posting the file." }, { "payer_name": "BLUE SHIELD OUT OF STATE", "plan_name": "STANFORD HEALTHCARE ALLIANCE PLAN", "methodology": "percent of total billed charges", "standard_charge_dollar": 7871.58, "standard_charge_percentage": 48.59, "count": "0", "additional_payer_notes": "Zero final payments for the item or service in the 15 months prior to posting the file." }, { "payer_name": "BLUE SHIELD", "plan_name": "STANFORD HEALTHCARE ALLIANCE PLAN", "methodology": "percent of total billed charges", "standard_charge_dollar": 7871.58, "standard_charge_percentage": 48.59, "count": "0", "additional_payer_notes": "Zero final payments for the item or service in the 15 months prior to posting the file." }, { "payer_name": "BLUE SHIELD", "plan_name": "STANFORD HEALTHCARE ALLIANCE PLAN", "methodology": "percent of total billed charges", "standard_charge_dollar": 7871.58, "standard_charge_percentage": 48.59, "count": "0", "additional_payer_notes": "Zero final payments for the item or service in the 15 months prior to posting the file." }, { "payer_name": "BLUE SHIELD", "plan_name": "STANFORD HEALTHCARE ALLIANCE PLAN", "methodology": "percent of total billed charges", "standard_charge_dollar": 7871.58, "standard_charge_percentage": 48.59, "count": "0", "additional_payer_notes": "Zero final payments for the item or service in the 15 months prior to posting the file." }, { "payer_name": "CIGNA", "plan_name": "CIGNA COM ALT HMO PLAN", "methodology": "percent of total billed charges", "standard_charge_dollar": 6836.4, "standard_charge_percentage": 42.2, "count": "0", "additional_payer_notes": "Zero final payments for the item or service in the 15 months prior to posting the file." }, { "payer_name": "CIGNA", "plan_name": "CIGNA COM ALT HMO PLAN", "methodology": "percent of total billed charges", "standard_charge_dollar": 6836.4, "standard_charge_percentage": 42.2, "count": "0", "additional_payer_notes": "Zero final payments for the item or service in the 15 months prior to posting the file." }, { "payer_name": "UNITED HEALTHCARE", "plan_name": "SUTTER SELECT & SUTTER HEALTH PLAN HMO PLANS", "methodology": "per diem", "standard_charge_dollar": 28538.0, "standard_charge_algorithm": "Per diem ($28,538).", "count": "0", "additional_payer_notes": "Zero final payments for the item or service in the 15 months prior to posting the file." }, { "payer_name": "UNITED HEALTHCARE", "plan_name": "SUTTER SELECT & SUTTER HEALTH PLAN HMO PLANS", "methodology": "per diem", "standard_charge_dollar": 28538.0, "standard_charge_algorithm": "Per diem ($28,538).", "count": "0", "additional_payer_notes": "Zero final payments for the item or service in the 15 months prior to posting the file." }, { "payer_name": "SUTTER", "plan_name": "SUTTER SELECT & SUTTER HEALTH PLAN HMO PLANS", "methodology": "per diem", "standard_charge_dollar": 28538.0, "standard_charge_algorithm": "Per diem ($28,538).", "count": "0", "additional_payer_notes": "Zero final payments for the item or service in the 15 months prior to posting the file." }, { "payer_name": "UNITED HEALTHCARE", "plan_name": "SUTTER SELECT & SUTTER HEALTH PLAN HMO PLANS", "methodology": "per diem", "standard_charge_dollar": 28538.0, "standard_charge_algorithm": "Per diem ($28,538).", "count": "0", "additional_payer_notes": "Zero final payments for the item or service in the 15 months prior to posting the file." }, { "payer_name": "UMR", "plan_name": "SUTTER SELECT & SUTTER HEALTH PLAN HMO PLANS", "methodology": "per diem", "standard_charge_dollar": 28538.0, "standard_charge_algorithm": "Per diem ($28,538).", "count": "0", "additional_payer_notes": "Zero final payments for the item or service in the 15 months prior to posting the file." }, { "payer_name": "UNITED HEALTHCARE", "plan_name": "SUTTER SELECT & SUTTER HEALTH PLAN HMO PLANS", "methodology": "per diem", "standard_charge_dollar": 28538.0, "standard_charge_algorithm": "Per diem ($28,538).", "count": "0", "additional_payer_notes": "Zero final payments for the item or service in the 15 months prior to posting the file." } ] } ] }, { "description": "HC Impl Putty Bone Gp054", "code_information": [ { "code": "PX-2120171054", "type": "CDM" }, { "code": "C9359", "type": "HCPCS" }, { "code": "0278", "type": "RC" } ], "standard_charges": [ { "setting": "outpatient", "gross_charge": 17000.0, "discounted_cash": 8500.0, "minimum": 7174.0, "maximum": 8840.0, "additional_generic_notes": "Zero final payments for the item or service in the 15 months prior to posting the file.", "payers_information": [ { "payer_name": "AETNA", "plan_name": "AETNA ALL OTHER PLANS", "methodology": "percent of total billed charges", "standard_charge_dollar": 8840.0, "standard_charge_percentage": 52.0, "count": "0", "additional_payer_notes": "Zero final payments for the item or service in the 15 months prior to posting the file." }, { "payer_name": "AETNA", "plan_name": "AETNA ALL OTHER PLANS", "methodology": "percent of total billed charges", "standard_charge_dollar": 8840.0, "standard_charge_percentage": 52.0, "count": "0", "additional_payer_notes": "Zero final payments for the item or service in the 15 months prior to posting the file." }, { "payer_name": "MERITAIN HEALTH", "plan_name": "AETNA ALL OTHER PLANS", "methodology": "percent of total billed charges", "standard_charge_dollar": 8840.0, "standard_charge_percentage": 52.0, "count": "0", "additional_payer_notes": "Zero final payments for the item or service in the 15 months prior to posting the file." }, { "payer_name": "BLUE SHIELD OUT OF STATE", "plan_name": "STANFORD HEALTHCARE ALLIANCE PLAN", "methodology": "percent of total billed charges", "standard_charge_dollar": 8260.3, "standard_charge_percentage": 48.59, "count": "0", "additional_payer_notes": "Zero final payments for the item or service in the 15 months prior to posting the file." }, { "payer_name": "BLUE SHIELD", "plan_name": "STANFORD HEALTHCARE ALLIANCE PLAN", "methodology": "percent of total billed charges", "standard_charge_dollar": 8260.3, "standard_charge_percentage": 48.59, "count": "0", "additional_payer_notes": "Zero final payments for the item or service in the 15 months prior to posting the file." }, { "payer_name": "BLUE SHIELD", "plan_name": "STANFORD HEALTHCARE ALLIANCE PLAN", "methodology": "percent of total billed charges", "standard_charge_dollar": 8260.3, "standard_charge_percentage": 48.59, "count": "0", "additional_payer_notes": "Zero final payments for the item or service in the 15 months prior to posting the file." }, { "payer_name": "BLUE SHIELD", "plan_name": "STANFORD HEALTHCARE ALLIANCE PLAN", "methodology": "percent of total billed charges", "standard_charge_dollar": 8260.3, "standard_charge_percentage": 48.59, "count": "0", "additional_payer_notes": "Zero final payments for the item or service in the 15 months prior to posting the file." }, { "payer_name": "CIGNA", "plan_name": "CIGNA COM ALT HMO PLAN", "methodology": "percent of total billed charges", "standard_charge_dollar": 7174.0, "standard_charge_percentage": 42.2, "count": "0", "additional_payer_notes": "Zero final payments for the item or service in the 15 months prior to posting the file." }, { "payer_name": "CIGNA", "plan_name": "CIGNA COM ALT HMO PLAN", "methodology": "percent of total billed charges", "standard_charge_dollar": 7174.0, "standard_charge_percentage": 42.2, "count": "0", "additional_payer_notes": "Zero final payments for the item or service in the 15 months prior to posting the file." }, { "payer_name": "UNITED HEALTHCARE", "plan_name": "SUTTER SELECT & SUTTER HEALTH PLAN HMO PLANS", "methodology": "per diem", "standard_charge_dollar": 28538.0, "standard_charge_algorithm": "Per diem ($28,538).", "count": "0", "additional_payer_notes": "Zero final payments for the item or service in the 15 months prior to posting the file." }, { "payer_name": "UNITED HEALTHCARE", "plan_name": "SUTTER SELECT & SUTTER HEALTH PLAN HMO PLANS", "methodology": "per diem", "standard_charge_dollar": 28538.0, "standard_charge_algorithm": "Per diem ($28,538).", "count": "0", "additional_payer_notes": "Zero final payments for the item or service in the 15 months prior to posting the file." }, { "payer_name": "SUTTER", "plan_name": "SUTTER SELECT & SUTTER HEALTH PLAN HMO PLANS", "methodology": "per diem", "standard_charge_dollar": 28538.0, "standard_charge_algorithm": "Per diem ($28,538).", "count": "0", "additional_payer_notes": "Zero final payments for the item or service in the 15 months prior to posting the file." }, { "payer_name": "UNITED HEALTHCARE", "plan_name": "SUTTER SELECT & SUTTER HEALTH PLAN HMO PLANS", "methodology": "per diem", "standard_charge_dollar": 28538.0, "standard_charge_algorithm": "Per diem ($28,538).", "count": "0", "additional_payer_notes": "Zero final payments for the item or service in the 15 months prior to posting the file." }, { "payer_name": "UMR", "plan_name": "SUTTER SELECT & SUTTER HEALTH PLAN HMO PLANS", "methodology": "per diem", "standard_charge_dollar": 28538.0, "standard_charge_algorithm": "Per diem ($28,538).", "count": "0", "additional_payer_notes": "Zero final payments for the item or service in the 15 months prior to posting the file." }, { "payer_name": "UNITED HEALTHCARE", "plan_name": "SUTTER SELECT & SUTTER HEALTH PLAN HMO PLANS", "methodology": "per diem", "standard_charge_dollar": 28538.0, "standard_charge_algorithm": "Per diem ($28,538).", "count": "0", "additional_payer_notes": "Zero final payments for the item or service in the 15 months prior to posting the file." } ] } ] }, { "description": "HC Impl Putty Bone Gp055", "code_information": [ { "code": "PX-2120171055", "type": "CDM" }, { "code": "C9359", "type": "HCPCS" }, { "code": "0278", "type": "RC" } ], "standard_charges": [ { "setting": "outpatient", "gross_charge": 17000.0, "discounted_cash": 8500.0, "minimum": 7174.0, "maximum": 8840.0, "additional_generic_notes": "Zero final payments for the item or service in the 15 months prior to posting the file.", "payers_information": [ { "payer_name": "AETNA", "plan_name": "AETNA ALL OTHER PLANS", "methodology": "percent of total billed charges", "standard_charge_dollar": 8840.0, "standard_charge_percentage": 52.0, "count": "0", "additional_payer_notes": "Zero final payments for the item or service in the 15 months prior to posting the file." }, { "payer_name": "AETNA", "plan_name": "AETNA ALL OTHER PLANS", "methodology": "percent of total billed charges", "standard_charge_dollar": 8840.0, "standard_charge_percentage": 52.0, "count": "0", "additional_payer_notes": "Zero final payments for the item or service in the 15 months prior to posting the file." }, { "payer_name": "MERITAIN HEALTH", "plan_name": "AETNA ALL OTHER PLANS", "methodology": "percent of total billed charges", "standard_charge_dollar": 8840.0, "standard_charge_percentage": 52.0, "count": "0", "additional_payer_notes": "Zero final payments for the item or service in the 15 months prior to posting the file." }, { "payer_name": "BLUE SHIELD OUT OF STATE", "plan_name": "STANFORD HEALTHCARE ALLIANCE PLAN", "methodology": "percent of total billed charges", "standard_charge_dollar": 8260.3, "standard_charge_percentage": 48.59, "count": "0", "additional_payer_notes": "Zero final payments for the item or service in the 15 months prior to posting the file." }, { "payer_name": "BLUE SHIELD", "plan_name": "STANFORD HEALTHCARE ALLIANCE PLAN", "methodology": "percent of total billed charges", "standard_charge_dollar": 8260.3, "standard_charge_percentage": 48.59, "count": "0", "additional_payer_notes": "Zero final payments for the item or service in the 15 months prior to posting the file." }, { "payer_name": "BLUE SHIELD", "plan_name": "STANFORD HEALTHCARE ALLIANCE PLAN", "methodology": "percent of total billed charges", "standard_charge_dollar": 8260.3, "standard_charge_percentage": 48.59, "count": "0", "additional_payer_notes": "Zero final payments for the item or service in the 15 months prior to posting the file." }, { "payer_name": "BLUE SHIELD", "plan_name": "STANFORD HEALTHCARE ALLIANCE PLAN", "methodology": "percent of total billed charges", "standard_charge_dollar": 8260.3, "standard_charge_percentage": 48.59, "count": "0", "additional_payer_notes": "Zero final payments for the item or service in the 15 months prior to posting the file." }, { "payer_name": "CIGNA", "plan_name": "CIGNA COM ALT HMO PLAN", "methodology": "percent of total billed charges", "standard_charge_dollar": 7174.0, "standard_charge_percentage": 42.2, "count": "0", "additional_payer_notes": "Zero final payments for the item or service in the 15 months prior to posting the file." }, { "payer_name": "CIGNA", "plan_name": "CIGNA COM ALT HMO PLAN", "methodology": "percent of total billed charges", "standard_charge_dollar": 7174.0, "standard_charge_percentage": 42.2, "count": "0", "additional_payer_notes": "Zero final payments for the item or service in the 15 months prior to posting the file." }, { "payer_name": "UNITED HEALTHCARE", "plan_name": "SUTTER SELECT & SUTTER HEALTH PLAN HMO PLANS", "methodology": "per diem", "standard_charge_dollar": 28538.0, "standard_charge_algorithm": "Per diem ($28,538).", "count": "0", "additional_payer_notes": "Zero final payments for the item or service in the 15 months prior to posting the file." }, { "payer_name": "UNITED HEALTHCARE", "plan_name": "SUTTER SELECT & SUTTER HEALTH PLAN HMO PLANS", "methodology": "per diem", "standard_charge_dollar": 28538.0, "standard_charge_algorithm": "Per diem ($28,538).", "count": "0", "additional_payer_notes": "Zero final payments for the item or service in the 15 months prior to posting the file." }, { "payer_name": "SUTTER", "plan_name": "SUTTER SELECT & SUTTER HEALTH PLAN HMO PLANS", "methodology": "per diem", "standard_charge_dollar": 28538.0, "standard_charge_algorithm": "Per diem ($28,538).", "count": "0", "additional_payer_notes": "Zero final payments for the item or service in the 15 months prior to posting the file." }, { "payer_name": "UNITED HEALTHCARE", "plan_name": "SUTTER SELECT & SUTTER HEALTH PLAN HMO PLANS", "methodology": "per diem", "standard_charge_dollar": 28538.0, "standard_charge_algorithm": "Per diem ($28,538).", "count": "0", "additional_payer_notes": "Zero final payments for the item or service in the 15 months prior to posting the file." }, { "payer_name": "UMR", "plan_name": "SUTTER SELECT & SUTTER HEALTH PLAN HMO PLANS", "methodology": "per diem", "standard_charge_dollar": 28538.0, "standard_charge_algorithm": "Per diem ($28,538).", "count": "0", "additional_payer_notes": "Zero final payments for the item or service in the 15 months prior to posting the file." }, { "payer_name": "UNITED HEALTHCARE", "plan_name": "SUTTER SELECT & SUTTER HEALTH PLAN HMO PLANS", "methodology": "per diem", "standard_charge_dollar": 28538.0, "standard_charge_algorithm": "Per diem ($28,538).", "count": "0", "additional_payer_notes": "Zero final payments for the item or service in the 15 months prior to posting the file." } ] } ] }, { "description": "HC Impl Putty Bone Gp063", "code_information": [ { "code": "PX-2120171063", "type": "CDM" }, { "code": "C9359", "type": "HCPCS" }, { "code": "0278", "type": "RC" } ], "standard_charges": [ { "setting": "outpatient", "gross_charge": 23200.0, "discounted_cash": 11600.0, "minimum": 9790.4, "maximum": 12064.0, "additional_generic_notes": "Zero final payments for the item or service in the 15 months prior to posting the file.", "payers_information": [ { "payer_name": "AETNA", "plan_name": "AETNA ALL OTHER PLANS", "methodology": "percent of total billed charges", "standard_charge_dollar": 12064.0, "standard_charge_percentage": 52.0, "count": "0", "additional_payer_notes": "Zero final payments for the item or service in the 15 months prior to posting the file." }, { "payer_name": "AETNA", "plan_name": "AETNA ALL OTHER PLANS", "methodology": "percent of total billed charges", "standard_charge_dollar": 12064.0, "standard_charge_percentage": 52.0, "count": "0", "additional_payer_notes": "Zero final payments for the item or service in the 15 months prior to posting the file." }, { "payer_name": "MERITAIN HEALTH", "plan_name": "AETNA ALL OTHER PLANS", "methodology": "percent of total billed charges", "standard_charge_dollar": 12064.0, "standard_charge_percentage": 52.0, "count": "0", "additional_payer_notes": "Zero final payments for the item or service in the 15 months prior to posting the file." }, { "payer_name": "BLUE SHIELD OUT OF STATE", "plan_name": "STANFORD HEALTHCARE ALLIANCE PLAN", "methodology": "percent of total billed charges", "standard_charge_dollar": 11272.88, "standard_charge_percentage": 48.59, "count": "0", "additional_payer_notes": "Zero final payments for the item or service in the 15 months prior to posting the file." }, { "payer_name": "BLUE SHIELD", "plan_name": "STANFORD HEALTHCARE ALLIANCE PLAN", "methodology": "percent of total billed charges", "standard_charge_dollar": 11272.88, "standard_charge_percentage": 48.59, "count": "0", "additional_payer_notes": "Zero final payments for the item or service in the 15 months prior to posting the file." }, { "payer_name": "BLUE SHIELD", "plan_name": "STANFORD HEALTHCARE ALLIANCE PLAN", "methodology": "percent of total billed charges", "standard_charge_dollar": 11272.88, "standard_charge_percentage": 48.59, "count": "0", "additional_payer_notes": "Zero final payments for the item or service in the 15 months prior to posting the file." }, { "payer_name": "BLUE SHIELD", "plan_name": "STANFORD HEALTHCARE ALLIANCE PLAN", "methodology": "percent of total billed charges", "standard_charge_dollar": 11272.88, "standard_charge_percentage": 48.59, "count": "0", "additional_payer_notes": "Zero final payments for the item or service in the 15 months prior to posting the file." }, { "payer_name": "CIGNA", "plan_name": "CIGNA COM ALT HMO PLAN", "methodology": "percent of total billed charges", "standard_charge_dollar": 9790.4, "standard_charge_percentage": 42.2, "count": "0", "additional_payer_notes": "Zero final payments for the item or service in the 15 months prior to posting the file." }, { "payer_name": "CIGNA", "plan_name": "CIGNA COM ALT HMO PLAN", "methodology": "percent of total billed charges", "standard_charge_dollar": 9790.4, "standard_charge_percentage": 42.2, "count": "0", "additional_payer_notes": "Zero final payments for the item or service in the 15 months prior to posting the file." }, { "payer_name": "UNITED HEALTHCARE", "plan_name": "SUTTER SELECT & SUTTER HEALTH PLAN HMO PLANS", "methodology": "per diem", "standard_charge_dollar": 28538.0, "standard_charge_algorithm": "Per diem ($28,538).", "count": "0", "additional_payer_notes": "Zero final payments for the item or service in the 15 months prior to posting the file." }, { "payer_name": "UNITED HEALTHCARE", "plan_name": "SUTTER SELECT & SUTTER HEALTH PLAN HMO PLANS", "methodology": "per diem", "standard_charge_dollar": 28538.0, "standard_charge_algorithm": "Per diem ($28,538).", "count": "0", "additional_payer_notes": "Zero final payments for the item or service in the 15 months prior to posting the file." }, { "payer_name": "SUTTER", "plan_name": "SUTTER SELECT & SUTTER HEALTH PLAN HMO PLANS", "methodology": "per diem", "standard_charge_dollar": 28538.0, "standard_charge_algorithm": "Per diem ($28,538).", "count": "0", "additional_payer_notes": "Zero final payments for the item or service in the 15 months prior to posting the file." }, { "payer_name": "UNITED HEALTHCARE", "plan_name": "SUTTER SELECT & SUTTER HEALTH PLAN HMO PLANS", "methodology": "per diem", "standard_charge_dollar": 28538.0, "standard_charge_algorithm": "Per diem ($28,538).", "count": "0", "additional_payer_notes": "Zero final payments for the item or service in the 15 months prior to posting the file." }, { "payer_name": "UMR", "plan_name": "SUTTER SELECT & SUTTER HEALTH PLAN HMO PLANS", "methodology": "per diem", "standard_charge_dollar": 28538.0, "standard_charge_algorithm": "Per diem ($28,538).", "count": "0", "additional_payer_notes": "Zero final payments for the item or service in the 15 months prior to posting the file." }, { "payer_name": "UNITED HEALTHCARE", "plan_name": "SUTTER SELECT & SUTTER HEALTH PLAN HMO PLANS", "methodology": "per diem", "standard_charge_dollar": 28538.0, "standard_charge_algorithm": "Per diem ($28,538).", "count": "0", "additional_payer_notes": "Zero final payments for the item or service in the 15 months prior to posting the file." } ] } ] }, { "description": "HC Thrmbctmy Rotational Clnr Gp048", "code_information": [ { "code": "PX-2120181048", "type": "CDM" }, { "code": "C1757", "type": "HCPCS" }, { "code": "0272", "type": "RC" } ], "standard_charges": [ { "setting": "outpatient", "gross_charge": 14000.0, "discounted_cash": 7000.0, "minimum": 5908.0, "maximum": 7280.0, "additional_generic_notes": "Zero final payments for the item or service in the 15 months prior to posting the file.", "payers_information": [ { "payer_name": "AETNA", "plan_name": "AETNA ALL OTHER PLANS", "methodology": "percent of total billed charges", "standard_charge_dollar": 7280.0, "standard_charge_percentage": 52.0, "count": "0", "additional_payer_notes": "Zero final payments for the item or service in the 15 months prior to posting the file." }, { "payer_name": "AETNA", "plan_name": "AETNA ALL OTHER PLANS", "methodology": "percent of total billed charges", "standard_charge_dollar": 7280.0, "standard_charge_percentage": 52.0, "count": "0", "additional_payer_notes": "Zero final payments for the item or service in the 15 months prior to posting the file." }, { "payer_name": "MERITAIN HEALTH", "plan_name": "AETNA ALL OTHER PLANS", "methodology": "percent of total billed charges", "standard_charge_dollar": 7280.0, "standard_charge_percentage": 52.0, "count": "0", "additional_payer_notes": "Zero final payments for the item or service in the 15 months prior to posting the file." }, { "payer_name": "BLUE SHIELD OUT OF STATE", "plan_name": "STANFORD HEALTHCARE ALLIANCE PLAN", "methodology": "percent of total billed charges", "standard_charge_dollar": 6802.6, "standard_charge_percentage": 48.59, "count": "0", "additional_payer_notes": "Zero final payments for the item or service in the 15 months prior to posting the file." }, { "payer_name": "BLUE SHIELD", "plan_name": "STANFORD HEALTHCARE ALLIANCE PLAN", "methodology": "percent of total billed charges", "standard_charge_dollar": 6802.6, "standard_charge_percentage": 48.59, "count": "0", "additional_payer_notes": "Zero final payments for the item or service in the 15 months prior to posting the file." }, { "payer_name": "BLUE SHIELD", "plan_name": "STANFORD HEALTHCARE ALLIANCE PLAN", "methodology": "percent of total billed charges", "standard_charge_dollar": 6802.6, "standard_charge_percentage": 48.59, "count": "0", "additional_payer_notes": "Zero final payments for the item or service in the 15 months prior to posting the file." }, { "payer_name": "BLUE SHIELD", "plan_name": "STANFORD HEALTHCARE ALLIANCE PLAN", "methodology": "percent of total billed charges", "standard_charge_dollar": 6802.6, "standard_charge_percentage": 48.59, "count": "0", "additional_payer_notes": "Zero final payments for the item or service in the 15 months prior to posting the file." }, { "payer_name": "CIGNA", "plan_name": "CIGNA COM ALT HMO PLAN", "methodology": "percent of total billed charges", "standard_charge_dollar": 5908.0, "standard_charge_percentage": 42.2, "count": "0", "additional_payer_notes": "Zero final payments for the item or service in the 15 months prior to posting the file." }, { "payer_name": "CIGNA", "plan_name": "CIGNA COM ALT HMO PLAN", "methodology": "percent of total billed charges", "standard_charge_dollar": 5908.0, "standard_charge_percentage": 42.2, "count": "0", "additional_payer_notes": "Zero final payments for the item or service in the 15 months prior to posting the file." }, { "payer_name": "HEALTH NET", "plan_name": "HEALTHNET HMO, PPO, POS, EPO, CANOPY HEALTHNET HMO, OTHER-IN-NETWORK PLANS", "methodology": "per diem", "standard_charge_dollar": 8000.0, "standard_charge_algorithm": "Expected reimbursement is the lesser of Per diem ($8,000) for the length of stay and 70% of billed.", "count": "0", "additional_payer_notes": "Zero final payments for the item or service in the 15 months prior to posting the file." }, { "payer_name": "HEALTH NET", "plan_name": "HEALTHNET HMO, PPO, POS, EPO, CANOPY HEALTHNET HMO, OTHER-IN-NETWORK PLANS", "methodology": "per diem", "standard_charge_dollar": 8000.0, "standard_charge_algorithm": "Expected reimbursement is the lesser of Per diem ($8,000) for the length of stay and 70% of billed.", "count": "0", "additional_payer_notes": "Zero final payments for the item or service in the 15 months prior to posting the file." }, { "payer_name": "UNITED HEALTHCARE", "plan_name": "SUTTER SELECT & SUTTER HEALTH PLAN HMO PLANS", "methodology": "per diem", "standard_charge_dollar": 28538.0, "standard_charge_algorithm": "Per diem ($28,538).", "count": "0", "additional_payer_notes": "Zero final payments for the item or service in the 15 months prior to posting the file." }, { "payer_name": "UNITED HEALTHCARE", "plan_name": "SUTTER SELECT & SUTTER HEALTH PLAN HMO PLANS", "methodology": "per diem", "standard_charge_dollar": 28538.0, "standard_charge_algorithm": "Per diem ($28,538).", "count": "0", "additional_payer_notes": "Zero final payments for the item or service in the 15 months prior to posting the file." }, { "payer_name": "SUTTER", "plan_name": "SUTTER SELECT & SUTTER HEALTH PLAN HMO PLANS", "methodology": "per diem", "standard_charge_dollar": 28538.0, "standard_charge_algorithm": "Per diem ($28,538).", "count": "0", "additional_payer_notes": "Zero final payments for the item or service in the 15 months prior to posting the file." }, { "payer_name": "UNITED HEALTHCARE", "plan_name": "SUTTER SELECT & SUTTER HEALTH PLAN HMO PLANS", "methodology": "per diem", "standard_charge_dollar": 28538.0, "standard_charge_algorithm": "Per diem ($28,538).", "count": "0", "additional_payer_notes": "Zero final payments for the item or service in the 15 months prior to posting the file." }, { "payer_name": "UMR", "plan_name": "SUTTER SELECT & SUTTER HEALTH PLAN HMO PLANS", "methodology": "per diem", "standard_charge_dollar": 28538.0, "standard_charge_algorithm": "Per diem ($28,538).", "count": "0", "additional_payer_notes": "Zero final payments for the item or service in the 15 months prior to posting the file." }, { "payer_name": "UNITED HEALTHCARE", "plan_name": "SUTTER SELECT & SUTTER HEALTH PLAN HMO PLANS", "methodology": "per diem", "standard_charge_dollar": 28538.0, "standard_charge_algorithm": "Per diem ($28,538).", "count": "0", "additional_payer_notes": "Zero final payments for the item or service in the 15 months prior to posting the file." } ] } ] }, { "description": "HC Impl Stent Ncor Tmp WO D Gp024", "code_information": [ { "code": "PX-2120187024", "type": "CDM" }, { "code": "C2617", "type": "HCPCS" }, { "code": "0272", "type": "RC" } ], "standard_charges": [ { "setting": "outpatient", "gross_charge": 4000.0, "discounted_cash": 2000.0, "minimum": 1688.0, "maximum": 2080.0, "additional_generic_notes": "Zero final payments for the item or service in the 15 months prior to posting the file.", "payers_information": [ { "payer_name": "AETNA", "plan_name": "AETNA ALL OTHER PLANS", "methodology": "percent of total billed charges", "standard_charge_dollar": 2080.0, "standard_charge_percentage": 52.0, "count": "0", "additional_payer_notes": "Zero final payments for the item or service in the 15 months prior to posting the file." }, { "payer_name": "AETNA", "plan_name": "AETNA ALL OTHER PLANS", "methodology": "percent of total billed charges", "standard_charge_dollar": 2080.0, "standard_charge_percentage": 52.0, "count": "0", "additional_payer_notes": "Zero final payments for the item or service in the 15 months prior to posting the file." }, { "payer_name": "MERITAIN HEALTH", "plan_name": "AETNA ALL OTHER PLANS", "methodology": "percent of total billed charges", "standard_charge_dollar": 2080.0, "standard_charge_percentage": 52.0, "count": "0", "additional_payer_notes": "Zero final payments for the item or service in the 15 months prior to posting the file." }, { "payer_name": "BLUE SHIELD OUT OF STATE", "plan_name": "STANFORD HEALTHCARE ALLIANCE PLAN", "methodology": "percent of total billed charges", "standard_charge_dollar": 1943.6, "standard_charge_percentage": 48.59, "median_amount": 214.55, "10th_percentile": 88.7, "90th_percentile": 214.55, "count": "1 through 10" }, { "payer_name": "BLUE SHIELD", "plan_name": "STANFORD HEALTHCARE ALLIANCE PLAN", "methodology": "percent of total billed charges", "standard_charge_dollar": 1943.6, "standard_charge_percentage": 48.59, "median_amount": 435.44, "10th_percentile": 110.87, "90th_percentile": 435.44, "count": "1 through 10" }, { "payer_name": "BLUE SHIELD", "plan_name": "STANFORD HEALTHCARE ALLIANCE PLAN", "methodology": "percent of total billed charges", "standard_charge_dollar": 1943.6, "standard_charge_percentage": 48.59, "count": "0", "additional_payer_notes": "Zero final payments for the item or service in the 15 months prior to posting the file." }, { "payer_name": "BLUE SHIELD", "plan_name": "STANFORD HEALTHCARE ALLIANCE PLAN", "methodology": "percent of total billed charges", "standard_charge_dollar": 1943.6, "standard_charge_percentage": 48.59, "count": "0", "additional_payer_notes": "Zero final payments for the item or service in the 15 months prior to posting the file." }, { "payer_name": "CIGNA", "plan_name": "CIGNA COM ALT HMO PLAN", "methodology": "percent of total billed charges", "standard_charge_dollar": 1688.0, "standard_charge_percentage": 42.2, "count": "0", "additional_payer_notes": "Zero final payments for the item or service in the 15 months prior to posting the file." }, { "payer_name": "CIGNA", "plan_name": "CIGNA COM ALT HMO PLAN", "methodology": "percent of total billed charges", "standard_charge_dollar": 1688.0, "standard_charge_percentage": 42.2, "count": "0", "additional_payer_notes": "Zero final payments for the item or service in the 15 months prior to posting the file." }, { "payer_name": "HEALTH NET", "plan_name": "HEALTHNET HMO, PPO, POS, EPO, CANOPY HEALTHNET HMO, OTHER-IN-NETWORK PLANS", "methodology": "per diem", "standard_charge_dollar": 8000.0, "standard_charge_algorithm": "Expected reimbursement is the lesser of Per diem ($8,000) for the length of stay and 70% of billed.", "count": "0", "additional_payer_notes": "Zero final payments for the item or service in the 15 months prior to posting the file." }, { "payer_name": "HEALTH NET", "plan_name": "HEALTHNET HMO, PPO, POS, EPO, CANOPY HEALTHNET HMO, OTHER-IN-NETWORK PLANS", "methodology": "per diem", "standard_charge_dollar": 8000.0, "standard_charge_algorithm": "Expected reimbursement is the lesser of Per diem ($8,000) for the length of stay and 70% of billed.", "median_amount": 486.01, "10th_percentile": 486.01, "90th_percentile": 486.01, "count": "1 through 10" }, { "payer_name": "UNITED HEALTHCARE", "plan_name": "SUTTER SELECT & SUTTER HEALTH PLAN HMO PLANS", "methodology": "per diem", "standard_charge_dollar": 28538.0, "standard_charge_algorithm": "Per diem ($28,538).", "count": "0", "additional_payer_notes": "Zero final payments for the item or service in the 15 months prior to posting the file." }, { "payer_name": "UNITED HEALTHCARE", "plan_name": "SUTTER SELECT & SUTTER HEALTH PLAN HMO PLANS", "methodology": "per diem", "standard_charge_dollar": 28538.0, "standard_charge_algorithm": "Per diem ($28,538).", "count": "0", "additional_payer_notes": "Zero final payments for the item or service in the 15 months prior to posting the file." }, { "payer_name": "SUTTER", "plan_name": "SUTTER SELECT & SUTTER HEALTH PLAN HMO PLANS", "methodology": "per diem", "standard_charge_dollar": 28538.0, "standard_charge_algorithm": "Per diem ($28,538).", "median_amount": 142.99, "10th_percentile": 142.99, "90th_percentile": 142.99, "count": "1 through 10" }, { "payer_name": "UNITED HEALTHCARE", "plan_name": "SUTTER SELECT & SUTTER HEALTH PLAN HMO PLANS", "methodology": "per diem", "standard_charge_dollar": 28538.0, "standard_charge_algorithm": "Per diem ($28,538).", "count": "0", "additional_payer_notes": "Zero final payments for the item or service in the 15 months prior to posting the file." }, { "payer_name": "UMR", "plan_name": "SUTTER SELECT & SUTTER HEALTH PLAN HMO PLANS", "methodology": "per diem", "standard_charge_dollar": 28538.0, "standard_charge_algorithm": "Per diem ($28,538).", "count": "0", "additional_payer_notes": "Zero final payments for the item or service in the 15 months prior to posting the file." }, { "payer_name": "UNITED HEALTHCARE", "plan_name": "SUTTER SELECT & SUTTER HEALTH PLAN HMO PLANS", "methodology": "per diem", "standard_charge_dollar": 28538.0, "standard_charge_algorithm": "Per diem ($28,538).", "count": "0", "additional_payer_notes": "Zero final payments for the item or service in the 15 months prior to posting the file." } ] } ] }, { "description": "Hc Bar Pectus Template Gp012", "code_information": [ { "code": "PX-2120190012", "type": "CDM" }, { "code": "99999", "type": "CPT" }, { "code": "0272", "type": "RC" } ], "standard_charges": [ { "setting": "outpatient", "gross_charge": 810.0, "discounted_cash": 405.0, "minimum": 341.82, "maximum": 421.2, "additional_generic_notes": "Zero final payments for the item or service in the 15 months prior to posting the file.", "payers_information": [ { "payer_name": "AETNA", "plan_name": "AETNA ALL OTHER PLANS", "methodology": "percent of total billed charges", "standard_charge_dollar": 421.2, "standard_charge_percentage": 52.0, "count": "0", "additional_payer_notes": "Zero final payments for the item or service in the 15 months prior to posting the file." }, { "payer_name": "AETNA", "plan_name": "AETNA ALL OTHER PLANS", "methodology": "percent of total billed charges", "standard_charge_dollar": 421.2, "standard_charge_percentage": 52.0, "count": "0", "additional_payer_notes": "Zero final payments for the item or service in the 15 months prior to posting the file." }, { "payer_name": "MERITAIN HEALTH", "plan_name": "AETNA ALL OTHER PLANS", "methodology": "percent of total billed charges", "standard_charge_dollar": 421.2, "standard_charge_percentage": 52.0, "count": "0", "additional_payer_notes": "Zero final payments for the item or service in the 15 months prior to posting the file." }, { "payer_name": "BLUE SHIELD OUT OF STATE", "plan_name": "STANFORD HEALTHCARE ALLIANCE PLAN", "methodology": "percent of total billed charges", "standard_charge_dollar": 393.58, "standard_charge_percentage": 48.59, "count": "0", "additional_payer_notes": "Zero final payments for the item or service in the 15 months prior to posting the file." }, { "payer_name": "BLUE SHIELD", "plan_name": "STANFORD HEALTHCARE ALLIANCE PLAN", "methodology": "percent of total billed charges", "standard_charge_dollar": 393.58, "standard_charge_percentage": 48.59, "count": "0", "additional_payer_notes": "Zero final payments for the item or service in the 15 months prior to posting the file." }, { "payer_name": "BLUE SHIELD", "plan_name": "STANFORD HEALTHCARE ALLIANCE PLAN", "methodology": "percent of total billed charges", "standard_charge_dollar": 393.58, "standard_charge_percentage": 48.59, "count": "0", "additional_payer_notes": "Zero final payments for the item or service in the 15 months prior to posting the file." }, { "payer_name": "CIGNA", "plan_name": "CIGNA COM ALT HMO PLAN", "methodology": "percent of total billed charges", "standard_charge_dollar": 341.82, "standard_charge_percentage": 42.2, "count": "0", "additional_payer_notes": "Zero final payments for the item or service in the 15 months prior to posting the file." }, { "payer_name": "CIGNA", "plan_name": "CIGNA COM ALT HMO PLAN", "methodology": "percent of total billed charges", "standard_charge_dollar": 341.82, "standard_charge_percentage": 42.2, "count": "0", "additional_payer_notes": "Zero final payments for the item or service in the 15 months prior to posting the file." }, { "payer_name": "HEALTH NET", "plan_name": "HEALTHNET HMO, PPO, POS, EPO, CANOPY HEALTHNET HMO, OTHER-IN-NETWORK PLANS", "methodology": "per diem", "standard_charge_dollar": 8000.0, "standard_charge_algorithm": "Expected reimbursement is the lesser of Per diem ($8,000) for the length of stay and 70% of billed.", "count": "0", "additional_payer_notes": "Zero final payments for the item or service in the 15 months prior to posting the file." }, { "payer_name": "HEALTH NET", "plan_name": "HEALTHNET HMO, PPO, POS, EPO, CANOPY HEALTHNET HMO, OTHER-IN-NETWORK PLANS", "methodology": "per diem", "standard_charge_dollar": 8000.0, "standard_charge_algorithm": "Expected reimbursement is the lesser of Per diem ($8,000) for the length of stay and 70% of billed.", "count": "0", "additional_payer_notes": "Zero final payments for the item or service in the 15 months prior to posting the file." }, { "payer_name": "UNITED HEALTHCARE", "plan_name": "SUTTER SELECT & SUTTER HEALTH PLAN HMO PLANS", "methodology": "per diem", "standard_charge_dollar": 28538.0, "standard_charge_algorithm": "Per diem ($28,538).", "count": "0", "additional_payer_notes": "Zero final payments for the item or service in the 15 months prior to posting the file." }, { "payer_name": "UNITED HEALTHCARE", "plan_name": "SUTTER SELECT & SUTTER HEALTH PLAN HMO PLANS", "methodology": "per diem", "standard_charge_dollar": 28538.0, "standard_charge_algorithm": "Per diem ($28,538).", "count": "0", "additional_payer_notes": "Zero final payments for the item or service in the 15 months prior to posting the file." }, { "payer_name": "SUTTER", "plan_name": "SUTTER SELECT & SUTTER HEALTH PLAN HMO PLANS", "methodology": "per diem", "standard_charge_dollar": 28538.0, "standard_charge_algorithm": "Per diem ($28,538).", "count": "0", "additional_payer_notes": "Zero final payments for the item or service in the 15 months prior to posting the file." }, { "payer_name": "UNITED HEALTHCARE", "plan_name": "SUTTER SELECT & SUTTER HEALTH PLAN HMO PLANS", "methodology": "per diem", "standard_charge_dollar": 28538.0, "standard_charge_algorithm": "Per diem ($28,538).", "count": "0", "additional_payer_notes": "Zero final payments for the item or service in the 15 months prior to posting the file." }, { "payer_name": "UMR", "plan_name": "SUTTER SELECT & SUTTER HEALTH PLAN HMO PLANS", "methodology": "per diem", "standard_charge_dollar": 28538.0, "standard_charge_algorithm": "Per diem ($28,538).", "count": "0", "additional_payer_notes": "Zero final payments for the item or service in the 15 months prior to posting the file." } ] } ] }, { "description": "HC Bar Pectus Template Gp014", "code_information": [ { "code": "PX-2120190014", "type": "CDM" }, { "code": "99999", "type": "CPT" }, { "code": "0272", "type": "RC" } ], "standard_charges": [ { "setting": "outpatient", "gross_charge": 1080.0, "discounted_cash": 540.0, "minimum": 455.76, "maximum": 561.6, "additional_generic_notes": "Zero final payments for the item or service in the 15 months prior to posting the file.", "payers_information": [ { "payer_name": "AETNA", "plan_name": "AETNA ALL OTHER PLANS", "methodology": "percent of total billed charges", "standard_charge_dollar": 561.6, "standard_charge_percentage": 52.0, "count": "0", "additional_payer_notes": "Zero final payments for the item or service in the 15 months prior to posting the file." }, { "payer_name": "AETNA", "plan_name": "AETNA ALL OTHER PLANS", "methodology": "percent of total billed charges", "standard_charge_dollar": 561.6, "standard_charge_percentage": 52.0, "count": "0", "additional_payer_notes": "Zero final payments for the item or service in the 15 months prior to posting the file." }, { "payer_name": "MERITAIN HEALTH", "plan_name": "AETNA ALL OTHER PLANS", "methodology": "percent of total billed charges", "standard_charge_dollar": 561.6, "standard_charge_percentage": 52.0, "count": "0", "additional_payer_notes": "Zero final payments for the item or service in the 15 months prior to posting the file." }, { "payer_name": "BLUE SHIELD OUT OF STATE", "plan_name": "STANFORD HEALTHCARE ALLIANCE PLAN", "methodology": "percent of total billed charges", "standard_charge_dollar": 524.77, "standard_charge_percentage": 48.59, "count": "0", "additional_payer_notes": "Zero final payments for the item or service in the 15 months prior to posting the file." }, { "payer_name": "BLUE SHIELD", "plan_name": "STANFORD HEALTHCARE ALLIANCE PLAN", "methodology": "percent of total billed charges", "standard_charge_dollar": 524.77, "standard_charge_percentage": 48.59, "median_amount": 68.24, "10th_percentile": 13.6, "90th_percentile": 1043.06, "count": "30" }, { "payer_name": "BLUE SHIELD", "plan_name": "STANFORD HEALTHCARE ALLIANCE PLAN", "methodology": "percent of total billed charges", "standard_charge_dollar": 524.77, "standard_charge_percentage": 48.59, "count": "0", "additional_payer_notes": "Zero final payments for the item or service in the 15 months prior to posting the file." }, { "payer_name": "BLUE SHIELD", "plan_name": "STANFORD HEALTHCARE ALLIANCE PLAN", "methodology": "percent of total billed charges", "standard_charge_dollar": 524.77, "standard_charge_percentage": 48.59, "count": "0", "additional_payer_notes": "Zero final payments for the item or service in the 15 months prior to posting the file." }, { "payer_name": "CIGNA", "plan_name": "CIGNA COM ALT HMO PLAN", "methodology": "percent of total billed charges", "standard_charge_dollar": 455.76, "standard_charge_percentage": 42.2, "count": "0", "additional_payer_notes": "Zero final payments for the item or service in the 15 months prior to posting the file." }, { "payer_name": "CIGNA", "plan_name": "CIGNA COM ALT HMO PLAN", "methodology": "percent of total billed charges", "standard_charge_dollar": 455.76, "standard_charge_percentage": 42.2, "count": "0", "additional_payer_notes": "Zero final payments for the item or service in the 15 months prior to posting the file." }, { "payer_name": "HEALTH NET", "plan_name": "HEALTHNET HMO, PPO, POS, EPO, CANOPY HEALTHNET HMO, OTHER-IN-NETWORK PLANS", "methodology": "per diem", "standard_charge_dollar": 8000.0, "standard_charge_algorithm": "Expected reimbursement is the lesser of Per diem ($8,000) for the length of stay and 70% of billed.", "count": "0", "additional_payer_notes": "Zero final payments for the item or service in the 15 months prior to posting the file." }, { "payer_name": "HEALTH NET", "plan_name": "HEALTHNET HMO, PPO, POS, EPO, CANOPY HEALTHNET HMO, OTHER-IN-NETWORK PLANS", "methodology": "per diem", "standard_charge_dollar": 8000.0, "standard_charge_algorithm": "Expected reimbursement is the lesser of Per diem ($8,000) for the length of stay and 70% of billed.", "count": "0", "additional_payer_notes": "Zero final payments for the item or service in the 15 months prior to posting the file." }, { "payer_name": "UNITED HEALTHCARE", "plan_name": "SUTTER SELECT & SUTTER HEALTH PLAN HMO PLANS", "methodology": "per diem", "standard_charge_dollar": 28538.0, "standard_charge_algorithm": "Per diem ($28,538).", "count": "0", "additional_payer_notes": "Zero final payments for the item or service in the 15 months prior to posting the file." }, { "payer_name": "UNITED HEALTHCARE", "plan_name": "SUTTER SELECT & SUTTER HEALTH PLAN HMO PLANS", "methodology": "per diem", "standard_charge_dollar": 28538.0, "standard_charge_algorithm": "Per diem ($28,538).", "count": "0", "additional_payer_notes": "Zero final payments for the item or service in the 15 months prior to posting the file." }, { "payer_name": "SUTTER", "plan_name": "SUTTER SELECT & SUTTER HEALTH PLAN HMO PLANS", "methodology": "per diem", "standard_charge_dollar": 28538.0, "standard_charge_algorithm": "Per diem ($28,538).", "count": "0", "additional_payer_notes": "Zero final payments for the item or service in the 15 months prior to posting the file." }, { "payer_name": "UNITED HEALTHCARE", "plan_name": "SUTTER SELECT & SUTTER HEALTH PLAN HMO PLANS", "methodology": "per diem", "standard_charge_dollar": 28538.0, "standard_charge_algorithm": "Per diem ($28,538).", "count": "0", "additional_payer_notes": "Zero final payments for the item or service in the 15 months prior to posting the file." }, { "payer_name": "UMR", "plan_name": "SUTTER SELECT & SUTTER HEALTH PLAN HMO PLANS", "methodology": "per diem", "standard_charge_dollar": 28538.0, "standard_charge_algorithm": "Per diem ($28,538).", "count": "0", "additional_payer_notes": "Zero final payments for the item or service in the 15 months prior to posting the file." } ] } ] }, { "description": "Hc Pill Cam Gp005", "code_information": [ { "code": "PX-2120204005", "type": "CDM" }, { "code": "99999", "type": "CPT" }, { "code": "0272", "type": "RC" } ], "standard_charges": [ { "setting": "outpatient", "gross_charge": 195.0, "discounted_cash": 97.5, "minimum": 82.29, "maximum": 101.4, "additional_generic_notes": "Zero final payments for the item or service in the 15 months prior to posting the file.", "payers_information": [ { "payer_name": "AETNA", "plan_name": "AETNA ALL OTHER PLANS", "methodology": "percent of total billed charges", "standard_charge_dollar": 101.4, "standard_charge_percentage": 52.0, "count": "0", "additional_payer_notes": "Zero final payments for the item or service in the 15 months prior to posting the file." }, { "payer_name": "AETNA", "plan_name": "AETNA ALL OTHER PLANS", "methodology": "percent of total billed charges", "standard_charge_dollar": 101.4, "standard_charge_percentage": 52.0, "count": "0", "additional_payer_notes": "Zero final payments for the item or service in the 15 months prior to posting the file." }, { "payer_name": "MERITAIN HEALTH", "plan_name": "AETNA ALL OTHER PLANS", "methodology": "percent of total billed charges", "standard_charge_dollar": 101.4, "standard_charge_percentage": 52.0, "count": "0", "additional_payer_notes": "Zero final payments for the item or service in the 15 months prior to posting the file." }, { "payer_name": "BLUE SHIELD OUT OF STATE", "plan_name": "STANFORD HEALTHCARE ALLIANCE PLAN", "methodology": "percent of total billed charges", "standard_charge_dollar": 94.75, "standard_charge_percentage": 48.59, "count": "0", "additional_payer_notes": "Zero final payments for the item or service in the 15 months prior to posting the file." }, { "payer_name": "BLUE SHIELD", "plan_name": "STANFORD HEALTHCARE ALLIANCE PLAN", "methodology": "percent of total billed charges", "standard_charge_dollar": 94.75, "standard_charge_percentage": 48.59, "count": "0", "additional_payer_notes": "Zero final payments for the item or service in the 15 months prior to posting the file." }, { "payer_name": "BLUE SHIELD", "plan_name": "STANFORD HEALTHCARE ALLIANCE PLAN", "methodology": "percent of total billed charges", "standard_charge_dollar": 94.75, "standard_charge_percentage": 48.59, "count": "0", "additional_payer_notes": "Zero final payments for the item or service in the 15 months prior to posting the file." }, { "payer_name": "CIGNA", "plan_name": "CIGNA COM ALT HMO PLAN", "methodology": "percent of total billed charges", "standard_charge_dollar": 82.29, "standard_charge_percentage": 42.2, "count": "0", "additional_payer_notes": "Zero final payments for the item or service in the 15 months prior to posting the file." }, { "payer_name": "CIGNA", "plan_name": "CIGNA COM ALT HMO PLAN", "methodology": "percent of total billed charges", "standard_charge_dollar": 82.29, "standard_charge_percentage": 42.2, "count": "0", "additional_payer_notes": "Zero final payments for the item or service in the 15 months prior to posting the file." }, { "payer_name": "HEALTH NET", "plan_name": "HEALTHNET HMO, PPO, POS, EPO, CANOPY HEALTHNET HMO, OTHER-IN-NETWORK PLANS", "methodology": "per diem", "standard_charge_dollar": 8000.0, "standard_charge_algorithm": "Expected reimbursement is the lesser of Per diem ($8,000) for the length of stay and 70% of billed.", "count": "0", "additional_payer_notes": "Zero final payments for the item or service in the 15 months prior to posting the file." }, { "payer_name": "HEALTH NET", "plan_name": "HEALTHNET HMO, PPO, POS, EPO, CANOPY HEALTHNET HMO, OTHER-IN-NETWORK PLANS", "methodology": "per diem", "standard_charge_dollar": 8000.0, "standard_charge_algorithm": "Expected reimbursement is the lesser of Per diem ($8,000) for the length of stay and 70% of billed.", "count": "0", "additional_payer_notes": "Zero final payments for the item or service in the 15 months prior to posting the file." }, { "payer_name": "UNITED HEALTHCARE", "plan_name": "SUTTER SELECT & SUTTER HEALTH PLAN HMO PLANS", "methodology": "per diem", "standard_charge_dollar": 28538.0, "standard_charge_algorithm": "Per diem ($28,538).", "count": "0", "additional_payer_notes": "Zero final payments for the item or service in the 15 months prior to posting the file." }, { "payer_name": "UNITED HEALTHCARE", "plan_name": "SUTTER SELECT & SUTTER HEALTH PLAN HMO PLANS", "methodology": "per diem", "standard_charge_dollar": 28538.0, "standard_charge_algorithm": "Per diem ($28,538).", "count": "0", "additional_payer_notes": "Zero final payments for the item or service in the 15 months prior to posting the file." }, { "payer_name": "SUTTER", "plan_name": "SUTTER SELECT & SUTTER HEALTH PLAN HMO PLANS", "methodology": "per diem", "standard_charge_dollar": 28538.0, "standard_charge_algorithm": "Per diem ($28,538).", "count": "0", "additional_payer_notes": "Zero final payments for the item or service in the 15 months prior to posting the file." }, { "payer_name": "UNITED HEALTHCARE", "plan_name": "SUTTER SELECT & SUTTER HEALTH PLAN HMO PLANS", "methodology": "per diem", "standard_charge_dollar": 28538.0, "standard_charge_algorithm": "Per diem ($28,538).", "count": "0", "additional_payer_notes": "Zero final payments for the item or service in the 15 months prior to posting the file." }, { "payer_name": "UMR", "plan_name": "SUTTER SELECT & SUTTER HEALTH PLAN HMO PLANS", "methodology": "per diem", "standard_charge_dollar": 28538.0, "standard_charge_algorithm": "Per diem ($28,538).", "count": "0", "additional_payer_notes": "Zero final payments for the item or service in the 15 months prior to posting the file." } ] } ] }, { "description": "HC Pill Cam Gp006", "code_information": [ { "code": "PX-2120204006", "type": "CDM" }, { "code": "99999", "type": "CPT" }, { "code": "0272", "type": "RC" } ], "standard_charges": [ { "setting": "outpatient", "gross_charge": 293.0, "discounted_cash": 146.5, "minimum": 123.65, "maximum": 152.36, "additional_generic_notes": "Zero final payments for the item or service in the 15 months prior to posting the file.", "payers_information": [ { "payer_name": "AETNA", "plan_name": "AETNA ALL OTHER PLANS", "methodology": "percent of total billed charges", "standard_charge_dollar": 152.36, "standard_charge_percentage": 52.0, "count": "0", "additional_payer_notes": "Zero final payments for the item or service in the 15 months prior to posting the file." }, { "payer_name": "AETNA", "plan_name": "AETNA ALL OTHER PLANS", "methodology": "percent of total billed charges", "standard_charge_dollar": 152.36, "standard_charge_percentage": 52.0, "count": "0", "additional_payer_notes": "Zero final payments for the item or service in the 15 months prior to posting the file." }, { "payer_name": "MERITAIN HEALTH", "plan_name": "AETNA ALL OTHER PLANS", "methodology": "percent of total billed charges", "standard_charge_dollar": 152.36, "standard_charge_percentage": 52.0, "count": "0", "additional_payer_notes": "Zero final payments for the item or service in the 15 months prior to posting the file." }, { "payer_name": "BLUE SHIELD OUT OF STATE", "plan_name": "STANFORD HEALTHCARE ALLIANCE PLAN", "methodology": "percent of total billed charges", "standard_charge_dollar": 142.37, "standard_charge_percentage": 48.59, "count": "0", "additional_payer_notes": "Zero final payments for the item or service in the 15 months prior to posting the file." }, { "payer_name": "BLUE SHIELD", "plan_name": "STANFORD HEALTHCARE ALLIANCE PLAN", "methodology": "percent of total billed charges", "standard_charge_dollar": 142.37, "standard_charge_percentage": 48.59, "count": "0", "additional_payer_notes": "Zero final payments for the item or service in the 15 months prior to posting the file." }, { "payer_name": "BLUE SHIELD", "plan_name": "STANFORD HEALTHCARE ALLIANCE PLAN", "methodology": "percent of total billed charges", "standard_charge_dollar": 142.37, "standard_charge_percentage": 48.59, "count": "0", "additional_payer_notes": "Zero final payments for the item or service in the 15 months prior to posting the file." }, { "payer_name": "CIGNA", "plan_name": "CIGNA COM ALT HMO PLAN", "methodology": "percent of total billed charges", "standard_charge_dollar": 123.65, "standard_charge_percentage": 42.2, "count": "0", "additional_payer_notes": "Zero final payments for the item or service in the 15 months prior to posting the file." }, { "payer_name": "CIGNA", "plan_name": "CIGNA COM ALT HMO PLAN", "methodology": "percent of total billed charges", "standard_charge_dollar": 123.65, "standard_charge_percentage": 42.2, "count": "0", "additional_payer_notes": "Zero final payments for the item or service in the 15 months prior to posting the file." }, { "payer_name": "HEALTH NET", "plan_name": "HEALTHNET HMO, PPO, POS, EPO, CANOPY HEALTHNET HMO, OTHER-IN-NETWORK PLANS", "methodology": "per diem", "standard_charge_dollar": 8000.0, "standard_charge_algorithm": "Expected reimbursement is the lesser of Per diem ($8,000) for the length of stay and 70% of billed.", "count": "0", "additional_payer_notes": "Zero final payments for the item or service in the 15 months prior to posting the file." }, { "payer_name": "HEALTH NET", "plan_name": "HEALTHNET HMO, PPO, POS, EPO, CANOPY HEALTHNET HMO, OTHER-IN-NETWORK PLANS", "methodology": "per diem", "standard_charge_dollar": 8000.0, "standard_charge_algorithm": "Expected reimbursement is the lesser of Per diem ($8,000) for the length of stay and 70% of billed.", "count": "0", "additional_payer_notes": "Zero final payments for the item or service in the 15 months prior to posting the file." }, { "payer_name": "UNITED HEALTHCARE", "plan_name": "SUTTER SELECT & SUTTER HEALTH PLAN HMO PLANS", "methodology": "per diem", "standard_charge_dollar": 28538.0, "standard_charge_algorithm": "Per diem ($28,538).", "count": "0", "additional_payer_notes": "Zero final payments for the item or service in the 15 months prior to posting the file." }, { "payer_name": "UNITED HEALTHCARE", "plan_name": "SUTTER SELECT & SUTTER HEALTH PLAN HMO PLANS", "methodology": "per diem", "standard_charge_dollar": 28538.0, "standard_charge_algorithm": "Per diem ($28,538).", "count": "0", "additional_payer_notes": "Zero final payments for the item or service in the 15 months prior to posting the file." }, { "payer_name": "SUTTER", "plan_name": "SUTTER SELECT & SUTTER HEALTH PLAN HMO PLANS", "methodology": "per diem", "standard_charge_dollar": 28538.0, "standard_charge_algorithm": "Per diem ($28,538).", "count": "0", "additional_payer_notes": "Zero final payments for the item or service in the 15 months prior to posting the file." }, { "payer_name": "UNITED HEALTHCARE", "plan_name": "SUTTER SELECT & SUTTER HEALTH PLAN HMO PLANS", "methodology": "per diem", "standard_charge_dollar": 28538.0, "standard_charge_algorithm": "Per diem ($28,538).", "count": "0", "additional_payer_notes": "Zero final payments for the item or service in the 15 months prior to posting the file." }, { "payer_name": "UMR", "plan_name": "SUTTER SELECT & SUTTER HEALTH PLAN HMO PLANS", "methodology": "per diem", "standard_charge_dollar": 28538.0, "standard_charge_algorithm": "Per diem ($28,538).", "count": "0", "additional_payer_notes": "Zero final payments for the item or service in the 15 months prior to posting the file." } ] } ] }, { "description": "HC Pill Cam Gp023", "code_information": [ { "code": "PX-2120204023", "type": "CDM" }, { "code": "99999", "type": "CPT" }, { "code": "0272", "type": "RC" } ], "standard_charges": [ { "setting": "outpatient", "gross_charge": 3600.0, "discounted_cash": 1800.0, "minimum": 1519.2, "maximum": 1872.0, "additional_generic_notes": "Zero final payments for the item or service in the 15 months prior to posting the file.", "payers_information": [ { "payer_name": "AETNA", "plan_name": "AETNA ALL OTHER PLANS", "methodology": "percent of total billed charges", "standard_charge_dollar": 1872.0, "standard_charge_percentage": 52.0, "count": "0", "additional_payer_notes": "Zero final payments for the item or service in the 15 months prior to posting the file." }, { "payer_name": "AETNA", "plan_name": "AETNA ALL OTHER PLANS", "methodology": "percent of total billed charges", "standard_charge_dollar": 1872.0, "standard_charge_percentage": 52.0, "count": "0", "additional_payer_notes": "Zero final payments for the item or service in the 15 months prior to posting the file." }, { "payer_name": "MERITAIN HEALTH", "plan_name": "AETNA ALL OTHER PLANS", "methodology": "percent of total billed charges", "standard_charge_dollar": 1872.0, "standard_charge_percentage": 52.0, "count": "0", "additional_payer_notes": "Zero final payments for the item or service in the 15 months prior to posting the file." }, { "payer_name": "BLUE SHIELD OUT OF STATE", "plan_name": "STANFORD HEALTHCARE ALLIANCE PLAN", "methodology": "percent of total billed charges", "standard_charge_dollar": 1749.24, "standard_charge_percentage": 48.59, "count": "0", "additional_payer_notes": "Zero final payments for the item or service in the 15 months prior to posting the file." }, { "payer_name": "BLUE SHIELD", "plan_name": "STANFORD HEALTHCARE ALLIANCE PLAN", "methodology": "percent of total billed charges", "standard_charge_dollar": 1749.24, "standard_charge_percentage": 48.59, "median_amount": 68.24, "10th_percentile": 13.6, "90th_percentile": 1043.06, "count": "30" }, { "payer_name": "BLUE SHIELD", "plan_name": "STANFORD HEALTHCARE ALLIANCE PLAN", "methodology": "percent of total billed charges", "standard_charge_dollar": 1749.24, "standard_charge_percentage": 48.59, "count": "0", "additional_payer_notes": "Zero final payments for the item or service in the 15 months prior to posting the file." }, { "payer_name": "BLUE SHIELD", "plan_name": "STANFORD HEALTHCARE ALLIANCE PLAN", "methodology": "percent of total billed charges", "standard_charge_dollar": 1749.24, "standard_charge_percentage": 48.59, "count": "0", "additional_payer_notes": "Zero final payments for the item or service in the 15 months prior to posting the file." }, { "payer_name": "CIGNA", "plan_name": "CIGNA COM ALT HMO PLAN", "methodology": "percent of total billed charges", "standard_charge_dollar": 1519.2, "standard_charge_percentage": 42.2, "count": "0", "additional_payer_notes": "Zero final payments for the item or service in the 15 months prior to posting the file." }, { "payer_name": "CIGNA", "plan_name": "CIGNA COM ALT HMO PLAN", "methodology": "percent of total billed charges", "standard_charge_dollar": 1519.2, "standard_charge_percentage": 42.2, "count": "0", "additional_payer_notes": "Zero final payments for the item or service in the 15 months prior to posting the file." }, { "payer_name": "HEALTH NET", "plan_name": "HEALTHNET HMO, PPO, POS, EPO, CANOPY HEALTHNET HMO, OTHER-IN-NETWORK PLANS", "methodology": "per diem", "standard_charge_dollar": 8000.0, "standard_charge_algorithm": "Expected reimbursement is the lesser of Per diem ($8,000) for the length of stay and 70% of billed.", "count": "0", "additional_payer_notes": "Zero final payments for the item or service in the 15 months prior to posting the file." }, { "payer_name": "HEALTH NET", "plan_name": "HEALTHNET HMO, PPO, POS, EPO, CANOPY HEALTHNET HMO, OTHER-IN-NETWORK PLANS", "methodology": "per diem", "standard_charge_dollar": 8000.0, "standard_charge_algorithm": "Expected reimbursement is the lesser of Per diem ($8,000) for the length of stay and 70% of billed.", "count": "0", "additional_payer_notes": "Zero final payments for the item or service in the 15 months prior to posting the file." }, { "payer_name": "UNITED HEALTHCARE", "plan_name": "SUTTER SELECT & SUTTER HEALTH PLAN HMO PLANS", "methodology": "per diem", "standard_charge_dollar": 28538.0, "standard_charge_algorithm": "Per diem ($28,538).", "count": "0", "additional_payer_notes": "Zero final payments for the item or service in the 15 months prior to posting the file." }, { "payer_name": "UNITED HEALTHCARE", "plan_name": "SUTTER SELECT & SUTTER HEALTH PLAN HMO PLANS", "methodology": "per diem", "standard_charge_dollar": 28538.0, "standard_charge_algorithm": "Per diem ($28,538).", "count": "0", "additional_payer_notes": "Zero final payments for the item or service in the 15 months prior to posting the file." }, { "payer_name": "SUTTER", "plan_name": "SUTTER SELECT & SUTTER HEALTH PLAN HMO PLANS", "methodology": "per diem", "standard_charge_dollar": 28538.0, "standard_charge_algorithm": "Per diem ($28,538).", "count": "0", "additional_payer_notes": "Zero final payments for the item or service in the 15 months prior to posting the file." }, { "payer_name": "UNITED HEALTHCARE", "plan_name": "SUTTER SELECT & SUTTER HEALTH PLAN HMO PLANS", "methodology": "per diem", "standard_charge_dollar": 28538.0, "standard_charge_algorithm": "Per diem ($28,538).", "count": "0", "additional_payer_notes": "Zero final payments for the item or service in the 15 months prior to posting the file." }, { "payer_name": "UMR", "plan_name": "SUTTER SELECT & SUTTER HEALTH PLAN HMO PLANS", "methodology": "per diem", "standard_charge_dollar": 28538.0, "standard_charge_algorithm": "Per diem ($28,538).", "count": "0", "additional_payer_notes": "Zero final payments for the item or service in the 15 months prior to posting the file." } ] } ] }, { "description": "HC Introducer Gp002", "code_information": [ { "code": "PX-2120206002", "type": "CDM" }, { "code": "C1894", "type": "HCPCS" }, { "code": "0272", "type": "RC" } ], "standard_charges": [ { "setting": "outpatient", "gross_charge": 50.0, "discounted_cash": 25.0, "minimum": 21.1, "maximum": 26.0, "additional_generic_notes": "Zero final payments for the item or service in the 15 months prior to posting the file.", "payers_information": [ { "payer_name": "AETNA", "plan_name": "AETNA ALL OTHER PLANS", "methodology": "percent of total billed charges", "standard_charge_dollar": 26.0, "standard_charge_percentage": 52.0, "count": "0", "additional_payer_notes": "Zero final payments for the item or service in the 15 months prior to posting the file." }, { "payer_name": "AETNA", "plan_name": "AETNA ALL OTHER PLANS", "methodology": "percent of total billed charges", "standard_charge_dollar": 26.0, "standard_charge_percentage": 52.0, "count": "0", "additional_payer_notes": "Zero final payments for the item or service in the 15 months prior to posting the file." }, { "payer_name": "BLUE SHIELD", "plan_name": "STANFORD HEALTHCARE ALLIANCE PLAN", "methodology": "percent of total billed charges", "standard_charge_dollar": 24.3, "standard_charge_percentage": 48.59, "count": "0", "additional_payer_notes": "Zero final payments for the item or service in the 15 months prior to posting the file." }, { "payer_name": "CIGNA", "plan_name": "CIGNA COM ALT HMO PLAN", "methodology": "percent of total billed charges", "standard_charge_dollar": 21.1, "standard_charge_percentage": 42.2, "count": "0", "additional_payer_notes": "Zero final payments for the item or service in the 15 months prior to posting the file." }, { "payer_name": "CIGNA", "plan_name": "CIGNA COM ALT HMO PLAN", "methodology": "percent of total billed charges", "standard_charge_dollar": 21.1, "standard_charge_percentage": 42.2, "count": "0", "additional_payer_notes": "Zero final payments for the item or service in the 15 months prior to posting the file." }, { "payer_name": "HEALTH NET", "plan_name": "HEALTHNET HMO, PPO, POS, EPO, CANOPY HEALTHNET HMO, OTHER-IN-NETWORK PLANS", "methodology": "per diem", "standard_charge_dollar": 8000.0, "standard_charge_algorithm": "Expected reimbursement is the lesser of Per diem ($8,000) for the length of stay and 70% of billed.", "count": "0", "additional_payer_notes": "Zero final payments for the item or service in the 15 months prior to posting the file." }, { "payer_name": "HEALTH NET", "plan_name": "HEALTHNET HMO, PPO, POS, EPO, CANOPY HEALTHNET HMO, OTHER-IN-NETWORK PLANS", "methodology": "per diem", "standard_charge_dollar": 8000.0, "standard_charge_algorithm": "Expected reimbursement is the lesser of Per diem ($8,000) for the length of stay and 70% of billed.", "count": "0", "additional_payer_notes": "Zero final payments for the item or service in the 15 months prior to posting the file." }, { "payer_name": "UNITED HEALTHCARE", "plan_name": "SUTTER SELECT & SUTTER HEALTH PLAN HMO PLANS", "methodology": "per diem", "standard_charge_dollar": 28538.0, "standard_charge_algorithm": "Per diem ($28,538).", "count": "0", "additional_payer_notes": "Zero final payments for the item or service in the 15 months prior to posting the file." }, { "payer_name": "UNITED HEALTHCARE", "plan_name": "SUTTER SELECT & SUTTER HEALTH PLAN HMO PLANS", "methodology": "per diem", "standard_charge_dollar": 28538.0, "standard_charge_algorithm": "Per diem ($28,538).", "count": "0", "additional_payer_notes": "Zero final payments for the item or service in the 15 months prior to posting the file." }, { "payer_name": "UNITED HEALTHCARE", "plan_name": "SUTTER SELECT & SUTTER HEALTH PLAN HMO PLANS", "methodology": "per diem", "standard_charge_dollar": 28538.0, "standard_charge_algorithm": "Per diem ($28,538).", "count": "0", "additional_payer_notes": "Zero final payments for the item or service in the 15 months prior to posting the file." } ] } ] }, { "description": "HC Introducer Gp003", "code_information": [ { "code": "PX-2120206003", "type": "CDM" }, { "code": "C1894", "type": "HCPCS" }, { "code": "0272", "type": "RC" } ], "standard_charges": [ { "setting": "outpatient", "gross_charge": 100.0, "discounted_cash": 50.0, "minimum": 42.2, "maximum": 52.0, "additional_generic_notes": "Zero final payments for the item or service in the 15 months prior to posting the file.", "payers_information": [ { "payer_name": "AETNA", "plan_name": "AETNA ALL OTHER PLANS", "methodology": "percent of total billed charges", "standard_charge_dollar": 52.0, "standard_charge_percentage": 52.0, "count": "0", "additional_payer_notes": "Zero final payments for the item or service in the 15 months prior to posting the file." }, { "payer_name": "AETNA", "plan_name": "AETNA ALL OTHER PLANS", "methodology": "percent of total billed charges", "standard_charge_dollar": 52.0, "standard_charge_percentage": 52.0, "count": "0", "additional_payer_notes": "Zero final payments for the item or service in the 15 months prior to posting the file." }, { "payer_name": "BLUE SHIELD", "plan_name": "STANFORD HEALTHCARE ALLIANCE PLAN", "methodology": "percent of total billed charges", "standard_charge_dollar": 48.59, "standard_charge_percentage": 48.59, "count": "0", "additional_payer_notes": "Zero final payments for the item or service in the 15 months prior to posting the file." }, { "payer_name": "CIGNA", "plan_name": "CIGNA COM ALT HMO PLAN", "methodology": "percent of total billed charges", "standard_charge_dollar": 42.2, "standard_charge_percentage": 42.2, "count": "0", "additional_payer_notes": "Zero final payments for the item or service in the 15 months prior to posting the file." }, { "payer_name": "CIGNA", "plan_name": "CIGNA COM ALT HMO PLAN", "methodology": "percent of total billed charges", "standard_charge_dollar": 42.2, "standard_charge_percentage": 42.2, "count": "0", "additional_payer_notes": "Zero final payments for the item or service in the 15 months prior to posting the file." }, { "payer_name": "HEALTH NET", "plan_name": "HEALTHNET HMO, PPO, POS, EPO, CANOPY HEALTHNET HMO, OTHER-IN-NETWORK PLANS", "methodology": "per diem", "standard_charge_dollar": 8000.0, "standard_charge_algorithm": "Expected reimbursement is the lesser of Per diem ($8,000) for the length of stay and 70% of billed.", "count": "0", "additional_payer_notes": "Zero final payments for the item or service in the 15 months prior to posting the file." }, { "payer_name": "HEALTH NET", "plan_name": "HEALTHNET HMO, PPO, POS, EPO, CANOPY HEALTHNET HMO, OTHER-IN-NETWORK PLANS", "methodology": "per diem", "standard_charge_dollar": 8000.0, "standard_charge_algorithm": "Expected reimbursement is the lesser of Per diem ($8,000) for the length of stay and 70% of billed.", "count": "0", "additional_payer_notes": "Zero final payments for the item or service in the 15 months prior to posting the file." }, { "payer_name": "UNITED HEALTHCARE", "plan_name": "SUTTER SELECT & SUTTER HEALTH PLAN HMO PLANS", "methodology": "per diem", "standard_charge_dollar": 28538.0, "standard_charge_algorithm": "Per diem ($28,538).", "count": "0", "additional_payer_notes": "Zero final payments for the item or service in the 15 months prior to posting the file." }, { "payer_name": "UNITED HEALTHCARE", "plan_name": "SUTTER SELECT & SUTTER HEALTH PLAN HMO PLANS", "methodology": "per diem", "standard_charge_dollar": 28538.0, "standard_charge_algorithm": "Per diem ($28,538).", "count": "0", "additional_payer_notes": "Zero final payments for the item or service in the 15 months prior to posting the file." }, { "payer_name": "UNITED HEALTHCARE", "plan_name": "SUTTER SELECT & SUTTER HEALTH PLAN HMO PLANS", "methodology": "per diem", "standard_charge_dollar": 28538.0, "standard_charge_algorithm": "Per diem ($28,538).", "count": "0", "additional_payer_notes": "Zero final payments for the item or service in the 15 months prior to posting the file." } ] } ] }, { "description": "HC Introducer Gp004", "code_information": [ { "code": "PX-2120206004", "type": "CDM" }, { "code": "C1894", "type": "HCPCS" }, { "code": "0272", "type": "RC" } ], "standard_charges": [ { "setting": "outpatient", "gross_charge": 146.0, "discounted_cash": 73.0, "minimum": 61.61, "maximum": 75.92, "additional_generic_notes": "Zero final payments for the item or service in the 15 months prior to posting the file.", "payers_information": [ { "payer_name": "AETNA", "plan_name": "AETNA ALL OTHER PLANS", "methodology": "percent of total billed charges", "standard_charge_dollar": 75.92, "standard_charge_percentage": 52.0, "count": "0", "additional_payer_notes": "Zero final payments for the item or service in the 15 months prior to posting the file." }, { "payer_name": "AETNA", "plan_name": "AETNA ALL OTHER PLANS", "methodology": "percent of total billed charges", "standard_charge_dollar": 75.92, "standard_charge_percentage": 52.0, "count": "0", "additional_payer_notes": "Zero final payments for the item or service in the 15 months prior to posting the file." }, { "payer_name": "BLUE SHIELD", "plan_name": "STANFORD HEALTHCARE ALLIANCE PLAN", "methodology": "percent of total billed charges", "standard_charge_dollar": 70.94, "standard_charge_percentage": 48.59, "count": "0", "additional_payer_notes": "Zero final payments for the item or service in the 15 months prior to posting the file." }, { "payer_name": "CIGNA", "plan_name": "CIGNA COM ALT HMO PLAN", "methodology": "percent of total billed charges", "standard_charge_dollar": 61.61, "standard_charge_percentage": 42.2, "count": "0", "additional_payer_notes": "Zero final payments for the item or service in the 15 months prior to posting the file." }, { "payer_name": "CIGNA", "plan_name": "CIGNA COM ALT HMO PLAN", "methodology": "percent of total billed charges", "standard_charge_dollar": 61.61, "standard_charge_percentage": 42.2, "count": "0", "additional_payer_notes": "Zero final payments for the item or service in the 15 months prior to posting the file." }, { "payer_name": "HEALTH NET", "plan_name": "HEALTHNET HMO, PPO, POS, EPO, CANOPY HEALTHNET HMO, OTHER-IN-NETWORK PLANS", "methodology": "per diem", "standard_charge_dollar": 8000.0, "standard_charge_algorithm": "Expected reimbursement is the lesser of Per diem ($8,000) for the length of stay and 70% of billed.", "count": "0", "additional_payer_notes": "Zero final payments for the item or service in the 15 months prior to posting the file." }, { "payer_name": "HEALTH NET", "plan_name": "HEALTHNET HMO, PPO, POS, EPO, CANOPY HEALTHNET HMO, OTHER-IN-NETWORK PLANS", "methodology": "per diem", "standard_charge_dollar": 8000.0, "standard_charge_algorithm": "Expected reimbursement is the lesser of Per diem ($8,000) for the length of stay and 70% of billed.", "count": "0", "additional_payer_notes": "Zero final payments for the item or service in the 15 months prior to posting the file." }, { "payer_name": "UNITED HEALTHCARE", "plan_name": "SUTTER SELECT & SUTTER HEALTH PLAN HMO PLANS", "methodology": "per diem", "standard_charge_dollar": 28538.0, "standard_charge_algorithm": "Per diem ($28,538).", "count": "0", "additional_payer_notes": "Zero final payments for the item or service in the 15 months prior to posting the file." }, { "payer_name": "UNITED HEALTHCARE", "plan_name": "SUTTER SELECT & SUTTER HEALTH PLAN HMO PLANS", "methodology": "per diem", "standard_charge_dollar": 28538.0, "standard_charge_algorithm": "Per diem ($28,538).", "count": "0", "additional_payer_notes": "Zero final payments for the item or service in the 15 months prior to posting the file." }, { "payer_name": "UNITED HEALTHCARE", "plan_name": "SUTTER SELECT & SUTTER HEALTH PLAN HMO PLANS", "methodology": "per diem", "standard_charge_dollar": 28538.0, "standard_charge_algorithm": "Per diem ($28,538).", "count": "0", "additional_payer_notes": "Zero final payments for the item or service in the 15 months prior to posting the file." } ] } ] }, { "description": "HC Introducer Gp005", "code_information": [ { "code": "PX-2120206005", "type": "CDM" }, { "code": "C1894", "type": "HCPCS" }, { "code": "0272", "type": "RC" } ], "standard_charges": [ { "setting": "outpatient", "gross_charge": 195.0, "discounted_cash": 97.5, "minimum": 82.29, "maximum": 101.4, "additional_generic_notes": "Zero final payments for the item or service in the 15 months prior to posting the file.", "payers_information": [ { "payer_name": "AETNA", "plan_name": "AETNA ALL OTHER PLANS", "methodology": "percent of total billed charges", "standard_charge_dollar": 101.4, "standard_charge_percentage": 52.0, "count": "0", "additional_payer_notes": "Zero final payments for the item or service in the 15 months prior to posting the file." }, { "payer_name": "AETNA", "plan_name": "AETNA ALL OTHER PLANS", "methodology": "percent of total billed charges", "standard_charge_dollar": 101.4, "standard_charge_percentage": 52.0, "count": "0", "additional_payer_notes": "Zero final payments for the item or service in the 15 months prior to posting the file." }, { "payer_name": "BLUE SHIELD", "plan_name": "STANFORD HEALTHCARE ALLIANCE PLAN", "methodology": "percent of total billed charges", "standard_charge_dollar": 94.75, "standard_charge_percentage": 48.59, "count": "0", "additional_payer_notes": "Zero final payments for the item or service in the 15 months prior to posting the file." }, { "payer_name": "CIGNA", "plan_name": "CIGNA COM ALT HMO PLAN", "methodology": "percent of total billed charges", "standard_charge_dollar": 82.29, "standard_charge_percentage": 42.2, "count": "0", "additional_payer_notes": "Zero final payments for the item or service in the 15 months prior to posting the file." }, { "payer_name": "CIGNA", "plan_name": "CIGNA COM ALT HMO PLAN", "methodology": "percent of total billed charges", "standard_charge_dollar": 82.29, "standard_charge_percentage": 42.2, "count": "0", "additional_payer_notes": "Zero final payments for the item or service in the 15 months prior to posting the file." }, { "payer_name": "HEALTH NET", "plan_name": "HEALTHNET HMO, PPO, POS, EPO, CANOPY HEALTHNET HMO, OTHER-IN-NETWORK PLANS", "methodology": "per diem", "standard_charge_dollar": 8000.0, "standard_charge_algorithm": "Expected reimbursement is the lesser of Per diem ($8,000) for the length of stay and 70% of billed.", "count": "0", "additional_payer_notes": "Zero final payments for the item or service in the 15 months prior to posting the file." }, { "payer_name": "HEALTH NET", "plan_name": "HEALTHNET HMO, PPO, POS, EPO, CANOPY HEALTHNET HMO, OTHER-IN-NETWORK PLANS", "methodology": "per diem", "standard_charge_dollar": 8000.0, "standard_charge_algorithm": "Expected reimbursement is the lesser of Per diem ($8,000) for the length of stay and 70% of billed.", "count": "0", "additional_payer_notes": "Zero final payments for the item or service in the 15 months prior to posting the file." }, { "payer_name": "UNITED HEALTHCARE", "plan_name": "SUTTER SELECT & SUTTER HEALTH PLAN HMO PLANS", "methodology": "per diem", "standard_charge_dollar": 28538.0, "standard_charge_algorithm": "Per diem ($28,538).", "count": "0", "additional_payer_notes": "Zero final payments for the item or service in the 15 months prior to posting the file." }, { "payer_name": "UNITED HEALTHCARE", "plan_name": "SUTTER SELECT & SUTTER HEALTH PLAN HMO PLANS", "methodology": "per diem", "standard_charge_dollar": 28538.0, "standard_charge_algorithm": "Per diem ($28,538).", "count": "0", "additional_payer_notes": "Zero final payments for the item or service in the 15 months prior to posting the file." }, { "payer_name": "UNITED HEALTHCARE", "plan_name": "SUTTER SELECT & SUTTER HEALTH PLAN HMO PLANS", "methodology": "per diem", "standard_charge_dollar": 28538.0, "standard_charge_algorithm": "Per diem ($28,538).", "count": "0", "additional_payer_notes": "Zero final payments for the item or service in the 15 months prior to posting the file." } ] } ] }, { "description": "HC Introducer Gp006", "code_information": [ { "code": "PX-2120206006", "type": "CDM" }, { "code": "C1894", "type": "HCPCS" }, { "code": "0272", "type": "RC" } ], "standard_charges": [ { "setting": "outpatient", "gross_charge": 293.0, "discounted_cash": 146.5, "minimum": 123.65, "maximum": 152.36, "additional_generic_notes": "Zero final payments for the item or service in the 15 months prior to posting the file.", "payers_information": [ { "payer_name": "AETNA", "plan_name": "AETNA ALL OTHER PLANS", "methodology": "percent of total billed charges", "standard_charge_dollar": 152.36, "standard_charge_percentage": 52.0, "count": "0", "additional_payer_notes": "Zero final payments for the item or service in the 15 months prior to posting the file." }, { "payer_name": "AETNA", "plan_name": "AETNA ALL OTHER PLANS", "methodology": "percent of total billed charges", "standard_charge_dollar": 152.36, "standard_charge_percentage": 52.0, "count": "0", "additional_payer_notes": "Zero final payments for the item or service in the 15 months prior to posting the file." }, { "payer_name": "BLUE SHIELD", "plan_name": "STANFORD HEALTHCARE ALLIANCE PLAN", "methodology": "percent of total billed charges", "standard_charge_dollar": 142.37, "standard_charge_percentage": 48.59, "count": "0", "additional_payer_notes": "Zero final payments for the item or service in the 15 months prior to posting the file." }, { "payer_name": "CIGNA", "plan_name": "CIGNA COM ALT HMO PLAN", "methodology": "percent of total billed charges", "standard_charge_dollar": 123.65, "standard_charge_percentage": 42.2, "count": "0", "additional_payer_notes": "Zero final payments for the item or service in the 15 months prior to posting the file." }, { "payer_name": "CIGNA", "plan_name": "CIGNA COM ALT HMO PLAN", "methodology": "percent of total billed charges", "standard_charge_dollar": 123.65, "standard_charge_percentage": 42.2, "count": "0", "additional_payer_notes": "Zero final payments for the item or service in the 15 months prior to posting the file." }, { "payer_name": "HEALTH NET", "plan_name": "HEALTHNET HMO, PPO, POS, EPO, CANOPY HEALTHNET HMO, OTHER-IN-NETWORK PLANS", "methodology": "per diem", "standard_charge_dollar": 8000.0, "standard_charge_algorithm": "Expected reimbursement is the lesser of Per diem ($8,000) for the length of stay and 70% of billed.", "count": "0", "additional_payer_notes": "Zero final payments for the item or service in the 15 months prior to posting the file." }, { "payer_name": "HEALTH NET", "plan_name": "HEALTHNET HMO, PPO, POS, EPO, CANOPY HEALTHNET HMO, OTHER-IN-NETWORK PLANS", "methodology": "per diem", "standard_charge_dollar": 8000.0, "standard_charge_algorithm": "Expected reimbursement is the lesser of Per diem ($8,000) for the length of stay and 70% of billed.", "count": "0", "additional_payer_notes": "Zero final payments for the item or service in the 15 months prior to posting the file." }, { "payer_name": "UNITED HEALTHCARE", "plan_name": "SUTTER SELECT & SUTTER HEALTH PLAN HMO PLANS", "methodology": "per diem", "standard_charge_dollar": 28538.0, "standard_charge_algorithm": "Per diem ($28,538).", "count": "0", "additional_payer_notes": "Zero final payments for the item or service in the 15 months prior to posting the file." }, { "payer_name": "UNITED HEALTHCARE", "plan_name": "SUTTER SELECT & SUTTER HEALTH PLAN HMO PLANS", "methodology": "per diem", "standard_charge_dollar": 28538.0, "standard_charge_algorithm": "Per diem ($28,538).", "count": "0", "additional_payer_notes": "Zero final payments for the item or service in the 15 months prior to posting the file." }, { "payer_name": "UNITED HEALTHCARE", "plan_name": "SUTTER SELECT & SUTTER HEALTH PLAN HMO PLANS", "methodology": "per diem", "standard_charge_dollar": 28538.0, "standard_charge_algorithm": "Per diem ($28,538).", "count": "0", "additional_payer_notes": "Zero final payments for the item or service in the 15 months prior to posting the file." }, { "payer_name": "UMR", "plan_name": "SUTTER SELECT & SUTTER HEALTH PLAN HMO PLANS", "methodology": "per diem", "standard_charge_dollar": 28538.0, "standard_charge_algorithm": "Per diem ($28,538).", "median_amount": 259.04, "10th_percentile": 213.12, "90th_percentile": 259.04, "count": "1 through 10" }, { "payer_name": "UNITED HEALTHCARE", "plan_name": "SUTTER SELECT & SUTTER HEALTH PLAN HMO PLANS", "methodology": "per diem", "standard_charge_dollar": 28538.0, "standard_charge_algorithm": "Per diem ($28,538).", "median_amount": 257.61, "10th_percentile": 107.25, "90th_percentile": 257.61, "count": "1 through 10" } ] } ] }, { "description": "HC Introducer Gp007", "code_information": [ { "code": "PX-2120206007", "type": "CDM" }, { "code": "C1894", "type": "HCPCS" }, { "code": "0272", "type": "RC" } ], "standard_charges": [ { "setting": "outpatient", "gross_charge": 380.0, "discounted_cash": 190.0, "minimum": 160.36, "maximum": 197.6, "additional_generic_notes": "Zero final payments for the item or service in the 15 months prior to posting the file.", "payers_information": [ { "payer_name": "AETNA", "plan_name": "AETNA ALL OTHER PLANS", "methodology": "percent of total billed charges", "standard_charge_dollar": 197.6, "standard_charge_percentage": 52.0, "count": "0", "additional_payer_notes": "Zero final payments for the item or service in the 15 months prior to posting the file." }, { "payer_name": "AETNA", "plan_name": "AETNA ALL OTHER PLANS", "methodology": "percent of total billed charges", "standard_charge_dollar": 197.6, "standard_charge_percentage": 52.0, "count": "0", "additional_payer_notes": "Zero final payments for the item or service in the 15 months prior to posting the file." }, { "payer_name": "MERITAIN HEALTH", "plan_name": "AETNA ALL OTHER PLANS", "methodology": "percent of total billed charges", "standard_charge_dollar": 197.6, "standard_charge_percentage": 52.0, "median_amount": 293.0, "10th_percentile": 187.29, "90th_percentile": 293.0, "count": "1 through 10" }, { "payer_name": "BLUE SHIELD", "plan_name": "STANFORD HEALTHCARE ALLIANCE PLAN", "methodology": "percent of total billed charges", "standard_charge_dollar": 184.64, "standard_charge_percentage": 48.59, "count": "0", "additional_payer_notes": "Zero final payments for the item or service in the 15 months prior to posting the file." }, { "payer_name": "CIGNA", "plan_name": "CIGNA COM ALT HMO PLAN", "methodology": "percent of total billed charges", "standard_charge_dollar": 160.36, "standard_charge_percentage": 42.2, "count": "0", "additional_payer_notes": "Zero final payments for the item or service in the 15 months prior to posting the file." }, { "payer_name": "CIGNA", "plan_name": "CIGNA COM ALT HMO PLAN", "methodology": "percent of total billed charges", "standard_charge_dollar": 160.36, "standard_charge_percentage": 42.2, "count": "0", "additional_payer_notes": "Zero final payments for the item or service in the 15 months prior to posting the file." }, { "payer_name": "HEALTH NET", "plan_name": "HEALTHNET HMO, PPO, POS, EPO, CANOPY HEALTHNET HMO, OTHER-IN-NETWORK PLANS", "methodology": "per diem", "standard_charge_dollar": 8000.0, "standard_charge_algorithm": "Expected reimbursement is the lesser of Per diem ($8,000) for the length of stay and 70% of billed.", "count": "0", "additional_payer_notes": "Zero final payments for the item or service in the 15 months prior to posting the file." }, { "payer_name": "HEALTH NET", "plan_name": "HEALTHNET HMO, PPO, POS, EPO, CANOPY HEALTHNET HMO, OTHER-IN-NETWORK PLANS", "methodology": "per diem", "standard_charge_dollar": 8000.0, "standard_charge_algorithm": "Expected reimbursement is the lesser of Per diem ($8,000) for the length of stay and 70% of billed.", "count": "0", "additional_payer_notes": "Zero final payments for the item or service in the 15 months prior to posting the file." }, { "payer_name": "UNITED HEALTHCARE", "plan_name": "SUTTER SELECT & SUTTER HEALTH PLAN HMO PLANS", "methodology": "per diem", "standard_charge_dollar": 28538.0, "standard_charge_algorithm": "Per diem ($28,538).", "count": "0", "additional_payer_notes": "Zero final payments for the item or service in the 15 months prior to posting the file." }, { "payer_name": "UNITED HEALTHCARE", "plan_name": "SUTTER SELECT & SUTTER HEALTH PLAN HMO PLANS", "methodology": "per diem", "standard_charge_dollar": 28538.0, "standard_charge_algorithm": "Per diem ($28,538).", "count": "0", "additional_payer_notes": "Zero final payments for the item or service in the 15 months prior to posting the file." }, { "payer_name": "UNITED HEALTHCARE", "plan_name": "SUTTER SELECT & SUTTER HEALTH PLAN HMO PLANS", "methodology": "per diem", "standard_charge_dollar": 28538.0, "standard_charge_algorithm": "Per diem ($28,538).", "count": "0", "additional_payer_notes": "Zero final payments for the item or service in the 15 months prior to posting the file." }, { "payer_name": "UMR", "plan_name": "SUTTER SELECT & SUTTER HEALTH PLAN HMO PLANS", "methodology": "per diem", "standard_charge_dollar": 28538.0, "standard_charge_algorithm": "Per diem ($28,538).", "median_amount": 259.04, "10th_percentile": 213.12, "90th_percentile": 259.04, "count": "1 through 10" }, { "payer_name": "UNITED HEALTHCARE", "plan_name": "SUTTER SELECT & SUTTER HEALTH PLAN HMO PLANS", "methodology": "per diem", "standard_charge_dollar": 28538.0, "standard_charge_algorithm": "Per diem ($28,538).", "median_amount": 257.61, "10th_percentile": 107.25, "90th_percentile": 257.61, "count": "1 through 10" } ] } ] }, { "description": "HC Introducer Gp008", "code_information": [ { "code": "PX-2120206008", "type": "CDM" }, { "code": "C1894", "type": "HCPCS" }, { "code": "0272", "type": "RC" } ], "standard_charges": [ { "setting": "outpatient", "gross_charge": 475.0, "discounted_cash": 237.5, "minimum": 200.45, "maximum": 247.0, "additional_generic_notes": "Zero final payments for the item or service in the 15 months prior to posting the file.", "payers_information": [ { "payer_name": "AETNA", "plan_name": "AETNA ALL OTHER PLANS", "methodology": "percent of total billed charges", "standard_charge_dollar": 247.0, "standard_charge_percentage": 52.0, "count": "0", "additional_payer_notes": "Zero final payments for the item or service in the 15 months prior to posting the file." }, { "payer_name": "AETNA", "plan_name": "AETNA ALL OTHER PLANS", "methodology": "percent of total billed charges", "standard_charge_dollar": 247.0, "standard_charge_percentage": 52.0, "count": "0", "additional_payer_notes": "Zero final payments for the item or service in the 15 months prior to posting the file." }, { "payer_name": "MERITAIN HEALTH", "plan_name": "AETNA ALL OTHER PLANS", "methodology": "percent of total billed charges", "standard_charge_dollar": 247.0, "standard_charge_percentage": 52.0, "median_amount": 293.0, "10th_percentile": 187.29, "90th_percentile": 293.0, "count": "1 through 10" }, { "payer_name": "BLUE SHIELD", "plan_name": "STANFORD HEALTHCARE ALLIANCE PLAN", "methodology": "percent of total billed charges", "standard_charge_dollar": 230.8, "standard_charge_percentage": 48.59, "count": "0", "additional_payer_notes": "Zero final payments for the item or service in the 15 months prior to posting the file." }, { "payer_name": "CIGNA", "plan_name": "CIGNA COM ALT HMO PLAN", "methodology": "percent of total billed charges", "standard_charge_dollar": 200.45, "standard_charge_percentage": 42.2, "count": "0", "additional_payer_notes": "Zero final payments for the item or service in the 15 months prior to posting the file." }, { "payer_name": "CIGNA", "plan_name": "CIGNA COM ALT HMO PLAN", "methodology": "percent of total billed charges", "standard_charge_dollar": 200.45, "standard_charge_percentage": 42.2, "count": "0", "additional_payer_notes": "Zero final payments for the item or service in the 15 months prior to posting the file." }, { "payer_name": "HEALTH NET", "plan_name": "HEALTHNET HMO, PPO, POS, EPO, CANOPY HEALTHNET HMO, OTHER-IN-NETWORK PLANS", "methodology": "per diem", "standard_charge_dollar": 8000.0, "standard_charge_algorithm": "Expected reimbursement is the lesser of Per diem ($8,000) for the length of stay and 70% of billed.", "count": "0", "additional_payer_notes": "Zero final payments for the item or service in the 15 months prior to posting the file." }, { "payer_name": "HEALTH NET", "plan_name": "HEALTHNET HMO, PPO, POS, EPO, CANOPY HEALTHNET HMO, OTHER-IN-NETWORK PLANS", "methodology": "per diem", "standard_charge_dollar": 8000.0, "standard_charge_algorithm": "Expected reimbursement is the lesser of Per diem ($8,000) for the length of stay and 70% of billed.", "count": "0", "additional_payer_notes": "Zero final payments for the item or service in the 15 months prior to posting the file." }, { "payer_name": "UNITED HEALTHCARE", "plan_name": "SUTTER SELECT & SUTTER HEALTH PLAN HMO PLANS", "methodology": "per diem", "standard_charge_dollar": 28538.0, "standard_charge_algorithm": "Per diem ($28,538).", "count": "0", "additional_payer_notes": "Zero final payments for the item or service in the 15 months prior to posting the file." }, { "payer_name": "UNITED HEALTHCARE", "plan_name": "SUTTER SELECT & SUTTER HEALTH PLAN HMO PLANS", "methodology": "per diem", "standard_charge_dollar": 28538.0, "standard_charge_algorithm": "Per diem ($28,538).", "count": "0", "additional_payer_notes": "Zero final payments for the item or service in the 15 months prior to posting the file." }, { "payer_name": "UNITED HEALTHCARE", "plan_name": "SUTTER SELECT & SUTTER HEALTH PLAN HMO PLANS", "methodology": "per diem", "standard_charge_dollar": 28538.0, "standard_charge_algorithm": "Per diem ($28,538).", "count": "0", "additional_payer_notes": "Zero final payments for the item or service in the 15 months prior to posting the file." }, { "payer_name": "UMR", "plan_name": "SUTTER SELECT & SUTTER HEALTH PLAN HMO PLANS", "methodology": "per diem", "standard_charge_dollar": 28538.0, "standard_charge_algorithm": "Per diem ($28,538).", "median_amount": 259.04, "10th_percentile": 213.12, "90th_percentile": 259.04, "count": "1 through 10" }, { "payer_name": "UNITED HEALTHCARE", "plan_name": "SUTTER SELECT & SUTTER HEALTH PLAN HMO PLANS", "methodology": "per diem", "standard_charge_dollar": 28538.0, "standard_charge_algorithm": "Per diem ($28,538).", "median_amount": 257.61, "10th_percentile": 107.25, "90th_percentile": 257.61, "count": "1 through 10" } ] } ] }, { "description": "HC Introducer Gp009", "code_information": [ { "code": "PX-2120206009", "type": "CDM" }, { "code": "C1894", "type": "HCPCS" }, { "code": "0272", "type": "RC" } ], "standard_charges": [ { "setting": "outpatient", "gross_charge": 570.0, "discounted_cash": 285.0, "minimum": 240.54, "maximum": 296.4, "additional_generic_notes": "Zero final payments for the item or service in the 15 months prior to posting the file.", "payers_information": [ { "payer_name": "AETNA", "plan_name": "AETNA ALL OTHER PLANS", "methodology": "percent of total billed charges", "standard_charge_dollar": 296.4, "standard_charge_percentage": 52.0, "count": "0", "additional_payer_notes": "Zero final payments for the item or service in the 15 months prior to posting the file." }, { "payer_name": "AETNA", "plan_name": "AETNA ALL OTHER PLANS", "methodology": "percent of total billed charges", "standard_charge_dollar": 296.4, "standard_charge_percentage": 52.0, "count": "0", "additional_payer_notes": "Zero final payments for the item or service in the 15 months prior to posting the file." }, { "payer_name": "MERITAIN HEALTH", "plan_name": "AETNA ALL OTHER PLANS", "methodology": "percent of total billed charges", "standard_charge_dollar": 296.4, "standard_charge_percentage": 52.0, "median_amount": 293.0, "10th_percentile": 187.29, "90th_percentile": 293.0, "count": "1 through 10" }, { "payer_name": "BLUE SHIELD", "plan_name": "STANFORD HEALTHCARE ALLIANCE PLAN", "methodology": "percent of total billed charges", "standard_charge_dollar": 276.96, "standard_charge_percentage": 48.59, "count": "0", "additional_payer_notes": "Zero final payments for the item or service in the 15 months prior to posting the file." }, { "payer_name": "CIGNA", "plan_name": "CIGNA COM ALT HMO PLAN", "methodology": "percent of total billed charges", "standard_charge_dollar": 240.54, "standard_charge_percentage": 42.2, "count": "0", "additional_payer_notes": "Zero final payments for the item or service in the 15 months prior to posting the file." }, { "payer_name": "CIGNA", "plan_name": "CIGNA COM ALT HMO PLAN", "methodology": "percent of total billed charges", "standard_charge_dollar": 240.54, "standard_charge_percentage": 42.2, "count": "0", "additional_payer_notes": "Zero final payments for the item or service in the 15 months prior to posting the file." }, { "payer_name": "HEALTH NET", "plan_name": "HEALTHNET HMO, PPO, POS, EPO, CANOPY HEALTHNET HMO, OTHER-IN-NETWORK PLANS", "methodology": "per diem", "standard_charge_dollar": 8000.0, "standard_charge_algorithm": "Expected reimbursement is the lesser of Per diem ($8,000) for the length of stay and 70% of billed.", "count": "0", "additional_payer_notes": "Zero final payments for the item or service in the 15 months prior to posting the file." }, { "payer_name": "HEALTH NET", "plan_name": "HEALTHNET HMO, PPO, POS, EPO, CANOPY HEALTHNET HMO, OTHER-IN-NETWORK PLANS", "methodology": "per diem", "standard_charge_dollar": 8000.0, "standard_charge_algorithm": "Expected reimbursement is the lesser of Per diem ($8,000) for the length of stay and 70% of billed.", "count": "0", "additional_payer_notes": "Zero final payments for the item or service in the 15 months prior to posting the file." }, { "payer_name": "UNITED HEALTHCARE", "plan_name": "SUTTER SELECT & SUTTER HEALTH PLAN HMO PLANS", "methodology": "per diem", "standard_charge_dollar": 28538.0, "standard_charge_algorithm": "Per diem ($28,538).", "count": "0", "additional_payer_notes": "Zero final payments for the item or service in the 15 months prior to posting the file." }, { "payer_name": "UNITED HEALTHCARE", "plan_name": "SUTTER SELECT & SUTTER HEALTH PLAN HMO PLANS", "methodology": "per diem", "standard_charge_dollar": 28538.0, "standard_charge_algorithm": "Per diem ($28,538).", "count": "0", "additional_payer_notes": "Zero final payments for the item or service in the 15 months prior to posting the file." }, { "payer_name": "UNITED HEALTHCARE", "plan_name": "SUTTER SELECT & SUTTER HEALTH PLAN HMO PLANS", "methodology": "per diem", "standard_charge_dollar": 28538.0, "standard_charge_algorithm": "Per diem ($28,538).", "count": "0", "additional_payer_notes": "Zero final payments for the item or service in the 15 months prior to posting the file." }, { "payer_name": "UMR", "plan_name": "SUTTER SELECT & SUTTER HEALTH PLAN HMO PLANS", "methodology": "per diem", "standard_charge_dollar": 28538.0, "standard_charge_algorithm": "Per diem ($28,538).", "median_amount": 259.04, "10th_percentile": 213.12, "90th_percentile": 259.04, "count": "1 through 10" }, { "payer_name": "UNITED HEALTHCARE", "plan_name": "SUTTER SELECT & SUTTER HEALTH PLAN HMO PLANS", "methodology": "per diem", "standard_charge_dollar": 28538.0, "standard_charge_algorithm": "Per diem ($28,538).", "median_amount": 257.61, "10th_percentile": 107.25, "90th_percentile": 257.61, "count": "1 through 10" } ] } ] }, { "description": "HC Introducer Gp010", "code_information": [ { "code": "PX-2120206010", "type": "CDM" }, { "code": "C1894", "type": "HCPCS" }, { "code": "0272", "type": "RC" } ], "standard_charges": [ { "setting": "outpatient", "gross_charge": 665.0, "discounted_cash": 332.5, "minimum": 280.63, "maximum": 345.8, "additional_generic_notes": "Zero final payments for the item or service in the 15 months prior to posting the file.", "payers_information": [ { "payer_name": "AETNA", "plan_name": "AETNA ALL OTHER PLANS", "methodology": "percent of total billed charges", "standard_charge_dollar": 345.8, "standard_charge_percentage": 52.0, "count": "0", "additional_payer_notes": "Zero final payments for the item or service in the 15 months prior to posting the file." }, { "payer_name": "AETNA", "plan_name": "AETNA ALL OTHER PLANS", "methodology": "percent of total billed charges", "standard_charge_dollar": 345.8, "standard_charge_percentage": 52.0, "count": "0", "additional_payer_notes": "Zero final payments for the item or service in the 15 months prior to posting the file." }, { "payer_name": "MERITAIN HEALTH", "plan_name": "AETNA ALL OTHER PLANS", "methodology": "percent of total billed charges", "standard_charge_dollar": 345.8, "standard_charge_percentage": 52.0, "median_amount": 293.0, "10th_percentile": 187.29, "90th_percentile": 293.0, "count": "1 through 10" }, { "payer_name": "BLUE SHIELD", "plan_name": "STANFORD HEALTHCARE ALLIANCE PLAN", "methodology": "percent of total billed charges", "standard_charge_dollar": 323.12, "standard_charge_percentage": 48.59, "count": "0", "additional_payer_notes": "Zero final payments for the item or service in the 15 months prior to posting the file." }, { "payer_name": "CIGNA", "plan_name": "CIGNA COM ALT HMO PLAN", "methodology": "percent of total billed charges", "standard_charge_dollar": 280.63, "standard_charge_percentage": 42.2, "count": "0", "additional_payer_notes": "Zero final payments for the item or service in the 15 months prior to posting the file." }, { "payer_name": "CIGNA", "plan_name": "CIGNA COM ALT HMO PLAN", "methodology": "percent of total billed charges", "standard_charge_dollar": 280.63, "standard_charge_percentage": 42.2, "count": "0", "additional_payer_notes": "Zero final payments for the item or service in the 15 months prior to posting the file." }, { "payer_name": "HEALTH NET", "plan_name": "HEALTHNET HMO, PPO, POS, EPO, CANOPY HEALTHNET HMO, OTHER-IN-NETWORK PLANS", "methodology": "per diem", "standard_charge_dollar": 8000.0, "standard_charge_algorithm": "Expected reimbursement is the lesser of Per diem ($8,000) for the length of stay and 70% of billed.", "count": "0", "additional_payer_notes": "Zero final payments for the item or service in the 15 months prior to posting the file." }, { "payer_name": "HEALTH NET", "plan_name": "HEALTHNET HMO, PPO, POS, EPO, CANOPY HEALTHNET HMO, OTHER-IN-NETWORK PLANS", "methodology": "per diem", "standard_charge_dollar": 8000.0, "standard_charge_algorithm": "Expected reimbursement is the lesser of Per diem ($8,000) for the length of stay and 70% of billed.", "count": "0", "additional_payer_notes": "Zero final payments for the item or service in the 15 months prior to posting the file." }, { "payer_name": "UNITED HEALTHCARE", "plan_name": "SUTTER SELECT & SUTTER HEALTH PLAN HMO PLANS", "methodology": "per diem", "standard_charge_dollar": 28538.0, "standard_charge_algorithm": "Per diem ($28,538).", "count": "0", "additional_payer_notes": "Zero final payments for the item or service in the 15 months prior to posting the file." }, { "payer_name": "UNITED HEALTHCARE", "plan_name": "SUTTER SELECT & SUTTER HEALTH PLAN HMO PLANS", "methodology": "per diem", "standard_charge_dollar": 28538.0, "standard_charge_algorithm": "Per diem ($28,538).", "count": "0", "additional_payer_notes": "Zero final payments for the item or service in the 15 months prior to posting the file." }, { "payer_name": "UNITED HEALTHCARE", "plan_name": "SUTTER SELECT & SUTTER HEALTH PLAN HMO PLANS", "methodology": "per diem", "standard_charge_dollar": 28538.0, "standard_charge_algorithm": "Per diem ($28,538).", "count": "0", "additional_payer_notes": "Zero final payments for the item or service in the 15 months prior to posting the file." }, { "payer_name": "UMR", "plan_name": "SUTTER SELECT & SUTTER HEALTH PLAN HMO PLANS", "methodology": "per diem", "standard_charge_dollar": 28538.0, "standard_charge_algorithm": "Per diem ($28,538).", "median_amount": 259.04, "10th_percentile": 213.12, "90th_percentile": 259.04, "count": "1 through 10" }, { "payer_name": "UNITED HEALTHCARE", "plan_name": "SUTTER SELECT & SUTTER HEALTH PLAN HMO PLANS", "methodology": "per diem", "standard_charge_dollar": 28538.0, "standard_charge_algorithm": "Per diem ($28,538).", "median_amount": 257.61, "10th_percentile": 107.25, "90th_percentile": 257.61, "count": "1 through 10" } ] } ] }, { "description": "HC Introducer Gp011", "code_information": [ { "code": "PX-2120206011", "type": "CDM" }, { "code": "C1894", "type": "HCPCS" }, { "code": "0272", "type": "RC" } ], "standard_charges": [ { "setting": "outpatient", "gross_charge": 740.0, "discounted_cash": 370.0, "minimum": 312.28, "maximum": 384.8, "additional_generic_notes": "Zero final payments for the item or service in the 15 months prior to posting the file.", "payers_information": [ { "payer_name": "AETNA", "plan_name": "AETNA ALL OTHER PLANS", "methodology": "percent of total billed charges", "standard_charge_dollar": 384.8, "standard_charge_percentage": 52.0, "count": "0", "additional_payer_notes": "Zero final payments for the item or service in the 15 months prior to posting the file." }, { "payer_name": "AETNA", "plan_name": "AETNA ALL OTHER PLANS", "methodology": "percent of total billed charges", "standard_charge_dollar": 384.8, "standard_charge_percentage": 52.0, "count": "0", "additional_payer_notes": "Zero final payments for the item or service in the 15 months prior to posting the file." }, { "payer_name": "MERITAIN HEALTH", "plan_name": "AETNA ALL OTHER PLANS", "methodology": "percent of total billed charges", "standard_charge_dollar": 384.8, "standard_charge_percentage": 52.0, "median_amount": 293.0, "10th_percentile": 187.29, "90th_percentile": 293.0, "count": "1 through 10" }, { "payer_name": "BLUE SHIELD", "plan_name": "STANFORD HEALTHCARE ALLIANCE PLAN", "methodology": "percent of total billed charges", "standard_charge_dollar": 359.57, "standard_charge_percentage": 48.59, "count": "0", "additional_payer_notes": "Zero final payments for the item or service in the 15 months prior to posting the file." }, { "payer_name": "CIGNA", "plan_name": "CIGNA COM ALT HMO PLAN", "methodology": "percent of total billed charges", "standard_charge_dollar": 312.28, "standard_charge_percentage": 42.2, "count": "0", "additional_payer_notes": "Zero final payments for the item or service in the 15 months prior to posting the file." }, { "payer_name": "CIGNA", "plan_name": "CIGNA COM ALT HMO PLAN", "methodology": "percent of total billed charges", "standard_charge_dollar": 312.28, "standard_charge_percentage": 42.2, "count": "0", "additional_payer_notes": "Zero final payments for the item or service in the 15 months prior to posting the file." }, { "payer_name": "HEALTH NET", "plan_name": "HEALTHNET HMO, PPO, POS, EPO, CANOPY HEALTHNET HMO, OTHER-IN-NETWORK PLANS", "methodology": "per diem", "standard_charge_dollar": 8000.0, "standard_charge_algorithm": "Expected reimbursement is the lesser of Per diem ($8,000) for the length of stay and 70% of billed.", "count": "0", "additional_payer_notes": "Zero final payments for the item or service in the 15 months prior to posting the file." }, { "payer_name": "HEALTH NET", "plan_name": "HEALTHNET HMO, PPO, POS, EPO, CANOPY HEALTHNET HMO, OTHER-IN-NETWORK PLANS", "methodology": "per diem", "standard_charge_dollar": 8000.0, "standard_charge_algorithm": "Expected reimbursement is the lesser of Per diem ($8,000) for the length of stay and 70% of billed.", "count": "0", "additional_payer_notes": "Zero final payments for the item or service in the 15 months prior to posting the file." }, { "payer_name": "UNITED HEALTHCARE", "plan_name": "SUTTER SELECT & SUTTER HEALTH PLAN HMO PLANS", "methodology": "per diem", "standard_charge_dollar": 28538.0, "standard_charge_algorithm": "Per diem ($28,538).", "count": "0", "additional_payer_notes": "Zero final payments for the item or service in the 15 months prior to posting the file." }, { "payer_name": "UNITED HEALTHCARE", "plan_name": "SUTTER SELECT & SUTTER HEALTH PLAN HMO PLANS", "methodology": "per diem", "standard_charge_dollar": 28538.0, "standard_charge_algorithm": "Per diem ($28,538).", "count": "0", "additional_payer_notes": "Zero final payments for the item or service in the 15 months prior to posting the file." }, { "payer_name": "UNITED HEALTHCARE", "plan_name": "SUTTER SELECT & SUTTER HEALTH PLAN HMO PLANS", "methodology": "per diem", "standard_charge_dollar": 28538.0, "standard_charge_algorithm": "Per diem ($28,538).", "count": "0", "additional_payer_notes": "Zero final payments for the item or service in the 15 months prior to posting the file." }, { "payer_name": "UMR", "plan_name": "SUTTER SELECT & SUTTER HEALTH PLAN HMO PLANS", "methodology": "per diem", "standard_charge_dollar": 28538.0, "standard_charge_algorithm": "Per diem ($28,538).", "median_amount": 259.04, "10th_percentile": 213.12, "90th_percentile": 259.04, "count": "1 through 10" }, { "payer_name": "UNITED HEALTHCARE", "plan_name": "SUTTER SELECT & SUTTER HEALTH PLAN HMO PLANS", "methodology": "per diem", "standard_charge_dollar": 28538.0, "standard_charge_algorithm": "Per diem ($28,538).", "median_amount": 257.61, "10th_percentile": 107.25, "90th_percentile": 257.61, "count": "1 through 10" } ] } ] }, { "description": "HC Introducer Gp012", "code_information": [ { "code": "PX-2120206012", "type": "CDM" }, { "code": "C1893", "type": "HCPCS" }, { "code": "0272", "type": "RC" } ], "standard_charges": [ { "setting": "outpatient", "gross_charge": 810.0, "discounted_cash": 405.0, "minimum": 341.82, "maximum": 421.2, "additional_generic_notes": "Zero final payments for the item or service in the 15 months prior to posting the file.", "payers_information": [ { "payer_name": "AETNA", "plan_name": "AETNA ALL OTHER PLANS", "methodology": "percent of total billed charges", "standard_charge_dollar": 421.2, "standard_charge_percentage": 52.0, "count": "0", "additional_payer_notes": "Zero final payments for the item or service in the 15 months prior to posting the file." }, { "payer_name": "AETNA", "plan_name": "AETNA ALL OTHER PLANS", "methodology": "percent of total billed charges", "standard_charge_dollar": 421.2, "standard_charge_percentage": 52.0, "count": "0", "additional_payer_notes": "Zero final payments for the item or service in the 15 months prior to posting the file." }, { "payer_name": "MERITAIN HEALTH", "plan_name": "AETNA ALL OTHER PLANS", "methodology": "percent of total billed charges", "standard_charge_dollar": 421.2, "standard_charge_percentage": 52.0, "count": "0", "additional_payer_notes": "Zero final payments for the item or service in the 15 months prior to posting the file." }, { "payer_name": "BLUE SHIELD OUT OF STATE", "plan_name": "STANFORD HEALTHCARE ALLIANCE PLAN", "methodology": "percent of total billed charges", "standard_charge_dollar": 393.58, "standard_charge_percentage": 48.59, "median_amount": 529.76, "10th_percentile": 311.39, "90th_percentile": 565.26, "count": "1 through 10" }, { "payer_name": "BLUE SHIELD", "plan_name": "STANFORD HEALTHCARE ALLIANCE PLAN", "methodology": "percent of total billed charges", "standard_charge_dollar": 393.58, "standard_charge_percentage": 48.59, "count": "0", "additional_payer_notes": "Zero final payments for the item or service in the 15 months prior to posting the file." }, { "payer_name": "BLUE SHIELD", "plan_name": "STANFORD HEALTHCARE ALLIANCE PLAN", "methodology": "percent of total billed charges", "standard_charge_dollar": 393.58, "standard_charge_percentage": 48.59, "count": "0", "additional_payer_notes": "Zero final payments for the item or service in the 15 months prior to posting the file." }, { "payer_name": "CIGNA", "plan_name": "CIGNA COM ALT HMO PLAN", "methodology": "percent of total billed charges", "standard_charge_dollar": 341.82, "standard_charge_percentage": 42.2, "count": "0", "additional_payer_notes": "Zero final payments for the item or service in the 15 months prior to posting the file." }, { "payer_name": "CIGNA", "plan_name": "CIGNA COM ALT HMO PLAN", "methodology": "percent of total billed charges", "standard_charge_dollar": 341.82, "standard_charge_percentage": 42.2, "count": "0", "additional_payer_notes": "Zero final payments for the item or service in the 15 months prior to posting the file." }, { "payer_name": "HEALTH NET", "plan_name": "HEALTHNET HMO, PPO, POS, EPO, CANOPY HEALTHNET HMO, OTHER-IN-NETWORK PLANS", "methodology": "per diem", "standard_charge_dollar": 8000.0, "standard_charge_algorithm": "Expected reimbursement is the lesser of Per diem ($8,000) for the length of stay and 70% of billed.", "count": "0", "additional_payer_notes": "Zero final payments for the item or service in the 15 months prior to posting the file." }, { "payer_name": "HEALTH NET", "plan_name": "HEALTHNET HMO, PPO, POS, EPO, CANOPY HEALTHNET HMO, OTHER-IN-NETWORK PLANS", "methodology": "per diem", "standard_charge_dollar": 8000.0, "standard_charge_algorithm": "Expected reimbursement is the lesser of Per diem ($8,000) for the length of stay and 70% of billed.", "count": "0", "additional_payer_notes": "Zero final payments for the item or service in the 15 months prior to posting the file." }, { "payer_name": "UNITED HEALTHCARE", "plan_name": "SUTTER SELECT & SUTTER HEALTH PLAN HMO PLANS", "methodology": "per diem", "standard_charge_dollar": 28538.0, "standard_charge_algorithm": "Per diem ($28,538).", "count": "0", "additional_payer_notes": "Zero final payments for the item or service in the 15 months prior to posting the file." }, { "payer_name": "UNITED HEALTHCARE", "plan_name": "SUTTER SELECT & SUTTER HEALTH PLAN HMO PLANS", "methodology": "per diem", "standard_charge_dollar": 28538.0, "standard_charge_algorithm": "Per diem ($28,538).", "count": "0", "additional_payer_notes": "Zero final payments for the item or service in the 15 months prior to posting the file." }, { "payer_name": "SUTTER", "plan_name": "SUTTER SELECT & SUTTER HEALTH PLAN HMO PLANS", "methodology": "per diem", "standard_charge_dollar": 28538.0, "standard_charge_algorithm": "Per diem ($28,538).", "median_amount": 447.36, "10th_percentile": 447.36, "90th_percentile": 447.36, "count": "1 through 10" }, { "payer_name": "UNITED HEALTHCARE", "plan_name": "SUTTER SELECT & SUTTER HEALTH PLAN HMO PLANS", "methodology": "per diem", "standard_charge_dollar": 28538.0, "standard_charge_algorithm": "Per diem ($28,538).", "count": "0", "additional_payer_notes": "Zero final payments for the item or service in the 15 months prior to posting the file." }, { "payer_name": "UMR", "plan_name": "SUTTER SELECT & SUTTER HEALTH PLAN HMO PLANS", "methodology": "per diem", "standard_charge_dollar": 28538.0, "standard_charge_algorithm": "Per diem ($28,538).", "median_amount": 329.07, "10th_percentile": 329.07, "90th_percentile": 329.07, "count": "1 through 10" }, { "payer_name": "UNITED HEALTHCARE", "plan_name": "SUTTER SELECT & SUTTER HEALTH PLAN HMO PLANS", "methodology": "per diem", "standard_charge_dollar": 28538.0, "standard_charge_algorithm": "Per diem ($28,538).", "count": "0", "additional_payer_notes": "Zero final payments for the item or service in the 15 months prior to posting the file." } ] } ] }, { "description": "HC Introducer Gp013", "code_information": [ { "code": "PX-2120206013", "type": "CDM" }, { "code": "C1894", "type": "HCPCS" }, { "code": "0272", "type": "RC" } ], "standard_charges": [ { "setting": "outpatient", "gross_charge": 900.0, "discounted_cash": 450.0, "minimum": 379.8, "maximum": 468.0, "additional_generic_notes": "Zero final payments for the item or service in the 15 months prior to posting the file.", "payers_information": [ { "payer_name": "AETNA", "plan_name": "AETNA ALL OTHER PLANS", "methodology": "percent of total billed charges", "standard_charge_dollar": 468.0, "standard_charge_percentage": 52.0, "count": "0", "additional_payer_notes": "Zero final payments for the item or service in the 15 months prior to posting the file." }, { "payer_name": "AETNA", "plan_name": "AETNA ALL OTHER PLANS", "methodology": "percent of total billed charges", "standard_charge_dollar": 468.0, "standard_charge_percentage": 52.0, "count": "0", "additional_payer_notes": "Zero final payments for the item or service in the 15 months prior to posting the file." }, { "payer_name": "MERITAIN HEALTH", "plan_name": "AETNA ALL OTHER PLANS", "methodology": "percent of total billed charges", "standard_charge_dollar": 468.0, "standard_charge_percentage": 52.0, "median_amount": 293.0, "10th_percentile": 187.29, "90th_percentile": 293.0, "count": "1 through 10" }, { "payer_name": "BLUE SHIELD", "plan_name": "STANFORD HEALTHCARE ALLIANCE PLAN", "methodology": "percent of total billed charges", "standard_charge_dollar": 437.31, "standard_charge_percentage": 48.59, "count": "0", "additional_payer_notes": "Zero final payments for the item or service in the 15 months prior to posting the file." }, { "payer_name": "CIGNA", "plan_name": "CIGNA COM ALT HMO PLAN", "methodology": "percent of total billed charges", "standard_charge_dollar": 379.8, "standard_charge_percentage": 42.2, "count": "0", "additional_payer_notes": "Zero final payments for the item or service in the 15 months prior to posting the file." }, { "payer_name": "CIGNA", "plan_name": "CIGNA COM ALT HMO PLAN", "methodology": "percent of total billed charges", "standard_charge_dollar": 379.8, "standard_charge_percentage": 42.2, "count": "0", "additional_payer_notes": "Zero final payments for the item or service in the 15 months prior to posting the file." }, { "payer_name": "HEALTH NET", "plan_name": "HEALTHNET HMO, PPO, POS, EPO, CANOPY HEALTHNET HMO, OTHER-IN-NETWORK PLANS", "methodology": "per diem", "standard_charge_dollar": 8000.0, "standard_charge_algorithm": "Expected reimbursement is the lesser of Per diem ($8,000) for the length of stay and 70% of billed.", "count": "0", "additional_payer_notes": "Zero final payments for the item or service in the 15 months prior to posting the file." }, { "payer_name": "HEALTH NET", "plan_name": "HEALTHNET HMO, PPO, POS, EPO, CANOPY HEALTHNET HMO, OTHER-IN-NETWORK PLANS", "methodology": "per diem", "standard_charge_dollar": 8000.0, "standard_charge_algorithm": "Expected reimbursement is the lesser of Per diem ($8,000) for the length of stay and 70% of billed.", "count": "0", "additional_payer_notes": "Zero final payments for the item or service in the 15 months prior to posting the file." }, { "payer_name": "UNITED HEALTHCARE", "plan_name": "SUTTER SELECT & SUTTER HEALTH PLAN HMO PLANS", "methodology": "per diem", "standard_charge_dollar": 28538.0, "standard_charge_algorithm": "Per diem ($28,538).", "count": "0", "additional_payer_notes": "Zero final payments for the item or service in the 15 months prior to posting the file." }, { "payer_name": "UNITED HEALTHCARE", "plan_name": "SUTTER SELECT & SUTTER HEALTH PLAN HMO PLANS", "methodology": "per diem", "standard_charge_dollar": 28538.0, "standard_charge_algorithm": "Per diem ($28,538).", "count": "0", "additional_payer_notes": "Zero final payments for the item or service in the 15 months prior to posting the file." }, { "payer_name": "UNITED HEALTHCARE", "plan_name": "SUTTER SELECT & SUTTER HEALTH PLAN HMO PLANS", "methodology": "per diem", "standard_charge_dollar": 28538.0, "standard_charge_algorithm": "Per diem ($28,538).", "count": "0", "additional_payer_notes": "Zero final payments for the item or service in the 15 months prior to posting the file." }, { "payer_name": "UMR", "plan_name": "SUTTER SELECT & SUTTER HEALTH PLAN HMO PLANS", "methodology": "per diem", "standard_charge_dollar": 28538.0, "standard_charge_algorithm": "Per diem ($28,538).", "median_amount": 259.04, "10th_percentile": 213.12, "90th_percentile": 259.04, "count": "1 through 10" }, { "payer_name": "UNITED HEALTHCARE", "plan_name": "SUTTER SELECT & SUTTER HEALTH PLAN HMO PLANS", "methodology": "per diem", "standard_charge_dollar": 28538.0, "standard_charge_algorithm": "Per diem ($28,538).", "median_amount": 257.61, "10th_percentile": 107.25, "90th_percentile": 257.61, "count": "1 through 10" } ] } ] }, { "description": "HC Introducer Gp014", "code_information": [ { "code": "PX-2120206014", "type": "CDM" }, { "code": "C1894", "type": "HCPCS" }, { "code": "0272", "type": "RC" } ], "standard_charges": [ { "setting": "outpatient", "gross_charge": 1080.0, "discounted_cash": 540.0, "minimum": 455.76, "maximum": 561.6, "additional_generic_notes": "Zero final payments for the item or service in the 15 months prior to posting the file.", "payers_information": [ { "payer_name": "AETNA", "plan_name": "AETNA ALL OTHER PLANS", "methodology": "percent of total billed charges", "standard_charge_dollar": 561.6, "standard_charge_percentage": 52.0, "count": "0", "additional_payer_notes": "Zero final payments for the item or service in the 15 months prior to posting the file." }, { "payer_name": "AETNA", "plan_name": "AETNA ALL OTHER PLANS", "methodology": "percent of total billed charges", "standard_charge_dollar": 561.6, "standard_charge_percentage": 52.0, "count": "0", "additional_payer_notes": "Zero final payments for the item or service in the 15 months prior to posting the file." }, { "payer_name": "MERITAIN HEALTH", "plan_name": "AETNA ALL OTHER PLANS", "methodology": "percent of total billed charges", "standard_charge_dollar": 561.6, "standard_charge_percentage": 52.0, "median_amount": 293.0, "10th_percentile": 187.29, "90th_percentile": 293.0, "count": "1 through 10" }, { "payer_name": "BLUE SHIELD", "plan_name": "STANFORD HEALTHCARE ALLIANCE PLAN", "methodology": "percent of total billed charges", "standard_charge_dollar": 524.77, "standard_charge_percentage": 48.59, "count": "0", "additional_payer_notes": "Zero final payments for the item or service in the 15 months prior to posting the file." }, { "payer_name": "CIGNA", "plan_name": "CIGNA COM ALT HMO PLAN", "methodology": "percent of total billed charges", "standard_charge_dollar": 455.76, "standard_charge_percentage": 42.2, "count": "0", "additional_payer_notes": "Zero final payments for the item or service in the 15 months prior to posting the file." }, { "payer_name": "CIGNA", "plan_name": "CIGNA COM ALT HMO PLAN", "methodology": "percent of total billed charges", "standard_charge_dollar": 455.76, "standard_charge_percentage": 42.2, "count": "0", "additional_payer_notes": "Zero final payments for the item or service in the 15 months prior to posting the file." }, { "payer_name": "HEALTH NET", "plan_name": "HEALTHNET HMO, PPO, POS, EPO, CANOPY HEALTHNET HMO, OTHER-IN-NETWORK PLANS", "methodology": "per diem", "standard_charge_dollar": 8000.0, "standard_charge_algorithm": "Expected reimbursement is the lesser of Per diem ($8,000) for the length of stay and 70% of billed.", "count": "0", "additional_payer_notes": "Zero final payments for the item or service in the 15 months prior to posting the file." }, { "payer_name": "HEALTH NET", "plan_name": "HEALTHNET HMO, PPO, POS, EPO, CANOPY HEALTHNET HMO, OTHER-IN-NETWORK PLANS", "methodology": "per diem", "standard_charge_dollar": 8000.0, "standard_charge_algorithm": "Expected reimbursement is the lesser of Per diem ($8,000) for the length of stay and 70% of billed.", "count": "0", "additional_payer_notes": "Zero final payments for the item or service in the 15 months prior to posting the file." }, { "payer_name": "UNITED HEALTHCARE", "plan_name": "SUTTER SELECT & SUTTER HEALTH PLAN HMO PLANS", "methodology": "per diem", "standard_charge_dollar": 28538.0, "standard_charge_algorithm": "Per diem ($28,538).", "count": "0", "additional_payer_notes": "Zero final payments for the item or service in the 15 months prior to posting the file." }, { "payer_name": "UNITED HEALTHCARE", "plan_name": "SUTTER SELECT & SUTTER HEALTH PLAN HMO PLANS", "methodology": "per diem", "standard_charge_dollar": 28538.0, "standard_charge_algorithm": "Per diem ($28,538).", "count": "0", "additional_payer_notes": "Zero final payments for the item or service in the 15 months prior to posting the file." }, { "payer_name": "UNITED HEALTHCARE", "plan_name": "SUTTER SELECT & SUTTER HEALTH PLAN HMO PLANS", "methodology": "per diem", "standard_charge_dollar": 28538.0, "standard_charge_algorithm": "Per diem ($28,538).", "count": "0", "additional_payer_notes": "Zero final payments for the item or service in the 15 months prior to posting the file." }, { "payer_name": "UMR", "plan_name": "SUTTER SELECT & SUTTER HEALTH PLAN HMO PLANS", "methodology": "per diem", "standard_charge_dollar": 28538.0, "standard_charge_algorithm": "Per diem ($28,538).", "median_amount": 259.04, "10th_percentile": 213.12, "90th_percentile": 259.04, "count": "1 through 10" }, { "payer_name": "UNITED HEALTHCARE", "plan_name": "SUTTER SELECT & SUTTER HEALTH PLAN HMO PLANS", "methodology": "per diem", "standard_charge_dollar": 28538.0, "standard_charge_algorithm": "Per diem ($28,538).", "median_amount": 257.61, "10th_percentile": 107.25, "90th_percentile": 257.61, "count": "1 through 10" } ] } ] }, { "description": "HC Introducer Gp015", "code_information": [ { "code": "PX-2120206015", "type": "CDM" }, { "code": "99999", "type": "CPT" }, { "code": "0272", "type": "RC" } ], "standard_charges": [ { "setting": "outpatient", "gross_charge": 1225.0, "discounted_cash": 612.5, "minimum": 516.95, "maximum": 637.0, "additional_generic_notes": "Zero final payments for the item or service in the 15 months prior to posting the file.", "payers_information": [ { "payer_name": "AETNA", "plan_name": "AETNA ALL OTHER PLANS", "methodology": "percent of total billed charges", "standard_charge_dollar": 637.0, "standard_charge_percentage": 52.0, "count": "0", "additional_payer_notes": "Zero final payments for the item or service in the 15 months prior to posting the file." }, { "payer_name": "AETNA", "plan_name": "AETNA ALL OTHER PLANS", "methodology": "percent of total billed charges", "standard_charge_dollar": 637.0, "standard_charge_percentage": 52.0, "count": "0", "additional_payer_notes": "Zero final payments for the item or service in the 15 months prior to posting the file." }, { "payer_name": "MERITAIN HEALTH", "plan_name": "AETNA ALL OTHER PLANS", "methodology": "percent of total billed charges", "standard_charge_dollar": 637.0, "standard_charge_percentage": 52.0, "count": "0", "additional_payer_notes": "Zero final payments for the item or service in the 15 months prior to posting the file." }, { "payer_name": "BLUE SHIELD OUT OF STATE", "plan_name": "STANFORD HEALTHCARE ALLIANCE PLAN", "methodology": "percent of total billed charges", "standard_charge_dollar": 595.23, "standard_charge_percentage": 48.59, "count": "0", "additional_payer_notes": "Zero final payments for the item or service in the 15 months prior to posting the file." }, { "payer_name": "BLUE SHIELD", "plan_name": "STANFORD HEALTHCARE ALLIANCE PLAN", "methodology": "percent of total billed charges", "standard_charge_dollar": 595.23, "standard_charge_percentage": 48.59, "median_amount": 68.24, "10th_percentile": 13.6, "90th_percentile": 1043.06, "count": "30" }, { "payer_name": "BLUE SHIELD", "plan_name": "STANFORD HEALTHCARE ALLIANCE PLAN", "methodology": "percent of total billed charges", "standard_charge_dollar": 595.23, "standard_charge_percentage": 48.59, "count": "0", "additional_payer_notes": "Zero final payments for the item or service in the 15 months prior to posting the file." }, { "payer_name": "BLUE SHIELD", "plan_name": "STANFORD HEALTHCARE ALLIANCE PLAN", "methodology": "percent of total billed charges", "standard_charge_dollar": 595.23, "standard_charge_percentage": 48.59, "count": "0", "additional_payer_notes": "Zero final payments for the item or service in the 15 months prior to posting the file." }, { "payer_name": "CIGNA", "plan_name": "CIGNA COM ALT HMO PLAN", "methodology": "percent of total billed charges", "standard_charge_dollar": 516.95, "standard_charge_percentage": 42.2, "count": "0", "additional_payer_notes": "Zero final payments for the item or service in the 15 months prior to posting the file." }, { "payer_name": "CIGNA", "plan_name": "CIGNA COM ALT HMO PLAN", "methodology": "percent of total billed charges", "standard_charge_dollar": 516.95, "standard_charge_percentage": 42.2, "count": "0", "additional_payer_notes": "Zero final payments for the item or service in the 15 months prior to posting the file." }, { "payer_name": "HEALTH NET", "plan_name": "HEALTHNET HMO, PPO, POS, EPO, CANOPY HEALTHNET HMO, OTHER-IN-NETWORK PLANS", "methodology": "per diem", "standard_charge_dollar": 8000.0, "standard_charge_algorithm": "Expected reimbursement is the lesser of Per diem ($8,000) for the length of stay and 70% of billed.", "count": "0", "additional_payer_notes": "Zero final payments for the item or service in the 15 months prior to posting the file." }, { "payer_name": "HEALTH NET", "plan_name": "HEALTHNET HMO, PPO, POS, EPO, CANOPY HEALTHNET HMO, OTHER-IN-NETWORK PLANS", "methodology": "per diem", "standard_charge_dollar": 8000.0, "standard_charge_algorithm": "Expected reimbursement is the lesser of Per diem ($8,000) for the length of stay and 70% of billed.", "count": "0", "additional_payer_notes": "Zero final payments for the item or service in the 15 months prior to posting the file." }, { "payer_name": "UNITED HEALTHCARE", "plan_name": "SUTTER SELECT & SUTTER HEALTH PLAN HMO PLANS", "methodology": "per diem", "standard_charge_dollar": 28538.0, "standard_charge_algorithm": "Per diem ($28,538).", "count": "0", "additional_payer_notes": "Zero final payments for the item or service in the 15 months prior to posting the file." }, { "payer_name": "UNITED HEALTHCARE", "plan_name": "SUTTER SELECT & SUTTER HEALTH PLAN HMO PLANS", "methodology": "per diem", "standard_charge_dollar": 28538.0, "standard_charge_algorithm": "Per diem ($28,538).", "count": "0", "additional_payer_notes": "Zero final payments for the item or service in the 15 months prior to posting the file." }, { "payer_name": "SUTTER", "plan_name": "SUTTER SELECT & SUTTER HEALTH PLAN HMO PLANS", "methodology": "per diem", "standard_charge_dollar": 28538.0, "standard_charge_algorithm": "Per diem ($28,538).", "count": "0", "additional_payer_notes": "Zero final payments for the item or service in the 15 months prior to posting the file." }, { "payer_name": "UNITED HEALTHCARE", "plan_name": "SUTTER SELECT & SUTTER HEALTH PLAN HMO PLANS", "methodology": "per diem", "standard_charge_dollar": 28538.0, "standard_charge_algorithm": "Per diem ($28,538).", "count": "0", "additional_payer_notes": "Zero final payments for the item or service in the 15 months prior to posting the file." }, { "payer_name": "UMR", "plan_name": "SUTTER SELECT & SUTTER HEALTH PLAN HMO PLANS", "methodology": "per diem", "standard_charge_dollar": 28538.0, "standard_charge_algorithm": "Per diem ($28,538).", "count": "0", "additional_payer_notes": "Zero final payments for the item or service in the 15 months prior to posting the file." } ] } ] }, { "description": "HC Introducer Gp016", "code_information": [ { "code": "PX-2120206016", "type": "CDM" }, { "code": "C1893", "type": "HCPCS" }, { "code": "0272", "type": "RC" } ], "standard_charges": [ { "setting": "outpatient", "gross_charge": 1400.0, "discounted_cash": 700.0, "minimum": 590.8, "maximum": 728.0, "additional_generic_notes": "Zero final payments for the item or service in the 15 months prior to posting the file.", "payers_information": [ { "payer_name": "AETNA", "plan_name": "AETNA ALL OTHER PLANS", "methodology": "percent of total billed charges", "standard_charge_dollar": 728.0, "standard_charge_percentage": 52.0, "count": "0", "additional_payer_notes": "Zero final payments for the item or service in the 15 months prior to posting the file." }, { "payer_name": "AETNA", "plan_name": "AETNA ALL OTHER PLANS", "methodology": "percent of total billed charges", "standard_charge_dollar": 728.0, "standard_charge_percentage": 52.0, "count": "0", "additional_payer_notes": "Zero final payments for the item or service in the 15 months prior to posting the file." }, { "payer_name": "MERITAIN HEALTH", "plan_name": "AETNA ALL OTHER PLANS", "methodology": "percent of total billed charges", "standard_charge_dollar": 728.0, "standard_charge_percentage": 52.0, "count": "0", "additional_payer_notes": "Zero final payments for the item or service in the 15 months prior to posting the file." }, { "payer_name": "BLUE SHIELD OUT OF STATE", "plan_name": "STANFORD HEALTHCARE ALLIANCE PLAN", "methodology": "percent of total billed charges", "standard_charge_dollar": 680.26, "standard_charge_percentage": 48.59, "median_amount": 529.76, "10th_percentile": 311.39, "90th_percentile": 565.26, "count": "1 through 10" }, { "payer_name": "BLUE SHIELD", "plan_name": "STANFORD HEALTHCARE ALLIANCE PLAN", "methodology": "percent of total billed charges", "standard_charge_dollar": 680.26, "standard_charge_percentage": 48.59, "count": "0", "additional_payer_notes": "Zero final payments for the item or service in the 15 months prior to posting the file." }, { "payer_name": "BLUE SHIELD", "plan_name": "STANFORD HEALTHCARE ALLIANCE PLAN", "methodology": "percent of total billed charges", "standard_charge_dollar": 680.26, "standard_charge_percentage": 48.59, "median_amount": 1073.84, "10th_percentile": 529.76, "90th_percentile": 1073.84, "count": "1 through 10" }, { "payer_name": "BLUE SHIELD", "plan_name": "STANFORD HEALTHCARE ALLIANCE PLAN", "methodology": "percent of total billed charges", "standard_charge_dollar": 680.26, "standard_charge_percentage": 48.59, "count": "0", "additional_payer_notes": "Zero final payments for the item or service in the 15 months prior to posting the file." }, { "payer_name": "CIGNA", "plan_name": "CIGNA COM ALT HMO PLAN", "methodology": "percent of total billed charges", "standard_charge_dollar": 590.8, "standard_charge_percentage": 42.2, "count": "0", "additional_payer_notes": "Zero final payments for the item or service in the 15 months prior to posting the file." }, { "payer_name": "CIGNA", "plan_name": "CIGNA COM ALT HMO PLAN", "methodology": "percent of total billed charges", "standard_charge_dollar": 590.8, "standard_charge_percentage": 42.2, "count": "0", "additional_payer_notes": "Zero final payments for the item or service in the 15 months prior to posting the file." }, { "payer_name": "HEALTH NET", "plan_name": "HEALTHNET HMO, PPO, POS, EPO, CANOPY HEALTHNET HMO, OTHER-IN-NETWORK PLANS", "methodology": "per diem", "standard_charge_dollar": 8000.0, "standard_charge_algorithm": "Expected reimbursement is the lesser of Per diem ($8,000) for the length of stay and 70% of billed.", "count": "0", "additional_payer_notes": "Zero final payments for the item or service in the 15 months prior to posting the file." }, { "payer_name": "HEALTH NET", "plan_name": "HEALTHNET HMO, PPO, POS, EPO, CANOPY HEALTHNET HMO, OTHER-IN-NETWORK PLANS", "methodology": "per diem", "standard_charge_dollar": 8000.0, "standard_charge_algorithm": "Expected reimbursement is the lesser of Per diem ($8,000) for the length of stay and 70% of billed.", "count": "0", "additional_payer_notes": "Zero final payments for the item or service in the 15 months prior to posting the file." }, { "payer_name": "UNITED HEALTHCARE", "plan_name": "SUTTER SELECT & SUTTER HEALTH PLAN HMO PLANS", "methodology": "per diem", "standard_charge_dollar": 28538.0, "standard_charge_algorithm": "Per diem ($28,538).", "count": "0", "additional_payer_notes": "Zero final payments for the item or service in the 15 months prior to posting the file." }, { "payer_name": "UNITED HEALTHCARE", "plan_name": "SUTTER SELECT & SUTTER HEALTH PLAN HMO PLANS", "methodology": "per diem", "standard_charge_dollar": 28538.0, "standard_charge_algorithm": "Per diem ($28,538).", "count": "0", "additional_payer_notes": "Zero final payments for the item or service in the 15 months prior to posting the file." }, { "payer_name": "SUTTER", "plan_name": "SUTTER SELECT & SUTTER HEALTH PLAN HMO PLANS", "methodology": "per diem", "standard_charge_dollar": 28538.0, "standard_charge_algorithm": "Per diem ($28,538).", "median_amount": 447.36, "10th_percentile": 447.36, "90th_percentile": 447.36, "count": "1 through 10" }, { "payer_name": "UNITED HEALTHCARE", "plan_name": "SUTTER SELECT & SUTTER HEALTH PLAN HMO PLANS", "methodology": "per diem", "standard_charge_dollar": 28538.0, "standard_charge_algorithm": "Per diem ($28,538).", "count": "0", "additional_payer_notes": "Zero final payments for the item or service in the 15 months prior to posting the file." }, { "payer_name": "UMR", "plan_name": "SUTTER SELECT & SUTTER HEALTH PLAN HMO PLANS", "methodology": "per diem", "standard_charge_dollar": 28538.0, "standard_charge_algorithm": "Per diem ($28,538).", "median_amount": 329.07, "10th_percentile": 329.07, "90th_percentile": 329.07, "count": "1 through 10" }, { "payer_name": "UNITED HEALTHCARE", "plan_name": "SUTTER SELECT & SUTTER HEALTH PLAN HMO PLANS", "methodology": "per diem", "standard_charge_dollar": 28538.0, "standard_charge_algorithm": "Per diem ($28,538).", "count": "0", "additional_payer_notes": "Zero final payments for the item or service in the 15 months prior to posting the file." } ] } ] }, { "description": "HC Introducer Gp017", "code_information": [ { "code": "PX-2120206017", "type": "CDM" }, { "code": "C1894", "type": "HCPCS" }, { "code": "0272", "type": "RC" } ], "standard_charges": [ { "setting": "outpatient", "gross_charge": 1575.0, "discounted_cash": 787.5, "minimum": 664.65, "maximum": 819.0, "additional_generic_notes": "Zero final payments for the item or service in the 15 months prior to posting the file.", "payers_information": [ { "payer_name": "AETNA", "plan_name": "AETNA ALL OTHER PLANS", "methodology": "percent of total billed charges", "standard_charge_dollar": 819.0, "standard_charge_percentage": 52.0, "count": "0", "additional_payer_notes": "Zero final payments for the item or service in the 15 months prior to posting the file." }, { "payer_name": "AETNA", "plan_name": "AETNA ALL OTHER PLANS", "methodology": "percent of total billed charges", "standard_charge_dollar": 819.0, "standard_charge_percentage": 52.0, "count": "0", "additional_payer_notes": "Zero final payments for the item or service in the 15 months prior to posting the file." }, { "payer_name": "MERITAIN HEALTH", "plan_name": "AETNA ALL OTHER PLANS", "methodology": "percent of total billed charges", "standard_charge_dollar": 819.0, "standard_charge_percentage": 52.0, "median_amount": 293.0, "10th_percentile": 187.29, "90th_percentile": 293.0, "count": "1 through 10" }, { "payer_name": "BLUE SHIELD", "plan_name": "STANFORD HEALTHCARE ALLIANCE PLAN", "methodology": "percent of total billed charges", "standard_charge_dollar": 765.29, "standard_charge_percentage": 48.59, "count": "0", "additional_payer_notes": "Zero final payments for the item or service in the 15 months prior to posting the file." }, { "payer_name": "CIGNA", "plan_name": "CIGNA COM ALT HMO PLAN", "methodology": "percent of total billed charges", "standard_charge_dollar": 664.65, "standard_charge_percentage": 42.2, "count": "0", "additional_payer_notes": "Zero final payments for the item or service in the 15 months prior to posting the file." }, { "payer_name": "CIGNA", "plan_name": "CIGNA COM ALT HMO PLAN", "methodology": "percent of total billed charges", "standard_charge_dollar": 664.65, "standard_charge_percentage": 42.2, "count": "0", "additional_payer_notes": "Zero final payments for the item or service in the 15 months prior to posting the file." }, { "payer_name": "HEALTH NET", "plan_name": "HEALTHNET HMO, PPO, POS, EPO, CANOPY HEALTHNET HMO, OTHER-IN-NETWORK PLANS", "methodology": "per diem", "standard_charge_dollar": 8000.0, "standard_charge_algorithm": "Expected reimbursement is the lesser of Per diem ($8,000) for the length of stay and 70% of billed.", "count": "0", "additional_payer_notes": "Zero final payments for the item or service in the 15 months prior to posting the file." }, { "payer_name": "HEALTH NET", "plan_name": "HEALTHNET HMO, PPO, POS, EPO, CANOPY HEALTHNET HMO, OTHER-IN-NETWORK PLANS", "methodology": "per diem", "standard_charge_dollar": 8000.0, "standard_charge_algorithm": "Expected reimbursement is the lesser of Per diem ($8,000) for the length of stay and 70% of billed.", "count": "0", "additional_payer_notes": "Zero final payments for the item or service in the 15 months prior to posting the file." }, { "payer_name": "UNITED HEALTHCARE", "plan_name": "SUTTER SELECT & SUTTER HEALTH PLAN HMO PLANS", "methodology": "per diem", "standard_charge_dollar": 28538.0, "standard_charge_algorithm": "Per diem ($28,538).", "count": "0", "additional_payer_notes": "Zero final payments for the item or service in the 15 months prior to posting the file." }, { "payer_name": "UNITED HEALTHCARE", "plan_name": "SUTTER SELECT & SUTTER HEALTH PLAN HMO PLANS", "methodology": "per diem", "standard_charge_dollar": 28538.0, "standard_charge_algorithm": "Per diem ($28,538).", "count": "0", "additional_payer_notes": "Zero final payments for the item or service in the 15 months prior to posting the file." }, { "payer_name": "UNITED HEALTHCARE", "plan_name": "SUTTER SELECT & SUTTER HEALTH PLAN HMO PLANS", "methodology": "per diem", "standard_charge_dollar": 28538.0, "standard_charge_algorithm": "Per diem ($28,538).", "count": "0", "additional_payer_notes": "Zero final payments for the item or service in the 15 months prior to posting the file." }, { "payer_name": "UMR", "plan_name": "SUTTER SELECT & SUTTER HEALTH PLAN HMO PLANS", "methodology": "per diem", "standard_charge_dollar": 28538.0, "standard_charge_algorithm": "Per diem ($28,538).", "median_amount": 259.04, "10th_percentile": 213.12, "90th_percentile": 259.04, "count": "1 through 10" }, { "payer_name": "UNITED HEALTHCARE", "plan_name": "SUTTER SELECT & SUTTER HEALTH PLAN HMO PLANS", "methodology": "per diem", "standard_charge_dollar": 28538.0, "standard_charge_algorithm": "Per diem ($28,538).", "median_amount": 257.61, "10th_percentile": 107.25, "90th_percentile": 257.61, "count": "1 through 10" } ] } ] }, { "description": "HC Introducer Gp018", "code_information": [ { "code": "PX-2120206018", "type": "CDM" }, { "code": "C1893", "type": "HCPCS" }, { "code": "0272", "type": "RC" } ], "standard_charges": [ { "setting": "outpatient", "gross_charge": 1750.0, "discounted_cash": 875.0, "minimum": 738.5, "maximum": 910.0, "additional_generic_notes": "Zero final payments for the item or service in the 15 months prior to posting the file.", "payers_information": [ { "payer_name": "AETNA", "plan_name": "AETNA ALL OTHER PLANS", "methodology": "percent of total billed charges", "standard_charge_dollar": 910.0, "standard_charge_percentage": 52.0, "count": "0", "additional_payer_notes": "Zero final payments for the item or service in the 15 months prior to posting the file." }, { "payer_name": "AETNA", "plan_name": "AETNA ALL OTHER PLANS", "methodology": "percent of total billed charges", "standard_charge_dollar": 910.0, "standard_charge_percentage": 52.0, "count": "0", "additional_payer_notes": "Zero final payments for the item or service in the 15 months prior to posting the file." }, { "payer_name": "MERITAIN HEALTH", "plan_name": "AETNA ALL OTHER PLANS", "methodology": "percent of total billed charges", "standard_charge_dollar": 910.0, "standard_charge_percentage": 52.0, "count": "0", "additional_payer_notes": "Zero final payments for the item or service in the 15 months prior to posting the file." }, { "payer_name": "BLUE SHIELD OUT OF STATE", "plan_name": "STANFORD HEALTHCARE ALLIANCE PLAN", "methodology": "percent of total billed charges", "standard_charge_dollar": 850.33, "standard_charge_percentage": 48.59, "median_amount": 529.76, "10th_percentile": 311.39, "90th_percentile": 565.26, "count": "1 through 10" }, { "payer_name": "BLUE SHIELD", "plan_name": "STANFORD HEALTHCARE ALLIANCE PLAN", "methodology": "percent of total billed charges", "standard_charge_dollar": 850.33, "standard_charge_percentage": 48.59, "count": "0", "additional_payer_notes": "Zero final payments for the item or service in the 15 months prior to posting the file." }, { "payer_name": "BLUE SHIELD", "plan_name": "STANFORD HEALTHCARE ALLIANCE PLAN", "methodology": "percent of total billed charges", "standard_charge_dollar": 850.33, "standard_charge_percentage": 48.59, "median_amount": 1073.84, "10th_percentile": 529.76, "90th_percentile": 1073.84, "count": "1 through 10" }, { "payer_name": "BLUE SHIELD", "plan_name": "STANFORD HEALTHCARE ALLIANCE PLAN", "methodology": "percent of total billed charges", "standard_charge_dollar": 850.33, "standard_charge_percentage": 48.59, "count": "0", "additional_payer_notes": "Zero final payments for the item or service in the 15 months prior to posting the file." }, { "payer_name": "CIGNA", "plan_name": "CIGNA COM ALT HMO PLAN", "methodology": "percent of total billed charges", "standard_charge_dollar": 738.5, "standard_charge_percentage": 42.2, "count": "0", "additional_payer_notes": "Zero final payments for the item or service in the 15 months prior to posting the file." }, { "payer_name": "CIGNA", "plan_name": "CIGNA COM ALT HMO PLAN", "methodology": "percent of total billed charges", "standard_charge_dollar": 738.5, "standard_charge_percentage": 42.2, "count": "0", "additional_payer_notes": "Zero final payments for the item or service in the 15 months prior to posting the file." }, { "payer_name": "HEALTH NET", "plan_name": "HEALTHNET HMO, PPO, POS, EPO, CANOPY HEALTHNET HMO, OTHER-IN-NETWORK PLANS", "methodology": "per diem", "standard_charge_dollar": 8000.0, "standard_charge_algorithm": "Expected reimbursement is the lesser of Per diem ($8,000) for the length of stay and 70% of billed.", "count": "0", "additional_payer_notes": "Zero final payments for the item or service in the 15 months prior to posting the file." }, { "payer_name": "HEALTH NET", "plan_name": "HEALTHNET HMO, PPO, POS, EPO, CANOPY HEALTHNET HMO, OTHER-IN-NETWORK PLANS", "methodology": "per diem", "standard_charge_dollar": 8000.0, "standard_charge_algorithm": "Expected reimbursement is the lesser of Per diem ($8,000) for the length of stay and 70% of billed.", "count": "0", "additional_payer_notes": "Zero final payments for the item or service in the 15 months prior to posting the file." }, { "payer_name": "UNITED HEALTHCARE", "plan_name": "SUTTER SELECT & SUTTER HEALTH PLAN HMO PLANS", "methodology": "per diem", "standard_charge_dollar": 28538.0, "standard_charge_algorithm": "Per diem ($28,538).", "count": "0", "additional_payer_notes": "Zero final payments for the item or service in the 15 months prior to posting the file." }, { "payer_name": "UNITED HEALTHCARE", "plan_name": "SUTTER SELECT & SUTTER HEALTH PLAN HMO PLANS", "methodology": "per diem", "standard_charge_dollar": 28538.0, "standard_charge_algorithm": "Per diem ($28,538).", "count": "0", "additional_payer_notes": "Zero final payments for the item or service in the 15 months prior to posting the file." }, { "payer_name": "SUTTER", "plan_name": "SUTTER SELECT & SUTTER HEALTH PLAN HMO PLANS", "methodology": "per diem", "standard_charge_dollar": 28538.0, "standard_charge_algorithm": "Per diem ($28,538).", "median_amount": 447.36, "10th_percentile": 447.36, "90th_percentile": 447.36, "count": "1 through 10" }, { "payer_name": "UNITED HEALTHCARE", "plan_name": "SUTTER SELECT & SUTTER HEALTH PLAN HMO PLANS", "methodology": "per diem", "standard_charge_dollar": 28538.0, "standard_charge_algorithm": "Per diem ($28,538).", "count": "0", "additional_payer_notes": "Zero final payments for the item or service in the 15 months prior to posting the file." }, { "payer_name": "UMR", "plan_name": "SUTTER SELECT & SUTTER HEALTH PLAN HMO PLANS", "methodology": "per diem", "standard_charge_dollar": 28538.0, "standard_charge_algorithm": "Per diem ($28,538).", "median_amount": 329.07, "10th_percentile": 329.07, "90th_percentile": 329.07, "count": "1 through 10" }, { "payer_name": "UNITED HEALTHCARE", "plan_name": "SUTTER SELECT & SUTTER HEALTH PLAN HMO PLANS", "methodology": "per diem", "standard_charge_dollar": 28538.0, "standard_charge_algorithm": "Per diem ($28,538).", "count": "0", "additional_payer_notes": "Zero final payments for the item or service in the 15 months prior to posting the file." } ] } ] }, { "description": "HC Sheath Gp019", "code_information": [ { "code": "PX-2120206019", "type": "CDM" }, { "code": "C1894", "type": "HCPCS" }, { "code": "0272", "type": "RC" } ], "standard_charges": [ { "setting": "outpatient", "gross_charge": 2125.0, "discounted_cash": 1062.5, "minimum": 896.75, "maximum": 1105.0, "additional_generic_notes": "Zero final payments for the item or service in the 15 months prior to posting the file.", "payers_information": [ { "payer_name": "AETNA", "plan_name": "AETNA ALL OTHER PLANS", "methodology": "percent of total billed charges", "standard_charge_dollar": 1105.0, "standard_charge_percentage": 52.0, "count": "0", "additional_payer_notes": "Zero final payments for the item or service in the 15 months prior to posting the file." }, { "payer_name": "AETNA", "plan_name": "AETNA ALL OTHER PLANS", "methodology": "percent of total billed charges", "standard_charge_dollar": 1105.0, "standard_charge_percentage": 52.0, "count": "0", "additional_payer_notes": "Zero final payments for the item or service in the 15 months prior to posting the file." }, { "payer_name": "MERITAIN HEALTH", "plan_name": "AETNA ALL OTHER PLANS", "methodology": "percent of total billed charges", "standard_charge_dollar": 1105.0, "standard_charge_percentage": 52.0, "median_amount": 293.0, "10th_percentile": 187.29, "90th_percentile": 293.0, "count": "1 through 10" }, { "payer_name": "BLUE SHIELD", "plan_name": "STANFORD HEALTHCARE ALLIANCE PLAN", "methodology": "percent of total billed charges", "standard_charge_dollar": 1032.54, "standard_charge_percentage": 48.59, "count": "0", "additional_payer_notes": "Zero final payments for the item or service in the 15 months prior to posting the file." }, { "payer_name": "CIGNA", "plan_name": "CIGNA COM ALT HMO PLAN", "methodology": "percent of total billed charges", "standard_charge_dollar": 896.75, "standard_charge_percentage": 42.2, "count": "0", "additional_payer_notes": "Zero final payments for the item or service in the 15 months prior to posting the file." }, { "payer_name": "CIGNA", "plan_name": "CIGNA COM ALT HMO PLAN", "methodology": "percent of total billed charges", "standard_charge_dollar": 896.75, "standard_charge_percentage": 42.2, "count": "0", "additional_payer_notes": "Zero final payments for the item or service in the 15 months prior to posting the file." }, { "payer_name": "HEALTH NET", "plan_name": "HEALTHNET HMO, PPO, POS, EPO, CANOPY HEALTHNET HMO, OTHER-IN-NETWORK PLANS", "methodology": "per diem", "standard_charge_dollar": 8000.0, "standard_charge_algorithm": "Expected reimbursement is the lesser of Per diem ($8,000) for the length of stay and 70% of billed.", "count": "0", "additional_payer_notes": "Zero final payments for the item or service in the 15 months prior to posting the file." }, { "payer_name": "HEALTH NET", "plan_name": "HEALTHNET HMO, PPO, POS, EPO, CANOPY HEALTHNET HMO, OTHER-IN-NETWORK PLANS", "methodology": "per diem", "standard_charge_dollar": 8000.0, "standard_charge_algorithm": "Expected reimbursement is the lesser of Per diem ($8,000) for the length of stay and 70% of billed.", "count": "0", "additional_payer_notes": "Zero final payments for the item or service in the 15 months prior to posting the file." }, { "payer_name": "UNITED HEALTHCARE", "plan_name": "SUTTER SELECT & SUTTER HEALTH PLAN HMO PLANS", "methodology": "per diem", "standard_charge_dollar": 28538.0, "standard_charge_algorithm": "Per diem ($28,538).", "count": "0", "additional_payer_notes": "Zero final payments for the item or service in the 15 months prior to posting the file." }, { "payer_name": "UNITED HEALTHCARE", "plan_name": "SUTTER SELECT & SUTTER HEALTH PLAN HMO PLANS", "methodology": "per diem", "standard_charge_dollar": 28538.0, "standard_charge_algorithm": "Per diem ($28,538).", "count": "0", "additional_payer_notes": "Zero final payments for the item or service in the 15 months prior to posting the file." }, { "payer_name": "UNITED HEALTHCARE", "plan_name": "SUTTER SELECT & SUTTER HEALTH PLAN HMO PLANS", "methodology": "per diem", "standard_charge_dollar": 28538.0, "standard_charge_algorithm": "Per diem ($28,538).", "count": "0", "additional_payer_notes": "Zero final payments for the item or service in the 15 months prior to posting the file." }, { "payer_name": "UMR", "plan_name": "SUTTER SELECT & SUTTER HEALTH PLAN HMO PLANS", "methodology": "per diem", "standard_charge_dollar": 28538.0, "standard_charge_algorithm": "Per diem ($28,538).", "median_amount": 259.04, "10th_percentile": 213.12, "90th_percentile": 259.04, "count": "1 through 10" }, { "payer_name": "UNITED HEALTHCARE", "plan_name": "SUTTER SELECT & SUTTER HEALTH PLAN HMO PLANS", "methodology": "per diem", "standard_charge_dollar": 28538.0, "standard_charge_algorithm": "Per diem ($28,538).", "median_amount": 257.61, "10th_percentile": 107.25, "90th_percentile": 257.61, "count": "1 through 10" } ] } ] }, { "description": "HC Introducer Gp020", "code_information": [ { "code": "PX-2120206020", "type": "CDM" }, { "code": "C1894", "type": "HCPCS" }, { "code": "0272", "type": "RC" } ], "standard_charges": [ { "setting": "outpatient", "gross_charge": 2550.0, "discounted_cash": 1275.0, "minimum": 1076.1, "maximum": 1326.0, "additional_generic_notes": "Zero final payments for the item or service in the 15 months prior to posting the file.", "payers_information": [ { "payer_name": "AETNA", "plan_name": "AETNA ALL OTHER PLANS", "methodology": "percent of total billed charges", "standard_charge_dollar": 1326.0, "standard_charge_percentage": 52.0, "count": "0", "additional_payer_notes": "Zero final payments for the item or service in the 15 months prior to posting the file." }, { "payer_name": "AETNA", "plan_name": "AETNA ALL OTHER PLANS", "methodology": "percent of total billed charges", "standard_charge_dollar": 1326.0, "standard_charge_percentage": 52.0, "count": "0", "additional_payer_notes": "Zero final payments for the item or service in the 15 months prior to posting the file." }, { "payer_name": "MERITAIN HEALTH", "plan_name": "AETNA ALL OTHER PLANS", "methodology": "percent of total billed charges", "standard_charge_dollar": 1326.0, "standard_charge_percentage": 52.0, "median_amount": 293.0, "10th_percentile": 187.29, "90th_percentile": 293.0, "count": "1 through 10" }, { "payer_name": "BLUE SHIELD OUT OF STATE", "plan_name": "STANFORD HEALTHCARE ALLIANCE PLAN", "methodology": "percent of total billed charges", "standard_charge_dollar": 1239.05, "standard_charge_percentage": 48.59, "median_amount": 427.76, "10th_percentile": 147.88, "90th_percentile": 2533.39, "count": "105" }, { "payer_name": "BLUE SHIELD", "plan_name": "STANFORD HEALTHCARE ALLIANCE PLAN", "methodology": "percent of total billed charges", "standard_charge_dollar": 1239.05, "standard_charge_percentage": 48.59, "count": "0", "additional_payer_notes": "Zero final payments for the item or service in the 15 months prior to posting the file." }, { "payer_name": "CIGNA", "plan_name": "CIGNA COM ALT HMO PLAN", "methodology": "percent of total billed charges", "standard_charge_dollar": 1076.1, "standard_charge_percentage": 42.2, "count": "0", "additional_payer_notes": "Zero final payments for the item or service in the 15 months prior to posting the file." }, { "payer_name": "CIGNA", "plan_name": "CIGNA COM ALT HMO PLAN", "methodology": "percent of total billed charges", "standard_charge_dollar": 1076.1, "standard_charge_percentage": 42.2, "count": "0", "additional_payer_notes": "Zero final payments for the item or service in the 15 months prior to posting the file." }, { "payer_name": "HEALTH NET", "plan_name": "HEALTHNET HMO, PPO, POS, EPO, CANOPY HEALTHNET HMO, OTHER-IN-NETWORK PLANS", "methodology": "per diem", "standard_charge_dollar": 8000.0, "standard_charge_algorithm": "Expected reimbursement is the lesser of Per diem ($8,000) for the length of stay and 70% of billed.", "count": "0", "additional_payer_notes": "Zero final payments for the item or service in the 15 months prior to posting the file." }, { "payer_name": "HEALTH NET", "plan_name": "HEALTHNET HMO, PPO, POS, EPO, CANOPY HEALTHNET HMO, OTHER-IN-NETWORK PLANS", "methodology": "per diem", "standard_charge_dollar": 8000.0, "standard_charge_algorithm": "Expected reimbursement is the lesser of Per diem ($8,000) for the length of stay and 70% of billed.", "count": "0", "additional_payer_notes": "Zero final payments for the item or service in the 15 months prior to posting the file." }, { "payer_name": "UNITED HEALTHCARE", "plan_name": "SUTTER SELECT & SUTTER HEALTH PLAN HMO PLANS", "methodology": "per diem", "standard_charge_dollar": 28538.0, "standard_charge_algorithm": "Per diem ($28,538).", "count": "0", "additional_payer_notes": "Zero final payments for the item or service in the 15 months prior to posting the file." }, { "payer_name": "UNITED HEALTHCARE", "plan_name": "SUTTER SELECT & SUTTER HEALTH PLAN HMO PLANS", "methodology": "per diem", "standard_charge_dollar": 28538.0, "standard_charge_algorithm": "Per diem ($28,538).", "count": "0", "additional_payer_notes": "Zero final payments for the item or service in the 15 months prior to posting the file." }, { "payer_name": "UNITED HEALTHCARE", "plan_name": "SUTTER SELECT & SUTTER HEALTH PLAN HMO PLANS", "methodology": "per diem", "standard_charge_dollar": 28538.0, "standard_charge_algorithm": "Per diem ($28,538).", "count": "0", "additional_payer_notes": "Zero final payments for the item or service in the 15 months prior to posting the file." }, { "payer_name": "UMR", "plan_name": "SUTTER SELECT & SUTTER HEALTH PLAN HMO PLANS", "methodology": "per diem", "standard_charge_dollar": 28538.0, "standard_charge_algorithm": "Per diem ($28,538).", "median_amount": 259.04, "10th_percentile": 213.12, "90th_percentile": 259.04, "count": "1 through 10" }, { "payer_name": "UNITED HEALTHCARE", "plan_name": "SUTTER SELECT & SUTTER HEALTH PLAN HMO PLANS", "methodology": "per diem", "standard_charge_dollar": 28538.0, "standard_charge_algorithm": "Per diem ($28,538).", "median_amount": 257.61, "10th_percentile": 107.25, "90th_percentile": 257.61, "count": "1 through 10" } ] } ] }, { "description": "HC Introducer Gp0210", "code_information": [ { "code": "PX-2120206021", "type": "CDM" }, { "code": "C1894", "type": "HCPCS" }, { "code": "0272", "type": "RC" } ], "standard_charges": [ { "setting": "outpatient", "gross_charge": 2888.0, "discounted_cash": 1444.0, "minimum": 1218.74, "maximum": 1501.76, "additional_generic_notes": "Zero final payments for the item or service in the 15 months prior to posting the file.", "payers_information": [ { "payer_name": "AETNA", "plan_name": "AETNA ALL OTHER PLANS", "methodology": "percent of total billed charges", "standard_charge_dollar": 1501.76, "standard_charge_percentage": 52.0, "count": "0", "additional_payer_notes": "Zero final payments for the item or service in the 15 months prior to posting the file." }, { "payer_name": "AETNA", "plan_name": "AETNA ALL OTHER PLANS", "methodology": "percent of total billed charges", "standard_charge_dollar": 1501.76, "standard_charge_percentage": 52.0, "count": "0", "additional_payer_notes": "Zero final payments for the item or service in the 15 months prior to posting the file." }, { "payer_name": "MERITAIN HEALTH", "plan_name": "AETNA ALL OTHER PLANS", "methodology": "percent of total billed charges", "standard_charge_dollar": 1501.76, "standard_charge_percentage": 52.0, "median_amount": 293.0, "10th_percentile": 187.29, "90th_percentile": 293.0, "count": "1 through 10" }, { "payer_name": "BLUE SHIELD OUT OF STATE", "plan_name": "STANFORD HEALTHCARE ALLIANCE PLAN", "methodology": "percent of total billed charges", "standard_charge_dollar": 1403.28, "standard_charge_percentage": 48.59, "median_amount": 427.76, "10th_percentile": 147.88, "90th_percentile": 2533.39, "count": "105" }, { "payer_name": "BLUE SHIELD", "plan_name": "STANFORD HEALTHCARE ALLIANCE PLAN", "methodology": "percent of total billed charges", "standard_charge_dollar": 1403.28, "standard_charge_percentage": 48.59, "count": "0", "additional_payer_notes": "Zero final payments for the item or service in the 15 months prior to posting the file." }, { "payer_name": "CIGNA", "plan_name": "CIGNA COM ALT HMO PLAN", "methodology": "percent of total billed charges", "standard_charge_dollar": 1218.74, "standard_charge_percentage": 42.2, "count": "0", "additional_payer_notes": "Zero final payments for the item or service in the 15 months prior to posting the file." }, { "payer_name": "CIGNA", "plan_name": "CIGNA COM ALT HMO PLAN", "methodology": "percent of total billed charges", "standard_charge_dollar": 1218.74, "standard_charge_percentage": 42.2, "count": "0", "additional_payer_notes": "Zero final payments for the item or service in the 15 months prior to posting the file." }, { "payer_name": "HEALTH NET", "plan_name": "HEALTHNET HMO, PPO, POS, EPO, CANOPY HEALTHNET HMO, OTHER-IN-NETWORK PLANS", "methodology": "per diem", "standard_charge_dollar": 8000.0, "standard_charge_algorithm": "Expected reimbursement is the lesser of Per diem ($8,000) for the length of stay and 70% of billed.", "count": "0", "additional_payer_notes": "Zero final payments for the item or service in the 15 months prior to posting the file." }, { "payer_name": "HEALTH NET", "plan_name": "HEALTHNET HMO, PPO, POS, EPO, CANOPY HEALTHNET HMO, OTHER-IN-NETWORK PLANS", "methodology": "per diem", "standard_charge_dollar": 8000.0, "standard_charge_algorithm": "Expected reimbursement is the lesser of Per diem ($8,000) for the length of stay and 70% of billed.", "count": "0", "additional_payer_notes": "Zero final payments for the item or service in the 15 months prior to posting the file." }, { "payer_name": "UNITED HEALTHCARE", "plan_name": "SUTTER SELECT & SUTTER HEALTH PLAN HMO PLANS", "methodology": "per diem", "standard_charge_dollar": 28538.0, "standard_charge_algorithm": "Per diem ($28,538).", "count": "0", "additional_payer_notes": "Zero final payments for the item or service in the 15 months prior to posting the file." }, { "payer_name": "UNITED HEALTHCARE", "plan_name": "SUTTER SELECT & SUTTER HEALTH PLAN HMO PLANS", "methodology": "per diem", "standard_charge_dollar": 28538.0, "standard_charge_algorithm": "Per diem ($28,538).", "count": "0", "additional_payer_notes": "Zero final payments for the item or service in the 15 months prior to posting the file." }, { "payer_name": "UNITED HEALTHCARE", "plan_name": "SUTTER SELECT & SUTTER HEALTH PLAN HMO PLANS", "methodology": "per diem", "standard_charge_dollar": 28538.0, "standard_charge_algorithm": "Per diem ($28,538).", "count": "0", "additional_payer_notes": "Zero final payments for the item or service in the 15 months prior to posting the file." }, { "payer_name": "UMR", "plan_name": "SUTTER SELECT & SUTTER HEALTH PLAN HMO PLANS", "methodology": "per diem", "standard_charge_dollar": 28538.0, "standard_charge_algorithm": "Per diem ($28,538).", "median_amount": 259.04, "10th_percentile": 213.12, "90th_percentile": 259.04, "count": "1 through 10" }, { "payer_name": "UNITED HEALTHCARE", "plan_name": "SUTTER SELECT & SUTTER HEALTH PLAN HMO PLANS", "methodology": "per diem", "standard_charge_dollar": 28538.0, "standard_charge_algorithm": "Per diem ($28,538).", "median_amount": 257.61, "10th_percentile": 107.25, "90th_percentile": 257.61, "count": "1 through 10" } ] } ] }, { "description": "Hc Introducer Gp022", "code_information": [ { "code": "PX-2120206022", "type": "CDM" }, { "code": "C1894", "type": "HCPCS" }, { "code": "0272", "type": "RC" } ], "standard_charges": [ { "setting": "outpatient", "gross_charge": 3300.0, "discounted_cash": 1650.0, "minimum": 1392.6, "maximum": 1716.0, "additional_generic_notes": "Zero final payments for the item or service in the 15 months prior to posting the file.", "payers_information": [ { "payer_name": "AETNA", "plan_name": "AETNA ALL OTHER PLANS", "methodology": "percent of total billed charges", "standard_charge_dollar": 1716.0, "standard_charge_percentage": 52.0, "count": "0", "additional_payer_notes": "Zero final payments for the item or service in the 15 months prior to posting the file." }, { "payer_name": "AETNA", "plan_name": "AETNA ALL OTHER PLANS", "methodology": "percent of total billed charges", "standard_charge_dollar": 1716.0, "standard_charge_percentage": 52.0, "count": "0", "additional_payer_notes": "Zero final payments for the item or service in the 15 months prior to posting the file." }, { "payer_name": "MERITAIN HEALTH", "plan_name": "AETNA ALL OTHER PLANS", "methodology": "percent of total billed charges", "standard_charge_dollar": 1716.0, "standard_charge_percentage": 52.0, "median_amount": 293.0, "10th_percentile": 187.29, "90th_percentile": 293.0, "count": "1 through 10" }, { "payer_name": "BLUE SHIELD OUT OF STATE", "plan_name": "STANFORD HEALTHCARE ALLIANCE PLAN", "methodology": "percent of total billed charges", "standard_charge_dollar": 1603.47, "standard_charge_percentage": 48.59, "median_amount": 427.76, "10th_percentile": 147.88, "90th_percentile": 2533.39, "count": "105" }, { "payer_name": "BLUE SHIELD", "plan_name": "STANFORD HEALTHCARE ALLIANCE PLAN", "methodology": "percent of total billed charges", "standard_charge_dollar": 1603.47, "standard_charge_percentage": 48.59, "count": "0", "additional_payer_notes": "Zero final payments for the item or service in the 15 months prior to posting the file." }, { "payer_name": "CIGNA", "plan_name": "CIGNA COM ALT HMO PLAN", "methodology": "percent of total billed charges", "standard_charge_dollar": 1392.6, "standard_charge_percentage": 42.2, "count": "0", "additional_payer_notes": "Zero final payments for the item or service in the 15 months prior to posting the file." }, { "payer_name": "CIGNA", "plan_name": "CIGNA COM ALT HMO PLAN", "methodology": "percent of total billed charges", "standard_charge_dollar": 1392.6, "standard_charge_percentage": 42.2, "count": "0", "additional_payer_notes": "Zero final payments for the item or service in the 15 months prior to posting the file." }, { "payer_name": "HEALTH NET", "plan_name": "HEALTHNET HMO, PPO, POS, EPO, CANOPY HEALTHNET HMO, OTHER-IN-NETWORK PLANS", "methodology": "per diem", "standard_charge_dollar": 8000.0, "standard_charge_algorithm": "Expected reimbursement is the lesser of Per diem ($8,000) for the length of stay and 70% of billed.", "count": "0", "additional_payer_notes": "Zero final payments for the item or service in the 15 months prior to posting the file." }, { "payer_name": "HEALTH NET", "plan_name": "HEALTHNET HMO, PPO, POS, EPO, CANOPY HEALTHNET HMO, OTHER-IN-NETWORK PLANS", "methodology": "per diem", "standard_charge_dollar": 8000.0, "standard_charge_algorithm": "Expected reimbursement is the lesser of Per diem ($8,000) for the length of stay and 70% of billed.", "count": "0", "additional_payer_notes": "Zero final payments for the item or service in the 15 months prior to posting the file." }, { "payer_name": "UNITED HEALTHCARE", "plan_name": "SUTTER SELECT & SUTTER HEALTH PLAN HMO PLANS", "methodology": "per diem", "standard_charge_dollar": 28538.0, "standard_charge_algorithm": "Per diem ($28,538).", "count": "0", "additional_payer_notes": "Zero final payments for the item or service in the 15 months prior to posting the file." }, { "payer_name": "UNITED HEALTHCARE", "plan_name": "SUTTER SELECT & SUTTER HEALTH PLAN HMO PLANS", "methodology": "per diem", "standard_charge_dollar": 28538.0, "standard_charge_algorithm": "Per diem ($28,538).", "count": "0", "additional_payer_notes": "Zero final payments for the item or service in the 15 months prior to posting the file." }, { "payer_name": "SUTTER", "plan_name": "SUTTER SELECT & SUTTER HEALTH PLAN HMO PLANS", "methodology": "per diem", "standard_charge_dollar": 28538.0, "standard_charge_algorithm": "Per diem ($28,538).", "median_amount": 592.22, "10th_percentile": 192.7, "90th_percentile": 3120.24, "count": "13" }, { "payer_name": "UNITED HEALTHCARE", "plan_name": "SUTTER SELECT & SUTTER HEALTH PLAN HMO PLANS", "methodology": "per diem", "standard_charge_dollar": 28538.0, "standard_charge_algorithm": "Per diem ($28,538).", "count": "0", "additional_payer_notes": "Zero final payments for the item or service in the 15 months prior to posting the file." }, { "payer_name": "UMR", "plan_name": "SUTTER SELECT & SUTTER HEALTH PLAN HMO PLANS", "methodology": "per diem", "standard_charge_dollar": 28538.0, "standard_charge_algorithm": "Per diem ($28,538).", "median_amount": 259.04, "10th_percentile": 213.12, "90th_percentile": 259.04, "count": "1 through 10" }, { "payer_name": "UNITED HEALTHCARE", "plan_name": "SUTTER SELECT & SUTTER HEALTH PLAN HMO PLANS", "methodology": "per diem", "standard_charge_dollar": 28538.0, "standard_charge_algorithm": "Per diem ($28,538).", "median_amount": 257.61, "10th_percentile": 107.25, "90th_percentile": 257.61, "count": "1 through 10" } ] } ] }, { "description": "HC Introducer Gp023", "code_information": [ { "code": "PX-2120206023", "type": "CDM" }, { "code": "C1894", "type": "HCPCS" }, { "code": "0272", "type": "RC" } ], "standard_charges": [ { "setting": "outpatient", "gross_charge": 3600.0, "discounted_cash": 1800.0, "minimum": 1519.2, "maximum": 1872.0, "additional_generic_notes": "Zero final payments for the item or service in the 15 months prior to posting the file.", "payers_information": [ { "payer_name": "AETNA", "plan_name": "AETNA ALL OTHER PLANS", "methodology": "percent of total billed charges", "standard_charge_dollar": 1872.0, "standard_charge_percentage": 52.0, "count": "0", "additional_payer_notes": "Zero final payments for the item or service in the 15 months prior to posting the file." }, { "payer_name": "AETNA", "plan_name": "AETNA ALL OTHER PLANS", "methodology": "percent of total billed charges", "standard_charge_dollar": 1872.0, "standard_charge_percentage": 52.0, "count": "0", "additional_payer_notes": "Zero final payments for the item or service in the 15 months prior to posting the file." }, { "payer_name": "MERITAIN HEALTH", "plan_name": "AETNA ALL OTHER PLANS", "methodology": "percent of total billed charges", "standard_charge_dollar": 1872.0, "standard_charge_percentage": 52.0, "median_amount": 293.0, "10th_percentile": 187.29, "90th_percentile": 293.0, "count": "1 through 10" }, { "payer_name": "BLUE SHIELD OUT OF STATE", "plan_name": "STANFORD HEALTHCARE ALLIANCE PLAN", "methodology": "percent of total billed charges", "standard_charge_dollar": 1749.24, "standard_charge_percentage": 48.59, "median_amount": 427.76, "10th_percentile": 147.88, "90th_percentile": 2533.39, "count": "105" }, { "payer_name": "BLUE SHIELD", "plan_name": "STANFORD HEALTHCARE ALLIANCE PLAN", "methodology": "percent of total billed charges", "standard_charge_dollar": 1749.24, "standard_charge_percentage": 48.59, "count": "0", "additional_payer_notes": "Zero final payments for the item or service in the 15 months prior to posting the file." }, { "payer_name": "CIGNA", "plan_name": "CIGNA COM ALT HMO PLAN", "methodology": "percent of total billed charges", "standard_charge_dollar": 1519.2, "standard_charge_percentage": 42.2, "count": "0", "additional_payer_notes": "Zero final payments for the item or service in the 15 months prior to posting the file." }, { "payer_name": "CIGNA", "plan_name": "CIGNA COM ALT HMO PLAN", "methodology": "percent of total billed charges", "standard_charge_dollar": 1519.2, "standard_charge_percentage": 42.2, "count": "0", "additional_payer_notes": "Zero final payments for the item or service in the 15 months prior to posting the file." }, { "payer_name": "HEALTH NET", "plan_name": "HEALTHNET HMO, PPO, POS, EPO, CANOPY HEALTHNET HMO, OTHER-IN-NETWORK PLANS", "methodology": "per diem", "standard_charge_dollar": 8000.0, "standard_charge_algorithm": "Expected reimbursement is the lesser of Per diem ($8,000) for the length of stay and 70% of billed.", "count": "0", "additional_payer_notes": "Zero final payments for the item or service in the 15 months prior to posting the file." }, { "payer_name": "HEALTH NET", "plan_name": "HEALTHNET HMO, PPO, POS, EPO, CANOPY HEALTHNET HMO, OTHER-IN-NETWORK PLANS", "methodology": "per diem", "standard_charge_dollar": 8000.0, "standard_charge_algorithm": "Expected reimbursement is the lesser of Per diem ($8,000) for the length of stay and 70% of billed.", "count": "0", "additional_payer_notes": "Zero final payments for the item or service in the 15 months prior to posting the file." }, { "payer_name": "UNITED HEALTHCARE", "plan_name": "SUTTER SELECT & SUTTER HEALTH PLAN HMO PLANS", "methodology": "per diem", "standard_charge_dollar": 28538.0, "standard_charge_algorithm": "Per diem ($28,538).", "count": "0", "additional_payer_notes": "Zero final payments for the item or service in the 15 months prior to posting the file." }, { "payer_name": "UNITED HEALTHCARE", "plan_name": "SUTTER SELECT & SUTTER HEALTH PLAN HMO PLANS", "methodology": "per diem", "standard_charge_dollar": 28538.0, "standard_charge_algorithm": "Per diem ($28,538).", "count": "0", "additional_payer_notes": "Zero final payments for the item or service in the 15 months prior to posting the file." }, { "payer_name": "SUTTER", "plan_name": "SUTTER SELECT & SUTTER HEALTH PLAN HMO PLANS", "methodology": "per diem", "standard_charge_dollar": 28538.0, "standard_charge_algorithm": "Per diem ($28,538).", "median_amount": 592.22, "10th_percentile": 192.7, "90th_percentile": 3120.24, "count": "13" }, { "payer_name": "UNITED HEALTHCARE", "plan_name": "SUTTER SELECT & SUTTER HEALTH PLAN HMO PLANS", "methodology": "per diem", "standard_charge_dollar": 28538.0, "standard_charge_algorithm": "Per diem ($28,538).", "count": "0", "additional_payer_notes": "Zero final payments for the item or service in the 15 months prior to posting the file." }, { "payer_name": "UMR", "plan_name": "SUTTER SELECT & SUTTER HEALTH PLAN HMO PLANS", "methodology": "per diem", "standard_charge_dollar": 28538.0, "standard_charge_algorithm": "Per diem ($28,538).", "median_amount": 259.04, "10th_percentile": 213.12, "90th_percentile": 259.04, "count": "1 through 10" }, { "payer_name": "UNITED HEALTHCARE", "plan_name": "SUTTER SELECT & SUTTER HEALTH PLAN HMO PLANS", "methodology": "per diem", "standard_charge_dollar": 28538.0, "standard_charge_algorithm": "Per diem ($28,538).", "median_amount": 257.61, "10th_percentile": 107.25, "90th_percentile": 257.61, "count": "1 through 10" } ] } ] }, { "description": "HC Introducer Gp025", "code_information": [ { "code": "PX-2120206025", "type": "CDM" }, { "code": "C1894", "type": "HCPCS" }, { "code": "0272", "type": "RC" } ], "standard_charges": [ { "setting": "outpatient", "gross_charge": 4263.0, "discounted_cash": 2131.5, "minimum": 1798.99, "maximum": 2216.76, "additional_generic_notes": "Zero final payments for the item or service in the 15 months prior to posting the file.", "payers_information": [ { "payer_name": "AETNA", "plan_name": "AETNA ALL OTHER PLANS", "methodology": "percent of total billed charges", "standard_charge_dollar": 2216.76, "standard_charge_percentage": 52.0, "count": "0", "additional_payer_notes": "Zero final payments for the item or service in the 15 months prior to posting the file." }, { "payer_name": "AETNA", "plan_name": "AETNA ALL OTHER PLANS", "methodology": "percent of total billed charges", "standard_charge_dollar": 2216.76, "standard_charge_percentage": 52.0, "count": "0", "additional_payer_notes": "Zero final payments for the item or service in the 15 months prior to posting the file." }, { "payer_name": "MERITAIN HEALTH", "plan_name": "AETNA ALL OTHER PLANS", "methodology": "percent of total billed charges", "standard_charge_dollar": 2216.76, "standard_charge_percentage": 52.0, "median_amount": 293.0, "10th_percentile": 187.29, "90th_percentile": 293.0, "count": "1 through 10" }, { "payer_name": "BLUE SHIELD OUT OF STATE", "plan_name": "STANFORD HEALTHCARE ALLIANCE PLAN", "methodology": "percent of total billed charges", "standard_charge_dollar": 2071.39, "standard_charge_percentage": 48.59, "median_amount": 427.76, "10th_percentile": 147.88, "90th_percentile": 2533.39, "count": "105" }, { "payer_name": "BLUE SHIELD", "plan_name": "STANFORD HEALTHCARE ALLIANCE PLAN", "methodology": "percent of total billed charges", "standard_charge_dollar": 2071.39, "standard_charge_percentage": 48.59, "median_amount": 685.9, "10th_percentile": 191.79, "90th_percentile": 3993.56, "count": "71" }, { "payer_name": "BLUE SHIELD", "plan_name": "STANFORD HEALTHCARE ALLIANCE PLAN", "methodology": "percent of total billed charges", "standard_charge_dollar": 2071.39, "standard_charge_percentage": 48.59, "median_amount": 373.48, "10th_percentile": 147.88, "90th_percentile": 3886.2, "count": "21" }, { "payer_name": "BLUE SHIELD", "plan_name": "STANFORD HEALTHCARE ALLIANCE PLAN", "methodology": "percent of total billed charges", "standard_charge_dollar": 2071.39, "standard_charge_percentage": 48.59, "count": "0", "additional_payer_notes": "Zero final payments for the item or service in the 15 months prior to posting the file." }, { "payer_name": "CIGNA", "plan_name": "CIGNA COM ALT HMO PLAN", "methodology": "percent of total billed charges", "standard_charge_dollar": 1798.99, "standard_charge_percentage": 42.2, "count": "0", "additional_payer_notes": "Zero final payments for the item or service in the 15 months prior to posting the file." }, { "payer_name": "CIGNA", "plan_name": "CIGNA COM ALT HMO PLAN", "methodology": "percent of total billed charges", "standard_charge_dollar": 1798.99, "standard_charge_percentage": 42.2, "count": "0", "additional_payer_notes": "Zero final payments for the item or service in the 15 months prior to posting the file." }, { "payer_name": "HEALTH NET", "plan_name": "HEALTHNET HMO, PPO, POS, EPO, CANOPY HEALTHNET HMO, OTHER-IN-NETWORK PLANS", "methodology": "per diem", "standard_charge_dollar": 8000.0, "standard_charge_algorithm": "Expected reimbursement is the lesser of Per diem ($8,000) for the length of stay and 70% of billed.", "count": "0", "additional_payer_notes": "Zero final payments for the item or service in the 15 months prior to posting the file." }, { "payer_name": "HEALTH NET", "plan_name": "HEALTHNET HMO, PPO, POS, EPO, CANOPY HEALTHNET HMO, OTHER-IN-NETWORK PLANS", "methodology": "per diem", "standard_charge_dollar": 8000.0, "standard_charge_algorithm": "Expected reimbursement is the lesser of Per diem ($8,000) for the length of stay and 70% of billed.", "count": "0", "additional_payer_notes": "Zero final payments for the item or service in the 15 months prior to posting the file." }, { "payer_name": "UNITED HEALTHCARE", "plan_name": "SUTTER SELECT & SUTTER HEALTH PLAN HMO PLANS", "methodology": "per diem", "standard_charge_dollar": 28538.0, "standard_charge_algorithm": "Per diem ($28,538).", "count": "0", "additional_payer_notes": "Zero final payments for the item or service in the 15 months prior to posting the file." }, { "payer_name": "UNITED HEALTHCARE", "plan_name": "SUTTER SELECT & SUTTER HEALTH PLAN HMO PLANS", "methodology": "per diem", "standard_charge_dollar": 28538.0, "standard_charge_algorithm": "Per diem ($28,538).", "count": "0", "additional_payer_notes": "Zero final payments for the item or service in the 15 months prior to posting the file." }, { "payer_name": "SUTTER", "plan_name": "SUTTER SELECT & SUTTER HEALTH PLAN HMO PLANS", "methodology": "per diem", "standard_charge_dollar": 28538.0, "standard_charge_algorithm": "Per diem ($28,538).", "median_amount": 592.22, "10th_percentile": 192.7, "90th_percentile": 3120.24, "count": "13" }, { "payer_name": "UNITED HEALTHCARE", "plan_name": "SUTTER SELECT & SUTTER HEALTH PLAN HMO PLANS", "methodology": "per diem", "standard_charge_dollar": 28538.0, "standard_charge_algorithm": "Per diem ($28,538).", "count": "0", "additional_payer_notes": "Zero final payments for the item or service in the 15 months prior to posting the file." }, { "payer_name": "UMR", "plan_name": "SUTTER SELECT & SUTTER HEALTH PLAN HMO PLANS", "methodology": "per diem", "standard_charge_dollar": 28538.0, "standard_charge_algorithm": "Per diem ($28,538).", "median_amount": 259.04, "10th_percentile": 213.12, "90th_percentile": 259.04, "count": "1 through 10" }, { "payer_name": "UNITED HEALTHCARE", "plan_name": "SUTTER SELECT & SUTTER HEALTH PLAN HMO PLANS", "methodology": "per diem", "standard_charge_dollar": 28538.0, "standard_charge_algorithm": "Per diem ($28,538).", "median_amount": 257.61, "10th_percentile": 107.25, "90th_percentile": 257.61, "count": "1 through 10" } ] } ] }, { "description": "HC Introducer Gp027", "code_information": [ { "code": "PX-2120206027", "type": "CDM" }, { "code": "C1894", "type": "HCPCS" }, { "code": "0272", "type": "RC" } ], "standard_charges": [ { "setting": "outpatient", "gross_charge": 4875.0, "discounted_cash": 2437.5, "minimum": 2057.25, "maximum": 2535.0, "additional_generic_notes": "Zero final payments for the item or service in the 15 months prior to posting the file.", "payers_information": [ { "payer_name": "AETNA", "plan_name": "AETNA ALL OTHER PLANS", "methodology": "percent of total billed charges", "standard_charge_dollar": 2535.0, "standard_charge_percentage": 52.0, "count": "0", "additional_payer_notes": "Zero final payments for the item or service in the 15 months prior to posting the file." }, { "payer_name": "AETNA", "plan_name": "AETNA ALL OTHER PLANS", "methodology": "percent of total billed charges", "standard_charge_dollar": 2535.0, "standard_charge_percentage": 52.0, "count": "0", "additional_payer_notes": "Zero final payments for the item or service in the 15 months prior to posting the file." }, { "payer_name": "MERITAIN HEALTH", "plan_name": "AETNA ALL OTHER PLANS", "methodology": "percent of total billed charges", "standard_charge_dollar": 2535.0, "standard_charge_percentage": 52.0, "median_amount": 293.0, "10th_percentile": 187.29, "90th_percentile": 293.0, "count": "1 through 10" }, { "payer_name": "BLUE SHIELD OUT OF STATE", "plan_name": "STANFORD HEALTHCARE ALLIANCE PLAN", "methodology": "percent of total billed charges", "standard_charge_dollar": 2368.76, "standard_charge_percentage": 48.59, "median_amount": 427.76, "10th_percentile": 147.88, "90th_percentile": 2533.39, "count": "105" }, { "payer_name": "BLUE SHIELD", "plan_name": "STANFORD HEALTHCARE ALLIANCE PLAN", "methodology": "percent of total billed charges", "standard_charge_dollar": 2368.76, "standard_charge_percentage": 48.59, "median_amount": 685.9, "10th_percentile": 191.79, "90th_percentile": 3993.56, "count": "71" }, { "payer_name": "BLUE SHIELD", "plan_name": "STANFORD HEALTHCARE ALLIANCE PLAN", "methodology": "percent of total billed charges", "standard_charge_dollar": 2368.76, "standard_charge_percentage": 48.59, "median_amount": 373.48, "10th_percentile": 147.88, "90th_percentile": 3886.2, "count": "21" }, { "payer_name": "BLUE SHIELD", "plan_name": "STANFORD HEALTHCARE ALLIANCE PLAN", "methodology": "percent of total billed charges", "standard_charge_dollar": 2368.76, "standard_charge_percentage": 48.59, "count": "0", "additional_payer_notes": "Zero final payments for the item or service in the 15 months prior to posting the file." }, { "payer_name": "CIGNA", "plan_name": "CIGNA COM ALT HMO PLAN", "methodology": "percent of total billed charges", "standard_charge_dollar": 2057.25, "standard_charge_percentage": 42.2, "count": "0", "additional_payer_notes": "Zero final payments for the item or service in the 15 months prior to posting the file." }, { "payer_name": "CIGNA", "plan_name": "CIGNA COM ALT HMO PLAN", "methodology": "percent of total billed charges", "standard_charge_dollar": 2057.25, "standard_charge_percentage": 42.2, "count": "0", "additional_payer_notes": "Zero final payments for the item or service in the 15 months prior to posting the file." }, { "payer_name": "HEALTH NET", "plan_name": "HEALTHNET HMO, PPO, POS, EPO, CANOPY HEALTHNET HMO, OTHER-IN-NETWORK PLANS", "methodology": "per diem", "standard_charge_dollar": 8000.0, "standard_charge_algorithm": "Expected reimbursement is the lesser of Per diem ($8,000) for the length of stay and 70% of billed.", "count": "0", "additional_payer_notes": "Zero final payments for the item or service in the 15 months prior to posting the file." }, { "payer_name": "HEALTH NET", "plan_name": "HEALTHNET HMO, PPO, POS, EPO, CANOPY HEALTHNET HMO, OTHER-IN-NETWORK PLANS", "methodology": "per diem", "standard_charge_dollar": 8000.0, "standard_charge_algorithm": "Expected reimbursement is the lesser of Per diem ($8,000) for the length of stay and 70% of billed.", "count": "0", "additional_payer_notes": "Zero final payments for the item or service in the 15 months prior to posting the file." }, { "payer_name": "UNITED HEALTHCARE", "plan_name": "SUTTER SELECT & SUTTER HEALTH PLAN HMO PLANS", "methodology": "per diem", "standard_charge_dollar": 28538.0, "standard_charge_algorithm": "Per diem ($28,538).", "count": "0", "additional_payer_notes": "Zero final payments for the item or service in the 15 months prior to posting the file." }, { "payer_name": "UNITED HEALTHCARE", "plan_name": "SUTTER SELECT & SUTTER HEALTH PLAN HMO PLANS", "methodology": "per diem", "standard_charge_dollar": 28538.0, "standard_charge_algorithm": "Per diem ($28,538).", "count": "0", "additional_payer_notes": "Zero final payments for the item or service in the 15 months prior to posting the file." }, { "payer_name": "SUTTER", "plan_name": "SUTTER SELECT & SUTTER HEALTH PLAN HMO PLANS", "methodology": "per diem", "standard_charge_dollar": 28538.0, "standard_charge_algorithm": "Per diem ($28,538).", "median_amount": 592.22, "10th_percentile": 192.7, "90th_percentile": 3120.24, "count": "13" }, { "payer_name": "UNITED HEALTHCARE", "plan_name": "SUTTER SELECT & SUTTER HEALTH PLAN HMO PLANS", "methodology": "per diem", "standard_charge_dollar": 28538.0, "standard_charge_algorithm": "Per diem ($28,538).", "count": "0", "additional_payer_notes": "Zero final payments for the item or service in the 15 months prior to posting the file." }, { "payer_name": "UMR", "plan_name": "SUTTER SELECT & SUTTER HEALTH PLAN HMO PLANS", "methodology": "per diem", "standard_charge_dollar": 28538.0, "standard_charge_algorithm": "Per diem ($28,538).", "median_amount": 259.04, "10th_percentile": 213.12, "90th_percentile": 259.04, "count": "1 through 10" }, { "payer_name": "UNITED HEALTHCARE", "plan_name": "SUTTER SELECT & SUTTER HEALTH PLAN HMO PLANS", "methodology": "per diem", "standard_charge_dollar": 28538.0, "standard_charge_algorithm": "Per diem ($28,538).", "median_amount": 257.61, "10th_percentile": 107.25, "90th_percentile": 257.61, "count": "1 through 10" } ] } ] }, { "description": "Hc Introducer Gp028", "code_information": [ { "code": "PX-2120206028", "type": "CDM" }, { "code": "C1894", "type": "HCPCS" }, { "code": "0272", "type": "RC" } ], "standard_charges": [ { "setting": "outpatient", "gross_charge": 5250.0, "discounted_cash": 2625.0, "minimum": 2215.5, "maximum": 2730.0, "additional_generic_notes": "Zero final payments for the item or service in the 15 months prior to posting the file.", "payers_information": [ { "payer_name": "AETNA", "plan_name": "AETNA ALL OTHER PLANS", "methodology": "percent of total billed charges", "standard_charge_dollar": 2730.0, "standard_charge_percentage": 52.0, "count": "0", "additional_payer_notes": "Zero final payments for the item or service in the 15 months prior to posting the file." }, { "payer_name": "AETNA", "plan_name": "AETNA ALL OTHER PLANS", "methodology": "percent of total billed charges", "standard_charge_dollar": 2730.0, "standard_charge_percentage": 52.0, "count": "0", "additional_payer_notes": "Zero final payments for the item or service in the 15 months prior to posting the file." }, { "payer_name": "MERITAIN HEALTH", "plan_name": "AETNA ALL OTHER PLANS", "methodology": "percent of total billed charges", "standard_charge_dollar": 2730.0, "standard_charge_percentage": 52.0, "median_amount": 293.0, "10th_percentile": 187.29, "90th_percentile": 293.0, "count": "1 through 10" }, { "payer_name": "BLUE SHIELD OUT OF STATE", "plan_name": "STANFORD HEALTHCARE ALLIANCE PLAN", "methodology": "percent of total billed charges", "standard_charge_dollar": 2550.98, "standard_charge_percentage": 48.59, "median_amount": 427.76, "10th_percentile": 147.88, "90th_percentile": 2533.39, "count": "105" }, { "payer_name": "BLUE SHIELD", "plan_name": "STANFORD HEALTHCARE ALLIANCE PLAN", "methodology": "percent of total billed charges", "standard_charge_dollar": 2550.98, "standard_charge_percentage": 48.59, "median_amount": 685.9, "10th_percentile": 191.79, "90th_percentile": 3993.56, "count": "71" }, { "payer_name": "BLUE SHIELD", "plan_name": "STANFORD HEALTHCARE ALLIANCE PLAN", "methodology": "percent of total billed charges", "standard_charge_dollar": 2550.98, "standard_charge_percentage": 48.59, "median_amount": 373.48, "10th_percentile": 147.88, "90th_percentile": 3886.2, "count": "21" }, { "payer_name": "BLUE SHIELD", "plan_name": "STANFORD HEALTHCARE ALLIANCE PLAN", "methodology": "percent of total billed charges", "standard_charge_dollar": 2550.98, "standard_charge_percentage": 48.59, "count": "0", "additional_payer_notes": "Zero final payments for the item or service in the 15 months prior to posting the file." }, { "payer_name": "CIGNA", "plan_name": "CIGNA COM ALT HMO PLAN", "methodology": "percent of total billed charges", "standard_charge_dollar": 2215.5, "standard_charge_percentage": 42.2, "count": "0", "additional_payer_notes": "Zero final payments for the item or service in the 15 months prior to posting the file." }, { "payer_name": "CIGNA", "plan_name": "CIGNA COM ALT HMO PLAN", "methodology": "percent of total billed charges", "standard_charge_dollar": 2215.5, "standard_charge_percentage": 42.2, "count": "0", "additional_payer_notes": "Zero final payments for the item or service in the 15 months prior to posting the file." }, { "payer_name": "HEALTH NET", "plan_name": "HEALTHNET HMO, PPO, POS, EPO, CANOPY HEALTHNET HMO, OTHER-IN-NETWORK PLANS", "methodology": "per diem", "standard_charge_dollar": 8000.0, "standard_charge_algorithm": "Expected reimbursement is the lesser of Per diem ($8,000) for the length of stay and 70% of billed.", "count": "0", "additional_payer_notes": "Zero final payments for the item or service in the 15 months prior to posting the file." }, { "payer_name": "HEALTH NET", "plan_name": "HEALTHNET HMO, PPO, POS, EPO, CANOPY HEALTHNET HMO, OTHER-IN-NETWORK PLANS", "methodology": "per diem", "standard_charge_dollar": 8000.0, "standard_charge_algorithm": "Expected reimbursement is the lesser of Per diem ($8,000) for the length of stay and 70% of billed.", "count": "0", "additional_payer_notes": "Zero final payments for the item or service in the 15 months prior to posting the file." }, { "payer_name": "UNITED HEALTHCARE", "plan_name": "SUTTER SELECT & SUTTER HEALTH PLAN HMO PLANS", "methodology": "per diem", "standard_charge_dollar": 28538.0, "standard_charge_algorithm": "Per diem ($28,538).", "count": "0", "additional_payer_notes": "Zero final payments for the item or service in the 15 months prior to posting the file." }, { "payer_name": "UNITED HEALTHCARE", "plan_name": "SUTTER SELECT & SUTTER HEALTH PLAN HMO PLANS", "methodology": "per diem", "standard_charge_dollar": 28538.0, "standard_charge_algorithm": "Per diem ($28,538).", "count": "0", "additional_payer_notes": "Zero final payments for the item or service in the 15 months prior to posting the file." }, { "payer_name": "SUTTER", "plan_name": "SUTTER SELECT & SUTTER HEALTH PLAN HMO PLANS", "methodology": "per diem", "standard_charge_dollar": 28538.0, "standard_charge_algorithm": "Per diem ($28,538).", "median_amount": 592.22, "10th_percentile": 192.7, "90th_percentile": 3120.24, "count": "13" }, { "payer_name": "UNITED HEALTHCARE", "plan_name": "SUTTER SELECT & SUTTER HEALTH PLAN HMO PLANS", "methodology": "per diem", "standard_charge_dollar": 28538.0, "standard_charge_algorithm": "Per diem ($28,538).", "count": "0", "additional_payer_notes": "Zero final payments for the item or service in the 15 months prior to posting the file." }, { "payer_name": "UMR", "plan_name": "SUTTER SELECT & SUTTER HEALTH PLAN HMO PLANS", "methodology": "per diem", "standard_charge_dollar": 28538.0, "standard_charge_algorithm": "Per diem ($28,538).", "median_amount": 259.04, "10th_percentile": 213.12, "90th_percentile": 259.04, "count": "1 through 10" }, { "payer_name": "UNITED HEALTHCARE", "plan_name": "SUTTER SELECT & SUTTER HEALTH PLAN HMO PLANS", "methodology": "per diem", "standard_charge_dollar": 28538.0, "standard_charge_algorithm": "Per diem ($28,538).", "median_amount": 257.61, "10th_percentile": 107.25, "90th_percentile": 257.61, "count": "1 through 10" } ] } ] }, { "description": "HC Introducer Gp032", "code_information": [ { "code": "PX-2120206032", "type": "CDM" }, { "code": "C1894", "type": "HCPCS" }, { "code": "0272", "type": "RC" } ], "standard_charges": [ { "setting": "outpatient", "gross_charge": 6300.0, "discounted_cash": 3150.0, "minimum": 2658.6, "maximum": 3276.0, "additional_generic_notes": "Zero final payments for the item or service in the 15 months prior to posting the file.", "payers_information": [ { "payer_name": "AETNA", "plan_name": "AETNA ALL OTHER PLANS", "methodology": "percent of total billed charges", "standard_charge_dollar": 3276.0, "standard_charge_percentage": 52.0, "count": "0", "additional_payer_notes": "Zero final payments for the item or service in the 15 months prior to posting the file." }, { "payer_name": "AETNA", "plan_name": "AETNA ALL OTHER PLANS", "methodology": "percent of total billed charges", "standard_charge_dollar": 3276.0, "standard_charge_percentage": 52.0, "count": "0", "additional_payer_notes": "Zero final payments for the item or service in the 15 months prior to posting the file." }, { "payer_name": "MERITAIN HEALTH", "plan_name": "AETNA ALL OTHER PLANS", "methodology": "percent of total billed charges", "standard_charge_dollar": 3276.0, "standard_charge_percentage": 52.0, "median_amount": 293.0, "10th_percentile": 187.29, "90th_percentile": 293.0, "count": "1 through 10" }, { "payer_name": "BLUE SHIELD OUT OF STATE", "plan_name": "STANFORD HEALTHCARE ALLIANCE PLAN", "methodology": "percent of total billed charges", "standard_charge_dollar": 3061.17, "standard_charge_percentage": 48.59, "median_amount": 427.76, "10th_percentile": 147.88, "90th_percentile": 2533.39, "count": "105" }, { "payer_name": "BLUE SHIELD", "plan_name": "STANFORD HEALTHCARE ALLIANCE PLAN", "methodology": "percent of total billed charges", "standard_charge_dollar": 3061.17, "standard_charge_percentage": 48.59, "median_amount": 685.9, "10th_percentile": 191.79, "90th_percentile": 3993.56, "count": "71" }, { "payer_name": "BLUE SHIELD", "plan_name": "STANFORD HEALTHCARE ALLIANCE PLAN", "methodology": "percent of total billed charges", "standard_charge_dollar": 3061.17, "standard_charge_percentage": 48.59, "median_amount": 373.48, "10th_percentile": 147.88, "90th_percentile": 3886.2, "count": "21" }, { "payer_name": "BLUE SHIELD", "plan_name": "STANFORD HEALTHCARE ALLIANCE PLAN", "methodology": "percent of total billed charges", "standard_charge_dollar": 3061.17, "standard_charge_percentage": 48.59, "count": "0", "additional_payer_notes": "Zero final payments for the item or service in the 15 months prior to posting the file." }, { "payer_name": "CIGNA", "plan_name": "CIGNA COM ALT HMO PLAN", "methodology": "percent of total billed charges", "standard_charge_dollar": 2658.6, "standard_charge_percentage": 42.2, "count": "0", "additional_payer_notes": "Zero final payments for the item or service in the 15 months prior to posting the file." }, { "payer_name": "CIGNA", "plan_name": "CIGNA COM ALT HMO PLAN", "methodology": "percent of total billed charges", "standard_charge_dollar": 2658.6, "standard_charge_percentage": 42.2, "count": "0", "additional_payer_notes": "Zero final payments for the item or service in the 15 months prior to posting the file." }, { "payer_name": "HEALTH NET", "plan_name": "HEALTHNET HMO, PPO, POS, EPO, CANOPY HEALTHNET HMO, OTHER-IN-NETWORK PLANS", "methodology": "per diem", "standard_charge_dollar": 8000.0, "standard_charge_algorithm": "Expected reimbursement is the lesser of Per diem ($8,000) for the length of stay and 70% of billed.", "count": "0", "additional_payer_notes": "Zero final payments for the item or service in the 15 months prior to posting the file." }, { "payer_name": "HEALTH NET", "plan_name": "HEALTHNET HMO, PPO, POS, EPO, CANOPY HEALTHNET HMO, OTHER-IN-NETWORK PLANS", "methodology": "per diem", "standard_charge_dollar": 8000.0, "standard_charge_algorithm": "Expected reimbursement is the lesser of Per diem ($8,000) for the length of stay and 70% of billed.", "count": "0", "additional_payer_notes": "Zero final payments for the item or service in the 15 months prior to posting the file." }, { "payer_name": "UNITED HEALTHCARE", "plan_name": "SUTTER SELECT & SUTTER HEALTH PLAN HMO PLANS", "methodology": "per diem", "standard_charge_dollar": 28538.0, "standard_charge_algorithm": "Per diem ($28,538).", "count": "0", "additional_payer_notes": "Zero final payments for the item or service in the 15 months prior to posting the file." }, { "payer_name": "UNITED HEALTHCARE", "plan_name": "SUTTER SELECT & SUTTER HEALTH PLAN HMO PLANS", "methodology": "per diem", "standard_charge_dollar": 28538.0, "standard_charge_algorithm": "Per diem ($28,538).", "count": "0", "additional_payer_notes": "Zero final payments for the item or service in the 15 months prior to posting the file." }, { "payer_name": "SUTTER", "plan_name": "SUTTER SELECT & SUTTER HEALTH PLAN HMO PLANS", "methodology": "per diem", "standard_charge_dollar": 28538.0, "standard_charge_algorithm": "Per diem ($28,538).", "median_amount": 592.22, "10th_percentile": 192.7, "90th_percentile": 3120.24, "count": "13" }, { "payer_name": "UNITED HEALTHCARE", "plan_name": "SUTTER SELECT & SUTTER HEALTH PLAN HMO PLANS", "methodology": "per diem", "standard_charge_dollar": 28538.0, "standard_charge_algorithm": "Per diem ($28,538).", "count": "0", "additional_payer_notes": "Zero final payments for the item or service in the 15 months prior to posting the file." }, { "payer_name": "UMR", "plan_name": "SUTTER SELECT & SUTTER HEALTH PLAN HMO PLANS", "methodology": "per diem", "standard_charge_dollar": 28538.0, "standard_charge_algorithm": "Per diem ($28,538).", "median_amount": 259.04, "10th_percentile": 213.12, "90th_percentile": 259.04, "count": "1 through 10" }, { "payer_name": "UNITED HEALTHCARE", "plan_name": "SUTTER SELECT & SUTTER HEALTH PLAN HMO PLANS", "methodology": "per diem", "standard_charge_dollar": 28538.0, "standard_charge_algorithm": "Per diem ($28,538).", "median_amount": 257.61, "10th_percentile": 107.25, "90th_percentile": 257.61, "count": "1 through 10" } ] } ] }, { "description": "HC Introducer Gp033", "code_information": [ { "code": "PX-2120206033", "type": "CDM" }, { "code": "C1894", "type": "HCPCS" }, { "code": "0272", "type": "RC" } ], "standard_charges": [ { "setting": "outpatient", "gross_charge": 6413.0, "discounted_cash": 3206.5, "minimum": 2706.29, "maximum": 3334.76, "additional_generic_notes": "Zero final payments for the item or service in the 15 months prior to posting the file.", "payers_information": [ { "payer_name": "AETNA", "plan_name": "AETNA ALL OTHER PLANS", "methodology": "percent of total billed charges", "standard_charge_dollar": 3334.76, "standard_charge_percentage": 52.0, "count": "0", "additional_payer_notes": "Zero final payments for the item or service in the 15 months prior to posting the file." }, { "payer_name": "AETNA", "plan_name": "AETNA ALL OTHER PLANS", "methodology": "percent of total billed charges", "standard_charge_dollar": 3334.76, "standard_charge_percentage": 52.0, "count": "0", "additional_payer_notes": "Zero final payments for the item or service in the 15 months prior to posting the file." }, { "payer_name": "MERITAIN HEALTH", "plan_name": "AETNA ALL OTHER PLANS", "methodology": "percent of total billed charges", "standard_charge_dollar": 3334.76, "standard_charge_percentage": 52.0, "median_amount": 293.0, "10th_percentile": 187.29, "90th_percentile": 293.0, "count": "1 through 10" }, { "payer_name": "BLUE SHIELD OUT OF STATE", "plan_name": "STANFORD HEALTHCARE ALLIANCE PLAN", "methodology": "percent of total billed charges", "standard_charge_dollar": 3116.08, "standard_charge_percentage": 48.59, "median_amount": 427.76, "10th_percentile": 147.88, "90th_percentile": 2533.39, "count": "105" }, { "payer_name": "BLUE SHIELD", "plan_name": "STANFORD HEALTHCARE ALLIANCE PLAN", "methodology": "percent of total billed charges", "standard_charge_dollar": 3116.08, "standard_charge_percentage": 48.59, "median_amount": 685.9, "10th_percentile": 191.79, "90th_percentile": 3993.56, "count": "71" }, { "payer_name": "BLUE SHIELD", "plan_name": "STANFORD HEALTHCARE ALLIANCE PLAN", "methodology": "percent of total billed charges", "standard_charge_dollar": 3116.08, "standard_charge_percentage": 48.59, "median_amount": 373.48, "10th_percentile": 147.88, "90th_percentile": 3886.2, "count": "21" }, { "payer_name": "BLUE SHIELD", "plan_name": "STANFORD HEALTHCARE ALLIANCE PLAN", "methodology": "percent of total billed charges", "standard_charge_dollar": 3116.08, "standard_charge_percentage": 48.59, "count": "0", "additional_payer_notes": "Zero final payments for the item or service in the 15 months prior to posting the file." }, { "payer_name": "CIGNA", "plan_name": "CIGNA COM ALT HMO PLAN", "methodology": "percent of total billed charges", "standard_charge_dollar": 2706.29, "standard_charge_percentage": 42.2, "count": "0", "additional_payer_notes": "Zero final payments for the item or service in the 15 months prior to posting the file." }, { "payer_name": "CIGNA", "plan_name": "CIGNA COM ALT HMO PLAN", "methodology": "percent of total billed charges", "standard_charge_dollar": 2706.29, "standard_charge_percentage": 42.2, "count": "0", "additional_payer_notes": "Zero final payments for the item or service in the 15 months prior to posting the file." }, { "payer_name": "HEALTH NET", "plan_name": "HEALTHNET HMO, PPO, POS, EPO, CANOPY HEALTHNET HMO, OTHER-IN-NETWORK PLANS", "methodology": "per diem", "standard_charge_dollar": 8000.0, "standard_charge_algorithm": "Expected reimbursement is the lesser of Per diem ($8,000) for the length of stay and 70% of billed.", "count": "0", "additional_payer_notes": "Zero final payments for the item or service in the 15 months prior to posting the file." }, { "payer_name": "HEALTH NET", "plan_name": "HEALTHNET HMO, PPO, POS, EPO, CANOPY HEALTHNET HMO, OTHER-IN-NETWORK PLANS", "methodology": "per diem", "standard_charge_dollar": 8000.0, "standard_charge_algorithm": "Expected reimbursement is the lesser of Per diem ($8,000) for the length of stay and 70% of billed.", "count": "0", "additional_payer_notes": "Zero final payments for the item or service in the 15 months prior to posting the file." }, { "payer_name": "UNITED HEALTHCARE", "plan_name": "SUTTER SELECT & SUTTER HEALTH PLAN HMO PLANS", "methodology": "per diem", "standard_charge_dollar": 28538.0, "standard_charge_algorithm": "Per diem ($28,538).", "count": "0", "additional_payer_notes": "Zero final payments for the item or service in the 15 months prior to posting the file." }, { "payer_name": "UNITED HEALTHCARE", "plan_name": "SUTTER SELECT & SUTTER HEALTH PLAN HMO PLANS", "methodology": "per diem", "standard_charge_dollar": 28538.0, "standard_charge_algorithm": "Per diem ($28,538).", "count": "0", "additional_payer_notes": "Zero final payments for the item or service in the 15 months prior to posting the file." }, { "payer_name": "SUTTER", "plan_name": "SUTTER SELECT & SUTTER HEALTH PLAN HMO PLANS", "methodology": "per diem", "standard_charge_dollar": 28538.0, "standard_charge_algorithm": "Per diem ($28,538).", "median_amount": 592.22, "10th_percentile": 192.7, "90th_percentile": 3120.24, "count": "13" }, { "payer_name": "UNITED HEALTHCARE", "plan_name": "SUTTER SELECT & SUTTER HEALTH PLAN HMO PLANS", "methodology": "per diem", "standard_charge_dollar": 28538.0, "standard_charge_algorithm": "Per diem ($28,538).", "count": "0", "additional_payer_notes": "Zero final payments for the item or service in the 15 months prior to posting the file." }, { "payer_name": "UMR", "plan_name": "SUTTER SELECT & SUTTER HEALTH PLAN HMO PLANS", "methodology": "per diem", "standard_charge_dollar": 28538.0, "standard_charge_algorithm": "Per diem ($28,538).", "median_amount": 259.04, "10th_percentile": 213.12, "90th_percentile": 259.04, "count": "1 through 10" }, { "payer_name": "UNITED HEALTHCARE", "plan_name": "SUTTER SELECT & SUTTER HEALTH PLAN HMO PLANS", "methodology": "per diem", "standard_charge_dollar": 28538.0, "standard_charge_algorithm": "Per diem ($28,538).", "median_amount": 257.61, "10th_percentile": 107.25, "90th_percentile": 257.61, "count": "1 through 10" } ] } ] }, { "description": "HC Introducer Gp034", "code_information": [ { "code": "PX-2120206034", "type": "CDM" }, { "code": "C1894", "type": "HCPCS" }, { "code": "0272", "type": "RC" } ], "standard_charges": [ { "setting": "outpatient", "gross_charge": 6750.0, "discounted_cash": 3375.0, "minimum": 2848.5, "maximum": 3510.0, "additional_generic_notes": "Zero final payments for the item or service in the 15 months prior to posting the file.", "payers_information": [ { "payer_name": "AETNA", "plan_name": "AETNA ALL OTHER PLANS", "methodology": "percent of total billed charges", "standard_charge_dollar": 3510.0, "standard_charge_percentage": 52.0, "count": "0", "additional_payer_notes": "Zero final payments for the item or service in the 15 months prior to posting the file." }, { "payer_name": "AETNA", "plan_name": "AETNA ALL OTHER PLANS", "methodology": "percent of total billed charges", "standard_charge_dollar": 3510.0, "standard_charge_percentage": 52.0, "count": "0", "additional_payer_notes": "Zero final payments for the item or service in the 15 months prior to posting the file." }, { "payer_name": "MERITAIN HEALTH", "plan_name": "AETNA ALL OTHER PLANS", "methodology": "percent of total billed charges", "standard_charge_dollar": 3510.0, "standard_charge_percentage": 52.0, "median_amount": 293.0, "10th_percentile": 187.29, "90th_percentile": 293.0, "count": "1 through 10" }, { "payer_name": "BLUE SHIELD OUT OF STATE", "plan_name": "STANFORD HEALTHCARE ALLIANCE PLAN", "methodology": "percent of total billed charges", "standard_charge_dollar": 3279.83, "standard_charge_percentage": 48.59, "median_amount": 427.76, "10th_percentile": 147.88, "90th_percentile": 2533.39, "count": "105" }, { "payer_name": "BLUE SHIELD", "plan_name": "STANFORD HEALTHCARE ALLIANCE PLAN", "methodology": "percent of total billed charges", "standard_charge_dollar": 3279.83, "standard_charge_percentage": 48.59, "median_amount": 685.9, "10th_percentile": 191.79, "90th_percentile": 3993.56, "count": "71" }, { "payer_name": "BLUE SHIELD", "plan_name": "STANFORD HEALTHCARE ALLIANCE PLAN", "methodology": "percent of total billed charges", "standard_charge_dollar": 3279.83, "standard_charge_percentage": 48.59, "median_amount": 373.48, "10th_percentile": 147.88, "90th_percentile": 3886.2, "count": "21" }, { "payer_name": "BLUE SHIELD", "plan_name": "STANFORD HEALTHCARE ALLIANCE PLAN", "methodology": "percent of total billed charges", "standard_charge_dollar": 3279.83, "standard_charge_percentage": 48.59, "count": "0", "additional_payer_notes": "Zero final payments for the item or service in the 15 months prior to posting the file." }, { "payer_name": "CIGNA", "plan_name": "CIGNA COM ALT HMO PLAN", "methodology": "percent of total billed charges", "standard_charge_dollar": 2848.5, "standard_charge_percentage": 42.2, "count": "0", "additional_payer_notes": "Zero final payments for the item or service in the 15 months prior to posting the file." }, { "payer_name": "CIGNA", "plan_name": "CIGNA COM ALT HMO PLAN", "methodology": "percent of total billed charges", "standard_charge_dollar": 2848.5, "standard_charge_percentage": 42.2, "count": "0", "additional_payer_notes": "Zero final payments for the item or service in the 15 months prior to posting the file." }, { "payer_name": "HEALTH NET", "plan_name": "HEALTHNET HMO, PPO, POS, EPO, CANOPY HEALTHNET HMO, OTHER-IN-NETWORK PLANS", "methodology": "per diem", "standard_charge_dollar": 8000.0, "standard_charge_algorithm": "Expected reimbursement is the lesser of Per diem ($8,000) for the length of stay and 70% of billed.", "count": "0", "additional_payer_notes": "Zero final payments for the item or service in the 15 months prior to posting the file." }, { "payer_name": "HEALTH NET", "plan_name": "HEALTHNET HMO, PPO, POS, EPO, CANOPY HEALTHNET HMO, OTHER-IN-NETWORK PLANS", "methodology": "per diem", "standard_charge_dollar": 8000.0, "standard_charge_algorithm": "Expected reimbursement is the lesser of Per diem ($8,000) for the length of stay and 70% of billed.", "count": "0", "additional_payer_notes": "Zero final payments for the item or service in the 15 months prior to posting the file." }, { "payer_name": "UNITED HEALTHCARE", "plan_name": "SUTTER SELECT & SUTTER HEALTH PLAN HMO PLANS", "methodology": "per diem", "standard_charge_dollar": 28538.0, "standard_charge_algorithm": "Per diem ($28,538).", "count": "0", "additional_payer_notes": "Zero final payments for the item or service in the 15 months prior to posting the file." }, { "payer_name": "UNITED HEALTHCARE", "plan_name": "SUTTER SELECT & SUTTER HEALTH PLAN HMO PLANS", "methodology": "per diem", "standard_charge_dollar": 28538.0, "standard_charge_algorithm": "Per diem ($28,538).", "count": "0", "additional_payer_notes": "Zero final payments for the item or service in the 15 months prior to posting the file." }, { "payer_name": "SUTTER", "plan_name": "SUTTER SELECT & SUTTER HEALTH PLAN HMO PLANS", "methodology": "per diem", "standard_charge_dollar": 28538.0, "standard_charge_algorithm": "Per diem ($28,538).", "median_amount": 592.22, "10th_percentile": 192.7, "90th_percentile": 3120.24, "count": "13" }, { "payer_name": "UNITED HEALTHCARE", "plan_name": "SUTTER SELECT & SUTTER HEALTH PLAN HMO PLANS", "methodology": "per diem", "standard_charge_dollar": 28538.0, "standard_charge_algorithm": "Per diem ($28,538).", "count": "0", "additional_payer_notes": "Zero final payments for the item or service in the 15 months prior to posting the file." }, { "payer_name": "UMR", "plan_name": "SUTTER SELECT & SUTTER HEALTH PLAN HMO PLANS", "methodology": "per diem", "standard_charge_dollar": 28538.0, "standard_charge_algorithm": "Per diem ($28,538).", "median_amount": 259.04, "10th_percentile": 213.12, "90th_percentile": 259.04, "count": "1 through 10" }, { "payer_name": "UNITED HEALTHCARE", "plan_name": "SUTTER SELECT & SUTTER HEALTH PLAN HMO PLANS", "methodology": "per diem", "standard_charge_dollar": 28538.0, "standard_charge_algorithm": "Per diem ($28,538).", "median_amount": 257.61, "10th_percentile": 107.25, "90th_percentile": 257.61, "count": "1 through 10" } ] } ] }, { "description": "HC Introducer Gp036", "code_information": [ { "code": "PX-2120206036", "type": "CDM" }, { "code": "C1894", "type": "HCPCS" }, { "code": "0272", "type": "RC" } ], "standard_charges": [ { "setting": "outpatient", "gross_charge": 7800.0, "discounted_cash": 3900.0, "minimum": 3291.6, "maximum": 4056.0, "additional_generic_notes": "Zero final payments for the item or service in the 15 months prior to posting the file.", "payers_information": [ { "payer_name": "AETNA", "plan_name": "AETNA ALL OTHER PLANS", "methodology": "percent of total billed charges", "standard_charge_dollar": 4056.0, "standard_charge_percentage": 52.0, "count": "0", "additional_payer_notes": "Zero final payments for the item or service in the 15 months prior to posting the file." }, { "payer_name": "AETNA", "plan_name": "AETNA ALL OTHER PLANS", "methodology": "percent of total billed charges", "standard_charge_dollar": 4056.0, "standard_charge_percentage": 52.0, "count": "0", "additional_payer_notes": "Zero final payments for the item or service in the 15 months prior to posting the file." }, { "payer_name": "MERITAIN HEALTH", "plan_name": "AETNA ALL OTHER PLANS", "methodology": "percent of total billed charges", "standard_charge_dollar": 4056.0, "standard_charge_percentage": 52.0, "median_amount": 293.0, "10th_percentile": 187.29, "90th_percentile": 293.0, "count": "1 through 10" }, { "payer_name": "BLUE SHIELD OUT OF STATE", "plan_name": "STANFORD HEALTHCARE ALLIANCE PLAN", "methodology": "percent of total billed charges", "standard_charge_dollar": 3790.02, "standard_charge_percentage": 48.59, "median_amount": 427.76, "10th_percentile": 147.88, "90th_percentile": 2533.39, "count": "105" }, { "payer_name": "BLUE SHIELD", "plan_name": "STANFORD HEALTHCARE ALLIANCE PLAN", "methodology": "percent of total billed charges", "standard_charge_dollar": 3790.02, "standard_charge_percentage": 48.59, "median_amount": 685.9, "10th_percentile": 191.79, "90th_percentile": 3993.56, "count": "71" }, { "payer_name": "BLUE SHIELD", "plan_name": "STANFORD HEALTHCARE ALLIANCE PLAN", "methodology": "percent of total billed charges", "standard_charge_dollar": 3790.02, "standard_charge_percentage": 48.59, "median_amount": 373.48, "10th_percentile": 147.88, "90th_percentile": 3886.2, "count": "21" }, { "payer_name": "BLUE SHIELD", "plan_name": "STANFORD HEALTHCARE ALLIANCE PLAN", "methodology": "percent of total billed charges", "standard_charge_dollar": 3790.02, "standard_charge_percentage": 48.59, "count": "0", "additional_payer_notes": "Zero final payments for the item or service in the 15 months prior to posting the file." }, { "payer_name": "CIGNA", "plan_name": "CIGNA COM ALT HMO PLAN", "methodology": "percent of total billed charges", "standard_charge_dollar": 3291.6, "standard_charge_percentage": 42.2, "count": "0", "additional_payer_notes": "Zero final payments for the item or service in the 15 months prior to posting the file." }, { "payer_name": "CIGNA", "plan_name": "CIGNA COM ALT HMO PLAN", "methodology": "percent of total billed charges", "standard_charge_dollar": 3291.6, "standard_charge_percentage": 42.2, "count": "0", "additional_payer_notes": "Zero final payments for the item or service in the 15 months prior to posting the file." }, { "payer_name": "HEALTH NET", "plan_name": "HEALTHNET HMO, PPO, POS, EPO, CANOPY HEALTHNET HMO, OTHER-IN-NETWORK PLANS", "methodology": "per diem", "standard_charge_dollar": 8000.0, "standard_charge_algorithm": "Expected reimbursement is the lesser of Per diem ($8,000) for the length of stay and 70% of billed.", "count": "0", "additional_payer_notes": "Zero final payments for the item or service in the 15 months prior to posting the file." }, { "payer_name": "HEALTH NET", "plan_name": "HEALTHNET HMO, PPO, POS, EPO, CANOPY HEALTHNET HMO, OTHER-IN-NETWORK PLANS", "methodology": "per diem", "standard_charge_dollar": 8000.0, "standard_charge_algorithm": "Expected reimbursement is the lesser of Per diem ($8,000) for the length of stay and 70% of billed.", "count": "0", "additional_payer_notes": "Zero final payments for the item or service in the 15 months prior to posting the file." }, { "payer_name": "UNITED HEALTHCARE", "plan_name": "SUTTER SELECT & SUTTER HEALTH PLAN HMO PLANS", "methodology": "per diem", "standard_charge_dollar": 28538.0, "standard_charge_algorithm": "Per diem ($28,538).", "count": "0", "additional_payer_notes": "Zero final payments for the item or service in the 15 months prior to posting the file." }, { "payer_name": "UNITED HEALTHCARE", "plan_name": "SUTTER SELECT & SUTTER HEALTH PLAN HMO PLANS", "methodology": "per diem", "standard_charge_dollar": 28538.0, "standard_charge_algorithm": "Per diem ($28,538).", "count": "0", "additional_payer_notes": "Zero final payments for the item or service in the 15 months prior to posting the file." }, { "payer_name": "SUTTER", "plan_name": "SUTTER SELECT & SUTTER HEALTH PLAN HMO PLANS", "methodology": "per diem", "standard_charge_dollar": 28538.0, "standard_charge_algorithm": "Per diem ($28,538).", "median_amount": 592.22, "10th_percentile": 192.7, "90th_percentile": 3120.24, "count": "13" }, { "payer_name": "UNITED HEALTHCARE", "plan_name": "SUTTER SELECT & SUTTER HEALTH PLAN HMO PLANS", "methodology": "per diem", "standard_charge_dollar": 28538.0, "standard_charge_algorithm": "Per diem ($28,538).", "count": "0", "additional_payer_notes": "Zero final payments for the item or service in the 15 months prior to posting the file." }, { "payer_name": "UMR", "plan_name": "SUTTER SELECT & SUTTER HEALTH PLAN HMO PLANS", "methodology": "per diem", "standard_charge_dollar": 28538.0, "standard_charge_algorithm": "Per diem ($28,538).", "median_amount": 259.04, "10th_percentile": 213.12, "90th_percentile": 259.04, "count": "1 through 10" }, { "payer_name": "UNITED HEALTHCARE", "plan_name": "SUTTER SELECT & SUTTER HEALTH PLAN HMO PLANS", "methodology": "per diem", "standard_charge_dollar": 28538.0, "standard_charge_algorithm": "Per diem ($28,538).", "median_amount": 257.61, "10th_percentile": 107.25, "90th_percentile": 257.61, "count": "1 through 10" } ] } ] }, { "description": "HC Introducer Gp037", "code_information": [ { "code": "PX-2120206037", "type": "CDM" }, { "code": "C1894", "type": "HCPCS" }, { "code": "0272", "type": "RC" } ], "standard_charges": [ { "setting": "outpatient", "gross_charge": 8125.0, "discounted_cash": 4062.5, "minimum": 3428.75, "maximum": 4225.0, "additional_generic_notes": "Zero final payments for the item or service in the 15 months prior to posting the file.", "payers_information": [ { "payer_name": "AETNA", "plan_name": "AETNA ALL OTHER PLANS", "methodology": "percent of total billed charges", "standard_charge_dollar": 4225.0, "standard_charge_percentage": 52.0, "count": "0", "additional_payer_notes": "Zero final payments for the item or service in the 15 months prior to posting the file." }, { "payer_name": "AETNA", "plan_name": "AETNA ALL OTHER PLANS", "methodology": "percent of total billed charges", "standard_charge_dollar": 4225.0, "standard_charge_percentage": 52.0, "count": "0", "additional_payer_notes": "Zero final payments for the item or service in the 15 months prior to posting the file." }, { "payer_name": "MERITAIN HEALTH", "plan_name": "AETNA ALL OTHER PLANS", "methodology": "percent of total billed charges", "standard_charge_dollar": 4225.0, "standard_charge_percentage": 52.0, "median_amount": 293.0, "10th_percentile": 187.29, "90th_percentile": 293.0, "count": "1 through 10" }, { "payer_name": "BLUE SHIELD OUT OF STATE", "plan_name": "STANFORD HEALTHCARE ALLIANCE PLAN", "methodology": "percent of total billed charges", "standard_charge_dollar": 3947.94, "standard_charge_percentage": 48.59, "median_amount": 427.76, "10th_percentile": 147.88, "90th_percentile": 2533.39, "count": "105" }, { "payer_name": "BLUE SHIELD", "plan_name": "STANFORD HEALTHCARE ALLIANCE PLAN", "methodology": "percent of total billed charges", "standard_charge_dollar": 3947.94, "standard_charge_percentage": 48.59, "median_amount": 685.9, "10th_percentile": 191.79, "90th_percentile": 3993.56, "count": "71" }, { "payer_name": "BLUE SHIELD", "plan_name": "STANFORD HEALTHCARE ALLIANCE PLAN", "methodology": "percent of total billed charges", "standard_charge_dollar": 3947.94, "standard_charge_percentage": 48.59, "median_amount": 373.48, "10th_percentile": 147.88, "90th_percentile": 3886.2, "count": "21" }, { "payer_name": "BLUE SHIELD", "plan_name": "STANFORD HEALTHCARE ALLIANCE PLAN", "methodology": "percent of total billed charges", "standard_charge_dollar": 3947.94, "standard_charge_percentage": 48.59, "count": "0", "additional_payer_notes": "Zero final payments for the item or service in the 15 months prior to posting the file." }, { "payer_name": "CIGNA", "plan_name": "CIGNA COM ALT HMO PLAN", "methodology": "percent of total billed charges", "standard_charge_dollar": 3428.75, "standard_charge_percentage": 42.2, "count": "0", "additional_payer_notes": "Zero final payments for the item or service in the 15 months prior to posting the file." }, { "payer_name": "CIGNA", "plan_name": "CIGNA COM ALT HMO PLAN", "methodology": "percent of total billed charges", "standard_charge_dollar": 3428.75, "standard_charge_percentage": 42.2, "count": "0", "additional_payer_notes": "Zero final payments for the item or service in the 15 months prior to posting the file." }, { "payer_name": "HEALTH NET", "plan_name": "HEALTHNET HMO, PPO, POS, EPO, CANOPY HEALTHNET HMO, OTHER-IN-NETWORK PLANS", "methodology": "per diem", "standard_charge_dollar": 8000.0, "standard_charge_algorithm": "Expected reimbursement is the lesser of Per diem ($8,000) for the length of stay and 70% of billed.", "count": "0", "additional_payer_notes": "Zero final payments for the item or service in the 15 months prior to posting the file." }, { "payer_name": "HEALTH NET", "plan_name": "HEALTHNET HMO, PPO, POS, EPO, CANOPY HEALTHNET HMO, OTHER-IN-NETWORK PLANS", "methodology": "per diem", "standard_charge_dollar": 8000.0, "standard_charge_algorithm": "Expected reimbursement is the lesser of Per diem ($8,000) for the length of stay and 70% of billed.", "count": "0", "additional_payer_notes": "Zero final payments for the item or service in the 15 months prior to posting the file." }, { "payer_name": "UNITED HEALTHCARE", "plan_name": "SUTTER SELECT & SUTTER HEALTH PLAN HMO PLANS", "methodology": "per diem", "standard_charge_dollar": 28538.0, "standard_charge_algorithm": "Per diem ($28,538).", "count": "0", "additional_payer_notes": "Zero final payments for the item or service in the 15 months prior to posting the file." }, { "payer_name": "UNITED HEALTHCARE", "plan_name": "SUTTER SELECT & SUTTER HEALTH PLAN HMO PLANS", "methodology": "per diem", "standard_charge_dollar": 28538.0, "standard_charge_algorithm": "Per diem ($28,538).", "count": "0", "additional_payer_notes": "Zero final payments for the item or service in the 15 months prior to posting the file." }, { "payer_name": "SUTTER", "plan_name": "SUTTER SELECT & SUTTER HEALTH PLAN HMO PLANS", "methodology": "per diem", "standard_charge_dollar": 28538.0, "standard_charge_algorithm": "Per diem ($28,538).", "median_amount": 592.22, "10th_percentile": 192.7, "90th_percentile": 3120.24, "count": "13" }, { "payer_name": "UNITED HEALTHCARE", "plan_name": "SUTTER SELECT & SUTTER HEALTH PLAN HMO PLANS", "methodology": "per diem", "standard_charge_dollar": 28538.0, "standard_charge_algorithm": "Per diem ($28,538).", "count": "0", "additional_payer_notes": "Zero final payments for the item or service in the 15 months prior to posting the file." }, { "payer_name": "UMR", "plan_name": "SUTTER SELECT & SUTTER HEALTH PLAN HMO PLANS", "methodology": "per diem", "standard_charge_dollar": 28538.0, "standard_charge_algorithm": "Per diem ($28,538).", "median_amount": 259.04, "10th_percentile": 213.12, "90th_percentile": 259.04, "count": "1 through 10" }, { "payer_name": "UNITED HEALTHCARE", "plan_name": "SUTTER SELECT & SUTTER HEALTH PLAN HMO PLANS", "methodology": "per diem", "standard_charge_dollar": 28538.0, "standard_charge_algorithm": "Per diem ($28,538).", "median_amount": 257.61, "10th_percentile": 107.25, "90th_percentile": 257.61, "count": "1 through 10" } ]