hospital_name last_updated_on version hospital_location hospital_address license_number|MO "To the best of its knowledge and belief, the 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 indicated." "Little Hills Healthcare, LLC" 5/31/2024 2.0.0 "Weldon, Missouri" 4801 Weldon Spring Parkway license_4405455 | MO TRUE description code |1 code|1|type billing_class setting drug_unit_of_measurement drug_type_of_measurement modifiers standard_charge | gross standard_charge|discounted_cash standard_charge|min standard_charge | max standard_charge|[payer_AARP]|[plan_COMMERCIAL]|negotiated_dollar standard_charge|[payer_AARP]|[plan_COMMERCIAL] |negotiated_percentage standard_charge|[payer_AARP]|[plan_COMMERCIAL] |negotiated_algorithm estimated_amount|[payer_AARP]|[plan_COMMERCIAL] standard_charge|[payer_AARP]|[plan_COMMERCIAL] |methodology additional_payer_notes |[payer_AARP]|[Plan_COMMERCIAL] standard_charge|[payer_ADULT MEDICAID]|[plan_SELF PAY CHARITY]|negotiated_dollar standard_charge|[payer_ADULT MEDICAID]|[plan_SELF PAY CHARITY] |negotiated_percentage standard_charge|[payer_ADULT MEDICAID]|[plan_SELF PAY CHARITY] |negotiated_algorithm estimated_amount|[payer_ADULT MEDICAID]|[plan_SELF PAY CHARITY] standard_charge|[payer_ADULT MEDICAID]|[plan_SELF PAY CHARITY] |methodology additional_payer_notes |[payer_ADULT MEDICAID]|[Plan_SELF PAY CHARITY] standard_charge|[payer_AETNA]|[plan_HMO/PPO]|negotiated_dollar standard_charge|[payer_AETNA]|[plan_HMO/PPO] |negotiated_percentage standard_charge|[payer_AETNA]|[plan_HMO/PPO] |negotiated_algorithm estimated_amount|[payer_AETNA]|[plan_HMO/PPO] standard_charge|[payer_AETNA]|[plan_HMO/PPO] |methodology additional_payer_notes |[payer_AETNA]|[Plan_HMO/PPO] standard_charge|[payer_AETNA BETTER HEALTH ILL]|[plan_MANAGED MEDICAID]|negotiated_dollar standard_charge|[payer_AETNA BETTER HEALTH ILL]|[plan_MANAGED MEDICAID] |negotiated_percentage standard_charge|[payer_AETNA BETTER HEALTH ILL]|[plan_MANAGED MEDICAID] |negotiated_algorithm estimated_amount|[payer_AETNA BETTER HEALTH ILL]|[plan_MANAGED MEDICAID] standard_charge|[payer_AETNA BETTER HEALTH ILL]|[plan_MANAGED MEDICAID] |methodology additional_payer_notes |[payer_AETNA BETTER HEALTH ILL]|[Plan_MANAGED MEDICAID] standard_charge|[payer_AETNA BETTER HEALTH MCR]|[plan_MANAGED MEDICAID]|negotiated_dollar standard_charge|[payer_AETNA BETTER HEALTH MCR]|[plan_MANAGED MEDICAID] |negotiated_percentage standard_charge|[payer_AETNA BETTER HEALTH MCR]|[plan_MANAGED MEDICAID] |negotiated_algorithm estimated_amount|[payer_AETNA BETTER HEALTH MCR]|[plan_MANAGED MEDICAID] standard_charge|[payer_AETNA BETTER HEALTH MCR]|[plan_MANAGED MEDICAID] |methodology additional_payer_notes |[payer_AETNA BETTER HEALTH MCR]|[Plan_MANAGED MEDICAID] standard_charge|[payer_AETNA BETTER HEALTH MCR]|[plan_MANAGED MEDICARE]|negotiated_dollar standard_charge|[payer_AETNA BETTER HEALTH MCR]|[plan_MANAGED MEDICARE] |negotiated_percentage standard_charge|[payer_AETNA BETTER HEALTH MCR]|[plan_MANAGED MEDICARE] |negotiated_algorithm estimated_amount|[payer_AETNA BETTER HEALTH MCR]|[plan_MANAGED MEDICARE] standard_charge|[payer_AETNA BETTER HEALTH MCR]|[plan_MANAGED MEDICARE] |methodology additional_payer_notes |[payer_AETNA BETTER HEALTH MCR]|[Plan_MANAGED MEDICARE] standard_charge|[payer_AETNA MCR ADVANTAGE]|[plan_MANAGED MEDICARE]|negotiated_dollar standard_charge|[payer_AETNA MCR ADVANTAGE]|[plan_MANAGED MEDICARE] |negotiated_percentage standard_charge|[payer_AETNA MCR ADVANTAGE]|[plan_MANAGED MEDICARE] |negotiated_algorithm estimated_amount|[payer_AETNA MCR ADVANTAGE]|[plan_MANAGED MEDICARE] standard_charge|[payer_AETNA MCR ADVANTAGE]|[plan_MANAGED MEDICARE] |methodology additional_payer_notes |[payer_AETNA MCR ADVANTAGE]|[Plan_MANAGED MEDICARE] standard_charge|[payer_ALLEGIANCE CIGNA]|[plan_HMO/PPO]|negotiated_dollar standard_charge|[payer_ALLEGIANCE CIGNA]|[plan_HMO/PPO] |negotiated_percentage standard_charge|[payer_ALLEGIANCE CIGNA]|[plan_HMO/PPO] |negotiated_algorithm estimated_amount|[payer_ALLEGIANCE CIGNA]|[plan_HMO/PPO] standard_charge|[payer_ALLEGIANCE CIGNA]|[plan_HMO/PPO] |methodology additional_payer_notes |[payer_ALLEGIANCE CIGNA]|[Plan_HMO/PPO] standard_charge|[payer_ALLWELL]|[plan_MANAGED MEDICARE]|negotiated_dollar standard_charge|[payer_ALLWELL]|[plan_MANAGED MEDICARE] |negotiated_percentage standard_charge|[payer_ALLWELL]|[plan_MANAGED MEDICARE] |negotiated_algorithm estimated_amount|[payer_ALLWELL]|[plan_MANAGED MEDICARE] standard_charge|[payer_ALLWELL]|[plan_MANAGED MEDICARE] |methodology additional_payer_notes |[payer_ALLWELL]|[Plan_MANAGED MEDICARE] standard_charge|[payer_AMBETTER]|[plan_HMO/PPO]|negotiated_dollar standard_charge|[payer_AMBETTER]|[plan_HMO/PPO] |negotiated_percentage standard_charge|[payer_AMBETTER]|[plan_HMO/PPO] |negotiated_algorithm estimated_amount|[payer_AMBETTER]|[plan_HMO/PPO] standard_charge|[payer_AMBETTER]|[plan_HMO/PPO] |methodology additional_payer_notes |[payer_AMBETTER]|[Plan_HMO/PPO] standard_charge|[payer_AUXIANT]|[plan_COMMERCIAL]|negotiated_dollar standard_charge|[payer_AUXIANT]|[plan_COMMERCIAL] |negotiated_percentage standard_charge|[payer_AUXIANT]|[plan_COMMERCIAL] |negotiated_algorithm estimated_amount|[payer_AUXIANT]|[plan_COMMERCIAL] standard_charge|[payer_AUXIANT]|[plan_COMMERCIAL] |methodology additional_payer_notes |[payer_AUXIANT]|[Plan_COMMERCIAL] standard_charge|[payer_BCBS COMMUNITY PLAN ILL]|[plan_MANAGED MEDICAID]|negotiated_dollar standard_charge|[payer_BCBS COMMUNITY PLAN ILL]|[plan_MANAGED MEDICAID] |negotiated_percentage standard_charge|[payer_BCBS COMMUNITY PLAN ILL]|[plan_MANAGED MEDICAID] |negotiated_algorithm estimated_amount|[payer_BCBS COMMUNITY PLAN ILL]|[plan_MANAGED MEDICAID] standard_charge|[payer_BCBS COMMUNITY PLAN ILL]|[plan_MANAGED MEDICAID] |methodology additional_payer_notes |[payer_BCBS COMMUNITY PLAN ILL]|[Plan_MANAGED MEDICAID] standard_charge|[payer_BCBS FEDERAL]|[plan_BLUE CROSS]|negotiated_dollar standard_charge|[payer_BCBS FEDERAL]|[plan_BLUE CROSS] |negotiated_percentage standard_charge|[payer_BCBS FEDERAL]|[plan_BLUE CROSS] |negotiated_algorithm estimated_amount|[payer_BCBS FEDERAL]|[plan_BLUE CROSS] standard_charge|[payer_BCBS FEDERAL]|[plan_BLUE CROSS] |methodology additional_payer_notes |[payer_BCBS FEDERAL]|[Plan_BLUE CROSS] standard_charge|[payer_BCBS MCR ADVANTAGE]|[plan_MANAGED MEDICARE]|negotiated_dollar standard_charge|[payer_BCBS MCR ADVANTAGE]|[plan_MANAGED MEDICARE] |negotiated_percentage standard_charge|[payer_BCBS MCR ADVANTAGE]|[plan_MANAGED MEDICARE] |negotiated_algorithm estimated_amount|[payer_BCBS MCR ADVANTAGE]|[plan_MANAGED MEDICARE] standard_charge|[payer_BCBS MCR ADVANTAGE]|[plan_MANAGED MEDICARE] |methodology additional_payer_notes |[payer_BCBS MCR ADVANTAGE]|[Plan_MANAGED MEDICARE] standard_charge|[payer_BCBS MERCY EPO]|[plan_BLUE CROSS]|negotiated_dollar standard_charge|[payer_BCBS MERCY EPO]|[plan_BLUE CROSS] |negotiated_percentage standard_charge|[payer_BCBS MERCY EPO]|[plan_BLUE CROSS] |negotiated_algorithm estimated_amount|[payer_BCBS MERCY EPO]|[plan_BLUE CROSS] standard_charge|[payer_BCBS MERCY EPO]|[plan_BLUE CROSS] |methodology additional_payer_notes |[payer_BCBS MERCY EPO]|[Plan_BLUE CROSS] standard_charge|[payer_BCBS MO]|[plan_BLUE CROSS]|negotiated_dollar standard_charge|[payer_BCBS MO]|[plan_BLUE CROSS] |negotiated_percentage standard_charge|[payer_BCBS MO]|[plan_BLUE CROSS] |negotiated_algorithm estimated_amount|[payer_BCBS MO]|[plan_BLUE CROSS] standard_charge|[payer_BCBS MO]|[plan_BLUE CROSS] |methodology additional_payer_notes |[payer_BCBS MO]|[Plan_BLUE CROSS] standard_charge|[payer_BCBS OF ILL]|[plan_BLUE CROSS]|negotiated_dollar standard_charge|[payer_BCBS OF ILL]|[plan_BLUE CROSS] |negotiated_percentage standard_charge|[payer_BCBS OF ILL]|[plan_BLUE CROSS] |negotiated_algorithm estimated_amount|[payer_BCBS OF ILL]|[plan_BLUE CROSS] standard_charge|[payer_BCBS OF ILL]|[plan_BLUE CROSS] |methodology additional_payer_notes |[payer_BCBS OF ILL]|[Plan_BLUE CROSS] standard_charge|[payer_BCBS OUT OF STATE]|[plan_BLUE CROSS]|negotiated_dollar standard_charge|[payer_BCBS OUT OF STATE]|[plan_BLUE CROSS] |negotiated_percentage standard_charge|[payer_BCBS OUT OF STATE]|[plan_BLUE CROSS] |negotiated_algorithm estimated_amount|[payer_BCBS OUT OF STATE]|[plan_BLUE CROSS] standard_charge|[payer_BCBS OUT OF STATE]|[plan_BLUE CROSS] |methodology additional_payer_notes |[payer_BCBS OUT OF STATE]|[Plan_BLUE CROSS] standard_charge|[payer_BEHAVIORAL HEALTH SYSTEMS]|[plan_HMO/PPO]|negotiated_dollar standard_charge|[payer_BEHAVIORAL HEALTH SYSTEMS]|[plan_HMO/PPO] |negotiated_percentage standard_charge|[payer_BEHAVIORAL HEALTH SYSTEMS]|[plan_HMO/PPO] |negotiated_algorithm estimated_amount|[payer_BEHAVIORAL HEALTH SYSTEMS]|[plan_HMO/PPO] standard_charge|[payer_BEHAVIORAL HEALTH SYSTEMS]|[plan_HMO/PPO] |methodology additional_payer_notes |[payer_BEHAVIORAL HEALTH SYSTEMS]|[Plan_HMO/PPO] standard_charge|[payer_CARELON BEHAVIORAL HEALTH]|[plan_HMO/PPO]|negotiated_dollar standard_charge|[payer_CARELON BEHAVIORAL HEALTH]|[plan_HMO/PPO] |negotiated_percentage standard_charge|[payer_CARELON BEHAVIORAL HEALTH]|[plan_HMO/PPO] |negotiated_algorithm estimated_amount|[payer_CARELON BEHAVIORAL HEALTH]|[plan_HMO/PPO] standard_charge|[payer_CARELON BEHAVIORAL HEALTH]|[plan_HMO/PPO] |methodology additional_payer_notes |[payer_CARELON BEHAVIORAL HEALTH]|[Plan_HMO/PPO] standard_charge|[payer_CARPENTERS MERITAIN]|[plan_HMO/PPO]|negotiated_dollar standard_charge|[payer_CARPENTERS MERITAIN]|[plan_HMO/PPO] |negotiated_percentage standard_charge|[payer_CARPENTERS MERITAIN]|[plan_HMO/PPO] |negotiated_algorithm estimated_amount|[payer_CARPENTERS MERITAIN]|[plan_HMO/PPO] standard_charge|[payer_CARPENTERS MERITAIN]|[plan_HMO/PPO] |methodology additional_payer_notes |[payer_CARPENTERS MERITAIN]|[Plan_HMO/PPO] standard_charge|[payer_CHAMP VA]|[plan_VETERANS ADMIN]|negotiated_dollar standard_charge|[payer_CHAMP VA]|[plan_VETERANS ADMIN] |negotiated_percentage standard_charge|[payer_CHAMP VA]|[plan_VETERANS ADMIN] |negotiated_algorithm estimated_amount|[payer_CHAMP VA]|[plan_VETERANS ADMIN] standard_charge|[payer_CHAMP VA]|[plan_VETERANS ADMIN] |methodology additional_payer_notes |[payer_CHAMP VA]|[Plan_VETERANS ADMIN] standard_charge|[payer_CIGNA]|[plan_HMO/PPO]|negotiated_dollar standard_charge|[payer_CIGNA]|[plan_HMO/PPO] |negotiated_percentage standard_charge|[payer_CIGNA]|[plan_HMO/PPO] |negotiated_algorithm estimated_amount|[payer_CIGNA]|[plan_HMO/PPO] standard_charge|[payer_CIGNA]|[plan_HMO/PPO] |methodology additional_payer_notes |[payer_CIGNA]|[Plan_HMO/PPO] standard_charge|[payer_CIGNA MEDICARE]|[plan_MANAGED MEDICARE]|negotiated_dollar standard_charge|[payer_CIGNA MEDICARE]|[plan_MANAGED MEDICARE] |negotiated_percentage standard_charge|[payer_CIGNA MEDICARE]|[plan_MANAGED MEDICARE] |negotiated_algorithm estimated_amount|[payer_CIGNA MEDICARE]|[plan_MANAGED MEDICARE] standard_charge|[payer_CIGNA MEDICARE]|[plan_MANAGED MEDICARE] |methodology additional_payer_notes |[payer_CIGNA MEDICARE]|[Plan_MANAGED MEDICARE] standard_charge|[payer_COMPSYCH]|[plan_HMO/PPO]|negotiated_dollar standard_charge|[payer_COMPSYCH]|[plan_HMO/PPO] |negotiated_percentage standard_charge|[payer_COMPSYCH]|[plan_HMO/PPO] |negotiated_algorithm estimated_amount|[payer_COMPSYCH]|[plan_HMO/PPO] standard_charge|[payer_COMPSYCH]|[plan_HMO/PPO] |methodology additional_payer_notes |[payer_COMPSYCH]|[Plan_HMO/PPO] standard_charge|[payer_COX HEALTHPLANS]|[plan_COMMERCIAL]|negotiated_dollar standard_charge|[payer_COX HEALTHPLANS]|[plan_COMMERCIAL] |negotiated_percentage standard_charge|[payer_COX HEALTHPLANS]|[plan_COMMERCIAL] |negotiated_algorithm estimated_amount|[payer_COX HEALTHPLANS]|[plan_COMMERCIAL] standard_charge|[payer_COX HEALTHPLANS]|[plan_COMMERCIAL] |methodology additional_payer_notes |[payer_COX HEALTHPLANS]|[Plan_COMMERCIAL] standard_charge|[payer_DISTRICT 9 HEALTH & WELF]|[plan_COMMERCIAL]|negotiated_dollar standard_charge|[payer_DISTRICT 9 HEALTH & WELF]|[plan_COMMERCIAL] |negotiated_percentage standard_charge|[payer_DISTRICT 9 HEALTH & WELF]|[plan_COMMERCIAL] |negotiated_algorithm estimated_amount|[payer_DISTRICT 9 HEALTH & WELF]|[plan_COMMERCIAL] standard_charge|[payer_DISTRICT 9 HEALTH & WELF]|[plan_COMMERCIAL] |methodology additional_payer_notes |[payer_DISTRICT 9 HEALTH & WELF]|[Plan_COMMERCIAL] standard_charge|[payer_GOLDEN RULE]|[plan_HMO/PPO]|negotiated_dollar standard_charge|[payer_GOLDEN RULE]|[plan_HMO/PPO] |negotiated_percentage standard_charge|[payer_GOLDEN RULE]|[plan_HMO/PPO] |negotiated_algorithm estimated_amount|[payer_GOLDEN RULE]|[plan_HMO/PPO] standard_charge|[payer_GOLDEN RULE]|[plan_HMO/PPO] |methodology additional_payer_notes |[payer_GOLDEN RULE]|[Plan_HMO/PPO] standard_charge|[payer_HEALTH PARTNERS]|[plan_COMMERCIAL]|negotiated_dollar standard_charge|[payer_HEALTH PARTNERS]|[plan_COMMERCIAL] |negotiated_percentage standard_charge|[payer_HEALTH PARTNERS]|[plan_COMMERCIAL] |negotiated_algorithm estimated_amount|[payer_HEALTH PARTNERS]|[plan_COMMERCIAL] standard_charge|[payer_HEALTH PARTNERS]|[plan_COMMERCIAL] |methodology additional_payer_notes |[payer_HEALTH PARTNERS]|[Plan_COMMERCIAL] standard_charge|[payer_HEALTHCOMP]|[plan_HMO/PPO]|negotiated_dollar standard_charge|[payer_HEALTHCOMP]|[plan_HMO/PPO] |negotiated_percentage standard_charge|[payer_HEALTHCOMP]|[plan_HMO/PPO] |negotiated_algorithm estimated_amount|[payer_HEALTHCOMP]|[plan_HMO/PPO] standard_charge|[payer_HEALTHCOMP]|[plan_HMO/PPO] |methodology additional_payer_notes |[payer_HEALTHCOMP]|[Plan_HMO/PPO] standard_charge|[payer_HEALTHLINK HMO]|[plan_HMO/PPO]|negotiated_dollar standard_charge|[payer_HEALTHLINK HMO]|[plan_HMO/PPO] |negotiated_percentage standard_charge|[payer_HEALTHLINK HMO]|[plan_HMO/PPO] |negotiated_algorithm estimated_amount|[payer_HEALTHLINK HMO]|[plan_HMO/PPO] standard_charge|[payer_HEALTHLINK HMO]|[plan_HMO/PPO] |methodology additional_payer_notes |[payer_HEALTHLINK HMO]|[Plan_HMO/PPO] standard_charge|[payer_HEALTHLINK PPO]|[plan_HMO/PPO]|negotiated_dollar standard_charge|[payer_HEALTHLINK PPO]|[plan_HMO/PPO] |negotiated_percentage standard_charge|[payer_HEALTHLINK PPO]|[plan_HMO/PPO] |negotiated_algorithm estimated_amount|[payer_HEALTHLINK PPO]|[plan_HMO/PPO] standard_charge|[payer_HEALTHLINK PPO]|[plan_HMO/PPO] |methodology additional_payer_notes |[payer_HEALTHLINK PPO]|[Plan_HMO/PPO] standard_charge|[payer_HEALTHLINK PPO SOI]|[plan_HMO/PPO]|negotiated_dollar standard_charge|[payer_HEALTHLINK PPO SOI]|[plan_HMO/PPO] |negotiated_percentage standard_charge|[payer_HEALTHLINK PPO SOI]|[plan_HMO/PPO] |negotiated_algorithm estimated_amount|[payer_HEALTHLINK PPO SOI]|[plan_HMO/PPO] standard_charge|[payer_HEALTHLINK PPO SOI]|[plan_HMO/PPO] |methodology additional_payer_notes |[payer_HEALTHLINK PPO SOI]|[Plan_HMO/PPO] standard_charge|[payer_HEALTHY BLUE]|[plan_MANAGED MEDICAID]|negotiated_dollar standard_charge|[payer_HEALTHY BLUE]|[plan_MANAGED MEDICAID] |negotiated_percentage standard_charge|[payer_HEALTHY BLUE]|[plan_MANAGED MEDICAID] |negotiated_algorithm estimated_amount|[payer_HEALTHY BLUE]|[plan_MANAGED MEDICAID] standard_charge|[payer_HEALTHY BLUE]|[plan_MANAGED MEDICAID] |methodology additional_payer_notes |[payer_HEALTHY BLUE]|[Plan_MANAGED MEDICAID] standard_charge|[payer_HOME STATE CENPATICO]|[plan_MANAGED MEDICAID]|negotiated_dollar standard_charge|[payer_HOME STATE CENPATICO]|[plan_MANAGED MEDICAID] |negotiated_percentage standard_charge|[payer_HOME STATE CENPATICO]|[plan_MANAGED MEDICAID] |negotiated_algorithm estimated_amount|[payer_HOME STATE CENPATICO]|[plan_MANAGED MEDICAID] standard_charge|[payer_HOME STATE CENPATICO]|[plan_MANAGED MEDICAID] |methodology additional_payer_notes |[payer_HOME STATE CENPATICO]|[Plan_MANAGED MEDICAID] standard_charge|[payer_HUMANA COMMERCIAL]|[plan_HMO/PPO]|negotiated_dollar standard_charge|[payer_HUMANA COMMERCIAL]|[plan_HMO/PPO] |negotiated_percentage standard_charge|[payer_HUMANA COMMERCIAL]|[plan_HMO/PPO] |negotiated_algorithm estimated_amount|[payer_HUMANA COMMERCIAL]|[plan_HMO/PPO] standard_charge|[payer_HUMANA COMMERCIAL]|[plan_HMO/PPO] |methodology additional_payer_notes |[payer_HUMANA COMMERCIAL]|[Plan_HMO/PPO] standard_charge|[payer_HUMANA MEDICARE HMO]|[plan_MANAGED MEDICARE]|negotiated_dollar standard_charge|[payer_HUMANA MEDICARE HMO]|[plan_MANAGED MEDICARE] |negotiated_percentage standard_charge|[payer_HUMANA MEDICARE HMO]|[plan_MANAGED MEDICARE] |negotiated_algorithm estimated_amount|[payer_HUMANA MEDICARE HMO]|[plan_MANAGED MEDICARE] standard_charge|[payer_HUMANA MEDICARE HMO]|[plan_MANAGED MEDICARE] |methodology additional_payer_notes |[payer_HUMANA MEDICARE HMO]|[Plan_MANAGED MEDICARE] standard_charge|[payer_IBEW]|[plan_HMO/PPO]|negotiated_dollar standard_charge|[payer_IBEW]|[plan_HMO/PPO] |negotiated_percentage standard_charge|[payer_IBEW]|[plan_HMO/PPO] |negotiated_algorithm estimated_amount|[payer_IBEW]|[plan_HMO/PPO] standard_charge|[payer_IBEW]|[plan_HMO/PPO] |methodology additional_payer_notes |[payer_IBEW]|[Plan_HMO/PPO] standard_charge|[payer_LINECO]|[plan_HMO/PPO]|negotiated_dollar standard_charge|[payer_LINECO]|[plan_HMO/PPO] |negotiated_percentage standard_charge|[payer_LINECO]|[plan_HMO/PPO] |negotiated_algorithm estimated_amount|[payer_LINECO]|[plan_HMO/PPO] standard_charge|[payer_LINECO]|[plan_HMO/PPO] |methodology additional_payer_notes |[payer_LINECO]|[Plan_HMO/PPO] standard_charge|[payer_MAGELLAN]|[plan_HMO/PPO]|negotiated_dollar standard_charge|[payer_MAGELLAN]|[plan_HMO/PPO] |negotiated_percentage standard_charge|[payer_MAGELLAN]|[plan_HMO/PPO] |negotiated_algorithm estimated_amount|[payer_MAGELLAN]|[plan_HMO/PPO] standard_charge|[payer_MAGELLAN]|[plan_HMO/PPO] |methodology additional_payer_notes |[payer_MAGELLAN]|[Plan_HMO/PPO] standard_charge|[payer_MANAGED HEALTH NETWORK]|[plan_MANAGED MEDICARE]|negotiated_dollar standard_charge|[payer_MANAGED HEALTH NETWORK]|[plan_MANAGED MEDICARE] |negotiated_percentage standard_charge|[payer_MANAGED HEALTH NETWORK]|[plan_MANAGED MEDICARE] |negotiated_algorithm estimated_amount|[payer_MANAGED HEALTH NETWORK]|[plan_MANAGED MEDICARE] standard_charge|[payer_MANAGED HEALTH NETWORK]|[plan_MANAGED MEDICARE] |methodology additional_payer_notes |[payer_MANAGED HEALTH NETWORK]|[Plan_MANAGED MEDICARE] standard_charge|[payer_MEDICA]|[plan_HMO/PPO]|negotiated_dollar standard_charge|[payer_MEDICA]|[plan_HMO/PPO] |negotiated_percentage standard_charge|[payer_MEDICA]|[plan_HMO/PPO] |negotiated_algorithm estimated_amount|[payer_MEDICA]|[plan_HMO/PPO] standard_charge|[payer_MEDICA]|[plan_HMO/PPO] |methodology additional_payer_notes |[payer_MEDICA]|[Plan_HMO/PPO] standard_charge|[payer_MEDICAID COLORADO]|[plan_MEDICAID: OUT OF STATE]|negotiated_dollar standard_charge|[payer_MEDICAID COLORADO]|[plan_MEDICAID: OUT OF STATE] |negotiated_percentage standard_charge|[payer_MEDICAID COLORADO]|[plan_MEDICAID: OUT OF STATE] |negotiated_algorithm estimated_amount|[payer_MEDICAID COLORADO]|[plan_MEDICAID: OUT OF STATE] standard_charge|[payer_MEDICAID COLORADO]|[plan_MEDICAID: OUT OF STATE] |methodology additional_payer_notes |[payer_MEDICAID COLORADO]|[Plan_MEDICAID: OUT OF STATE] standard_charge|[payer_MEDICAID ILLINOIS]|[plan_MEDICAID: OUT OF STATE]|negotiated_dollar standard_charge|[payer_MEDICAID ILLINOIS]|[plan_MEDICAID: OUT OF STATE] |negotiated_percentage standard_charge|[payer_MEDICAID ILLINOIS]|[plan_MEDICAID: OUT OF STATE] |negotiated_algorithm estimated_amount|[payer_MEDICAID ILLINOIS]|[plan_MEDICAID: OUT OF STATE] standard_charge|[payer_MEDICAID ILLINOIS]|[plan_MEDICAID: OUT OF STATE] |methodology additional_payer_notes |[payer_MEDICAID ILLINOIS]|[Plan_MEDICAID: OUT OF STATE] standard_charge|[payer_MEDICAID MISSOURI]|[plan_MEDICAID ]|negotiated_dollar standard_charge|[payer_MEDICAID MISSOURI]|[plan_MEDICAID ] |negotiated_percentage standard_charge|[payer_MEDICAID MISSOURI]|[plan_MEDICAID ] |negotiated_algorithm estimated_amount|[payer_MEDICAID MISSOURI]|[plan_MEDICAID ] standard_charge|[payer_MEDICAID MISSOURI]|[plan_MEDICAID ] |methodology additional_payer_notes |[payer_MEDICAID MISSOURI]|[Plan_MEDICAID ] standard_charge|[payer_MEDICAID NEBRASKA]|[plan_MEDICAID: OUT OF STATE]|negotiated_dollar standard_charge|[payer_MEDICAID NEBRASKA]|[plan_MEDICAID: OUT OF STATE] |negotiated_percentage standard_charge|[payer_MEDICAID NEBRASKA]|[plan_MEDICAID: OUT OF STATE] |negotiated_algorithm estimated_amount|[payer_MEDICAID NEBRASKA]|[plan_MEDICAID: OUT OF STATE] standard_charge|[payer_MEDICAID NEBRASKA]|[plan_MEDICAID: OUT OF STATE] |methodology additional_payer_notes |[payer_MEDICAID NEBRASKA]|[Plan_MEDICAID: OUT OF STATE] standard_charge|[payer_MEDICAID PENDING]|[plan_PENDING MEDICAID]|negotiated_dollar standard_charge|[payer_MEDICAID PENDING]|[plan_PENDING MEDICAID] |negotiated_percentage standard_charge|[payer_MEDICAID PENDING]|[plan_PENDING MEDICAID] |negotiated_algorithm estimated_amount|[payer_MEDICAID PENDING]|[plan_PENDING MEDICAID] standard_charge|[payer_MEDICAID PENDING]|[plan_PENDING MEDICAID] |methodology additional_payer_notes |[payer_MEDICAID PENDING]|[Plan_PENDING MEDICAID] standard_charge|[payer_MEDICARE]|[plan_MEDICARE]|negotiated_dollar standard_charge|[payer_MEDICARE]|[plan_MEDICARE] |negotiated_percentage standard_charge|[payer_MEDICARE]|[plan_MEDICARE] |negotiated_algorithm estimated_amount|[payer_MEDICARE]|[plan_MEDICARE] standard_charge|[payer_MEDICARE]|[plan_MEDICARE] |methodology additional_payer_notes |[payer_MEDICARE]|[Plan_MEDICARE] standard_charge|[payer_MEDICARE ESSENCE HEALTH]|[plan_MANAGED MEDICARE]|negotiated_dollar standard_charge|[payer_MEDICARE ESSENCE HEALTH]|[plan_MANAGED MEDICARE] |negotiated_percentage standard_charge|[payer_MEDICARE ESSENCE HEALTH]|[plan_MANAGED MEDICARE] |negotiated_algorithm estimated_amount|[payer_MEDICARE ESSENCE HEALTH]|[plan_MANAGED MEDICARE] standard_charge|[payer_MEDICARE ESSENCE HEALTH]|[plan_MANAGED MEDICARE] |methodology additional_payer_notes |[payer_MEDICARE ESSENCE HEALTH]|[Plan_MANAGED MEDICARE] standard_charge|[payer_MERCY BENEFIT ADMIN]|[plan_HMO/PPO]|negotiated_dollar standard_charge|[payer_MERCY BENEFIT ADMIN]|[plan_HMO/PPO] |negotiated_percentage standard_charge|[payer_MERCY BENEFIT ADMIN]|[plan_HMO/PPO] |negotiated_algorithm estimated_amount|[payer_MERCY BENEFIT ADMIN]|[plan_HMO/PPO] standard_charge|[payer_MERCY BENEFIT ADMIN]|[plan_HMO/PPO] |methodology additional_payer_notes |[payer_MERCY BENEFIT ADMIN]|[Plan_HMO/PPO] standard_charge|[payer_MERCY HEALTH PLANS]|[plan_HMO/PPO]|negotiated_dollar standard_charge|[payer_MERCY HEALTH PLANS]|[plan_HMO/PPO] |negotiated_percentage standard_charge|[payer_MERCY HEALTH PLANS]|[plan_HMO/PPO] |negotiated_algorithm estimated_amount|[payer_MERCY HEALTH PLANS]|[plan_HMO/PPO] standard_charge|[payer_MERCY HEALTH PLANS]|[plan_HMO/PPO] |methodology additional_payer_notes |[payer_MERCY HEALTH PLANS]|[Plan_HMO/PPO] standard_charge|[payer_MERIDIAN HEALTHPLANS ILL]|[plan_MANAGED MEDICAID]|negotiated_dollar standard_charge|[payer_MERIDIAN HEALTHPLANS ILL]|[plan_MANAGED MEDICAID] |negotiated_percentage standard_charge|[payer_MERIDIAN HEALTHPLANS ILL]|[plan_MANAGED MEDICAID] |negotiated_algorithm estimated_amount|[payer_MERIDIAN HEALTHPLANS ILL]|[plan_MANAGED MEDICAID] standard_charge|[payer_MERIDIAN HEALTHPLANS ILL]|[plan_MANAGED MEDICAID] |methodology additional_payer_notes |[payer_MERIDIAN HEALTHPLANS ILL]|[Plan_MANAGED MEDICAID] standard_charge|[payer_MERITAIN]|[plan_HMO/PPO]|negotiated_dollar standard_charge|[payer_MERITAIN]|[plan_HMO/PPO] |negotiated_percentage standard_charge|[payer_MERITAIN]|[plan_HMO/PPO] |negotiated_algorithm estimated_amount|[payer_MERITAIN]|[plan_HMO/PPO] standard_charge|[payer_MERITAIN]|[plan_HMO/PPO] |methodology additional_payer_notes |[payer_MERITAIN]|[Plan_HMO/PPO] standard_charge|[payer_MISC HMO/PPO]|[plan_HMO/PPO]|negotiated_dollar standard_charge|[payer_MISC HMO/PPO]|[plan_HMO/PPO] |negotiated_percentage standard_charge|[payer_MISC HMO/PPO]|[plan_HMO/PPO] |negotiated_algorithm estimated_amount|[payer_MISC HMO/PPO]|[plan_HMO/PPO] standard_charge|[payer_MISC HMO/PPO]|[plan_HMO/PPO] |methodology additional_payer_notes |[payer_MISC HMO/PPO]|[Plan_HMO/PPO] standard_charge|[payer_MISC MGD MCARE]|[plan_MANAGED MEDICARE]|negotiated_dollar standard_charge|[payer_MISC MGD MCARE]|[plan_MANAGED MEDICARE] |negotiated_percentage standard_charge|[payer_MISC MGD MCARE]|[plan_MANAGED MEDICARE] |negotiated_algorithm estimated_amount|[payer_MISC MGD MCARE]|[plan_MANAGED MEDICARE] standard_charge|[payer_MISC MGD MCARE]|[plan_MANAGED MEDICARE] |methodology additional_payer_notes |[payer_MISC MGD MCARE]|[Plan_MANAGED MEDICARE] standard_charge|[payer_MO BLUE CROSS PATHWAYS]|[plan_BLUE CROSS]|negotiated_dollar standard_charge|[payer_MO BLUE CROSS PATHWAYS]|[plan_BLUE CROSS] |negotiated_percentage standard_charge|[payer_MO BLUE CROSS PATHWAYS]|[plan_BLUE CROSS] |negotiated_algorithm estimated_amount|[payer_MO BLUE CROSS PATHWAYS]|[plan_BLUE CROSS] standard_charge|[payer_MO BLUE CROSS PATHWAYS]|[plan_BLUE CROSS] |methodology additional_payer_notes |[payer_MO BLUE CROSS PATHWAYS]|[Plan_BLUE CROSS] standard_charge|[payer_MOLINA HEALTHCARE OF ILL]|[plan_MANAGED MEDICAID]|negotiated_dollar standard_charge|[payer_MOLINA HEALTHCARE OF ILL]|[plan_MANAGED MEDICAID] |negotiated_percentage standard_charge|[payer_MOLINA HEALTHCARE OF ILL]|[plan_MANAGED MEDICAID] |negotiated_algorithm estimated_amount|[payer_MOLINA HEALTHCARE OF ILL]|[plan_MANAGED MEDICAID] standard_charge|[payer_MOLINA HEALTHCARE OF ILL]|[plan_MANAGED MEDICAID] |methodology additional_payer_notes |[payer_MOLINA HEALTHCARE OF ILL]|[Plan_MANAGED MEDICAID] standard_charge|[payer_NE DHHS]|[plan_MEDICAID: OUT OF STATE]|negotiated_dollar standard_charge|[payer_NE DHHS]|[plan_MEDICAID: OUT OF STATE] |negotiated_percentage standard_charge|[payer_NE DHHS]|[plan_MEDICAID: OUT OF STATE] |negotiated_algorithm estimated_amount|[payer_NE DHHS]|[plan_MEDICAID: OUT OF STATE] standard_charge|[payer_NE DHHS]|[plan_MEDICAID: OUT OF STATE] |methodology additional_payer_notes |[payer_NE DHHS]|[Plan_MEDICAID: OUT OF STATE] standard_charge|[payer_PROVIDER PARTNERS HEALTH]|[plan_MANAGED MEDICARE]|negotiated_dollar standard_charge|[payer_PROVIDER PARTNERS HEALTH]|[plan_MANAGED MEDICARE] |negotiated_percentage standard_charge|[payer_PROVIDER PARTNERS HEALTH]|[plan_MANAGED MEDICARE] |negotiated_algorithm estimated_amount|[payer_PROVIDER PARTNERS HEALTH]|[plan_MANAGED MEDICARE] standard_charge|[payer_PROVIDER PARTNERS HEALTH]|[plan_MANAGED MEDICARE] |methodology additional_payer_notes |[payer_PROVIDER PARTNERS HEALTH]|[Plan_MANAGED MEDICARE] standard_charge|[payer_RURAL CARRIER BENEFIT]|[plan_HMO/PPO]|negotiated_dollar standard_charge|[payer_RURAL CARRIER BENEFIT]|[plan_HMO/PPO] |negotiated_percentage standard_charge|[payer_RURAL CARRIER BENEFIT]|[plan_HMO/PPO] |negotiated_algorithm estimated_amount|[payer_RURAL CARRIER BENEFIT]|[plan_HMO/PPO] standard_charge|[payer_RURAL CARRIER BENEFIT]|[plan_HMO/PPO] |methodology additional_payer_notes |[payer_RURAL CARRIER BENEFIT]|[Plan_HMO/PPO] standard_charge|[payer_SUREST]|[plan_HMO/PPO]|negotiated_dollar standard_charge|[payer_SUREST]|[plan_HMO/PPO] |negotiated_percentage standard_charge|[payer_SUREST]|[plan_HMO/PPO] |negotiated_algorithm estimated_amount|[payer_SUREST]|[plan_HMO/PPO] standard_charge|[payer_SUREST]|[plan_HMO/PPO] |methodology additional_payer_notes |[payer_SUREST]|[Plan_HMO/PPO] standard_charge|[payer_TRICARE EAST]|[plan_TRICARE]|negotiated_dollar standard_charge|[payer_TRICARE EAST]|[plan_TRICARE] |negotiated_percentage standard_charge|[payer_TRICARE EAST]|[plan_TRICARE] |negotiated_algorithm estimated_amount|[payer_TRICARE EAST]|[plan_TRICARE] standard_charge|[payer_TRICARE EAST]|[plan_TRICARE] |methodology additional_payer_notes |[payer_TRICARE EAST]|[Plan_TRICARE] standard_charge|[payer_TRICARE FOR LIFE]|[plan_COMMERCIAL]|negotiated_dollar standard_charge|[payer_TRICARE FOR LIFE]|[plan_COMMERCIAL] |negotiated_percentage standard_charge|[payer_TRICARE FOR LIFE]|[plan_COMMERCIAL] |negotiated_algorithm estimated_amount|[payer_TRICARE FOR LIFE]|[plan_COMMERCIAL] standard_charge|[payer_TRICARE FOR LIFE]|[plan_COMMERCIAL] |methodology additional_payer_notes |[payer_TRICARE FOR LIFE]|[Plan_COMMERCIAL] standard_charge|[payer_TRICARE WEST]|[plan_TRICARE]|negotiated_dollar standard_charge|[payer_TRICARE WEST]|[plan_TRICARE] |negotiated_percentage standard_charge|[payer_TRICARE WEST]|[plan_TRICARE] |negotiated_algorithm estimated_amount|[payer_TRICARE WEST]|[plan_TRICARE] standard_charge|[payer_TRICARE WEST]|[plan_TRICARE] |methodology additional_payer_notes |[payer_TRICARE WEST]|[Plan_TRICARE] standard_charge|[payer_UHC]|[plan_HMO/PPO]|negotiated_dollar standard_charge|[payer_UHC]|[plan_HMO/PPO] |negotiated_percentage standard_charge|[payer_UHC]|[plan_HMO/PPO] |negotiated_algorithm estimated_amount|[payer_UHC]|[plan_HMO/PPO] standard_charge|[payer_UHC]|[plan_HMO/PPO] |methodology additional_payer_notes |[payer_UHC]|[Plan_HMO/PPO] standard_charge|[payer_UHC ALL SAVERS]|[plan_HMO/PPO]|negotiated_dollar standard_charge|[payer_UHC ALL SAVERS]|[plan_HMO/PPO] |negotiated_percentage standard_charge|[payer_UHC ALL SAVERS]|[plan_HMO/PPO] |negotiated_algorithm estimated_amount|[payer_UHC ALL SAVERS]|[plan_HMO/PPO] standard_charge|[payer_UHC ALL SAVERS]|[plan_HMO/PPO] |methodology additional_payer_notes |[payer_UHC ALL SAVERS]|[Plan_HMO/PPO] standard_charge|[payer_UHC CARE IMPROVEMENT PLUS]|[plan_MANAGED MEDICARE]|negotiated_dollar standard_charge|[payer_UHC CARE IMPROVEMENT PLUS]|[plan_MANAGED MEDICARE] |negotiated_percentage standard_charge|[payer_UHC CARE IMPROVEMENT PLUS]|[plan_MANAGED MEDICARE] |negotiated_algorithm estimated_amount|[payer_UHC CARE IMPROVEMENT PLUS]|[plan_MANAGED MEDICARE] standard_charge|[payer_UHC CARE IMPROVEMENT PLUS]|[plan_MANAGED MEDICARE] |methodology additional_payer_notes |[payer_UHC CARE IMPROVEMENT PLUS]|[Plan_MANAGED MEDICARE] standard_charge|[payer_UHC COMM MCARE]|[plan_MANAGED MEDICARE]|negotiated_dollar standard_charge|[payer_UHC COMM MCARE]|[plan_MANAGED MEDICARE] |negotiated_percentage standard_charge|[payer_UHC COMM MCARE]|[plan_MANAGED MEDICARE] |negotiated_algorithm estimated_amount|[payer_UHC COMM MCARE]|[plan_MANAGED MEDICARE] standard_charge|[payer_UHC COMM MCARE]|[plan_MANAGED MEDICARE] |methodology additional_payer_notes |[payer_UHC COMM MCARE]|[Plan_MANAGED MEDICARE] standard_charge|[payer_UHC COMPLETE]|[plan_MANAGED MEDICARE]|negotiated_dollar standard_charge|[payer_UHC COMPLETE]|[plan_MANAGED MEDICARE] |negotiated_percentage standard_charge|[payer_UHC COMPLETE]|[plan_MANAGED MEDICARE] |negotiated_algorithm estimated_amount|[payer_UHC COMPLETE]|[plan_MANAGED MEDICARE] standard_charge|[payer_UHC COMPLETE]|[plan_MANAGED MEDICARE] |methodology additional_payer_notes |[payer_UHC COMPLETE]|[Plan_MANAGED MEDICARE] standard_charge|[payer_UHC OF MIDWEST]|[plan_MANAGED MEDICAID]|negotiated_dollar standard_charge|[payer_UHC OF MIDWEST]|[plan_MANAGED MEDICAID] |negotiated_percentage standard_charge|[payer_UHC OF MIDWEST]|[plan_MANAGED MEDICAID] |negotiated_algorithm estimated_amount|[payer_UHC OF MIDWEST]|[plan_MANAGED MEDICAID] standard_charge|[payer_UHC OF MIDWEST]|[plan_MANAGED MEDICAID] |methodology additional_payer_notes |[payer_UHC OF MIDWEST]|[Plan_MANAGED MEDICAID] standard_charge|[payer_UHC SHARED SERVICES]|[plan_HMO/PPO]|negotiated_dollar standard_charge|[payer_UHC SHARED SERVICES]|[plan_HMO/PPO] |negotiated_percentage standard_charge|[payer_UHC SHARED SERVICES]|[plan_HMO/PPO] |negotiated_algorithm estimated_amount|[payer_UHC SHARED SERVICES]|[plan_HMO/PPO] standard_charge|[payer_UHC SHARED SERVICES]|[plan_HMO/PPO] |methodology additional_payer_notes |[payer_UHC SHARED SERVICES]|[Plan_HMO/PPO] standard_charge|[payer_UMR]|[plan_HMO/PPO]|negotiated_dollar standard_charge|[payer_UMR]|[plan_HMO/PPO] |negotiated_percentage standard_charge|[payer_UMR]|[plan_HMO/PPO] |negotiated_algorithm estimated_amount|[payer_UMR]|[plan_HMO/PPO] standard_charge|[payer_UMR]|[plan_HMO/PPO] |methodology additional_payer_notes |[payer_UMR]|[Plan_HMO/PPO] standard_charge|[payer_VA CCN OPTUM]|[plan_VETERANS ADMIN]|negotiated_dollar standard_charge|[payer_VA CCN OPTUM]|[plan_VETERANS ADMIN] |negotiated_percentage standard_charge|[payer_VA CCN OPTUM]|[plan_VETERANS ADMIN] |negotiated_algorithm estimated_amount|[payer_VA CCN OPTUM]|[plan_VETERANS ADMIN] standard_charge|[payer_VA CCN OPTUM]|[plan_VETERANS ADMIN] |methodology additional_payer_notes |[payer_VA CCN OPTUM]|[Plan_VETERANS ADMIN] standard_charge|[payer_WEB TPA AETNA]|[plan_HMO/PPO]|negotiated_dollar standard_charge|[payer_WEB TPA AETNA]|[plan_HMO/PPO] |negotiated_percentage standard_charge|[payer_WEB TPA AETNA]|[plan_HMO/PPO] |negotiated_algorithm estimated_amount|[payer_WEB TPA AETNA]|[plan_HMO/PPO] standard_charge|[payer_WEB TPA AETNA]|[plan_HMO/PPO] |methodology additional_payer_notes |[payer_WEB TPA AETNA]|[Plan_HMO/PPO] standard_charge|[payer_WEB TPA CIGNA]|[plan_HMO/PPO]|negotiated_dollar standard_charge|[payer_WEB TPA CIGNA]|[plan_HMO/PPO] |negotiated_percentage standard_charge|[payer_WEB TPA CIGNA]|[plan_HMO/PPO] |negotiated_algorithm estimated_amount|[payer_WEB TPA CIGNA]|[plan_HMO/PPO] standard_charge|[payer_WEB TPA CIGNA]|[plan_HMO/PPO] |methodology additional_payer_notes |[payer_WEB TPA CIGNA]|[Plan_HMO/PPO] standard_charge|[payer_WELLCARE HEALTH PLANS]|[plan_MANAGED MEDICARE]|negotiated_dollar standard_charge|[payer_WELLCARE HEALTH PLANS]|[plan_MANAGED MEDICARE] |negotiated_percentage standard_charge|[payer_WELLCARE HEALTH PLANS]|[plan_MANAGED MEDICARE] |negotiated_algorithm estimated_amount|[payer_WELLCARE HEALTH PLANS]|[plan_MANAGED MEDICARE] standard_charge|[payer_WELLCARE HEALTH PLANS]|[plan_MANAGED MEDICARE] |methodology additional_payer_notes |[payer_WELLCARE HEALTH PLANS]|[Plan_MANAGED MEDICARE] standard_charge|[payer_WELLFIRST]|[plan_HMO/PPO]|negotiated_dollar standard_charge|[payer_WELLFIRST]|[plan_HMO/PPO] |negotiated_percentage standard_charge|[payer_WELLFIRST]|[plan_HMO/PPO] |negotiated_algorithm estimated_amount|[payer_WELLFIRST]|[plan_HMO/PPO] standard_charge|[payer_WELLFIRST]|[plan_HMO/PPO] |methodology additional_payer_notes |[payer_WELLFIRST]|[Plan_HMO/PPO] standard_charge|[payer_WELLFIRST MCARE]|[plan_MANAGED MEDICARE]|negotiated_dollar standard_charge|[payer_WELLFIRST MCARE]|[plan_MANAGED MEDICARE] |negotiated_percentage standard_charge|[payer_WELLFIRST MCARE]|[plan_MANAGED MEDICARE] |negotiated_algorithm estimated_amount|[payer_WELLFIRST MCARE]|[plan_MANAGED MEDICARE] standard_charge|[payer_WELLFIRST MCARE]|[plan_MANAGED MEDICARE] |methodology additional_payer_notes |[payer_WELLFIRST MCARE]|[Plan_MANAGED MEDICARE] additional_generic_notes ROOM AND BOARD PSYCH ADOLESCENT 124 RC facility inpatient 2450 1100 462 1080 820 per diem 945 per diem 462 per diem 462 per diem 945 per diem 994 per diem other DRG 925 per diem 462 per diem other DRG 915 per diem 925 per diem 849 per diem 994 per diem 994 per diem 900 per diem 900 per diem 950 per diem 948 per diem 994 per diem 945 per diem 950 per diem 950 per diem 950 per diem 845 per diem 1066 per diem 1080 per diem 915 per diem 849 per diem 975 per diem 945 per diem 948 per diem 462 per diem 820 per diem 820 per diem 915 per diem 915 per diem 915 per diem 462 per diem 945 per diem 462 per diem 948 per diem 948 per diem 563 per diem 948 per diem 948 per diem other DRG other DRG other DRG 820 per diem 948 per diem 948 per diem other DRG 945 per diem 994 per diem other DRG 975 per diem other DRG ROOM AND BOARD PSYCH GERIATRIC 124 RC facility inpatient 2450 1100 462 1080 820 per diem 945 per diem 462 per diem 462 per diem 945 per diem 994 per diem other DRG 925 per diem 462 per diem other DRG 915 per diem 925 per diem 849 per diem 994 per diem 994 per diem 900 per diem 900 per diem 950 per diem 948 per diem 994 per diem 945 per diem 950 per diem 950 per diem 950 per diem 845 per diem 1066 per diem 1080 per diem 915 per diem 849 per diem 975 per diem 945 per diem 948 per diem 462 per diem 820 per diem 820 per diem 915 per diem 915 per diem 915 per diem 462 per diem 945 per diem 462 per diem 948 per diem 948 per diem 563 per diem 948 per diem 948 per diem other DRG other DRG other DRG 820 per diem 948 per diem 948 per diem other DRG 945 per diem 994 per diem other DRG 975 per diem other DRG ROOM AND BOARD DETOX ADULT 126 RC facility inpatient 2450 1100 462 1080 820 per diem 945 per diem 462 per diem 462 per diem 945 per diem 994 per diem other DRG 925 per diem 462 per diem other DRG 915 per diem 925 per diem 849 per diem 994 per diem 994 per diem 900 per diem 900 per diem 950 per diem 948 per diem 994 per diem 945 per diem 950 per diem 950 per diem 950 per diem 845 per diem 1066 per diem 1080 per diem 915 per diem 849 per diem 975 per diem 945 per diem 948 per diem 462 per diem 820 per diem 820 per diem 915 per diem 915 per diem 915 per diem 462 per diem 945 per diem 462 per diem 948 per diem 948 per diem 563 per diem 948 per diem 948 per diem other DRG other DRG other DRG 820 per diem 948 per diem 948 per diem other DRG 945 per diem 994 per diem other DRG 975 per diem other DRG ROOM AND BOARD REHAB 128 RC facility inpatient 2450 1100 563 1080 945 per diem 945 per diem 994 per diem other DRG 925 per diem other DRG 915 per diem 925 per diem 849 per diem 994 per diem 994 per diem 900 per diem 900 per diem 948 per diem 994 per diem 945 per diem 845 per diem 1066 per diem 1080 per diem 915 per diem 849 per diem 975 per diem 945 per diem 948 per diem 915 per diem 915 per diem 915 per diem 945 per diem 948 per diem 948 per diem 563 per diem 948 per diem 948 per diem other DRG other DRG other DRG 820 per diem 948 per diem 948 per diem other DRG 945 per diem 994 per diem other DRG 975 per diem other DRG TRANSCRANIAL MAGNETIC STIMULATION-INITIAL TREATMNT 900 RC facility both 700 525 192 400 261 per diem 360 per diem 261 per diem 360 per diem 273 per diem 261 per diem 239 per diem 261 per diem 309 per diem 239 per diem 239 per diem 239 per diem 400 per diem 345 per diem 273 per diem 261 per diem 273 per diem 261 per diem 325 per diem 360 per diem 250 per diem 285 per diem 192 per diem 240 per diem 250 per diem 250 per diem 250 per diem 300 per diem 261 per diem 309 per diem 345 per diem 395 per diem 360 per diem 285 per diem 261 per diem 309 per diem 309 per diem 309 per diem 360 per diem 225 per diem 287 per diem 285 per diem 285 per diem 261 per diem 285 per diem 285 per diem 261 per diem 261 per diem 261 per diem 285 per diem 285 per diem 261 per diem 360 per diem 273 per diem 261 per diem 357 per diem 261 per diem TRANSCRANIAL MAGNETIC STIMULATION-MOTOR THRESH/RED 900 RC facility both 467 350 192 357 261 per diem 240 per diem 261 per diem 240 per diem 192 per diem 261 per diem 239 per diem 261 per diem 283 per diem 239 per diem 239 per diem 239 per diem 225 per diem 300 per diem 192 per diem 261 per diem 192 per diem 261 per diem 325 per diem 240 per diem 250 per diem 295 per diem 192 per diem 240 per diem 250 per diem 250 per diem 250 per diem 285 per diem 261 per diem 283 per diem 300 per diem 192 per diem 240 per diem 295 per diem 261 per diem 283 per diem 283 per diem 283 per diem 240 per diem 225 per diem 287 per diem 295 per diem 295 per diem 261 per diem 295 per diem 295 per diem 261 per diem 261 per diem 261 per diem 295 per diem 295 per diem 261 per diem 240 per diem 192 per diem 261 per diem 357 per diem 261 per diem TRANSCRANIAL MAGNETIC STIMULATION-SUBSEQUENT TRTMN 900 RC facility both 467 350 192 422 261 per diem 240 per diem 261 per diem 240 per diem 192 per diem 261 per diem 239 per diem 261 per diem 283 per diem 239 per diem 239 per diem 239 per diem 250 per diem 422 per diem 240 per diem 261 per diem 240 per diem 261 per diem 325 per diem 240 per diem 250 per diem 290 per diem 192 per diem 240 per diem 250 per diem 250 per diem 250 per diem 300 per diem 261 per diem 309 per diem 422 per diem 395 per diem 240 per diem 290 per diem 261 per diem 309 per diem 309 per diem 309 per diem 240 per diem 225 per diem 287 per diem 290 per diem 290 per diem 261 per diem 290 per diem 290 per diem 261 per diem 261 per diem 261 per diem 290 per diem 290 per diem 261 per diem 240 per diem 240 per diem 261 per diem 357 per diem 261 per diem ELECTOCONVULSIVE THERAPY INPATIENT 901 RC facility inpatient 1927 750 300 1336 464 per diem 660 per diem 660 per diem 688 per diem 464 per diem 550 per diem 493 per diem 464 per diem 497 per diem 493 per diem 493 per diem 493 per diem 900 per diem 519 per diem 688 per diem 464 per diem 688 per diem 464 per diem 1330 per diem 510 per diem 948 per diem 1336 per diem 1320 per diem 510 per diem 510 per diem 510 per diem 300 per diem 300 per diem 698 per diem 464 per diem 497 per diem 519 per diem 652 per diem 660 per diem 618 per diem 464 per diem 497 per diem 497 per diem 497 per diem 660 per diem 465 per diem 511 per diem 618 per diem 618 per diem 464 per diem 464 per diem 618 per diem 618 per diem 464 per diem 464 per diem 464 per diem 618 per diem 618 per diem 464 per diem 660 per diem 688 per diem 464 per diem 561 per diem 464 per diem ELECTOCONVULSIVE THERAPY OUTPATIENT 901 RC facility outpatient 1927 750 300 1336 464 per diem 660 per diem 660 per diem 688 per diem 464 per diem 550 per diem 493 per diem 464 per diem 497 per diem 493 per diem 493 per diem 493 per diem 900 per diem 519 per diem 688 per diem 464 per diem 688 per diem 464 per diem 1330 per diem 510 per diem 948 per diem 1336 per diem 1320 per diem 510 per diem 510 per diem 510 per diem 300 per diem 300 per diem 698 per diem 464 per diem 497 per diem 519 per diem 652 per diem 660 per diem 618 per diem 464 per diem 497 per diem 497 per diem 497 per diem 660 per diem 465 per diem 511 per diem 618 per diem 618 per diem 462 per diem 464 per diem 618 per diem 618 per diem 464 per diem 464 per diem 464 per diem 618 per diem 618 per diem 464 per diem 660 per diem 688 per diem 464 per diem 561 per diem 464 per diem INTENSIVE OUTPATIENT PROGRAM ADOLESCENT - MRVL VIRT 905 RC facility outpatient 612 225 150 285 239 per diem 235 per diem 235 per diem 265 per diem 225 per diem 175 per diem 285 per diem 170 per diem 175 per diem 175 per diem 255 per diem 260 per diem 273 per diem 273 per diem 225 per diem 235 per diem 255 per diem 254 per diem 273 per diem 235 per diem 255 per diem 255 per diem 255 per diem 200 per diem 180 per diem 285 per diem 285 per diem 260 per diem 265 per diem 235 per diem 254 per diem 285 per diem 285 per diem 285 per diem 235 per diem 165 per diem 254 per diem 254 per diem 254 per diem 254 per diem 239 per diem 239 per diem 239 per diem 150 per diem 254 per diem 254 per diem 235 per diem 273 per diem 254 per diem INTENSIVE OUTPATIENT PROGRAM PSYCH ADULT-CPH 905 RC facility outpatient 612 225 150 285 239 per diem 235 per diem 235 per diem 265 per diem 225 per diem 175 per diem 285 per diem 170 per diem 175 per diem 175 per diem 255 per diem 260 per diem 273 per diem 273 per diem 225 per diem 235 per diem 255 per diem 254 per diem 273 per diem 235 per diem 255 per diem 255 per diem 255 per diem 200 per diem 180 per diem 285 per diem 285 per diem 260 per diem 265 per diem 235 per diem 254 per diem 285 per diem 285 per diem 285 per diem 235 per diem 165 per diem 254 per diem 254 per diem 254 per diem 254 per diem 239 per diem 239 per diem 239 per diem 150 per diem 254 per diem 254 per diem 235 per diem 273 per diem 254 per diem INTENSIVE OUTPATIENT PROGRAM CD ADU - SC EV V 906 RC facility outpatient 612 225 150 285 239 per diem 235 per diem 235 per diem 265 per diem 225 per diem 175 per diem 285 per diem 170 per diem 175 per diem 175 per diem 255 per diem 260 per diem 273 per diem 273 per diem 225 per diem 235 per diem 255 per diem 254 per diem 273 per diem 235 per diem 255 per diem 255 per diem 255 per diem 200 per diem 180 per diem 285 per diem 285 per diem 260 per diem 265 per diem 235 per diem 254 per diem 285 per diem 285 per diem 285 per diem 235 per diem 165 per diem 254 per diem 254 per diem 254 per diem 254 per diem 239 per diem 239 per diem 239 per diem 150 per diem 254 per diem 254 per diem 235 per diem 273 per diem 254 per diem ADOLESCENT PARTIAL HOSPITAL PROGRAM W/BOARDING 912 RC facility outpatient 816 265 225 756 375 per diem 398 per diem 398 per diem 398 per diem 414 per diem 258 per diem 380 per diem 756 per diem 281 per diem 258 per diem 397 per diem 281 per diem 281 per diem 281 per diem 410 per diem 398 per diem 426 per diem 258 per diem 426 per diem 258 per diem 370 per diem 375 per diem 355 per diem 412 per diem 426 per diem 398 per diem 355 per diem 355 per diem 355 per diem 300 per diem 300 per diem 470 per diem 258 per diem 397 per diem 398 per diem 430 per diem 398 per diem 412 per diem 258 per diem 397 per diem 397 per diem 397 per diem 398 per diem 265 per diem 283 per diem 412 per diem 412 per diem 258 per diem 412 per diem 412 per diem 375 per diem 375 per diem 375 per diem 274 per diem 412 per diem 412 per diem 258 per diem 398 per diem 426 per diem 258 per diem 409 per diem 258 per diem ADOLESCENT CD PARTIAL HOSPITAL PROGRAM W/BOARD 913 RC facility outpatient 816 265 225 756 375 per diem 398 per diem 398 per diem 398 per diem 414 per diem 258 per diem 380 per diem 756 per diem 281 per diem 258 per diem 397 per diem 281 per diem 281 per diem 281 per diem 410 per diem 398 per diem 426 per diem 258 per diem 426 per diem 258 per diem 370 per diem 375 per diem 355 per diem 412 per diem 426 per diem 398 per diem 355 per diem 355 per diem 355 per diem 300 per diem 300 per diem 470 per diem 258 per diem 397 per diem 398 per diem 430 per diem 398 per diem 412 per diem 258 per diem 397 per diem 397 per diem 397 per diem 398 per diem 265 per diem 283 per diem 412 per diem 412 per diem 258 per diem 412 per diem 412 per diem 375 per diem 375 per diem 375 per diem 274 per diem 412 per diem 412 per diem 258 per diem 398 per diem 426 per diem 258 per diem 409 per diem 258 per diem ADULT CD PARTIAL HOSPITAL PROGRAM W/BOARD 913 RC facility outpatient 816 265 225 756 375 per diem 398 per diem 398 per diem 398 per diem 414 per diem 258 per diem 380 per diem 756 per diem 281 per diem 258 per diem 397 per diem 281 per diem 281 per diem 281 per diem 410 per diem 398 per diem 426 per diem 258 per diem 426 per diem 258 per diem 370 per diem 375 per diem 355 per diem 412 per diem 426 per diem 398 per diem 355 per diem 355 per diem 355 per diem 300 per diem 300 per diem 470 per diem 258 per diem 397 per diem 398 per diem 430 per diem 398 per diem 412 per diem 258 per diem 397 per diem 397 per diem 397 per diem 398 per diem 265 per diem 283 per diem 412 per diem 412 per diem 258 per diem 412 per diem 412 per diem 375 per diem 375 per diem 375 per diem 274 per diem 412 per diem 412 per diem 258 per diem 398 per diem 426 per diem 258 per diem 409 per diem 258 per diem PARTIAL HOSPITAL PROGRAM CD ADOLESCENT GRP1 TL1 913 RC facility outpatient 816 265 225 756 375 per diem 398 per diem 398 per diem 398 per diem 414 per diem 258 per diem 380 per diem 756 per diem 281 per diem 258 per diem 397 per diem 281 per diem 281 per diem 281 per diem 410 per diem 398 per diem 426 per diem 258 per diem 426 per diem 258 per diem 370 per diem 375 per diem 355 per diem 412 per diem 426 per diem 398 per diem 355 per diem 355 per diem 355 per diem 300 per diem 300 per diem 470 per diem 258 per diem 397 per diem 398 per diem 430 per diem 398 per diem 412 per diem 258 per diem 397 per diem 397 per diem 397 per diem 398 per diem 265 per diem 283 per diem 412 per diem 412 per diem 258 per diem 412 per diem 412 per diem 375 per diem 375 per diem 375 per diem 274 per diem 412 per diem 412 per diem 258 per diem 398 per diem 426 per diem 258 per diem 409 per diem 258 per diem PARTIAL HOSPITAL PROGRAM CD ADU GRP1 913 RC facility outpatient 816 265 225 756 375 per diem 398 per diem 398 per diem 398 per diem 414 per diem 258 per diem 380 per diem 756 per diem 281 per diem 258 per diem 397 per diem 281 per diem 281 per diem 281 per diem 410 per diem 398 per diem 426 per diem 258 per diem 426 per diem 258 per diem 370 per diem 375 per diem 355 per diem 412 per diem 426 per diem 398 per diem 355 per diem 355 per diem 355 per diem 300 per diem 300 per diem 470 per diem 258 per diem 397 per diem 398 per diem 430 per diem 398 per diem 412 per diem 258 per diem 397 per diem 397 per diem 397 per diem 398 per diem 265 per diem 283 per diem 412 per diem 412 per diem 258 per diem 412 per diem 412 per diem 375 per diem 375 per diem 375 per diem 274 per diem 412 per diem 412 per diem 258 per diem 398 per diem 426 per diem 258 per diem 409 per diem 258 per diem INTENSIVE OUTPATIENT PROGRAM ADO-G1-CPH EVE V 915 RC facility outpatient 204 153 219 240 219 per diem 219 per diem 219 per diem 219 per diem 219 per diem 219 per diem 240 per diem 219 per diem 219 per diem 219 per diem 219 per diem INTENSIVE OUTPATIENT PROGRAM ADU-GRP1 CPH VIR 915 RC facility outpatient 204 153 219 240 219 per diem 219 per diem 219 per diem 219 per diem 219 per diem 219 per diem 240 per diem 219 per diem 219 per diem 219 per diem 219 per diem PARTIAL HOSPITAL PROGRAM ADU GRP1 - WC VI 915 RC facility outpatient 204 153 219 756 398 per diem 258 per diem 398 per diem 258 per diem 258 per diem 273 per diem 273 per diem 410 per diem 219 per diem 219 per diem 375 per diem 426 per diem 258 per diem 398 per diem 258 per diem 397 per diem 756 per diem 756 per diem 283 per diem 258 per diem 375 per diem 375 per diem 412 per diem 219 per diem 219 per diem 219 per diem VOP ADU-1G-SC DY V V 915 RC facility outpatient 204 153 219 258 219 per diem 219 per diem 258 per diem 258 per diem 258 per diem 258 per diem 240 per diem 219 per diem 258 per diem 258 per diem 258 per diem PARTIAL HOSPITAL PROGRAM LODGING FEE 995 RC facility outpatient 25 25 398 398 398 per diem ROOM AND BOARD RTC PSYCH ADOLESCENT 1002 RC facility outpatient 933 700 479 670 640 per diem 651 per diem 525 per diem 479 per diem 583 per diem 479 per diem 479 per diem 479 per diem 625 per diem 582 per diem 651 per diem 651 per diem 595 per diem 670 per diem 550 per diem 550 per diem 550 per diem 650 per diem 582 per diem 635 per diem 670 per diem 600 per diem 605 per diem 485 per diem 484 per diem 583 per diem 583 per diem 640 per diem 479 per diem 484 per diem 670 per diem 670 per diem 670 per diem 670 per diem 670 per diem 670 per diem 640 per diem 651 per diem 637 per diem ROOM AND BOARD RTC PSYCH ADULT 1002 RC facility outpatient 933 700 479 670 640 per diem 651 per diem 525 per diem 479 per diem 583 per diem 479 per diem 479 per diem 479 per diem 625 per diem 582 per diem 651 per diem 651 per diem 595 per diem 670 per diem 550 per diem 550 per diem 550 per diem 650 per diem 582 per diem 635 per diem 670 per diem 600 per diem 605 per diem 485 per diem 484 per diem 583 per diem 583 per diem 640 per diem 479 per diem 484 per diem 670 per diem 670 per diem 670 per diem 670 per diem 670 per diem 670 per diem 640 per diem 651 per diem 637 per diem 90792 Psychiatric Diag Eval With Med 90792 RC facility both 243 150 107 184 184 fee schedule based on diaginosis 142 fee schedule based on diaginosis 107 fee schedule based on diaginosis 135 fee schedule based on diaginosis 134 fee schedule based on diaginosis 153 fee schedule based on diaginosis 175 fee schedule based on diaginosis 169 fee schedule based on diaginosis 152 fee schedule based on diaginosis 170 fee schedule based on diaginosis 143 fee schedule based on diaginosis 143 per diem 120 fee schedule based on diaginosis 143 fee schedule based on diaginosis 144 fee schedule based on diaginosis 148 fee schedule based on diaginosis 90833 30 Minute Add On 90833 RC facility both 103 61 33 76 63 fee schedule based on diaginosis 64 fee schedule based on diaginosis 38 fee schedule based on diaginosis 62 fee schedule based on diaginosis 34 fee schedule based on diaginosis 38 fee schedule based on diaginosis 33 fee schedule based on diaginosis 56 fee schedule based on diaginosis 58 fee schedule based on diaginosis 62 fee schedule based on diaginosis 76 fee schedule based on diaginosis 90870 Electroconvulsive Therapy 90870 RC facility both 270 111 103 196 105 fee schedule based on diaginosis 103 fee schedule based on diaginosis 143 fee schedule based on diaginosis 106 fee schedule based on diaginosis 196 fee schedule based on diaginosis 174 fee schedule based on diaginosis 196 fee schedule based on diaginosis 99212 Est Office Visit 99212 RC facility both 81 32 30 35 30 fee schedule based on diaginosis 35 fee schedule based on diaginosis 99213 Est Patient/med Management/low 99213 RC facility both 151 62 35 95 95 fee schedule based on diaginosis 66 fee schedule based on diaginosis 51 fee schedule based on diaginosis 66 fee schedule based on diaginosis 38 fee schedule based on diaginosis 52 fee schedule based on diaginosis 54 fee schedule based on diaginosis 53 fee schedule based on diaginosis 44 fee schedule based on diaginosis 75 fee schedule based on diaginosis 35 fee schedule based on diaginosis 48 fee schedule based on diaginosis 67 fee schedule based on diaginosis 59 fee schedule based on diaginosis 50 fee schedule based on diaginosis 66 fee schedule based on diaginosis 58 fee schedule based on diaginosis 54 fee schedule based on diaginosis 74 fee schedule based on diaginosis 80 fee schedule based on diaginosis 70 fee schedule based on diaginosis 99214 Est Patient/med Management/ Mo 99214 RC facility both 167 89 39 113 110 fee schedule based on diaginosis 95 fee schedule based on diaginosis 96 fee schedule based on diaginosis 58 fee schedule based on diaginosis 78 fee schedule based on diaginosis 85 fee schedule based on diaginosis 68 fee schedule based on diaginosis 106 fee schedule based on diaginosis 39 fee schedule based on diaginosis 82 fee schedule based on diaginosis 85 fee schedule based on diaginosis 70 fee schedule based on diaginosis 87 fee schedule based on diaginosis 113 fee schedule based on diaginosis 99215 Est Office Visit 99215 RC facility both 211 126 99 133 133 fee schedule based on diaginosis 115 fee schedule based on diaginosis 120 fee schedule based on diaginosis 120 fee schedule based on diaginosis 99 fee schedule based on diaginosis 99222 Initial Hospital Care (50 Min) 99222 RC facility both 173 135 40 136 129 fee schedule based on diaginosis 136 fee schedule based on diaginosis 120 fee schedule based on diaginosis 126 fee schedule based on diaginosis 106 fee schedule based on diaginosis 111 fee schedule based on diaginosis 40 fee schedule based on diaginosis 118 fee schedule based on diaginosis 129 fee schedule based on diaginosis 129 fee schedule based on diaginosis 83 fee schedule based on diaginosis 106 fee schedule based on diaginosis 108 fee schedule based on diaginosis 126 fee schedule based on diaginosis 99223 Initial Hospital Care (70 Min) 99223 RC facility both 232 182 54 215 184 fee schedule based on diaginosis 215 fee schedule based on diaginosis 184 fee schedule based on diaginosis 155 fee schedule based on diaginosis 181 fee schedule based on diaginosis 163 fee schedule based on diaginosis 54 fee schedule based on diaginosis 172 fee schedule based on diaginosis 172 fee schedule based on diaginosis 174 fee schedule based on diaginosis 161 fee schedule based on diaginosis 172 fee schedule based on diaginosis 99231 Subseq Care (15 Min) 99231 RC facility both 70 51 16 49 36 fee schedule based on diaginosis 32 fee schedule based on diaginosis 16 fee schedule based on diaginosis 49 fee schedule based on diaginosis 49 fee schedule based on diaginosis 33 fee schedule based on diaginosis 45 fee schedule based on diaginosis 99232 Subseq Care (25 Min) 99232 RC facility both 113 81 27 105 105 fee schedule based on diaginosis 78 fee schedule based on diaginosis 80 fee schedule based on diaginosis 63 fee schedule based on diaginosis 66 fee schedule based on diaginosis 52 fee schedule based on diaginosis 54 fee schedule based on diaginosis 58 fee schedule based on diaginosis 27 fee schedule based on diaginosis 75 fee schedule based on diaginosis 76 fee schedule based on diaginosis 51 fee schedule based on diaginosis 42 fee schedule based on diaginosis 77 fee schedule based on diaginosis 44 fee schedule based on diaginosis 88 fee schedule based on diaginosis 55 fee schedule based on diaginosis 62 fee schedule based on diaginosis 78 fee schedule based on diaginosis 76 fee schedule based on diaginosis 99233 Subseq Care (35 Min) 99233 RC facility both 130 121 30 118 104 fee schedule based on diaginosis 118 fee schedule based on diaginosis 114 fee schedule based on diaginosis 98 fee schedule based on diaginosis 98 fee schedule based on diaginosis 95 fee schedule based on diaginosis 91 fee schedule based on diaginosis 90 fee schedule based on diaginosis 93 fee schedule based on diaginosis 84 fee schedule based on diaginosis 30 fee schedule based on diaginosis 106 fee schedule based on diaginosis 115 fee schedule based on diaginosis 117 fee schedule based on diaginosis 83 fee schedule based on diaginosis 117 fee schedule based on diaginosis 115 fee schedule based on diaginosis 99238 Discharge Day Mgmt 99238 RC facility both 146 82 34 88 80 fee schedule based on diaginosis 80 fee schedule based on diaginosis 63 fee schedule based on diaginosis 69 fee schedule based on diaginosis 67 fee schedule based on diaginosis 59 fee schedule based on diaginosis 34 fee schedule based on diaginosis 80 fee schedule based on diaginosis 79 fee schedule based on diaginosis 42 fee schedule based on diaginosis 78 fee schedule based on diaginosis 44 fee schedule based on diaginosis 88 fee schedule based on diaginosis 62 fee schedule based on diaginosis 82 fee schedule based on diaginosis 75 fee schedule based on diaginosis 78 fee schedule based on diaginosis