{ "hospital_name": "SBH-Davenport, LLC", "location_name": [ "SBH-Davenport, LLC" ], "hospital_address": [ "770 Tanglefoot Lane, Bettendorf, IA 52722" ], "type_2_npi": [ "1831720556" ], "license_information": { "license_number": "139", "state": "IA" }, "last_updated_on": "2026-03-31", "version": "3.0", "attestation": { "attestation": "To the best of its knowledge and belief, this hospital has included all applicable standard charge information in accordance with the requirements of 45 CFR 180.50, and the information encoded is true, accurate, and complete as of the date in the file. This hospital has included all payer-specific negotiated charges in dollars that can be expressed as a dollar amount. For payer-specific negotiated charges that cannot be expressed as a dollar amount in the machine-readable file or not knowable in advance, the hospital attests that the payer-specific negotiated charge is based on a contractual algorithm, percentage or formula that precludes the provision of a dollar amount and has provided all necessary information available to the hospital for the public to be able to derive the dollar amount, including, but not limited to, the specific fee schedule or components referenced in such percentage, algorithm or formula.", "confirm_attestation": true, "attester_name": "Adam Curl" }, "standard_charge_information": [ { "description": "Telehealth Adol Psych IOP 3 hrs", "code_information": [ { "code": "90853", "type": "CPT" } ], "standard_charges": [ { "setting": "outpatient", "gross_charge": 410.0, "discounted_cash_price": 175.0, "payer_specific_negotiated_charges": [ { "payer_name": "Aetna", "plan_name": "All Plans", "negotiated_rate": 230.0 }, { "payer_name": "Aetna", "plan_name": "All Plans", "negotiated_rate": 235.0 }, { "payer_name": "Allied Benefit Systems", "plan_name": "All Plans", "negotiated_rate": 200.0 }, { "payer_name": "BCBS Iowa- Wellmark HMO", "plan_name": "All Plans", "negotiated_rate": 374.0 }, { "payer_name": "BCBS Iowa- Wellmark PPO", "plan_name": "All Plans", "negotiated_rate": 374.0 }, { "payer_name": "Bind Benefits", "plan_name": "All Plans", "negotiated_rate": 225.0 }, { "payer_name": "Employee Benefit Management Services (EB", "plan_name": "All Plans", "negotiated_rate": 200.0 }, { "payer_name": "GEHA - UHC", "plan_name": "All Plans", "negotiated_rate": 225.0 }, { "payer_name": "Gravie Administrators", "plan_name": "All Plans", "negotiated_rate": 218.0 }, { "payer_name": "Health Alliance Connect - Medicare Advan", "plan_name": "All Plans", "negotiated_rate": 68.24 }, { "payer_name": "HFN", "plan_name": "All Plans", "negotiated_rate": 212.0 }, { "payer_name": "IA Medicaid - Molina", "plan_name": "All Plans", "negotiated_rate": 250.0 }, { "payer_name": "IA Medicaid - Wellpoint - Amerigroup", "plan_name": "All Plans", "negotiated_rate": 242.0 }, { "payer_name": "Loomis Co", "plan_name": "All Plans", "negotiated_rate": 150.0 }, { "payer_name": "Meritain Health", "plan_name": "All Plans", "negotiated_rate": 212.0 }, { "payer_name": "Optum Health - United Healthcare", "plan_name": "All Plans", "negotiated_rate": 308.0 }, { "payer_name": "Sano-Nomi Health", "plan_name": "All Plans", "negotiated_rate": 410.0 }, { "payer_name": "Surest", "plan_name": "All Plans", "negotiated_rate": 175.0 } ], "minimum": 68.24, "maximum": 410.0 } ] }, { "description": "Telehealth Adult IOP 3 hrs", "code_information": [ { "code": "H0015", "type": "HCPCS" } ], "standard_charges": [ { "setting": "outpatient", "gross_charge": 410.0, "discounted_cash_price": 175.0, "payer_specific_negotiated_charges": [ { "payer_name": "Aetna", "plan_name": "All Plans", "negotiated_rate": 230.0 }, { "payer_name": "Aetna", "plan_name": "All Plans", "negotiated_rate": 235.0 }, { "payer_name": "Allied Benefit Systems", "plan_name": "All Plans", "negotiated_rate": 200.0 }, { "payer_name": "BCBS Iowa- Wellmark HMO", "plan_name": "All Plans", "negotiated_rate": 374.0 }, { "payer_name": "BCBS Iowa- Wellmark PPO", "plan_name": "All Plans", "negotiated_rate": 374.0 }, { "payer_name": "Bind Benefits", "plan_name": "All Plans", "negotiated_rate": 225.0 }, { "payer_name": "Employee Benefit Management Services (EB", "plan_name": "All Plans", "negotiated_rate": 200.0 }, { "payer_name": "GEHA - UHC", "plan_name": "All Plans", "negotiated_rate": 225.0 }, { "payer_name": "Gravie Administrators", "plan_name": "All Plans", "negotiated_rate": 218.0 }, { "payer_name": "Health Alliance Connect - Medicare Advan", "plan_name": "All Plans", "negotiated_rate": 68.24 }, { "payer_name": "HFN", "plan_name": "All Plans", "negotiated_rate": 212.0 }, { "payer_name": "IA Medicaid - Molina", "plan_name": "All Plans", "negotiated_rate": 250.0 }, { "payer_name": "IA Medicaid - Wellpoint - Amerigroup", "plan_name": "All Plans", "negotiated_rate": 242.0 }, { "payer_name": "Loomis Co", "plan_name": "All Plans", "negotiated_rate": 150.0 }, { "payer_name": "Meritain Health", "plan_name": "All Plans", "negotiated_rate": 212.0 }, { "payer_name": "Optum Health - United Healthcare", "plan_name": "All Plans", "negotiated_rate": 257.0 }, { "payer_name": "Sano-Nomi Health", "plan_name": "All Plans", "negotiated_rate": 410.0 }, { "payer_name": "Surest", "plan_name": "All Plans", "negotiated_rate": 175.0 } ], "minimum": 68.24, "maximum": 410.0 } ] }, { "description": "Telehealth Adult Psych IOP 3 hrs", "code_information": [ { "code": "90853", "type": "CPT" } ], "standard_charges": [ { "setting": "outpatient", "gross_charge": 410.0, "discounted_cash_price": 175.0, "payer_specific_negotiated_charges": [ { "payer_name": "Aetna", "plan_name": "All Plans", "negotiated_rate": 230.0 }, { "payer_name": "Aetna", "plan_name": "All Plans", "negotiated_rate": 235.0 }, { "payer_name": "All Savers", "plan_name": "All Plans", "negotiated_rate": 225.0 }, { "payer_name": "Allied Benefit Systems", "plan_name": "All Plans", "negotiated_rate": 200.0 }, { "payer_name": "BCBS Iowa- Wellmark HMO", "plan_name": "All Plans", "negotiated_rate": 374.0 }, { "payer_name": "BCBS Iowa- Wellmark PPO", "plan_name": "All Plans", "negotiated_rate": 374.0 }, { "payer_name": "Bind Benefits", "plan_name": "All Plans", "negotiated_rate": 225.0 }, { "payer_name": "Employee Benefit Management Services (EB", "plan_name": "All Plans", "negotiated_rate": 200.0 }, { "payer_name": "Employee Benefit Systems", "plan_name": "All Plans", "negotiated_rate": 231.0 }, { "payer_name": "GEHA - UHC", "plan_name": "All Plans", "negotiated_rate": 225.0 }, { "payer_name": "Gravie Administrators", "plan_name": "All Plans", "negotiated_rate": 218.0 }, { "payer_name": "Health Alliance Connect - Medicare Advan", "plan_name": "All Plans", "negotiated_rate": 68.24 }, { "payer_name": "HFN", "plan_name": "All Plans", "negotiated_rate": 212.0 }, { "payer_name": "IA Medicaid - Molina", "plan_name": "All Plans", "negotiated_rate": 250.0 }, { "payer_name": "IA Medicaid - Wellpoint - Amerigroup", "plan_name": "All Plans", "negotiated_rate": 242.0 }, { "payer_name": "Loomis Co", "plan_name": "All Plans", "negotiated_rate": 150.0 }, { "payer_name": "Meritain Health", "plan_name": "All Plans", "negotiated_rate": 212.0 }, { "payer_name": "Optum Health - United Healthcare", "plan_name": "All Plans", "negotiated_rate": 257.0 }, { "payer_name": "Sano-Nomi Health", "plan_name": "All Plans", "negotiated_rate": 410.0 }, { "payer_name": "Surest", "plan_name": "All Plans", "negotiated_rate": 175.0 }, { "payer_name": "UMR", "plan_name": "All Plans", "negotiated_rate": 257.0 } ], "minimum": 68.24, "maximum": 410.0 } ] }, { "description": "Telehealth PHP Psych Adult Daily", "code_information": [ { "code": "H0035", "type": "HCPCS" } ], "standard_charges": [ { "setting": "outpatient", "gross_charge": 652.0, "discounted_cash_price": 350.0, "payer_specific_negotiated_charges": [ { "payer_name": "Aetna", "plan_name": "All Plans", "negotiated_rate": 440.0 }, { "payer_name": "Aetna", "plan_name": "All Plans", "negotiated_rate": 446.0 }, { "payer_name": "All Savers", "plan_name": "All Plans", "negotiated_rate": 225.0 }, { "payer_name": "BCBS Iowa- Wellmark HMO", "plan_name": "All Plans", "negotiated_rate": 652.0 }, { "payer_name": "BCBS Iowa- Wellmark PPO", "plan_name": "All Plans", "negotiated_rate": 652.0 }, { "payer_name": "Bind Benefits", "plan_name": "All Plans", "negotiated_rate": 500.0 }, { "payer_name": "IA Medicaid - Molina", "plan_name": "All Plans", "negotiated_rate": 450.0 }, { "payer_name": "IA Medicaid - Wellpoint - Amerigroup", "plan_name": "All Plans", "negotiated_rate": 425.0 }, { "payer_name": "Meritain Health", "plan_name": "All Plans", "negotiated_rate": 405.0 }, { "payer_name": "Mines And Associates", "plan_name": "All Plans", "negotiated_rate": 550.0 }, { "payer_name": "Optum Health - United Healthcare", "plan_name": "All Plans", "negotiated_rate": 500.0 }, { "payer_name": "Sano-Nomi Health", "plan_name": "All Plans", "negotiated_rate": 595.0 }, { "payer_name": "Surest", "plan_name": "All Plans", "negotiated_rate": 350.0 }, { "payer_name": "The Alliance", "plan_name": "All Plans", "negotiated_rate": 450.0 } ], "minimum": 225.0, "maximum": 652.0 } ] }, { "description": "Telehealth PHP Psych Child/Adol Daily", "code_information": [ { "code": "H0035", "type": "HCPCS" } ], "standard_charges": [ { "setting": "outpatient", "gross_charge": 652.0, "discounted_cash_price": 350.0, "payer_specific_negotiated_charges": [ { "payer_name": "Aetna", "plan_name": "All Plans", "negotiated_rate": 405.0 }, { "payer_name": "BCBS Iowa- Wellmark HMO", "plan_name": "All Plans", "negotiated_rate": 652.0 }, { "payer_name": "BCBS Iowa- Wellmark PPO", "plan_name": "All Plans", "negotiated_rate": 652.0 }, { "payer_name": "Bind Benefits", "plan_name": "All Plans", "negotiated_rate": 500.0 }, { "payer_name": "HFN", "plan_name": "All Plans", "negotiated_rate": 405.0 }, { "payer_name": "IA Medicaid - Molina", "plan_name": "All Plans", "negotiated_rate": 450.0 }, { "payer_name": "IA Medicaid - Wellpoint - Amerigroup", "plan_name": "All Plans", "negotiated_rate": 425.0 }, { "payer_name": "Meritain Health", "plan_name": "All Plans", "negotiated_rate": 405.0 }, { "payer_name": "Mines And Associates", "plan_name": "All Plans", "negotiated_rate": 550.0 }, { "payer_name": "Optum Health - United Healthcare", "plan_name": "All Plans", "negotiated_rate": 500.0 }, { "payer_name": "Sano-Nomi Health", "plan_name": "All Plans", "negotiated_rate": 595.0 }, { "payer_name": "Surest", "plan_name": "All Plans", "negotiated_rate": 350.0 }, { "payer_name": "The Alliance", "plan_name": "All Plans", "negotiated_rate": 450.0 }, { "payer_name": "Tricare East Region Claims", "plan_name": "All Plans", "negotiated_rate": 233.51 } ], "minimum": 233.51, "maximum": 652.0 } ] }, { "description": "Telehealth PHP CD Adult Daily", "code_information": [ { "code": "H0035", "type": "HCPCS" } ], "standard_charges": [ { "setting": "outpatient", "gross_charge": 652.0, "discounted_cash_price": 350.0, "payer_specific_negotiated_charges": [ { "payer_name": "Aetna", "plan_name": "All Plans", "negotiated_rate": 405.0 }, { "payer_name": "BCBS Iowa- Wellmark HMO", "plan_name": "All Plans", "negotiated_rate": 652.0 }, { "payer_name": "BCBS Iowa- Wellmark PPO", "plan_name": "All Plans", "negotiated_rate": 652.0 }, { "payer_name": "Bind Benefits", "plan_name": "All Plans", "negotiated_rate": 500.0 }, { "payer_name": "HFN", "plan_name": "All Plans", "negotiated_rate": 405.0 }, { "payer_name": "IA Medicaid - Molina", "plan_name": "All Plans", "negotiated_rate": 450.0 }, { "payer_name": "IA Medicaid - Wellpoint - Amerigroup", "plan_name": "All Plans", "negotiated_rate": 425.0 }, { "payer_name": "Meritain Health", "plan_name": "All Plans", "negotiated_rate": 405.0 }, { "payer_name": "Optum Health - United Healthcare", "plan_name": "All Plans", "negotiated_rate": 500.0 }, { "payer_name": "Sano-Nomi Health", "plan_name": "All Plans", "negotiated_rate": 595.0 }, { "payer_name": "Tricare East Region Claims", "plan_name": "All Plans", "negotiated_rate": 233.51 } ], "minimum": 233.51, "maximum": 652.0 } ] }, { "description": "PHP Psych Gero Daily", "code_information": [ { "code": "H0035", "type": "HCPCS" } ], "standard_charges": [ { "setting": "outpatient", "gross_charge": 1000.0, "discounted_cash_price": 350.0, "payer_specific_negotiated_charges": [ { "payer_name": "Aetna", "plan_name": "All Plans", "negotiated_rate": 405.0 }, { "payer_name": "All Savers", "plan_name": "All Plans", "negotiated_rate": 500.0 }, { "payer_name": "BCBS Iowa- Wellmark HMO", "plan_name": "All Plans", "negotiated_rate": 652.0 }, { "payer_name": "BCBS Iowa- Wellmark PPO", "plan_name": "All Plans", "negotiated_rate": 652.0 }, { "payer_name": "Bind Benefits", "plan_name": "All Plans", "negotiated_rate": 500.0 }, { "payer_name": "GEHA - UHC", "plan_name": "All Plans", "negotiated_rate": 500.0 }, { "payer_name": "Golden Rule Insurance", "plan_name": "All Plans", "negotiated_rate": 1000.0 }, { "payer_name": "HFN", "plan_name": "All Plans", "negotiated_rate": 405.0 }, { "payer_name": "IA Medicaid - Molina", "plan_name": "All Plans", "negotiated_rate": 450.0 }, { "payer_name": "IA Medicaid - Wellpoint - Amerigroup", "plan_name": "All Plans", "negotiated_rate": 425.0 }, { "payer_name": "Meritain Health", "plan_name": "All Plans", "negotiated_rate": 405.0 }, { "payer_name": "Optum Health - United Healthcare", "plan_name": "All Plans", "negotiated_rate": 500.0 }, { "payer_name": "Plumbers & Pipefitters LU # 25", "plan_name": "All Plans", "negotiated_rate": 350.0 }, { "payer_name": "Sano-Nomi Health", "plan_name": "All Plans", "negotiated_rate": 545.0 }, { "payer_name": "Tricare East Region Claims", "plan_name": "All Plans", "negotiated_rate": 233.51 }, { "payer_name": "UHC Medicare Advantage Plan", "plan_name": "All Plans", "negotiated_rate": 400.0 }, { "payer_name": "United Healthcare Shared Services", "plan_name": "All Plans", "negotiated_rate": 500.0 } ], "minimum": 233.51, "maximum": 1000.0 } ] }, { "description": "PHP Psych Adult Daily", "code_information": [ { "code": "H0035", "type": "HCPCS" } ], "standard_charges": [ { "setting": "outpatient", "gross_charge": 652.0, "discounted_cash_price": 350.0, "payer_specific_negotiated_charges": [ { "payer_name": "Aetna", "plan_name": "All Plans", "negotiated_rate": 440.0 }, { "payer_name": "Aetna", "plan_name": "All Plans", "negotiated_rate": 446.0 }, { "payer_name": "Aetna Better Health Of IL Medicaid", "plan_name": "All Plans", "negotiated_rate": 374.89 }, { "payer_name": "Aetna Medicare Advantage Plan", "plan_name": "All Plans", "negotiated_rate": 417.0 }, { "payer_name": "All Savers", "plan_name": "All Plans", "negotiated_rate": 500.0 }, { "payer_name": "Ambetter Home State Health", "plan_name": "All Plans", "negotiated_rate": 350.0 }, { "payer_name": "Ambetter Of Illinois", "plan_name": "All Plans", "negotiated_rate": 350.0 }, { "payer_name": "BCBS Iowa- Wellmark HMO", "plan_name": "All Plans", "negotiated_rate": 652.0 }, { "payer_name": "BCBS Iowa- Wellmark PPO", "plan_name": "All Plans", "negotiated_rate": 652.0 }, { "payer_name": "Bind Benefits", "plan_name": "All Plans", "negotiated_rate": 500.0 }, { "payer_name": "Blue Medicare Advantage Plan", "plan_name": "All Plans", "negotiated_rate": 252.28 }, { "payer_name": "Cigna Behavioral Health", "plan_name": "All Plans", "negotiated_rate": 424.0 }, { "payer_name": "Cigna Behavioral Health", "plan_name": "All Plans", "negotiated_rate": 433.0 }, { "payer_name": "GEHA - UHC", "plan_name": "All Plans", "negotiated_rate": 500.0 }, { "payer_name": "Golden Rule Insurance", "plan_name": "All Plans", "negotiated_rate": 500.0 }, { "payer_name": "GPA", "plan_name": "All Plans", "negotiated_rate": 350.0 }, { "payer_name": "Health Alliance Connect - Medicare Advan", "plan_name": "All Plans", "negotiated_rate": 350.0 }, { "payer_name": "Health Partners", "plan_name": "All Plans", "negotiated_rate": 405.0 }, { "payer_name": "HFN", "plan_name": "All Plans", "negotiated_rate": 405.0 }, { "payer_name": "Humana", "plan_name": "All Plans", "negotiated_rate": 375.0 }, { "payer_name": "Humana Medicare - DRG HMO/PPO", "plan_name": "All Plans", "negotiated_rate": 250.0 }, { "payer_name": "IA Medicaid - Molina", "plan_name": "All Plans", "negotiated_rate": 450.0 }, { "payer_name": "IA Medicaid - Total Care", "plan_name": "All Plans", "negotiated_rate": 290.0 }, { "payer_name": "IA Medicaid - Wellpoint - Amerigroup", "plan_name": "All Plans", "negotiated_rate": 425.0 }, { "payer_name": "Kaiser-Cigna", "plan_name": "All Plans", "negotiated_rate": 416.0 }, { "payer_name": "Magellan", "plan_name": "All Plans", "negotiated_rate": 400.0 }, { "payer_name": "Magnacare", "plan_name": "All Plans", "negotiated_rate": 400.0 }, { "payer_name": "Medica", "plan_name": "All Plans", "negotiated_rate": 252.28 }, { "payer_name": "Meritain Health", "plan_name": "All Plans", "negotiated_rate": 405.0 }, { "payer_name": "Mines And Associates", "plan_name": "All Plans", "negotiated_rate": 550.0 }, { "payer_name": "Optum Health - United Healthcare", "plan_name": "All Plans", "negotiated_rate": 500.0 }, { "payer_name": "Oscar Health", "plan_name": "All Plans", "negotiated_rate": 300.0 }, { "payer_name": "Plumbers & Pipefitters LU # 25", "plan_name": "All Plans", "negotiated_rate": 350.0 }, { "payer_name": "Prairie States Enterprises, Inc.", "plan_name": "All Plans", "negotiated_rate": 425.0 }, { "payer_name": "Quad City Community Healthcare", "plan_name": "All Plans", "negotiated_rate": 550.0 }, { "payer_name": "Sano-Nomi Health", "plan_name": "All Plans", "negotiated_rate": 595.0 }, { "payer_name": "Sisco Benefits", "plan_name": "All Plans", "negotiated_rate": 500.0 }, { "payer_name": "The Alliance", "plan_name": "All Plans", "negotiated_rate": 450.0 }, { "payer_name": "Tricare East Region Claims", "plan_name": "All Plans", "negotiated_rate": 233.51 }, { "payer_name": "UHC Dual Complete Medicare Advantage", "plan_name": "All Plans", "negotiated_rate": 350.0 }, { "payer_name": "UHC Medicare Advantage Plan", "plan_name": "All Plans", "negotiated_rate": 400.0 }, { "payer_name": "UMR", "plan_name": "All Plans", "negotiated_rate": 500.0 }, { "payer_name": "United Healthcare Shared Services", "plan_name": "All Plans", "negotiated_rate": 500.0 }, { "payer_name": "WellCare Health Plans - Medicare Advanta", "plan_name": "All Plans", "negotiated_rate": 500.0 } ], "minimum": 233.51, "maximum": 652.0 } ] }, { "description": "Tri/Medi Adult Psych PHP - 3 u", "code_information": [ { "code": "G0411", "type": "HCPCS" } ], "standard_charges": [ { "setting": "outpatient", "gross_charge": 175.0, "discounted_cash_price": 175.0, "payer_specific_negotiated_charges": [ { "payer_name": "Aetna Medicare Advantage Plan", "plan_name": "All Plans", "negotiated_rate": 175.0 } ], "minimum": 175.0, "maximum": 175.0 } ] }, { "description": "Tri/Medi Adult Psych PHP - 5 u", "code_information": [ { "code": "G0411", "type": "HCPCS" } ], "standard_charges": [ { "setting": "outpatient", "gross_charge": 225.0, "discounted_cash_price": 225.0, "payer_specific_negotiated_charges": [ { "payer_name": "Aetna Medicare Advantage Plan", "plan_name": "All Plans", "negotiated_rate": 175.0 }, { "payer_name": "Tricare East Region Claims", "plan_name": "All Plans", "negotiated_rate": 225.0 } ], "minimum": 175.0, "maximum": 225.0 } ] }, { "description": "PHP Psych Child/Adol Daily", "code_information": [ { "code": "H0035", "type": "HCPCS" } ], "standard_charges": [ { "setting": "outpatient", "gross_charge": 652.0, "discounted_cash_price": 350.0, "payer_specific_negotiated_charges": [ { "payer_name": "Aetna", "plan_name": "All Plans", "negotiated_rate": 440.0 }, { "payer_name": "Aetna", "plan_name": "All Plans", "negotiated_rate": 446.0 }, { "payer_name": "Aetna Better Health Of IL Medicaid", "plan_name": "All Plans", "negotiated_rate": 374.89 }, { "payer_name": "All Savers", "plan_name": "All Plans", "negotiated_rate": 500.0 }, { "payer_name": "BCBS Iowa- Wellmark HMO", "plan_name": "All Plans", "negotiated_rate": 652.0 }, { "payer_name": "BCBS Iowa- Wellmark PPO", "plan_name": "All Plans", "negotiated_rate": 652.0 }, { "payer_name": "Bind Benefits", "plan_name": "All Plans", "negotiated_rate": 500.0 }, { "payer_name": "Cigna Behavioral Health", "plan_name": "All Plans", "negotiated_rate": 424.0 }, { "payer_name": "Cigna Behavioral Health", "plan_name": "All Plans", "negotiated_rate": 433.0 }, { "payer_name": "Consociate Health", "plan_name": "All Plans", "negotiated_rate": 300.0 }, { "payer_name": "GEHA - UHC", "plan_name": "All Plans", "negotiated_rate": 500.0 }, { "payer_name": "Golden Rule Insurance", "plan_name": "All Plans", "negotiated_rate": 500.0 }, { "payer_name": "Health Alliance", "plan_name": "All Plans", "negotiated_rate": 350.0 }, { "payer_name": "HFN", "plan_name": "All Plans", "negotiated_rate": 405.0 }, { "payer_name": "IA Medicaid - Molina", "plan_name": "All Plans", "negotiated_rate": 450.0 }, { "payer_name": "IA Medicaid - Total Care", "plan_name": "All Plans", "negotiated_rate": 290.0 }, { "payer_name": "IA Medicaid - Wellpoint - Amerigroup", "plan_name": "All Plans", "negotiated_rate": 425.0 }, { "payer_name": "Kaiser-Cigna", "plan_name": "All Plans", "negotiated_rate": 416.0 }, { "payer_name": "Magellan", "plan_name": "All Plans", "negotiated_rate": 400.0 }, { "payer_name": "Midland Choice", "plan_name": "All Plans", "negotiated_rate": 496.0 }, { "payer_name": "Midlands Choice", "plan_name": "All Plans", "negotiated_rate": 496.0 }, { "payer_name": "Mines And Associates", "plan_name": "All Plans", "negotiated_rate": 550.0 }, { "payer_name": "Optum Health - 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UHC", "plan_name": "All Plans", "negotiated_rate": 225.0 }, { "payer_name": "GPA", "plan_name": "All Plans", "negotiated_rate": 180.0 }, { "payer_name": "Gravie Administrators", "plan_name": "All Plans", "negotiated_rate": 218.0 }, { "payer_name": "Health Alliance Connect - Medicare Advan", "plan_name": "All Plans", "negotiated_rate": 68.24 }, { "payer_name": "Health Partners", "plan_name": "All Plans", "negotiated_rate": 225.0 }, { "payer_name": "Health Partners Medicare Advantage", "plan_name": "All Plans", "negotiated_rate": 225.0 }, { "payer_name": "HFN", "plan_name": "All Plans", "negotiated_rate": 212.0 }, { "payer_name": "Humana Medicare - DRG HMO/PPO", "plan_name": "All Plans", "negotiated_rate": 217.53 }, { "payer_name": "IA Medicaid - Molina", "plan_name": "All Plans", "negotiated_rate": 250.0 }, { "payer_name": "IA Medicaid - Total Care", "plan_name": "All Plans", "negotiated_rate": 150.0 }, { "payer_name": "IA Medicaid - Wellpoint - Amerigroup", "plan_name": "All Plans", "negotiated_rate": 242.0 }, { "payer_name": "IL BCBS Medicaid Community Plan", "plan_name": "All Plans", "negotiated_rate": 500.0 }, { "payer_name": "Kaiser-Cigna", "plan_name": "All Plans", "negotiated_rate": 260.0 }, { "payer_name": "Loomis Co", "plan_name": "All Plans", "negotiated_rate": 150.0 }, { "payer_name": "Magellan", "plan_name": "All Plans", "negotiated_rate": 240.0 }, { "payer_name": "Magnacare", "plan_name": "All Plans", "negotiated_rate": 250.0 }, { "payer_name": "Medica", "plan_name": "All Plans", "negotiated_rate": 231.0 }, { "payer_name": "Meritain Health", "plan_name": "All Plans", "negotiated_rate": 212.0 }, { "payer_name": "Midland Choice", "plan_name": "All Plans", "negotiated_rate": 263.0 }, { "payer_name": "Midlands Choice", "plan_name": "All Plans", "negotiated_rate": 263.0 }, { "payer_name": "Mines And Associates", "plan_name": "All Plans", "negotiated_rate": 300.0 }, { "payer_name": "Optum Health - 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Medicare Advanta", "plan_name": "All Plans", "negotiated_rate": 350.0 } ], "minimum": 68.24, "maximum": 500.0 } ] }, { "description": "Tri/Medi Psych Adult IOP-3uni", "code_information": [ { "code": "90853", "type": "CPT" } ], "standard_charges": [ { "setting": "outpatient", "gross_charge": 225.0, "discounted_cash_price": 225.0, "payer_specific_negotiated_charges": [ { "payer_name": "Humana Medicare - DRG HMO/PPO", "plan_name": "All Plans", "negotiated_rate": 217.53 }, { "payer_name": "Tricare East Region Claims", "plan_name": "All Plans", "negotiated_rate": 225.0 } ], "minimum": 217.53, "maximum": 225.0 } ] }, { "description": "Adol Psych IOP 3 hrs", "code_information": [ { "code": "90853", "type": "CPT" } ], "standard_charges": [ { "setting": "outpatient", "gross_charge": 410.0, "discounted_cash_price": 175.0, "payer_specific_negotiated_charges": [ { "payer_name": "Aetna", "plan_name": "All Plans", "negotiated_rate": 230.0 }, { "payer_name": "Aetna", "plan_name": "All Plans", "negotiated_rate": 235.0 }, { "payer_name": "Aetna Better Health Of IL Medicaid", "plan_name": "All Plans", "negotiated_rate": 359.63 }, { "payer_name": "All Savers", "plan_name": "All Plans", "negotiated_rate": 175.0 }, { "payer_name": "Allied Benefit Systems", "plan_name": "All Plans", "negotiated_rate": 200.0 }, { "payer_name": "BCBS Iowa- Wellmark HMO", "plan_name": "All Plans", "negotiated_rate": 374.0 }, { "payer_name": "BCBS Iowa- Wellmark PPO", "plan_name": "All Plans", "negotiated_rate": 374.0 }, { "payer_name": "Bind Benefits", "plan_name": "All Plans", "negotiated_rate": 225.0 }, { "payer_name": "Cigna Behavioral Health", "plan_name": "All Plans", "negotiated_rate": 265.0 }, { "payer_name": "Cigna Behavioral Health", "plan_name": "All Plans", "negotiated_rate": 271.0 }, { "payer_name": "Consociate Health", "plan_name": "All Plans", "negotiated_rate": 200.0 }, { "payer_name": "Employee Benefit Management Services (EB", "plan_name": "All Plans", "negotiated_rate": 200.0 }, { "payer_name": "GEHA - UHC", "plan_name": "All Plans", "negotiated_rate": 225.0 }, { "payer_name": "Golden Rule Insurance", "plan_name": "All Plans", "negotiated_rate": 225.0 }, { "payer_name": "Gravie Administrators", "plan_name": "All Plans", "negotiated_rate": 218.0 }, { "payer_name": "Health Alliance Connect - Medicare Advan", "plan_name": "All Plans", "negotiated_rate": 68.24 }, { "payer_name": "Health Partners", "plan_name": "All Plans", "negotiated_rate": 225.0 }, { "payer_name": "HFN", "plan_name": "All Plans", "negotiated_rate": 212.0 }, { "payer_name": "IA Medicaid - Molina", "plan_name": "All Plans", "negotiated_rate": 250.0 }, { "payer_name": "IA Medicaid - Total Care", "plan_name": "All Plans", "negotiated_rate": 150.0 }, { "payer_name": "IA Medicaid - Wellpoint - Amerigroup", "plan_name": "All Plans", "negotiated_rate": 242.0 }, { "payer_name": "Illinois Medicaid - IL Meridian", "plan_name": "All Plans", "negotiated_rate": 200.0 }, { "payer_name": "Imagine360", "plan_name": "All Plans", "negotiated_rate": 192.1 }, { "payer_name": "Kaiser-Cigna", "plan_name": "All Plans", "negotiated_rate": 260.0 }, { "payer_name": "Loomis Co", "plan_name": "All Plans", "negotiated_rate": 150.0 }, { "payer_name": "Magellan", "plan_name": "All Plans", "negotiated_rate": 240.0 }, { "payer_name": "Magnacare", "plan_name": "All Plans", "negotiated_rate": 250.0 }, { "payer_name": "Meritain Health", "plan_name": "All Plans", "negotiated_rate": 212.0 }, { "payer_name": "Midland Choice", "plan_name": "All Plans", "negotiated_rate": 263.0 }, { "payer_name": "Midlands Choice", "plan_name": "All Plans", "negotiated_rate": 263.0 }, { "payer_name": "Mines And Associates", "plan_name": "All Plans", "negotiated_rate": 300.0 }, { "payer_name": "National Association Of Letter Carriers", "plan_name": "All Plans", "negotiated_rate": 175.0 }, { "payer_name": "Optum Health - United Healthcare", "plan_name": "All Plans", "negotiated_rate": 308.0 }, { "payer_name": "Plumbers & Pipefitters LU # 25", "plan_name": "All Plans", "negotiated_rate": 175.0 }, { "payer_name": "Prairie States Enterprises, Inc.", "plan_name": "All Plans", "negotiated_rate": 225.0 }, { "payer_name": "Sano-Nomi Health", "plan_name": "All Plans", "negotiated_rate": 410.0 }, { "payer_name": "The Alliance", "plan_name": "All Plans", "negotiated_rate": 250.0 }, { "payer_name": "Tricare East Region Claims", "plan_name": "All Plans", "negotiated_rate": 225.0 }, { "payer_name": "Tricare West Region Claims", "plan_name": "All Plans", "negotiated_rate": 321.1 }, { "payer_name": "UMR", "plan_name": "All Plans", "negotiated_rate": 308.0 }, { "payer_name": "United Healthcare Shared Services", "plan_name": "All Plans", "negotiated_rate": 308.0 }, { "payer_name": "WPS Health Insurance", "plan_name": "All Plans", "negotiated_rate": 150.0 } ], "minimum": 68.24, "maximum": 410.0 } ] }, { "description": "Tri/Medi Psych Adol IOP-3 unit", "code_information": [ { "code": "90853", "type": "CPT" } ], "standard_charges": [ { "setting": "outpatient", "gross_charge": 225.0, "discounted_cash_price": 225.0, "payer_specific_negotiated_charges": [ { "payer_name": "Tricare East Region Claims", "plan_name": "All Plans", "negotiated_rate": 225.0 } ], "minimum": 225.0, "maximum": 225.0 } ] }, { "description": "Adol CD IOP 3 hrs", "code_information": [ { "code": "H0015", "type": "HCPCS" } ], "standard_charges": [ { "setting": "outpatient", "gross_charge": 410.0, "discounted_cash_price": 175.0, "payer_specific_negotiated_charges": [ { "payer_name": "Aetna", "plan_name": "All Plans", "negotiated_rate": 230.0 }, { "payer_name": "Aetna", "plan_name": "All Plans", "negotiated_rate": 235.0 }, { "payer_name": "All Savers", "plan_name": "All Plans", "negotiated_rate": 225.0 }, { "payer_name": "Allied Benefit Systems", "plan_name": "All Plans", "negotiated_rate": 200.0 }, { "payer_name": "BCBS Iowa- Wellmark HMO", "plan_name": "All Plans", "negotiated_rate": 374.0 }, { "payer_name": "BCBS Iowa- Wellmark PPO", "plan_name": "All Plans", "negotiated_rate": 374.0 }, { "payer_name": "Bind Benefits", "plan_name": "All Plans", "negotiated_rate": 225.0 }, { "payer_name": "Employee Benefit Management Services (EB", "plan_name": "All Plans", "negotiated_rate": 200.0 }, { "payer_name": "GEHA - UHC", "plan_name": "All Plans", "negotiated_rate": 225.0 }, { "payer_name": "Golden Rule Insurance", "plan_name": "All Plans", "negotiated_rate": 225.0 }, { "payer_name": "Gravie Administrators", "plan_name": "All Plans", "negotiated_rate": 218.0 }, { "payer_name": "Health Alliance Connect - Medicare Advan", "plan_name": "All Plans", "negotiated_rate": 68.24 }, { "payer_name": "HFN", "plan_name": "All Plans", "negotiated_rate": 212.0 }, { "payer_name": "IA Medicaid - Molina", "plan_name": "All Plans", "negotiated_rate": 250.0 }, { "payer_name": "IA Medicaid - Wellpoint - Amerigroup", "plan_name": "All Plans", "negotiated_rate": 242.0 }, { "payer_name": "Loomis Co", "plan_name": "All Plans", "negotiated_rate": 150.0 }, { "payer_name": "Meritain Health", "plan_name": "All Plans", "negotiated_rate": 212.0 }, { "payer_name": "Optum Health - United Healthcare", "plan_name": "All Plans", "negotiated_rate": 308.0 }, { "payer_name": "Sano-Nomi Health", "plan_name": "All Plans", "negotiated_rate": 410.0 }, { "payer_name": "Tricare East Region Claims", "plan_name": "All Plans", "negotiated_rate": 225.0 } ], "minimum": 68.24, "maximum": 410.0 } ] }, { "description": "PHP Daily Adult", "code_information": [ { "code": "H0035", "type": "HCPCS" } ], "standard_charges": [ { "setting": "outpatient", "gross_charge": 550.0, "discounted_cash_price": 550.0, "payer_specific_negotiated_charges": [ { "payer_name": "Quartz One Health", "plan_name": "All Plans", "negotiated_rate": 550.0 }, { "payer_name": "UHC Dual Complete Medicare Advantage", "plan_name": "All Plans", "negotiated_rate": 350.0 } ], "minimum": 350.0, "maximum": 550.0 } ] }, { "description": "Gero IOP 3 hrs", "code_information": [ { "code": "90853", "type": "CPT" } ], "standard_charges": [ { "setting": "outpatient", "gross_charge": 350.0, "discounted_cash_price": 350.0, "payer_specific_negotiated_charges": [ { "payer_name": "Quad City Community Healthcare", "plan_name": "All Plans", "negotiated_rate": 350.0 } ], "minimum": 350.0, "maximum": 350.0 } ] }, { "description": "Adult Psych IOP 3 Hrs", "code_information": [ { "code": "90853", "type": "CPT" } ], "standard_charges": [ { "setting": "outpatient", "gross_charge": 350.0, "discounted_cash_price": 350.0, "payer_specific_negotiated_charges": [ { "payer_name": "Quartz One Health", "plan_name": "All Plans", "negotiated_rate": 350.0 } ], "minimum": 350.0, "maximum": 350.0 } ] }, { "description": "Telehealth Adult Psych IOP 3 hrs", "code_information": [ { "code": "90853", "type": "CPT" } ], "standard_charges": [ { "setting": "outpatient", "gross_charge": 374.0, "discounted_cash_price": 374.0, "payer_specific_negotiated_charges": [ { "payer_name": "Aetna", "plan_name": "All Plans", "negotiated_rate": 230.0 }, { "payer_name": "Aetna", "plan_name": "All Plans", "negotiated_rate": 235.0 }, { "payer_name": "Aetna Better Health Of IL Medicaid", "plan_name": "All Plans", "negotiated_rate": 359.63 }, { "payer_name": "Allied Benefit Systems", "plan_name": "All Plans", "negotiated_rate": 200.0 }, { "payer_name": "BCBS Iowa- Wellmark HMO", "plan_name": "All Plans", "negotiated_rate": 374.0 }, { "payer_name": "BCBS Iowa- Wellmark PPO", "plan_name": "All Plans", "negotiated_rate": 374.0 }, { "payer_name": "IA Medicaid - Molina", "plan_name": "All Plans", "negotiated_rate": 250.0 }, { "payer_name": "IA Medicaid - Total Care", "plan_name": "All Plans", "negotiated_rate": 150.0 }, { "payer_name": "IA Medicaid - Wellpoint - Amerigroup", "plan_name": "All Plans", "negotiated_rate": 236.0 }, { "payer_name": "Mines And Associates", "plan_name": "All Plans", "negotiated_rate": 300.0 }, { "payer_name": "Optum Health - United Healthcare", "plan_name": "All Plans", "negotiated_rate": 257.0 }, { "payer_name": "Oscar Health", "plan_name": "All Plans", "negotiated_rate": 150.0 }, { "payer_name": "Sisco Benefits", "plan_name": "All Plans", "negotiated_rate": 225.0 }, { "payer_name": "The Alliance", "plan_name": "All Plans", "negotiated_rate": 250.0 }, { "payer_name": "UHC Dual Complete Medicare Advantage", "plan_name": "All Plans", "negotiated_rate": 180.0 }, { "payer_name": "UMR", "plan_name": "All Plans", "negotiated_rate": 257.0 } ], "minimum": 150.0, "maximum": 374.0 } ] } ] }