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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": "3D IMAGING W POSTPROCESS", "code_information": [{"code": "76377", "type": "CPT"}, {"code": "5057637", "type": "CDM"}, {"code": "350", "type": "RC"}], "standard_charges": [{"gross_charge": 385.0, "discounted_cash": 288.75, "setting": "both", "billing_class": "facility"}]}, {"description": "3D IMAGNG NO POSTPROCESS", 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"discounted_cash": 11.25, "setting": "both", "billing_class": "facility"}]}, {"description": "INS CATH REN ART 1ST BIL", "code_information": [{"code": "4616252", "type": "CDM"}, {"code": "360", "type": "RC"}], "standard_charges": [{"gross_charge": 23937.0, "discounted_cash": 17952.75, "setting": "both", "billing_class": "facility"}]}, {"description": "INS CATH REN ART 1ST UNI", "code_information": [{"code": "4616251", "type": "CDM"}, {"code": "360", "type": "RC"}], "standard_charges": [{"gross_charge": 20894.0, "discounted_cash": 15670.5, "setting": "both", "billing_class": "facility"}]}, {"description": "INS CATH REN ART 2ND BIL", "code_information": [{"code": "4616254", "type": "CDM"}, {"code": "360", "type": "RC"}], "standard_charges": [{"gross_charge": 27378.0, "discounted_cash": 20533.5, "setting": "both", "billing_class": "facility"}]}, {"description": "INS DETEMIR 1 UNIT IJ", "drug_information": {"unit": 1.0, "type": "EA"}, "code_information": [{"code": "J3490", "type": 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"CDM"}, {"code": "250", "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": "637", "type": "RC"}], "standard_charges": [{"gross_charge": 4.0, "discounted_cash": 3.0, "setting": "both", "billing_class": "facility"}]}, {"description": "INS GLULISINE PER 1U IJ", "drug_information": {"unit": 1.0, "type": "EA"}, "code_information": [{"code": "J3490", "type": "HCPCS"}, {"code": "5321432", "type": "CDM"}, {"code": "250", "type": "RC"}], "standard_charges": [{"gross_charge": 5.0, "discounted_cash": 3.75, "setting": "both", "billing_class": "facility"}]}, {"description": "INS GLULISINE PER 1U IJ", "drug_information": {"unit": 1.0, "type": "EA"}, "code_information": [{"code": "J3490", "type": "HCPCS"}, {"code": "5321432", "type": "CDM"}, {"code": "637", "type": "RC"}], "standard_charges": [{"gross_charge": 5.0, "discounted_cash": 3.75, "setting": "both", "billing_class": "facility"}]}, {"description": "INS HUM 70/30 10ML", "drug_information": {"unit": 1.0, "type": "EA"}, "code_information": [{"code": "J3490", "type": "HCPCS"}, {"code": "5321456", "type": "CDM"}, {"code": "250", "type": "RC"}], "standard_charges": [{"gross_charge": 202.0, "discounted_cash": 151.5, "setting": "both", "billing_class": "facility"}]}, {"description": "INS HUM 70/30 10ML", "drug_information": {"unit": 1.0, "type": "EA"}, "code_information": [{"code": "J3490", "type": "HCPCS"}, {"code": "5321456", "type": "CDM"}, {"code": "637", "type": "RC"}], "standard_charges": [{"gross_charge": 202.0, "discounted_cash": 151.5, "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"}, 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"HCPCS"}, {"code": "5321457", "type": "CDM"}, {"code": "637", "type": "RC"}], "standard_charges": [{"gross_charge": 35.0, "discounted_cash": 26.25, "setting": "both", "billing_class": "facility"}]}, {"description": "INS HUM NPH DOSE", "drug_information": {"unit": 1.0, "type": "EA"}, "code_information": [{"code": "J3490", "type": "HCPCS"}, {"code": "5321462", "type": "CDM"}, {"code": "250", "type": "RC"}], "standard_charges": [{"gross_charge": 35.0, "discounted_cash": 26.25, "setting": "both", "billing_class": "facility"}]}, {"description": "INS HUM NPH DOSE", "drug_information": {"unit": 1.0, "type": "EA"}, "code_information": [{"code": "J3490", "type": "HCPCS"}, {"code": "5321462", "type": "CDM"}, {"code": "637", "type": "RC"}], "standard_charges": [{"gross_charge": 35.0, "discounted_cash": 26.25, "setting": "both", "billing_class": "facility"}]}, {"description": "INS HUM REG DOSE", "drug_information": {"unit": 1.0, "type": "EA"}, "code_information": [{"code": "J3490", "type": "HCPCS"}, {"code": "5321451", "type": "CDM"}, {"code": "250", "type": "RC"}], "standard_charges": [{"gross_charge": 35.0, "discounted_cash": 26.25, "setting": "both", "billing_class": "facility"}]}, {"description": "INS HUM REG DOSE", "drug_information": {"unit": 1.0, "type": "EA"}, "code_information": [{"code": "J3490", "type": "HCPCS"}, {"code": "5321451", "type": "CDM"}, {"code": "637", "type": "RC"}], "standard_charges": [{"gross_charge": 35.0, "discounted_cash": 26.25, "setting": "both", "billing_class": "facility"}]}, {"description": "INS HUM ULTRALENTE DOSE", "drug_information": {"unit": 1.0, "type": "EA"}, "code_information": [{"code": "J3490", "type": "HCPCS"}, {"code": "5321464", "type": "CDM"}, {"code": "250", "type": "RC"}], "standard_charges": [{"gross_charge": 14.0, "discounted_cash": 10.5, "setting": "both", "billing_class": "facility"}]}, {"description": "INS HUM ULTRALENTE DOSE", "drug_information": {"unit": 1.0, "type": "EA"}, "code_information": [{"code": "J3490", "type": "HCPCS"}, {"code": "5321464", "type": "CDM"}, {"code": "637", "type": "RC"}], "standard_charges": [{"gross_charge": 14.0, "discounted_cash": 10.5, "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": "250", "type": "RC"}], "standard_charges": [{"gross_charge": 13.0, "discounted_cash": 9.75, "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": 13.0, "discounted_cash": 9.75, "setting": "both", "billing_class": "facility"}]}, {"description": "INS LISPRO PER 5U IJ", "drug_information": {"unit": 1.0, "type": "EA"}, "code_information": [{"code": 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"637", "type": "RC"}], "standard_charges": [{"gross_charge": 4.0, "discounted_cash": 3.0, "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": 5.0, "discounted_cash": 3.75, "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": 5.0, "discounted_cash": 3.75, "setting": "both", "billing_class": "facility"}]}, {"description": "INS REG NEO PER 1U IJ", "drug_information": {"unit": 1.0, "type": "EA"}, "code_information": [{"code": "J3490", "type": "HCPCS"}, {"code": "5321251", "type": "CDM"}, {"code": "250", "type": "RC"}], "standard_charges": [{"gross_charge": 2.0, "discounted_cash": 1.5, "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": 24075.0, "discounted_cash": 18056.25, "setting": "both", "billing_class": "facility"}]}, {"description": "INS/PM GEN W/EXIST LD", "code_information": [{"code": "4613212", "type": "CDM"}, {"code": "360", "type": "RC"}], "standard_charges": [{"gross_charge": 95190.0, "discounted_cash": 71392.5, "setting": "both", "billing_class": "facility"}]}, {"description": "INS/PMGEN W/EXISDUALLDS", "code_information": [{"code": "4612505", "type": "CDM"}, {"code": "360", "type": "RC"}], "standard_charges": [{"gross_charge": 128441.0, "discounted_cash": 96330.75, "setting": "both", "billing_class": "facility"}]}, {"description": "INS/RPL PM W/TRNSV LD AT", "code_information": [{"code": "4613206", "type": "CDM"}, {"code": "360", "type": "RC"}], "standard_charges": [{"gross_charge": 128441.0, "discounted_cash": 96330.75, "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": 101968.0, "discounted_cash": 76476.0, "setting": "both", "billing_class": "facility"}]}, {"description": "INS/RPL PMW/TRNSV LD A-V", "code_information": [{"code": "4613208", "type": "CDM"}, {"code": "360", "type": "RC"}], "standard_charges": [{"gross_charge": 101968.0, "discounted_cash": 76476.0, "setting": "both", "billing_class": "facility"}]}, {"description": "INSERT HUM LNR BEAR ZIMMER CL", "code_information": [{"code": "C1776", "type": "HCPCS"}, {"code": "4012937", "type": "CDM"}, {"code": "278", "type": "RC"}], "standard_charges": [{"gross_charge": 12149.0, "discounted_cash": 9111.75, "setting": "both", "billing_class": 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"facility"}]}, {"description": "PHOSPHATASE ALKALINE", "code_information": [{"code": "84075", "type": "CPT"}, {"code": "4104075", "type": "CDM"}, {"code": "300", "type": "RC"}], "standard_charges": [{"gross_charge": 1094.0, "discounted_cash": 820.5, "setting": "both", "billing_class": "facility"}]}, {"description": "PHOSPHATASE ALKALINE", "code_information": [{"code": "84075", "type": "CPT"}, {"code": "7254075", "type": "CDM"}, {"code": "300", "type": "RC"}], "standard_charges": [{"gross_charge": 51.0, "discounted_cash": 38.25, "setting": "both", "billing_class": "facility"}]}, {"description": "PHOSPHATASE HEAT STABLE", "code_information": [{"code": "84078", "type": "CPT"}, {"code": "4104078", "type": "CDM"}, {"code": "300", "type": "RC"}], "standard_charges": [{"gross_charge": 1239.0, "discounted_cash": 929.25, "setting": "both", "billing_class": "facility"}]}, {"description": "PHOSPHATASE ISO ALK", "code_information": [{"code": "84080", "type": "CPT"}, {"code": "7004080", "type": 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