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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":"Mary Beth Remorenko"},"modifier_information":[{"description":"Modifier description not available","code":"SPE","modifier_payer_information":[{"payer_name":"Aetna","plan_name":"All Commercial Plans","description":"The modified price is presented in the standard charge value."},{"payer_name":"Aetna","plan_name":"Medicare Managed Care Plan","description":"The modified price is presented in the standard charge value."},{"payer_name":"Ambetter","plan_name":"Exchange","description":"The modified price is presented in the standard charge value."},{"payer_name":"AmeriHealth","plan_name":"Caritas Medicaid Managed Care Plan","description":"The modified price is presented in the standard charge value."},{"payer_name":"BCBS","plan_name":"Anthem NH Medicare Managed Care Plan","description":"The modified price is presented in the standard charge value."},{"payer_name":"BCBS","plan_name":"Anthem NH PPO/Indemnity/FEP","description":"The modified price is presented in the standard charge value."},{"payer_name":"BCBS","plan_name":"Anthem NH QHP Exchange","description":"The modified price is presented in the standard charge value."},{"payer_name":"Cigna","plan_name":"All Commercial Plans","description":"The modified price is presented in the standard charge value."},{"payer_name":"Harvard Pilgrim Healthcare","plan_name":"All Commercial Plans","description":"The modified price is presented in the standard charge value."},{"payer_name":"Humana","plan_name":"Medicare Managed Care Plan","description":"The modified price is presented in the standard charge value."},{"payer_name":"NH Healthy Families","plan_name":"Medicaid Managed Care Plan","description":"The modified price is presented in the standard charge value."},{"payer_name":"UnitedHealthCare","plan_name":"All Commercial Plans","description":"The modified price is presented in the standard charge value."},{"payer_name":"UnitedHealthCare","plan_name":"Medicare Managed Care Plan","description":"The modified price is presented in the standard charge value."},{"payer_name":"USFHP","plan_name":"Government","description":"The modified price is presented in the standard charge value."},{"payer_name":"Wellcare Health Plan","plan_name":"Medicaid Managed Care Plan","description":"The modified price is presented in the standard charge value."},{"payer_name":"Wellsense Health Plan","plan_name":"Medicaid Managed Care Plan","description":"The modified price is presented in the standard charge value."}]},{"description":"Technical Component; represents the costs of equipment, supplies, and technician personnel for a procedure, excluding the physician's interpretation. 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The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm."},{"payer_name":"Usfhp","plan_name":"Government","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages Tricare methodology. Available, referenceable Tricare logic found here: https://www.health.mil/Military-Health-Topics/Access-Cost-Quality-and-Safety/TRICARE-Health-Plan/Rates-and-Reimbursement]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Wellcare Health Plan","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.mass.gov/topics/masshealth]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Wellsense Health Plan","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. 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Available, referenceable algorithm logic found here: https://www.dhhs.nh.gov/programs-services/medicaid]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."}]}]},{"description":"Complicated Peptic Ulcer With Mcc","code_information":[{"code":"380","type":"MS-DRG"}],"standard_charges":[{"setting":"inpatient","billing_class":"facility","minimum":15072.26,"maximum":46150.94,"payers_information":[{"payer_name":"Aetna","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":15373.71,"additional_payer_notes":"MSDRG Base Rate"},{"payer_name":"Ambetter","plan_name":"Exchange","methodology":"fee schedule","standard_charge_dollar":21101.16,"additional_payer_notes":"MSDRG Base Rate"},{"payer_name":"Bcbs","plan_name":"Anthem Nh Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":15072.26,"additional_payer_notes":"MSDRG Base Rate"},{"payer_name":"Bcbs","plan_name":"Anthem Nh Ppo/Indemnity/Fep","methodology":"fee schedule","standard_charge_dollar":46150.94},{"payer_name":"Bcbs","plan_name":"Anthem Nh Qhp Exchange","methodology":"fee schedule","standard_charge_dollar":15524.43,"additional_payer_notes":"MSDRG Base Rate"},{"payer_name":"Humana","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":15072.26,"additional_payer_notes":"MSDRG Base Rate"},{"payer_name":"Unitedhealthcare","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":15072.26,"additional_payer_notes":"MSDRG Base Rate"}]},{"setting":"inpatient","billing_class":"facility","payers_information":[{"payer_name":"Aetna","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[MSDRG Base Rate: FEE SCHEDULE]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Ambetter","plan_name":"Exchange","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Bcbs","plan_name":"Anthem Nh Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[MSDRG Base Rate: FEE SCHEDULE]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Bcbs","plan_name":"Anthem Nh Ppo/Indemnity/Fep","methodology":"other","standard_charge_algorithm":"[Stop Loss: Total Charges > 200000 | Excess % of Charge: 36.10] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [Nursery  Level 1- Boarder-Per Diem: 1668] [Nursery  Level 2-Per Diem: 1668] [Nursery  Level 3-Per Diem: 1668] [Nursery  Level 4-NICU-Per Diem: 1668]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Bcbs","plan_name":"Anthem Nh Qhp Exchange","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Humana","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[MSDRG Base Rate: FEE SCHEDULE]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Nh Healthy Families","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. 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Available, referenceable algorithm logic found here: https://www.dhhs.nh.gov/programs-services/medicaid]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."}]}]},{"description":"Inflammatory Bowel Disease With Mcc","code_information":[{"code":"385","type":"MS-DRG"}],"standard_charges":[{"setting":"inpatient","billing_class":"facility","minimum":12154.13,"maximum":37215.7,"payers_information":[{"payer_name":"Aetna","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":12397.21,"additional_payer_notes":"MSDRG Base Rate"},{"payer_name":"Ambetter","plan_name":"Exchange","methodology":"fee schedule","standard_charge_dollar":17015.78,"additional_payer_notes":"MSDRG Base Rate"},{"payer_name":"Bcbs","plan_name":"Anthem Nh Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":12154.13,"additional_payer_notes":"MSDRG Base Rate"},{"payer_name":"Bcbs","plan_name":"Anthem Nh Ppo/Indemnity/Fep","methodology":"fee schedule","standard_charge_dollar":37215.7},{"payer_name":"Bcbs","plan_name":"Anthem Nh Qhp Exchange","methodology":"fee schedule","standard_charge_dollar":12518.75,"additional_payer_notes":"MSDRG Base Rate"},{"payer_name":"Humana","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":12154.13,"additional_payer_notes":"MSDRG Base Rate"},{"payer_name":"Unitedhealthcare","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":12154.13,"additional_payer_notes":"MSDRG Base Rate"}]},{"setting":"inpatient","billing_class":"facility","payers_information":[{"payer_name":"Aetna","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[MSDRG Base Rate: FEE SCHEDULE]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Ambetter","plan_name":"Exchange","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Bcbs","plan_name":"Anthem Nh Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[MSDRG Base Rate: FEE SCHEDULE]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Bcbs","plan_name":"Anthem Nh Ppo/Indemnity/Fep","methodology":"other","standard_charge_algorithm":"[Stop Loss: Total Charges > 200000 | Excess % of Charge: 36.10] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [Nursery  Level 1- Boarder-Per Diem: 1668] [Nursery  Level 2-Per Diem: 1668] [Nursery  Level 3-Per Diem: 1668] [Nursery  Level 4-NICU-Per Diem: 1668]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Bcbs","plan_name":"Anthem Nh Qhp Exchange","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Humana","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[MSDRG Base Rate: FEE SCHEDULE]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Nh Healthy Families","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. 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Available, referenceable algorithm logic found here: https://www.dhhs.nh.gov/programs-services/medicaid]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Unitedhealthcare","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[MSDRG Base Rate: FEE SCHEDULE]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Usfhp","plan_name":"Government","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages Tricare methodology. Available, referenceable Tricare logic found here: https://www.health.mil/Military-Health-Topics/Access-Cost-Quality-and-Safety/TRICARE-Health-Plan/Rates-and-Reimbursement]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Wellcare Health Plan","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.mass.gov/topics/masshealth]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Wellsense Health Plan","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhhs.nh.gov/programs-services/medicaid]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."}]}]},{"description":"Appendix Procedures With Mcc","code_information":[{"code":"397","type":"MS-DRG"}],"standard_charges":[{"setting":"inpatient","billing_class":"facility","minimum":18395.96,"maximum":56328.05,"payers_information":[{"payer_name":"Aetna","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":18763.88,"additional_payer_notes":"MSDRG Base Rate"},{"payer_name":"Ambetter","plan_name":"Exchange","methodology":"fee schedule","standard_charge_dollar":25754.34,"additional_payer_notes":"MSDRG Base Rate"},{"payer_name":"Bcbs","plan_name":"Anthem Nh Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":18395.96,"additional_payer_notes":"MSDRG Base Rate"},{"payer_name":"Bcbs","plan_name":"Anthem Nh Ppo/Indemnity/Fep","methodology":"fee schedule","standard_charge_dollar":56328.05},{"payer_name":"Bcbs","plan_name":"Anthem Nh Qhp Exchange","methodology":"fee schedule","standard_charge_dollar":18947.84,"additional_payer_notes":"MSDRG Base Rate"},{"payer_name":"Humana","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":18395.96,"additional_payer_notes":"MSDRG Base Rate"},{"payer_name":"Unitedhealthcare","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":18395.96,"additional_payer_notes":"MSDRG Base Rate"}]},{"setting":"inpatient","billing_class":"facility","payers_information":[{"payer_name":"Aetna","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[MSDRG Base Rate: FEE SCHEDULE]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Ambetter","plan_name":"Exchange","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Bcbs","plan_name":"Anthem Nh Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[MSDRG Base Rate: FEE SCHEDULE]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Bcbs","plan_name":"Anthem Nh Ppo/Indemnity/Fep","methodology":"other","standard_charge_algorithm":"[Stop Loss: Total Charges > 200000 | Excess % of Charge: 36.10] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [Nursery  Level 1- Boarder-Per Diem: 1668] [Nursery  Level 2-Per Diem: 1668] [Nursery  Level 3-Per Diem: 1668] [Nursery  Level 4-NICU-Per Diem: 1668]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Bcbs","plan_name":"Anthem Nh Qhp Exchange","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Humana","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[MSDRG Base Rate: FEE SCHEDULE]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Nh Healthy Families","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhhs.nh.gov/programs-services/medicaid]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Unitedhealthcare","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[MSDRG Base Rate: FEE SCHEDULE]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Usfhp","plan_name":"Government","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages Tricare methodology. Available, referenceable Tricare logic found here: https://www.health.mil/Military-Health-Topics/Access-Cost-Quality-and-Safety/TRICARE-Health-Plan/Rates-and-Reimbursement]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Wellcare Health Plan","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.mass.gov/topics/masshealth]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Wellsense Health Plan","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhhs.nh.gov/programs-services/medicaid]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."}]}]},{"description":"Appendix Procedures With Cc","code_information":[{"code":"398","type":"MS-DRG"}],"standard_charges":[{"setting":"inpatient","billing_class":"facility","minimum":11626.42,"maximum":35599.87,"payers_information":[{"payer_name":"Aetna","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":11858.95,"additional_payer_notes":"MSDRG Base Rate"},{"payer_name":"Ambetter","plan_name":"Exchange","methodology":"fee schedule","standard_charge_dollar":16276.99,"additional_payer_notes":"MSDRG Base Rate"},{"payer_name":"Bcbs","plan_name":"Anthem Nh Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":11626.42,"additional_payer_notes":"MSDRG Base Rate"},{"payer_name":"Bcbs","plan_name":"Anthem Nh Ppo/Indemnity/Fep","methodology":"fee schedule","standard_charge_dollar":35599.87},{"payer_name":"Bcbs","plan_name":"Anthem Nh Qhp Exchange","methodology":"fee schedule","standard_charge_dollar":11975.21,"additional_payer_notes":"MSDRG Base Rate"},{"payer_name":"Humana","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":11626.42,"additional_payer_notes":"MSDRG Base Rate"},{"payer_name":"Unitedhealthcare","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":11626.42,"additional_payer_notes":"MSDRG Base Rate"}]},{"setting":"inpatient","billing_class":"facility","payers_information":[{"payer_name":"Aetna","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[MSDRG Base Rate: FEE SCHEDULE]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Ambetter","plan_name":"Exchange","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Bcbs","plan_name":"Anthem Nh Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[MSDRG Base Rate: FEE SCHEDULE]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Bcbs","plan_name":"Anthem Nh Ppo/Indemnity/Fep","methodology":"other","standard_charge_algorithm":"[Stop Loss: Total Charges > 200000 | Excess % of Charge: 36.10] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [Nursery  Level 1- Boarder-Per Diem: 1668] [Nursery  Level 2-Per Diem: 1668] [Nursery  Level 3-Per Diem: 1668] [Nursery  Level 4-NICU-Per Diem: 1668]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Bcbs","plan_name":"Anthem Nh Qhp Exchange","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Humana","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[MSDRG Base Rate: FEE SCHEDULE]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Nh Healthy Families","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhhs.nh.gov/programs-services/medicaid]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Unitedhealthcare","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[MSDRG Base Rate: FEE SCHEDULE]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Usfhp","plan_name":"Government","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages Tricare methodology. Available, referenceable Tricare logic found here: https://www.health.mil/Military-Health-Topics/Access-Cost-Quality-and-Safety/TRICARE-Health-Plan/Rates-and-Reimbursement]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Wellcare Health Plan","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.mass.gov/topics/masshealth]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Wellsense Health Plan","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhhs.nh.gov/programs-services/medicaid]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."}]}]},{"description":"Appendix Procedures Without Cc/Mcc","code_information":[{"code":"399","type":"MS-DRG"}],"standard_charges":[{"setting":"inpatient","billing_class":"facility","minimum":8792.79,"maximum":26923.34,"payers_information":[{"payer_name":"Aetna","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":8968.65,"additional_payer_notes":"MSDRG Base Rate"},{"payer_name":"Ambetter","plan_name":"Exchange","methodology":"fee schedule","standard_charge_dollar":12309.91,"additional_payer_notes":"MSDRG Base Rate"},{"payer_name":"Bcbs","plan_name":"Anthem Nh Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":8792.79,"additional_payer_notes":"MSDRG Base Rate"},{"payer_name":"Bcbs","plan_name":"Anthem Nh Ppo/Indemnity/Fep","methodology":"fee schedule","standard_charge_dollar":26923.34},{"payer_name":"Bcbs","plan_name":"Anthem Nh Qhp Exchange","methodology":"fee schedule","standard_charge_dollar":9056.57,"additional_payer_notes":"MSDRG Base Rate"},{"payer_name":"Humana","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":8792.79,"additional_payer_notes":"MSDRG Base Rate"},{"payer_name":"Unitedhealthcare","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":8792.79,"additional_payer_notes":"MSDRG Base Rate"}]},{"setting":"inpatient","billing_class":"facility","payers_information":[{"payer_name":"Aetna","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[MSDRG Base Rate: FEE SCHEDULE]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Ambetter","plan_name":"Exchange","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Bcbs","plan_name":"Anthem Nh Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[MSDRG Base Rate: FEE SCHEDULE]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Bcbs","plan_name":"Anthem Nh Ppo/Indemnity/Fep","methodology":"other","standard_charge_algorithm":"[Stop Loss: Total Charges > 200000 | Excess % of Charge: 36.10] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [Nursery  Level 1- Boarder-Per Diem: 1668] [Nursery  Level 2-Per Diem: 1668] [Nursery  Level 3-Per Diem: 1668] [Nursery  Level 4-NICU-Per Diem: 1668]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Bcbs","plan_name":"Anthem Nh Qhp Exchange","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Humana","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[MSDRG Base Rate: FEE SCHEDULE]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Nh Healthy Families","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhhs.nh.gov/programs-services/medicaid]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Unitedhealthcare","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[MSDRG Base Rate: FEE SCHEDULE]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Usfhp","plan_name":"Government","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages Tricare methodology. Available, referenceable Tricare logic found here: https://www.health.mil/Military-Health-Topics/Access-Cost-Quality-and-Safety/TRICARE-Health-Plan/Rates-and-Reimbursement]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Wellcare Health Plan","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.mass.gov/topics/masshealth]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Wellsense Health Plan","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhhs.nh.gov/programs-services/medicaid]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."}]}]},{"description":"Major Gastrointestinal Disorders And Peritoneal Infections Without Cc/Mcc","code_information":[{"code":"373","type":"MS-DRG"}],"standard_charges":[{"setting":"inpatient","billing_class":"facility","minimum":5587.38,"maximum":17108.45,"payers_information":[{"payer_name":"Aetna","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":5699.13,"additional_payer_notes":"MSDRG Base Rate"},{"payer_name":"Ambetter","plan_name":"Exchange","methodology":"fee schedule","standard_charge_dollar":7822.33,"additional_payer_notes":"MSDRG Base Rate"},{"payer_name":"Bcbs","plan_name":"Anthem Nh Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":5587.38,"additional_payer_notes":"MSDRG Base Rate"},{"payer_name":"Bcbs","plan_name":"Anthem Nh Ppo/Indemnity/Fep","methodology":"fee schedule","standard_charge_dollar":17108.45},{"payer_name":"Bcbs","plan_name":"Anthem Nh Qhp Exchange","methodology":"fee schedule","standard_charge_dollar":5755.0,"additional_payer_notes":"MSDRG Base Rate"},{"payer_name":"Humana","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":5587.38,"additional_payer_notes":"MSDRG Base Rate"},{"payer_name":"Unitedhealthcare","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":5587.38,"additional_payer_notes":"MSDRG Base Rate"}]},{"setting":"inpatient","billing_class":"facility","payers_information":[{"payer_name":"Aetna","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[MSDRG Base Rate: FEE SCHEDULE]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Ambetter","plan_name":"Exchange","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Bcbs","plan_name":"Anthem Nh Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[MSDRG Base Rate: FEE SCHEDULE]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Bcbs","plan_name":"Anthem Nh Ppo/Indemnity/Fep","methodology":"other","standard_charge_algorithm":"[Stop Loss: Total Charges > 200000 | Excess % of Charge: 36.10] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [Nursery  Level 1- Boarder-Per Diem: 1668] [Nursery  Level 2-Per Diem: 1668] [Nursery  Level 3-Per Diem: 1668] [Nursery  Level 4-NICU-Per Diem: 1668]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Bcbs","plan_name":"Anthem Nh Qhp Exchange","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Humana","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[MSDRG Base Rate: FEE SCHEDULE]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Nh Healthy Families","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhhs.nh.gov/programs-services/medicaid]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Unitedhealthcare","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[MSDRG Base Rate: FEE SCHEDULE]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Usfhp","plan_name":"Government","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages Tricare methodology. Available, referenceable Tricare logic found here: https://www.health.mil/Military-Health-Topics/Access-Cost-Quality-and-Safety/TRICARE-Health-Plan/Rates-and-Reimbursement]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Wellcare Health Plan","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.mass.gov/topics/masshealth]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Wellsense Health Plan","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhhs.nh.gov/programs-services/medicaid]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."}]}]},{"description":"Major Gastrointestinal Disorders And Peritoneal Infections With Cc","code_information":[{"code":"372","type":"MS-DRG"}],"standard_charges":[{"setting":"inpatient","billing_class":"facility","minimum":7842.61,"maximum":24013.92,"payers_information":[{"payer_name":"Aetna","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":7999.46,"additional_payer_notes":"MSDRG Base Rate"},{"payer_name":"Ambetter","plan_name":"Exchange","methodology":"fee schedule","standard_charge_dollar":10979.65,"additional_payer_notes":"MSDRG Base Rate"},{"payer_name":"Bcbs","plan_name":"Anthem Nh Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":7842.61,"additional_payer_notes":"MSDRG Base Rate"},{"payer_name":"Bcbs","plan_name":"Anthem Nh Ppo/Indemnity/Fep","methodology":"fee schedule","standard_charge_dollar":24013.92},{"payer_name":"Bcbs","plan_name":"Anthem Nh Qhp Exchange","methodology":"fee schedule","standard_charge_dollar":8077.89,"additional_payer_notes":"MSDRG Base Rate"},{"payer_name":"Humana","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":7842.61,"additional_payer_notes":"MSDRG Base Rate"},{"payer_name":"Unitedhealthcare","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":7842.61,"additional_payer_notes":"MSDRG Base Rate"}]},{"setting":"inpatient","billing_class":"facility","payers_information":[{"payer_name":"Aetna","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[MSDRG Base Rate: FEE SCHEDULE]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Ambetter","plan_name":"Exchange","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Bcbs","plan_name":"Anthem Nh Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[MSDRG Base Rate: FEE SCHEDULE]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Bcbs","plan_name":"Anthem Nh Ppo/Indemnity/Fep","methodology":"other","standard_charge_algorithm":"[Stop Loss: Total Charges > 200000 | Excess % of Charge: 36.10] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [Nursery  Level 1- Boarder-Per Diem: 1668] [Nursery  Level 2-Per Diem: 1668] [Nursery  Level 3-Per Diem: 1668] [Nursery  Level 4-NICU-Per Diem: 1668]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Bcbs","plan_name":"Anthem Nh Qhp Exchange","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Humana","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[MSDRG Base Rate: FEE SCHEDULE]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Nh Healthy Families","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhhs.nh.gov/programs-services/medicaid]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Unitedhealthcare","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[MSDRG Base Rate: FEE SCHEDULE]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Usfhp","plan_name":"Government","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages Tricare methodology. Available, referenceable Tricare logic found here: https://www.health.mil/Military-Health-Topics/Access-Cost-Quality-and-Safety/TRICARE-Health-Plan/Rates-and-Reimbursement]","count":"1 through 10","median_amount":9945.59,"10th_percentile":9945.59,"90th_percentile":9945.59,"additional_payer_notes":"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm."},{"payer_name":"Wellcare Health Plan","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.mass.gov/topics/masshealth]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Wellsense Health Plan","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. 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Available, referenceable algorithm logic found here: https://www.dhhs.nh.gov/programs-services/medicaid]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."}]}]},{"description":"Percutaneous Cardiovascular Procedures Without Intraluminal Device Without Mcc","code_information":[{"code":"251","type":"MS-DRG"}],"standard_charges":[{"setting":"inpatient","billing_class":"facility","minimum":11479.71,"maximum":35150.64,"payers_information":[{"payer_name":"Aetna","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":11709.3,"additional_payer_notes":"MSDRG Base Rate"},{"payer_name":"Ambetter","plan_name":"Exchange","methodology":"fee schedule","standard_charge_dollar":16071.59,"additional_payer_notes":"MSDRG Base Rate"},{"payer_name":"Bcbs","plan_name":"Anthem Nh Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":11479.71,"additional_payer_notes":"MSDRG Base Rate"},{"payer_name":"Bcbs","plan_name":"Anthem Nh Ppo/Indemnity/Fep","methodology":"fee schedule","standard_charge_dollar":35150.64},{"payer_name":"Bcbs","plan_name":"Anthem Nh Qhp Exchange","methodology":"fee schedule","standard_charge_dollar":11824.1,"additional_payer_notes":"MSDRG Base Rate"},{"payer_name":"Humana","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":11479.71,"additional_payer_notes":"MSDRG Base Rate"},{"payer_name":"Unitedhealthcare","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":11479.71,"additional_payer_notes":"MSDRG Base Rate"}]},{"setting":"inpatient","billing_class":"facility","payers_information":[{"payer_name":"Aetna","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[MSDRG Base Rate: FEE SCHEDULE]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Ambetter","plan_name":"Exchange","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Bcbs","plan_name":"Anthem Nh Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[MSDRG Base Rate: FEE SCHEDULE]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Bcbs","plan_name":"Anthem Nh Ppo/Indemnity/Fep","methodology":"other","standard_charge_algorithm":"[Stop Loss: Total Charges > 200000 | Excess % of Charge: 36.10] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [Nursery  Level 1- Boarder-Per Diem: 1668] [Nursery  Level 2-Per Diem: 1668] [Nursery  Level 3-Per Diem: 1668] [Nursery  Level 4-NICU-Per Diem: 1668]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Bcbs","plan_name":"Anthem Nh Qhp Exchange","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Humana","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[MSDRG Base Rate: FEE SCHEDULE]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Nh Healthy Families","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. 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The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm."},{"payer_name":"Bcbs","plan_name":"Anthem Nh Qhp Exchange","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Humana","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[MSDRG Base Rate: FEE SCHEDULE]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Nh Healthy Families","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. 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Available, referenceable algorithm logic found here: https://www.dhhs.nh.gov/programs-services/medicaid]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."}]}]},{"description":"Pleural Effusion Without Cc/Mcc","code_information":[{"code":"188","type":"MS-DRG"}],"standard_charges":[{"setting":"inpatient","billing_class":"facility","minimum":5509.03,"maximum":16868.54,"payers_information":[{"payer_name":"Aetna","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":5619.21,"additional_payer_notes":"MSDRG Base Rate"},{"payer_name":"Ambetter","plan_name":"Exchange","methodology":"fee schedule","standard_charge_dollar":7712.64,"additional_payer_notes":"MSDRG Base Rate"},{"payer_name":"Bcbs","plan_name":"Anthem Nh Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":5509.03,"additional_payer_notes":"MSDRG Base Rate"},{"payer_name":"Bcbs","plan_name":"Anthem Nh Ppo/Indemnity/Fep","methodology":"fee schedule","standard_charge_dollar":16868.54},{"payer_name":"Bcbs","plan_name":"Anthem Nh Qhp Exchange","methodology":"fee schedule","standard_charge_dollar":5674.3,"additional_payer_notes":"MSDRG Base Rate"},{"payer_name":"Humana","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":5509.03,"additional_payer_notes":"MSDRG Base Rate"},{"payer_name":"Unitedhealthcare","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":5509.03,"additional_payer_notes":"MSDRG Base Rate"}]},{"setting":"inpatient","billing_class":"facility","payers_information":[{"payer_name":"Aetna","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[MSDRG Base Rate: FEE SCHEDULE]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Ambetter","plan_name":"Exchange","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Bcbs","plan_name":"Anthem Nh Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[MSDRG Base Rate: FEE SCHEDULE]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Bcbs","plan_name":"Anthem Nh Ppo/Indemnity/Fep","methodology":"other","standard_charge_algorithm":"[Stop Loss: Total Charges > 200000 | Excess % of Charge: 36.10] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [Nursery  Level 1- Boarder-Per Diem: 1668] [Nursery  Level 2-Per Diem: 1668] [Nursery  Level 3-Per Diem: 1668] [Nursery  Level 4-NICU-Per Diem: 1668]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Bcbs","plan_name":"Anthem Nh Qhp Exchange","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Humana","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[MSDRG Base Rate: FEE SCHEDULE]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Nh Healthy Families","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. 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Available, referenceable algorithm logic found here: https://www.dhhs.nh.gov/programs-services/medicaid]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."}]}]},{"description":"Multiple Sclerosis And Cerebellar Ataxia Without Cc/Mcc","code_information":[{"code":"060","type":"MS-DRG"}],"standard_charges":[{"setting":"inpatient","billing_class":"facility","minimum":7065.26,"maximum":21633.7,"payers_information":[{"payer_name":"Aetna","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":7206.57,"additional_payer_notes":"MSDRG Base Rate"},{"payer_name":"Ambetter","plan_name":"Exchange","methodology":"fee schedule","standard_charge_dollar":9891.36,"additional_payer_notes":"MSDRG Base Rate"},{"payer_name":"Bcbs","plan_name":"Anthem Nh Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":7065.26,"additional_payer_notes":"MSDRG Base Rate"},{"payer_name":"Bcbs","plan_name":"Anthem Nh Ppo/Indemnity/Fep","methodology":"fee schedule","standard_charge_dollar":21633.7},{"payer_name":"Bcbs","plan_name":"Anthem Nh Qhp Exchange","methodology":"fee schedule","standard_charge_dollar":7277.22,"additional_payer_notes":"MSDRG Base Rate"},{"payer_name":"Humana","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":7065.26,"additional_payer_notes":"MSDRG Base Rate"},{"payer_name":"Unitedhealthcare","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":7065.26,"additional_payer_notes":"MSDRG Base Rate"}]},{"setting":"inpatient","billing_class":"facility","payers_information":[{"payer_name":"Aetna","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[MSDRG Base Rate: FEE SCHEDULE]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Ambetter","plan_name":"Exchange","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Bcbs","plan_name":"Anthem Nh Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[MSDRG Base Rate: FEE SCHEDULE]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Bcbs","plan_name":"Anthem Nh Ppo/Indemnity/Fep","methodology":"other","standard_charge_algorithm":"[Stop Loss: Total Charges > 200000 | Excess % of Charge: 36.10] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [Nursery  Level 1- Boarder-Per Diem: 1668] [Nursery  Level 2-Per Diem: 1668] [Nursery  Level 3-Per Diem: 1668] [Nursery  Level 4-NICU-Per Diem: 1668]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Bcbs","plan_name":"Anthem Nh Qhp Exchange","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Humana","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[MSDRG Base Rate: FEE SCHEDULE]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Nh Healthy Families","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. 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Available, referenceable algorithm logic found here: https://www.dhhs.nh.gov/programs-services/medicaid]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."}]}]},{"description":"Percutaneous Coronary Atherectomy Without Intraluminal Device","code_information":[{"code":"318","type":"MS-DRG"}],"standard_charges":[{"setting":"inpatient","billing_class":"facility","minimum":18605.66,"maximum":56970.14,"payers_information":[{"payer_name":"Aetna","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":18977.77,"additional_payer_notes":"MSDRG Base Rate"},{"payer_name":"Ambetter","plan_name":"Exchange","methodology":"fee schedule","standard_charge_dollar":26047.92,"additional_payer_notes":"MSDRG Base Rate"},{"payer_name":"Bcbs","plan_name":"Anthem Nh Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":18605.66,"additional_payer_notes":"MSDRG Base Rate"},{"payer_name":"Bcbs","plan_name":"Anthem Nh Ppo/Indemnity/Fep","methodology":"fee schedule","standard_charge_dollar":56970.14},{"payer_name":"Bcbs","plan_name":"Anthem Nh Qhp Exchange","methodology":"fee schedule","standard_charge_dollar":19163.83,"additional_payer_notes":"MSDRG Base Rate"},{"payer_name":"Humana","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":18605.66,"additional_payer_notes":"MSDRG Base Rate"},{"payer_name":"Unitedhealthcare","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":18605.66,"additional_payer_notes":"MSDRG Base Rate"}]},{"setting":"inpatient","billing_class":"facility","payers_information":[{"payer_name":"Aetna","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[MSDRG Base Rate: FEE SCHEDULE]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Ambetter","plan_name":"Exchange","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Bcbs","plan_name":"Anthem Nh Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[MSDRG Base Rate: FEE SCHEDULE]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Bcbs","plan_name":"Anthem Nh Ppo/Indemnity/Fep","methodology":"other","standard_charge_algorithm":"[Stop Loss: Total Charges > 200000 | Excess % of Charge: 36.10] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [Nursery  Level 1- Boarder-Per Diem: 1668] [Nursery  Level 2-Per Diem: 1668] [Nursery  Level 3-Per Diem: 1668] [Nursery  Level 4-NICU-Per Diem: 1668]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Bcbs","plan_name":"Anthem Nh Qhp Exchange","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Humana","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[MSDRG Base Rate: FEE SCHEDULE]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Nh Healthy Families","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. 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The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm."},{"payer_name":"Humana","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[MSDRG Base Rate: FEE SCHEDULE]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Nh Healthy Families","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. 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The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm."},{"payer_name":"Usfhp","plan_name":"Government","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages Tricare methodology. Available, referenceable Tricare logic found here: https://www.health.mil/Military-Health-Topics/Access-Cost-Quality-and-Safety/TRICARE-Health-Plan/Rates-and-Reimbursement]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Wellcare Health Plan","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. 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The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm."},{"payer_name":"Nh Healthy Families","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhhs.nh.gov/programs-services/medicaid]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Unitedhealthcare","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[MSDRG Base Rate: FEE SCHEDULE]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Usfhp","plan_name":"Government","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages Tricare methodology. 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The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm."},{"payer_name":"Nh Healthy Families","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhhs.nh.gov/programs-services/medicaid]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Unitedhealthcare","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[MSDRG Base Rate: FEE SCHEDULE]","count":"1 through 10","median_amount":25898.61,"10th_percentile":25898.61,"90th_percentile":25898.61,"additional_payer_notes":"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm."},{"payer_name":"Usfhp","plan_name":"Government","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages Tricare methodology. Available, referenceable Tricare logic found here: https://www.health.mil/Military-Health-Topics/Access-Cost-Quality-and-Safety/TRICARE-Health-Plan/Rates-and-Reimbursement]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Wellcare Health Plan","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. 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The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm."},{"payer_name":"Usfhp","plan_name":"Government","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages Tricare methodology. Available, referenceable Tricare logic found here: https://www.health.mil/Military-Health-Topics/Access-Cost-Quality-and-Safety/TRICARE-Health-Plan/Rates-and-Reimbursement]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Wellcare Health Plan","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.mass.gov/topics/masshealth]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Wellsense Health Plan","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. 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The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm."},{"payer_name":"Nh Healthy Families","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhhs.nh.gov/programs-services/medicaid]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Unitedhealthcare","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[MSDRG Base Rate: FEE SCHEDULE]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Usfhp","plan_name":"Government","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages Tricare methodology. 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Available, referenceable algorithm logic found here: https://www.dhhs.nh.gov/programs-services/medicaid]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Unitedhealthcare","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[MSDRG Base Rate: FEE SCHEDULE]","count":"1 through 10","median_amount":10098.64,"10th_percentile":10098.64,"90th_percentile":10098.64,"additional_payer_notes":"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer’s algorithm."},{"payer_name":"Usfhp","plan_name":"Government","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages Tricare methodology. Available, referenceable Tricare logic found here: https://www.health.mil/Military-Health-Topics/Access-Cost-Quality-and-Safety/TRICARE-Health-Plan/Rates-and-Reimbursement]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Wellcare Health Plan","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.mass.gov/topics/masshealth]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Wellsense Health Plan","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhhs.nh.gov/programs-services/medicaid]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."}]}]},{"description":"Cranial And Peripheral Nerve Disorders With Mcc","code_information":[{"code":"073","type":"MS-DRG"}],"standard_charges":[{"setting":"inpatient","billing_class":"facility","minimum":12323.12,"maximum":37733.14,"payers_information":[{"payer_name":"Aetna","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":12569.58,"additional_payer_notes":"MSDRG Base Rate"},{"payer_name":"Ambetter","plan_name":"Exchange","methodology":"fee schedule","standard_charge_dollar":17252.37,"additional_payer_notes":"MSDRG Base Rate"},{"payer_name":"Bcbs","plan_name":"Anthem Nh Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":12323.12,"additional_payer_notes":"MSDRG Base Rate"},{"payer_name":"Bcbs","plan_name":"Anthem Nh Ppo/Indemnity/Fep","methodology":"fee schedul