{ "hospital_name": "The Pavilion at Williamsburg Place, Inc.", "last_updated_on": "2026-05-20", "version": "3.0.0", "location_name": [ "The Pavilion at Williamsburg Place" ], "hospital_address": [ "5483 Mooretown Road, Williamsburg, VA 23188" ], "license_information": { "state": "VA", "license_number": "131" }, "type_2_npi": [ "1427326289" ], "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": "Angela Paisley-Rich" }, "standard_charge_information": [ { "description": "Acute Adult R&B", "code_information": [ { "code": "124", "type": "RC" }, { "code": "110001", "type": "LOCAL" } ], "standard_charges": [ { "setting": "inpatient", "payers_information": [ { "payer_name": "ACMG", "plan_name": "ACMG", "standard_charge_dollar": 800.0, "methodology": "fee schedule" }, { "payer_name": "AETNA", "plan_name": "AETNA", "standard_charge_dollar": 1141.0, "methodology": "fee schedule" }, { "payer_name": "Aetna Better Medicaid", "plan_name": "Aetna Better Medicaid", "standard_charge_dollar": 1210.23, "methodology": "fee schedule" }, { "payer_name": "ALEXANDRIA CSB", "plan_name": "ALEXANDRIA CSB", "standard_charge_dollar": 960.0, "methodology": "fee schedule" }, { "payer_name": "ALLEGHANY HIGHLANDS CSB", "plan_name": "ALLEGHANY HIGHLANDS CSB", "standard_charge_dollar": 800.0, "methodology": "fee schedule" }, { "payer_name": "AmeriHealth Caritas District Of Columbia", "plan_name": "AmeriHealth Caritas District Of Columbia", "standard_charge_dollar": 900.0, "methodology": "fee schedule" }, { "payer_name": "ANTHEM BCBS EXCHANGE", "plan_name": "ANTHEM BCBS EXCHANGE", "standard_charge_dollar": 969.2, "methodology": "fee schedule" }, { "payer_name": "ANTHEM BCBS HMO/PPO/PAR", "plan_name": "ANTHEM BCBS HMO/PPO/PAR", "standard_charge_dollar": 969.2, "methodology": "fee schedule" }, { "payer_name": "ANTHEM CCC PLUS MCD", "plan_name": "ANTHEM CCC PLUS MCD", "standard_charge_dollar": 1210.23, "methodology": "fee schedule" }, { "payer_name": "Anthem HealthKeepers Commercial HMO", "plan_name": "Anthem HealthKeepers Commercial HMO", "standard_charge_dollar": 969.2, "methodology": "fee schedule" }, { "payer_name": "Anthem HealthKeepers Medicaid", "plan_name": "Anthem HealthKeepers Medicaid", "standard_charge_dollar": 1210.23, "methodology": "fee schedule" }, { "payer_name": "ARLINGTON CSB", "plan_name": "ARLINGTON CSB", "standard_charge_dollar": 960.0, "methodology": "fee schedule" }, { "payer_name": "BCBS FEP", "plan_name": "BCBS FEP", "standard_charge_dollar": 969.2, "methodology": "fee schedule" }, { "payer_name": "BCBS OUT OF STATE EXCHANGE", "plan_name": "BCBS OUT OF STATE EXCHANGE", "standard_charge_dollar": 969.2, "methodology": "fee schedule" }, { "payer_name": "BCBS OUT OF STATE HMO/PPO/PAR", "plan_name": "BCBS OUT OF STATE HMO/PPO/PAR", "standard_charge_dollar": 969.2, "methodology": "fee schedule" }, { "payer_name": "BEACON HEALTH/Carelon", "plan_name": "BEACON HEALTH/Carelon", "standard_charge_dollar": 983.0, "methodology": "fee schedule" }, { "payer_name": "Behavioral Health Systems", "plan_name": "Behavioral Health Systems", "standard_charge_dollar": 800.0, "methodology": "fee schedule" }, { "payer_name": "BLUE RIDGE BEHAVIORAL HEALTHCARE", "plan_name": "BLUE RIDGE BEHAVIORAL HEALTHCARE", "standard_charge_dollar": 937.3, "methodology": "fee schedule" }, { "payer_name": "Bright Health", "plan_name": "Bright Health", "standard_charge_dollar": 800.0, "methodology": "fee schedule" }, { "payer_name": "CHESAPEAKE CSB", "plan_name": "CHESAPEAKE CSB", "standard_charge_dollar": 675.45, "methodology": "fee schedule" }, { "payer_name": "CHESTERFIELD CSB", "plan_name": "CHESTERFIELD CSB", "standard_charge_dollar": 1014.0, "methodology": "fee schedule" }, { "payer_name": "CIGNA", "plan_name": "CIGNA", "standard_charge_dollar": 959.0, "methodology": "fee schedule" }, { "payer_name": "CIGNA GLOBAL HEALTH", "plan_name": "CIGNA GLOBAL HEALTH", "standard_charge_dollar": 959.0, "methodology": "fee schedule" }, { "payer_name": "COLONIAL CSB", "plan_name": "COLONIAL CSB", "standard_charge_dollar": 675.45, "methodology": "fee schedule" }, { "payer_name": "Commonwealth Care Alliance", "plan_name": "Commonwealth Care Alliance", "standard_charge_dollar": 832.9, "methodology": "fee schedule" }, { "payer_name": "COMPSYCH", "plan_name": "COMPSYCH", "standard_charge_dollar": 1125.0, "methodology": "fee schedule" }, { "payer_name": "CROSSROADS CSB", "plan_name": "CROSSROADS CSB", "standard_charge_dollar": 1014.0, "methodology": "fee schedule" }, { "payer_name": "CUMBERLAND MOUNTAIN CSB", "plan_name": "CUMBERLAND MOUNTAIN CSB", "standard_charge_dollar": 824.0, "methodology": "fee schedule" }, { "payer_name": "DANVILLE PITTSYLVANIA CSB", "plan_name": "DANVILLE PITTSYLVANIA CSB", "standard_charge_dollar": 825.0, "methodology": 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Imagine Health Group Plan", "plan_name": "GPA - Imagine Health Group Plan", "standard_charge_dollar": 500.0, "methodology": "fee schedule" }, { "payer_name": "HAMPTON-NEWPORT NEWS CSB", "plan_name": "HAMPTON-NEWPORT NEWS CSB", "standard_charge_dollar": 675.45, "methodology": "fee schedule" }, { "payer_name": "HANOVER CSB", "plan_name": "HANOVER CSB", "standard_charge_dollar": 1014.0, "methodology": "fee schedule" }, { "payer_name": "HEALTHSCOPE BENEFITS", "plan_name": "HEALTHSCOPE BENEFITS", "standard_charge_dollar": 800.0, "methodology": "fee schedule" }, { "payer_name": "HENRICO CSB", "plan_name": "HENRICO CSB", "standard_charge_dollar": 1014.0, "methodology": "fee schedule" }, { "payer_name": "HIGHLANDS CSB", "plan_name": "HIGHLANDS CSB", "standard_charge_dollar": 824.0, "methodology": "fee schedule" }, { "payer_name": "HORIZON CSB", "plan_name": "HORIZON CSB", "standard_charge_dollar": 1000.0, "methodology": "fee schedule" }, { "payer_name": "HUMANA", "plan_name": "HUMANA", "standard_charge_dollar": 950.0, "methodology": "fee schedule" }, { "payer_name": "HUMANA HMO POS", "plan_name": "HUMANA HMO POS", "standard_charge_dollar": 950.0, "methodology": "fee schedule" }, { "payer_name": "HUMANA MEDICAID", "plan_name": "HUMANA MEDICAID", "standard_charge_dollar": 1210.23, "methodology": "fee schedule" }, { "payer_name": "John Hopkins Health Services", "plan_name": "John Hopkins Health Services", "standard_charge_dollar": 800.0, "methodology": "fee schedule" }, { "payer_name": "KAISER HMO/PPO", "plan_name": "KAISER HMO/PPO", "standard_charge_dollar": 1000.0, "methodology": "fee schedule" }, { "payer_name": "KAISER MCD", "plan_name": "KAISER MCD", "standard_charge_dollar": 1210.23, "methodology": "fee schedule" }, { "payer_name": "KAISER MCR ADV", "plan_name": "KAISER MCR ADV", "standard_charge_dollar": 1000.0, "methodology": "fee schedule" }, { "payer_name": "LOUDON CSB", "plan_name": "LOUDON CSB", "standard_charge_dollar": 960.0, "methodology": "fee schedule" }, { "payer_name": "Medcost", "plan_name": "Medcost", "standard_charge_dollar": 1000.0, "methodology": "fee schedule" }, { "payer_name": "Medica - UHC", "plan_name": "Medica - UHC", "standard_charge_dollar": 800.0, "methodology": "fee schedule" }, { "payer_name": "MERITAIN HEALTH", "plan_name": "MERITAIN HEALTH", "standard_charge_dollar": 1076.0, "methodology": "fee schedule" }, { "payer_name": "MHNET", "plan_name": "MHNET", "standard_charge_dollar": 815.0, "methodology": "fee schedule" }, { "payer_name": "MIDDLE PENINSULA-NORTHERN NECK CSB", "plan_name": "MIDDLE PENINSULA-NORTHERN NECK CSB", "standard_charge_dollar": 675.45, "methodology": "fee schedule" }, { "payer_name": "MOLINA CCC MCD", "plan_name": "MOLINA CCC MCD", "standard_charge_dollar": 1210.23, "methodology": "fee schedule" }, { "payer_name": "MT ROGERS CSB", "plan_name": "MT ROGERS CSB", "standard_charge_dollar": 824.0, "methodology": "fee schedule" }, { "payer_name": "NC Medicaid - Vaya", "plan_name": "NC Medicaid - Vaya", "standard_charge_dollar": 500.0, "methodology": "fee schedule" }, { "payer_name": "NEW RIVER VALLEY CSB", "plan_name": "NEW RIVER VALLEY CSB", "standard_charge_dollar": 824.0, "methodology": "fee schedule" }, { "payer_name": "NORFOLK CSB", "plan_name": "NORFOLK CSB", "standard_charge_dollar": 675.45, "methodology": "fee schedule" }, { "payer_name": "NORTH WEST CSB", "plan_name": "NORTH WEST CSB", "standard_charge_dollar": 800.0, "methodology": "fee schedule" }, { "payer_name": "Optima - VP VA PREM MCD HMO Sentara", "plan_name": "Optima - VP VA PREM MCD HMO Sentara", "standard_charge_dollar": 1210.23, "methodology": "fee schedule" }, { "payer_name": "Optima -VP PREM Medicare HMO SNP Sentara", "plan_name": "Optima -VP PREM Medicare HMO SNP Sentara", "standard_charge_dollar": 637.0, "methodology": "fee schedule" }, { "payer_name": "OPTIMA COMM CARE MCD Sentara", "plan_name": "OPTIMA COMM CARE MCD Sentara", "standard_charge_dollar": 1210.23, "methodology": "fee schedule" }, { "payer_name": "OPTIMA FAMILY CARE Sentara", "plan_name": "OPTIMA FAMILY CARE Sentara", "standard_charge_dollar": 1210.23, "methodology": "fee schedule" }, { "payer_name": "Optima-VP-VA PREM CCC MCD Sentara", "plan_name": "Optima-VP-VA PREM CCC MCD Sentara", "standard_charge_dollar": 1210.23, "methodology": "fee schedule" }, { "payer_name": "Optimum Health Care, Inc.", "plan_name": "Optimum Health Care, Inc.", "standard_charge_dollar": 1210.23, "methodology": "fee schedule" }, { "payer_name": "OPTIMUMCARE", "plan_name": "OPTIMUMCARE", "standard_charge_dollar": 1210.23, "methodology": "fee schedule" }, { "payer_name": "OPTUM", "plan_name": "OPTUM", "standard_charge_dollar": 976.0, "methodology": "fee schedule" }, { "payer_name": "PIEDMONT COMM HEALTH PLAN", "plan_name": "PIEDMONT COMM HEALTH PLAN", "standard_charge_dollar": 1000.0, "methodology": "fee schedule" }, { "payer_name": "PIEDMONT CSB", "plan_name": "PIEDMONT CSB", "standard_charge_dollar": 875.0, "methodology": "fee schedule" }, { "payer_name": "PLANNING DISTRICT ONE", "plan_name": "PLANNING DISTRICT ONE", "standard_charge_dollar": 824.0, "methodology": "fee schedule" }, { "payer_name": "PORTSMOUTH CSB", "plan_name": "PORTSMOUTH CSB", "standard_charge_dollar": 675.45, "methodology": "fee schedule" }, { "payer_name": "PRINCE WILLIAMS CSB", "plan_name": "PRINCE WILLIAMS CSB", "standard_charge_dollar": 960.0, "methodology": "fee schedule" }, { "payer_name": "RAPPAHANNOCK AREA CSB", "plan_name": "RAPPAHANNOCK AREA CSB", "standard_charge_dollar": 800.0, "methodology": "fee schedule" }, { "payer_name": "RAPPAHANNOCK RAPIDAN CSB", "plan_name": "RAPPAHANNOCK RAPIDAN CSB", "standard_charge_dollar": 800.0, "methodology": "fee schedule" }, { "payer_name": "REGION 10 CSB", "plan_name": "REGION 10 CSB", "standard_charge_dollar": 800.0, "methodology": "fee schedule" }, { "payer_name": "RICHMOND BHA", "plan_name": "RICHMOND BHA", "standard_charge_dollar": 1014.0, "methodology": "fee schedule" }, { "payer_name": "ROCKBRIDGE CSB", "plan_name": "ROCKBRIDGE CSB", "standard_charge_dollar": 800.0, "methodology": "fee schedule" }, { "payer_name": "ROCKINGHAM CSB", "plan_name": "ROCKINGHAM CSB", "standard_charge_dollar": 1000.0, "methodology": "fee schedule" }, { "payer_name": "Sentara Optima Commercial", "plan_name": "Sentara Optima Commercial", "standard_charge_dollar": 976.0, "methodology": "fee schedule" }, { "payer_name": "SOUTHSIDE CSB", "plan_name": "SOUTHSIDE CSB", "standard_charge_dollar": 882.0, "methodology": "fee schedule" }, { "payer_name": "Surest", "plan_name": "Surest", "standard_charge_dollar": 800.0, "methodology": "fee schedule" }, { "payer_name": "TDO", "plan_name": "TDO", "standard_charge_dollar": 1210.23, "methodology": "fee schedule" }, { "payer_name": "TRICARE EAST REGION", "plan_name": "TRICARE EAST REGION", "standard_charge_dollar": 749.0, "methodology": "fee schedule" }, { "payer_name": "TRICARE WEST REGION", "plan_name": "TRICARE WEST REGION", "standard_charge_dollar": 749.0, "methodology": "fee schedule" }, { "payer_name": "UHC", "plan_name": "UHC", "standard_charge_dollar": 976.0, "methodology": "fee schedule" }, { "payer_name": "UHC COMM PLAN MCD", "plan_name": "UHC COMM PLAN MCD", "standard_charge_dollar": 1210.23, "methodology": "fee schedule" }, { "payer_name": "UHC OXFORD", "plan_name": "UHC OXFORD", "standard_charge_dollar": 976.0, "methodology": "fee schedule" }, { "payer_name": "UHC STUDENT RES", "plan_name": "UHC STUDENT RES", "standard_charge_dollar": 976.0, "methodology": "fee schedule" }, { "payer_name": "UMR", "plan_name": "UMR", "standard_charge_dollar": 800.0, "methodology": "fee schedule" }, { "payer_name": "UMWA", "plan_name": "UMWA", "standard_charge_dollar": 644.41, "methodology": "fee schedule" }, { "payer_name": "UNITED HEALTHCARE SHARED SERVICES", "plan_name": "UNITED HEALTHCARE SHARED SERVICES", "standard_charge_dollar": 976.0, "methodology": "fee schedule" }, { "payer_name": "VALLEY CSB", "plan_name": "VALLEY CSB", "standard_charge_dollar": 1000.0, "methodology": "fee schedule" }, { "payer_name": "VIRGINIA BEACH CSB", "plan_name": "VIRGINIA BEACH CSB", "standard_charge_dollar": 675.45, "methodology": "fee schedule" }, { "payer_name": "WESTERN TIDEWATER CSB", "plan_name": "WESTERN TIDEWATER CSB", "standard_charge_dollar": 675.45, "methodology": "fee schedule" }, { "payer_name": "WPAS", "plan_name": "WPAS", "standard_charge_dollar": 800.0, "methodology": "fee schedule" } ], "gross_charge": 3000.0, "discounted_cash": 800.0, "minimum": 500.0, "maximum": 1210.23 } ] }, { "description": "Acute Child R&B", "code_information": [ { "code": "124", "type": "RC" }, { "code": "110002", "type": "LOCAL" } ], "standard_charges": [ { "setting": "inpatient", "payers_information": [ { "payer_name": "TRICARE EAST REGION", "plan_name": "TRICARE EAST REGION", "standard_charge_dollar": 749.0, "methodology": "fee schedule" } ], "gross_charge": 3000.0, "minimum": 749.0, "maximum": 749.0 } ] }, { "description": "Acute Gero R&B", "code_information": [ { "code": "124", "type": "RC" }, { "code": "110000", "type": "LOCAL" } ], "standard_charges": [ { "setting": "inpatient", "payers_information": [ { "payer_name": "ACMG", "plan_name": "ACMG", "standard_charge_dollar": 800.0, "methodology": "fee schedule" }, { "payer_name": "AETNA", "plan_name": "AETNA", "standard_charge_dollar": 1141.0, "methodology": "fee schedule" }, { "payer_name": "Aetna Better Medicaid", "plan_name": "Aetna Better Medicaid", "standard_charge_dollar": 1210.23, "methodology": "fee schedule" }, { "payer_name": "ALEXANDRIA CSB", "plan_name": "ALEXANDRIA CSB", "standard_charge_dollar": 960.0, "methodology": "fee schedule" }, { "payer_name": "ALLEGHANY HIGHLANDS CSB", "plan_name": "ALLEGHANY HIGHLANDS CSB", "standard_charge_dollar": 800.0, "methodology": "fee schedule" }, { "payer_name": "AmeriHealth Caritas District Of Columbia", "plan_name": "AmeriHealth Caritas District Of Columbia", "standard_charge_dollar": 900.0, "methodology": "fee 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"methodology": "fee schedule" }, { "payer_name": "BCBS OUT OF STATE EXCHANGE", "plan_name": "BCBS OUT OF STATE EXCHANGE", "standard_charge_dollar": 969.2, "methodology": "fee schedule" }, { "payer_name": "BCBS OUT OF STATE HMO/PPO/PAR", "plan_name": "BCBS OUT OF STATE HMO/PPO/PAR", "standard_charge_dollar": 969.2, "methodology": "fee schedule" }, { "payer_name": "BEACON HEALTH/Carelon", "plan_name": "BEACON HEALTH/Carelon", "standard_charge_dollar": 983.0, "methodology": "fee schedule" }, { "payer_name": "Behavioral Health Systems", "plan_name": "Behavioral Health Systems", "standard_charge_dollar": 800.0, "methodology": "fee schedule" }, { "payer_name": "BLUE RIDGE BEHAVIORAL HEALTHCARE", "plan_name": "BLUE RIDGE BEHAVIORAL HEALTHCARE", "standard_charge_dollar": 937.3, "methodology": "fee schedule" }, { "payer_name": "CHESAPEAKE CSB", "plan_name": "CHESAPEAKE CSB", "standard_charge_dollar": 675.45, "methodology": "fee schedule" }, { "payer_name": "CHESTERFIELD CSB", "plan_name": 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"plan_name": "ANTHEM CCC PLUS MCD", "standard_charge_dollar": 500.0, "methodology": "fee schedule" }, { "payer_name": "Anthem HealthKeepers Commercial HMO", "plan_name": "Anthem HealthKeepers Commercial HMO", "standard_charge_dollar": 472.88, "methodology": "fee schedule" }, { "payer_name": "Anthem HealthKeepers Medicaid", "plan_name": "Anthem HealthKeepers Medicaid", "standard_charge_dollar": 139.0, "methodology": "fee schedule" }, { "payer_name": "BCBS FEP", "plan_name": "BCBS FEP", "standard_charge_dollar": 472.88, "methodology": "fee schedule" }, { "payer_name": "BCBS OUT OF STATE EXCHANGE", "plan_name": "BCBS OUT OF STATE EXCHANGE", "standard_charge_dollar": 472.88, "methodology": "fee schedule" }, { "payer_name": "BCBS OUT OF STATE HMO/PPO/PAR", "plan_name": "BCBS OUT OF STATE HMO/PPO/PAR", "standard_charge_dollar": 472.88, "methodology": "fee schedule" }, { "payer_name": "CIGNA", "plan_name": "CIGNA", "standard_charge_dollar": 423.0, "methodology": "fee schedule" }, { "payer_name": "CIGNA GLOBAL HEALTH", "plan_name": "CIGNA GLOBAL HEALTH", "standard_charge_dollar": 423.0, "methodology": "fee schedule" }, { "payer_name": "COMPSYCH", "plan_name": "COMPSYCH", "standard_charge_dollar": 465.0, "methodology": "fee schedule" }, { "payer_name": "HUMANA MEDICAID", "plan_name": "HUMANA MEDICAID", "standard_charge_dollar": 500.0, "methodology": "fee schedule" }, { "payer_name": "OPTIMA COMM CARE MCD Sentara", "plan_name": "OPTIMA COMM CARE MCD Sentara", "standard_charge_dollar": 500.0, "methodology": "fee schedule" }, { "payer_name": "OPTUM", "plan_name": "OPTUM", "standard_charge_dollar": 500.0, "methodology": "fee schedule" }, { "payer_name": "Sentara Optima Commercial", "plan_name": "Sentara Optima Commercial", "standard_charge_dollar": 439.0, "methodology": "fee schedule" }, { "payer_name": "TRICARE EAST REGION", "plan_name": "TRICARE EAST REGION", "standard_charge_dollar": 433.8, "methodology": "fee schedule" }, { "payer_name": "UHC", "plan_name": "UHC", "standard_charge_dollar": 500.0, "methodology": "fee schedule" }, { "payer_name": "UHC COMM PLAN MCD", "plan_name": "UHC COMM PLAN MCD", "standard_charge_dollar": 500.0, "methodology": "fee schedule" }, { "payer_name": "UHC MANAGED MEDICARE ADVANTAGE", "plan_name": "UHC MANAGED MEDICARE ADVANTAGE", "standard_charge_dollar": 390.0, "methodology": "fee schedule" }, { "payer_name": "UHC OXFORD", "plan_name": "UHC OXFORD", "standard_charge_dollar": 500.0, "methodology": "fee schedule" }, { "payer_name": "UHC STUDENT RES", "plan_name": "UHC STUDENT RES", "standard_charge_dollar": 500.0, "methodology": "fee schedule" }, { "payer_name": "UMR", "plan_name": "UMR", "standard_charge_dollar": 500.0, "methodology": "fee schedule" }, { "payer_name": "UNITED HEALTHCARE SHARED SERVICES", "plan_name": "UNITED HEALTHCARE SHARED SERVICES", "standard_charge_dollar": 500.0, "methodology": "fee schedule" } ], "gross_charge": 2500.0, "minimum": 139.0, "maximum": 500.0 } ] }, { "description": "Telehealth PHP Psych Adult Daily", "code_information": [ { "code": "H0035", "type": "HCPCS" }, { "code": "846", "type": "LOCAL" } ], "standard_charges": [ { "setting": "outpatient", "payers_information": [ { "payer_name": "AETNA", "plan_name": "AETNA", "standard_charge_dollar": 448.0, "methodology": "fee schedule" }, { "payer_name": "ANTHEM BCBS EXCHANGE", "plan_name": "ANTHEM BCBS EXCHANGE", "standard_charge_dollar": 461.25, "methodology": "fee schedule" }, { "payer_name": "ANTHEM BCBS HMO/PPO/PAR", "plan_name": "ANTHEM BCBS HMO/PPO/PAR", "standard_charge_dollar": 461.25, "methodology": "fee schedule" }, { "payer_name": "ANTHEM CCC PLUS MCD", "plan_name": "ANTHEM CCC PLUS MCD", "standard_charge_dollar": 500.0, "methodology": "fee schedule" }, { "payer_name": "Anthem HealthKeepers Medicaid", "plan_name": "Anthem HealthKeepers Medicaid", "standard_charge_dollar": 139.0, "methodology": "fee schedule" }, { "payer_name": "HUMANA MEDICAID", "plan_name": "HUMANA MEDICAID", "standard_charge_dollar": 500.0, "methodology": "fee schedule" }, { "payer_name": "HUMANA MEDICARE", "plan_name": "HUMANA MEDICARE", "standard_charge_dollar": 500.0, "methodology": "fee schedule" }, { "payer_name": "OPTIMA COMM CARE MCD Sentara", "plan_name": "OPTIMA COMM CARE MCD Sentara", "standard_charge_dollar": 500.0, "methodology": "fee schedule" }, { "payer_name": "Optima-VP-VA PREM CCC MCD Sentara", "plan_name": "Optima-VP-VA PREM CCC MCD Sentara", "standard_charge_dollar": 500.0, "methodology": "fee schedule" }, { "payer_name": "Sentara Optima Commercial", "plan_name": "Sentara Optima Commercial", "standard_charge_dollar": 425.0, "methodology": "fee schedule" }, { "payer_name": "TRICARE EAST REGION", "plan_name": "TRICARE EAST REGION", "standard_charge_dollar": 433.8, "methodology": "fee schedule" }, { "payer_name": "UHC", "plan_name": "UHC", "standard_charge_dollar": 500.0, "methodology": "fee schedule" }, { "payer_name": "UHC COMM PLAN MCD", "plan_name": "UHC COMM PLAN MCD", "standard_charge_dollar": 250.0, "methodology": "fee schedule" }, { "payer_name": "UMR", "plan_name": "UMR", "standard_charge_dollar": 500.0, "methodology": "fee schedule" } ], "gross_charge": 2500.0, "minimum": 139.0, "maximum": 500.0 } ] }, { "description": "DC <30 minutes", "code_information": [ { "code": "99238", "type": "CPT" }, { "code": "99238", "type": "LOCAL" } ], "standard_charges": [ { "setting": "inpatient", "payers_information": [ { "payer_name": "Alignment Health Plan Medicare Advantage", "plan_name": "Alignment Health Plan Medicare Advantage", "standard_charge_dollar": 31.81, "methodology": "fee schedule" }, { "payer_name": "ANTHEM BCBS HMO/PPO/PAR", "plan_name": "ANTHEM BCBS HMO/PPO/PAR", "standard_charge_dollar": 63.2, "methodology": "fee schedule" }, { "payer_name": "ANTHEM CCC PLUS MCD", "plan_name": "ANTHEM CCC PLUS MCD", "standard_charge_dollar": 63.2, "methodology": "fee schedule" }, { "payer_name": "Anthem HealthKeepers Commercial HMO", "plan_name": "Anthem HealthKeepers Commercial HMO", "standard_charge_dollar": 63.2, "methodology": "fee schedule" }, { "payer_name": "Anthem HealthKeepers Medicaid", "plan_name": "Anthem HealthKeepers Medicaid", "standard_charge_dollar": 63.2, "methodology": "fee schedule" }, { "payer_name": "BCBS MEDICARE ADV", "plan_name": "BCBS MEDICARE ADV", "standard_charge_dollar": 31.81, "methodology": "fee schedule" }, { "payer_name": "BCBS OUT OF STATE HMO/PPO/PAR", "plan_name": "BCBS OUT OF STATE HMO/PPO/PAR", "standard_charge_dollar": 70.23, "methodology": "fee schedule" }, { "payer_name": "CIGNA", "plan_name": "CIGNA", "standard_charge_dollar": 68.84, "methodology": "fee schedule" }, { "payer_name": "HUMANA MEDICARE", "plan_name": "HUMANA MEDICARE", "standard_charge_dollar": 72.23, "methodology": "fee schedule" }, { "payer_name": "OPTIMA COMM CARE MCD Sentara", "plan_name": "OPTIMA COMM CARE MCD Sentara", "standard_charge_dollar": 51.44, "methodology": "fee schedule" }, { "payer_name": "Sentara Optima Commercial", "plan_name": "Sentara Optima Commercial", "standard_charge_dollar": 70.47, "methodology": "fee schedule" }, { "payer_name": "TRICARE EAST REGION", "plan_name": "TRICARE EAST REGION", "standard_charge_dollar": 73.8, "methodology": "fee schedule" } ], "gross_charge": 240.0, "minimum": 31.81, "maximum": 73.8 } ] }, { "description": "Psych Eval - Medical Services", "code_information": [ { "code": "90792", "type": "CPT" }, { "code": "90792", "type": "LOCAL" } ], "standard_charges": [ { "setting": "outpatient", "payers_information": [ { "payer_name": "Alignment Health Plan Medicare Advantage", "plan_name": "Alignment Health Plan Medicare Advantage", "standard_charge_dollar": 175.89, "methodology": "fee schedule" }, { "payer_name": "ANTHEM BCBS HMO/PPO/PAR", "plan_name": "ANTHEM BCBS HMO/PPO/PAR", "standard_charge_dollar": 140.0, "methodology": "fee schedule" }, { "payer_name": "ANTHEM CCC PLUS MCD", "plan_name": "ANTHEM CCC PLUS MCD", "standard_charge_dollar": 140.0, "methodology": "fee schedule" }, { "payer_name": "Anthem HealthKeepers Medicaid", "plan_name": "Anthem HealthKeepers Medicaid", "standard_charge_dollar": 140.0, "methodology": "fee schedule" }, { "payer_name": "BCBS FEP", "plan_name": "BCBS FEP", "standard_charge_dollar": 155.63, "methodology": "fee schedule" }, { "payer_name": "BCBS MEDICARE ADV", "plan_name": "BCBS MEDICARE ADV", "standard_charge_dollar": 175.89, "methodology": "fee schedule" }, { "payer_name": "BCBS OUT OF STATE HMO/PPO/PAR", "plan_name": "BCBS OUT OF STATE HMO/PPO/PAR", "standard_charge_dollar": 140.0, "methodology": "fee schedule" }, { "payer_name": "CIGNA", "plan_name": "CIGNA", "standard_charge_dollar": 149.11, "methodology": "fee schedule" }, { "payer_name": "CIGNA GLOBAL HEALTH", "plan_name": "CIGNA GLOBAL HEALTH", "standard_charge_dollar": 140.4, "methodology": "fee schedule" }, { "payer_name": "HUMANA MEDICARE", "plan_name": "HUMANA MEDICARE", "standard_charge_dollar": 83.28, "methodology": "fee schedule" }, { "payer_name": "OPTIMA COMM CARE MCD Sentara", "plan_name": "OPTIMA COMM CARE MCD Sentara", "standard_charge_dollar": 135.55, "methodology": "fee schedule" }, { "payer_name": "OPTIMA MEDICARE Sentara", "plan_name": "OPTIMA MEDICARE Sentara", "standard_charge_dollar": 135.55, "methodology": "fee schedule" }, { "payer_name": "Sentara Optima Commercial", "plan_name": "Sentara Optima Commercial", "standard_charge_dollar": 209.16, "methodology": "fee schedule" }, { "payer_name": "TRICARE EAST REGION", "plan_name": "TRICARE EAST REGION", "standard_charge_dollar": 142.33, "methodology": "fee schedule" } ], "gross_charge": 310.0, "minimum": 83.28, "maximum": 209.16 } ] }, { "description": "Psych Eval - No Med Services", "code_information": [ { "code": "90791", "type": "CPT" }, { "code": "90791", "type": "LOCAL" } ], "standard_charges": [ { "setting": "outpatient", "payers_information": [ { "payer_name": "ANTHEM BCBS HMO/PPO/PAR", "plan_name": "ANTHEM BCBS HMO/PPO/PAR", "standard_charge_dollar": 128.0, "methodology": "fee schedule" }, { "payer_name": "Anthem HealthKeepers Commercial HMO", "plan_name": "Anthem HealthKeepers Commercial HMO", "standard_charge_dollar": 118.0, "methodology": "fee schedule" }, { "payer_name": "CIGNA", "plan_name": "CIGNA", "standard_charge_dollar": 149.11, "methodology": "fee schedule" }, { "payer_name": "OPTIMA COMM CARE MCD Sentara", "plan_name": "OPTIMA COMM CARE MCD Sentara", "standard_charge_dollar": 121.18, "methodology": "fee schedule" }, { "payer_name": "TRICARE EAST REGION", "plan_name": "TRICARE EAST REGION", "standard_charge_dollar": 142.33, "methodology": "fee schedule" } ], "gross_charge": 250.0, "minimum": 118.0, "maximum": 149.11 } ] }, { "description": "SUBSEQ HOSP (25 MIN)", "code_information": [ { "code": "99232", "type": "CPT" }, { "code": "99232", "type": "LOCAL" } ], "standard_charges": [ { "setting": "inpatient", "payers_information": [ { "payer_name": "Alignment Health Plan Medicare Advantage", "plan_name": "Alignment Health Plan Medicare Advantage", "standard_charge_dollar": 48.57, "methodology": "fee schedule" }, { "payer_name": "ANTHEM BCBS HMO/PPO/PAR", "plan_name": "ANTHEM BCBS HMO/PPO/PAR", "standard_charge_dollar": 62.9, "methodology": "fee schedule" }, { "payer_name": "ANTHEM CCC PLUS MCD", "plan_name": "ANTHEM CCC PLUS MCD", "standard_charge_dollar": 50.94, "methodology": "fee schedule" }, { "payer_name": "Anthem HealthKeepers Commercial HMO", "plan_name": "Anthem HealthKeepers Commercial HMO", "standard_charge_dollar": 62.9, "methodology": "fee schedule" }, { "payer_name": "Anthem HealthKeepers Medicaid", "plan_name": "Anthem HealthKeepers Medicaid", "standard_charge_dollar": 50.94, "methodology": "fee schedule" }, { "payer_name": "BCBS MEDICARE ADV", "plan_name": "BCBS MEDICARE ADV", "standard_charge_dollar": 48.57, "methodology": "fee schedule" }, { "payer_name": "BCBS OUT OF STATE HMO/PPO/PAR", "plan_name": "BCBS OUT OF STATE HMO/PPO/PAR", "standard_charge_dollar": 69.89, "methodology": "fee schedule" }, { "payer_name": "CIGNA", "plan_name": "CIGNA", "standard_charge_dollar": 60.0, "methodology": "fee schedule" }, { "payer_name": "CIGNA GLOBAL HEALTH", "plan_name": "CIGNA GLOBAL HEALTH", "standard_charge_dollar": 48.0, "methodology": "fee schedule" }, { "payer_name": "HUMANA MEDICARE", "plan_name": "HUMANA MEDICARE", "standard_charge_dollar": 48.22, "methodology": "fee schedule" }, { "payer_name": "OPTIMA COMM CARE MCD Sentara", "plan_name": "OPTIMA COMM CARE MCD Sentara", "standard_charge_dollar": 50.94, "methodology": "fee schedule" }, { "payer_name": "OPTIMA FAMILY CARE Sentara", "plan_name": "OPTIMA FAMILY CARE Sentara", "standard_charge_dollar": 50.94, "methodology": "fee schedule" }, { "payer_name": "OPTIMA MEDICARE Sentara", "plan_name": "OPTIMA MEDICARE Sentara", "standard_charge_dollar": 50.94, "methodology": "fee schedule" }, { "payer_name": "Sentara Optima Commercial", "plan_name": "Sentara Optima Commercial", "standard_charge_dollar": 69.79, "methodology": "fee schedule" }, { "payer_name": "TRICARE EAST REGION", "plan_name": "TRICARE EAST REGION", "standard_charge_dollar": 73.12, "methodology": "fee schedule" } ], "gross_charge": 200.0, "minimum": 48.0, "maximum": 73.12 } ] }, { "description": "SUBSEQ HOSP (35 MIN)", "code_information": [ { "code": "99233", "type": "CPT" }, { "code": "99233", "type": "LOCAL" } ], "standard_charges": [ { "setting": "inpatient", "payers_information": [ { "payer_name": "CIGNA", "plan_name": "CIGNA", "standard_charge_dollar": 80.0, "methodology": "fee schedule" } ], "gross_charge": 200.0, "minimum": 80.0, "maximum": 80.0 } ] }, { "description": "SUBSEQ HOSP (15 MIN)", "code_information": [ { "code": "99231", "type": "CPT" }, { "code": "99231", "type": "LOCAL" } ], "standard_charges": [ { "setting": "inpatient", "payers_information": [ { "payer_name": "Alignment Health Plan Medicare Advantage", "plan_name": "Alignment Health Plan Medicare Advantage", "standard_charge_dollar": 25.94, "methodology": "fee schedule" }, { "payer_name": "ANTHEM BCBS HMO/PPO/PAR", "plan_name": "ANTHEM BCBS HMO/PPO/PAR", "standard_charge_dollar": 34.39, "methodology": "fee schedule" }, { "payer_name": "ANTHEM CCC PLUS MCD", "plan_name": "ANTHEM CCC PLUS MCD", "standard_charge_dollar": 34.39, "methodology": "fee schedule" }, { "payer_name": "Anthem HealthKeepers Commercial HMO", "plan_name": "Anthem HealthKeepers Commercial HMO", "standard_charge_dollar": 34.39, "methodology": "fee schedule" }, { "payer_name": "Anthem HealthKeepers Medicaid", "plan_name": "Anthem HealthKeepers Medicaid", "standard_charge_dollar": 34.39, "methodology": "fee schedule" }, { "payer_name": "BCBS FEP", "plan_name": "BCBS FEP", "standard_charge_dollar": 38.22, "methodology": "fee schedule" }, { "payer_name": "BCBS MEDICARE ADV", "plan_name": "BCBS MEDICARE ADV", "standard_charge_dollar": 25.94, "methodology": "fee schedule" }, { "payer_name": "BCBS OUT OF STATE HMO/PPO/PAR", "plan_name": "BCBS OUT OF STATE HMO/PPO/PAR", "standard_charge_dollar": 38.22, "methodology": "fee schedule" }, { "payer_name": "CIGNA", "plan_name": "CIGNA", "standard_charge_dollar": 36.0, "methodology": "fee schedule" }, { "payer_name": "CIGNA GLOBAL HEALTH", "plan_name": "CIGNA GLOBAL HEALTH", "standard_charge_dollar": 40.0, "methodology": "fee schedule" }, { "payer_name": "HUMANA MEDICARE", "plan_name": "HUMANA MEDICARE", "standard_charge_dollar": 38.38, "methodology": "fee schedule" }, { "payer_name": "OPTIMA COMM CARE MCD Sentara", "plan_name": "OPTIMA COMM CARE MCD Sentara", "standard_charge_dollar": 27.72, "methodology": "fee schedule" }, { "payer_name": "OPTIMA FAMILY CARE Sentara", "plan_name": "OPTIMA FAMILY CARE Sentara", "standard_charge_dollar": 20.26, "methodology": "fee schedule" }, { "payer_name": "OPTIMA MEDICARE Sentara", "plan_name": "OPTIMA MEDICARE Sentara", "standard_charge_dollar": 20.26, "methodology": "fee schedule" }, { "payer_name": "Sentara Optima Commercial", "plan_name": "Sentara Optima Commercial", "standard_charge_dollar": 37.98, "methodology": "fee schedule" }, { "payer_name": "TRICARE EAST REGION", "plan_name": "TRICARE EAST REGION", "standard_charge_dollar": 33.8, "methodology": "fee schedule" } ], "gross_charge": 140.0, "minimum": 20.26, "maximum": 40.0 } ] } ] }