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For payer-specific negotiated charges that cannot be expressed as a dollar amount in the machine-readable file or not knowable in advance, the hospital attests that the payer-specific negotiated charge is based on a contractual algorithm, percentage or formula that precludes the provision of a dollar amount and has provided all necessary information available to the hospital for the public to be able to derive the dollar amount, including, but not limited to, the specific fee schedule or components referenced in such percentage, algorithm or formula.", "confirm_attestation": true, "attester_name": "Geoffrey Vines"}, "standard_charge_information": [{"description": "17-HYDROXY PREGNENOLONE", "code_information": [{"code": "7258414", "type": "CDM"}, {"code": "300", "type": "RC"}], "standard_charges": [{"gross_charge": 141.0, "discounted_cash": 105.75, "setting": "both", "billing_class": "facility"}]}, {"description": "3D IMAGING W POSTPROCESS", "code_information": [{"code": "4616377", 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5541.0, "setting": "both", "billing_class": "facility"}]}, {"description": "INJECT SPINE DISK LMBR", "code_information": [{"code": "4917715", "type": "CDM"}, {"code": "360", "type": "RC"}], "standard_charges": [{"gross_charge": 1392.0, "discounted_cash": 1044.0, "setting": "both", "billing_class": "facility"}]}, {"description": "INJECTABLE BULK AGENT", "code_information": [{"code": "L8606", "type": "HCPCS"}, {"code": "8182614", "type": "CDM"}, {"code": "278", "type": "RC"}], "standard_charges": [{"gross_charge": 6710.0, "discounted_cash": 5032.5, "setting": "both", "billing_class": "facility"}]}, {"description": "INS BEAR JRNY II XR XLPE SN CL", "code_information": [{"code": "C1776", "type": "HCPCS"}, {"code": "4012889", "type": "CDM"}, {"code": "278", "type": "RC"}], "standard_charges": [{"gross_charge": 5972.0, "discounted_cash": 4479.0, "setting": "both", "billing_class": "facility"}]}, {"description": "INS BR MD PVDB HGHPRM MCRPT CL", "code_information": [{"code": "C1776", "type": 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"discounted_cash": 12922.5, "setting": "both", "billing_class": "facility"}]}, {"description": "INS ENDOVA VENACAVA FILT", "code_information": [{"code": "4627191", "type": "CDM"}, {"code": "360", "type": "RC"}], "standard_charges": [{"gross_charge": 18353.0, "discounted_cash": 13764.75, "setting": "both", "billing_class": "facility"}]}, {"description": "INS ENDOVA VENACAVA FILT", "code_information": [{"code": "4917191", "type": "CDM"}, {"code": "360", "type": "RC"}], "standard_charges": [{"gross_charge": 15808.0, "discounted_cash": 11856.0, "setting": "both", "billing_class": "facility"}]}, {"description": "INS GLARG PER 5U IJ", "drug_information": {"unit": 1.0, "type": "EA"}, "code_information": [{"code": "J1815", "type": "HCPCS"}, {"code": "5321260", "type": "CDM"}, {"code": "250", "type": "RC"}], "standard_charges": [{"gross_charge": 4.0, "discounted_cash": 3.0, "setting": "both", "billing_class": "facility"}]}, {"description": "INS GLARG PER 5U IJ", "drug_information": {"unit": 1.0, "type": "EA"}, "code_information": [{"code": "J1815", "type": "HCPCS"}, {"code": "5321260", "type": "CDM"}, {"code": "637", "type": "RC"}], "standard_charges": [{"gross_charge": 4.0, "discounted_cash": 3.0, "setting": "both", "billing_class": "facility"}]}, {"description": "INS GLARGINE-YFGN PER 5U IJ", "drug_information": {"unit": 1.0, "type": "EA"}, "code_information": [{"code": "J1815", "type": "HCPCS"}, {"code": "5321518", "type": "CDM"}, {"code": "250", "type": "RC"}], "standard_charges": [{"gross_charge": 2.0, "discounted_cash": 1.5, "setting": "both", "billing_class": "facility"}]}, {"description": "INS GLARGINE-YFGN PER 5U IJ", "drug_information": {"unit": 1.0, "type": "EA"}, "code_information": [{"code": "J1815", "type": "HCPCS"}, {"code": "5321518", "type": "CDM"}, {"code": "637", "type": "RC"}], "standard_charges": [{"gross_charge": 2.0, "discounted_cash": 1.5, "setting": "both", "billing_class": "facility"}]}, {"description": "INS HUM 70/30 3ML VL IJ", "drug_information": {"unit": 1.0, "type": "EA"}, "code_information": [{"code": "J1815", "type": "HCPCS"}, {"code": "5321499", "type": "CDM"}, {"code": "250", "type": "RC"}], "standard_charges": [{"gross_charge": 38.0, "discounted_cash": 28.5, "setting": "both", "billing_class": "facility"}]}, {"description": "INS HUM 70/30 3ML VL IJ", "drug_information": {"unit": 1.0, "type": "EA"}, "code_information": [{"code": "J1815", "type": "HCPCS"}, {"code": "5321499", "type": "CDM"}, {"code": "637", "type": "RC"}], "standard_charges": [{"gross_charge": 38.0, "discounted_cash": 28.5, "setting": "both", "billing_class": "facility"}]}, {"description": "INS HUMAN R 1U/ML DILUTE", "drug_information": {"unit": 1.0, "type": "EA"}, "code_information": [{"code": "J7999", "type": "HCPCS"}, {"code": "5321410", "type": "CDM"}, {"code": "250", "type": "RC"}], "standard_charges": [{"gross_charge": 19.0, "discounted_cash": 14.25, "setting": "both", "billing_class": "facility"}]}, {"description": "INS HUMAN R 1U/ML DILUTE", "drug_information": {"unit": 1.0, "type": "EA"}, "code_information": [{"code": "J7999", "type": "HCPCS"}, {"code": "5321410", "type": "CDM"}, {"code": "636", "type": "RC"}], "standard_charges": [{"gross_charge": 19.0, "discounted_cash": 14.25, "setting": "both", "billing_class": "facility"}]}, {"description": "INS LISP 75/25 PER 5U IJ", "drug_information": {"unit": 1.0, "type": "EA"}, "code_information": [{"code": "J1815", "type": "HCPCS"}, {"code": "5321266", "type": "CDM"}, {"code": "250", "type": "RC"}], "standard_charges": [{"gross_charge": 2.0, "discounted_cash": 1.5, "setting": "both", "billing_class": "facility"}]}, {"description": "INS LISP 75/25 PER 5U IJ", "drug_information": {"unit": 1.0, "type": "EA"}, "code_information": [{"code": "J1815", "type": "HCPCS"}, {"code": "5321266", "type": "CDM"}, {"code": "637", "type": "RC"}], "standard_charges": [{"gross_charge": 2.0, "discounted_cash": 1.5, "setting": "both", "billing_class": "facility"}]}, {"description": 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"code_information": [{"code": "J1815", "type": "HCPCS"}, {"code": "5321270", "type": "CDM"}, {"code": "250", "type": "RC"}], "standard_charges": [{"gross_charge": 129.0, "discounted_cash": 96.75, "setting": "both", "billing_class": "facility"}]}, {"description": "INS N/R 70/30 PER 5U IJ", "drug_information": {"unit": 1.0, "type": "EA"}, "code_information": [{"code": "J1815", "type": "HCPCS"}, {"code": "5321270", "type": "CDM"}, {"code": "637", "type": "RC"}], "standard_charges": [{"gross_charge": 129.0, "discounted_cash": 96.75, "setting": "both", "billing_class": "facility"}]}, {"description": "INS NPH HUM PER 5U IJ", "drug_information": {"unit": 1.0, "type": "EA"}, "code_information": [{"code": "J1815", "type": "HCPCS"}, {"code": "5321262", "type": "CDM"}, {"code": "250", "type": "RC"}], "standard_charges": [{"gross_charge": 0.29, "discounted_cash": 0.22, "setting": "both", "billing_class": "facility"}]}, {"description": "INS NPH HUM PER 5U IJ", "drug_information": {"unit": 1.0, "type": "EA"}, "code_information": [{"code": "J1815", "type": "HCPCS"}, {"code": "5321262", "type": "CDM"}, {"code": "637", "type": "RC"}], "standard_charges": [{"gross_charge": 0.29, "discounted_cash": 0.22, "setting": "both", "billing_class": "facility"}]}, {"description": "INS REG HUM PER 5U IJ", "drug_information": {"unit": 1.0, "type": "EA"}, "code_information": [{"code": "J1815", "type": "HCPCS"}, {"code": "5321265", "type": "CDM"}, {"code": "250", "type": "RC"}], "standard_charges": [{"gross_charge": 1.0, "discounted_cash": 0.75, "setting": "both", "billing_class": "facility"}]}, {"description": "INS REG HUM PER 5U IJ", "drug_information": {"unit": 1.0, "type": "EA"}, "code_information": [{"code": "J1815", "type": "HCPCS"}, {"code": "5321265", "type": "CDM"}, {"code": "637", "type": "RC"}], "standard_charges": [{"gross_charge": 1.0, "discounted_cash": 0.75, "setting": "both", "billing_class": "facility"}]}, {"description": "INS TEMP BLAD CTH COMPLX", "code_information": [{"code": "4911703", "type": "CDM"}, {"code": "360", "type": "RC"}], "standard_charges": [{"gross_charge": 906.0, "discounted_cash": 679.5, "setting": "both", "billing_class": "facility"}]}, {"description": "INS TUNN INTRAPER CATH", "code_information": [{"code": "4919418", "type": "CDM"}, {"code": "360", "type": "RC"}], "standard_charges": [{"gross_charge": 24934.0, "discounted_cash": 18700.5, "setting": "both", "billing_class": "facility"}]}, {"description": "INS VAD LEFT HRT PERC ART", "code_information": [{"code": "4613986", "type": "CDM"}, {"code": "360", "type": "RC"}], "standard_charges": [{"gross_charge": 26444.0, "discounted_cash": 19833.0, "setting": "both", "billing_class": "facility"}]}, {"description": "INS/RPL PM W/TRNSV LD VE", "code_information": [{"code": "4613207", "type": "CDM"}, {"code": "360", "type": "RC"}], "standard_charges": [{"gross_charge": 17296.0, "discounted_cash": 12972.0, "setting": "both", "billing_class": "facility"}]}, {"description": "INS/RPL 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"RC"}], "standard_charges": [{"gross_charge": 232.0, "discounted_cash": 174.0, "setting": "both", "billing_class": "facility"}]}, {"description": "PHOSPHORUS", "code_information": [{"code": "4124100", "type": "CDM"}, {"code": "300", "type": "RC"}], "standard_charges": [{"gross_charge": 4.0, "discounted_cash": 3.0, "setting": "both", "billing_class": "facility"}]}, {"description": "PHOSPHORUS URINE", "code_information": [{"code": "4104102", "type": "CDM"}, {"code": "300", "type": "RC"}], "standard_charges": [{"gross_charge": 76.0, "discounted_cash": 57.0, "setting": "both", "billing_class": "facility"}]}, {"description": "PHYSOSTIGM 1MG/ML 2ML IJ", "drug_information": {"unit": 1.0, "type": "EA"}, "code_information": [{"code": "J3490", "type": "HCPCS"}, {"code": "5323345", "type": "CDM"}, {"code": "250", "type": "RC"}], "standard_charges": [{"gross_charge": 108.0, "discounted_cash": 81.0, "setting": "both", "billing_class": "facility"}]}, {"description": "PHYTONADIONE 5MG TB", 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