{ "hospital_name": "Advanced Care Hospital of Montana", "last_updated_on": "2026-03-23", "version": "3.0.0", "location_name": [ "Advanced Care Hospital of Montana", "Advanced Care Hospital of Montana - IRU" ], "hospital_address": [ "3528 Gabel Rd, Billings, MT 59102", "3528 Gabel Road, Billings, MT 59102" ], "license_information": { "state": "MT" }, "type_2_npi": [ "1356536312", "1639991540" ], "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": "Julie Cuppett" }, "standard_charge_information": [ { "description": "Occupational Therapy - General Classification", "code_information": [ { "code": "0430", "type": "RC" } ], "standard_charges": [ { "setting": "outpatient", "payers_information": [ { "payer_name": "National Comp Care", "plan_name": "Workers' Compensation", "standard_charge_dollar": 90, "methodology": "fee schedule", "median_amount": 90, "10th_percentile": 90, "90th_percentile": 90, "count": "1 through 10" }, { "payer_name": "United Healthcare (UHC)", "plan_name": "DSNP", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Coventry Health Care", "plan_name": "Auto Network", "standard_charge_percentage": 90, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Coventry Health Care", "plan_name": "Workers' Compensation", "standard_charge_percentage": 95, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "TriWest Healthcare Alliance Corporation", "plan_name": "VA CCN", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Blue Cross Blue Shield of Montana", "plan_name": "Medicare Advantage", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "United Healthcare (UHC)", "plan_name": "Medicare Advantage", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Allegiance Provider Direct", "plan_name": "Medicare", "standard_charge_percentage": 229.99999999999997, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "PacificSource Health Plans", "plan_name": "PPO (PSN Network and Smart Health Network)", "standard_charge_percentage": 80, "methodology": "percent of total billed charges", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Medicare (CMS)", "plan_name": "Medicare", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "First Choice Health Network fka Health InfoNet", "plan_name": "Commercial", "standard_charge_percentage": 85, "methodology": "percent of total billed charges", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Claritev fka MultiPlan", "plan_name": "Auto Medical Program", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Claritev fka MultiPlan", "plan_name": "Workers' Compensation Program", "standard_charge_percentage": 90, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Claritev fka MultiPlan", "plan_name": "PPO", "standard_charge_percentage": 75, "methodology": "percent of total billed charges", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "First Choice of the Midwest", "plan_name": "PPO", "standard_charge_percentage": 90, "methodology": "percent of total billed charges", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Employee Benefit Management Services (EBMS)", "plan_name": "EBMS SelectCare Network", "standard_charge_percentage": 80, "methodology": "percent of total billed charges", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Medica Insurance Company", "plan_name": "Medicare Cost", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "First Choice Health Network fka Health InfoNet", "plan_name": "Medicare Advantage", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "First Choice Health Network fka Health InfoNet", "plan_name": "Workers Compensation", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Allegiance Provider Direct", "plan_name": "Montana Association of Counties (MACo)", "standard_charge_percentage": 229.99999999999997, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Allegiance Provider Direct", "plan_name": "State of Montana Employee Benefit Plan (Self-Funded)", "standard_charge_percentage": 229.99999999999997, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Allegiance Provider Direct", "plan_name": "Montana Municipal Interlocal Authority (MMIA)", "standard_charge_percentage": 229.99999999999997, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Blue Cross Blue Shield of Montana", "plan_name": "HealthLink Network", "standard_charge_percentage": 75, "methodology": "percent of total billed charges", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Blue Cross Blue Shield of Montana", "plan_name": "Traditional Network", "standard_charge_percentage": 75, "methodology": "percent of total billed charges", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Blue Cross Blue Shield of Montana", "plan_name": "POS Network", "standard_charge_percentage": 75, "methodology": "percent of total billed charges", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Blue Cross Blue Shield of Montana", "plan_name": "Closed Plan Network", "standard_charge_percentage": 75, "methodology": "percent of total billed charges", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Blue Cross Blue Shield of Montana", "plan_name": "Retail HMO POS Network", "standard_charge_percentage": 75, "methodology": "percent of total billed charges", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Blue Cross Blue Shield of Montana", "plan_name": "Blue Options Network", "standard_charge_percentage": 75, "methodology": "percent of total billed charges", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Medicaid (State)", "plan_name": "Medicaid", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "PacificSource Health Plans", "plan_name": "Medicare Advantage", "standard_charge_percentage": 103, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" } ], "minimum": 90, "maximum": 90 } ] }, { "description": "Rheumatoid factor quant", "code_information": [ { "code": "86431", "type": "HCPCS" } ], "standard_charges": [ { "setting": "outpatient", "payers_information": [ { "payer_name": "United Healthcare (UHC)", "plan_name": "DSNP", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "United Healthcare (UHC)", "plan_name": "Medicare Advantage", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" } ] } ] }, { "description": "Tb test cell immun measure", "code_information": [ { "code": "86480", "type": "HCPCS" } ], "standard_charges": [ { "setting": "outpatient", "payers_information": [ { "payer_name": "United Healthcare (UHC)", "plan_name": "DSNP", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "United Healthcare (UHC)", "plan_name": "Medicare Advantage", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" } ] } ] }, { "description": "Syphilis test non-trep qual", "code_information": [ { "code": "86592", "type": "HCPCS" } ], "standard_charges": [ { "setting": "outpatient", "payers_information": [ { "payer_name": "United Healthcare (UHC)", "plan_name": "DSNP", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "United Healthcare (UHC)", "plan_name": "Medicare Advantage", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" } ] } ] }, { "description": "Herpes simplex nes antbdy", "code_information": [ { "code": "86694", "type": "HCPCS" } ], "standard_charges": [ { "setting": "outpatient", "payers_information": [ { "payer_name": "United Healthcare (UHC)", "plan_name": "DSNP", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "United Healthcare (UHC)", "plan_name": "Medicare Advantage", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" } ] } ] }, { "description": "Herpes simplex type 1 test", "code_information": [ { "code": "86695", "type": "HCPCS" } ], "standard_charges": [ { "setting": "outpatient", "payers_information": [ { "payer_name": "United Healthcare (UHC)", "plan_name": "DSNP", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "United Healthcare (UHC)", "plan_name": "Medicare Advantage", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" } ] } ] }, { "description": "Herpes simplex type 2 test", "code_information": [ { "code": "86696", "type": "HCPCS" } ], "standard_charges": [ { "setting": "outpatient", "payers_information": [ { "payer_name": "United Healthcare (UHC)", "plan_name": "DSNP", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "United Healthcare (UHC)", "plan_name": "Medicare Advantage", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" } ] } ] }, { "description": "Hep b core antibody igm", "code_information": [ { "code": "86705", "type": "HCPCS" } ], "standard_charges": [ { "setting": "outpatient", "payers_information": [ { "payer_name": "United Healthcare (UHC)", "plan_name": "DSNP", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "United Healthcare (UHC)", "plan_name": "Medicare Advantage", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" } ] } ] }, { "description": "Hep b surface antibody", "code_information": [ { "code": "86706", "type": "HCPCS" } ], "standard_charges": [ { "setting": "outpatient", "payers_information": [ { "payer_name": "United Healthcare (UHC)", "plan_name": "DSNP", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "United Healthcare (UHC)", "plan_name": "Medicare Advantage", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" } ] } ] }, { "description": "Lymph choriomeningitis ab", "code_information": [ { "code": "86727", "type": "HCPCS" } ], "standard_charges": [ { "setting": "outpatient", "payers_information": [ { "payer_name": "United Healthcare (UHC)", "plan_name": "DSNP", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "United Healthcare (UHC)", "plan_name": "Medicare Advantage", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" } ] } ] }, { "description": "Mumps antibody", "code_information": [ { "code": "86735", "type": "HCPCS" } ], "standard_charges": [ { "setting": "outpatient", "payers_information": [ { "payer_name": "United Healthcare (UHC)", "plan_name": "DSNP", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "United Healthcare (UHC)", "plan_name": "Medicare Advantage", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" } ] } ] }, { "description": "All Inclusive Rate - Room and Board Plus Ancillary", "code_information": [ { "code": "0100", "type": "RC" } ], "standard_charges": [ { "setting": "inpatient", "payers_information": [ { "payer_name": "Allegiance Provider Direct", "plan_name": "PPO", "standard_charge_dollar": 1500, "methodology": "per diem", "median_amount": 1500, "10th_percentile": 1500, "90th_percentile": 1500, "count": "1 through 10" }, { "payer_name": "United Healthcare (UHC)", "plan_name": "HMO", "standard_charge_dollar": 1545, "methodology": "per diem", "median_amount": 1545, "10th_percentile": 1545, "90th_percentile": 1545, "count": "1 through 10" }, { "payer_name": "United Healthcare (UHC)", "plan_name": "PPO", "standard_charge_dollar": 1545, "methodology": "per diem", "median_amount": 1545, "10th_percentile": 1545, "90th_percentile": 1545, "count": "1 through 10" }, { "payer_name": "United Healthcare (UHC)", "plan_name": "Indemnity", "standard_charge_dollar": 1545, "methodology": "per diem", "median_amount": 1545, "10th_percentile": 1545, "90th_percentile": 1545, "count": "1 through 10" } ], "minimum": 1500, "maximum": 1545 } ] }, { "description": "All Inclusive Rate - Room and Board", "code_information": [ { "code": "0101", "type": "RC" } ], "standard_charges": [ { "setting": "inpatient", "payers_information": [ { "payer_name": "Allegiance Provider Direct", "plan_name": "PPO", "standard_charge_dollar": 1500, "methodology": "per diem", "median_amount": 1500, "10th_percentile": 1500, "90th_percentile": 1500, "count": "1 through 10" }, { "payer_name": "United Healthcare (UHC)", "plan_name": "HMO", "standard_charge_dollar": 1545, "methodology": "per diem", "median_amount": 1545, "10th_percentile": 1545, "90th_percentile": 1545, "count": "1 through 10" }, { "payer_name": "United Healthcare (UHC)", "plan_name": "PPO", "standard_charge_dollar": 1545, "methodology": "per diem", "median_amount": 1545, "10th_percentile": 1545, "90th_percentile": 1545, "count": "1 through 10" }, { "payer_name": "United Healthcare (UHC)", "plan_name": "Indemnity", "standard_charge_dollar": 1545, "methodology": "per diem", "median_amount": 1545, "10th_percentile": 1545, "90th_percentile": 1545, "count": "1 through 10" } ], "minimum": 1500, "maximum": 1545 } ] }, { "description": "Room & Board - Private (One Bed) - General Classification", "code_information": [ { "code": "0110", "type": "RC" } ], "standard_charges": [ { "setting": "inpatient", "payers_information": [ { "payer_name": "Allegiance Provider Direct", "plan_name": "PPO", "standard_charge_dollar": 1900, "methodology": "per diem", "median_amount": 1900, "10th_percentile": 1900, "90th_percentile": 1900, "count": "1 through 10" }, { "payer_name": "PacificSource Health Plans", "plan_name": "PPO (PSN Network and Smart Health Network)", "standard_charge_percentage": 80, "methodology": "percent of total billed charges", "median_amount": 1236.48, "10th_percentile": 1236.48, "90th_percentile": 1236.48, "count": "62" }, { "payer_name": "TriWest Healthcare Alliance Corporation", "plan_name": "VA CCN", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Blue Cross Blue Shield of Montana", "plan_name": "Medicare Advantage", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Claritev fka MultiPlan", "plan_name": "Workers' Compensation Program", "standard_charge_percentage": 90, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "United Healthcare (UHC)", "plan_name": "Medicare Advantage", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "First Choice of the Midwest", "plan_name": "PPO", "standard_charge_percentage": 90, "methodology": "percent of total billed charges", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "United Healthcare (UHC)", "plan_name": "DSNP", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Employee Benefit Management Services (EBMS)", "plan_name": "EBMS SelectCare Network", "standard_charge_percentage": 80, "methodology": "percent of total billed charges", "median_amount": 1236.48, "10th_percentile": 1236.48, "90th_percentile": 1236.48, "count": "1 through 10" }, { "payer_name": "Claritev fka MultiPlan", "plan_name": "Auto Medical Program", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Coventry Health Care", "plan_name": "Auto Network", "standard_charge_percentage": 90, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Allegiance Provider Direct", "plan_name": "Medicare", "standard_charge_percentage": 229.99999999999997, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Claritev fka MultiPlan", "plan_name": "PPO", "standard_charge_percentage": 75, "methodology": "percent of total billed charges", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Medica Insurance Company", "plan_name": "Medicare Cost", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Medicare (CMS)", "plan_name": "Medicare", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Indian Health Services (IHS)", "plan_name": "Commercial", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "National Comp Care", "plan_name": "Workers' Compensation", "standard_charge_dollar": 1800, "methodology": "per diem", "median_amount": 1800, "10th_percentile": 1800, "90th_percentile": 1800, "count": "1 through 10" }, { "payer_name": "First Choice Health Network fka Health InfoNet", "plan_name": "Commercial", "standard_charge_percentage": 85, "methodology": "percent of total billed charges", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Humana Insurance Company", "plan_name": "Humana Medicare Advantage HMO", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Humana Insurance Company", "plan_name": "Humana Medicare Advantage PPO", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Humana Insurance Company", "plan_name": "Humana Medicare Advantage PFFS", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "First Choice Health Network fka Health InfoNet", "plan_name": "Workers Compensation", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Allegiance Provider Direct", "plan_name": "State of Montana Employee Benefit Plan (Self-Funded)", "standard_charge_percentage": 229.99999999999997, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Allegiance Provider Direct", "plan_name": "Montana Municipal Interlocal Authority (MMIA)", "standard_charge_percentage": 229.99999999999997, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "United Healthcare (UHC)", "plan_name": "HMO", "standard_charge_dollar": 1545, "methodology": "per diem", "median_amount": 1545, "10th_percentile": 1545, "90th_percentile": 1545, "count": "1 through 10" }, { "payer_name": "United Healthcare (UHC)", "plan_name": "PPO", "standard_charge_dollar": 1545, "methodology": "per diem", "median_amount": 1545, "10th_percentile": 1545, "90th_percentile": 1545, "count": "1 through 10" }, { "payer_name": "United Healthcare (UHC)", "plan_name": "Indemnity", "standard_charge_dollar": 1545, "methodology": "per diem", "median_amount": 1545, "10th_percentile": 1545, "90th_percentile": 1545, "count": "1 through 10" }, { "payer_name": "Allegiance Provider Direct", "plan_name": "Montana Association of Counties (MACo)", "standard_charge_percentage": 229.99999999999997, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "First Choice Health Network fka Health InfoNet", "plan_name": "Medicare Advantage", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Medicaid (State)", "plan_name": "Medicaid", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "TriWest Healthcare Alliance Corporation", "plan_name": "TRICARE Prime", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "TriWest Healthcare Alliance Corporation", "plan_name": "TRICARE Select", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Blue Cross Blue Shield of Montana", "plan_name": "HealthLink Network", "standard_charge_percentage": 75, "methodology": "percent of total billed charges", "median_amount": 1159.2, "10th_percentile": 1159.2, "90th_percentile": 1159.2, "count": "340" }, { "payer_name": "Blue Cross Blue Shield of Montana", "plan_name": "Traditional Network", "standard_charge_percentage": 75, "methodology": "percent of total billed charges", "median_amount": 1159.2, "10th_percentile": 1159.2, "90th_percentile": 1159.2, "count": "340" }, { "payer_name": "Blue Cross Blue Shield of Montana", "plan_name": "POS Network", "standard_charge_percentage": 75, "methodology": "percent of total billed charges", "median_amount": 1159.2, "10th_percentile": 1159.2, "90th_percentile": 1159.2, "count": "340" }, { "payer_name": "Blue Cross Blue Shield of Montana", "plan_name": "Closed Plan Network", "standard_charge_percentage": 75, "methodology": "percent of total billed charges", "median_amount": 1159.2, "10th_percentile": 1159.2, "90th_percentile": 1159.2, "count": "340" }, { "payer_name": "Blue Cross Blue Shield of Montana", "plan_name": "Retail HMO POS Network", "standard_charge_percentage": 75, "methodology": "percent of total billed charges", "median_amount": 1159.2, "10th_percentile": 1159.2, "90th_percentile": 1159.2, "count": "340" }, { "payer_name": "Blue Cross Blue Shield of Montana", "plan_name": "Blue Options Network", "standard_charge_percentage": 75, "methodology": "percent of total billed charges", "median_amount": 1159.2, "10th_percentile": 1159.2, "90th_percentile": 1159.2, "count": "340" }, { "payer_name": "Montana Health Cooperative dba Mountain Health Co-Op HPN Product", "plan_name": "MT Connected Care", "standard_charge_dollar": 1825, "methodology": "per diem", "median_amount": 1825, "10th_percentile": 1825, "90th_percentile": 1825, "count": "1 through 10" }, { "payer_name": "Montana Health Cooperative dba Mountain Health Co-Op HPN Product", "plan_name": "MT Access Care", "standard_charge_dollar": 1825, "methodology": "per diem", "median_amount": 1825, "10th_percentile": 1825, "90th_percentile": 1825, "count": "1 through 10" }, { "payer_name": "PacificSource Health Plans", "plan_name": "Medicare Advantage", "standard_charge_percentage": 103, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" } ], "minimum": 1159.2, "maximum": 1900 } ] }, { "description": "Room & Board - Private (One Bed) - Medical/Surgical/GYN", "code_information": [ { "code": "0111", "type": "RC" } ], "standard_charges": [ { "setting": "inpatient", "payers_information": [ { "payer_name": "Allegiance Provider Direct", "plan_name": "PPO", "standard_charge_dollar": 1500, "methodology": "per diem", "median_amount": 1500, "10th_percentile": 1500, "90th_percentile": 1500, "count": "1 through 10" }, { "payer_name": "PacificSource Health Plans", "plan_name": "PPO (PSN Network and Smart Health Network)", "standard_charge_percentage": 80, "methodology": "percent of total billed charges", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "TriWest Healthcare Alliance Corporation", "plan_name": "VA CCN", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Blue Cross Blue Shield of Montana", "plan_name": "Medicare Advantage", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Claritev fka MultiPlan", "plan_name": "Workers' Compensation Program", "standard_charge_percentage": 90, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "United Healthcare (UHC)", "plan_name": "Medicare Advantage", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "First Choice of the Midwest", "plan_name": "PPO", "standard_charge_percentage": 90, "methodology": "percent of total billed charges", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "United Healthcare (UHC)", "plan_name": "DSNP", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Employee Benefit Management Services (EBMS)", "plan_name": "EBMS SelectCare Network", "standard_charge_percentage": 80, "methodology": "percent of total billed charges", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Claritev fka MultiPlan", "plan_name": "Auto Medical Program", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Coventry Health Care", "plan_name": "Auto Network", "standard_charge_percentage": 90, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Allegiance Provider Direct", "plan_name": "Medicare", "standard_charge_percentage": 229.99999999999997, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Claritev fka MultiPlan", "plan_name": "PPO", "standard_charge_percentage": 75, "methodology": "percent of total billed charges", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Medica Insurance Company", "plan_name": "Medicare Cost", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Medicare (CMS)", "plan_name": "Medicare", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Indian Health Services (IHS)", "plan_name": "Commercial", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "National Comp Care", "plan_name": "Workers' Compensation", "standard_charge_dollar": 1800, "methodology": "per diem", "median_amount": 1800, "10th_percentile": 1800, "90th_percentile": 1800, "count": "1 through 10" }, { "payer_name": "First Choice Health Network fka Health InfoNet", "plan_name": "Commercial", "standard_charge_percentage": 85, "methodology": "percent of total billed charges", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Humana Insurance Company", "plan_name": "Humana Medicare Advantage HMO", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Humana Insurance Company", "plan_name": "Humana Medicare Advantage PPO", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Humana Insurance Company", "plan_name": "Humana Medicare Advantage PFFS", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "First Choice Health Network fka Health InfoNet", "plan_name": "Workers Compensation", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Allegiance Provider Direct", "plan_name": "State of Montana Employee Benefit Plan (Self-Funded)", "standard_charge_percentage": 229.99999999999997, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Allegiance Provider Direct", "plan_name": "Montana Municipal Interlocal Authority (MMIA)", "standard_charge_percentage": 229.99999999999997, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "United Healthcare (UHC)", "plan_name": "HMO", "standard_charge_dollar": 1545, "methodology": "per diem", "median_amount": 1545, "10th_percentile": 1545, "90th_percentile": 1545, "count": "1 through 10" }, { "payer_name": "United Healthcare (UHC)", "plan_name": "PPO", "standard_charge_dollar": 1545, "methodology": "per diem", "median_amount": 1545, "10th_percentile": 1545, "90th_percentile": 1545, "count": "1 through 10" }, { "payer_name": "United Healthcare (UHC)", "plan_name": "Indemnity", "standard_charge_dollar": 1545, "methodology": "per diem", "median_amount": 1545, "10th_percentile": 1545, "90th_percentile": 1545, "count": "1 through 10" }, { "payer_name": "Allegiance Provider Direct", "plan_name": "Montana Association of Counties (MACo)", "standard_charge_percentage": 229.99999999999997, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "First Choice Health Network fka Health InfoNet", "plan_name": "Medicare Advantage", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Medicaid (State)", "plan_name": "Medicaid", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "TriWest Healthcare Alliance Corporation", "plan_name": "TRICARE Prime", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "TriWest Healthcare Alliance Corporation", "plan_name": "TRICARE Select", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Blue Cross Blue Shield of Montana", "plan_name": "HealthLink Network", "standard_charge_percentage": 75, "methodology": "percent of total billed charges", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Blue Cross Blue Shield of Montana", "plan_name": "Traditional Network", "standard_charge_percentage": 75, "methodology": "percent of total billed charges", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Blue Cross Blue Shield of Montana", "plan_name": "POS Network", "standard_charge_percentage": 75, "methodology": "percent of total billed charges", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Blue Cross Blue Shield of Montana", "plan_name": "Closed Plan Network", "standard_charge_percentage": 75, "methodology": "percent of total billed charges", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Blue Cross Blue Shield of Montana", "plan_name": "Retail HMO POS Network", "standard_charge_percentage": 75, "methodology": "percent of total billed charges", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Blue Cross Blue Shield of Montana", "plan_name": "Blue Options Network", "standard_charge_percentage": 75, "methodology": "percent of total billed charges", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "PacificSource Health Plans", "plan_name": "Medicare Advantage", "standard_charge_percentage": 103, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" } ], "minimum": 1500, "maximum": 1800 } ] }, { "description": "Room & Board - Semi-private (Two Beds) - General Classification", "code_information": [ { "code": "0120", "type": "RC" } ], "standard_charges": [ { "setting": "inpatient", "payers_information": [ { "payer_name": "Allegiance Provider Direct", "plan_name": "PPO", "standard_charge_dollar": 1900, "methodology": "per diem", "median_amount": 1900, "10th_percentile": 1900, "90th_percentile": 1900, "count": "1 through 10" }, { "payer_name": "PacificSource Health Plans", "plan_name": "PPO (PSN Network and Smart Health Network)", "standard_charge_percentage": 80, "methodology": "percent of total billed charges", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "TriWest Healthcare Alliance Corporation", "plan_name": "VA CCN", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Blue Cross Blue Shield of Montana", "plan_name": "Medicare Advantage", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Claritev fka MultiPlan", "plan_name": "Workers' Compensation Program", "standard_charge_percentage": 90, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "United Healthcare (UHC)", "plan_name": "Medicare Advantage", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "First Choice of the Midwest", "plan_name": "PPO", "standard_charge_percentage": 90, "methodology": "percent of total billed charges", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "United Healthcare (UHC)", "plan_name": "DSNP", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Employee Benefit Management Services (EBMS)", "plan_name": "EBMS SelectCare Network", "standard_charge_percentage": 80, "methodology": "percent of total billed charges", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Claritev fka MultiPlan", "plan_name": "Auto Medical Program", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Coventry Health Care", "plan_name": "Auto Network", "standard_charge_percentage": 90, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Allegiance Provider Direct", "plan_name": "Medicare", "standard_charge_percentage": 229.99999999999997, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Claritev fka MultiPlan", "plan_name": "PPO", "standard_charge_percentage": 75, "methodology": "percent of total billed charges", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Medica Insurance Company", "plan_name": "Medicare Cost", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Medicare (CMS)", "plan_name": "Medicare", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Indian Health Services (IHS)", "plan_name": "Commercial", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "National Comp Care", "plan_name": "Workers' Compensation", "standard_charge_dollar": 1800, "methodology": "per diem", "median_amount": 1800, "10th_percentile": 1800, "90th_percentile": 1800, "count": "1 through 10" }, { "payer_name": "First Choice Health Network fka Health InfoNet", "plan_name": "Commercial", "standard_charge_percentage": 85, "methodology": "percent of total billed charges", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Humana Insurance Company", "plan_name": "Humana Medicare Advantage HMO", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Humana Insurance Company", "plan_name": "Humana Medicare Advantage PPO", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Humana Insurance Company", "plan_name": "Humana Medicare Advantage PFFS", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "First Choice Health Network fka Health InfoNet", "plan_name": "Workers Compensation", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Allegiance Provider Direct", "plan_name": "State of Montana Employee Benefit Plan (Self-Funded)", "standard_charge_percentage": 229.99999999999997, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Allegiance Provider Direct", "plan_name": "Montana Municipal Interlocal Authority (MMIA)", "standard_charge_percentage": 229.99999999999997, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "United Healthcare (UHC)", "plan_name": "HMO", "standard_charge_dollar": 1545, "methodology": "per diem", "median_amount": 1545, "10th_percentile": 1545, "90th_percentile": 1545, "count": "1 through 10" }, { "payer_name": "United Healthcare (UHC)", "plan_name": "PPO", "standard_charge_dollar": 1545, "methodology": "per diem", "median_amount": 1545, "10th_percentile": 1545, "90th_percentile": 1545, "count": "1 through 10" }, { "payer_name": "United Healthcare (UHC)", "plan_name": "Indemnity", "standard_charge_dollar": 1545, "methodology": "per diem", "median_amount": 1545, "10th_percentile": 1545, "90th_percentile": 1545, "count": "1 through 10" }, { "payer_name": "Allegiance Provider Direct", "plan_name": "Montana Association of Counties (MACo)", "standard_charge_percentage": 229.99999999999997, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "First Choice Health Network fka Health InfoNet", "plan_name": "Medicare Advantage", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Medicaid (State)", "plan_name": "Medicaid", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "TriWest Healthcare Alliance Corporation", "plan_name": "TRICARE Prime", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "TriWest Healthcare Alliance Corporation", "plan_name": "TRICARE Select", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Blue Cross Blue Shield of Montana", "plan_name": "HealthLink Network", "standard_charge_percentage": 75, "methodology": "percent of total billed charges", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Blue Cross Blue Shield of Montana", "plan_name": "Traditional Network", "standard_charge_percentage": 75, "methodology": "percent of total billed charges", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Blue Cross Blue Shield of Montana", "plan_name": "POS Network", "standard_charge_percentage": 75, "methodology": "percent of total billed charges", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Blue Cross Blue Shield of Montana", "plan_name": "Closed Plan Network", "standard_charge_percentage": 75, "methodology": "percent of total billed charges", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Blue Cross Blue Shield of Montana", "plan_name": "Retail HMO POS Network", "standard_charge_percentage": 75, "methodology": "percent of total billed charges", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Blue Cross Blue Shield of Montana", "plan_name": "Blue Options Network", "standard_charge_percentage": 75, "methodology": "percent of total billed charges", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "PacificSource Health Plans", "plan_name": "Medicare Advantage", "standard_charge_percentage": 103, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" } ], "minimum": 1545, "maximum": 1900 } ] }, { "description": "Room & Board - Semi-private (Two Beds) - Medical/Surgical/GYN", "code_information": [ { "code": "0121", "type": "RC" } ], "standard_charges": [ { "setting": "inpatient", "payers_information": [ { "payer_name": "Allegiance Provider Direct", "plan_name": "PPO", "standard_charge_dollar": 1900, "methodology": "per diem", "median_amount": 1900, "10th_percentile": 1900, "90th_percentile": 1900, "count": "1 through 10" }, { "payer_name": "United Healthcare (UHC)", "plan_name": "HMO", "standard_charge_dollar": 1545, "methodology": "per diem", "median_amount": 1545, "10th_percentile": 1545, "90th_percentile": 1545, "count": "1 through 10" }, { "payer_name": "United Healthcare (UHC)", "plan_name": "PPO", "standard_charge_dollar": 1545, "methodology": "per diem", "median_amount": 1545, "10th_percentile": 1545, "90th_percentile": 1545, "count": "1 through 10" }, { "payer_name": "United Healthcare (UHC)", "plan_name": "Indemnity", "standard_charge_dollar": 1545, "methodology": "per diem", "median_amount": 1545, "10th_percentile": 1545, "90th_percentile": 1545, "count": "1 through 10" } ], "minimum": 1545, "maximum": 1900 } ] }, { "description": "Room & Board - Three and Four Beds - General Classification", "code_information": [ { "code": "0130", "type": "RC" } ], "standard_charges": [ { "setting": "inpatient", "payers_information": [ { "payer_name": "Allegiance Provider Direct", "plan_name": "PPO", "standard_charge_dollar": 1900, "methodology": "per diem", "median_amount": 1900, "10th_percentile": 1900, "90th_percentile": 1900, "count": "1 through 10" }, { "payer_name": "United Healthcare (UHC)", "plan_name": "HMO", "standard_charge_dollar": 1545, "methodology": "per diem", "median_amount": 1545, "10th_percentile": 1545, "90th_percentile": 1545, "count": "1 through 10" }, { "payer_name": "United Healthcare (UHC)", "plan_name": "PPO", "standard_charge_dollar": 1545, "methodology": "per diem", "median_amount": 1545, "10th_percentile": 1545, "90th_percentile": 1545, "count": "1 through 10" }, { "payer_name": "United Healthcare (UHC)", "plan_name": "Indemnity", "standard_charge_dollar": 1545, "methodology": "per diem", "median_amount": 1545, "10th_percentile": 1545, "90th_percentile": 1545, "count": "1 through 10" } ], "minimum": 1545, "maximum": 1900 } ] }, { "description": "Room & Board - Three and Four Beds - Medical/Surgical/GYN", "code_information": [ { "code": "0131", "type": "RC" } ], "standard_charges": [ { "setting": "inpatient", "payers_information": [ { "payer_name": "Allegiance Provider Direct", "plan_name": "PPO", "standard_charge_dollar": 1900, "methodology": "per diem", "median_amount": 1900, "10th_percentile": 1900, "90th_percentile": 1900, "count": "1 through 10" }, { "payer_name": "United Healthcare (UHC)", "plan_name": "HMO", "standard_charge_dollar": 1545, "methodology": "per diem", "median_amount": 1545, "10th_percentile": 1545, "90th_percentile": 1545, "count": "1 through 10" }, { "payer_name": "United Healthcare (UHC)", "plan_name": "PPO", "standard_charge_dollar": 1545, "methodology": "per diem", "median_amount": 1545, "10th_percentile": 1545, "90th_percentile": 1545, "count": "1 through 10" }, { "payer_name": "United Healthcare (UHC)", "plan_name": "Indemnity", "standard_charge_dollar": 1545, "methodology": "per diem", "median_amount": 1545, "10th_percentile": 1545, "90th_percentile": 1545, "count": "1 through 10" } ], "minimum": 1545, "maximum": 1900 } ] }, { "description": "Room & Board - Deluxe Private - General Classification", "code_information": [ { "code": "0140", "type": "RC" } ], "standard_charges": [ { "setting": "inpatient", "payers_information": [ { "payer_name": "Allegiance Provider Direct", "plan_name": "PPO", "standard_charge_dollar": 1900, "methodology": "per diem", "median_amount": 1900, "10th_percentile": 1900, "90th_percentile": 1900, "count": "1 through 10" }, { "payer_name": "United Healthcare (UHC)", "plan_name": "HMO", "standard_charge_dollar": 1545, "methodology": "per diem", "median_amount": 1545, "10th_percentile": 1545, "90th_percentile": 1545, "count": "1 through 10" }, { "payer_name": "United Healthcare (UHC)", "plan_name": "PPO", "standard_charge_dollar": 1545, "methodology": "per diem", "median_amount": 1545, "10th_percentile": 1545, "90th_percentile": 1545, "count": "1 through 10" }, { "payer_name": "United Healthcare (UHC)", "plan_name": "Indemnity", "standard_charge_dollar": 1545, "methodology": "per diem", "median_amount": 1545, "10th_percentile": 1545, "90th_percentile": 1545, "count": "1 through 10" } ], "minimum": 1545, "maximum": 1900 } ] }, { "description": "Room & Board - Deluxe Private - Medical/Surgical/GYN", "code_information": [ { "code": "0141", "type": "RC" } ], "standard_charges": [ { "setting": "inpatient", "payers_information": [ { "payer_name": "Allegiance Provider Direct", "plan_name": "PPO", "standard_charge_dollar": 1900, "methodology": "per diem", "median_amount": 1900, "10th_percentile": 1900, "90th_percentile": 1900, "count": "1 through 10" }, { "payer_name": "United Healthcare (UHC)", "plan_name": "HMO", "standard_charge_dollar": 1545, "methodology": "per diem", "median_amount": 1545, "10th_percentile": 1545, "90th_percentile": 1545, "count": "1 through 10" }, { "payer_name": "United Healthcare (UHC)", "plan_name": "PPO", "standard_charge_dollar": 1545, "methodology": "per diem", "median_amount": 1545, "10th_percentile": 1545, "90th_percentile": 1545, "count": "1 through 10" }, { "payer_name": "United Healthcare (UHC)", "plan_name": "Indemnity", "standard_charge_dollar": 1545, "methodology": "per diem", "median_amount": 1545, "10th_percentile": 1545, "90th_percentile": 1545, "count": "1 through 10" } ], "minimum": 1545, "maximum": 1900 } ] }, { "description": "Room & Board - Ward - General Classification", "code_information": [ { "code": "0150", "type": "RC" } ], "standard_charges": [ { "setting": "inpatient", "payers_information": [ { "payer_name": "Allegiance Provider Direct", "plan_name": "PPO", "standard_charge_dollar": 1900, "methodology": "per diem", "median_amount": 1900, "10th_percentile": 1900, "90th_percentile": 1900, "count": "1 through 10" }, { "payer_name": "United Healthcare (UHC)", "plan_name": "HMO", "standard_charge_dollar": 1545, "methodology": "per diem", "median_amount": 1545, "10th_percentile": 1545, "90th_percentile": 1545, "count": "1 through 10" }, { "payer_name": "United Healthcare (UHC)", "plan_name": "PPO", "standard_charge_dollar": 1545, "methodology": "per diem", "median_amount": 1545, "10th_percentile": 1545, "90th_percentile": 1545, "count": "1 through 10" }, { "payer_name": "United Healthcare (UHC)", "plan_name": "Indemnity", "standard_charge_dollar": 1545, "methodology": "per diem", "median_amount": 1545, "10th_percentile": 1545, "90th_percentile": 1545, "count": "1 through 10" } ], "minimum": 1545, "maximum": 1900 } ] }, { "description": "Room & Board - Ward - Medical/Surgical/GYN", "code_information": [ { "code": "0151", "type": "RC" } ], "standard_charges": [ { "setting": "inpatient", "payers_information": [ { "payer_name": "Allegiance Provider Direct", "plan_name": "PPO", "standard_charge_dollar": 1900, "methodology": "per diem", "median_amount": 1900, "10th_percentile": 1900, "90th_percentile": 1900, "count": "1 through 10" }, { "payer_name": "United Healthcare (UHC)", "plan_name": "HMO", "standard_charge_dollar": 1545, "methodology": "per diem", "median_amount": 1545, "10th_percentile": 1545, "90th_percentile": 1545, "count": "1 through 10" }, { "payer_name": "United Healthcare (UHC)", "plan_name": "PPO", "standard_charge_dollar": 1545, "methodology": "per diem", "median_amount": 1545, "10th_percentile": 1545, "90th_percentile": 1545, "count": "1 through 10" }, { "payer_name": "United Healthcare (UHC)", "plan_name": "Indemnity", "standard_charge_dollar": 1545, "methodology": "per diem", "median_amount": 1545, "10th_percentile": 1545, "90th_percentile": 1545, "count": "1 through 10" } ], "minimum": 1545, "maximum": 1900 } ] }, { "description": "Intensive Care Unit - Intermediate ICU", "code_information": [ { "code": "0206", "type": "RC" } ], "standard_charges": [ { "setting": "inpatient", "payers_information": [ { "payer_name": "Allegiance Provider Direct", "plan_name": "PPO", "standard_charge_dollar": 2200, "methodology": "per diem", "median_amount": 2200, "10th_percentile": 2200, "90th_percentile": 2200, "count": "1 through 10" }, { "payer_name": "PacificSource Health Plans", "plan_name": "PPO (PSN Network and Smart Health Network)", "standard_charge_percentage": 80, "methodology": "percent of total billed charges", "median_amount": 1648.64, "10th_percentile": 1648.64, "90th_percentile": 1648.64, "count": "1 through 10" }, { "payer_name": "TriWest Healthcare Alliance Corporation", "plan_name": "VA CCN", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Blue Cross Blue Shield of Montana", "plan_name": "Medicare Advantage", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Claritev fka MultiPlan", "plan_name": "Workers' Compensation Program", "standard_charge_percentage": 90, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "United Healthcare (UHC)", "plan_name": "Medicare Advantage", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "First Choice of the Midwest", "plan_name": "PPO", "standard_charge_percentage": 90, "methodology": "percent of total billed charges", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "United Healthcare (UHC)", "plan_name": "DSNP", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Employee Benefit Management Services (EBMS)", "plan_name": "EBMS SelectCare Network", "standard_charge_percentage": 80, "methodology": "percent of total billed charges", "median_amount": 1648.64, "10th_percentile": 1648.64, "90th_percentile": 1648.64, "count": "52" }, { "payer_name": "Claritev fka MultiPlan", "plan_name": "Auto Medical Program", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Coventry Health Care", "plan_name": "Auto Network", "standard_charge_percentage": 90, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Allegiance Provider Direct", "plan_name": "Medicare", "standard_charge_percentage": 229.99999999999997, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Claritev fka MultiPlan", "plan_name": "PPO", "standard_charge_percentage": 75, "methodology": "percent of total billed charges", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Medica Insurance Company", "plan_name": "Medicare Cost", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Medicare (CMS)", "plan_name": "Medicare", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Indian Health Services (IHS)", "plan_name": "Commercial", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "National Comp Care", "plan_name": "Workers' Compensation", "standard_charge_dollar": 1800, "methodology": "per diem", "median_amount": 1800, "10th_percentile": 1800, "90th_percentile": 1800, "count": "1 through 10" }, { "payer_name": "First Choice Health Network fka Health InfoNet", "plan_name": "Commercial", "standard_charge_percentage": 85, "methodology": "percent of total billed charges", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Humana Insurance Company", "plan_name": "Humana Medicare Advantage HMO", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Humana Insurance Company", "plan_name": "Humana Medicare Advantage PPO", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Humana Insurance Company", "plan_name": "Humana Medicare Advantage PFFS", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "First Choice Health Network fka Health InfoNet", "plan_name": "Workers Compensation", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Allegiance Provider Direct", "plan_name": "State of Montana Employee Benefit Plan (Self-Funded)", "standard_charge_percentage": 229.99999999999997, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Allegiance Provider Direct", "plan_name": "Montana Municipal Interlocal Authority (MMIA)", "standard_charge_percentage": 229.99999999999997, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Allegiance Provider Direct", "plan_name": "Montana Association of Counties (MACo)", "standard_charge_percentage": 229.99999999999997, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "First Choice Health Network fka Health InfoNet", "plan_name": "Medicare Advantage", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Medicaid (State)", "plan_name": "Medicaid", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "TriWest Healthcare Alliance Corporation", "plan_name": "TRICARE Prime", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "TriWest Healthcare Alliance Corporation", "plan_name": "TRICARE Select", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "United Healthcare (UHC)", "plan_name": "HMO", "standard_charge_dollar": 1854, "methodology": "per diem", "median_amount": 1854, "10th_percentile": 1854, "90th_percentile": 1854, "count": "1 through 10" }, { "payer_name": "United Healthcare (UHC)", "plan_name": "PPO", "standard_charge_dollar": 1854, "methodology": "per diem", "median_amount": 1854, "10th_percentile": 1854, "90th_percentile": 1854, "count": "1 through 10" }, { "payer_name": "United Healthcare (UHC)", "plan_name": "Indemnity", "standard_charge_dollar": 1854, "methodology": "per diem", "median_amount": 1854, "10th_percentile": 1854, "90th_percentile": 1854, "count": "1 through 10" }, { "payer_name": "Blue Cross Blue Shield of Montana", "plan_name": "HealthLink Network", "standard_charge_percentage": 75, "methodology": "percent of total billed charges", "median_amount": 1545.6, "10th_percentile": 1545.6, "90th_percentile": 1545.6, "count": "101" }, { "payer_name": "Blue Cross Blue Shield of Montana", "plan_name": "Traditional Network", "standard_charge_percentage": 75, "methodology": "percent of total billed charges", "median_amount": 1545.6, "10th_percentile": 1545.6, "90th_percentile": 1545.6, "count": "101" }, { "payer_name": "Blue Cross Blue Shield of Montana", "plan_name": "POS Network", "standard_charge_percentage": 75, "methodology": "percent of total billed charges", "median_amount": 1545.6, "10th_percentile": 1545.6, "90th_percentile": 1545.6, "count": "101" }, { "payer_name": "Blue Cross Blue Shield of Montana", "plan_name": "Closed Plan Network", "standard_charge_percentage": 75, "methodology": "percent of total billed charges", "median_amount": 1545.6, "10th_percentile": 1545.6, "90th_percentile": 1545.6, "count": "101" }, { "payer_name": "Blue Cross Blue Shield of Montana", "plan_name": "Retail HMO POS Network", "standard_charge_percentage": 75, "methodology": "percent of total billed charges", "median_amount": 1545.6, "10th_percentile": 1545.6, "90th_percentile": 1545.6, "count": "101" }, { "payer_name": "Blue Cross Blue Shield of Montana", "plan_name": "Blue Options Network", "standard_charge_percentage": 75, "methodology": "percent of total billed charges", "median_amount": 1545.6, "10th_percentile": 1545.6, "90th_percentile": 1545.6, "count": "101" }, { "payer_name": "Montana Health Cooperative dba Mountain Health Co-Op HPN Product", "plan_name": "MT Connected Care", "standard_charge_dollar": 2025, "methodology": "per diem", "median_amount": 2025, "10th_percentile": 2025, "90th_percentile": 2025, "count": "1 through 10" }, { "payer_name": "Montana Health Cooperative dba Mountain Health Co-Op HPN Product", "plan_name": "MT Access Care", "standard_charge_dollar": 2025, "methodology": "per diem", "median_amount": 2025, "10th_percentile": 2025, "90th_percentile": 2025, "count": "1 through 10" }, { "payer_name": "PacificSource Health Plans", "plan_name": "Medicare Advantage", "standard_charge_percentage": 103, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" } ], "minimum": 1545.6, "maximum": 2200 } ] }, { "description": "Coronary Care Unit - Intermediate CCU", "code_information": [ { "code": "0214", "type": "RC" } ], "standard_charges": [ { "setting": "inpatient", "payers_information": [ { "payer_name": "Allegiance Provider Direct", "plan_name": "PPO", "standard_charge_dollar": 2200, "methodology": "per diem", "median_amount": 2200, "10th_percentile": 2200, "90th_percentile": 2200, "count": "1 through 10" }, { "payer_name": "PacificSource Health Plans", "plan_name": "PPO (PSN Network and Smart Health Network)", "standard_charge_percentage": 80, "methodology": "percent of total billed charges", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Coventry Health Care", "plan_name": "Auto Network", "standard_charge_percentage": 90, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Indian Health Services (IHS)", "plan_name": "Commercial", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Humana Insurance Company", "plan_name": "Humana Medicare Advantage HMO", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Humana Insurance Company", "plan_name": "Humana Medicare Advantage PPO", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Humana Insurance Company", "plan_name": "Humana Medicare Advantage PFFS", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "United Healthcare (UHC)", "plan_name": "HMO", "standard_charge_dollar": 1854, "methodology": "per diem", "median_amount": 1854, "10th_percentile": 1854, "90th_percentile": 1854, "count": "1 through 10" }, { "payer_name": "United Healthcare (UHC)", "plan_name": "PPO", "standard_charge_dollar": 1854, "methodology": "per diem", "median_amount": 1854, "10th_percentile": 1854, "90th_percentile": 1854, "count": "1 through 10" }, { "payer_name": "United Healthcare (UHC)", "plan_name": "Indemnity", "standard_charge_dollar": 1854, "methodology": "per diem", "median_amount": 1854, "10th_percentile": 1854, "90th_percentile": 1854, "count": "1 through 10" } ], "minimum": 1854, "maximum": 2200 } ] }, { "description": "Coronary Care Unit - Other", "code_information": [ { "code": "0219", "type": "RC" } ], "standard_charges": [ { "setting": "inpatient", "payers_information": [ { "payer_name": "Allegiance Provider Direct", "plan_name": "PPO", "standard_charge_dollar": 2350, "methodology": "per diem", "median_amount": 2350, "10th_percentile": 2350, "90th_percentile": 2350, "count": "1 through 10" }, { "payer_name": "United Healthcare (UHC)", "plan_name": "HMO", "standard_charge_dollar": 2060, "methodology": "per diem", "median_amount": 2060, "10th_percentile": 2060, "90th_percentile": 2060, "count": "1 through 10" }, { "payer_name": "United Healthcare (UHC)", "plan_name": "PPO", "standard_charge_dollar": 2060, "methodology": "per diem", "median_amount": 2060, "10th_percentile": 2060, "90th_percentile": 2060, "count": "1 through 10" }, { "payer_name": "United Healthcare (UHC)", "plan_name": "Indemnity", "standard_charge_dollar": 2060, "methodology": "per diem", "median_amount": 2060, "10th_percentile": 2060, "90th_percentile": 2060, "count": "1 through 10" } ], "minimum": 2060, "maximum": 2350 } ] }, { "description": "Intrvasc us noncoronary addl", "code_information": [ { "code": "37253", "type": "HCPCS" } ], "standard_charges": [ { "setting": "outpatient", "payers_information": [ { "payer_name": "United Healthcare (UHC)", "plan_name": "DSNP", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "United Healthcare (UHC)", "plan_name": "Medicare Advantage", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" } ] } ] }, { "description": "Phleb veins - extrem 20+", "code_information": [ { "code": "37766", "type": "HCPCS" } ], "standard_charges": [ { "setting": "outpatient", "payers_information": [ { "payer_name": "United Healthcare (UHC)", "plan_name": "DSNP", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "United Healthcare (UHC)", "plan_name": "Medicare Advantage", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" } ] } ] }, { "description": "Dx bone marrow bx & aspir", "code_information": [ { "code": "38222", "type": "HCPCS" } ], "standard_charges": [ { "setting": "outpatient", "payers_information": [ { "payer_name": "United Healthcare (UHC)", "plan_name": "DSNP", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "United Healthcare (UHC)", "plan_name": "Medicare Advantage", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" } ] } ] }, { "description": "Biopsy/removal lymph nodes", "code_information": [ { "code": "38500", "type": "HCPCS" } ], "standard_charges": [ { "setting": "outpatient", "payers_information": [ { "payer_name": "United Healthcare (UHC)", "plan_name": "DSNP", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "United Healthcare (UHC)", "plan_name": "Medicare Advantage", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" } ] } ] }, { "description": "Needle biopsy lymph nodes", "code_information": [ { "code": "38505", "type": "HCPCS" } ], "standard_charges": [ { "setting": "outpatient", "payers_information": [ { "payer_name": "United Healthcare (UHC)", "plan_name": "DSNP", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "United Healthcare (UHC)", "plan_name": "Medicare Advantage", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" } ] } ] }, { "description": "Biopsy/removal lymph nodes", "code_information": [ { "code": "38525", "type": "HCPCS" } ], "standard_charges": [ { "setting": "outpatient", "payers_information": [ { "payer_name": "United Healthcare (UHC)", "plan_name": "DSNP", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "United Healthcare (UHC)", "plan_name": "Medicare Advantage", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" } ] } ] }, { "description": "Open bx/exc inguinofem nodes", "code_information": [ { "code": "38531", "type": "HCPCS" } ], "standard_charges": [ { "setting": "outpatient", "payers_information": [ { "payer_name": "United Healthcare (UHC)", "plan_name": "DSNP", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "United Healthcare (UHC)", "plan_name": "Medicare Advantage", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" } ] } ] }, { "description": "Laparoscopy lymph node biop", "code_information": [ { "code": "38570", "type": "HCPCS" } ], "standard_charges": [ { "setting": "outpatient", "payers_information": [ { "payer_name": "United Healthcare (UHC)", "plan_name": "DSNP", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "United Healthcare (UHC)", "plan_name": "Medicare Advantage", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" } ] } ] }, { "description": "Laparoscopy lymphadenectomy", "code_information": [ { "code": "38571", "type": "HCPCS" } ], "standard_charges": [ { "setting": "outpatient", "payers_information": [ { "payer_name": "United Healthcare (UHC)", "plan_name": "DSNP", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "United Healthcare (UHC)", "plan_name": "Medicare Advantage", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" } ] } ] }, { "description": "Io map of sent lymph node", "code_information": [ { "code": "38900", "type": "HCPCS" } ], "standard_charges": [ { "setting": "outpatient", "payers_information": [ { "payer_name": "United Healthcare (UHC)", "plan_name": "DSNP", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "United Healthcare (UHC)", "plan_name": "Medicare Advantage", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" } ] } ] }, { "description": "Remove tonsils and adenoids", "code_information": [ { "code": "42821", "type": "HCPCS" } ], "standard_charges": [ { "setting": "outpatient", "payers_information": [ { "payer_name": "United Healthcare (UHC)", "plan_name": "DSNP", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "United Healthcare (UHC)", "plan_name": "Medicare Advantage", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" } ] } ] }, { "description": "Removal of tonsils", "code_information": [ { "code": "42826", "type": "HCPCS" } ], "standard_charges": [ { "setting": "outpatient", "payers_information": [ { "payer_name": "United Healthcare (UHC)", "plan_name": "DSNP", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "United Healthcare (UHC)", "plan_name": "Medicare Advantage", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" } ] } ] }, { "description": "Egd diagnostic brush wash", "code_information": [ { "code": "43235", "type": "HCPCS" } ], "standard_charges": [ { "setting": "outpatient", "payers_information": [ { "payer_name": "United Healthcare (UHC)", "plan_name": "DSNP", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "United Healthcare (UHC)", "plan_name": "Medicare Advantage", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" } ] } ] }, { "description": "Egd biopsy single/multiple", "code_information": [ { "code": "43239", "type": "HCPCS" } ], "standard_charges": [ { "setting": "outpatient", "payers_information": [ { "payer_name": "United Healthcare (UHC)", "plan_name": "DSNP", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "United Healthcare (UHC)", "plan_name": "Medicare Advantage", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" } ] } ] }, { "description": "Egd varices ligation", "code_information": [ { "code": "43244", "type": "HCPCS" } ], "standard_charges": [ { "setting": "outpatient", "payers_information": [ { "payer_name": "United Healthcare (UHC)", "plan_name": "DSNP", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "United Healthcare (UHC)", "plan_name": "Medicare Advantage", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" } ] } ] }, { "description": "Egd place gastrostomy tube", "code_information": [ { "code": "43246", "type": "HCPCS" } ], "standard_charges": [ { "setting": "outpatient", "payers_information": [ { "payer_name": "United Healthcare (UHC)", "plan_name": "DSNP", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "United Healthcare (UHC)", "plan_name": "Medicare Advantage", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" } ] } ] }, { "description": "Laparoscopy fundoplasty", "code_information": [ { "code": "43280", "type": "HCPCS" } ], "standard_charges": [ { "setting": "outpatient", "payers_information": [ { "payer_name": "United Healthcare (UHC)", "plan_name": "DSNP", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "United Healthcare (UHC)", "plan_name": "Medicare Advantage", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" } ] } ] }, { "description": "Reposition gastrostomy tube", "code_information": [ { "code": "43761", "type": "HCPCS" } ], "standard_charges": [ { "setting": "outpatient", "payers_information": [ { "payer_name": "United Healthcare (UHC)", "plan_name": "DSNP", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "United Healthcare (UHC)", "plan_name": "Medicare Advantage", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" } ] } ] }, { "description": "Rplc gtube no revj trc", "code_information": [ { "code": "43762", "type": "HCPCS" } ], "standard_charges": [ { "setting": "outpatient", "payers_information": [ { "payer_name": "United Healthcare (UHC)", "plan_name": "DSNP", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "United Healthcare (UHC)", "plan_name": "Medicare Advantage", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" } ] } ] }, { "description": "Laparoscopy appendectomy", "code_information": [ { "code": "44970", "type": "HCPCS" } ], "standard_charges": [ { "setting": "outpatient", "payers_information": [ { "payer_name": "United Healthcare (UHC)", "plan_name": "DSNP", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "United Healthcare (UHC)", "plan_name": "Medicare Advantage", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" } ] } ] }, { "description": "Proctosigmoidoscopy dx", "code_information": [ { "code": "45300", "type": "HCPCS" } ], "standard_charges": [ { "setting": "outpatient", "payers_information": [ { "payer_name": "United Healthcare (UHC)", "plan_name": "DSNP", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "United Healthcare (UHC)", "plan_name": "Medicare Advantage", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" } ] } ] }, { "description": "Diagnostic colonoscopy", "code_information": [ { "code": "45378", "type": "HCPCS" } ], "standard_charges": [ { "setting": "outpatient", "payers_information": [ { "payer_name": "United Healthcare (UHC)", "plan_name": "DSNP", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "United Healthcare (UHC)", "plan_name": "Medicare Advantage", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" } ] } ] }, { "description": "Colonoscopy and biopsy", "code_information": [ { "code": "45380", "type": "HCPCS" } ], "standard_charges": [ { "setting": "outpatient", "payers_information": [ { "payer_name": "United Healthcare (UHC)", "plan_name": "DSNP", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "United Healthcare (UHC)", "plan_name": "Medicare Advantage", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" } ] } ] }, { "description": "Colonoscopy submucous njx", "code_information": [ { "code": "45381", "type": "HCPCS" } ], "standard_charges": [ { "setting": "outpatient", "payers_information": [ { "payer_name": "United Healthcare (UHC)", "plan_name": "DSNP", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "United Healthcare (UHC)", "plan_name": "Medicare Advantage", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" } ] } ] }, { "description": "Colonoscopy w/lesion removal", "code_information": [ { "code": "45385", "type": "HCPCS" } ], "standard_charges": [ { "setting": "outpatient", "payers_information": [ { "payer_name": "United Healthcare (UHC)", "plan_name": "DSNP", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "United Healthcare (UHC)", "plan_name": "Medicare Advantage", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" } ] } ] }, { "description": "Colonoscopy w/ablation", "code_information": [ { "code": "45388", "type": "HCPCS" } ], "standard_charges": [ { "setting": "outpatient", "payers_information": [ { "payer_name": "United Healthcare (UHC)", "plan_name": "DSNP", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "United Healthcare (UHC)", "plan_name": "Medicare Advantage", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" } ] } ] }, { "description": "Remove int/ext hem 1 group", "code_information": [ { "code": "46255", "type": "HCPCS" } ], "standard_charges": [ { "setting": "outpatient", "payers_information": [ { "payer_name": "United Healthcare (UHC)", "plan_name": "DSNP", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "United Healthcare (UHC)", "plan_name": "Medicare Advantage", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" } ] } ] }, { "description": "Remove in/ex hem groups 2+", "code_information": [ { "code": "46260", "type": "HCPCS" } ], "standard_charges": [ { "setting": "outpatient", "payers_information": [ { "payer_name": "United Healthcare (UHC)", "plan_name": "DSNP", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "United Healthcare (UHC)", "plan_name": "Medicare Advantage", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" } ] } ] }, { "description": "Diagnostic anoscopy & biopsy", "code_information": [ { "code": "46607", "type": "HCPCS" } ], "standard_charges": [ { "setting": "outpatient", "payers_information": [ { "payer_name": "United Healthcare (UHC)", "plan_name": "DSNP", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "United Healthcare (UHC)", "plan_name": "Medicare Advantage", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" } ] } ] }, { "description": "Destruction anal lesion(s)", "code_information": [ { "code": "46924", "type": "HCPCS" } ], "standard_charges": [ { "setting": "outpatient", "payers_information": [ { "payer_name": "United Healthcare (UHC)", "plan_name": "DSNP", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "United Healthcare (UHC)", "plan_name": "Medicare Advantage", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" } ] } ] }, { "description": "Needle biopsy of liver", "code_information": [ { "code": "47000", "type": "HCPCS" } ], "standard_charges": [ { "setting": "outpatient", "payers_information": [ { "payer_name": "United Healthcare (UHC)", "plan_name": "DSNP", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "United Healthcare (UHC)", "plan_name": "Medicare Advantage", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" } ] } ] }, { "description": "Laparoscopic cholecystectomy", "code_information": [ { "code": "47562", "type": "HCPCS" } ], "standard_charges": [ { "setting": "outpatient", "payers_information": [ { "payer_name": "United Healthcare (UHC)", "plan_name": "DSNP", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "United Healthcare (UHC)", "plan_name": "Medicare Advantage", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" } ] } ] }, { "description": "Laparo cholecystectomy/graph", "code_information": [ { "code": "47563", "type": "HCPCS" } ], "standard_charges": [ { "setting": "outpatient", "payers_information": [ { "payer_name": "United Healthcare (UHC)", "plan_name": "DSNP", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "United Healthcare (UHC)", "plan_name": "Medicare Advantage", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" } ] } ] }, { "description": "Abd paracentesis w/imaging", "code_information": [ { "code": "49083", "type": "HCPCS" } ], "standard_charges": [ { "setting": "outpatient", "payers_information": [ { "payer_name": "United Healthcare (UHC)", "plan_name": "DSNP", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "United Healthcare (UHC)", "plan_name": "Medicare Advantage", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" } ] } ] }, { "description": "Laparoscopy aspiration", "code_information": [ { "code": "49322", "type": "HCPCS" } ], "standard_charges": [ { "setting": "outpatient", "payers_information": [ { "payer_name": "United Healthcare (UHC)", "plan_name": "DSNP", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "United Healthcare (UHC)", "plan_name": "Medicare Advantage", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" } ] } ] }, { "description": "Lap insert tunnel ip cath", "code_information": [ { "code": "49324", "type": "HCPCS" } ], "standard_charges": [ { "setting": "outpatient", "payers_information": [ { "payer_name": "United Healthcare (UHC)", "plan_name": "DSNP", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "United Healthcare (UHC)", "plan_name": "Medicare Advantage", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" } ] } ] }, { "description": "Remove tunneled ip cath", "code_information": [ { "code": "49422", "type": "HCPCS" } ], "standard_charges": [ { "setting": "outpatient", "payers_information": [ { "payer_name": "United Healthcare (UHC)", "plan_name": "DSNP", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "United Healthcare (UHC)", "plan_name": "Medicare Advantage", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" } ] } ] }, { "description": "Prp i/hern init reduc >5 yr", "code_information": [ { "code": "49505", "type": "HCPCS" } ], "standard_charges": [ { "setting": "outpatient", "payers_information": [ { "payer_name": "United Healthcare (UHC)", "plan_name": "DSNP", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "United Healthcare (UHC)", "plan_name": "Medicare Advantage", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" } ] } ] }, { "description": "Prp i/hern init block >5 yr", "code_information": [ { "code": "49507", "type": "HCPCS" } ], "standard_charges": [ { "setting": "outpatient", "payers_information": [ { "payer_name": "United Healthcare (UHC)", "plan_name": "DSNP", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "United Healthcare (UHC)", "plan_name": "Medicare Advantage", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" } ] } ] }, { "description": "Rerepair ing hernia reduce", "code_information": [ { "code": "49520", "type": "HCPCS" } ], "standard_charges": [ { "setting": "outpatient", "payers_information": [ { "payer_name": "United Healthcare (UHC)", "plan_name": "DSNP", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "United Healthcare (UHC)", "plan_name": "Medicare Advantage", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" } ] } ] }, { "description": "Rpr aa hrn 1st < 3 cm rdc", "code_information": [ { "code": "49591", "type": "HCPCS" } ], "standard_charges": [ { "setting": "outpatient", "payers_information": [ { "payer_name": "United Healthcare (UHC)", "plan_name": "DSNP", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "United Healthcare (UHC)", "plan_name": "Medicare Advantage", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" } ] } ] }, { "description": "Rpr aa hrn 1st < 3 ncr/strn", "code_information": [ { "code": "49592", "type": "HCPCS" } ], "standard_charges": [ { "setting": "outpatient", "payers_information": [ { "payer_name": "United Healthcare (UHC)", "plan_name": "DSNP", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "United Healthcare (UHC)", "plan_name": "Medicare Advantage", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" } ] } ] }, { "description": "Repair of humerus", "code_information": [ { "code": "24430", "type": "HCPCS" } ], "standard_charges": [ { "setting": "outpatient", "payers_information": [ { "payer_name": "United Healthcare (UHC)", "plan_name": "DSNP", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "United Healthcare (UHC)", "plan_name": "Medicare Advantage", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" } ] } ] }, { "description": "Treat humerus fracture", "code_information": [ { "code": "24516", "type": "HCPCS" } ], "standard_charges": [ { "setting": "outpatient", "payers_information": [ { "payer_name": "United Healthcare (UHC)", "plan_name": "DSNP", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "United Healthcare (UHC)", "plan_name": "Medicare Advantage", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" } ] } ] }, { "description": "Treat elbow dislocation", "code_information": [ { "code": "24615", "type": "HCPCS" } ], "standard_charges": [ { "setting": "outpatient", "payers_information": [ { "payer_name": "United Healthcare (UHC)", "plan_name": "DSNP", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "United Healthcare (UHC)", "plan_name": "Medicare Advantage", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" } ] } ] }, { "description": "Treat ulnar fracture", "code_information": [ { "code": "24685", "type": "HCPCS" } ], "standard_charges": [ { "setting": "outpatient", "payers_information": [ { "payer_name": "United Healthcare (UHC)", "plan_name": "DSNP", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "United Healthcare (UHC)", "plan_name": "Medicare Advantage", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" } ] } ] }, { "description": "Treat fx rad extra-articul", "code_information": [ { "code": "25607", "type": "HCPCS" } ], "standard_charges": [ { "setting": "outpatient", "payers_information": [ { "payer_name": "United Healthcare (UHC)", "plan_name": "DSNP", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "United Healthcare (UHC)", "plan_name": "Medicare Advantage", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" } ] } ] }, { "description": "Treat fx rad intra-articul", "code_information": [ { "code": "25608", "type": "HCPCS" } ], "standard_charges": [ { "setting": "outpatient", "payers_information": [ { "payer_name": "United Healthcare (UHC)", "plan_name": "DSNP", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "United Healthcare (UHC)", "plan_name": "Medicare Advantage", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" } ] } ] }, { "description": "Treat fracture ulnar styloid", "code_information": [ { "code": "25652", "type": "HCPCS" } ], "standard_charges": [ { "setting": "outpatient", "payers_information": [ { "payer_name": "United Healthcare (UHC)", "plan_name": "DSNP", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "United Healthcare (UHC)", "plan_name": "Medicare Advantage", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" } ] } ] }, { "description": "Treat thumb fracture", "code_information": [ { "code": "26645", "type": "HCPCS" } ], "standard_charges": [ { "setting": "outpatient", "payers_information": [ { "payer_name": "United Healthcare (UHC)", "plan_name": "DSNP", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "United Healthcare (UHC)", "plan_name": "Medicare Advantage", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" } ] } ] }, { "description": "Total hip arthroplasty", "code_information": [ { "code": "27130", "type": "HCPCS" } ], "standard_charges": [ { "setting": "outpatient", "payers_information": [ { "payer_name": "United Healthcare (UHC)", "plan_name": "DSNP", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "United Healthcare (UHC)", "plan_name": "Medicare Advantage", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" } ] } ] }, { "description": "Revision of unstable kneecap", "code_information": [ { "code": "27422", "type": "HCPCS" } ], "standard_charges": [ { "setting": "outpatient", "payers_information": [ { "payer_name": "United Healthcare (UHC)", "plan_name": "DSNP", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "United Healthcare (UHC)", "plan_name": "Medicare Advantage", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" } ] } ] }, { "description": "Lat retinacular release open", "code_information": [ { "code": "27425", "type": "HCPCS" } ], "standard_charges": [ { "setting": "outpatient", "payers_information": [ { "payer_name": "United Healthcare (UHC)", "plan_name": "DSNP", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "United Healthcare (UHC)", "plan_name": "Medicare Advantage", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" } ] } ] }, { "description": "Reconstruction knee", "code_information": [ { "code": "27427", "type": "HCPCS" } ], "standard_charges": [ { "setting": "outpatient", "payers_information": [ { "payer_name": "United Healthcare (UHC)", "plan_name": "DSNP", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "United Healthcare (UHC)", "plan_name": "Medicare Advantage", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" } ] } ] }, { "description": "Revision of knee joint", "code_information": [ { "code": "27446", "type": "HCPCS" } ], "standard_charges": [ { "setting": "outpatient", "payers_information": [ { "payer_name": "United Healthcare (UHC)", "plan_name": "DSNP", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "United Healthcare (UHC)", "plan_name": "Medicare Advantage", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" } ] } ] }, { "description": "Total knee arthroplasty", "code_information": [ { "code": "27447", "type": "HCPCS" } ], "standard_charges": [ { "setting": "outpatient", "payers_information": [ { "payer_name": "United Healthcare (UHC)", "plan_name": "DSNP", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "United Healthcare (UHC)", "plan_name": "Medicare Advantage", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" } ] } ] }, { "description": "Treat kneecap fracture", "code_information": [ { "code": "27524", "type": "HCPCS" } ], "standard_charges": [ { "setting": "outpatient", "payers_information": [ { "payer_name": "United Healthcare (UHC)", "plan_name": "DSNP", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "United Healthcare (UHC)", "plan_name": "Medicare Advantage", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" } ] } ] }, { "description": "Fixation of knee joint", "code_information": [ { "code": "27570", "type": "HCPCS" } ], "standard_charges": [ { "setting": "outpatient", "payers_information": [ { "payer_name": "United Healthcare (UHC)", "plan_name": "DSNP", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "United Healthcare (UHC)", "plan_name": "Medicare Advantage", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" } ] } ] }, { "description": "Reconstruction ankle joint", "code_information": [ { "code": "27703", "type": "HCPCS" } ], "standard_charges": [ { "setting": "outpatient", "payers_information": [ { "payer_name": "United Healthcare (UHC)", "plan_name": "DSNP", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "United Healthcare (UHC)", "plan_name": "Medicare Advantage", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" } ] } ] }, { "description": "Realignment of lower leg", "code_information": [ { "code": "27712", "type": "HCPCS" } ], "standard_charges": [ { "setting": "outpatient", "payers_information": [ { "payer_name": "United Healthcare (UHC)", "plan_name": "DSNP", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "United Healthcare (UHC)", "plan_name": "Medicare Advantage", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" } ] } ] }, { "description": "Part removal of metatarsal", "code_information": [ { "code": "28110", "type": "HCPCS" } ], "standard_charges": [ { "setting": "outpatient", "payers_information": [ { "payer_name": "United Healthcare (UHC)", "plan_name": "DSNP", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "United Healthcare (UHC)", "plan_name": "Medicare Advantage", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" } ] } ] }, { "description": "Repair of hammertoe", "code_information": [ { "code": "28285", "type": "HCPCS" } ], "standard_charges": [ { "setting": "outpatient", "payers_information": [ { "payer_name": "United Healthcare (UHC)", "plan_name": "DSNP", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "United Healthcare (UHC)", "plan_name": "Medicare Advantage", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" } ] } ] }, { "description": "Treat/graft heel fracture", "code_information": [ { "code": "28420", "type": "HCPCS" } ], "standard_charges": [ { "setting": "outpatient", "payers_information": [ { "payer_name": "United Healthcare (UHC)", "plan_name": "DSNP", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "United Healthcare (UHC)", "plan_name": "Medicare Advantage", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" } ] } ] }, { "description": "Apply long arm splint", "code_information": [ { "code": "29105", "type": "HCPCS" } ], "standard_charges": [ { "setting": "outpatient", "payers_information": [ { "payer_name": "United Healthcare (UHC)", "plan_name": "DSNP", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "United Healthcare (UHC)", "plan_name": "Medicare Advantage", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" } ] } ] }, { "description": "Apply forearm splint", "code_information": [ { "code": "29125", "type": "HCPCS" } ], "standard_charges": [ { "setting": "outpatient", "payers_information": [ { "payer_name": "United Healthcare (UHC)", "plan_name": "DSNP", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "National Comp Care", "plan_name": "Workers' Compensation", "standard_charge_percentage": 90, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Coventry Health Care", "plan_name": "Auto Network", "standard_charge_percentage": 90, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Coventry Health Care", "plan_name": "Workers' Compensation", "standard_charge_percentage": 95, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "TriWest Healthcare Alliance Corporation", "plan_name": "VA CCN", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Blue Cross Blue Shield of Montana", "plan_name": "Medicare Advantage", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "United Healthcare (UHC)", "plan_name": "Medicare Advantage", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Allegiance Provider Direct", "plan_name": "Medicare", "standard_charge_percentage": 229.99999999999997, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "PacificSource Health Plans", "plan_name": "PPO (PSN Network and Smart Health Network)", "standard_charge_percentage": 80, "methodology": "percent of total billed charges", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "First Choice Health Network fka Health InfoNet", "plan_name": "Commercial", "standard_charge_percentage": 85, "methodology": "percent of total billed charges", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Medicare (CMS)", "plan_name": "Medicare", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Claritev fka MultiPlan", "plan_name": "Auto Medical Program", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Claritev fka MultiPlan", "plan_name": "Workers' Compensation Program", "standard_charge_percentage": 90, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Claritev fka MultiPlan", "plan_name": "PPO", "standard_charge_percentage": 75, "methodology": "percent of total billed charges", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "First Choice of the Midwest", "plan_name": "PPO", "standard_charge_percentage": 90, "methodology": "percent of total billed charges", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Employee Benefit Management Services (EBMS)", "plan_name": "EBMS SelectCare Network", "standard_charge_percentage": 80, "methodology": "percent of total billed charges", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Medica Insurance Company", "plan_name": "Medicare Cost", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "First Choice Health Network fka Health InfoNet", "plan_name": "Medicare Advantage", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "First Choice Health Network fka Health InfoNet", "plan_name": "Workers Compensation", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Allegiance Provider Direct", "plan_name": "Montana Association of Counties (MACo)", "standard_charge_percentage": 229.99999999999997, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Allegiance Provider Direct", "plan_name": "State of Montana Employee Benefit Plan (Self-Funded)", "standard_charge_percentage": 229.99999999999997, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Allegiance Provider Direct", "plan_name": "Montana Municipal Interlocal Authority (MMIA)", "standard_charge_percentage": 229.99999999999997, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Medicaid (State)", "plan_name": "Medicaid", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Blue Cross Blue Shield of Montana", "plan_name": "HealthLink Network", "standard_charge_percentage": 75, "methodology": "percent of total billed charges", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Blue Cross Blue Shield of Montana", "plan_name": "Traditional Network", "standard_charge_percentage": 75, "methodology": "percent of total billed charges", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Blue Cross Blue Shield of Montana", "plan_name": "POS Network", "standard_charge_percentage": 75, "methodology": "percent of total billed charges", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Blue Cross Blue Shield of Montana", "plan_name": "Closed Plan Network", "standard_charge_percentage": 75, "methodology": "percent of total billed charges", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Blue Cross Blue Shield of Montana", "plan_name": "Retail HMO POS Network", "standard_charge_percentage": 75, "methodology": "percent of total billed charges", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Blue Cross Blue Shield of Montana", "plan_name": "Blue Options Network", "standard_charge_percentage": 75, "methodology": "percent of total billed charges", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "PacificSource Health Plans", "plan_name": "Medicare Advantage", "standard_charge_percentage": 103, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" } ] } ] }, { "description": "Application long leg splint", "code_information": [ { "code": "29505", "type": "HCPCS" } ], "standard_charges": [ { "setting": "outpatient", "payers_information": [ { "payer_name": "United Healthcare (UHC)", "plan_name": "DSNP", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "United Healthcare (UHC)", "plan_name": "Medicare Advantage", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" } ] } ] }, { "description": "Application lower leg splint", "code_information": [ { "code": "29515", "type": "HCPCS" } ], "standard_charges": [ { "setting": "outpatient", "payers_information": [ { "payer_name": "United Healthcare (UHC)", "plan_name": "DSNP", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "United Healthcare (UHC)", "plan_name": "Medicare Advantage", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" } ] } ] }, { "description": "Sho arthrs dx +- synovial bx", "code_information": [ { "code": "29805", "type": "HCPCS" } ], "standard_charges": [ { "setting": "outpatient", "payers_information": [ { "payer_name": "United Healthcare (UHC)", "plan_name": "DSNP", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "United Healthcare (UHC)", "plan_name": "Medicare Advantage", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" } ] } ] }, { "description": "Sho arthrs srg lmtd dbrdmt", "code_information": [ { "code": "29822", "type": "HCPCS" } ], "standard_charges": [ { "setting": "outpatient", "payers_information": [ { "payer_name": "United Healthcare (UHC)", "plan_name": "DSNP", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "United Healthcare (UHC)", "plan_name": "Medicare Advantage", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" } ] } ] }, { "description": "Sho arthrs srg decompression", "code_information": [ { "code": "29826", "type": "HCPCS" } ], "standard_charges": [ { "setting": "outpatient", "payers_information": [ { "payer_name": "United Healthcare (UHC)", "plan_name": "DSNP", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "United Healthcare (UHC)", "plan_name": "Medicare Advantage", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" } ] } ] }, { "description": "Sho arthrs srg rt8tr cuf rpr", "code_information": [ { "code": "29827", "type": "HCPCS" } ], "standard_charges": [ { "setting": "outpatient", "payers_information": [ { "payer_name": "United Healthcare (UHC)", "plan_name": "DSNP", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "United Healthcare (UHC)", "plan_name": "Medicare Advantage", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" } ] } ] }, { "description": "Sho arthrs srg bicp tenodsis", "code_information": [ { "code": "29828", "type": "HCPCS" } ], "standard_charges": [ { "setting": "outpatient", "payers_information": [ { "payer_name": "United Healthcare (UHC)", "plan_name": "DSNP", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "United Healthcare (UHC)", "plan_name": "Medicare Advantage", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" } ] } ] }, { "description": "Knee arthroscopy/surgery", "code_information": [ { "code": "29880", "type": "HCPCS" } ], "standard_charges": [ { "setting": "outpatient", "payers_information": [ { "payer_name": "United Healthcare (UHC)", "plan_name": "DSNP", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "United Healthcare (UHC)", "plan_name": "Medicare Advantage", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" } ] } ] }, { "description": "Knee arthroscopy/surgery", "code_information": [ { "code": "29881", "type": "HCPCS" } ], "standard_charges": [ { "setting": "outpatient", "payers_information": [ { "payer_name": "United Healthcare (UHC)", "plan_name": "DSNP", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "United Healthcare (UHC)", "plan_name": "Medicare Advantage", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" } ] } ] }, { "description": "Excise inferior turbinate", "code_information": [ { "code": "30130", "type": "HCPCS" } ], "standard_charges": [ { "setting": "outpatient", "payers_information": [ { "payer_name": "United Healthcare (UHC)", "plan_name": "DSNP", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "United Healthcare (UHC)", "plan_name": "Medicare Advantage", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" } ] } ] }, { "description": "Resect inferior turbinate", "code_information": [ { "code": "30140", "type": "HCPCS" } ], "standard_charges": [ { "setting": "outpatient", "payers_information": [ { "payer_name": "United Healthcare (UHC)", "plan_name": "DSNP", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "United Healthcare (UHC)", "plan_name": "Medicare Advantage", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" } ] } ] }, { "description": "Repair of nasal septum", "code_information": [ { "code": "30520", "type": "HCPCS" } ], "standard_charges": [ { "setting": "outpatient", "payers_information": [ { "payer_name": "United Healthcare (UHC)", "plan_name": "DSNP", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "United Healthcare (UHC)", "plan_name": "Medicare Advantage", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" } ] } ] }, { "description": "Ablate inf turbinate superf", "code_information": [ { "code": "30801", "type": "HCPCS" } ], "standard_charges": [ { "setting": "outpatient", "payers_information": [ { "payer_name": "United Healthcare (UHC)", "plan_name": "DSNP", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "United Healthcare (UHC)", "plan_name": "Medicare Advantage", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" } ] } ] }, { "description": "Nsl/sins ndsc surg bx polypc", "code_information": [ { "code": "31237", "type": "HCPCS" } ], "standard_charges": [ { "setting": "outpatient", "payers_information": [ { "payer_name": "United Healthcare (UHC)", "plan_name": "DSNP", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "United Healthcare (UHC)", "plan_name": "Medicare Advantage", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" } ] } ] }, { "description": "Nsl/sins ndsc w/prtl ethmdct", "code_information": [ { "code": "31254", "type": "HCPCS" } ], "standard_charges": [ { "setting": "outpatient", "payers_information": [ { "payer_name": "United Healthcare (UHC)", "plan_name": "DSNP", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "United Healthcare (UHC)", "plan_name": "Medicare Advantage", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" } ] } ] }, { "description": "Exploration maxillary sinus", "code_information": [ { "code": "31256", "type": "HCPCS" } ], "standard_charges": [ { "setting": "outpatient", "payers_information": [ { "payer_name": "United Healthcare (UHC)", "plan_name": "DSNP", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "United Healthcare (UHC)", "plan_name": "Medicare Advantage", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" } ] } ] }, { "description": "Nsl/sins ndsc tot w/sphendt", "code_information": [ { "code": "31257", "type": "HCPCS" } ], "standard_charges": [ { "setting": "outpatient", "payers_information": [ { "payer_name": "United Healthcare (UHC)", "plan_name": "DSNP", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "United Healthcare (UHC)", "plan_name": "Medicare Advantage", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" } ] } ] }, { "description": "Nsl/sins ndsc sphn tiss rmvl", "code_information": [ { "code": "31259", "type": "HCPCS" } ], "standard_charges": [ { "setting": "outpatient", "payers_information": [ { "payer_name": "United Healthcare (UHC)", "plan_name": "DSNP", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "United Healthcare (UHC)", "plan_name": "Medicare Advantage", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" } ] } ] }, { "description": "Endoscopy maxillary sinus", "code_information": [ { "code": "31267", "type": "HCPCS" } ], "standard_charges": [ { "setting": "outpatient", "payers_information": [ { "payer_name": "United Healthcare (UHC)", "plan_name": "DSNP", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "United Healthcare (UHC)", "plan_name": "Medicare Advantage", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" } ] } ] }, { "description": "Nsl/sins ndsc frnt tiss rmvl", "code_information": [ { "code": "31276", "type": "HCPCS" } ], "standard_charges": [ { "setting": "outpatient", "payers_information": [ { "payer_name": "United Healthcare (UHC)", "plan_name": "DSNP", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "United Healthcare (UHC)", "plan_name": "Medicare Advantage", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" } ] } ] }, { "description": "Nasal/sinus endoscopy surg", "code_information": [ { "code": "31288", "type": "HCPCS" } ], "standard_charges": [ { "setting": "outpatient", "payers_information": [ { "payer_name": "United Healthcare (UHC)", "plan_name": "DSNP", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "United Healthcare (UHC)", "plan_name": "Medicare Advantage", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" } ] } ] }, { "description": "Insert emergency airway", "code_information": [ { "code": "31500", "type": "HCPCS" } ], "standard_charges": [ { "setting": "outpatient", "payers_information": [ { "payer_name": "United Healthcare (UHC)", "plan_name": "DSNP", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "United Healthcare (UHC)", "plan_name": "Medicare Advantage", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" } ] } ] }, { "description": "Core ndl bx lng/med perq", "code_information": [ { "code": "32408", "type": "HCPCS" } ], "standard_charges": [ { "setting": "outpatient", "payers_information": [ { "payer_name": "United Healthcare (UHC)", "plan_name": "DSNP", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "United Healthcare (UHC)", "plan_name": "Medicare Advantage", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" } ] } ] }, { "description": "Aspirate pleura w/ imaging", "code_information": [ { "code": "32555", "type": "HCPCS" } ], "standard_charges": [ { "setting": "outpatient", "payers_information": [ { "payer_name": "United Healthcare (UHC)", "plan_name": "DSNP", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "United Healthcare (UHC)", "plan_name": "Medicare Advantage", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" } ] } ] }, { "description": "Insert heart pm ventricular", "code_information": [ { "code": "33207", "type": "HCPCS" } ], "standard_charges": [ { "setting": "outpatient", "payers_information": [ { "payer_name": "United Healthcare (UHC)", "plan_name": "DSNP", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "United Healthcare (UHC)", "plan_name": "Medicare Advantage", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" } ] } ] }, { "description": "Remove&replace pm gen singl", "code_information": [ { "code": "33227", "type": "HCPCS" } ], "standard_charges": [ { "setting": "outpatient", "payers_information": [ { "payer_name": "United Healthcare (UHC)", "plan_name": "DSNP", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "United Healthcare (UHC)", "plan_name": "Medicare Advantage", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" } ] } ] }, { "description": "Remv&replc pm gen dual lead", "code_information": [ { "code": "33228", "type": "HCPCS" } ], "standard_charges": [ { "setting": "outpatient", "payers_information": [ { "payer_name": "United Healthcare (UHC)", "plan_name": "DSNP", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "United Healthcare (UHC)", "plan_name": "Medicare Advantage", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" } ] } ] }, { "description": "Place catheter in vein", "code_information": [ { "code": "36012", "type": "HCPCS" } ], "standard_charges": [ { "setting": "outpatient", "payers_information": [ { "payer_name": "United Healthcare (UHC)", "plan_name": "DSNP", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "United Healthcare (UHC)", "plan_name": "Medicare Advantage", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" } ] } ] }, { "description": "Place catheter in aorta", "code_information": [ { "code": "36200", "type": "HCPCS" } ], "standard_charges": [ { "setting": "outpatient", "payers_information": [ { "payer_name": "United Healthcare (UHC)", "plan_name": "DSNP", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "United Healthcare (UHC)", "plan_name": "Medicare Advantage", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" } ] } ] }, { "description": "Place cath subclavian art", "code_information": [ { "code": "36225", "type": "HCPCS" } ], "standard_charges": [ { "setting": "outpatient", "payers_information": [ { "payer_name": "United Healthcare (UHC)", "plan_name": "DSNP", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "United Healthcare (UHC)", "plan_name": "Medicare Advantage", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" } ] } ] }, { "description": "Ins cath abd/l-ext art 3rd", "code_information": [ { "code": "36247", "type": "HCPCS" } ], "standard_charges": [ { "setting": "outpatient", "payers_information": [ { "payer_name": "United Healthcare (UHC)", "plan_name": "DSNP", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "United Healthcare (UHC)", "plan_name": "Medicare Advantage", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" } ] } ] }, { "description": "Ins cath abd/l-ext art addl", "code_information": [ { "code": "36248", "type": "HCPCS" } ], "standard_charges": [ { "setting": "outpatient", "payers_information": [ { "payer_name": "United Healthcare (UHC)", "plan_name": "DSNP", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "United Healthcare (UHC)", "plan_name": "Medicare Advantage", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" } ] } ] }, { "description": "Routine venipuncture", "code_information": [ { "code": "36415", "type": "HCPCS" } ], "standard_charges": [ { "setting": "outpatient", "payers_information": [ { "payer_name": "United Healthcare (UHC)", "plan_name": "DSNP", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "United Healthcare (UHC)", "plan_name": "Medicare Advantage", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" } ] } ] }, { "description": "Transfusion bld/bld compnt", "code_information": [ { "code": "36430", "type": "HCPCS" } ], "standard_charges": [ { "setting": "outpatient", "payers_information": [ { "payer_name": "United Healthcare (UHC)", "plan_name": "DSNP", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "United Healthcare (UHC)", "plan_name": "Medicare Advantage", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" } ] } ] }, { "description": "Intrauterine transfusion ftl", "code_information": [ { "code": "36460", "type": "HCPCS" } ], "standard_charges": [ { "setting": "outpatient", "payers_information": [ { "payer_name": "United Healthcare (UHC)", "plan_name": "DSNP", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "United Healthcare (UHC)", "plan_name": "Medicare Advantage", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" } ] } ] }, { "description": "Apheresis plasma", "code_information": [ { "code": "36514", "type": "HCPCS" } ], "standard_charges": [ { "setting": "outpatient", "payers_information": [ { "payer_name": "United Healthcare (UHC)", "plan_name": "DSNP", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "United Healthcare (UHC)", "plan_name": "Medicare Advantage", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" } ] } ] }, { "description": "Insert non-tunnel cv cath", "code_information": [ { "code": "36556", "type": "HCPCS" } ], "standard_charges": [ { "setting": "outpatient", "payers_information": [ { "payer_name": "United Healthcare (UHC)", "plan_name": "DSNP", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "United Healthcare (UHC)", "plan_name": "Medicare Advantage", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" } ] } ] }, { "description": "Insert tunneled cv cath", "code_information": [ { "code": "36558", "type": "HCPCS" } ], "standard_charges": [ { "setting": "outpatient", "payers_information": [ { "payer_name": "United Healthcare (UHC)", "plan_name": "DSNP", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "United Healthcare (UHC)", "plan_name": "Medicare Advantage", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" } ] } ] }, { "description": "Insert tunneled cv cath", "code_information": [ { "code": "36561", "type": "HCPCS" } ], "standard_charges": [ { "setting": "outpatient", "payers_information": [ { "payer_name": "United Healthcare (UHC)", "plan_name": "DSNP", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "United Healthcare (UHC)", "plan_name": "Medicare Advantage", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" } ] } ] }, { "description": "Insj picc 5 yr+ w/o imaging", "code_information": [ { "code": "36569", "type": "HCPCS" } ], "standard_charges": [ { "setting": "outpatient", "payers_information": [ { "payer_name": "United Healthcare (UHC)", "plan_name": "DSNP", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "United Healthcare (UHC)", "plan_name": "Medicare Advantage", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" } ] } ] }, { "description": "Insj picc rs&i 5 yr+", "code_information": [ { "code": "36573", "type": "HCPCS" } ], "standard_charges": [ { "setting": "outpatient", "payers_information": [ { "payer_name": "United Healthcare (UHC)", "plan_name": "DSNP", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "United Healthcare (UHC)", "plan_name": "Medicare Advantage", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" } ] } ] }, { "description": "Remove intrauterine device", "code_information": [ { "code": "58301", "type": "HCPCS" } ], "standard_charges": [ { "setting": "outpatient", "payers_information": [ { "payer_name": "United Healthcare (UHC)", "plan_name": "DSNP", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "United Healthcare (UHC)", "plan_name": "Medicare Advantage", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" } ] } ] }, { "description": "Laparo-asst vag hysterectomy", "code_information": [ { "code": "58550", "type": "HCPCS" } ], "standard_charges": [ { "setting": "outpatient", "payers_information": [ { "payer_name": "United Healthcare (UHC)", "plan_name": "DSNP", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "United Healthcare (UHC)", "plan_name": "Medicare Advantage", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" } ] } ] }, { "description": "Laparo-vag hyst incl t/o", "code_information": [ { "code": "58552", "type": "HCPCS" } ], "standard_charges": [ { "setting": "outpatient", "payers_information": [ { "payer_name": "United Healthcare (UHC)", "plan_name": "DSNP", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "United Healthcare (UHC)", "plan_name": "Medicare Advantage", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" } ] } ] }, { "description": "Laparo-vag hyst w/t/o compl", "code_information": [ { "code": "58554", "type": "HCPCS" } ], "standard_charges": [ { "setting": "outpatient", "payers_information": [ { "payer_name": "United Healthcare (UHC)", "plan_name": "DSNP", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "United Healthcare (UHC)", "plan_name": "Medicare Advantage", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" } ] } ] }, { "description": "Hysteroscopy biopsy", "code_information": [ { "code": "58558", "type": "HCPCS" } ], "standard_charges": [ { "setting": "outpatient", "payers_information": [ { "payer_name": "United Healthcare (UHC)", "plan_name": "DSNP", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "United Healthcare (UHC)", "plan_name": "Medicare Advantage", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" } ] } ] }, { "description": "Hysteroscopy remove myoma", "code_information": [ { "code": "58561", "type": "HCPCS" } ], "standard_charges": [ { "setting": "outpatient", "payers_information": [ { "payer_name": "United Healthcare (UHC)", "plan_name": "DSNP", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "United Healthcare (UHC)", "plan_name": "Medicare Advantage", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" } ] } ] }, { "description": "Hysteroscopy ablation", "code_information": [ { "code": "58563", "type": "HCPCS" } ], "standard_charges": [ { "setting": "outpatient", "payers_information": [ { "payer_name": "United Healthcare (UHC)", "plan_name": "DSNP", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "United Healthcare (UHC)", "plan_name": "Medicare Advantage", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" } ] } ] }, { "description": "Tlh uterus 250 g or less", "code_information": [ { "code": "58570", "type": "HCPCS" } ], "standard_charges": [ { "setting": "outpatient", "payers_information": [ { "payer_name": "United Healthcare (UHC)", "plan_name": "DSNP", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "United Healthcare (UHC)", "plan_name": "Medicare Advantage", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" } ] } ] }, { "description": "Tlh w/t/o 250 g or less", "code_information": [ { "code": "58571", "type": "HCPCS" } ], "standard_charges": [ { "setting": "outpatient", "payers_information": [ { "payer_name": "United Healthcare (UHC)", "plan_name": "DSNP", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "United Healthcare (UHC)", "plan_name": "Medicare Advantage", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" } ] } ] }, { "description": "Laparoscopy remove adnexa", "code_information": [ { "code": "58661", "type": "HCPCS" } ], "standard_charges": [ { "setting": "outpatient", "payers_information": [ { "payer_name": "United Healthcare (UHC)", "plan_name": "DSNP", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "United Healthcare (UHC)", "plan_name": "Medicare Advantage", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" } ] } ] }, { "description": "Laparoscopy excise lesions", "code_information": [ { "code": "58662", "type": "HCPCS" } ], "standard_charges": [ { "setting": "outpatient", "payers_information": [ { "payer_name": "United Healthcare (UHC)", "plan_name": "DSNP", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "United Healthcare (UHC)", "plan_name": "Medicare Advantage", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" } ] } ] }, { "description": "Rpr aa hrn 1st 3-10 ncr/strn", "code_information": [ { "code": "49594", "type": "HCPCS" } ], "standard_charges": [ { "setting": "outpatient", "payers_information": [ { "payer_name": "United Healthcare (UHC)", "plan_name": "DSNP", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "United Healthcare (UHC)", "plan_name": "Medicare Advantage", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" } ] } ] }, { "description": "Lap ing hernia repair init", "code_information": [ { "code": "49650", "type": "HCPCS" } ], "standard_charges": [ { "setting": "outpatient", "payers_information": [ { "payer_name": "United Healthcare (UHC)", "plan_name": "DSNP", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "United Healthcare (UHC)", "plan_name": "Medicare Advantage", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" } ] } ] }, { "description": "Lap ing hernia repair recur", "code_information": [ { "code": "49651", "type": "HCPCS" } ], "standard_charges": [ { "setting": "outpatient", "payers_information": [ { "payer_name": "United Healthcare (UHC)", "plan_name": "DSNP", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "United Healthcare (UHC)", "plan_name": "Medicare Advantage", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" } ] } ] }, { "description": "Exchange nephrostomy cath", "code_information": [ { "code": "50435", "type": "HCPCS" } ], "standard_charges": [ { "setting": "outpatient", "payers_information": [ { "payer_name": "United Healthcare (UHC)", "plan_name": "DSNP", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "United Healthcare (UHC)", "plan_name": "Medicare Advantage", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" } ] } ] }, { "description": "Laparo partial nephrectomy", "code_information": [ { "code": "50543", "type": "HCPCS" } ], "standard_charges": [ { "setting": "outpatient", "payers_information": [ { "payer_name": "United Healthcare (UHC)", "plan_name": "DSNP", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "United Healthcare (UHC)", "plan_name": "Medicare Advantage", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" } ] } ] }, { "description": "Fragmenting of kidney stone", "code_information": [ { "code": "50590", "type": "HCPCS" } ], "standard_charges": [ { "setting": "outpatient", "payers_information": [ { "payer_name": "United Healthcare (UHC)", "plan_name": "DSNP", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "United Healthcare (UHC)", "plan_name": "Medicare Advantage", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" } ] } ] }, { "description": "Unlisted laps px ureter", "code_information": [ { "code": "50949", "type": "HCPCS" } ], "standard_charges": [ { "setting": "outpatient", "payers_information": [ { "payer_name": "United Healthcare (UHC)", "plan_name": "DSNP", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "United Healthcare (UHC)", "plan_name": "Medicare Advantage", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" } ] } ] }, { "description": "Drain bl w/cath insertion", "code_information": [ { "code": "51102", "type": "HCPCS" } ], "standard_charges": [ { "setting": "outpatient", "payers_information": [ { "payer_name": "United Healthcare (UHC)", "plan_name": "DSNP", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "United Healthcare (UHC)", "plan_name": "Medicare Advantage", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" } ] } ] }, { "description": "Insert temp bladder cath", "code_information": [ { "code": "51702", "type": "HCPCS" } ], "standard_charges": [ { "setting": "outpatient", "payers_information": [ { "payer_name": "United Healthcare (UHC)", "plan_name": "DSNP", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "United Healthcare (UHC)", "plan_name": "Medicare Advantage", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" } ] } ] }, { "description": "Us urine capacity measure", "code_information": [ { "code": "51798", "type": "HCPCS" } ], "standard_charges": [ { "setting": "outpatient", "payers_information": [ { "payer_name": "United Healthcare (UHC)", "plan_name": "DSNP", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "United Healthcare (UHC)", "plan_name": "Medicare Advantage", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" } ] } ] }, { "description": "Cystoscopy w/biopsy(s)", "code_information": [ { "code": "52204", "type": "HCPCS" } ], "standard_charges": [ { "setting": "outpatient", "payers_information": [ { "payer_name": "United Healthcare (UHC)", "plan_name": "DSNP", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "United Healthcare (UHC)", "plan_name": "Medicare Advantage", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" } ] } ] }, { "description": "Cystoscopy and treatment", "code_information": [ { "code": "52224", "type": "HCPCS" } ], "standard_charges": [ { "setting": "outpatient", "payers_information": [ { "payer_name": "United Healthcare (UHC)", "plan_name": "DSNP", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "United Healthcare (UHC)", "plan_name": "Medicare Advantage", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" } ] } ] }, { "description": "Cystoscopy and treatment", "code_information": [ { "code": "52234", "type": "HCPCS" } ], "standard_charges": [ { "setting": "outpatient", "payers_information": [ { "payer_name": "United Healthcare (UHC)", "plan_name": "DSNP", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "United Healthcare (UHC)", "plan_name": "Medicare Advantage", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" } ] } ] }, { "description": "Cystoscopy and treatment", "code_information": [ { "code": "52235", "type": "HCPCS" } ], "standard_charges": [ { "setting": "outpatient", "payers_information": [ { "payer_name": "United Healthcare (UHC)", "plan_name": "DSNP", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "United Healthcare (UHC)", "plan_name": "Medicare Advantage", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" } ] } ] }, { "description": "Cystoscopy and treatment", "code_information": [ { "code": "52240", "type": "HCPCS" } ], "standard_charges": [ { "setting": "outpatient", "payers_information": [ { "payer_name": "United Healthcare (UHC)", "plan_name": "DSNP", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "United Healthcare (UHC)", "plan_name": "Medicare Advantage", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" } ] } ] }, { "description": "Cystoscopy and treatment", "code_information": [ { "code": "52310", "type": "HCPCS" } ], "standard_charges": [ { "setting": "outpatient", "payers_information": [ { "payer_name": "United Healthcare (UHC)", "plan_name": "DSNP", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "United Healthcare (UHC)", "plan_name": "Medicare Advantage", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" } ] } ] }, { "description": "Remove bladder stone", "code_information": [ { "code": "52317", "type": "HCPCS" } ], "standard_charges": [ { "setting": "outpatient", "payers_information": [ { "payer_name": "United Healthcare (UHC)", "plan_name": "DSNP", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "United Healthcare (UHC)", "plan_name": "Medicare Advantage", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" } ] } ] }, { "description": "Cystoscopy and treatment", "code_information": [ { "code": "52332", "type": "HCPCS" } ], "standard_charges": [ { "setting": "outpatient", "payers_information": [ { "payer_name": "United Healthcare (UHC)", "plan_name": "DSNP", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "United Healthcare (UHC)", "plan_name": "Medicare Advantage", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" } ] } ] }, { "description": "Cysto/uretero w/lithotripsy", "code_information": [ { "code": "52356", "type": "HCPCS" } ], "standard_charges": [ { "setting": "outpatient", "payers_information": [ { "payer_name": "United Healthcare (UHC)", "plan_name": "DSNP", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "United Healthcare (UHC)", "plan_name": "Medicare Advantage", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" } ] } ] }, { "description": "Prostatectomy (turp)", "code_information": [ { "code": "52601", "type": "HCPCS" } ], "standard_charges": [ { "setting": "outpatient", "payers_information": [ { "payer_name": "United Healthcare (UHC)", "plan_name": "DSNP", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "United Healthcare (UHC)", "plan_name": "Medicare Advantage", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" } ] } ] }, { "description": "Insert uro/ves nck sphincter", "code_information": [ { "code": "53445", "type": "HCPCS" } ], "standard_charges": [ { "setting": "outpatient", "payers_information": [ { "payer_name": "United Healthcare (UHC)", "plan_name": "DSNP", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "United Healthcare (UHC)", "plan_name": "Medicare Advantage", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" } ] } ] }, { "description": "Circum 28 days or older", "code_information": [ { "code": "54161", "type": "HCPCS" } ], "standard_charges": [ { "setting": "outpatient", "payers_information": [ { "payer_name": "United Healthcare (UHC)", "plan_name": "DSNP", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "United Healthcare (UHC)", "plan_name": "Medicare Advantage", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" } ] } ] }, { "description": "Removal of hydrocele", "code_information": [ { "code": "55040", "type": "HCPCS" } ], "standard_charges": [ { "setting": "outpatient", "payers_information": [ { "payer_name": "United Healthcare (UHC)", "plan_name": "DSNP", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "United Healthcare (UHC)", "plan_name": "Medicare Advantage", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" } ] } ] }, { "description": "Biopsy of prostate", "code_information": [ { "code": "55700", "type": "HCPCS" } ], "standard_charges": [ { "setting": "outpatient", "payers_information": [ { "payer_name": "United Healthcare (UHC)", "plan_name": "DSNP", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "United Healthcare (UHC)", "plan_name": "Medicare Advantage", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" } ] } ] }, { "description": "Abltj mal prst8 tiss hifu", "code_information": [ { "code": "55880", "type": "HCPCS" } ], "standard_charges": [ { "setting": "outpatient", "payers_information": [ { "payer_name": "United Healthcare (UHC)", "plan_name": "DSNP", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "United Healthcare (UHC)", "plan_name": "Medicare Advantage", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" } ] } ] }, { "description": "Cmbn ant pst colprhy", "code_information": [ { "code": "57260", "type": "HCPCS" } ], "standard_charges": [ { "setting": "outpatient", "payers_information": [ { "payer_name": "United Healthcare (UHC)", "plan_name": "DSNP", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "United Healthcare (UHC)", "plan_name": "Medicare Advantage", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" } ] } ] }, { "description": "Repair bladder defect", "code_information": [ { "code": "57288", "type": "HCPCS" } ], "standard_charges": [ { "setting": "outpatient", "payers_information": [ { "payer_name": "United Healthcare (UHC)", "plan_name": "DSNP", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "United Healthcare (UHC)", "plan_name": "Medicare Advantage", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" } ] } ] }, { "description": "Conz of cervix w/scope leep", "code_information": [ { "code": "57461", "type": "HCPCS" } ], "standard_charges": [ { "setting": "outpatient", "payers_information": [ { "payer_name": "United Healthcare (UHC)", "plan_name": "DSNP", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "United Healthcare (UHC)", "plan_name": "Medicare Advantage", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" } ] } ] }, { "description": "Conization of cervix", "code_information": [ { "code": "57522", "type": "HCPCS" } ], "standard_charges": [ { "setting": "outpatient", "payers_information": [ { "payer_name": "United Healthcare (UHC)", "plan_name": "DSNP", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "United Healthcare (UHC)", "plan_name": "Medicare Advantage", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" } ] } ] }, { "description": "Dilation and curettage", "code_information": [ { "code": "58120", "type": "HCPCS" } ], "standard_charges": [ { "setting": "outpatient", "payers_information": [ { "payer_name": "United Healthcare (UHC)", "plan_name": "DSNP", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "United Healthcare (UHC)", "plan_name": "Medicare Advantage", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" } ] } ] }, { "description": "X-ray exam hip uni 4/> views", "code_information": [ { "code": "73503", "type": "HCPCS" } ], "standard_charges": [ { "setting": "outpatient", "payers_information": [ { "payer_name": "United Healthcare (UHC)", "plan_name": "DSNP", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "United Healthcare (UHC)", "plan_name": "Medicare Advantage", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" } ] } ] }, { "description": "X-ray exam hips bi 2 views", "code_information": [ { "code": "73521", "type": "HCPCS" } ], "standard_charges": [ { "setting": "outpatient", "payers_information": [ { "payer_name": "United Healthcare (UHC)", "plan_name": "DSNP", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "United Healthcare (UHC)", "plan_name": "Medicare Advantage", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" } ] } ] }, { "description": "X-ray exam hips bi 3-4 views", "code_information": [ { "code": "73522", "type": "HCPCS" } ], "standard_charges": [ { "setting": "outpatient", "payers_information": [ { "payer_name": "United Healthcare (UHC)", "plan_name": "DSNP", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "United Healthcare (UHC)", "plan_name": "Medicare Advantage", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" } ] } ] }, { "description": "X-ray exam of femur 1", "code_information": [ { "code": "73551", "type": "HCPCS" } ], "standard_charges": [ { "setting": "outpatient", "payers_information": [ { "payer_name": "United Healthcare (UHC)", "plan_name": "DSNP", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "United Healthcare (UHC)", "plan_name": "Medicare Advantage", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" } ] } ] }, { "description": "X-ray exam of femur 2/>", "code_information": [ { "code": "73552", "type": "HCPCS" } ], "standard_charges": [ { "setting": "outpatient", "payers_information": [ { "payer_name": "United Healthcare (UHC)", "plan_name": "DSNP", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "United Healthcare (UHC)", "plan_name": "Medicare Advantage", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" } ] } ] }, { "description": "X-ray exam of knee 1 or 2", "code_information": [ { "code": "73560", "type": "HCPCS" } ], "standard_charges": [ { "setting": "outpatient", "payers_information": [ { "payer_name": "United Healthcare (UHC)", "plan_name": "DSNP", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "National Comp Care", "plan_name": "Workers' Compensation", "standard_charge_percentage": 90, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Coventry Health Care", "plan_name": "Auto Network", "standard_charge_percentage": 90, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Coventry Health Care", "plan_name": "Workers' Compensation", "standard_charge_percentage": 95, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Blue Cross Blue Shield of Montana", "plan_name": "Medicare Advantage", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "United Healthcare (UHC)", "plan_name": "Medicare Advantage", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Allegiance Provider Direct", "plan_name": "Medicare", "standard_charge_percentage": 229.99999999999997, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "PacificSource Health Plans", "plan_name": "PPO (PSN Network and Smart Health Network)", "standard_charge_percentage": 80, "methodology": "percent of total billed charges", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Medicare (CMS)", "plan_name": "Medicare", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "First Choice Health Network fka Health InfoNet", "plan_name": "Commercial", "standard_charge_percentage": 85, "methodology": "percent of total billed charges", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Claritev fka MultiPlan", "plan_name": "Auto Medical Program", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Claritev fka MultiPlan", "plan_name": "Workers' Compensation Program", "standard_charge_percentage": 90, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Claritev fka MultiPlan", "plan_name": "PPO", "standard_charge_percentage": 75, "methodology": "percent of total billed charges", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "First Choice of the Midwest", "plan_name": "PPO", "standard_charge_percentage": 90, "methodology": "percent of total billed charges", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Employee Benefit Management Services (EBMS)", "plan_name": "EBMS SelectCare Network", "standard_charge_percentage": 80, "methodology": "percent of total billed charges", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Medica Insurance Company", "plan_name": "Medicare Cost", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "First Choice Health Network fka Health InfoNet", "plan_name": "Medicare Advantage", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "First Choice Health Network fka Health InfoNet", "plan_name": "Workers Compensation", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Allegiance Provider Direct", "plan_name": "Montana Association of Counties (MACo)", "standard_charge_percentage": 229.99999999999997, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Allegiance Provider Direct", "plan_name": "State of Montana Employee Benefit Plan (Self-Funded)", "standard_charge_percentage": 229.99999999999997, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Allegiance Provider Direct", "plan_name": "Montana Municipal Interlocal Authority (MMIA)", "standard_charge_percentage": 229.99999999999997, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Medicaid (State)", "plan_name": "Medicaid", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Blue Cross Blue Shield of Montana", "plan_name": "HealthLink Network", "standard_charge_percentage": 75, "methodology": "percent of total billed charges", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Blue Cross Blue Shield of Montana", "plan_name": "Traditional Network", "standard_charge_percentage": 75, "methodology": "percent of total billed charges", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Blue Cross Blue Shield of Montana", "plan_name": "POS Network", "standard_charge_percentage": 75, "methodology": "percent of total billed charges", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Blue Cross Blue Shield of Montana", "plan_name": "Closed Plan Network", "standard_charge_percentage": 75, "methodology": "percent of total billed charges", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Blue Cross Blue Shield of Montana", "plan_name": "Retail HMO POS Network", "standard_charge_percentage": 75, "methodology": "percent of total billed charges", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Blue Cross Blue Shield of Montana", "plan_name": "Blue Options Network", "standard_charge_percentage": 75, "methodology": "percent of total billed charges", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "PacificSource Health Plans", "plan_name": "Medicare Advantage", "standard_charge_percentage": 103, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" } ] } ] }, { "description": "X-ray exam of knee 3", "code_information": [ { "code": "73562", "type": "HCPCS" } ], "standard_charges": [ { "setting": "outpatient", "payers_information": [ { "payer_name": "United Healthcare (UHC)", "plan_name": "DSNP", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "United Healthcare (UHC)", "plan_name": "Medicare Advantage", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" } ] } ] }, { "description": "X-ray exam knee 4 or more", "code_information": [ { "code": "73564", "type": "HCPCS" } ], "standard_charges": [ { "setting": "outpatient", "payers_information": [ { "payer_name": "United Healthcare (UHC)", "plan_name": "DSNP", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "United Healthcare (UHC)", "plan_name": "Medicare Advantage", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" } ] } ] }, { "description": "X-ray exam of knees", "code_information": [ { "code": "73565", "type": "HCPCS" } ], "standard_charges": [ { "setting": "outpatient", "payers_information": [ { "payer_name": "United Healthcare (UHC)", "plan_name": "DSNP", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "United Healthcare (UHC)", "plan_name": "Medicare Advantage", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" } ] } ] }, { "description": "X-ray exam of lower leg", "code_information": [ { "code": "73590", "type": "HCPCS" } ], "standard_charges": [ { "setting": "outpatient", "payers_information": [ { "payer_name": "United Healthcare (UHC)", "plan_name": "DSNP", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "United Healthcare (UHC)", "plan_name": "Medicare Advantage", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" } ] } ] }, { "description": "X-ray exam of ankle", "code_information": [ { "code": "73600", "type": "HCPCS" } ], "standard_charges": [ { "setting": "outpatient", "payers_information": [ { "payer_name": "United Healthcare (UHC)", "plan_name": "DSNP", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "United Healthcare (UHC)", "plan_name": "Medicare Advantage", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" } ] } ] }, { "description": "X-ray exam of ankle", "code_information": [ { "code": "73610", "type": "HCPCS" } ], "standard_charges": [ { "setting": "outpatient", "payers_information": [ { "payer_name": "United Healthcare (UHC)", "plan_name": "DSNP", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "National Comp Care", "plan_name": "Workers' Compensation", "standard_charge_percentage": 90, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Coventry Health Care", "plan_name": "Auto Network", "standard_charge_percentage": 90, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Coventry Health Care", "plan_name": "Workers' Compensation", "standard_charge_percentage": 95, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Blue Cross Blue Shield of Montana", "plan_name": "Medicare Advantage", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "United Healthcare (UHC)", "plan_name": "Medicare Advantage", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Allegiance Provider Direct", "plan_name": "Medicare", "standard_charge_percentage": 229.99999999999997, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "PacificSource Health Plans", "plan_name": "PPO (PSN Network and Smart Health Network)", "standard_charge_percentage": 80, "methodology": "percent of total billed charges", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Medicare (CMS)", "plan_name": "Medicare", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "First Choice Health Network fka Health InfoNet", "plan_name": "Commercial", "standard_charge_percentage": 85, "methodology": "percent of total billed charges", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Claritev fka MultiPlan", "plan_name": "Auto Medical Program", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Claritev fka MultiPlan", "plan_name": "Workers' Compensation Program", "standard_charge_percentage": 90, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Claritev fka MultiPlan", "plan_name": "PPO", "standard_charge_percentage": 75, "methodology": "percent of total billed charges", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "First Choice of the Midwest", "plan_name": "PPO", "standard_charge_percentage": 90, "methodology": "percent of total billed charges", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Employee Benefit Management Services (EBMS)", "plan_name": "EBMS SelectCare Network", "standard_charge_percentage": 80, "methodology": "percent of total billed charges", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Medica Insurance Company", "plan_name": "Medicare Cost", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "First Choice Health Network fka Health InfoNet", "plan_name": "Medicare Advantage", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "First Choice Health Network fka Health InfoNet", "plan_name": "Workers Compensation", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Allegiance Provider Direct", "plan_name": "Montana Association of Counties (MACo)", "standard_charge_percentage": 229.99999999999997, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Allegiance Provider Direct", "plan_name": "State of Montana Employee Benefit Plan (Self-Funded)", "standard_charge_percentage": 229.99999999999997, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Allegiance Provider Direct", "plan_name": "Montana Municipal Interlocal Authority (MMIA)", "standard_charge_percentage": 229.99999999999997, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Medicaid (State)", "plan_name": "Medicaid", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Blue Cross Blue Shield of Montana", "plan_name": "HealthLink Network", "standard_charge_percentage": 75, "methodology": "percent of total billed charges", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Blue Cross Blue Shield of Montana", "plan_name": "Traditional Network", "standard_charge_percentage": 75, "methodology": "percent of total billed charges", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Blue Cross Blue Shield of Montana", "plan_name": "POS Network", "standard_charge_percentage": 75, "methodology": "percent of total billed charges", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Blue Cross Blue Shield of Montana", "plan_name": "Closed Plan Network", "standard_charge_percentage": 75, "methodology": "percent of total billed charges", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Blue Cross Blue Shield of Montana", "plan_name": "Retail HMO POS Network", "standard_charge_percentage": 75, "methodology": "percent of total billed charges", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Blue Cross Blue Shield of Montana", "plan_name": "Blue Options Network", "standard_charge_percentage": 75, "methodology": "percent of total billed charges", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "PacificSource Health Plans", "plan_name": "Medicare Advantage", "standard_charge_percentage": 103, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" } ] } ] }, { "description": "X-ray exam of foot", "code_information": [ { "code": "73620", "type": "HCPCS" } ], "standard_charges": [ { "setting": "outpatient", "payers_information": [ { "payer_name": "United Healthcare (UHC)", "plan_name": "DSNP", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "United Healthcare (UHC)", "plan_name": "Medicare Advantage", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" } ] } ] }, { "description": "X-ray exam of foot", "code_information": [ { "code": "73630", "type": "HCPCS" } ], "standard_charges": [ { "setting": "outpatient", "payers_information": [ { "payer_name": "United Healthcare (UHC)", "plan_name": "DSNP", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "United Healthcare (UHC)", "plan_name": "Medicare Advantage", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" } ] } ] }, { "description": "X-ray exam of toe(s)", "code_information": [ { "code": "73660", "type": "HCPCS" } ], "standard_charges": [ { "setting": "outpatient", "payers_information": [ { "payer_name": "United Healthcare (UHC)", "plan_name": "DSNP", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "United Healthcare (UHC)", "plan_name": "Medicare Advantage", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" } ] } ] }, { "description": "Ct lower extremity w/o dye", "code_information": [ { "code": "73700", "type": "HCPCS" } ], "standard_charges": [ { "setting": "outpatient", "payers_information": [ { "payer_name": "United Healthcare (UHC)", "plan_name": "DSNP", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "United Healthcare (UHC)", "plan_name": "Medicare Advantage", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" } ] } ] }, { "description": "Ct lower extremity w/dye", "code_information": [ { "code": "73701", "type": "HCPCS" } ], "standard_charges": [ { "setting": "outpatient", "payers_information": [ { "payer_name": "United Healthcare (UHC)", "plan_name": "DSNP", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "United Healthcare (UHC)", "plan_name": "Medicare Advantage", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" } ] } ] }, { "description": "Mri jnt of lwr extre w/o dye", "code_information": [ { "code": "73721", "type": "HCPCS" } ], "standard_charges": [ { "setting": "outpatient", "payers_information": [ { "payer_name": "United Healthcare (UHC)", "plan_name": "DSNP", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "United Healthcare (UHC)", "plan_name": "Medicare Advantage", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" } ] } ] }, { "description": "X-ray exam abdomen 1 view", "code_information": [ { "code": "74018", "type": "HCPCS" } ], "standard_charges": [ { "setting": "outpatient", "payers_information": [ { "payer_name": "United Healthcare (UHC)", "plan_name": "DSNP", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "National Comp Care", "plan_name": "Workers' Compensation", "standard_charge_percentage": 90, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Coventry Health Care", "plan_name": "Auto Network", "standard_charge_percentage": 90, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Coventry Health Care", "plan_name": "Workers' Compensation", "standard_charge_percentage": 95, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Blue Cross Blue Shield of Montana", "plan_name": "Medicare Advantage", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "United Healthcare (UHC)", "plan_name": "Medicare Advantage", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Allegiance Provider Direct", "plan_name": "Medicare", "standard_charge_percentage": 229.99999999999997, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "PacificSource Health Plans", "plan_name": "PPO (PSN Network and Smart Health Network)", "standard_charge_percentage": 80, "methodology": "percent of total billed charges", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Medicare (CMS)", "plan_name": "Medicare", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "First Choice Health Network fka Health InfoNet", "plan_name": "Commercial", "standard_charge_percentage": 85, "methodology": "percent of total billed charges", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Claritev fka MultiPlan", "plan_name": "Auto Medical Program", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Claritev fka MultiPlan", "plan_name": "Workers' Compensation Program", "standard_charge_percentage": 90, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Claritev fka MultiPlan", "plan_name": "PPO", "standard_charge_percentage": 75, "methodology": "percent of total billed charges", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "First Choice of the Midwest", "plan_name": "PPO", "standard_charge_percentage": 90, "methodology": "percent of total billed charges", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Employee Benefit Management Services (EBMS)", "plan_name": "EBMS SelectCare Network", "standard_charge_percentage": 80, "methodology": "percent of total billed charges", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Medica Insurance Company", "plan_name": "Medicare Cost", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "First Choice Health Network fka Health InfoNet", "plan_name": "Medicare Advantage", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "First Choice Health Network fka Health InfoNet", "plan_name": "Workers Compensation", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Allegiance Provider Direct", "plan_name": "Montana Association of Counties (MACo)", "standard_charge_percentage": 229.99999999999997, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Allegiance Provider Direct", "plan_name": "State of Montana Employee Benefit Plan (Self-Funded)", "standard_charge_percentage": 229.99999999999997, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Allegiance Provider Direct", "plan_name": "Montana Municipal Interlocal Authority (MMIA)", "standard_charge_percentage": 229.99999999999997, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Medicaid (State)", "plan_name": "Medicaid", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Blue Cross Blue Shield of Montana", "plan_name": "HealthLink Network", "standard_charge_percentage": 75, "methodology": "percent of total billed charges", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Blue Cross Blue Shield of Montana", "plan_name": "Traditional Network", "standard_charge_percentage": 75, "methodology": "percent of total billed charges", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Blue Cross Blue Shield of Montana", "plan_name": "POS Network", "standard_charge_percentage": 75, "methodology": "percent of total billed charges", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Blue Cross Blue Shield of Montana", "plan_name": "Closed Plan Network", "standard_charge_percentage": 75, "methodology": "percent of total billed charges", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Blue Cross Blue Shield of Montana", "plan_name": "Retail HMO POS Network", "standard_charge_percentage": 75, "methodology": "percent of total billed charges", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Blue Cross Blue Shield of Montana", "plan_name": "Blue Options Network", "standard_charge_percentage": 75, "methodology": "percent of total billed charges", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "PacificSource Health Plans", "plan_name": "Medicare Advantage", "standard_charge_percentage": 103, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" } ] } ] }, { "description": "X-ray exam complete abdomen", "code_information": [ { "code": "74022", "type": "HCPCS" } ], "standard_charges": [ { "setting": "outpatient", "payers_information": [ { "payer_name": "United Healthcare (UHC)", "plan_name": "DSNP", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "United Healthcare (UHC)", "plan_name": "Medicare Advantage", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" } ] } ] }, { "description": "Ct abdomen w/o dye", "code_information": [ { "code": "74150", "type": "HCPCS" } ], "standard_charges": [ { "setting": "outpatient", "payers_information": [ { "payer_name": "United Healthcare (UHC)", "plan_name": "DSNP", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "United Healthcare (UHC)", "plan_name": "Medicare Advantage", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" } ] } ] }, { "description": "Ct abdomen w/o & w/dye", "code_information": [ { "code": "74170", "type": "HCPCS" } ], "standard_charges": [ { "setting": "outpatient", "payers_information": [ { "payer_name": "United Healthcare (UHC)", "plan_name": "DSNP", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "United Healthcare (UHC)", "plan_name": "Medicare Advantage", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" } ] } ] }, { "description": "Ct angio abd&pelv w/o&w/dye", "code_information": [ { "code": "74174", "type": "HCPCS" } ], "standard_charges": [ { "setting": "outpatient", "payers_information": [ { "payer_name": "United Healthcare (UHC)", "plan_name": "DSNP", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "United Healthcare (UHC)", "plan_name": "Medicare Advantage", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" } ] } ] }, { "description": "Ct angio abdom w/o & w/dye", "code_information": [ { "code": "74175", "type": "HCPCS" } ], "standard_charges": [ { "setting": "outpatient", "payers_information": [ { "payer_name": "United Healthcare (UHC)", "plan_name": "DSNP", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "United Healthcare (UHC)", "plan_name": "Medicare Advantage", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" } ] } ] }, { "description": "Ct abd & pelvis w/o contrast", "code_information": [ { "code": "74176", "type": "HCPCS" } ], "standard_charges": [ { "setting": "outpatient", "payers_information": [ { "payer_name": "United Healthcare (UHC)", "plan_name": "DSNP", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "United Healthcare (UHC)", "plan_name": "Medicare Advantage", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" } ] } ] }, { "description": "Ct abd & pelv w/contrast", "code_information": [ { "code": "74177", "type": "HCPCS" } ], "standard_charges": [ { "setting": "outpatient", "payers_information": [ { "payer_name": "United Healthcare (UHC)", "plan_name": "DSNP", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "National Comp Care", "plan_name": "Workers' Compensation", "standard_charge_percentage": 90, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Coventry Health Care", "plan_name": "Auto Network", "standard_charge_percentage": 90, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Coventry Health Care", "plan_name": "Workers' Compensation", "standard_charge_percentage": 95, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Blue Cross Blue Shield of Montana", "plan_name": "Medicare Advantage", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "United Healthcare (UHC)", "plan_name": "Medicare Advantage", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Allegiance Provider Direct", "plan_name": "Medicare", "standard_charge_percentage": 229.99999999999997, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "PacificSource Health Plans", "plan_name": "PPO (PSN Network and Smart Health Network)", "standard_charge_percentage": 80, "methodology": "percent of total billed charges", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "First Choice Health Network fka Health InfoNet", "plan_name": "Commercial", "standard_charge_percentage": 85, "methodology": "percent of total billed charges", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Medicare (CMS)", "plan_name": "Medicare", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Claritev fka MultiPlan", "plan_name": "Auto Medical Program", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Claritev fka MultiPlan", "plan_name": "Workers' Compensation Program", "standard_charge_percentage": 90, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Claritev fka MultiPlan", "plan_name": "PPO", "standard_charge_percentage": 75, "methodology": "percent of total billed charges", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "First Choice of the Midwest", "plan_name": "PPO", "standard_charge_percentage": 90, "methodology": "percent of total billed charges", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Employee Benefit Management Services (EBMS)", "plan_name": "EBMS SelectCare Network", "standard_charge_percentage": 80, "methodology": "percent of total billed charges", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Medica Insurance Company", "plan_name": "Medicare Cost", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "First Choice Health Network fka Health InfoNet", "plan_name": "Medicare Advantage", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "First Choice Health Network fka Health InfoNet", "plan_name": "Workers Compensation", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Allegiance Provider Direct", "plan_name": "Montana Association of Counties (MACo)", "standard_charge_percentage": 229.99999999999997, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Allegiance Provider Direct", "plan_name": "State of Montana Employee Benefit Plan (Self-Funded)", "standard_charge_percentage": 229.99999999999997, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Allegiance Provider Direct", "plan_name": "Montana Municipal Interlocal Authority (MMIA)", "standard_charge_percentage": 229.99999999999997, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Medicaid (State)", "plan_name": "Medicaid", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Blue Cross Blue Shield of Montana", "plan_name": "HealthLink Network", "standard_charge_percentage": 75, "methodology": "percent of total billed charges", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Blue Cross Blue Shield of Montana", "plan_name": "Traditional Network", "standard_charge_percentage": 75, "methodology": "percent of total billed charges", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Blue Cross Blue Shield of Montana", "plan_name": "POS Network", "standard_charge_percentage": 75, "methodology": "percent of total billed charges", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Blue Cross Blue Shield of Montana", "plan_name": "Closed Plan Network", "standard_charge_percentage": 75, "methodology": "percent of total billed charges", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Blue Cross Blue Shield of Montana", "plan_name": "Retail HMO POS Network", "standard_charge_percentage": 75, "methodology": "percent of total billed charges", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Blue Cross Blue Shield of Montana", "plan_name": "Blue Options Network", "standard_charge_percentage": 75, "methodology": "percent of total billed charges", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "PacificSource Health Plans", "plan_name": "Medicare Advantage", "standard_charge_percentage": 103, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" } ] } ] }, { "description": "Ct abd & pelv 1/> regns", "code_information": [ { "code": "74178", "type": "HCPCS" } ], "standard_charges": [ { "setting": "outpatient", "payers_information": [ { "payer_name": "United Healthcare (UHC)", "plan_name": "DSNP", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "United Healthcare (UHC)", "plan_name": "Medicare Advantage", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" } ] } ] }, { "description": "Mri abdomen w/o dye", "code_information": [ { "code": "74181", "type": "HCPCS" } ], "standard_charges": [ { "setting": "outpatient", "payers_information": [ { "payer_name": "United Healthcare (UHC)", "plan_name": "DSNP", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "United Healthcare (UHC)", "plan_name": "Medicare Advantage", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" } ] } ] }, { "description": "Mri abdomen w/o & w/dye", "code_information": [ { "code": "74183", "type": "HCPCS" } ], "standard_charges": [ { "setting": "outpatient", "payers_information": [ { "payer_name": "United Healthcare (UHC)", "plan_name": "DSNP", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "United Healthcare (UHC)", "plan_name": "Medicare Advantage", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" } ] } ] }, { "description": "X-ray xm swlng funcj c+", "code_information": [ { "code": "74230", "type": "HCPCS" } ], "standard_charges": [ { "setting": "outpatient", "payers_information": [ { "payer_name": "United Healthcare (UHC)", "plan_name": "DSNP", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "United Healthcare (UHC)", "plan_name": "Medicare Advantage", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" } ] } ] }, { "description": "X-ray xm sm int 1cntrst std", "code_information": [ { "code": "74250", "type": "HCPCS" } ], "standard_charges": [ { "setting": "outpatient", "payers_information": [ { "payer_name": "United Healthcare (UHC)", "plan_name": "DSNP", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "United Healthcare (UHC)", "plan_name": "Medicare Advantage", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" } ] } ] }, { "description": "X-ray bile/panc endoscopy", "code_information": [ { "code": "74330", "type": "HCPCS" } ], "standard_charges": [ { "setting": "outpatient", "payers_information": [ { "payer_name": "United Healthcare (UHC)", "plan_name": "DSNP", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "United Healthcare (UHC)", "plan_name": "Medicare Advantage", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" } ] } ] }, { "description": "Ct angio hrt w/3d image", "code_information": [ { "code": "75574", "type": "HCPCS" } ], "standard_charges": [ { "setting": "outpatient", "payers_information": [ { "payer_name": "United Healthcare (UHC)", "plan_name": "DSNP", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "United Healthcare (UHC)", "plan_name": "Medicare Advantage", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" } ] } ] }, { "description": "X-ray aorta leg arteries", "code_information": [ { "code": "75630", "type": "HCPCS" } ], "standard_charges": [ { "setting": "outpatient", "payers_information": [ { "payer_name": "United Healthcare (UHC)", "plan_name": "DSNP", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "United Healthcare (UHC)", "plan_name": "Medicare Advantage", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" } ] } ] }, { "description": "Ct angio abdominal arteries", "code_information": [ { "code": "75635", "type": "HCPCS" } ], "standard_charges": [ { "setting": "outpatient", "payers_information": [ { "payer_name": "United Healthcare (UHC)", "plan_name": "DSNP", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "United Healthcare (UHC)", "plan_name": "Medicare Advantage", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" } ] } ] }, { "description": "Artery x-rays arms/legs", "code_information": [ { "code": "75716", "type": "HCPCS" } ], "standard_charges": [ { "setting": "outpatient", "payers_information": [ { "payer_name": "United Healthcare (UHC)", "plan_name": "DSNP", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "United Healthcare (UHC)", "plan_name": "Medicare Advantage", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" } ] } ] }, { "description": "Artery x-rays abdomen", "code_information": [ { "code": "75726", "type": "HCPCS" } ], "standard_charges": [ { "setting": "outpatient", "payers_information": [ { "payer_name": "United Healthcare (UHC)", "plan_name": "DSNP", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "United Healthcare (UHC)", "plan_name": "Medicare Advantage", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" } ] } ] }, { "description": "Vein x-ray arm/leg", "code_information": [ { "code": "75820", "type": "HCPCS" } ], "standard_charges": [ { "setting": "outpatient", "payers_information": [ { "payer_name": "United Healthcare (UHC)", "plan_name": "DSNP", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "United Healthcare (UHC)", "plan_name": "Medicare Advantage", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" } ] } ] }, { "description": "Vein x-ray arms/legs", "code_information": [ { "code": "75822", "type": "HCPCS" } ], "standard_charges": [ { "setting": "outpatient", "payers_information": [ { "payer_name": "United Healthcare (UHC)", "plan_name": "DSNP", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "United Healthcare (UHC)", "plan_name": "Medicare Advantage", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" } ] } ] }, { "description": "Vein x-ray trunk", "code_information": [ { "code": "75825", "type": "HCPCS" } ], "standard_charges": [ { "setting": "outpatient", "payers_information": [ { "payer_name": "United Healthcare (UHC)", "plan_name": "DSNP", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "United Healthcare (UHC)", "plan_name": "Medicare Advantage", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" } ] } ] }, { "description": "Vein x-ray chest", "code_information": [ { "code": "75827", "type": "HCPCS" } ], "standard_charges": [ { "setting": "outpatient", "payers_information": [ { "payer_name": "United Healthcare (UHC)", "plan_name": "DSNP", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "United Healthcare (UHC)", "plan_name": "Medicare Advantage", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" } ] } ] }, { "description": "Fluoroscopy <1 hr phys/qhp", "code_information": [ { "code": "76000", "type": "HCPCS" } ], "standard_charges": [ { "setting": "outpatient", "payers_information": [ { "payer_name": "United Healthcare (UHC)", "plan_name": "DSNP", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "United Healthcare (UHC)", "plan_name": "Medicare Advantage", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" } ] } ] }, { "description": "X-ray exam surgical specimen", "code_information": [ { "code": "76098", "type": "HCPCS" } ], "standard_charges": [ { "setting": "outpatient", "payers_information": [ { "payer_name": "United Healthcare (UHC)", "plan_name": "DSNP", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "United Healthcare (UHC)", "plan_name": "Medicare Advantage", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" } ] } ] }, { "description": "Cat scan follow-up study", "code_information": [ { "code": "76380", "type": "HCPCS" } ], "standard_charges": [ { "setting": "outpatient", "payers_information": [ { "payer_name": "United Healthcare (UHC)", "plan_name": "DSNP", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "United Healthcare (UHC)", "plan_name": "Medicare Advantage", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" } ] } ] }, { "description": "Echo exam of eye thickness", "code_information": [ { "code": "76514", "type": "HCPCS" } ], "standard_charges": [ { "setting": "outpatient", "payers_information": [ { "payer_name": "United Healthcare (UHC)", "plan_name": "DSNP", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "United Healthcare (UHC)", "plan_name": "Medicare Advantage", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" } ] } ] }, { "description": "Fetal cord puncture prenatal", "code_information": [ { "code": "59012", "type": "HCPCS" } ], "standard_charges": [ { "setting": "outpatient", "payers_information": [ { "payer_name": "United Healthcare (UHC)", "plan_name": "DSNP", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "United Healthcare (UHC)", "plan_name": "Medicare Advantage", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" } ] } ] }, { "description": "Fetal non-stress test", "code_information": [ { "code": "59025", "type": "HCPCS" } ], "standard_charges": [ { "setting": "outpatient", "payers_information": [ { "payer_name": "United Healthcare (UHC)", "plan_name": "DSNP", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "United Healthcare (UHC)", "plan_name": "Medicare Advantage", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" } ] } ] }, { "description": "Care of miscarriage", "code_information": [ { "code": "59820", "type": "HCPCS" } ], "standard_charges": [ { "setting": "outpatient", "payers_information": [ { "payer_name": "United Healthcare (UHC)", "plan_name": "DSNP", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "United Healthcare (UHC)", "plan_name": "Medicare Advantage", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" } ] } ] }, { "description": "Unlisted fetal invas px w/us", "code_information": [ { "code": "59897", "type": "HCPCS" } ], "standard_charges": [ { "setting": "outpatient", "payers_information": [ { "payer_name": "United Healthcare (UHC)", "plan_name": "DSNP", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "United Healthcare (UHC)", "plan_name": "Medicare Advantage", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" } ] } ] }, { "description": "Partial removal of thyroid", "code_information": [ { "code": "60220", "type": "HCPCS" } ], "standard_charges": [ { "setting": "outpatient", "payers_information": [ { "payer_name": "United Healthcare (UHC)", "plan_name": "DSNP", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "United Healthcare (UHC)", "plan_name": "Medicare Advantage", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" } ] } ] }, { "description": "Scan proc cranial extra", "code_information": [ { "code": "61782", "type": "HCPCS" } ], "standard_charges": [ { "setting": "outpatient", "payers_information": [ { "payer_name": "United Healthcare (UHC)", "plan_name": "DSNP", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "United Healthcare (UHC)", "plan_name": "Medicare Advantage", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" } ] } ] }, { "description": "Dx lmbr spi pnxr", "code_information": [ { "code": "62270", "type": "HCPCS" } ], "standard_charges": [ { "setting": "outpatient", "payers_information": [ { "payer_name": "United Healthcare (UHC)", "plan_name": "DSNP", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "United Healthcare (UHC)", "plan_name": "Medicare Advantage", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" } ] } ] }, { "description": "Dx lmbr spi pnxr w/fluor/ct", "code_information": [ { "code": "62328", "type": "HCPCS" } ], "standard_charges": [ { "setting": "outpatient", "payers_information": [ { "payer_name": "United Healthcare (UHC)", "plan_name": "DSNP", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "United Healthcare (UHC)", "plan_name": "Medicare Advantage", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" } ] } ] }, { "description": "Njx aa&/strd other pn/branch", "code_information": [ { "code": "64450", "type": "HCPCS" } ], "standard_charges": [ { "setting": "outpatient", "payers_information": [ { "payer_name": "United Healthcare (UHC)", "plan_name": "DSNP", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "United Healthcare (UHC)", "plan_name": "Medicare Advantage", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" } ] } ] }, { "description": "Revise ulnar nerve at elbow", "code_information": [ { "code": "64718", "type": "HCPCS" } ], "standard_charges": [ { "setting": "outpatient", "payers_information": [ { "payer_name": "United Healthcare (UHC)", "plan_name": "DSNP", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "United Healthcare (UHC)", "plan_name": "Medicare Advantage", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" } ] } ] }, { "description": "Carpal tunnel surgery", "code_information": [ { "code": "64721", "type": "HCPCS" } ], "standard_charges": [ { "setting": "outpatient", "payers_information": [ { "payer_name": "United Healthcare (UHC)", "plan_name": "DSNP", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "United Healthcare (UHC)", "plan_name": "Medicare Advantage", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" } ] } ] }, { "description": "Removal of eye lesion", "code_information": [ { "code": "65426", "type": "HCPCS" } ], "standard_charges": [ { "setting": "outpatient", "payers_information": [ { "payer_name": "United Healthcare (UHC)", "plan_name": "DSNP", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "United Healthcare (UHC)", "plan_name": "Medicare Advantage", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" } ] } ] }, { "description": "Corneal transplant", "code_information": [ { "code": "65730", "type": "HCPCS" } ], "standard_charges": [ { "setting": "outpatient", "payers_information": [ { "payer_name": "United Healthcare (UHC)", "plan_name": "DSNP", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "United Healthcare (UHC)", "plan_name": "Medicare Advantage", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" } ] } ] }, { "description": "Corneal transplant", "code_information": [ { "code": "65755", "type": "HCPCS" } ], "standard_charges": [ { "setting": "outpatient", "payers_information": [ { "payer_name": "United Healthcare (UHC)", "plan_name": "DSNP", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "United Healthcare (UHC)", "plan_name": "Medicare Advantage", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" } ] } ] }, { "description": "Corneal trnspl endothelial", "code_information": [ { "code": "65756", "type": "HCPCS" } ], "standard_charges": [ { "setting": "outpatient", "payers_information": [ { "payer_name": "United Healthcare (UHC)", "plan_name": "DSNP", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "United Healthcare (UHC)", "plan_name": "Medicare Advantage", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" } ] } ] }, { "description": "Relieve inner eye pressure", "code_information": [ { "code": "65820", "type": "HCPCS" } ], "standard_charges": [ { "setting": "outpatient", "payers_information": [ { "payer_name": "United Healthcare (UHC)", "plan_name": "DSNP", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "United Healthcare (UHC)", "plan_name": "Medicare Advantage", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" } ] } ] }, { "description": "Glaucoma surgery", "code_information": [ { "code": "66170", "type": "HCPCS" } ], "standard_charges": [ { "setting": "outpatient", "payers_information": [ { "payer_name": "United Healthcare (UHC)", "plan_name": "DSNP", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "United Healthcare (UHC)", "plan_name": "Medicare Advantage", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" } ] } ] }, { "description": "Aqueous shunt eye w/graft", "code_information": [ { "code": "66180", "type": "HCPCS" } ], "standard_charges": [ { "setting": "outpatient", "payers_information": [ { "payer_name": "United Healthcare (UHC)", "plan_name": "DSNP", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "United Healthcare (UHC)", "plan_name": "Medicare Advantage", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" } ] } ] }, { "description": "Follow-up surgery of eye", "code_information": [ { "code": "66250", "type": "HCPCS" } ], "standard_charges": [ { "setting": "outpatient", "payers_information": [ { "payer_name": "United Healthcare (UHC)", "plan_name": "DSNP", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "United Healthcare (UHC)", "plan_name": "Medicare Advantage", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" } ] } ] }, { "description": "Incision of iris", "code_information": [ { "code": "66500", "type": "HCPCS" } ], "standard_charges": [ { "setting": "outpatient", "payers_information": [ { "payer_name": "United Healthcare (UHC)", "plan_name": "DSNP", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "United Healthcare (UHC)", "plan_name": "Medicare Advantage", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" } ] } ] }, { "description": "Removal of iris", "code_information": [ { "code": "66625", "type": "HCPCS" } ], "standard_charges": [ { "setting": "outpatient", "payers_information": [ { "payer_name": "United Healthcare (UHC)", "plan_name": "DSNP", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "United Healthcare (UHC)", "plan_name": "Medicare Advantage", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" } ] } ] }, { "description": "Removal of iris", "code_information": [ { "code": "66630", "type": "HCPCS" } ], "standard_charges": [ { "setting": "outpatient", "payers_information": [ { "payer_name": "United Healthcare (UHC)", "plan_name": "DSNP", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "United Healthcare (UHC)", "plan_name": "Medicare Advantage", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" } ] } ] }, { "description": "After cataract laser surgery", "code_information": [ { "code": "66821", "type": "HCPCS" } ], "standard_charges": [ { "setting": "outpatient", "payers_information": [ { "payer_name": "United Healthcare (UHC)", "plan_name": "DSNP", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "United Healthcare (UHC)", "plan_name": "Medicare Advantage", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" } ] } ] }, { "description": "Xcapsl ctrc rmvl cplx wo ecp", "code_information": [ { "code": "66982", "type": "HCPCS" } ], "standard_charges": [ { "setting": "outpatient", "payers_information": [ { "payer_name": "United Healthcare (UHC)", "plan_name": "DSNP", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "United Healthcare (UHC)", "plan_name": "Medicare Advantage", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" } ] } ] }, { "description": "Xcapsl ctrc rmvl w/o ecp", "code_information": [ { "code": "66984", "type": "HCPCS" } ], "standard_charges": [ { "setting": "outpatient", "payers_information": [ { "payer_name": "United Healthcare (UHC)", "plan_name": "DSNP", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "United Healthcare (UHC)", "plan_name": "Medicare Advantage", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" } ] } ] }, { "description": "Xcapsl ctrc rmvl insj 1+", "code_information": [ { "code": "66991", "type": "HCPCS" } ], "standard_charges": [ { "setting": "outpatient", "payers_information": [ { "payer_name": "United Healthcare (UHC)", "plan_name": "DSNP", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "United Healthcare (UHC)", "plan_name": "Medicare Advantage", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" } ] } ] }, { "description": "Injection eye drug", "code_information": [ { "code": "67028", "type": "HCPCS" } ], "standard_charges": [ { "setting": "outpatient", "payers_information": [ { "payer_name": "United Healthcare (UHC)", "plan_name": "DSNP", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "United Healthcare (UHC)", "plan_name": "Medicare Advantage", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" } ] } ] }, { "description": "Dstrj extensive retinopathy", "code_information": [ { "code": "67227", "type": "HCPCS" } ], "standard_charges": [ { "setting": "outpatient", "payers_information": [ { "payer_name": "United Healthcare (UHC)", "plan_name": "DSNP", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "United Healthcare (UHC)", "plan_name": "Medicare Advantage", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" } ] } ] }, { "description": "Reinforce/graft eye wall", "code_information": [ { "code": "67255", "type": "HCPCS" } ], "standard_charges": [ { "setting": "outpatient", "payers_information": [ { "payer_name": "United Healthcare (UHC)", "plan_name": "DSNP", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "United Healthcare (UHC)", "plan_name": "Medicare Advantage", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" } ] } ] }, { "description": "Remove eyelid lesion", "code_information": [ { "code": "67800", "type": "HCPCS" } ], "standard_charges": [ { "setting": "outpatient", "payers_information": [ { "payer_name": "United Healthcare (UHC)", "plan_name": "DSNP", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "United Healthcare (UHC)", "plan_name": "Medicare Advantage", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" } ] } ] }, { "description": "Remove impacted ear wax uni", "code_information": [ { "code": "69209", "type": "HCPCS" } ], "standard_charges": [ { "setting": "outpatient", "payers_information": [ { "payer_name": "United Healthcare (UHC)", "plan_name": "DSNP", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "United Healthcare (UHC)", "plan_name": "Medicare Advantage", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" } ] } ] }, { "description": "X-ray exam of nasal bones", "code_information": [ { "code": "70160", "type": "HCPCS" } ], "standard_charges": [ { "setting": "outpatient", "payers_information": [ { "payer_name": "United Healthcare (UHC)", "plan_name": "DSNP", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "United Healthcare (UHC)", "plan_name": "Medicare Advantage", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" } ] } ] }, { "description": "X-ray exam of neck", "code_information": [ { "code": "70360", "type": "HCPCS" } ], "standard_charges": [ { "setting": "outpatient", "payers_information": [ { "payer_name": "United Healthcare (UHC)", "plan_name": "DSNP", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "United Healthcare (UHC)", "plan_name": "Medicare Advantage", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" } ] } ] }, { "description": "Ct head/brain w/o dye", "code_information": [ { "code": "70450", "type": "HCPCS" } ], "standard_charges": [ { "setting": "outpatient", "payers_information": [ { "payer_name": "United Healthcare (UHC)", "plan_name": "DSNP", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "United Healthcare (UHC)", "plan_name": "Medicare Advantage", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" } ] } ] }, { "description": "Ct orbit/ear/fossa w/o dye", "code_information": [ { "code": "70480", "type": "HCPCS" } ], "standard_charges": [ { "setting": "outpatient", "payers_information": [ { "payer_name": "United Healthcare (UHC)", "plan_name": "DSNP", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "United Healthcare (UHC)", "plan_name": "Medicare Advantage", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" } ] } ] }, { "description": "Ct maxillofacial w/o dye", "code_information": [ { "code": "70486", "type": "HCPCS" } ], "standard_charges": [ { "setting": "outpatient", "payers_information": [ { "payer_name": "United Healthcare (UHC)", "plan_name": "DSNP", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "United Healthcare (UHC)", "plan_name": "Medicare Advantage", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" } ] } ] }, { "description": "Ct maxillofacial w/dye", "code_information": [ { "code": "70487", "type": "HCPCS" } ], "standard_charges": [ { "setting": "outpatient", "payers_information": [ { "payer_name": "United Healthcare (UHC)", "plan_name": "DSNP", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "United Healthcare (UHC)", "plan_name": "Medicare Advantage", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" } ] } ] }, { "description": "Ct soft tissue neck w/o dye", "code_information": [ { "code": "70490", "type": "HCPCS" } ], "standard_charges": [ { "setting": "outpatient", "payers_information": [ { "payer_name": "United Healthcare (UHC)", "plan_name": "DSNP", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "United Healthcare (UHC)", "plan_name": "Medicare Advantage", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" } ] } ] }, { "description": "Ct soft tissue neck w/dye", "code_information": [ { "code": "70491", "type": "HCPCS" } ], "standard_charges": [ { "setting": "outpatient", "payers_information": [ { "payer_name": "United Healthcare (UHC)", "plan_name": "DSNP", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "United Healthcare (UHC)", "plan_name": "Medicare Advantage", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" } ] } ] }, { "description": "Ct angiography head", "code_information": [ { "code": "70496", "type": "HCPCS" } ], "standard_charges": [ { "setting": "outpatient", "payers_information": [ { "payer_name": "United Healthcare (UHC)", "plan_name": "DSNP", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "United Healthcare (UHC)", "plan_name": "Medicare Advantage", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" } ] } ] }, { "description": "Ct angiography neck", "code_information": [ { "code": "70498", "type": "HCPCS" } ], "standard_charges": [ { "setting": "outpatient", "payers_information": [ { "payer_name": "United Healthcare (UHC)", "plan_name": "DSNP", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "United Healthcare (UHC)", "plan_name": "Medicare Advantage", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" } ] } ] }, { "description": "Mri brain stem w/o dye", "code_information": [ { "code": "70551", "type": "HCPCS" } ], "standard_charges": [ { "setting": "outpatient", "payers_information": [ { "payer_name": "United Healthcare (UHC)", "plan_name": "DSNP", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "United Healthcare (UHC)", "plan_name": "Medicare Advantage", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" } ] } ] }, { "description": "Mri brain stem w/o & w/dye", "code_information": [ { "code": "70553", "type": "HCPCS" } ], "standard_charges": [ { "setting": "outpatient", "payers_information": [ { "payer_name": "United Healthcare (UHC)", "plan_name": "DSNP", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "United Healthcare (UHC)", "plan_name": "Medicare Advantage", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" } ] } ] }, { "description": "X-ray exam chest 1 view", "code_information": [ { "code": "71045", "type": "HCPCS" } ], "standard_charges": [ { "setting": "outpatient", "payers_information": [ { "payer_name": "United Healthcare (UHC)", "plan_name": "DSNP", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "National Comp Care", "plan_name": "Workers' Compensation", "standard_charge_percentage": 90, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Coventry Health Care", "plan_name": "Auto Network", "standard_charge_percentage": 90, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Coventry Health Care", "plan_name": "Workers' Compensation", "standard_charge_percentage": 95, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "TriWest Healthcare Alliance Corporation", "plan_name": "VA CCN", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Blue Cross Blue Shield of Montana", "plan_name": "Medicare Advantage", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "United Healthcare (UHC)", "plan_name": "Medicare Advantage", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Allegiance Provider Direct", "plan_name": "Medicare", "standard_charge_percentage": 229.99999999999997, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "PacificSource Health Plans", "plan_name": "PPO (PSN Network and Smart Health Network)", "standard_charge_percentage": 80, "methodology": "percent of total billed charges", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "First Choice Health Network fka Health InfoNet", "plan_name": "Commercial", "standard_charge_percentage": 85, "methodology": "percent of total billed charges", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Medicare (CMS)", "plan_name": "Medicare", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Claritev fka MultiPlan", "plan_name": "Workers' Compensation Program", "standard_charge_percentage": 90, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Claritev fka MultiPlan", "plan_name": "Auto Medical Program", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Claritev fka MultiPlan", "plan_name": "PPO", "standard_charge_percentage": 75, "methodology": "percent of total billed charges", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "First Choice of the Midwest", "plan_name": "PPO", "standard_charge_percentage": 90, "methodology": "percent of total billed charges", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Employee Benefit Management Services (EBMS)", "plan_name": "EBMS SelectCare Network", "standard_charge_percentage": 80, "methodology": "percent of total billed charges", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Medica Insurance Company", "plan_name": "Medicare Cost", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "First Choice Health Network fka Health InfoNet", "plan_name": "Medicare Advantage", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "First Choice Health Network fka Health InfoNet", "plan_name": "Workers Compensation", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Allegiance Provider Direct", "plan_name": "Montana Association of Counties (MACo)", "standard_charge_percentage": 229.99999999999997, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Allegiance Provider Direct", "plan_name": "State of Montana Employee Benefit Plan (Self-Funded)", "standard_charge_percentage": 229.99999999999997, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Allegiance Provider Direct", "plan_name": "Montana Municipal Interlocal Authority (MMIA)", "standard_charge_percentage": 229.99999999999997, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Medicaid (State)", "plan_name": "Medicaid", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Blue Cross Blue Shield of Montana", "plan_name": "HealthLink Network", "standard_charge_percentage": 75, "methodology": "percent of total billed charges", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Blue Cross Blue Shield of Montana", "plan_name": "Traditional Network", "standard_charge_percentage": 75, "methodology": "percent of total billed charges", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Blue Cross Blue Shield of Montana", "plan_name": "POS Network", "standard_charge_percentage": 75, "methodology": "percent of total billed charges", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Blue Cross Blue Shield of Montana", "plan_name": "Closed Plan Network", "standard_charge_percentage": 75, "methodology": "percent of total billed charges", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Blue Cross Blue Shield of Montana", "plan_name": "Retail HMO POS Network", "standard_charge_percentage": 75, "methodology": "percent of total billed charges", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Blue Cross Blue Shield of Montana", "plan_name": "Blue Options Network", "standard_charge_percentage": 75, "methodology": "percent of total billed charges", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "PacificSource Health Plans", "plan_name": "Medicare Advantage", "standard_charge_percentage": 103, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" } ] } ] }, { "description": "X-ray exam chest 2 views", "code_information": [ { "code": "71046", "type": "HCPCS" } ], "standard_charges": [ { "setting": "outpatient", "payers_information": [ { "payer_name": "United Healthcare (UHC)", "plan_name": "DSNP", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "National Comp Care", "plan_name": "Workers' Compensation", "standard_charge_percentage": 90, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Coventry Health Care", "plan_name": "Auto Network", "standard_charge_percentage": 90, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Coventry Health Care", "plan_name": "Workers' Compensation", "standard_charge_percentage": 95, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "TriWest Healthcare Alliance Corporation", "plan_name": "VA CCN", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Blue Cross Blue Shield of Montana", "plan_name": "Medicare Advantage", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "United Healthcare (UHC)", "plan_name": "Medicare Advantage", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Allegiance Provider Direct", "plan_name": "Medicare", "standard_charge_percentage": 229.99999999999997, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "PacificSource Health Plans", "plan_name": "PPO (PSN Network and Smart Health Network)", "standard_charge_percentage": 80, "methodology": "percent of total billed charges", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "First Choice Health Network fka Health InfoNet", "plan_name": "Commercial", "standard_charge_percentage": 85, "methodology": "percent of total billed charges", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Medicare (CMS)", "plan_name": "Medicare", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Claritev fka MultiPlan", "plan_name": "Workers' Compensation Program", "standard_charge_percentage": 90, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Claritev fka MultiPlan", "plan_name": "Auto Medical Program", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Claritev fka MultiPlan", "plan_name": "PPO", "standard_charge_percentage": 75, "methodology": "percent of total billed charges", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "First Choice of the Midwest", "plan_name": "PPO", "standard_charge_percentage": 90, "methodology": "percent of total billed charges", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Employee Benefit Management Services (EBMS)", "plan_name": "EBMS SelectCare Network", "standard_charge_percentage": 80, "methodology": "percent of total billed charges", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Medica Insurance Company", "plan_name": "Medicare Cost", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "First Choice Health Network fka Health InfoNet", "plan_name": "Medicare Advantage", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "First Choice Health Network fka Health InfoNet", "plan_name": "Workers Compensation", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Allegiance Provider Direct", "plan_name": "Montana Association of Counties (MACo)", "standard_charge_percentage": 229.99999999999997, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Allegiance Provider Direct", "plan_name": "State of Montana Employee Benefit Plan (Self-Funded)", "standard_charge_percentage": 229.99999999999997, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Allegiance Provider Direct", "plan_name": "Montana Municipal Interlocal Authority (MMIA)", "standard_charge_percentage": 229.99999999999997, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Medicaid (State)", "plan_name": "Medicaid", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Blue Cross Blue Shield of Montana", "plan_name": "HealthLink Network", "standard_charge_percentage": 75, "methodology": "percent of total billed charges", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Blue Cross Blue Shield of Montana", "plan_name": "Traditional Network", "standard_charge_percentage": 75, "methodology": "percent of total billed charges", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Blue Cross Blue Shield of Montana", "plan_name": "POS Network", "standard_charge_percentage": 75, "methodology": "percent of total billed charges", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Blue Cross Blue Shield of Montana", "plan_name": "Closed Plan Network", "standard_charge_percentage": 75, "methodology": "percent of total billed charges", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Blue Cross Blue Shield of Montana", "plan_name": "Retail HMO POS Network", "standard_charge_percentage": 75, "methodology": "percent of total billed charges", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Blue Cross Blue Shield of Montana", "plan_name": "Blue Options Network", "standard_charge_percentage": 75, "methodology": "percent of total billed charges", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "PacificSource Health Plans", "plan_name": "Medicare Advantage", "standard_charge_percentage": 103, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" } ] } ] }, { "description": "X-ray exam ribs uni 2 views", "code_information": [ { "code": "71100", "type": "HCPCS" } ], "standard_charges": [ { "setting": "outpatient", "payers_information": [ { "payer_name": "United Healthcare (UHC)", "plan_name": "DSNP", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "United Healthcare (UHC)", "plan_name": "Medicare Advantage", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" } ] } ] }, { "description": "X-ray exam unilat ribs/chest", "code_information": [ { "code": "71101", "type": "HCPCS" } ], "standard_charges": [ { "setting": "outpatient", "payers_information": [ { "payer_name": "United Healthcare (UHC)", "plan_name": "DSNP", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "United Healthcare (UHC)", "plan_name": "Medicare Advantage", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" } ] } ] }, { "description": "X-ray exam ribs bil 3 views", "code_information": [ { "code": "71110", "type": "HCPCS" } ], "standard_charges": [ { "setting": "outpatient", "payers_information": [ { "payer_name": "United Healthcare (UHC)", "plan_name": "DSNP", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "United Healthcare (UHC)", "plan_name": "Medicare Advantage", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" } ] } ] }, { "description": "X-ray exam ribs/chest4/> vws", "code_information": [ { "code": "71111", "type": "HCPCS" } ], "standard_charges": [ { "setting": "outpatient", "payers_information": [ { "payer_name": "United Healthcare (UHC)", "plan_name": "DSNP", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "United Healthcare (UHC)", "plan_name": "Medicare Advantage", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" } ] } ] }, { "description": "Ct thorax dx c-", "code_information": [ { "code": "71250", "type": "HCPCS" } ], "standard_charges": [ { "setting": "outpatient", "payers_information": [ { "payer_name": "United Healthcare (UHC)", "plan_name": "DSNP", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "United Healthcare (UHC)", "plan_name": "Medicare Advantage", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" } ] } ] }, { "description": "Ct thorax dx c+", "code_information": [ { "code": "71260", "type": "HCPCS" } ], "standard_charges": [ { "setting": "outpatient", "payers_information": [ { "payer_name": "United Healthcare (UHC)", "plan_name": "DSNP", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "United Healthcare (UHC)", "plan_name": "Medicare Advantage", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" } ] } ] }, { "description": "Ct angiography chest", "code_information": [ { "code": "71275", "type": "HCPCS" } ], "standard_charges": [ { "setting": "outpatient", "payers_information": [ { "payer_name": "United Healthcare (UHC)", "plan_name": "DSNP", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "United Healthcare (UHC)", "plan_name": "Medicare Advantage", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" } ] } ] }, { "description": "X-ray exam of spine 1 view", "code_information": [ { "code": "72020", "type": "HCPCS" } ], "standard_charges": [ { "setting": "outpatient", "payers_information": [ { "payer_name": "United Healthcare (UHC)", "plan_name": "DSNP", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "United Healthcare (UHC)", "plan_name": "Medicare Advantage", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" } ] } ] }, { "description": "X-ray exam neck spine 2-3 vw", "code_information": [ { "code": "72040", "type": "HCPCS" } ], "standard_charges": [ { "setting": "outpatient", "payers_information": [ { "payer_name": "United Healthcare (UHC)", "plan_name": "DSNP", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "United Healthcare (UHC)", "plan_name": "Medicare Advantage", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" } ] } ] }, { "description": "X-ray exam neck spine 4/5vws", "code_information": [ { "code": "72050", "type": "HCPCS" } ], "standard_charges": [ { "setting": "outpatient", "payers_information": [ { "payer_name": "United Healthcare (UHC)", "plan_name": "DSNP", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "United Healthcare (UHC)", "plan_name": "Medicare Advantage", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" } ] } ] }, { "description": "X-ray exam thorac spine 2vws", "code_information": [ { "code": "72070", "type": "HCPCS" } ], "standard_charges": [ { "setting": "outpatient", "payers_information": [ { "payer_name": "United Healthcare (UHC)", "plan_name": "DSNP", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "United Healthcare (UHC)", "plan_name": "Medicare Advantage", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" } ] } ] }, { "description": "X-ray exam thorac spine 3vws", "code_information": [ { "code": "72072", "type": "HCPCS" } ], "standard_charges": [ { "setting": "outpatient", "payers_information": [ { "payer_name": "United Healthcare (UHC)", "plan_name": "DSNP", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "United Healthcare (UHC)", "plan_name": "Medicare Advantage", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" } ] } ] }, { "description": "X-ray exam l-s spine 2/3 vws", "code_information": [ { "code": "72100", "type": "HCPCS" } ], "standard_charges": [ { "setting": "outpatient", "payers_information": [ { "payer_name": "United Healthcare (UHC)", "plan_name": "DSNP", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "United Healthcare (UHC)", "plan_name": "Medicare Advantage", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" } ] } ] }, { "description": "X-ray exam l-2 spine 4/>vws", "code_information": [ { "code": "72110", "type": "HCPCS" } ], "standard_charges": [ { "setting": "outpatient", "payers_information": [ { "payer_name": "United Healthcare (UHC)", "plan_name": "DSNP", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "United Healthcare (UHC)", "plan_name": "Medicare Advantage", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" } ] } ] }, { "description": "Ct neck spine w/o dye", "code_information": [ { "code": "72125", "type": "HCPCS" } ], "standard_charges": [ { "setting": "outpatient", "payers_information": [ { "payer_name": "United Healthcare (UHC)", "plan_name": "DSNP", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "United Healthcare (UHC)", "plan_name": "Medicare Advantage", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" } ] } ] }, { "description": "Ct chest spine w/o dye", "code_information": [ { "code": "72128", "type": "HCPCS" } ], "standard_charges": [ { "setting": "outpatient", "payers_information": [ { "payer_name": "United Healthcare (UHC)", "plan_name": "DSNP", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "United Healthcare (UHC)", "plan_name": "Medicare Advantage", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" } ] } ] }, { "description": "Ct lumbar spine w/o dye", "code_information": [ { "code": "72131", "type": "HCPCS" } ], "standard_charges": [ { "setting": "outpatient", "payers_information": [ { "payer_name": "United Healthcare (UHC)", "plan_name": "DSNP", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "United Healthcare (UHC)", "plan_name": "Medicare Advantage", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" } ] } ] }, { "description": "Mri neck spine w/o dye", "code_information": [ { "code": "72141", "type": "HCPCS" } ], "standard_charges": [ { "setting": "outpatient", "payers_information": [ { "payer_name": "United Healthcare (UHC)", "plan_name": "DSNP", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "United Healthcare (UHC)", "plan_name": "Medicare Advantage", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" } ] } ] }, { "description": "Mri chest spine w/o dye", "code_information": [ { "code": "72146", "type": "HCPCS" } ], "standard_charges": [ { "setting": "outpatient", "payers_information": [ { "payer_name": "United Healthcare (UHC)", "plan_name": "DSNP", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "United Healthcare (UHC)", "plan_name": "Medicare Advantage", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" } ] } ] }, { "description": "Mri lumbar spine w/o dye", "code_information": [ { "code": "72148", "type": "HCPCS" } ], "standard_charges": [ { "setting": "outpatient", "payers_information": [ { "payer_name": "United Healthcare (UHC)", "plan_name": "DSNP", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "United Healthcare (UHC)", "plan_name": "Medicare Advantage", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" } ] } ] }, { "description": "Mri neck spine w/o & w/dye", "code_information": [ { "code": "72156", "type": "HCPCS" } ], "standard_charges": [ { "setting": "outpatient", "payers_information": [ { "payer_name": "United Healthcare (UHC)", "plan_name": "DSNP", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "United Healthcare (UHC)", "plan_name": "Medicare Advantage", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" } ] } ] }, { "description": "X-ray exam of pelvis", "code_information": [ { "code": "72170", "type": "HCPCS" } ], "standard_charges": [ { "setting": "outpatient", "payers_information": [ { "payer_name": "United Healthcare (UHC)", "plan_name": "DSNP", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "National Comp Care", "plan_name": "Workers' Compensation", "standard_charge_percentage": 90, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Coventry Health Care", "plan_name": "Auto Network", "standard_charge_percentage": 90, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Coventry Health Care", "plan_name": "Workers' Compensation", "standard_charge_percentage": 95, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Blue Cross Blue Shield of Montana", "plan_name": "Medicare Advantage", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "United Healthcare (UHC)", "plan_name": "Medicare Advantage", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Allegiance Provider Direct", "plan_name": "Medicare", "standard_charge_percentage": 229.99999999999997, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "PacificSource Health Plans", "plan_name": "PPO (PSN Network and Smart Health Network)", "standard_charge_percentage": 80, "methodology": "percent of total billed charges", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Medicare (CMS)", "plan_name": "Medicare", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "First Choice Health Network fka Health InfoNet", "plan_name": "Commercial", "standard_charge_percentage": 85, "methodology": "percent of total billed charges", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Claritev fka MultiPlan", "plan_name": "Auto Medical Program", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Claritev fka MultiPlan", "plan_name": "Workers' Compensation Program", "standard_charge_percentage": 90, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Claritev fka MultiPlan", "plan_name": "PPO", "standard_charge_percentage": 75, "methodology": "percent of total billed charges", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "First Choice of the Midwest", "plan_name": "PPO", "standard_charge_percentage": 90, "methodology": "percent of total billed charges", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Employee Benefit Management Services (EBMS)", "plan_name": "EBMS SelectCare Network", "standard_charge_percentage": 80, "methodology": "percent of total billed charges", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Medica Insurance Company", "plan_name": "Medicare Cost", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "First Choice Health Network fka Health InfoNet", "plan_name": "Medicare Advantage", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "First Choice Health Network fka Health InfoNet", "plan_name": "Workers Compensation", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Allegiance Provider Direct", "plan_name": "Montana Association of Counties (MACo)", "standard_charge_percentage": 229.99999999999997, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Allegiance Provider Direct", "plan_name": "State of Montana Employee Benefit Plan (Self-Funded)", "standard_charge_percentage": 229.99999999999997, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Allegiance Provider Direct", "plan_name": "Montana Municipal Interlocal Authority (MMIA)", "standard_charge_percentage": 229.99999999999997, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Medicaid (State)", "plan_name": "Medicaid", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Blue Cross Blue Shield of Montana", "plan_name": "HealthLink Network", "standard_charge_percentage": 75, "methodology": "percent of total billed charges", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Blue Cross Blue Shield of Montana", "plan_name": "Traditional Network", "standard_charge_percentage": 75, "methodology": "percent of total billed charges", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Blue Cross Blue Shield of Montana", "plan_name": "POS Network", "standard_charge_percentage": 75, "methodology": "percent of total billed charges", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Blue Cross Blue Shield of Montana", "plan_name": "Closed Plan Network", "standard_charge_percentage": 75, "methodology": "percent of total billed charges", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Blue Cross Blue Shield of Montana", "plan_name": "Retail HMO POS Network", "standard_charge_percentage": 75, "methodology": "percent of total billed charges", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Blue Cross Blue Shield of Montana", "plan_name": "Blue Options Network", "standard_charge_percentage": 75, "methodology": "percent of total billed charges", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "PacificSource Health Plans", "plan_name": "Medicare Advantage", "standard_charge_percentage": 103, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" } ] } ] }, { "description": "Ct angiograph pelv w/o&w/dye", "code_information": [ { "code": "72191", "type": "HCPCS" } ], "standard_charges": [ { "setting": "outpatient", "payers_information": [ { "payer_name": "United Healthcare (UHC)", "plan_name": "DSNP", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "United Healthcare (UHC)", "plan_name": "Medicare Advantage", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" } ] } ] }, { "description": "Ct pelvis w/o dye", "code_information": [ { "code": "72192", "type": "HCPCS" } ], "standard_charges": [ { "setting": "outpatient", "payers_information": [ { "payer_name": "United Healthcare (UHC)", "plan_name": "DSNP", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "United Healthcare (UHC)", "plan_name": "Medicare Advantage", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" } ] } ] }, { "description": "Ct pelvis w/dye", "code_information": [ { "code": "72193", "type": "HCPCS" } ], "standard_charges": [ { "setting": "outpatient", "payers_information": [ { "payer_name": "United Healthcare (UHC)", "plan_name": "DSNP", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "United Healthcare (UHC)", "plan_name": "Medicare Advantage", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" } ] } ] }, { "description": "Mri pelvis w/o dye", "code_information": [ { "code": "72195", "type": "HCPCS" } ], "standard_charges": [ { "setting": "outpatient", "payers_information": [ { "payer_name": "United Healthcare (UHC)", "plan_name": "DSNP", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "United Healthcare (UHC)", "plan_name": "Medicare Advantage", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" } ] } ] }, { "description": "Mri pelvis w/o & w/dye", "code_information": [ { "code": "72197", "type": "HCPCS" } ], "standard_charges": [ { "setting": "outpatient", "payers_information": [ { "payer_name": "United Healthcare (UHC)", "plan_name": "DSNP", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "United Healthcare (UHC)", "plan_name": "Medicare Advantage", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" } ] } ] }, { "description": "X-ray exam sacrum tailbone", "code_information": [ { "code": "72220", "type": "HCPCS" } ], "standard_charges": [ { "setting": "outpatient", "payers_information": [ { "payer_name": "United Healthcare (UHC)", "plan_name": "DSNP", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "United Healthcare (UHC)", "plan_name": "Medicare Advantage", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" } ] } ] }, { "description": "X-ray exam of collar bone", "code_information": [ { "code": "73000", "type": "HCPCS" } ], "standard_charges": [ { "setting": "outpatient", "payers_information": [ { "payer_name": "United Healthcare (UHC)", "plan_name": "DSNP", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "United Healthcare (UHC)", "plan_name": "Medicare Advantage", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" } ] } ] }, { "description": "X-ray exam of shoulder", "code_information": [ { "code": "73020", "type": "HCPCS" } ], "standard_charges": [ { "setting": "outpatient", "payers_information": [ { "payer_name": "United Healthcare (UHC)", "plan_name": "DSNP", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "United Healthcare (UHC)", "plan_name": "Medicare Advantage", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" } ] } ] }, { "description": "X-ray exam of shoulder", "code_information": [ { "code": "73030", "type": "HCPCS" } ], "standard_charges": [ { "setting": "outpatient", "payers_information": [ { "payer_name": "United Healthcare (UHC)", "plan_name": "DSNP", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "National Comp Care", "plan_name": "Workers' Compensation", "standard_charge_percentage": 90, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Coventry Health Care", "plan_name": "Auto Network", "standard_charge_percentage": 90, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Coventry Health Care", "plan_name": "Workers' Compensation", "standard_charge_percentage": 95, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Blue Cross Blue Shield of Montana", "plan_name": "Medicare Advantage", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "United Healthcare (UHC)", "plan_name": "Medicare Advantage", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Allegiance Provider Direct", "plan_name": "Medicare", "standard_charge_percentage": 229.99999999999997, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "PacificSource Health Plans", "plan_name": "PPO (PSN Network and Smart Health Network)", "standard_charge_percentage": 80, "methodology": "percent of total billed charges", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Medicare (CMS)", "plan_name": "Medicare", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "First Choice Health Network fka Health InfoNet", "plan_name": "Commercial", "standard_charge_percentage": 85, "methodology": "percent of total billed charges", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Claritev fka MultiPlan", "plan_name": "Auto Medical Program", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Claritev fka MultiPlan", "plan_name": "Workers' Compensation Program", "standard_charge_percentage": 90, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Claritev fka MultiPlan", "plan_name": "PPO", "standard_charge_percentage": 75, "methodology": "percent of total billed charges", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "First Choice of the Midwest", "plan_name": "PPO", "standard_charge_percentage": 90, "methodology": "percent of total billed charges", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Employee Benefit Management Services (EBMS)", "plan_name": "EBMS SelectCare Network", "standard_charge_percentage": 80, "methodology": "percent of total billed charges", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Medica Insurance Company", "plan_name": "Medicare Cost", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "First Choice Health Network fka Health InfoNet", "plan_name": "Medicare Advantage", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "First Choice Health Network fka Health InfoNet", "plan_name": "Workers Compensation", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Allegiance Provider Direct", "plan_name": "Montana Association of Counties (MACo)", "standard_charge_percentage": 229.99999999999997, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Allegiance Provider Direct", "plan_name": "State of Montana Employee Benefit Plan (Self-Funded)", "standard_charge_percentage": 229.99999999999997, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Allegiance Provider Direct", "plan_name": "Montana Municipal Interlocal Authority (MMIA)", "standard_charge_percentage": 229.99999999999997, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Medicaid (State)", "plan_name": "Medicaid", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Blue Cross Blue Shield of Montana", "plan_name": "HealthLink Network", "standard_charge_percentage": 75, "methodology": "percent of total billed charges", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Blue Cross Blue Shield of Montana", "plan_name": "Traditional Network", "standard_charge_percentage": 75, "methodology": "percent of total billed charges", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Blue Cross Blue Shield of Montana", "plan_name": "POS Network", "standard_charge_percentage": 75, "methodology": "percent of total billed charges", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Blue Cross Blue Shield of Montana", "plan_name": "Closed Plan Network", "standard_charge_percentage": 75, "methodology": "percent of total billed charges", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Blue Cross Blue Shield of Montana", "plan_name": "Retail HMO POS Network", "standard_charge_percentage": 75, "methodology": "percent of total billed charges", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Blue Cross Blue Shield of Montana", "plan_name": "Blue Options Network", "standard_charge_percentage": 75, "methodology": "percent of total billed charges", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "PacificSource Health Plans", "plan_name": "Medicare Advantage", "standard_charge_percentage": 103, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" } ] } ] }, { "description": "X-ray exam of humerus", "code_information": [ { "code": "73060", "type": "HCPCS" } ], "standard_charges": [ { "setting": "outpatient", "payers_information": [ { "payer_name": "United Healthcare (UHC)", "plan_name": "DSNP", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "United Healthcare (UHC)", "plan_name": "Medicare Advantage", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" } ] } ] }, { "description": "X-ray exam of elbow", "code_information": [ { "code": "73070", "type": "HCPCS" } ], "standard_charges": [ { "setting": "outpatient", "payers_information": [ { "payer_name": "United Healthcare (UHC)", "plan_name": "DSNP", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "United Healthcare (UHC)", "plan_name": "Medicare Advantage", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" } ] } ] }, { "description": "X-ray exam of elbow", "code_information": [ { "code": "73080", "type": "HCPCS" } ], "standard_charges": [ { "setting": "outpatient", "payers_information": [ { "payer_name": "United Healthcare (UHC)", "plan_name": "DSNP", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "United Healthcare (UHC)", "plan_name": "Medicare Advantage", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" } ] } ] }, { "description": "X-ray exam of forearm", "code_information": [ { "code": "73090", "type": "HCPCS" } ], "standard_charges": [ { "setting": "outpatient", "payers_information": [ { "payer_name": "United Healthcare (UHC)", "plan_name": "DSNP", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "United Healthcare (UHC)", "plan_name": "Medicare Advantage", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" } ] } ] }, { "description": "X-ray exam of wrist", "code_information": [ { "code": "73100", "type": "HCPCS" } ], "standard_charges": [ { "setting": "outpatient", "payers_information": [ { "payer_name": "United Healthcare (UHC)", "plan_name": "DSNP", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "National Comp Care", "plan_name": "Workers' Compensation", "standard_charge_percentage": 90, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Coventry Health Care", "plan_name": "Auto Network", "standard_charge_percentage": 90, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Coventry Health Care", "plan_name": "Workers' Compensation", "standard_charge_percentage": 95, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Blue Cross Blue Shield of Montana", "plan_name": "Medicare Advantage", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "United Healthcare (UHC)", "plan_name": "Medicare Advantage", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Allegiance Provider Direct", "plan_name": "Medicare", "standard_charge_percentage": 229.99999999999997, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "PacificSource Health Plans", "plan_name": "PPO (PSN Network and Smart Health Network)", "standard_charge_percentage": 80, "methodology": "percent of total billed charges", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Medicare (CMS)", "plan_name": "Medicare", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "First Choice Health Network fka Health InfoNet", "plan_name": "Commercial", "standard_charge_percentage": 85, "methodology": "percent of total billed charges", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Claritev fka MultiPlan", "plan_name": "Auto Medical Program", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Claritev fka MultiPlan", "plan_name": "Workers' Compensation Program", "standard_charge_percentage": 90, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Claritev fka MultiPlan", "plan_name": "PPO", "standard_charge_percentage": 75, "methodology": "percent of total billed charges", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "First Choice of the Midwest", "plan_name": "PPO", "standard_charge_percentage": 90, "methodology": "percent of total billed charges", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Employee Benefit Management Services (EBMS)", "plan_name": "EBMS SelectCare Network", "standard_charge_percentage": 80, "methodology": "percent of total billed charges", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Medica Insurance Company", "plan_name": "Medicare Cost", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "First Choice Health Network fka Health InfoNet", "plan_name": "Medicare Advantage", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "First Choice Health Network fka Health InfoNet", "plan_name": "Workers Compensation", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Allegiance Provider Direct", "plan_name": "Montana Association of Counties (MACo)", "standard_charge_percentage": 229.99999999999997, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Allegiance Provider Direct", "plan_name": "State of Montana Employee Benefit Plan (Self-Funded)", "standard_charge_percentage": 229.99999999999997, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Allegiance Provider Direct", "plan_name": "Montana Municipal Interlocal Authority (MMIA)", "standard_charge_percentage": 229.99999999999997, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Medicaid (State)", "plan_name": "Medicaid", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Blue Cross Blue Shield of Montana", "plan_name": "HealthLink Network", "standard_charge_percentage": 75, "methodology": "percent of total billed charges", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Blue Cross Blue Shield of Montana", "plan_name": "Traditional Network", "standard_charge_percentage": 75, "methodology": "percent of total billed charges", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Blue Cross Blue Shield of Montana", "plan_name": "POS Network", "standard_charge_percentage": 75, "methodology": "percent of total billed charges", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Blue Cross Blue Shield of Montana", "plan_name": "Closed Plan Network", "standard_charge_percentage": 75, "methodology": "percent of total billed charges", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Blue Cross Blue Shield of Montana", "plan_name": "Retail HMO POS Network", "standard_charge_percentage": 75, "methodology": "percent of total billed charges", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Blue Cross Blue Shield of Montana", "plan_name": "Blue Options Network", "standard_charge_percentage": 75, "methodology": "percent of total billed charges", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "PacificSource Health Plans", "plan_name": "Medicare Advantage", "standard_charge_percentage": 103, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" } ] } ] }, { "description": "X-ray exam of wrist", "code_information": [ { "code": "73110", "type": "HCPCS" } ], "standard_charges": [ { "setting": "outpatient", "payers_information": [ { "payer_name": "United Healthcare (UHC)", "plan_name": "DSNP", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "United Healthcare (UHC)", "plan_name": "Medicare Advantage", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" } ] } ] }, { "description": "X-ray exam of hand", "code_information": [ { "code": "73120", "type": "HCPCS" } ], "standard_charges": [ { "setting": "outpatient", "payers_information": [ { "payer_name": "United Healthcare (UHC)", "plan_name": "DSNP", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "United Healthcare (UHC)", "plan_name": "Medicare Advantage", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" } ] } ] }, { "description": "X-ray exam of hand", "code_information": [ { "code": "73130", "type": "HCPCS" } ], "standard_charges": [ { "setting": "outpatient", "payers_information": [ { "payer_name": "United Healthcare (UHC)", "plan_name": "DSNP", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "United Healthcare (UHC)", "plan_name": "Medicare Advantage", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" } ] } ] }, { "description": "X-ray exam of finger(s)", "code_information": [ { "code": "73140", "type": "HCPCS" } ], "standard_charges": [ { "setting": "outpatient", "payers_information": [ { "payer_name": "United Healthcare (UHC)", "plan_name": "DSNP", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "United Healthcare (UHC)", "plan_name": "Medicare Advantage", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" } ] } ] }, { "description": "Ct upper extremity w/o dye", "code_information": [ { "code": "73200", "type": "HCPCS" } ], "standard_charges": [ { "setting": "outpatient", "payers_information": [ { "payer_name": "United Healthcare (UHC)", "plan_name": "DSNP", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "United Healthcare (UHC)", "plan_name": "Medicare Advantage", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" } ] } ] }, { "description": "Mri joint upr extrem w/o dye", "code_information": [ { "code": "73221", "type": "HCPCS" } ], "standard_charges": [ { "setting": "outpatient", "payers_information": [ { "payer_name": "United Healthcare (UHC)", "plan_name": "DSNP", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "United Healthcare (UHC)", "plan_name": "Medicare Advantage", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" } ] } ] }, { "description": "X-ray exam hip uni 1 view", "code_information": [ { "code": "73501", "type": "HCPCS" } ], "standard_charges": [ { "setting": "outpatient", "payers_information": [ { "payer_name": "United Healthcare (UHC)", "plan_name": "DSNP", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "United Healthcare (UHC)", "plan_name": "Medicare Advantage", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" } ] } ] }, { "description": "X-ray exam hip uni 2-3 views", "code_information": [ { "code": "73502", "type": "HCPCS" } ], "standard_charges": [ { "setting": "outpatient", "payers_information": [ { "payer_name": "United Healthcare (UHC)", "plan_name": "DSNP", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "United Healthcare (UHC)", "plan_name": "Medicare Advantage", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" } ] } ] }, { "description": "Drug assay salicylate", "code_information": [ { "code": "80179", "type": "HCPCS" } ], "standard_charges": [ { "setting": "outpatient", "payers_information": [ { "payer_name": "United Healthcare (UHC)", "plan_name": "DSNP", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "United Healthcare (UHC)", "plan_name": "Medicare Advantage", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" } ] } ] }, { "description": "Assay of phenobarbital", "code_information": [ { "code": "80184", "type": "HCPCS" } ], "standard_charges": [ { "setting": "outpatient", "payers_information": [ { "payer_name": "United Healthcare (UHC)", "plan_name": "DSNP", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "United Healthcare (UHC)", "plan_name": "Medicare Advantage", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" } ] } ] }, { "description": "Assay of phenytoin total", "code_information": [ { "code": "80185", "type": "HCPCS" } ], "standard_charges": [ { "setting": "outpatient", "payers_information": [ { "payer_name": "United Healthcare (UHC)", "plan_name": "DSNP", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "United Healthcare (UHC)", "plan_name": "Medicare Advantage", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" } ] } ] }, { "description": "Assay of vancomycin", "code_information": [ { "code": "80202", "type": "HCPCS" } ], "standard_charges": [ { "setting": "outpatient", "payers_information": [ { "payer_name": "United Healthcare (UHC)", "plan_name": "DSNP", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "National Comp Care", "plan_name": "Workers' Compensation", "standard_charge_percentage": 90, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Coventry Health Care", "plan_name": "Auto Network", "standard_charge_percentage": 90, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Coventry Health Care", "plan_name": "Workers' Compensation", "standard_charge_percentage": 95, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Blue Cross Blue Shield of Montana", "plan_name": "Medicare Advantage", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "United Healthcare (UHC)", "plan_name": "Medicare Advantage", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Allegiance Provider Direct", "plan_name": "Medicare", "standard_charge_percentage": 229.99999999999997, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "PacificSource Health Plans", "plan_name": "PPO (PSN Network and Smart Health Network)", "standard_charge_percentage": 80, "methodology": "percent of total billed charges", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "First Choice Health Network fka Health InfoNet", "plan_name": "Commercial", "standard_charge_percentage": 85, "methodology": "percent of total billed charges", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Medicare (CMS)", "plan_name": "Medicare", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Claritev fka MultiPlan", "plan_name": "Auto Medical Program", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Claritev fka MultiPlan", "plan_name": "Workers' Compensation Program", "standard_charge_percentage": 90, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Claritev fka MultiPlan", "plan_name": "PPO", "standard_charge_percentage": 75, "methodology": "percent of total billed charges", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "First Choice of the Midwest", "plan_name": "PPO", "standard_charge_percentage": 90, "methodology": "percent of total billed charges", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Employee Benefit Management Services (EBMS)", "plan_name": "EBMS SelectCare Network", "standard_charge_percentage": 80, "methodology": "percent of total billed charges", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Medica Insurance Company", "plan_name": "Medicare Cost", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "First Choice Health Network fka Health InfoNet", "plan_name": "Medicare Advantage", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "First Choice Health Network fka Health InfoNet", "plan_name": "Workers Compensation", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Allegiance Provider Direct", "plan_name": "Montana Association of Counties (MACo)", "standard_charge_percentage": 229.99999999999997, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Allegiance Provider Direct", "plan_name": "State of Montana Employee Benefit Plan (Self-Funded)", "standard_charge_percentage": 229.99999999999997, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Allegiance Provider Direct", "plan_name": "Montana Municipal Interlocal Authority (MMIA)", "standard_charge_percentage": 229.99999999999997, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Medicaid (State)", "plan_name": "Medicaid", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Blue Cross Blue Shield of Montana", "plan_name": "HealthLink Network", "standard_charge_percentage": 75, "methodology": "percent of total billed charges", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Blue Cross Blue Shield of Montana", "plan_name": "Traditional Network", "standard_charge_percentage": 75, "methodology": "percent of total billed charges", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Blue Cross Blue Shield of Montana", "plan_name": "POS Network", "standard_charge_percentage": 75, "methodology": "percent of total billed charges", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Blue Cross Blue Shield of Montana", "plan_name": "Closed Plan Network", "standard_charge_percentage": 75, "methodology": "percent of total billed charges", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Blue Cross Blue Shield of Montana", "plan_name": "Retail HMO POS Network", "standard_charge_percentage": 75, "methodology": "percent of total billed charges", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Blue Cross Blue Shield of Montana", "plan_name": "Blue Options Network", "standard_charge_percentage": 75, "methodology": "percent of total billed charges", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "PacificSource Health Plans", "plan_name": "Medicare Advantage", "standard_charge_percentage": 103, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" } ] } ] }, { "description": "Drug test prsmv dir opt obs", "code_information": [ { "code": "80305", "type": "HCPCS" } ], "standard_charges": [ { "setting": "outpatient", "payers_information": [ { "payer_name": "United Healthcare (UHC)", "plan_name": "DSNP", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "United Healthcare (UHC)", "plan_name": "Medicare Advantage", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" } ] } ] }, { "description": "Drug test prsmv chem anlyzr", "code_information": [ { "code": "80307", "type": "HCPCS" } ], "standard_charges": [ { "setting": "outpatient", "payers_information": [ { "payer_name": "United Healthcare (UHC)", "plan_name": "DSNP", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "United Healthcare (UHC)", "plan_name": "Medicare Advantage", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" } ] } ] }, { "description": "Urinalysis auto w/scope", "code_information": [ { "code": "81001", "type": "HCPCS" } ], "standard_charges": [ { "setting": "outpatient", "payers_information": [ { "payer_name": "United Healthcare (UHC)", "plan_name": "DSNP", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "National Comp Care", "plan_name": "Workers' Compensation", "standard_charge_percentage": 90, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Coventry Health Care", "plan_name": "Auto Network", "standard_charge_percentage": 90, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Coventry Health Care", "plan_name": "Workers' Compensation", "standard_charge_percentage": 95, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Blue Cross Blue Shield of Montana", "plan_name": "Medicare Advantage", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "United Healthcare (UHC)", "plan_name": "Medicare Advantage", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Allegiance Provider Direct", "plan_name": "Medicare", "standard_charge_percentage": 229.99999999999997, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "PacificSource Health Plans", "plan_name": "PPO (PSN Network and Smart Health Network)", "standard_charge_percentage": 80, "methodology": "percent of total billed charges", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Medicare (CMS)", "plan_name": "Medicare", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "First Choice Health Network fka Health InfoNet", "plan_name": "Commercial", "standard_charge_percentage": 85, "methodology": "percent of total billed charges", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Claritev fka MultiPlan", "plan_name": "Auto Medical Program", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Claritev fka MultiPlan", "plan_name": "Workers' Compensation Program", "standard_charge_percentage": 90, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Claritev fka MultiPlan", "plan_name": "PPO", "standard_charge_percentage": 75, "methodology": "percent of total billed charges", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "First Choice of the Midwest", "plan_name": "PPO", "standard_charge_percentage": 90, "methodology": "percent of total billed charges", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Employee Benefit Management Services (EBMS)", "plan_name": "EBMS SelectCare Network", "standard_charge_percentage": 80, "methodology": "percent of total billed charges", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Medica Insurance Company", "plan_name": "Medicare Cost", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "First Choice Health Network fka Health InfoNet", "plan_name": "Medicare Advantage", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "First Choice Health Network fka Health InfoNet", "plan_name": "Workers Compensation", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Allegiance Provider Direct", "plan_name": "Montana Association of Counties (MACo)", "standard_charge_percentage": 229.99999999999997, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Allegiance Provider Direct", "plan_name": "State of Montana Employee Benefit Plan (Self-Funded)", "standard_charge_percentage": 229.99999999999997, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Allegiance Provider Direct", "plan_name": "Montana Municipal Interlocal Authority (MMIA)", "standard_charge_percentage": 229.99999999999997, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Medicaid (State)", "plan_name": "Medicaid", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Blue Cross Blue Shield of Montana", "plan_name": "HealthLink Network", "standard_charge_percentage": 75, "methodology": "percent of total billed charges", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Blue Cross Blue Shield of Montana", "plan_name": "Traditional Network", "standard_charge_percentage": 75, "methodology": "percent of total billed charges", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Blue Cross Blue Shield of Montana", "plan_name": "POS Network", "standard_charge_percentage": 75, "methodology": "percent of total billed charges", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Blue Cross Blue Shield of Montana", "plan_name": "Closed Plan Network", "standard_charge_percentage": 75, "methodology": "percent of total billed charges", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Blue Cross Blue Shield of Montana", "plan_name": "Retail HMO POS Network", "standard_charge_percentage": 75, "methodology": "percent of total billed charges", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Blue Cross Blue Shield of Montana", "plan_name": "Blue Options Network", "standard_charge_percentage": 75, "methodology": "percent of total billed charges", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "PacificSource Health Plans", "plan_name": "Medicare Advantage", "standard_charge_percentage": 103, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" } ] } ] }, { "description": "Urinalysis auto w/o scope", "code_information": [ { "code": "81003", "type": "HCPCS" } ], "standard_charges": [ { "setting": "outpatient", "payers_information": [ { "payer_name": "United Healthcare (UHC)", "plan_name": "DSNP", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "United Healthcare (UHC)", "plan_name": "Medicare Advantage", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" } ] } ] }, { "description": "Microscopic exam of urine", "code_information": [ { "code": "81015", "type": "HCPCS" } ], "standard_charges": [ { "setting": "outpatient", "payers_information": [ { "payer_name": "United Healthcare (UHC)", "plan_name": "DSNP", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "United Healthcare (UHC)", "plan_name": "Medicare Advantage", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" } ] } ] }, { "description": "Urine pregnancy test", "code_information": [ { "code": "81025", "type": "HCPCS" } ], "standard_charges": [ { "setting": "outpatient", "payers_information": [ { "payer_name": "United Healthcare (UHC)", "plan_name": "DSNP", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "United Healthcare (UHC)", "plan_name": "Medicare Advantage", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" } ] } ] }, { "description": "Acetone assay", "code_information": [ { "code": "82010", "type": "HCPCS" } ], "standard_charges": [ { "setting": "outpatient", "payers_information": [ { "payer_name": "United Healthcare (UHC)", "plan_name": "DSNP", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "United Healthcare (UHC)", "plan_name": "Medicare Advantage", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" } ] } ] }, { "description": "Assay of serum albumin", "code_information": [ { "code": "82040", "type": "HCPCS" } ], "standard_charges": [ { "setting": "outpatient", "payers_information": [ { "payer_name": "United Healthcare (UHC)", "plan_name": "DSNP", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "United Healthcare (UHC)", "plan_name": "Medicare Advantage", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" } ] } ] }, { "description": "Intensive Care Unit - General Classification", "code_information": [ { "code": "0200", "type": "RC" } ], "standard_charges": [ { "setting": "inpatient", "payers_information": [ { "payer_name": "PacificSource Health Plans", "plan_name": "PPO (PSN Network and Smart Health Network)", "standard_charge_percentage": 80, "methodology": "percent of total billed charges", "median_amount": 2060.8, "10th_percentile": 2060.8, "90th_percentile": 2060.8, "count": "31" }, { "payer_name": "TriWest Healthcare Alliance Corporation", "plan_name": "VA CCN", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Blue Cross Blue Shield of Montana", "plan_name": "Medicare Advantage", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Claritev fka MultiPlan", "plan_name": "Workers' Compensation Program", "standard_charge_percentage": 90, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "United Healthcare (UHC)", "plan_name": "Medicare Advantage", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "First Choice of the Midwest", "plan_name": "PPO", "standard_charge_percentage": 90, "methodology": "percent of total billed charges", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "United Healthcare (UHC)", "plan_name": "DSNP", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Employee Benefit Management Services (EBMS)", "plan_name": "EBMS SelectCare Network", "standard_charge_percentage": 80, "methodology": "percent of total billed charges", "median_amount": 2060.8, "10th_percentile": 2060.8, "90th_percentile": 2060.8, "count": "37" }, { "payer_name": "Claritev fka MultiPlan", "plan_name": "Auto Medical Program", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Coventry Health Care", "plan_name": "Auto Network", "standard_charge_percentage": 90, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Allegiance Provider Direct", "plan_name": "Medicare", "standard_charge_percentage": 229.99999999999997, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Claritev fka MultiPlan", "plan_name": "PPO", "standard_charge_percentage": 75, "methodology": "percent of total billed charges", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Medica Insurance Company", "plan_name": "Medicare Cost", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Medicare (CMS)", "plan_name": "Medicare", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Indian Health Services (IHS)", "plan_name": "Commercial", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "National Comp Care", "plan_name": "Workers' Compensation", "standard_charge_dollar": 1800, "methodology": "per diem", "median_amount": 1800, "10th_percentile": 1800, "90th_percentile": 1800, "count": "1 through 10" }, { "payer_name": "First Choice Health Network fka Health InfoNet", "plan_name": "Commercial", "standard_charge_percentage": 85, "methodology": "percent of total billed charges", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Humana Insurance Company", "plan_name": "Humana Medicare Advantage HMO", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Humana Insurance Company", "plan_name": "Humana Medicare Advantage PPO", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Humana Insurance Company", "plan_name": "Humana Medicare Advantage PFFS", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "First Choice Health Network fka Health InfoNet", "plan_name": "Workers Compensation", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Allegiance Provider Direct", "plan_name": "State of Montana Employee Benefit Plan (Self-Funded)", "standard_charge_percentage": 229.99999999999997, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Allegiance Provider Direct", "plan_name": "Montana Municipal Interlocal Authority (MMIA)", "standard_charge_percentage": 229.99999999999997, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "United Healthcare (UHC)", "plan_name": "HMO", "standard_charge_dollar": 2060, "methodology": "per diem", "median_amount": 2060, "10th_percentile": 2060, "90th_percentile": 2060, "count": "1 through 10" }, { "payer_name": "United Healthcare (UHC)", "plan_name": "PPO", "standard_charge_dollar": 2060, "methodology": "per diem", "median_amount": 2060, "10th_percentile": 2060, "90th_percentile": 2060, "count": "1 through 10" }, { "payer_name": "United Healthcare (UHC)", "plan_name": "Indemnity", "standard_charge_dollar": 2060, "methodology": "per diem", "median_amount": 2060, "10th_percentile": 2060, "90th_percentile": 2060, "count": "1 through 10" }, { "payer_name": "Allegiance Provider Direct", "plan_name": "Montana Association of Counties (MACo)", "standard_charge_percentage": 229.99999999999997, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "First Choice Health Network fka Health InfoNet", "plan_name": "Medicare Advantage", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Medicaid (State)", "plan_name": "Medicaid", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Allegiance Provider Direct", "plan_name": "PPO", "standard_charge_dollar": 2350, "methodology": "per diem", "median_amount": 2350, "10th_percentile": 2350, "90th_percentile": 2350, "count": "1 through 10" }, { "payer_name": "TriWest Healthcare Alliance Corporation", "plan_name": "TRICARE Prime", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "TriWest Healthcare Alliance Corporation", "plan_name": "TRICARE Select", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Blue Cross Blue Shield of Montana", "plan_name": "HealthLink Network", "standard_charge_percentage": 75, "methodology": "percent of total billed charges", "median_amount": 1932, "10th_percentile": 1932, "90th_percentile": 1932, "count": "149" }, { "payer_name": "Blue Cross Blue Shield of Montana", "plan_name": "Traditional Network", "standard_charge_percentage": 75, "methodology": "percent of total billed charges", "median_amount": 1932, "10th_percentile": 1932, "90th_percentile": 1932, "count": "149" }, { "payer_name": "Blue Cross Blue Shield of Montana", "plan_name": "POS Network", "standard_charge_percentage": 75, "methodology": "percent of total billed charges", "median_amount": 1932, "10th_percentile": 1932, "90th_percentile": 1932, "count": "149" }, { "payer_name": "Blue Cross Blue Shield of Montana", "plan_name": "Closed Plan Network", "standard_charge_percentage": 75, "methodology": "percent of total billed charges", "median_amount": 1932, "10th_percentile": 1932, "90th_percentile": 1932, "count": "149" }, { "payer_name": "Blue Cross Blue Shield of Montana", "plan_name": "Retail HMO POS Network", "standard_charge_percentage": 75, "methodology": "percent of total billed charges", "median_amount": 1932, "10th_percentile": 1932, "90th_percentile": 1932, "count": "149" }, { "payer_name": "Blue Cross Blue Shield of Montana", "plan_name": "Blue Options Network", "standard_charge_percentage": 75, "methodology": "percent of total billed charges", "median_amount": 1932, "10th_percentile": 1932, "90th_percentile": 1932, "count": "149" }, { "payer_name": "Montana Health Cooperative dba Mountain Health Co-Op HPN Product", "plan_name": "MT Connected Care", "standard_charge_dollar": 2525, "methodology": "per diem", "median_amount": 2525, "10th_percentile": 2525, "90th_percentile": 2525, "count": "1 through 10" }, { "payer_name": "Montana Health Cooperative dba Mountain Health Co-Op HPN Product", "plan_name": "MT Access Care", "standard_charge_dollar": 2525, "methodology": "per diem", "median_amount": 2525, "10th_percentile": 2525, "90th_percentile": 2525, "count": "1 through 10" }, { "payer_name": "PacificSource Health Plans", "plan_name": "Medicare Advantage", "standard_charge_percentage": 103, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" } ], "minimum": 1800, "maximum": 2525 } ] }, { "description": "Room & Board - Private (One Bed) - Rehabilitation", "code_information": [ { "code": "0118", "type": "RC" } ], "standard_charges": [ { "setting": "inpatient", "payers_information": [ { "payer_name": "PacificSource Health Plans", "plan_name": "PPO (PSN Network and Smart Health Network)", "standard_charge_percentage": 80, "methodology": "percent of total billed charges", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "TriWest Healthcare Alliance Corporation", "plan_name": "VA CCN", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Blue Cross Blue Shield of Montana", "plan_name": "Medicare Advantage", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Claritev fka MultiPlan", "plan_name": "Workers' Compensation Program", "standard_charge_percentage": 90, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "United Healthcare (UHC)", "plan_name": "Medicare Advantage", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "First Choice of the Midwest", "plan_name": "PPO", "standard_charge_percentage": 90, "methodology": "percent of total billed charges", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "United Healthcare (UHC)", "plan_name": "DSNP", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Employee Benefit Management Services (EBMS)", "plan_name": "EBMS SelectCare Network", "standard_charge_percentage": 80, "methodology": "percent of total billed charges", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Claritev fka MultiPlan", "plan_name": "Auto Medical Program", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Coventry Health Care", "plan_name": "Auto Network", "standard_charge_percentage": 90, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Allegiance Provider Direct", "plan_name": "Medicare", "standard_charge_percentage": 229.99999999999997, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Claritev fka MultiPlan", "plan_name": "PPO", "standard_charge_percentage": 75, "methodology": "percent of total billed charges", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Medica Insurance Company", "plan_name": "Medicare Cost", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Medicare (CMS)", "plan_name": "Medicare", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Indian Health Services (IHS)", "plan_name": "Commercial", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "First Choice Health Network fka Health InfoNet", "plan_name": "Commercial", "standard_charge_percentage": 85, "methodology": "percent of total billed charges", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Humana Insurance Company", "plan_name": "Humana Medicare Advantage HMO", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Humana Insurance Company", "plan_name": "Humana Medicare Advantage PPO", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Humana Insurance Company", "plan_name": "Humana Medicare Advantage PFFS", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "First Choice Health Network fka Health InfoNet", "plan_name": "Workers Compensation", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Allegiance Provider Direct", "plan_name": "State of Montana Employee Benefit Plan (Self-Funded)", "standard_charge_percentage": 229.99999999999997, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Allegiance Provider Direct", "plan_name": "Montana Municipal Interlocal Authority (MMIA)", "standard_charge_percentage": 229.99999999999997, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Allegiance Provider Direct", "plan_name": "Montana Association of Counties (MACo)", "standard_charge_percentage": 229.99999999999997, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "First Choice Health Network fka Health InfoNet", "plan_name": "Medicare Advantage", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "TriWest Healthcare Alliance Corporation", "plan_name": "TRICARE Prime", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "TriWest Healthcare Alliance Corporation", "plan_name": "TRICARE Select", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Blue Cross Blue Shield of Montana", "plan_name": "HealthLink Network", "standard_charge_percentage": 75, "methodology": "percent of total billed charges", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Blue Cross Blue Shield of Montana", "plan_name": "Traditional Network", "standard_charge_percentage": 75, "methodology": "percent of total billed charges", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Blue Cross Blue Shield of Montana", "plan_name": "POS Network", "standard_charge_percentage": 75, "methodology": "percent of total billed charges", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Blue Cross Blue Shield of Montana", "plan_name": "Closed Plan Network", "standard_charge_percentage": 75, "methodology": "percent of total billed charges", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Blue Cross Blue Shield of Montana", "plan_name": "Retail HMO POS Network", "standard_charge_percentage": 75, "methodology": "percent of total billed charges", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Blue Cross Blue Shield of Montana", "plan_name": "Blue Options Network", "standard_charge_percentage": 75, "methodology": "percent of total billed charges", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "PacificSource Health Plans", "plan_name": "Medicare Advantage", "standard_charge_percentage": 103, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" } ] } ] }, { "description": "Microbe susceptible diffuse", "code_information": [ { "code": "87181", "type": "HCPCS" } ], "standard_charges": [ { "setting": "outpatient", "payers_information": [ { "payer_name": "United Healthcare (UHC)", "plan_name": "DSNP", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "United Healthcare (UHC)", "plan_name": "Medicare Advantage", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" } ] } ] }, { "description": "Occupational Therapy - Group Rate", "code_information": [ { "code": "0433", "type": "RC" } ], "standard_charges": [ { "setting": "outpatient", "payers_information": [ { "payer_name": "United Healthcare (UHC)", "plan_name": "DSNP", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "United Healthcare (UHC)", "plan_name": "Medicare Advantage", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Blue Cross Blue Shield of Montana", "plan_name": "HealthLink Network", "standard_charge_percentage": 75, "methodology": "percent of total billed charges", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Blue Cross Blue Shield of Montana", "plan_name": "Traditional Network", "standard_charge_percentage": 75, "methodology": "percent of total billed charges", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Blue Cross Blue Shield of Montana", "plan_name": "POS Network", "standard_charge_percentage": 75, "methodology": "percent of total billed charges", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Blue Cross Blue Shield of Montana", "plan_name": "Closed Plan Network", "standard_charge_percentage": 75, "methodology": "percent of total billed charges", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Blue Cross Blue Shield of Montana", "plan_name": "Retail HMO POS Network", "standard_charge_percentage": 75, "methodology": "percent of total billed charges", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Blue Cross Blue Shield of Montana", "plan_name": "Blue Options Network", "standard_charge_percentage": 75, "methodology": "percent of total billed charges", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" } ] } ] }, { "description": "Occupational Therapy - Evaluation or Reevaluation", "code_information": [ { "code": "0434", "type": "RC" } ], "standard_charges": [ { "setting": "outpatient", "payers_information": [ { "payer_name": "United Healthcare (UHC)", "plan_name": "DSNP", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "National Comp Care", "plan_name": "Workers' Compensation", "standard_charge_dollar": 150, "methodology": "fee schedule", "median_amount": 150, "10th_percentile": 150, "90th_percentile": 150, "count": "1 through 10" }, { "payer_name": "Coventry Health Care", "plan_name": "Auto Network", "standard_charge_percentage": 90, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Coventry Health Care", "plan_name": "Workers' Compensation", "standard_charge_percentage": 95, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "TriWest Healthcare Alliance Corporation", "plan_name": "VA CCN", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Blue Cross Blue Shield of Montana", "plan_name": "Medicare Advantage", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "United Healthcare (UHC)", "plan_name": "Medicare Advantage", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Allegiance Provider Direct", "plan_name": "Medicare", "standard_charge_percentage": 229.99999999999997, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "PacificSource Health Plans", "plan_name": "PPO (PSN Network and Smart Health Network)", "standard_charge_percentage": 80, "methodology": "percent of total billed charges", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Medicare (CMS)", "plan_name": "Medicare", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "First Choice Health Network fka Health InfoNet", "plan_name": "Commercial", "standard_charge_percentage": 85, "methodology": "percent of total billed charges", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Claritev fka MultiPlan", "plan_name": "Auto Medical Program", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Claritev fka MultiPlan", "plan_name": "Workers' Compensation Program", "standard_charge_percentage": 90, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Claritev fka MultiPlan", "plan_name": "PPO", "standard_charge_percentage": 75, "methodology": "percent of total billed charges", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "First Choice of the Midwest", "plan_name": "PPO", "standard_charge_percentage": 90, "methodology": "percent of total billed charges", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Employee Benefit Management Services (EBMS)", "plan_name": "EBMS SelectCare Network", "standard_charge_percentage": 80, "methodology": "percent of total billed charges", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Medica Insurance Company", "plan_name": "Medicare Cost", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "First Choice Health Network fka Health InfoNet", "plan_name": "Medicare Advantage", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "First Choice Health Network fka Health InfoNet", "plan_name": "Workers Compensation", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Allegiance Provider Direct", "plan_name": "Montana Association of Counties (MACo)", "standard_charge_percentage": 229.99999999999997, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Allegiance Provider Direct", "plan_name": "State of Montana Employee Benefit Plan (Self-Funded)", "standard_charge_percentage": 229.99999999999997, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Allegiance Provider Direct", "plan_name": "Montana Municipal Interlocal Authority (MMIA)", "standard_charge_percentage": 229.99999999999997, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Blue Cross Blue Shield of Montana", "plan_name": "HealthLink Network", "standard_charge_percentage": 75, "methodology": "percent of total billed charges", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Blue Cross Blue Shield of Montana", "plan_name": "Traditional Network", "standard_charge_percentage": 75, "methodology": "percent of total billed charges", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Blue Cross Blue Shield of Montana", "plan_name": "POS Network", "standard_charge_percentage": 75, "methodology": "percent of total billed charges", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Blue Cross Blue Shield of Montana", "plan_name": "Closed Plan Network", "standard_charge_percentage": 75, "methodology": "percent of total billed charges", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Blue Cross Blue Shield of Montana", "plan_name": "Retail HMO POS Network", "standard_charge_percentage": 75, "methodology": "percent of total billed charges", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Blue Cross Blue Shield of Montana", "plan_name": "Blue Options Network", "standard_charge_percentage": 75, "methodology": "percent of total billed charges", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Medicaid (State)", "plan_name": "Medicaid", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "PacificSource Health Plans", "plan_name": "Medicare Advantage", "standard_charge_percentage": 103, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" } ], "minimum": 150, "maximum": 150 } ] }, { "description": "Occupational Therapy - Treatment", "code_information": [ { "code": "0435", "type": "RC" } ], "standard_charges": [ { "setting": "outpatient", "payers_information": [ { "payer_name": "United Healthcare (UHC)", "plan_name": "DSNP", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "United Healthcare (UHC)", "plan_name": "Medicare Advantage", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Blue Cross Blue Shield of Montana", "plan_name": "HealthLink Network", "standard_charge_percentage": 75, "methodology": "percent of total billed charges", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Blue Cross Blue Shield of Montana", "plan_name": "Traditional Network", "standard_charge_percentage": 75, "methodology": "percent of total billed charges", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Blue Cross Blue Shield of Montana", "plan_name": "POS Network", "standard_charge_percentage": 75, "methodology": "percent of total billed charges", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Blue Cross Blue Shield of Montana", "plan_name": "Closed Plan Network", "standard_charge_percentage": 75, "methodology": "percent of total billed charges", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Blue Cross Blue Shield of Montana", "plan_name": "Retail HMO POS Network", "standard_charge_percentage": 75, "methodology": "percent of total billed charges", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Blue Cross Blue Shield of Montana", "plan_name": "Blue Options Network", "standard_charge_percentage": 75, "methodology": "percent of total billed charges", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" } ] } ] }, { "description": "Occupational Therapy - Continuation", "code_information": [ { "code": "0436", "type": "RC" } ], "standard_charges": [ { "setting": "outpatient", "payers_information": [ { "payer_name": "United Healthcare (UHC)", "plan_name": "DSNP", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "United Healthcare (UHC)", "plan_name": "Medicare Advantage", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Blue Cross Blue Shield of Montana", "plan_name": "HealthLink Network", "standard_charge_percentage": 75, "methodology": "percent of total billed charges", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Blue Cross Blue Shield of Montana", "plan_name": "Traditional Network", "standard_charge_percentage": 75, "methodology": "percent of total billed charges", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Blue Cross Blue Shield of Montana", "plan_name": "POS Network", "standard_charge_percentage": 75, "methodology": "percent of total billed charges", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Blue Cross Blue Shield of Montana", "plan_name": "Closed Plan Network", "standard_charge_percentage": 75, "methodology": "percent of total billed charges", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Blue Cross Blue Shield of Montana", "plan_name": "Retail HMO POS Network", "standard_charge_percentage": 75, "methodology": "percent of total billed charges", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Blue Cross Blue Shield of Montana", "plan_name": "Blue Options Network", "standard_charge_percentage": 75, "methodology": "percent of total billed charges", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" } ] } ] }, { "description": "Occupational Therapy - Observation/Hourly", "code_information": [ { "code": "0437", "type": "RC" } ], "standard_charges": [ { "setting": "outpatient", "payers_information": [ { "payer_name": "United Healthcare (UHC)", "plan_name": "DSNP", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "United Healthcare (UHC)", "plan_name": "Medicare Advantage", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Blue Cross Blue Shield of Montana", "plan_name": "HealthLink Network", "standard_charge_percentage": 75, "methodology": "percent of total billed charges", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Blue Cross Blue Shield of Montana", "plan_name": "Traditional Network", "standard_charge_percentage": 75, "methodology": "percent of total billed charges", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Blue Cross Blue Shield of Montana", "plan_name": "POS Network", "standard_charge_percentage": 75, "methodology": "percent of total billed charges", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Blue Cross Blue Shield of Montana", "plan_name": "Closed Plan Network", "standard_charge_percentage": 75, "methodology": "percent of total billed charges", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Blue Cross Blue Shield of Montana", "plan_name": "Retail HMO POS Network", "standard_charge_percentage": 75, "methodology": "percent of total billed charges", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Blue Cross Blue Shield of Montana", "plan_name": "Blue Options Network", "standard_charge_percentage": 75, "methodology": "percent of total billed charges", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" } ] } ] }, { "description": "Occupational Therapy - Other", "code_information": [ { "code": "0438", "type": "RC" } ], "standard_charges": [ { "setting": "outpatient", "payers_information": [ { "payer_name": "United Healthcare (UHC)", "plan_name": "DSNP", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "United Healthcare (UHC)", "plan_name": "Medicare Advantage", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Blue Cross Blue Shield of Montana", "plan_name": "HealthLink Network", "standard_charge_percentage": 75, "methodology": "percent of total billed charges", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Blue Cross Blue Shield of Montana", "plan_name": "Traditional Network", "standard_charge_percentage": 75, "methodology": "percent of total billed charges", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Blue Cross Blue Shield of Montana", "plan_name": "POS Network", "standard_charge_percentage": 75, "methodology": "percent of total billed charges", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Blue Cross Blue Shield of Montana", "plan_name": "Closed Plan Network", "standard_charge_percentage": 75, "methodology": "percent of total billed charges", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Blue Cross Blue Shield of Montana", "plan_name": "Retail HMO POS Network", "standard_charge_percentage": 75, "methodology": "percent of total billed charges", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Blue Cross Blue Shield of Montana", "plan_name": "Blue Options Network", "standard_charge_percentage": 75, "methodology": "percent of total billed charges", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" } ] } ] }, { "description": "Occupational Therapy - Other", "code_information": [ { "code": "0439", "type": "RC" } ], "standard_charges": [ { "setting": "outpatient", "payers_information": [ { "payer_name": "United Healthcare (UHC)", "plan_name": "DSNP", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "United Healthcare (UHC)", "plan_name": "Medicare Advantage", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Blue Cross Blue Shield of Montana", "plan_name": "HealthLink Network", "standard_charge_percentage": 75, "methodology": "percent of total billed charges", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Blue Cross Blue Shield of Montana", "plan_name": "Traditional Network", "standard_charge_percentage": 75, "methodology": "percent of total billed charges", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Blue Cross Blue Shield of Montana", "plan_name": "POS Network", "standard_charge_percentage": 75, "methodology": "percent of total billed charges", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Blue Cross Blue Shield of Montana", "plan_name": "Closed Plan Network", "standard_charge_percentage": 75, "methodology": "percent of total billed charges", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Blue Cross Blue Shield of Montana", "plan_name": "Retail HMO POS Network", "standard_charge_percentage": 75, "methodology": "percent of total billed charges", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Blue Cross Blue Shield of Montana", "plan_name": "Blue Options Network", "standard_charge_percentage": 75, "methodology": "percent of total billed charges", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" } ] } ] }, { "description": "Speech Therapy - Language Pathology - General Classification", "code_information": [ { "code": "0440", "type": "RC" } ], "standard_charges": [ { "setting": "outpatient", "payers_information": [ { "payer_name": "United Healthcare (UHC)", "plan_name": "DSNP", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "National Comp Care", "plan_name": "Workers' Compensation", "standard_charge_dollar": 90, "methodology": "fee schedule", "median_amount": 90, "10th_percentile": 90, "90th_percentile": 90, "count": "1 through 10" }, { "payer_name": "Coventry Health Care", "plan_name": "Auto Network", "standard_charge_percentage": 90, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Coventry Health Care", "plan_name": "Workers' Compensation", "standard_charge_percentage": 95, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "TriWest Healthcare Alliance Corporation", "plan_name": "VA CCN", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Blue Cross Blue Shield of Montana", "plan_name": "Medicare Advantage", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "United Healthcare (UHC)", "plan_name": "Medicare Advantage", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Allegiance Provider Direct", "plan_name": "Medicare", "standard_charge_percentage": 229.99999999999997, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "PacificSource Health Plans", "plan_name": "PPO (PSN Network and Smart Health Network)", "standard_charge_percentage": 80, "methodology": "percent of total billed charges", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Medicare (CMS)", "plan_name": "Medicare", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "First Choice Health Network fka Health InfoNet", "plan_name": "Commercial", "standard_charge_percentage": 85, "methodology": "percent of total billed charges", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Claritev fka MultiPlan", "plan_name": "Auto Medical Program", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Claritev fka MultiPlan", "plan_name": "Workers' Compensation Program", "standard_charge_percentage": 90, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Claritev fka MultiPlan", "plan_name": "PPO", "standard_charge_percentage": 75, "methodology": "percent of total billed charges", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "First Choice of the Midwest", "plan_name": "PPO", "standard_charge_percentage": 90, "methodology": "percent of total billed charges", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Employee Benefit Management Services (EBMS)", "plan_name": "EBMS SelectCare Network", "standard_charge_percentage": 80, "methodology": "percent of total billed charges", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Medica Insurance Company", "plan_name": "Medicare Cost", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "First Choice Health Network fka Health InfoNet", "plan_name": "Medicare Advantage", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "First Choice Health Network fka Health InfoNet", "plan_name": "Workers Compensation", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Allegiance Provider Direct", "plan_name": "Montana Association of Counties (MACo)", "standard_charge_percentage": 229.99999999999997, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Allegiance Provider Direct", "plan_name": "State of Montana Employee Benefit Plan (Self-Funded)", "standard_charge_percentage": 229.99999999999997, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Allegiance Provider Direct", "plan_name": "Montana Municipal Interlocal Authority (MMIA)", "standard_charge_percentage": 229.99999999999997, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Blue Cross Blue Shield of Montana", "plan_name": "HealthLink Network", "standard_charge_percentage": 75, "methodology": "percent of total billed charges", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Blue Cross Blue Shield of Montana", "plan_name": "Traditional Network", "standard_charge_percentage": 75, "methodology": "percent of total billed charges", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Blue Cross Blue Shield of Montana", "plan_name": "POS Network", "standard_charge_percentage": 75, "methodology": "percent of total billed charges", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Blue Cross Blue Shield of Montana", "plan_name": "Closed Plan Network", "standard_charge_percentage": 75, "methodology": "percent of total billed charges", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Blue Cross Blue Shield of Montana", "plan_name": "Retail HMO POS Network", "standard_charge_percentage": 75, "methodology": "percent of total billed charges", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Blue Cross Blue Shield of Montana", "plan_name": "Blue Options Network", "standard_charge_percentage": 75, "methodology": "percent of total billed charges", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Medicaid (State)", "plan_name": "Medicaid", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "PacificSource Health Plans", "plan_name": "Medicare Advantage", "standard_charge_percentage": 103, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" } ], "minimum": 90, "maximum": 90 } ] }, { "description": "Speech Therapy - Language Pathology - Visit Charge", "code_information": [ { "code": "0441", "type": "RC" } ], "standard_charges": [ { "setting": "outpatient", "payers_information": [ { "payer_name": "United Healthcare (UHC)", "plan_name": "DSNP", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Blue Cross Blue Shield of Montana", "plan_name": "Medicare Advantage", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "United Healthcare (UHC)", "plan_name": "Medicare Advantage", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Blue Cross Blue Shield of Montana", "plan_name": "HealthLink Network", "standard_charge_percentage": 75, "methodology": "percent of total billed charges", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Blue Cross Blue Shield of Montana", "plan_name": "Traditional Network", "standard_charge_percentage": 75, "methodology": "percent of total billed charges", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Blue Cross Blue Shield of Montana", "plan_name": "POS Network", "standard_charge_percentage": 75, "methodology": "percent of total billed charges", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Blue Cross Blue Shield of Montana", "plan_name": "Closed Plan Network", "standard_charge_percentage": 75, "methodology": "percent of total billed charges", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Blue Cross Blue Shield of Montana", "plan_name": "Retail HMO POS Network", "standard_charge_percentage": 75, "methodology": "percent of total billed charges", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Blue Cross Blue Shield of Montana", "plan_name": "Blue Options Network", "standard_charge_percentage": 75, "methodology": "percent of total billed charges", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" } ] } ] }, { "description": "Speech Therapy - Language Pathology - Hourly Charge", "code_information": [ { "code": "0442", "type": "RC" } ], "standard_charges": [ { "setting": "outpatient", "payers_information": [ { "payer_name": "United Healthcare (UHC)", "plan_name": "DSNP", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "United Healthcare (UHC)", "plan_name": "Medicare Advantage", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Blue Cross Blue Shield of Montana", "plan_name": "HealthLink Network", "standard_charge_percentage": 75, "methodology": "percent of total billed charges", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Blue Cross Blue Shield of Montana", "plan_name": "Traditional Network", "standard_charge_percentage": 75, "methodology": "percent of total billed charges", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Blue Cross Blue Shield of Montana", "plan_name": "POS Network", "standard_charge_percentage": 75, "methodology": "percent of total billed charges", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Blue Cross Blue Shield of Montana", "plan_name": "Closed Plan Network", "standard_charge_percentage": 75, "methodology": "percent of total billed charges", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Blue Cross Blue Shield of Montana", "plan_name": "Retail HMO POS Network", "standard_charge_percentage": 75, "methodology": "percent of total billed charges", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Blue Cross Blue Shield of Montana", "plan_name": "Blue Options Network", "standard_charge_percentage": 75, "methodology": "percent of total billed charges", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" } ] } ] }, { "description": "Speech Therapy - Language Pathology - Group Rate", "code_information": [ { "code": "0443", "type": "RC" } ], "standard_charges": [ { "setting": "outpatient", "payers_information": [ { "payer_name": "United Healthcare (UHC)", "plan_name": "DSNP", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "United Healthcare (UHC)", "plan_name": "Medicare Advantage", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Blue Cross Blue Shield of Montana", "plan_name": "HealthLink Network", "standard_charge_percentage": 75, "methodology": "percent of total billed charges", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Blue Cross Blue Shield of Montana", "plan_name": "Traditional Network", "standard_charge_percentage": 75, "methodology": "percent of total billed charges", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Blue Cross Blue Shield of Montana", "plan_name": "POS Network", "standard_charge_percentage": 75, "methodology": "percent of total billed charges", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Blue Cross Blue Shield of Montana", "plan_name": "Closed Plan Network", "standard_charge_percentage": 75, "methodology": "percent of total billed charges", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Blue Cross Blue Shield of Montana", "plan_name": "Retail HMO POS Network", "standard_charge_percentage": 75, "methodology": "percent of total billed charges", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Blue Cross Blue Shield of Montana", "plan_name": "Blue Options Network", "standard_charge_percentage": 75, "methodology": "percent of total billed charges", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" } ] } ] }, { "description": "Pharmacy - General Classification", "code_information": [ { "code": "0250", "type": "RC" } ], "standard_charges": [ { "setting": "outpatient", "payers_information": [ { "payer_name": "United Healthcare (UHC)", "plan_name": "DSNP", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Blue Cross Blue Shield of Montana", "plan_name": "Medicare Advantage", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "United Healthcare (UHC)", "plan_name": "Medicare Advantage", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" } ] } ] }, { "description": "Pharmacy - Generic Drugs", "code_information": [ { "code": "0251", "type": "RC" } ], "standard_charges": [ { "setting": "outpatient", "payers_information": [ { "payer_name": "United Healthcare (UHC)", "plan_name": "DSNP", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Blue Cross Blue Shield of Montana", "plan_name": "Medicare Advantage", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "United Healthcare (UHC)", "plan_name": "Medicare Advantage", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" } ] } ] }, { "description": "Pharmacy - Non-generic Drugs", "code_information": [ { "code": "0252", "type": "RC" } ], "standard_charges": [ { "setting": "outpatient", "payers_information": [ { "payer_name": "United Healthcare (UHC)", "plan_name": "DSNP", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Blue Cross Blue Shield of Montana", "plan_name": "Medicare Advantage", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "United Healthcare (UHC)", "plan_name": "Medicare Advantage", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" } ] } ] }, { "description": "Pharmacy - Take Home Drugs", "code_information": [ { "code": "0253", "type": "RC" } ], "standard_charges": [ { "setting": "outpatient", "payers_information": [ { "payer_name": "United Healthcare (UHC)", "plan_name": "DSNP", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Blue Cross Blue Shield of Montana", "plan_name": "Medicare Advantage", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "United Healthcare (UHC)", "plan_name": "Medicare Advantage", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" } ] } ] }, { "description": "Pharmacy - Drugs Incident To Other Diagnostic Services", "code_information": [ { "code": "0254", "type": "RC" } ], "standard_charges": [ { "setting": "outpatient", "payers_information": [ { "payer_name": "United Healthcare (UHC)", "plan_name": "DSNP", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "United Healthcare (UHC)", "plan_name": "Medicare Advantage", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" } ] } ] }, { "description": "Pharmacy - Drugs Incident To Radiology", "code_information": [ { "code": "0255", "type": "RC" } ], "standard_charges": [ { "setting": "outpatient", "payers_information": [ { "payer_name": "United Healthcare (UHC)", "plan_name": "DSNP", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "United Healthcare (UHC)", "plan_name": "Medicare Advantage", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" } ] } ] }, { "description": "Pharmacy - Experimental Drugs", "code_information": [ { "code": "0256", "type": "RC" } ], "standard_charges": [ { "setting": "outpatient", "payers_information": [ { "payer_name": "United Healthcare (UHC)", "plan_name": "DSNP", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "United Healthcare (UHC)", "plan_name": "Medicare Advantage", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" } ] } ] }, { "description": "Pharmacy - Nonprescription", "code_information": [ { "code": "0257", "type": "RC" } ], "standard_charges": [ { "setting": "outpatient", "payers_information": [ { "payer_name": "United Healthcare (UHC)", "plan_name": "DSNP", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "United Healthcare (UHC)", "plan_name": "Medicare Advantage", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" } ] } ] }, { "description": "Pharmacy - IV Solutions", "code_information": [ { "code": "0258", "type": "RC" } ], "standard_charges": [ { "setting": "outpatient", "payers_information": [ { "payer_name": "United Healthcare (UHC)", "plan_name": "DSNP", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Blue Cross Blue Shield of Montana", "plan_name": "Medicare Advantage", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "United Healthcare (UHC)", "plan_name": "Medicare Advantage", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" } ] } ] }, { "description": "Pharmacy - Other", "code_information": [ { "code": "0259", "type": "RC" } ], "standard_charges": [ { "setting": "outpatient", "payers_information": [ { "payer_name": "United Healthcare (UHC)", "plan_name": "DSNP", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Blue Cross Blue Shield of Montana", "plan_name": "Medicare Advantage", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "United Healthcare (UHC)", "plan_name": "Medicare Advantage", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" } ] } ] }, { "description": "IV Therapy - General Classification", "code_information": [ { "code": "0260", "type": "RC" } ], "standard_charges": [ { "setting": "outpatient", "payers_information": [ { "payer_name": "United Healthcare (UHC)", "plan_name": "DSNP", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Blue Cross Blue Shield of Montana", "plan_name": "Medicare Advantage", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "United Healthcare (UHC)", "plan_name": "Medicare Advantage", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" } ] } ] }, { "description": "IV Therapy - Infusion Pump", "code_information": [ { "code": "0261", "type": "RC" } ], "standard_charges": [ { "setting": "outpatient", "payers_information": [ { "payer_name": "United Healthcare (UHC)", "plan_name": "DSNP", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Blue Cross Blue Shield of Montana", "plan_name": "Medicare Advantage", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "United Healthcare (UHC)", "plan_name": "Medicare Advantage", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" } ] } ] }, { "description": "IV Therapy/Pharmacy Services", "code_information": [ { "code": "0262", "type": "RC" } ], "standard_charges": [ { "setting": "outpatient", "payers_information": [ { "payer_name": "United Healthcare (UHC)", "plan_name": "DSNP", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Blue Cross Blue Shield of Montana", "plan_name": "Medicare Advantage", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "United Healthcare (UHC)", "plan_name": "Medicare Advantage", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" } ] } ] }, { "description": "IV Therapy/Drug/Supply Delivery", "code_information": [ { "code": "0263", "type": "RC" } ], "standard_charges": [ { "setting": "outpatient", "payers_information": [ { "payer_name": "United Healthcare (UHC)", "plan_name": "DSNP", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Blue Cross Blue Shield of Montana", "plan_name": "Medicare Advantage", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "United Healthcare (UHC)", "plan_name": "Medicare Advantage", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" } ] } ] }, { "description": "IV Therapy/Supplies", "code_information": [ { "code": "0264", "type": "RC" } ], "standard_charges": [ { "setting": "outpatient", "payers_information": [ { "payer_name": "United Healthcare (UHC)", "plan_name": "DSNP", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Blue Cross Blue Shield of Montana", "plan_name": "Medicare Advantage", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "United Healthcare (UHC)", "plan_name": "Medicare Advantage", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" } ] } ] }, { "description": "IV Therapy - Treatment", "code_information": [ { "code": "0265", "type": "RC" } ], "standard_charges": [ { "setting": "outpatient", "payers_information": [ { "payer_name": "United Healthcare (UHC)", "plan_name": "DSNP", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Blue Cross Blue Shield of Montana", "plan_name": "Medicare Advantage", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "United Healthcare (UHC)", "plan_name": "Medicare Advantage", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" } ] } ] }, { "description": "IV Therapy - Continuation", "code_information": [ { "code": "0266", "type": "RC" } ], "standard_charges": [ { "setting": "outpatient", "payers_information": [ { "payer_name": "United Healthcare (UHC)", "plan_name": "DSNP", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Blue Cross Blue Shield of Montana", "plan_name": "Medicare Advantage", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "United Healthcare (UHC)", "plan_name": "Medicare Advantage", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" } ] } ] }, { "description": "IV Therapy - Observation/Hourly", "code_information": [ { "code": "0267", "type": "RC" } ], "standard_charges": [ { "setting": "outpatient", "payers_information": [ { "payer_name": "United Healthcare (UHC)", "plan_name": "DSNP", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Blue Cross Blue Shield of Montana", "plan_name": "Medicare Advantage", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "United Healthcare (UHC)", "plan_name": "Medicare Advantage", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" } ] } ] }, { "description": "IV Therapy - Other", "code_information": [ { "code": "0268", "type": "RC" } ], "standard_charges": [ { "setting": "outpatient", "payers_information": [ { "payer_name": "United Healthcare (UHC)", "plan_name": "DSNP", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Blue Cross Blue Shield of Montana", "plan_name": "Medicare Advantage", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "United Healthcare (UHC)", "plan_name": "Medicare Advantage", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" } ] } ] }, { "description": "IV Therapy - Other", "code_information": [ { "code": "0269", "type": "RC" } ], "standard_charges": [ { "setting": "outpatient", "payers_information": [ { "payer_name": "United Healthcare (UHC)", "plan_name": "DSNP", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Blue Cross Blue Shield of Montana", "plan_name": "Medicare Advantage", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "United Healthcare (UHC)", "plan_name": "Medicare Advantage", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" } ] } ] }, { "description": "Medical/Surgical Supplies and Devices - General Classification", "code_information": [ { "code": "0270", "type": "RC" } ], "standard_charges": [ { "setting": "outpatient", "payers_information": [ { "payer_name": "United Healthcare (UHC)", "plan_name": "DSNP", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Blue Cross Blue Shield of Montana", "plan_name": "Medicare Advantage", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "United Healthcare (UHC)", "plan_name": "Medicare Advantage", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" } ] } ] }, { "description": "Laboratory - General Classification", "code_information": [ { "code": "0300", "type": "RC" } ], "standard_charges": [ { "setting": "outpatient", "payers_information": [ { "payer_name": "United Healthcare (UHC)", "plan_name": "DSNP", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "National Comp Care", "plan_name": "Workers' Compensation", "standard_charge_percentage": 90, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Coventry Health Care", "plan_name": "Auto Network", "standard_charge_percentage": 90, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Coventry Health Care", "plan_name": "Workers' Compensation", "standard_charge_percentage": 95, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "TriWest Healthcare Alliance Corporation", "plan_name": "VA CCN", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Blue Cross Blue Shield of Montana", "plan_name": "Medicare Advantage", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "United Healthcare (UHC)", "plan_name": "Medicare Advantage", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Allegiance Provider Direct", "plan_name": "Medicare", "standard_charge_percentage": 229.99999999999997, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "PacificSource Health Plans", "plan_name": "PPO (PSN Network and Smart Health Network)", "standard_charge_percentage": 80, "methodology": "percent of total billed charges", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "First Choice Health Network fka Health InfoNet", "plan_name": "Commercial", "standard_charge_percentage": 85, "methodology": "percent of total billed charges", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Medicare (CMS)", "plan_name": "Medicare", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Claritev fka MultiPlan", "plan_name": "Auto Medical Program", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Claritev fka MultiPlan", "plan_name": "Workers' Compensation Program", "standard_charge_percentage": 90, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Claritev fka MultiPlan", "plan_name": "PPO", "standard_charge_percentage": 75, "methodology": "percent of total billed charges", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "First Choice of the Midwest", "plan_name": "PPO", "standard_charge_percentage": 90, "methodology": "percent of total billed charges", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Employee Benefit Management Services (EBMS)", "plan_name": "EBMS SelectCare Network", "standard_charge_percentage": 80, "methodology": "percent of total billed charges", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Medica Insurance Company", "plan_name": "Medicare Cost", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "First Choice Health Network fka Health InfoNet", "plan_name": "Medicare Advantage", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "First Choice Health Network fka Health InfoNet", "plan_name": "Workers Compensation", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "United Healthcare (UHC)", "plan_name": "HMO", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "United Healthcare (UHC)", "plan_name": "PPO", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "United Healthcare (UHC)", "plan_name": "Indemnity", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Allegiance Provider Direct", "plan_name": "Montana Association of Counties (MACo)", "standard_charge_percentage": 229.99999999999997, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Allegiance Provider Direct", "plan_name": "State of Montana Employee Benefit Plan (Self-Funded)", "standard_charge_percentage": 229.99999999999997, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Allegiance Provider Direct", "plan_name": "Montana Municipal Interlocal Authority (MMIA)", "standard_charge_percentage": 229.99999999999997, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Blue Cross Blue Shield of Montana", "plan_name": "HealthLink Network", "standard_charge_percentage": 75, "methodology": "percent of total billed charges", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Blue Cross Blue Shield of Montana", "plan_name": "Traditional Network", "standard_charge_percentage": 75, "methodology": "percent of total billed charges", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Blue Cross Blue Shield of Montana", "plan_name": "POS Network", "standard_charge_percentage": 75, "methodology": "percent of total billed charges", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Blue Cross Blue Shield of Montana", "plan_name": "Closed Plan Network", "standard_charge_percentage": 75, "methodology": "percent of total billed charges", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Blue Cross Blue Shield of Montana", "plan_name": "Retail HMO POS Network", "standard_charge_percentage": 75, "methodology": "percent of total billed charges", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Blue Cross Blue Shield of Montana", "plan_name": "Blue Options Network", "standard_charge_percentage": 75, "methodology": "percent of total billed charges", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Medicaid (State)", "plan_name": "Medicaid", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "PacificSource Health Plans", "plan_name": "Medicare Advantage", "standard_charge_percentage": 103, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" } ] } ] }, { "description": "Laboratory - Chemistry", "code_information": [ { "code": "0301", "type": "RC" } ], "standard_charges": [ { "setting": "outpatient", "payers_information": [ { "payer_name": "United Healthcare (UHC)", "plan_name": "DSNP", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "National Comp Care", "plan_name": "Workers' Compensation", "standard_charge_percentage": 90, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Coventry Health Care", "plan_name": "Auto Network", "standard_charge_percentage": 90, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Coventry Health Care", "plan_name": "Workers' Compensation", "standard_charge_percentage": 95, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "TriWest Healthcare Alliance Corporation", "plan_name": "VA CCN", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Blue Cross Blue Shield of Montana", "plan_name": "Medicare Advantage", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "United Healthcare (UHC)", "plan_name": "Medicare Advantage", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Allegiance Provider Direct", "plan_name": "Medicare", "standard_charge_percentage": 229.99999999999997, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "PacificSource Health Plans", "plan_name": "PPO (PSN Network and Smart Health Network)", "standard_charge_percentage": 80, "methodology": "percent of total billed charges", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Medicare (CMS)", "plan_name": "Medicare", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "First Choice Health Network fka Health InfoNet", "plan_name": "Commercial", "standard_charge_percentage": 85, "methodology": "percent of total billed charges", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Claritev fka MultiPlan", "plan_name": "Auto Medical Program", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Claritev fka MultiPlan", "plan_name": "Workers' Compensation Program", "standard_charge_percentage": 90, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Claritev fka MultiPlan", "plan_name": "PPO", "standard_charge_percentage": 75, "methodology": "percent of total billed charges", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "First Choice of the Midwest", "plan_name": "PPO", "standard_charge_percentage": 90, "methodology": "percent of total billed charges", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Employee Benefit Management Services (EBMS)", "plan_name": "EBMS SelectCare Network", "standard_charge_percentage": 80, "methodology": "percent of total billed charges", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Medica Insurance Company", "plan_name": "Medicare Cost", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "First Choice Health Network fka Health InfoNet", "plan_name": "Medicare Advantage", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "First Choice Health Network fka Health InfoNet", "plan_name": "Workers Compensation", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "United Healthcare (UHC)", "plan_name": "HMO", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "United Healthcare (UHC)", "plan_name": "PPO", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "United Healthcare (UHC)", "plan_name": "Indemnity", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Allegiance Provider Direct", "plan_name": "Montana Association of Counties (MACo)", "standard_charge_percentage": 229.99999999999997, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Allegiance Provider Direct", "plan_name": "State of Montana Employee Benefit Plan (Self-Funded)", "standard_charge_percentage": 229.99999999999997, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Allegiance Provider Direct", "plan_name": "Montana Municipal Interlocal Authority (MMIA)", "standard_charge_percentage": 229.99999999999997, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Blue Cross Blue Shield of Montana", "plan_name": "HealthLink Network", "standard_charge_percentage": 75, "methodology": "percent of total billed charges", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Blue Cross Blue Shield of Montana", "plan_name": "Traditional Network", "standard_charge_percentage": 75, "methodology": "percent of total billed charges", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Blue Cross Blue Shield of Montana", "plan_name": "POS Network", "standard_charge_percentage": 75, "methodology": "percent of total billed charges", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Blue Cross Blue Shield of Montana", "plan_name": "Closed Plan Network", "standard_charge_percentage": 75, "methodology": "percent of total billed charges", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Blue Cross Blue Shield of Montana", "plan_name": "Retail HMO POS Network", "standard_charge_percentage": 75, "methodology": "percent of total billed charges", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Blue Cross Blue Shield of Montana", "plan_name": "Blue Options Network", "standard_charge_percentage": 75, "methodology": "percent of total billed charges", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Medicaid (State)", "plan_name": "Medicaid", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "PacificSource Health Plans", "plan_name": "Medicare Advantage", "standard_charge_percentage": 103, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" } ] } ] }, { "description": "Laboratory - Immunology", "code_information": [ { "code": "0302", "type": "RC" } ], "standard_charges": [ { "setting": "outpatient", "payers_information": [ { "payer_name": "United Healthcare (UHC)", "plan_name": "DSNP", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "United Healthcare (UHC)", "plan_name": "Medicare Advantage", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "United Healthcare (UHC)", "plan_name": "HMO", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "United Healthcare (UHC)", "plan_name": "PPO", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "United Healthcare (UHC)", "plan_name": "Indemnity", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" } ] } ] }, { "description": "Laboratory - Renal Patient (Home)", "code_information": [ { "code": "0303", "type": "RC" } ], "standard_charges": [ { "setting": "outpatient", "payers_information": [ { "payer_name": "United Healthcare (UHC)", "plan_name": "DSNP", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "United Healthcare (UHC)", "plan_name": "Medicare Advantage", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "United Healthcare (UHC)", "plan_name": "HMO", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "United Healthcare (UHC)", "plan_name": "PPO", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "United Healthcare (UHC)", "plan_name": "Indemnity", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" } ] } ] }, { "description": "Laboratory - Non-routine Dialysis", "code_information": [ { "code": "0304", "type": "RC" } ], "standard_charges": [ { "setting": "outpatient", "payers_information": [ { "payer_name": "United Healthcare (UHC)", "plan_name": "DSNP", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "United Healthcare (UHC)", "plan_name": "Medicare Advantage", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "United Healthcare (UHC)", "plan_name": "HMO", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "United Healthcare (UHC)", "plan_name": "PPO", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "United Healthcare (UHC)", "plan_name": "Indemnity", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" } ] } ] }, { "description": "Laboratory - Hematology", "code_information": [ { "code": "0305", "type": "RC" } ], "standard_charges": [ { "setting": "outpatient", "payers_information": [ { "payer_name": "United Healthcare (UHC)", "plan_name": "DSNP", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "United Healthcare (UHC)", "plan_name": "Medicare Advantage", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "United Healthcare (UHC)", "plan_name": "HMO", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "United Healthcare (UHC)", "plan_name": "PPO", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "United Healthcare (UHC)", "plan_name": "Indemnity", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" } ] } ] }, { "description": "Laboratory - Bacteriology & Microbiology", "code_information": [ { "code": "0306", "type": "RC" } ], "standard_charges": [ { "setting": "outpatient", "payers_information": [ { "payer_name": "United Healthcare (UHC)", "plan_name": "DSNP", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "United Healthcare (UHC)", "plan_name": "Medicare Advantage", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "United Healthcare (UHC)", "plan_name": "HMO", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "United Healthcare (UHC)", "plan_name": "PPO", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "United Healthcare (UHC)", "plan_name": "Indemnity", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" } ] } ] }, { "description": "Laboratory - Urology", "code_information": [ { "code": "0307", "type": "RC" } ], "standard_charges": [ { "setting": "outpatient", "payers_information": [ { "payer_name": "United Healthcare (UHC)", "plan_name": "DSNP", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "United Healthcare (UHC)", "plan_name": "Medicare Advantage", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "United Healthcare (UHC)", "plan_name": "HMO", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "United Healthcare (UHC)", "plan_name": "PPO", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "United Healthcare (UHC)", "plan_name": "Indemnity", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" } ] } ] }, { "description": "Laboratory - Other", "code_information": [ { "code": "0308", "type": "RC" } ], "standard_charges": [ { "setting": "outpatient", "payers_information": [ { "payer_name": "United Healthcare (UHC)", "plan_name": "DSNP", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "United Healthcare (UHC)", "plan_name": "Medicare Advantage", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" } ] } ] }, { "description": "Laboratory - Other", "code_information": [ { "code": "0309", "type": "RC" } ], "standard_charges": [ { "setting": "outpatient", "payers_information": [ { "payer_name": "United Healthcare (UHC)", "plan_name": "DSNP", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "United Healthcare (UHC)", "plan_name": "Medicare Advantage", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "United Healthcare (UHC)", "plan_name": "HMO", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "United Healthcare (UHC)", "plan_name": "PPO", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "United Healthcare (UHC)", "plan_name": "Indemnity", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" } ] } ] }, { "description": "Laboratory Pathology - General Classification", "code_information": [ { "code": "0310", "type": "RC" } ], "standard_charges": [ { "setting": "outpatient", "payers_information": [ { "payer_name": "United Healthcare (UHC)", "plan_name": "DSNP", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "United Healthcare (UHC)", "plan_name": "Medicare Advantage", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "United Healthcare (UHC)", "plan_name": "HMO", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "United Healthcare (UHC)", "plan_name": "PPO", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "United Healthcare (UHC)", "plan_name": "Indemnity", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" } ] } ] }, { "description": "Laboratory Pathology - Cytology", "code_information": [ { "code": "0311", "type": "RC" } ], "standard_charges": [ { "setting": "outpatient", "payers_information": [ { "payer_name": "United Healthcare (UHC)", "plan_name": "DSNP", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "United Healthcare (UHC)", "plan_name": "Medicare Advantage", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "United Healthcare (UHC)", "plan_name": "HMO", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "United Healthcare (UHC)", "plan_name": "PPO", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "United Healthcare (UHC)", "plan_name": "Indemnity", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" } ] } ] }, { "description": "Laboratory Pathology - Histology", "code_information": [ { "code": "0312", "type": "RC" } ], "standard_charges": [ { "setting": "outpatient", "payers_information": [ { "payer_name": "United Healthcare (UHC)", "plan_name": "DSNP", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "United Healthcare (UHC)", "plan_name": "Medicare Advantage", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "United Healthcare (UHC)", "plan_name": "HMO", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "United Healthcare (UHC)", "plan_name": "PPO", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "United Healthcare (UHC)", "plan_name": "Indemnity", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" } ] } ] }, { "description": "Laboratory – Pathology - Assessment", "code_information": [ { "code": "0313", "type": "RC" } ], "standard_charges": [ { "setting": "outpatient", "payers_information": [ { "payer_name": "United Healthcare (UHC)", "plan_name": "DSNP", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "United Healthcare (UHC)", "plan_name": "Medicare Advantage", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" } ] } ] }, { "description": "Laboratory Pathology - Biopsy", "code_information": [ { "code": "0314", "type": "RC" } ], "standard_charges": [ { "setting": "outpatient", "payers_information": [ { "payer_name": "United Healthcare (UHC)", "plan_name": "DSNP", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "United Healthcare (UHC)", "plan_name": "Medicare Advantage", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "United Healthcare (UHC)", "plan_name": "HMO", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "United Healthcare (UHC)", "plan_name": "PPO", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "United Healthcare (UHC)", "plan_name": "Indemnity", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" } ] } ] }, { "description": "Laboratory – Pathology - Treatment", "code_information": [ { "code": "0315", "type": "RC" } ], "standard_charges": [ { "setting": "outpatient", "payers_information": [ { "payer_name": "United Healthcare (UHC)", "plan_name": "DSNP", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "United Healthcare (UHC)", "plan_name": "Medicare Advantage", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" } ] } ] }, { "description": "Laboratory – Pathology - Continuation", "code_information": [ { "code": "0316", "type": "RC" } ], "standard_charges": [ { "setting": "outpatient", "payers_information": [ { "payer_name": "United Healthcare (UHC)", "plan_name": "DSNP", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "United Healthcare (UHC)", "plan_name": "Medicare Advantage", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" } ] } ] }, { "description": "Laboratory – Pathology - Observation/Hourly", "code_information": [ { "code": "0317", "type": "RC" } ], "standard_charges": [ { "setting": "outpatient", "payers_information": [ { "payer_name": "United Healthcare (UHC)", "plan_name": "DSNP", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "United Healthcare (UHC)", "plan_name": "Medicare Advantage", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" } ] } ] }, { "description": "Laboratory – Pathology - Other", "code_information": [ { "code": "0318", "type": "RC" } ], "standard_charges": [ { "setting": "outpatient", "payers_information": [ { "payer_name": "United Healthcare (UHC)", "plan_name": "DSNP", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "United Healthcare (UHC)", "plan_name": "Medicare Advantage", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" } ] } ] }, { "description": "Laboratory Pathology - Other", "code_information": [ { "code": "0319", "type": "RC" } ], "standard_charges": [ { "setting": "outpatient", "payers_information": [ { "payer_name": "United Healthcare (UHC)", "plan_name": "DSNP", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "United Healthcare (UHC)", "plan_name": "Medicare Advantage", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "United Healthcare (UHC)", "plan_name": "HMO", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "United Healthcare (UHC)", "plan_name": "PPO", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "United Healthcare (UHC)", "plan_name": "Indemnity", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" } ] } ] }, { "description": "Radiology - Diagnostic - General Classification", "code_information": [ { "code": "0320", "type": "RC" } ], "standard_charges": [ { "setting": "outpatient", "payers_information": [ { "payer_name": "United Healthcare (UHC)", "plan_name": "DSNP", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "United Healthcare (UHC)", "plan_name": "Medicare Advantage", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" } ] } ] }, { "description": "Radiology - Diagnostic - Angiocardiography", "code_information": [ { "code": "0321", "type": "RC" } ], "standard_charges": [ { "setting": "outpatient", "payers_information": [ { "payer_name": "United Healthcare (UHC)", "plan_name": "DSNP", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "United Healthcare (UHC)", "plan_name": "Medicare Advantage", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" } ] } ] }, { "description": "Radiology - Diagnostic - Arthrography", "code_information": [ { "code": "0322", "type": "RC" } ], "standard_charges": [ { "setting": "outpatient", "payers_information": [ { "payer_name": "United Healthcare (UHC)", "plan_name": "DSNP", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "United Healthcare (UHC)", "plan_name": "Medicare Advantage", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" } ] } ] }, { "description": "Radiology - Diagnostic - Arteriography", "code_information": [ { "code": "0323", "type": "RC" } ], "standard_charges": [ { "setting": "outpatient", "payers_information": [ { "payer_name": "United Healthcare (UHC)", "plan_name": "DSNP", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "United Healthcare (UHC)", "plan_name": "Medicare Advantage", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" } ] } ] }, { "description": "Radiology - Diagnostic - Chest X-Ray", "code_information": [ { "code": "0324", "type": "RC" } ], "standard_charges": [ { "setting": "outpatient", "payers_information": [ { "payer_name": "United Healthcare (UHC)", "plan_name": "DSNP", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "United Healthcare (UHC)", "plan_name": "Medicare Advantage", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" } ] } ] }, { "description": "Radiology - Diagnostic - Treatment", "code_information": [ { "code": "0325", "type": "RC" } ], "standard_charges": [ { "setting": "outpatient", "payers_information": [ { "payer_name": "United Healthcare (UHC)", "plan_name": "DSNP", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "United Healthcare (UHC)", "plan_name": "Medicare Advantage", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" } ] } ] }, { "description": "Radiology - Diagnostic - Continuation", "code_information": [ { "code": "0326", "type": "RC" } ], "standard_charges": [ { "setting": "outpatient", "payers_information": [ { "payer_name": "United Healthcare (UHC)", "plan_name": "DSNP", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "United Healthcare (UHC)", "plan_name": "Medicare Advantage", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" } ] } ] }, { "description": "Radiology - Diagnostic - Observation/Hourly", "code_information": [ { "code": "0327", "type": "RC" } ], "standard_charges": [ { "setting": "outpatient", "payers_information": [ { "payer_name": "United Healthcare (UHC)", "plan_name": "DSNP", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "United Healthcare (UHC)", "plan_name": "Medicare Advantage", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" } ] } ] }, { "description": "Radiology - Diagnostic - Other", "code_information": [ { "code": "0328", "type": "RC" } ], "standard_charges": [ { "setting": "outpatient", "payers_information": [ { "payer_name": "United Healthcare (UHC)", "plan_name": "DSNP", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "United Healthcare (UHC)", "plan_name": "Medicare Advantage", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" } ] } ] }, { "description": "Radiology - Diagnostic - Other", "code_information": [ { "code": "0329", "type": "RC" } ], "standard_charges": [ { "setting": "outpatient", "payers_information": [ { "payer_name": "United Healthcare (UHC)", "plan_name": "DSNP", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "United Healthcare (UHC)", "plan_name": "Medicare Advantage", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" } ] } ] }, { "description": "Radiology - Therapeutic and/or Chemotherapy Administration - General Classification", "code_information": [ { "code": "0330", "type": "RC" } ], "standard_charges": [ { "setting": "outpatient", "payers_information": [ { "payer_name": "United Healthcare (UHC)", "plan_name": "DSNP", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "United Healthcare (UHC)", "plan_name": "Medicare Advantage", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" } ] } ] }, { "description": "Radiology - Therapeutic - Chemotherapy Administration - Injected", "code_information": [ { "code": "0331", "type": "RC" } ], "standard_charges": [ { "setting": "outpatient", "payers_information": [ { "payer_name": "United Healthcare (UHC)", "plan_name": "DSNP", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "United Healthcare (UHC)", "plan_name": "Medicare Advantage", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" } ] } ] }, { "description": "Radiology - Therapeutic - Chemotherapy Administration - Oral", "code_information": [ { "code": "0332", "type": "RC" } ], "standard_charges": [ { "setting": "outpatient", "payers_information": [ { "payer_name": "United Healthcare (UHC)", "plan_name": "DSNP", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "United Healthcare (UHC)", "plan_name": "Medicare Advantage", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" } ] } ] }, { "description": "Radiology - Therapeutic - Radiation Therapy", "code_information": [ { "code": "0333", "type": "RC" } ], "standard_charges": [ { "setting": "outpatient", "payers_information": [ { "payer_name": "United Healthcare (UHC)", "plan_name": "DSNP", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "United Healthcare (UHC)", "plan_name": "Medicare Advantage", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" } ] } ] }, { "description": "Radiology – Therapeutic - Evaluation or Testing", "code_information": [ { "code": "0334", "type": "RC" } ], "standard_charges": [ { "setting": "outpatient", "payers_information": [ { "payer_name": "United Healthcare (UHC)", "plan_name": "DSNP", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "United Healthcare (UHC)", "plan_name": "Medicare Advantage", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" } ] } ] }, { "description": "Radiology - Therapeutic - Chemotherapy Administration - IV", "code_information": [ { "code": "0335", "type": "RC" } ], "standard_charges": [ { "setting": "outpatient", "payers_information": [ { "payer_name": "United Healthcare (UHC)", "plan_name": "DSNP", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "United Healthcare (UHC)", "plan_name": "Medicare Advantage", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" } ] } ] }, { "description": "Radiology – Therapeutic - Continuation", "code_information": [ { "code": "0336", "type": "RC" } ], "standard_charges": [ { "setting": "outpatient", "payers_information": [ { "payer_name": "United Healthcare (UHC)", "plan_name": "DSNP", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "United Healthcare (UHC)", "plan_name": "Medicare Advantage", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" } ] } ] }, { "description": "Radiology – Therapeutic - Observation/Hourly", "code_information": [ { "code": "0337", "type": "RC" } ], "standard_charges": [ { "setting": "outpatient", "payers_information": [ { "payer_name": "United Healthcare (UHC)", "plan_name": "DSNP", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "United Healthcare (UHC)", "plan_name": "Medicare Advantage", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" } ] } ] }, { "description": "Radiology – Therapeutic - Other", "code_information": [ { "code": "0338", "type": "RC" } ], "standard_charges": [ { "setting": "outpatient", "payers_information": [ { "payer_name": "United Healthcare (UHC)", "plan_name": "DSNP", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "United Healthcare (UHC)", "plan_name": "Medicare Advantage", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" } ] } ] }, { "description": "Radiology - Therapeutic - Other", "code_information": [ { "code": "0339", "type": "RC" } ], "standard_charges": [ { "setting": "outpatient", "payers_information": [ { "payer_name": "United Healthcare (UHC)", "plan_name": "DSNP", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "United Healthcare (UHC)", "plan_name": "Medicare Advantage", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" } ] } ] }, { "description": "Nuclear Medicine - General Classification", "code_information": [ { "code": "0340", "type": "RC" } ], "standard_charges": [ { "setting": "outpatient", "payers_information": [ { "payer_name": "United Healthcare (UHC)", "plan_name": "DSNP", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "United Healthcare (UHC)", "plan_name": "Medicare Advantage", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" } ] } ] }, { "description": "Nuclear Medicine - Diagnostic Procedures", "code_information": [ { "code": "0341", "type": "RC" } ], "standard_charges": [ { "setting": "outpatient", "payers_information": [ { "payer_name": "United Healthcare (UHC)", "plan_name": "DSNP", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "United Healthcare (UHC)", "plan_name": "Medicare Advantage", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" } ] } ] }, { "description": "Nuclear Medicine - Therapeutic Procedures", "code_information": [ { "code": "0342", "type": "RC" } ], "standard_charges": [ { "setting": "outpatient", "payers_information": [ { "payer_name": "United Healthcare (UHC)", "plan_name": "DSNP", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "United Healthcare (UHC)", "plan_name": "Medicare Advantage", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" } ] } ] }, { "description": "Nuclear Medicine - Diagnostic Radiopharmaceuticals", "code_information": [ { "code": "0343", "type": "RC" } ], "standard_charges": [ { "setting": "outpatient", "payers_information": [ { "payer_name": "United Healthcare (UHC)", "plan_name": "DSNP", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "United Healthcare (UHC)", "plan_name": "Medicare Advantage", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" } ] } ] }, { "description": "Nuclear Medicine - Therapeutic Radiopharmaceuticals", "code_information": [ { "code": "0344", "type": "RC" } ], "standard_charges": [ { "setting": "outpatient", "payers_information": [ { "payer_name": "United Healthcare (UHC)", "plan_name": "DSNP", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "United Healthcare (UHC)", "plan_name": "Medicare Advantage", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" } ] } ] }, { "description": "Nuclear Medicine - Treatment", "code_information": [ { "code": "0345", "type": "RC" } ], "standard_charges": [ { "setting": "outpatient", "payers_information": [ { "payer_name": "United Healthcare (UHC)", "plan_name": "DSNP", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "United Healthcare (UHC)", "plan_name": "Medicare Advantage", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" } ] } ] }, { "description": "Nuclear Medicine - Continuation", "code_information": [ { "code": "0346", "type": "RC" } ], "standard_charges": [ { "setting": "outpatient", "payers_information": [ { "payer_name": "United Healthcare (UHC)", "plan_name": "DSNP", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "United Healthcare (UHC)", "plan_name": "Medicare Advantage", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" } ] } ] }, { "description": "Nuclear Medicine - Observation/Hourly", "code_information": [ { "code": "0347", "type": "RC" } ], "standard_charges": [ { "setting": "outpatient", "payers_information": [ { "payer_name": "United Healthcare (UHC)", "plan_name": "DSNP", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "United Healthcare (UHC)", "plan_name": "Medicare Advantage", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" } ] } ] }, { "description": "Nuclear Medicine - Other", "code_information": [ { "code": "0348", "type": "RC" } ], "standard_charges": [ { "setting": "outpatient", "payers_information": [ { "payer_name": "United Healthcare (UHC)", "plan_name": "DSNP", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "United Healthcare (UHC)", "plan_name": "Medicare Advantage", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" } ] } ] }, { "description": "Nuclear Medicine - Other", "code_information": [ { "code": "0349", "type": "RC" } ], "standard_charges": [ { "setting": "outpatient", "payers_information": [ { "payer_name": "United Healthcare (UHC)", "plan_name": "DSNP", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "United Healthcare (UHC)", "plan_name": "Medicare Advantage", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" } ] } ] }, { "description": "CT Scan - General Classification", "code_information": [ { "code": "0350", "type": "RC" } ], "standard_charges": [ { "setting": "outpatient", "payers_information": [ { "payer_name": "United Healthcare (UHC)", "plan_name": "DSNP", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "United Healthcare (UHC)", "plan_name": "Medicare Advantage", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" } ] } ] }, { "description": "CT Scan - Head Scan", "code_information": [ { "code": "0351", "type": "RC" } ], "standard_charges": [ { "setting": "outpatient", "payers_information": [ { "payer_name": "United Healthcare (UHC)", "plan_name": "DSNP", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "United Healthcare (UHC)", "plan_name": "Medicare Advantage", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" } ] } ] }, { "description": "CT Scan - Body Scan", "code_information": [ { "code": "0352", "type": "RC" } ], "standard_charges": [ { "setting": "outpatient", "payers_information": [ { "payer_name": "United Healthcare (UHC)", "plan_name": "DSNP", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "United Healthcare (UHC)", "plan_name": "Medicare Advantage", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" } ] } ] }, { "description": "CT Scan - Assessment", "code_information": [ { "code": "0353", "type": "RC" } ], "standard_charges": [ { "setting": "outpatient", "payers_information": [ { "payer_name": "United Healthcare (UHC)", "plan_name": "DSNP", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "United Healthcare (UHC)", "plan_name": "Medicare Advantage", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" } ] } ] }, { "description": "CT Scan - Evaluation or Testing", "code_information": [ { "code": "0354", "type": "RC" } ], "standard_charges": [ { "setting": "outpatient", "payers_information": [ { "payer_name": "United Healthcare (UHC)", "plan_name": "DSNP", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "United Healthcare (UHC)", "plan_name": "Medicare Advantage", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" } ] } ] }, { "description": "CT Scan - Treatment", "code_information": [ { "code": "0355", "type": "RC" } ], "standard_charges": [ { "setting": "outpatient", "payers_information": [ { "payer_name": "United Healthcare (UHC)", "plan_name": "DSNP", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "United Healthcare (UHC)", "plan_name": "Medicare Advantage", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" } ] } ] }, { "description": "CT Scan - Continuation", "code_information": [ { "code": "0356", "type": "RC" } ], "standard_charges": [ { "setting": "outpatient", "payers_information": [ { "payer_name": "United Healthcare (UHC)", "plan_name": "DSNP", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "United Healthcare (UHC)", "plan_name": "Medicare Advantage", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" } ] } ] }, { "description": "CT Scan - Observation/Hourly", "code_information": [ { "code": "0357", "type": "RC" } ], "standard_charges": [ { "setting": "outpatient", "payers_information": [ { "payer_name": "United Healthcare (UHC)", "plan_name": "DSNP", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "United Healthcare (UHC)", "plan_name": "Medicare Advantage", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" } ] } ] }, { "description": "CT Scan - Other", "code_information": [ { "code": "0358", "type": "RC" } ], "standard_charges": [ { "setting": "outpatient", "payers_information": [ { "payer_name": "United Healthcare (UHC)", "plan_name": "DSNP", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "United Healthcare (UHC)", "plan_name": "Medicare Advantage", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" } ] } ] }, { "description": "CT Scan - Other", "code_information": [ { "code": "0359", "type": "RC" } ], "standard_charges": [ { "setting": "outpatient", "payers_information": [ { "payer_name": "United Healthcare (UHC)", "plan_name": "DSNP", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "United Healthcare (UHC)", "plan_name": "Medicare Advantage", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" } ] } ] }, { "description": "Operating Room Services - General Classification", "code_information": [ { "code": "0360", "type": "RC" } ], "standard_charges": [ { "setting": "outpatient", "payers_information": [ { "payer_name": "United Healthcare (UHC)", "plan_name": "DSNP", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "United Healthcare (UHC)", "plan_name": "Medicare Advantage", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" } ] } ] }, { "description": "Operating Room Services - Minor Surgery", "code_information": [ { "code": "0361", "type": "RC" } ], "standard_charges": [ { "setting": "outpatient", "payers_information": [ { "payer_name": "United Healthcare (UHC)", "plan_name": "DSNP", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "United Healthcare (UHC)", "plan_name": "Medicare Advantage", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" } ] } ] }, { "description": "Operating Room Services - Organ transplant - Other Than Kidney", "code_information": [ { "code": "0362", "type": "RC" } ], "standard_charges": [ { "setting": "outpatient", "payers_information": [ { "payer_name": "United Healthcare (UHC)", "plan_name": "DSNP", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "United Healthcare (UHC)", "plan_name": "Medicare Advantage", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" } ] } ] }, { "description": "Operating Room Services - Assessment", "code_information": [ { "code": "0363", "type": "RC" } ], "standard_charges": [ { "setting": "outpatient", "payers_information": [ { "payer_name": "United Healthcare (UHC)", "plan_name": "DSNP", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "United Healthcare (UHC)", "plan_name": "Medicare Advantage", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" } ] } ] }, { "description": "Operating Room Services - Evaluation or Testing", "code_information": [ { "code": "0364", "type": "RC" } ], "standard_charges": [ { "setting": "outpatient", "payers_information": [ { "payer_name": "United Healthcare (UHC)", "plan_name": "DSNP", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "United Healthcare (UHC)", "plan_name": "Medicare Advantage", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" } ] } ] }, { "description": "Operating Room Services - Treatment", "code_information": [ { "code": "0365", "type": "RC" } ], "standard_charges": [ { "setting": "outpatient", "payers_information": [ { "payer_name": "United Healthcare (UHC)", "plan_name": "DSNP", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "United Healthcare (UHC)", "plan_name": "Medicare Advantage", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" } ] } ] }, { "description": "Operating Room Services - Continuation", "code_information": [ { "code": "0366", "type": "RC" } ], "standard_charges": [ { "setting": "outpatient", "payers_information": [ { "payer_name": "United Healthcare (UHC)", "plan_name": "DSNP", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "United Healthcare (UHC)", "plan_name": "Medicare Advantage", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" } ] } ] }, { "description": "Operating Room Services - Kidney Transplant", "code_information": [ { "code": "0367", "type": "RC" } ], "standard_charges": [ { "setting": "outpatient", "payers_information": [ { "payer_name": "United Healthcare (UHC)", "plan_name": "DSNP", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "United Healthcare (UHC)", "plan_name": "Medicare Advantage", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" } ] } ] }, { "description": "Operating Room Services - Other", "code_information": [ { "code": "0368", "type": "RC" } ], "standard_charges": [ { "setting": "outpatient", "payers_information": [ { "payer_name": "United Healthcare (UHC)", "plan_name": "DSNP", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "United Healthcare (UHC)", "plan_name": "Medicare Advantage", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" } ] } ] }, { "description": "Operating Room Services - Other", "code_information": [ { "code": "0369", "type": "RC" } ], "standard_charges": [ { "setting": "outpatient", "payers_information": [ { "payer_name": "United Healthcare (UHC)", "plan_name": "DSNP", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "United Healthcare (UHC)", "plan_name": "Medicare Advantage", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" } ] } ] }, { "description": "Anesthesia - General Classification", "code_information": [ { "code": "0370", "type": "RC" } ], "standard_charges": [ { "setting": "outpatient", "payers_information": [ { "payer_name": "United Healthcare (UHC)", "plan_name": "DSNP", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "United Healthcare (UHC)", "plan_name": "Medicare Advantage", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" } ] } ] }, { "description": "Anesthesia - Incident to Radiology", "code_information": [ { "code": "0371", "type": "RC" } ], "standard_charges": [ { "setting": "outpatient", "payers_information": [ { "payer_name": "United Healthcare (UHC)", "plan_name": "DSNP", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "United Healthcare (UHC)", "plan_name": "Medicare Advantage", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" } ] } ] }, { "description": "Anesthesia - Incident to Other Diagnostic Services", "code_information": [ { "code": "0372", "type": "RC" } ], "standard_charges": [ { "setting": "outpatient", "payers_information": [ { "payer_name": "United Healthcare (UHC)", "plan_name": "DSNP", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "United Healthcare (UHC)", "plan_name": "Medicare Advantage", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" } ] } ] }, { "description": "Anesthesia - Assessment", "code_information": [ { "code": "0373", "type": "RC" } ], "standard_charges": [ { "setting": "outpatient", "payers_information": [ { "payer_name": "United Healthcare (UHC)", "plan_name": "DSNP", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "United Healthcare (UHC)", "plan_name": "Medicare Advantage", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" } ] } ] }, { "description": "Anesthesia - Acupuncture", "code_information": [ { "code": "0374", "type": "RC" } ], "standard_charges": [ { "setting": "outpatient", "payers_information": [ { "payer_name": "United Healthcare (UHC)", "plan_name": "DSNP", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "United Healthcare (UHC)", "plan_name": "Medicare Advantage", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" } ] } ] }, { "description": "Anesthesia - Treatment", "code_information": [ { "code": "0375", "type": "RC" } ], "standard_charges": [ { "setting": "outpatient", "payers_information": [ { "payer_name": "United Healthcare (UHC)", "plan_name": "DSNP", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "United Healthcare (UHC)", "plan_name": "Medicare Advantage", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" } ] } ] }, { "description": "Anesthesia - Continuation", "code_information": [ { "code": "0376", "type": "RC" } ], "standard_charges": [ { "setting": "outpatient", "payers_information": [ { "payer_name": "United Healthcare (UHC)", "plan_name": "DSNP", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "United Healthcare (UHC)", "plan_name": "Medicare Advantage", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" } ] } ] }, { "description": "Anesthesia - Observation/Hourly", "code_information": [ { "code": "0377", "type": "RC" } ], "standard_charges": [ { "setting": "outpatient", "payers_information": [ { "payer_name": "United Healthcare (UHC)", "plan_name": "DSNP", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "United Healthcare (UHC)", "plan_name": "Medicare Advantage", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" } ] } ] }, { "description": "Anesthesia - Other", "code_information": [ { "code": "0378", "type": "RC" } ], "standard_charges": [ { "setting": "outpatient", "payers_information": [ { "payer_name": "United Healthcare (UHC)", "plan_name": "DSNP", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "United Healthcare (UHC)", "plan_name": "Medicare Advantage", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" } ] } ] }, { "description": "Anesthesia - Other", "code_information": [ { "code": "0379", "type": "RC" } ], "standard_charges": [ { "setting": "outpatient", "payers_information": [ { "payer_name": "United Healthcare (UHC)", "plan_name": "DSNP", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "United Healthcare (UHC)", "plan_name": "Medicare Advantage", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" } ] } ] }, { "description": "Other Imaging Services - General Classification", "code_information": [ { "code": "0400", "type": "RC" } ], "standard_charges": [ { "setting": "outpatient", "payers_information": [ { "payer_name": "United Healthcare (UHC)", "plan_name": "DSNP", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "United Healthcare (UHC)", "plan_name": "Medicare Advantage", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" } ] } ] }, { "description": "Other Imaging Services - Diagnostic Mammography", "code_information": [ { "code": "0401", "type": "RC" } ], "standard_charges": [ { "setting": "outpatient", "payers_information": [ { "payer_name": "United Healthcare (UHC)", "plan_name": "DSNP", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "United Healthcare (UHC)", "plan_name": "Medicare Advantage", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" } ] } ] }, { "description": "Other Imaging Services - Ultrasound", "code_information": [ { "code": "0402", "type": "RC" } ], "standard_charges": [ { "setting": "outpatient", "payers_information": [ { "payer_name": "United Healthcare (UHC)", "plan_name": "DSNP", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "United Healthcare (UHC)", "plan_name": "Medicare Advantage", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" } ] } ] }, { "description": "Other Imaging Services - Screening Mammography", "code_information": [ { "code": "0403", "type": "RC" } ], "standard_charges": [ { "setting": "outpatient", "payers_information": [ { "payer_name": "United Healthcare (UHC)", "plan_name": "DSNP", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "United Healthcare (UHC)", "plan_name": "Medicare Advantage", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" } ] } ] }, { "description": "Other Imaging Services - Positron Emission Tomography", "code_information": [ { "code": "0404", "type": "RC" } ], "standard_charges": [ { "setting": "outpatient", "payers_information": [ { "payer_name": "United Healthcare (UHC)", "plan_name": "DSNP", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "United Healthcare (UHC)", "plan_name": "Medicare Advantage", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" } ] } ] }, { "description": "Other Imaging Services - Treatment", "code_information": [ { "code": "0405", "type": "RC" } ], "standard_charges": [ { "setting": "outpatient", "payers_information": [ { "payer_name": "United Healthcare (UHC)", "plan_name": "DSNP", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "United Healthcare (UHC)", "plan_name": "Medicare Advantage", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" } ] } ] }, { "description": "Other Imaging Services - Continuation", "code_information": [ { "code": "0406", "type": "RC" } ], "standard_charges": [ { "setting": "outpatient", "payers_information": [ { "payer_name": "United Healthcare (UHC)", "plan_name": "DSNP", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "United Healthcare (UHC)", "plan_name": "Medicare Advantage", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" } ] } ] }, { "description": "Other Imaging Services - Observation/Hourly", "code_information": [ { "code": "0407", "type": "RC" } ], "standard_charges": [ { "setting": "outpatient", "payers_information": [ { "payer_name": "United Healthcare (UHC)", "plan_name": "DSNP", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "United Healthcare (UHC)", "plan_name": "Medicare Advantage", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" } ] } ] }, { "description": "Other Imaging Services - Other", "code_information": [ { "code": "0408", "type": "RC" } ], "standard_charges": [ { "setting": "outpatient", "payers_information": [ { "payer_name": "United Healthcare (UHC)", "plan_name": "DSNP", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "United Healthcare (UHC)", "plan_name": "Medicare Advantage", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" } ] } ] }, { "description": "Other Imaging Services - Other", "code_information": [ { "code": "0409", "type": "RC" } ], "standard_charges": [ { "setting": "outpatient", "payers_information": [ { "payer_name": "United Healthcare (UHC)", "plan_name": "DSNP", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "United Healthcare (UHC)", "plan_name": "Medicare Advantage", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" } ] } ] }, { "description": "Respiratory Services - General Classification", "code_information": [ { "code": "0410", "type": "RC" } ], "standard_charges": [ { "setting": "outpatient", "payers_information": [ { "payer_name": "United Healthcare (UHC)", "plan_name": "DSNP", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "National Comp Care", "plan_name": "Workers' Compensation", "standard_charge_percentage": 90, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Coventry Health Care", "plan_name": "Auto Network", "standard_charge_percentage": 90, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Coventry Health Care", "plan_name": "Workers' Compensation", "standard_charge_percentage": 95, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "TriWest Healthcare Alliance Corporation", "plan_name": "VA CCN", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Blue Cross Blue Shield of Montana", "plan_name": "Medicare Advantage", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "United Healthcare (UHC)", "plan_name": "Medicare Advantage", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Allegiance Provider Direct", "plan_name": "Medicare", "standard_charge_percentage": 229.99999999999997, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "PacificSource Health Plans", "plan_name": "PPO (PSN Network and Smart Health Network)", "standard_charge_percentage": 80, "methodology": "percent of total billed charges", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Medicare (CMS)", "plan_name": "Medicare", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "First Choice Health Network fka Health InfoNet", "plan_name": "Commercial", "standard_charge_percentage": 85, "methodology": "percent of total billed charges", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Claritev fka MultiPlan", "plan_name": "Auto Medical Program", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Claritev fka MultiPlan", "plan_name": "Workers' Compensation Program", "standard_charge_percentage": 90, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Claritev fka MultiPlan", "plan_name": "PPO", "standard_charge_percentage": 75, "methodology": "percent of total billed charges", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "First Choice of the Midwest", "plan_name": "PPO", "standard_charge_percentage": 90, "methodology": "percent of total billed charges", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Employee Benefit Management Services (EBMS)", "plan_name": "EBMS SelectCare Network", "standard_charge_percentage": 80, "methodology": "percent of total billed charges", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Medica Insurance Company", "plan_name": "Medicare Cost", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "First Choice Health Network fka Health InfoNet", "plan_name": "Medicare Advantage", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "First Choice Health Network fka Health InfoNet", "plan_name": "Workers Compensation", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Allegiance Provider Direct", "plan_name": "Montana Association of Counties (MACo)", "standard_charge_percentage": 229.99999999999997, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Allegiance Provider Direct", "plan_name": "State of Montana Employee Benefit Plan (Self-Funded)", "standard_charge_percentage": 229.99999999999997, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Allegiance Provider Direct", "plan_name": "Montana Municipal Interlocal Authority (MMIA)", "standard_charge_percentage": 229.99999999999997, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Blue Cross Blue Shield of Montana", "plan_name": "HealthLink Network", "standard_charge_percentage": 75, "methodology": "percent of total billed charges", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Blue Cross Blue Shield of Montana", "plan_name": "Traditional Network", "standard_charge_percentage": 75, "methodology": "percent of total billed charges", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Blue Cross Blue Shield of Montana", "plan_name": "POS Network", "standard_charge_percentage": 75, "methodology": "percent of total billed charges", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Blue Cross Blue Shield of Montana", "plan_name": "Closed Plan Network", "standard_charge_percentage": 75, "methodology": "percent of total billed charges", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Blue Cross Blue Shield of Montana", "plan_name": "Retail HMO POS Network", "standard_charge_percentage": 75, "methodology": "percent of total billed charges", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Blue Cross Blue Shield of Montana", "plan_name": "Blue Options Network", "standard_charge_percentage": 75, "methodology": "percent of total billed charges", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Medicaid (State)", "plan_name": "Medicaid", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "PacificSource Health Plans", "plan_name": "Medicare Advantage", "standard_charge_percentage": 103, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" } ] } ] }, { "description": "Respiratory Services - Visit", "code_information": [ { "code": "0411", "type": "RC" } ], "standard_charges": [ { "setting": "outpatient", "payers_information": [ { "payer_name": "United Healthcare (UHC)", "plan_name": "DSNP", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "United Healthcare (UHC)", "plan_name": "Medicare Advantage", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Blue Cross Blue Shield of Montana", "plan_name": "HealthLink Network", "standard_charge_percentage": 75, "methodology": "percent of total billed charges", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Blue Cross Blue Shield of Montana", "plan_name": "Traditional Network", "standard_charge_percentage": 75, "methodology": "percent of total billed charges", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Blue Cross Blue Shield of Montana", "plan_name": "POS Network", "standard_charge_percentage": 75, "methodology": "percent of total billed charges", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Blue Cross Blue Shield of Montana", "plan_name": "Closed Plan Network", "standard_charge_percentage": 75, "methodology": "percent of total billed charges", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Blue Cross Blue Shield of Montana", "plan_name": "Retail HMO POS Network", "standard_charge_percentage": 75, "methodology": "percent of total billed charges", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Blue Cross Blue Shield of Montana", "plan_name": "Blue Options Network", "standard_charge_percentage": 75, "methodology": "percent of total billed charges", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" } ] } ] }, { "description": "Respiratory Services - Inhalation Services", "code_information": [ { "code": "0412", "type": "RC" } ], "standard_charges": [ { "setting": "outpatient", "payers_information": [ { "payer_name": "United Healthcare (UHC)", "plan_name": "DSNP", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "United Healthcare (UHC)", "plan_name": "Medicare Advantage", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Blue Cross Blue Shield of Montana", "plan_name": "HealthLink Network", "standard_charge_percentage": 75, "methodology": "percent of total billed charges", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Blue Cross Blue Shield of Montana", "plan_name": "Traditional Network", "standard_charge_percentage": 75, "methodology": "percent of total billed charges", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Blue Cross Blue Shield of Montana", "plan_name": "POS Network", "standard_charge_percentage": 75, "methodology": "percent of total billed charges", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Blue Cross Blue Shield of Montana", "plan_name": "Closed Plan Network", "standard_charge_percentage": 75, "methodology": "percent of total billed charges", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Blue Cross Blue Shield of Montana", "plan_name": "Retail HMO POS Network", "standard_charge_percentage": 75, "methodology": "percent of total billed charges", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Blue Cross Blue Shield of Montana", "plan_name": "Blue Options Network", "standard_charge_percentage": 75, "methodology": "percent of total billed charges", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" } ] } ] }, { "description": "Respiratory Services - Hyperbaric Oxygen Therapy", "code_information": [ { "code": "0413", "type": "RC" } ], "standard_charges": [ { "setting": "outpatient", "payers_information": [ { "payer_name": "United Healthcare (UHC)", "plan_name": "DSNP", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "United Healthcare (UHC)", "plan_name": "Medicare Advantage", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Blue Cross Blue Shield of Montana", "plan_name": "HealthLink Network", "standard_charge_percentage": 75, "methodology": "percent of total billed charges", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Blue Cross Blue Shield of Montana", "plan_name": "Traditional Network", "standard_charge_percentage": 75, "methodology": "percent of total billed charges", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Blue Cross Blue Shield of Montana", "plan_name": "POS Network", "standard_charge_percentage": 75, "methodology": "percent of total billed charges", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Blue Cross Blue Shield of Montana", "plan_name": "Closed Plan Network", "standard_charge_percentage": 75, "methodology": "percent of total billed charges", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Blue Cross Blue Shield of Montana", "plan_name": "Retail HMO POS Network", "standard_charge_percentage": 75, "methodology": "percent of total billed charges", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Blue Cross Blue Shield of Montana", "plan_name": "Blue Options Network", "standard_charge_percentage": 75, "methodology": "percent of total billed charges", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" } ] } ] }, { "description": "Respiratory Services - Evaluation or Testing", "code_information": [ { "code": "0414", "type": "RC" } ], "standard_charges": [ { "setting": "outpatient", "payers_information": [ { "payer_name": "United Healthcare (UHC)", "plan_name": "DSNP", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "United Healthcare (UHC)", "plan_name": "Medicare Advantage", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Blue Cross Blue Shield of Montana", "plan_name": "HealthLink Network", "standard_charge_percentage": 75, "methodology": "percent of total billed charges", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Blue Cross Blue Shield of Montana", "plan_name": "Traditional Network", "standard_charge_percentage": 75, "methodology": "percent of total billed charges", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Blue Cross Blue Shield of Montana", "plan_name": "POS Network", "standard_charge_percentage": 75, "methodology": "percent of total billed charges", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Blue Cross Blue Shield of Montana", "plan_name": "Closed Plan Network", "standard_charge_percentage": 75, "methodology": "percent of total billed charges", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Blue Cross Blue Shield of Montana", "plan_name": "Retail HMO POS Network", "standard_charge_percentage": 75, "methodology": "percent of total billed charges", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Blue Cross Blue Shield of Montana", "plan_name": "Blue Options Network", "standard_charge_percentage": 75, "methodology": "percent of total billed charges", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" } ] } ] }, { "description": "Respiratory Services - Treatment", "code_information": [ { "code": "0415", "type": "RC" } ], "standard_charges": [ { "setting": "outpatient", "payers_information": [ { "payer_name": "United Healthcare (UHC)", "plan_name": "DSNP", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "United Healthcare (UHC)", "plan_name": "Medicare Advantage", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Blue Cross Blue Shield of Montana", "plan_name": "HealthLink Network", "standard_charge_percentage": 75, "methodology": "percent of total billed charges", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Blue Cross Blue Shield of Montana", "plan_name": "Traditional Network", "standard_charge_percentage": 75, "methodology": "percent of total billed charges", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Blue Cross Blue Shield of Montana", "plan_name": "POS Network", "standard_charge_percentage": 75, "methodology": "percent of total billed charges", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Blue Cross Blue Shield of Montana", "plan_name": "Closed Plan Network", "standard_charge_percentage": 75, "methodology": "percent of total billed charges", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Blue Cross Blue Shield of Montana", "plan_name": "Retail HMO POS Network", "standard_charge_percentage": 75, "methodology": "percent of total billed charges", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Blue Cross Blue Shield of Montana", "plan_name": "Blue Options Network", "standard_charge_percentage": 75, "methodology": "percent of total billed charges", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" } ] } ] }, { "description": "Respiratory Services - Continuation", "code_information": [ { "code": "0416", "type": "RC" } ], "standard_charges": [ { "setting": "outpatient", "payers_information": [ { "payer_name": "United Healthcare (UHC)", "plan_name": "DSNP", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "United Healthcare (UHC)", "plan_name": "Medicare Advantage", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Blue Cross Blue Shield of Montana", "plan_name": "HealthLink Network", "standard_charge_percentage": 75, "methodology": "percent of total billed charges", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Blue Cross Blue Shield of Montana", "plan_name": "Traditional Network", "standard_charge_percentage": 75, "methodology": "percent of total billed charges", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Blue Cross Blue Shield of Montana", "plan_name": "POS Network", "standard_charge_percentage": 75, "methodology": "percent of total billed charges", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Blue Cross Blue Shield of Montana", "plan_name": "Closed Plan Network", "standard_charge_percentage": 75, "methodology": "percent of total billed charges", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Blue Cross Blue Shield of Montana", "plan_name": "Retail HMO POS Network", "standard_charge_percentage": 75, "methodology": "percent of total billed charges", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Blue Cross Blue Shield of Montana", "plan_name": "Blue Options Network", "standard_charge_percentage": 75, "methodology": "percent of total billed charges", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" } ] } ] }, { "description": "Respiratory Services - Observation/Hourly", "code_information": [ { "code": "0417", "type": "RC" } ], "standard_charges": [ { "setting": "outpatient", "payers_information": [ { "payer_name": "United Healthcare (UHC)", "plan_name": "DSNP", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "United Healthcare (UHC)", "plan_name": "Medicare Advantage", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Blue Cross Blue Shield of Montana", "plan_name": "HealthLink Network", "standard_charge_percentage": 75, "methodology": "percent of total billed charges", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Blue Cross Blue Shield of Montana", "plan_name": "Traditional Network", "standard_charge_percentage": 75, "methodology": "percent of total billed charges", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Blue Cross Blue Shield of Montana", "plan_name": "POS Network", "standard_charge_percentage": 75, "methodology": "percent of total billed charges", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Blue Cross Blue Shield of Montana", "plan_name": "Closed Plan Network", "standard_charge_percentage": 75, "methodology": "percent of total billed charges", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Blue Cross Blue Shield of Montana", "plan_name": "Retail HMO POS Network", "standard_charge_percentage": 75, "methodology": "percent of total billed charges", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Blue Cross Blue Shield of Montana", "plan_name": "Blue Options Network", "standard_charge_percentage": 75, "methodology": "percent of total billed charges", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" } ] } ] }, { "description": "Respiratory Services - Other", "code_information": [ { "code": "0418", "type": "RC" } ], "standard_charges": [ { "setting": "outpatient", "payers_information": [ { "payer_name": "United Healthcare (UHC)", "plan_name": "DSNP", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "United Healthcare (UHC)", "plan_name": "Medicare Advantage", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Blue Cross Blue Shield of Montana", "plan_name": "HealthLink Network", "standard_charge_percentage": 75, "methodology": "percent of total billed charges", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Blue Cross Blue Shield of Montana", "plan_name": "Traditional Network", "standard_charge_percentage": 75, "methodology": "percent of total billed charges", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Blue Cross Blue Shield of Montana", "plan_name": "POS Network", "standard_charge_percentage": 75, "methodology": "percent of total billed charges", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Blue Cross Blue Shield of Montana", "plan_name": "Closed Plan Network", "standard_charge_percentage": 75, "methodology": "percent of total billed charges", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Blue Cross Blue Shield of Montana", "plan_name": "Retail HMO POS Network", "standard_charge_percentage": 75, "methodology": "percent of total billed charges", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Blue Cross Blue Shield of Montana", "plan_name": "Blue Options Network", "standard_charge_percentage": 75, "methodology": "percent of total billed charges", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" } ] } ] }, { "description": "Respiratory Services - Other", "code_information": [ { "code": "0419", "type": "RC" } ], "standard_charges": [ { "setting": "outpatient", "payers_information": [ { "payer_name": "United Healthcare (UHC)", "plan_name": "DSNP", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "United Healthcare (UHC)", "plan_name": "Medicare Advantage", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Blue Cross Blue Shield of Montana", "plan_name": "HealthLink Network", "standard_charge_percentage": 75, "methodology": "percent of total billed charges", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Blue Cross Blue Shield of Montana", "plan_name": "Traditional Network", "standard_charge_percentage": 75, "methodology": "percent of total billed charges", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Blue Cross Blue Shield of Montana", "plan_name": "POS Network", "standard_charge_percentage": 75, "methodology": "percent of total billed charges", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Blue Cross Blue Shield of Montana", "plan_name": "Closed Plan Network", "standard_charge_percentage": 75, "methodology": "percent of total billed charges", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Blue Cross Blue Shield of Montana", "plan_name": "Retail HMO POS Network", "standard_charge_percentage": 75, "methodology": "percent of total billed charges", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Blue Cross Blue Shield of Montana", "plan_name": "Blue Options Network", "standard_charge_percentage": 75, "methodology": "percent of total billed charges", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" } ] } ] }, { "description": "Physical Therapy - General Classification", "code_information": [ { "code": "0420", "type": "RC" } ], "standard_charges": [ { "setting": "outpatient", "payers_information": [ { "payer_name": "United Healthcare (UHC)", "plan_name": "DSNP", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "National Comp Care", "plan_name": "Workers' Compensation", "standard_charge_dollar": 90, "methodology": "fee schedule", "median_amount": 90, "10th_percentile": 90, "90th_percentile": 90, "count": "1 through 10" }, { "payer_name": "Coventry Health Care", "plan_name": "Auto Network", "standard_charge_percentage": 90, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Coventry Health Care", "plan_name": "Workers' Compensation", "standard_charge_percentage": 95, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "TriWest Healthcare Alliance Corporation", "plan_name": "VA CCN", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Blue Cross Blue Shield of Montana", "plan_name": "Medicare Advantage", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "United Healthcare (UHC)", "plan_name": "Medicare Advantage", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Allegiance Provider Direct", "plan_name": "Medicare", "standard_charge_percentage": 229.99999999999997, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "PacificSource Health Plans", "plan_name": "PPO (PSN Network and Smart Health Network)", "standard_charge_percentage": 80, "methodology": "percent of total billed charges", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Medicare (CMS)", "plan_name": "Medicare", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "First Choice Health Network fka Health InfoNet", "plan_name": "Commercial", "standard_charge_percentage": 85, "methodology": "percent of total billed charges", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Claritev fka MultiPlan", "plan_name": "Auto Medical Program", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Claritev fka MultiPlan", "plan_name": "Workers' Compensation Program", "standard_charge_percentage": 90, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Claritev fka MultiPlan", "plan_name": "PPO", "standard_charge_percentage": 75, "methodology": "percent of total billed charges", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "First Choice of the Midwest", "plan_name": "PPO", "standard_charge_percentage": 90, "methodology": "percent of total billed charges", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Employee Benefit Management Services (EBMS)", "plan_name": "EBMS SelectCare Network", "standard_charge_percentage": 80, "methodology": "percent of total billed charges", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Medica Insurance Company", "plan_name": "Medicare Cost", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "First Choice Health Network fka Health InfoNet", "plan_name": "Medicare Advantage", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "First Choice Health Network fka Health InfoNet", "plan_name": "Workers Compensation", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Allegiance Provider Direct", "plan_name": "Montana Association of Counties (MACo)", "standard_charge_percentage": 229.99999999999997, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Allegiance Provider Direct", "plan_name": "State of Montana Employee Benefit Plan (Self-Funded)", "standard_charge_percentage": 229.99999999999997, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Allegiance Provider Direct", "plan_name": "Montana Municipal Interlocal Authority (MMIA)", "standard_charge_percentage": 229.99999999999997, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Blue Cross Blue Shield of Montana", "plan_name": "HealthLink Network", "standard_charge_percentage": 75, "methodology": "percent of total billed charges", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Blue Cross Blue Shield of Montana", "plan_name": "Traditional Network", "standard_charge_percentage": 75, "methodology": "percent of total billed charges", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Blue Cross Blue Shield of Montana", "plan_name": "POS Network", "standard_charge_percentage": 75, "methodology": "percent of total billed charges", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Blue Cross Blue Shield of Montana", "plan_name": "Closed Plan Network", "standard_charge_percentage": 75, "methodology": "percent of total billed charges", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Blue Cross Blue Shield of Montana", "plan_name": "Retail HMO POS Network", "standard_charge_percentage": 75, "methodology": "percent of total billed charges", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Blue Cross Blue Shield of Montana", "plan_name": "Blue Options Network", "standard_charge_percentage": 75, "methodology": "percent of total billed charges", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Medicaid (State)", "plan_name": "Medicaid", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "PacificSource Health Plans", "plan_name": "Medicare Advantage", "standard_charge_percentage": 103, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" } ], "minimum": 90, "maximum": 90 } ] }, { "description": "Physical Therapy - Visit Charge", "code_information": [ { "code": "0421", "type": "RC" } ], "standard_charges": [ { "setting": "outpatient", "payers_information": [ { "payer_name": "United Healthcare (UHC)", "plan_name": "DSNP", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "National Comp Care", "plan_name": "Workers' Compensation", "standard_charge_percentage": 90, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Coventry Health Care", "plan_name": "Auto Network", "standard_charge_percentage": 90, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Coventry Health Care", "plan_name": "Workers' Compensation", "standard_charge_percentage": 95, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "TriWest Healthcare Alliance Corporation", "plan_name": "VA CCN", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Blue Cross Blue Shield of Montana", "plan_name": "Medicare Advantage", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "United Healthcare (UHC)", "plan_name": "Medicare Advantage", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Allegiance Provider Direct", "plan_name": "Medicare", "standard_charge_percentage": 229.99999999999997, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "PacificSource Health Plans", "plan_name": "PPO (PSN Network and Smart Health Network)", "standard_charge_percentage": 80, "methodology": "percent of total billed charges", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Medicare (CMS)", "plan_name": "Medicare", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "First Choice Health Network fka Health InfoNet", "plan_name": "Commercial", "standard_charge_percentage": 85, "methodology": "percent of total billed charges", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Claritev fka MultiPlan", "plan_name": "Auto Medical Program", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Claritev fka MultiPlan", "plan_name": "Workers' Compensation Program", "standard_charge_percentage": 90, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Claritev fka MultiPlan", "plan_name": "PPO", "standard_charge_percentage": 75, "methodology": "percent of total billed charges", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "First Choice of the Midwest", "plan_name": "PPO", "standard_charge_percentage": 90, "methodology": "percent of total billed charges", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Employee Benefit Management Services (EBMS)", "plan_name": "EBMS SelectCare Network", "standard_charge_percentage": 80, "methodology": "percent of total billed charges", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Medica Insurance Company", "plan_name": "Medicare Cost", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "First Choice Health Network fka Health InfoNet", "plan_name": "Medicare Advantage", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "First Choice Health Network fka Health InfoNet", "plan_name": "Workers Compensation", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Allegiance Provider Direct", "plan_name": "Montana Association of Counties (MACo)", "standard_charge_percentage": 229.99999999999997, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Allegiance Provider Direct", "plan_name": "State of Montana Employee Benefit Plan (Self-Funded)", "standard_charge_percentage": 229.99999999999997, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Allegiance Provider Direct", "plan_name": "Montana Municipal Interlocal Authority (MMIA)", "standard_charge_percentage": 229.99999999999997, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Blue Cross Blue Shield of Montana", "plan_name": "HealthLink Network", "standard_charge_percentage": 75, "methodology": "percent of total billed charges", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Blue Cross Blue Shield of Montana", "plan_name": "Traditional Network", "standard_charge_percentage": 75, "methodology": "percent of total billed charges", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Blue Cross Blue Shield of Montana", "plan_name": "POS Network", "standard_charge_percentage": 75, "methodology": "percent of total billed charges", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Blue Cross Blue Shield of Montana", "plan_name": "Closed Plan Network", "standard_charge_percentage": 75, "methodology": "percent of total billed charges", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Blue Cross Blue Shield of Montana", "plan_name": "Retail HMO POS Network", "standard_charge_percentage": 75, "methodology": "percent of total billed charges", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Blue Cross Blue Shield of Montana", "plan_name": "Blue Options Network", "standard_charge_percentage": 75, "methodology": "percent of total billed charges", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Medicaid (State)", "plan_name": "Medicaid", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "PacificSource Health Plans", "plan_name": "Medicare Advantage", "standard_charge_percentage": 103, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" } ] } ] }, { "description": "Physical Therapy - Hourly Charge", "code_information": [ { "code": "0422", "type": "RC" } ], "standard_charges": [ { "setting": "outpatient", "payers_information": [ { "payer_name": "United Healthcare (UHC)", "plan_name": "DSNP", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "United Healthcare (UHC)", "plan_name": "Medicare Advantage", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" } ] } ] }, { "description": "Physical Therapy - Group Rate", "code_information": [ { "code": "0423", "type": "RC" } ], "standard_charges": [ { "setting": "outpatient", "payers_information": [ { "payer_name": "United Healthcare (UHC)", "plan_name": "DSNP", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "United Healthcare (UHC)", "plan_name": "Medicare Advantage", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" } ] } ] }, { "description": "Physical Therapy - Evaluation or Re-evaluation", "code_information": [ { "code": "0424", "type": "RC" } ], "standard_charges": [ { "setting": "outpatient", "payers_information": [ { "payer_name": "United Healthcare (UHC)", "plan_name": "DSNP", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "National Comp Care", "plan_name": "Workers' Compensation", "standard_charge_dollar": 150, "methodology": "fee schedule", "median_amount": 150, "10th_percentile": 150, "90th_percentile": 150, "count": "1 through 10" }, { "payer_name": "Coventry Health Care", "plan_name": "Auto Network", "standard_charge_percentage": 90, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Coventry Health Care", "plan_name": "Workers' Compensation", "standard_charge_percentage": 95, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "TriWest Healthcare Alliance Corporation", "plan_name": "VA CCN", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Blue Cross Blue Shield of Montana", "plan_name": "Medicare Advantage", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "United Healthcare (UHC)", "plan_name": "Medicare Advantage", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Allegiance Provider Direct", "plan_name": "Medicare", "standard_charge_percentage": 229.99999999999997, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "PacificSource Health Plans", "plan_name": "PPO (PSN Network and Smart Health Network)", "standard_charge_percentage": 80, "methodology": "percent of total billed charges", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Medicare (CMS)", "plan_name": "Medicare", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "First Choice Health Network fka Health InfoNet", "plan_name": "Commercial", "standard_charge_percentage": 85, "methodology": "percent of total billed charges", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Claritev fka MultiPlan", "plan_name": "Auto Medical Program", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Claritev fka MultiPlan", "plan_name": "Workers' Compensation Program", "standard_charge_percentage": 90, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Claritev fka MultiPlan", "plan_name": "PPO", "standard_charge_percentage": 75, "methodology": "percent of total billed charges", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "First Choice of the Midwest", "plan_name": "PPO", "standard_charge_percentage": 90, "methodology": "percent of total billed charges", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Employee Benefit Management Services (EBMS)", "plan_name": "EBMS SelectCare Network", "standard_charge_percentage": 80, "methodology": "percent of total billed charges", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Medica Insurance Company", "plan_name": "Medicare Cost", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "First Choice Health Network fka Health InfoNet", "plan_name": "Medicare Advantage", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "First Choice Health Network fka Health InfoNet", "plan_name": "Workers Compensation", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Allegiance Provider Direct", "plan_name": "Montana Association of Counties (MACo)", "standard_charge_percentage": 229.99999999999997, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Allegiance Provider Direct", "plan_name": "State of Montana Employee Benefit Plan (Self-Funded)", "standard_charge_percentage": 229.99999999999997, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Allegiance Provider Direct", "plan_name": "Montana Municipal Interlocal Authority (MMIA)", "standard_charge_percentage": 229.99999999999997, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Blue Cross Blue Shield of Montana", "plan_name": "HealthLink Network", "standard_charge_percentage": 75, "methodology": "percent of total billed charges", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Blue Cross Blue Shield of Montana", "plan_name": "Traditional Network", "standard_charge_percentage": 75, "methodology": "percent of total billed charges", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Blue Cross Blue Shield of Montana", "plan_name": "POS Network", "standard_charge_percentage": 75, "methodology": "percent of total billed charges", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Blue Cross Blue Shield of Montana", "plan_name": "Closed Plan Network", "standard_charge_percentage": 75, "methodology": "percent of total billed charges", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Blue Cross Blue Shield of Montana", "plan_name": "Retail HMO POS Network", "standard_charge_percentage": 75, "methodology": "percent of total billed charges", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Blue Cross Blue Shield of Montana", "plan_name": "Blue Options Network", "standard_charge_percentage": 75, "methodology": "percent of total billed charges", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Medicaid (State)", "plan_name": "Medicaid", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "PacificSource Health Plans", "plan_name": "Medicare Advantage", "standard_charge_percentage": 103, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" } ], "minimum": 150, "maximum": 150 } ] }, { "description": "Physical Therapy - Treatment", "code_information": [ { "code": "0425", "type": "RC" } ], "standard_charges": [ { "setting": "outpatient", "payers_information": [ { "payer_name": "United Healthcare (UHC)", "plan_name": "DSNP", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "United Healthcare (UHC)", "plan_name": "Medicare Advantage", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" } ] } ] }, { "description": "Physical Therapy - Continuation", "code_information": [ { "code": "0426", "type": "RC" } ], "standard_charges": [ { "setting": "outpatient", "payers_information": [ { "payer_name": "United Healthcare (UHC)", "plan_name": "DSNP", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "United Healthcare (UHC)", "plan_name": "Medicare Advantage", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" } ] } ] }, { "description": "Physical Therapy - Observation/Hourly", "code_information": [ { "code": "0427", "type": "RC" } ], "standard_charges": [ { "setting": "outpatient", "payers_information": [ { "payer_name": "United Healthcare (UHC)", "plan_name": "DSNP", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "United Healthcare (UHC)", "plan_name": "Medicare Advantage", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" } ] } ] }, { "description": "Physical Therapy - Other", "code_information": [ { "code": "0428", "type": "RC" } ], "standard_charges": [ { "setting": "outpatient", "payers_information": [ { "payer_name": "United Healthcare (UHC)", "plan_name": "DSNP", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "United Healthcare (UHC)", "plan_name": "Medicare Advantage", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" } ] } ] }, { "description": "Physical Therapy - Other", "code_information": [ { "code": "0429", "type": "RC" } ], "standard_charges": [ { "setting": "outpatient", "payers_information": [ { "payer_name": "United Healthcare (UHC)", "plan_name": "DSNP", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "United Healthcare (UHC)", "plan_name": "Medicare Advantage", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" } ] } ] }, { "description": "Occupational Therapy - Visit Charge", "code_information": [ { "code": "0431", "type": "RC" } ], "standard_charges": [ { "setting": "outpatient", "payers_information": [ { "payer_name": "United Healthcare (UHC)", "plan_name": "DSNP", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Blue Cross Blue Shield of Montana", "plan_name": "Medicare Advantage", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "United Healthcare (UHC)", "plan_name": "Medicare Advantage", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Blue Cross Blue Shield of Montana", "plan_name": "HealthLink Network", "standard_charge_percentage": 75, "methodology": "percent of total billed charges", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Blue Cross Blue Shield of Montana", "plan_name": "Traditional Network", "standard_charge_percentage": 75, "methodology": "percent of total billed charges", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Blue Cross Blue Shield of Montana", "plan_name": "POS Network", "standard_charge_percentage": 75, "methodology": "percent of total billed charges", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Blue Cross Blue Shield of Montana", "plan_name": "Closed Plan Network", "standard_charge_percentage": 75, "methodology": "percent of total billed charges", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Blue Cross Blue Shield of Montana", "plan_name": "Retail HMO POS Network", "standard_charge_percentage": 75, "methodology": "percent of total billed charges", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Blue Cross Blue Shield of Montana", "plan_name": "Blue Options Network", "standard_charge_percentage": 75, "methodology": "percent of total billed charges", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" } ] } ] }, { "description": "Occupational Therapy - Hourly Charge", "code_information": [ { "code": "0432", "type": "RC" } ], "standard_charges": [ { "setting": "outpatient", "payers_information": [ { "payer_name": "United Healthcare (UHC)", "plan_name": "DSNP", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "United Healthcare (UHC)", "plan_name": "Medicare Advantage", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Blue Cross Blue Shield of Montana", "plan_name": "HealthLink Network", "standard_charge_percentage": 75, "methodology": "percent of total billed charges", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Blue Cross Blue Shield of Montana", "plan_name": "Traditional Network", "standard_charge_percentage": 75, "methodology": "percent of total billed charges", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Blue Cross Blue Shield of Montana", "plan_name": "POS Network", "standard_charge_percentage": 75, "methodology": "percent of total billed charges", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Blue Cross Blue Shield of Montana", "plan_name": "Closed Plan Network", "standard_charge_percentage": 75, "methodology": "percent of total billed charges", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Blue Cross Blue Shield of Montana", "plan_name": "Retail HMO POS Network", "standard_charge_percentage": 75, "methodology": "percent of total billed charges", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Blue Cross Blue Shield of Montana", "plan_name": "Blue Options Network", "standard_charge_percentage": 75, "methodology": "percent of total billed charges", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" } ] } ] }, { "description": "Behavioral Health Treatment/Services - Rehabilitation", "code_information": [ { "code": "0911", "type": "RC" } ], "standard_charges": [ { "setting": "outpatient", "payers_information": [ { "payer_name": "United Healthcare (UHC)", "plan_name": "DSNP", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "United Healthcare (UHC)", "plan_name": "Medicare Advantage", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" } ] } ] }, { "description": "Behavioral Health Treatment/Services - Partial Hospitalization - Less Intensive", "code_information": [ { "code": "0912", "type": "RC" } ], "standard_charges": [ { "setting": "outpatient", "payers_information": [ { "payer_name": "United Healthcare (UHC)", "plan_name": "DSNP", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "United Healthcare (UHC)", "plan_name": "Medicare Advantage", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" } ] } ] }, { "description": "Behavioral Health Treatment/Services - Partial Hospitalization - Intensive", "code_information": [ { "code": "0913", "type": "RC" } ], "standard_charges": [ { "setting": "outpatient", "payers_information": [ { "payer_name": "United Healthcare (UHC)", "plan_name": "DSNP", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "United Healthcare (UHC)", "plan_name": "Medicare Advantage", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" } ] } ] }, { "description": "Behavioral Health Treatment/Services - Individual Therapy", "code_information": [ { "code": "0914", "type": "RC" } ], "standard_charges": [ { "setting": "outpatient", "payers_information": [ { "payer_name": "United Healthcare (UHC)", "plan_name": "DSNP", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "United Healthcare (UHC)", "plan_name": "Medicare Advantage", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" } ] } ] }, { "description": "Behavioral Health Treatment/Services - Group Therapy", "code_information": [ { "code": "0915", "type": "RC" } ], "standard_charges": [ { "setting": "outpatient", "payers_information": [ { "payer_name": "United Healthcare (UHC)", "plan_name": "DSNP", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "United Healthcare (UHC)", "plan_name": "Medicare Advantage", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" } ] } ] }, { "description": "Behavioral Health Treatment/Services - Family Therapy", "code_information": [ { "code": "0916", "type": "RC" } ], "standard_charges": [ { "setting": "outpatient", "payers_information": [ { "payer_name": "United Healthcare (UHC)", "plan_name": "DSNP", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "United Healthcare (UHC)", "plan_name": "Medicare Advantage", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" } ] } ] }, { "description": "Behavioral Health Treatment/Services - Bio Feedback", "code_information": [ { "code": "0917", "type": "RC" } ], "standard_charges": [ { "setting": "outpatient", "payers_information": [ { "payer_name": "United Healthcare (UHC)", "plan_name": "DSNP", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "United Healthcare (UHC)", "plan_name": "Medicare Advantage", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" } ] } ] }, { "description": "Behavioral Health Treatment/Services - Testing", "code_information": [ { "code": "0918", "type": "RC" } ], "standard_charges": [ { "setting": "outpatient", "payers_information": [ { "payer_name": "United Healthcare (UHC)", "plan_name": "DSNP", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "United Healthcare (UHC)", "plan_name": "Medicare Advantage", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" } ] } ] }, { "description": "Behavioral Health Treatment/Services - Other", "code_information": [ { "code": "0919", "type": "RC" } ], "standard_charges": [ { "setting": "outpatient", "payers_information": [ { "payer_name": "United Healthcare (UHC)", "plan_name": "DSNP", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "United Healthcare (UHC)", "plan_name": "Medicare Advantage", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" } ] } ] }, { "description": "Other Diagnostic Services - General Classification", "code_information": [ { "code": "0920", "type": "RC" } ], "standard_charges": [ { "setting": "outpatient", "payers_information": [ { "payer_name": "United Healthcare (UHC)", "plan_name": "DSNP", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "United Healthcare (UHC)", "plan_name": "Medicare Advantage", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" } ] } ] }, { "description": "Other Diagnostic Services - Peripheral Vascular Lab", "code_information": [ { "code": "0921", "type": "RC" } ], "standard_charges": [ { "setting": "outpatient", "payers_information": [ { "payer_name": "United Healthcare (UHC)", "plan_name": "DSNP", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "United Healthcare (UHC)", "plan_name": "Medicare Advantage", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" } ] } ] }, { "description": "Other Diagnostic Services - Electromyogram", "code_information": [ { "code": "0922", "type": "RC" } ], "standard_charges": [ { "setting": "outpatient", "payers_information": [ { "payer_name": "United Healthcare (UHC)", "plan_name": "DSNP", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "United Healthcare (UHC)", "plan_name": "Medicare Advantage", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" } ] } ] }, { "description": "Other Diagnostic Services - Pap Smear", "code_information": [ { "code": "0923", "type": "RC" } ], "standard_charges": [ { "setting": "outpatient", "payers_information": [ { "payer_name": "United Healthcare (UHC)", "plan_name": "DSNP", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "United Healthcare (UHC)", "plan_name": "Medicare Advantage", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "United Healthcare (UHC)", "plan_name": "HMO", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "United Healthcare (UHC)", "plan_name": "PPO", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "United Healthcare (UHC)", "plan_name": "Indemnity", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" } ] } ] }, { "description": "Other Diagnostic Services - Allergy Test", "code_information": [ { "code": "0924", "type": "RC" } ], "standard_charges": [ { "setting": "outpatient", "payers_information": [ { "payer_name": "United Healthcare (UHC)", "plan_name": "DSNP", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "United Healthcare (UHC)", "plan_name": "Medicare Advantage", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" } ] } ] }, { "description": "Other Diagnostic Services - Pregnancy Test", "code_information": [ { "code": "0925", "type": "RC" } ], "standard_charges": [ { "setting": "outpatient", "payers_information": [ { "payer_name": "United Healthcare (UHC)", "plan_name": "DSNP", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "United Healthcare (UHC)", "plan_name": "Medicare Advantage", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "United Healthcare (UHC)", "plan_name": "HMO", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "United Healthcare (UHC)", "plan_name": "PPO", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "United Healthcare (UHC)", "plan_name": "Indemnity", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" } ] } ] }, { "description": "Other Diagnostic Services - Continuation", "code_information": [ { "code": "0926", "type": "RC" } ], "standard_charges": [ { "setting": "outpatient", "payers_information": [ { "payer_name": "United Healthcare (UHC)", "plan_name": "DSNP", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "United Healthcare (UHC)", "plan_name": "Medicare Advantage", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" } ] } ] }, { "description": "Other Diagnostic Services - Observation/Hourly", "code_information": [ { "code": "0927", "type": "RC" } ], "standard_charges": [ { "setting": "outpatient", "payers_information": [ { "payer_name": "United Healthcare (UHC)", "plan_name": "DSNP", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "United Healthcare (UHC)", "plan_name": "Medicare Advantage", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" } ] } ] }, { "description": "Other Diagnostic Services - Other", "code_information": [ { "code": "0928", "type": "RC" } ], "standard_charges": [ { "setting": "outpatient", "payers_information": [ { "payer_name": "United Healthcare (UHC)", "plan_name": "DSNP", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "United Healthcare (UHC)", "plan_name": "Medicare Advantage", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" } ] } ] }, { "description": "Other Diagnostic Services - Other Diagnostic Service", "code_information": [ { "code": "0929", "type": "RC" } ], "standard_charges": [ { "setting": "outpatient", "payers_information": [ { "payer_name": "United Healthcare (UHC)", "plan_name": "DSNP", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "United Healthcare (UHC)", "plan_name": "Medicare Advantage", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" } ] } ] }, { "description": "Other Diagnostic Radiology - General Classification", "code_information": [ { "code": "0930", "type": "RC" } ], "standard_charges": [ { "setting": "outpatient", "payers_information": [ { "payer_name": "United Healthcare (UHC)", "plan_name": "DSNP", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "United Healthcare (UHC)", "plan_name": "Medicare Advantage", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" } ] } ] }, { "description": "Speech Therapy - Language Pathology - Evaluation or Reevaluation", "code_information": [ { "code": "0444", "type": "RC" } ], "standard_charges": [ { "setting": "outpatient", "payers_information": [ { "payer_name": "United Healthcare (UHC)", "plan_name": "DSNP", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "National Comp Care", "plan_name": "Workers' Compensation", "standard_charge_dollar": 150, "methodology": "fee schedule", "median_amount": 150, "10th_percentile": 150, "90th_percentile": 150, "count": "1 through 10" }, { "payer_name": "Coventry Health Care", "plan_name": "Auto Network", "standard_charge_percentage": 90, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Coventry Health Care", "plan_name": "Workers' Compensation", "standard_charge_percentage": 95, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "TriWest Healthcare Alliance Corporation", "plan_name": "VA CCN", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Blue Cross Blue Shield of Montana", "plan_name": "Medicare Advantage", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "United Healthcare (UHC)", "plan_name": "Medicare Advantage", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Allegiance Provider Direct", "plan_name": "State of Montana Employee Benefit Plan (Self-Funded)", "standard_charge_percentage": 229.99999999999997, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Allegiance Provider Direct", "plan_name": "Montana Municipal Interlocal Authority (MMIA)", "standard_charge_percentage": 229.99999999999997, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Medicare (CMS)", "plan_name": "Medicare", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Blue Cross Blue Shield of Montana", "plan_name": "HealthLink Network", "standard_charge_percentage": 75, "methodology": "percent of total billed charges", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Blue Cross Blue Shield of Montana", "plan_name": "Traditional Network", "standard_charge_percentage": 75, "methodology": "percent of total billed charges", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Blue Cross Blue Shield of Montana", "plan_name": "POS Network", "standard_charge_percentage": 75, "methodology": "percent of total billed charges", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Blue Cross Blue Shield of Montana", "plan_name": "Closed Plan Network", "standard_charge_percentage": 75, "methodology": "percent of total billed charges", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Blue Cross Blue Shield of Montana", "plan_name": "Retail HMO POS Network", "standard_charge_percentage": 75, "methodology": "percent of total billed charges", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Blue Cross Blue Shield of Montana", "plan_name": "Blue Options Network", "standard_charge_percentage": 75, "methodology": "percent of total billed charges", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Medicaid (State)", "plan_name": "Medicaid", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "PacificSource Health Plans", "plan_name": "Medicare Advantage", "standard_charge_percentage": 103, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" } ], "minimum": 150, "maximum": 150 } ] }, { "description": "Speech-Language Pathology - Treatment", "code_information": [ { "code": "0445", "type": "RC" } ], "standard_charges": [ { "setting": "outpatient", "payers_information": [ { "payer_name": "United Healthcare (UHC)", "plan_name": "DSNP", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "United Healthcare (UHC)", "plan_name": "Medicare Advantage", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Blue Cross Blue Shield of Montana", "plan_name": "HealthLink Network", "standard_charge_percentage": 75, "methodology": "percent of total billed charges", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Blue Cross Blue Shield of Montana", "plan_name": "Traditional Network", "standard_charge_percentage": 75, "methodology": "percent of total billed charges", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Blue Cross Blue Shield of Montana", "plan_name": "POS Network", "standard_charge_percentage": 75, "methodology": "percent of total billed charges", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Blue Cross Blue Shield of Montana", "plan_name": "Closed Plan Network", "standard_charge_percentage": 75, "methodology": "percent of total billed charges", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Blue Cross Blue Shield of Montana", "plan_name": "Retail HMO POS Network", "standard_charge_percentage": 75, "methodology": "percent of total billed charges", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Blue Cross Blue Shield of Montana", "plan_name": "Blue Options Network", "standard_charge_percentage": 75, "methodology": "percent of total billed charges", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" } ] } ] }, { "description": "Speech-Language Pathology - Continuation", "code_information": [ { "code": "0446", "type": "RC" } ], "standard_charges": [ { "setting": "outpatient", "payers_information": [ { "payer_name": "United Healthcare (UHC)", "plan_name": "DSNP", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "United Healthcare (UHC)", "plan_name": "Medicare Advantage", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Blue Cross Blue Shield of Montana", "plan_name": "HealthLink Network", "standard_charge_percentage": 75, "methodology": "percent of total billed charges", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Blue Cross Blue Shield of Montana", "plan_name": "Traditional Network", "standard_charge_percentage": 75, "methodology": "percent of total billed charges", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Blue Cross Blue Shield of Montana", "plan_name": "POS Network", "standard_charge_percentage": 75, "methodology": "percent of total billed charges", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Blue Cross Blue Shield of Montana", "plan_name": "Closed Plan Network", "standard_charge_percentage": 75, "methodology": "percent of total billed charges", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Blue Cross Blue Shield of Montana", "plan_name": "Retail HMO POS Network", "standard_charge_percentage": 75, "methodology": "percent of total billed charges", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Blue Cross Blue Shield of Montana", "plan_name": "Blue Options Network", "standard_charge_percentage": 75, "methodology": "percent of total billed charges", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" } ] } ] }, { "description": "Speech-Language Pathology - Observation/Hourly", "code_information": [ { "code": "0447", "type": "RC" } ], "standard_charges": [ { "setting": "outpatient", "payers_information": [ { "payer_name": "United Healthcare (UHC)", "plan_name": "DSNP", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "United Healthcare (UHC)", "plan_name": "Medicare Advantage", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Blue Cross Blue Shield of Montana", "plan_name": "HealthLink Network", "standard_charge_percentage": 75, "methodology": "percent of total billed charges", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Blue Cross Blue Shield of Montana", "plan_name": "Traditional Network", "standard_charge_percentage": 75, "methodology": "percent of total billed charges", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Blue Cross Blue Shield of Montana", "plan_name": "POS Network", "standard_charge_percentage": 75, "methodology": "percent of total billed charges", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Blue Cross Blue Shield of Montana", "plan_name": "Closed Plan Network", "standard_charge_percentage": 75, "methodology": "percent of total billed charges", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Blue Cross Blue Shield of Montana", "plan_name": "Retail HMO POS Network", "standard_charge_percentage": 75, "methodology": "percent of total billed charges", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Blue Cross Blue Shield of Montana", "plan_name": "Blue Options Network", "standard_charge_percentage": 75, "methodology": "percent of total billed charges", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" } ] } ] }, { "description": "Speech-Language Pathology - Other", "code_information": [ { "code": "0448", "type": "RC" } ], "standard_charges": [ { "setting": "outpatient", "payers_information": [ { "payer_name": "United Healthcare (UHC)", "plan_name": "DSNP", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "United Healthcare (UHC)", "plan_name": "Medicare Advantage", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Blue Cross Blue Shield of Montana", "plan_name": "HealthLink Network", "standard_charge_percentage": 75, "methodology": "percent of total billed charges", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Blue Cross Blue Shield of Montana", "plan_name": "Traditional Network", "standard_charge_percentage": 75, "methodology": "percent of total billed charges", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Blue Cross Blue Shield of Montana", "plan_name": "POS Network", "standard_charge_percentage": 75, "methodology": "percent of total billed charges", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Blue Cross Blue Shield of Montana", "plan_name": "Closed Plan Network", "standard_charge_percentage": 75, "methodology": "percent of total billed charges", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Blue Cross Blue Shield of Montana", "plan_name": "Retail HMO POS Network", "standard_charge_percentage": 75, "methodology": "percent of total billed charges", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Blue Cross Blue Shield of Montana", "plan_name": "Blue Options Network", "standard_charge_percentage": 75, "methodology": "percent of total billed charges", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" } ] } ] }, { "description": "Speech Therapy - Language Pathology - Other", "code_information": [ { "code": "0449", "type": "RC" } ], "standard_charges": [ { "setting": "outpatient", "payers_information": [ { "payer_name": "United Healthcare (UHC)", "plan_name": "DSNP", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "United Healthcare (UHC)", "plan_name": "Medicare Advantage", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Blue Cross Blue Shield of Montana", "plan_name": "HealthLink Network", "standard_charge_percentage": 75, "methodology": "percent of total billed charges", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Blue Cross Blue Shield of Montana", "plan_name": "Traditional Network", "standard_charge_percentage": 75, "methodology": "percent of total billed charges", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Blue Cross Blue Shield of Montana", "plan_name": "POS Network", "standard_charge_percentage": 75, "methodology": "percent of total billed charges", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Blue Cross Blue Shield of Montana", "plan_name": "Closed Plan Network", "standard_charge_percentage": 75, "methodology": "percent of total billed charges", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Blue Cross Blue Shield of Montana", "plan_name": "Retail HMO POS Network", "standard_charge_percentage": 75, "methodology": "percent of total billed charges", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Blue Cross Blue Shield of Montana", "plan_name": "Blue Options Network", "standard_charge_percentage": 75, "methodology": "percent of total billed charges", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" } ] } ] }, { "description": "Emergency Room - General Classification", "code_information": [ { "code": "0450", "type": "RC" } ], "standard_charges": [ { "setting": "outpatient", "payers_information": [ { "payer_name": "United Healthcare (UHC)", "plan_name": "DSNP", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "United Healthcare (UHC)", "plan_name": "Medicare Advantage", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" } ] } ] }, { "description": "Emergency Room - EMTALA Emergency Medical Screening Services", "code_information": [ { "code": "0451", "type": "RC" } ], "standard_charges": [ { "setting": "outpatient", "payers_information": [ { "payer_name": "United Healthcare (UHC)", "plan_name": "DSNP", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "United Healthcare (UHC)", "plan_name": "Medicare Advantage", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" } ] } ] }, { "description": "Emergency Room - Beyond EMTALA Screening", "code_information": [ { "code": "0452", "type": "RC" } ], "standard_charges": [ { "setting": "outpatient", "payers_information": [ { "payer_name": "United Healthcare (UHC)", "plan_name": "DSNP", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "United Healthcare (UHC)", "plan_name": "Medicare Advantage", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" } ] } ] }, { "description": "Emergency Room - Assessment", "code_information": [ { "code": "0453", "type": "RC" } ], "standard_charges": [ { "setting": "outpatient", "payers_information": [ { "payer_name": "United Healthcare (UHC)", "plan_name": "DSNP", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "United Healthcare (UHC)", "plan_name": "Medicare Advantage", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" } ] } ] }, { "description": "Emergency Room - Evaluation or Testing", "code_information": [ { "code": "0454", "type": "RC" } ], "standard_charges": [ { "setting": "outpatient", "payers_information": [ { "payer_name": "United Healthcare (UHC)", "plan_name": "DSNP", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "United Healthcare (UHC)", "plan_name": "Medicare Advantage", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" } ] } ] }, { "description": "Emergency Room - Treatment", "code_information": [ { "code": "0455", "type": "RC" } ], "standard_charges": [ { "setting": "outpatient", "payers_information": [ { "payer_name": "United Healthcare (UHC)", "plan_name": "DSNP", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "United Healthcare (UHC)", "plan_name": "Medicare Advantage", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" } ] } ] }, { "description": "Emergency Room - Urgent Care", "code_information": [ { "code": "0456", "type": "RC" } ], "standard_charges": [ { "setting": "outpatient", "payers_information": [ { "payer_name": "United Healthcare (UHC)", "plan_name": "DSNP", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "United Healthcare (UHC)", "plan_name": "Medicare Advantage", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" } ] } ] }, { "description": "Emergency Room - Observation/Hourly", "code_information": [ { "code": "0457", "type": "RC" } ], "standard_charges": [ { "setting": "outpatient", "payers_information": [ { "payer_name": "United Healthcare (UHC)", "plan_name": "DSNP", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "United Healthcare (UHC)", "plan_name": "Medicare Advantage", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" } ] } ] }, { "description": "Emergency Room - Other", "code_information": [ { "code": "0458", "type": "RC" } ], "standard_charges": [ { "setting": "outpatient", "payers_information": [ { "payer_name": "United Healthcare (UHC)", "plan_name": "DSNP", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "United Healthcare (UHC)", "plan_name": "Medicare Advantage", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" } ] } ] }, { "description": "Emergency Room - Other", "code_information": [ { "code": "0459", "type": "RC" } ], "standard_charges": [ { "setting": "outpatient", "payers_information": [ { "payer_name": "United Healthcare (UHC)", "plan_name": "DSNP", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "United Healthcare (UHC)", "plan_name": "Medicare Advantage", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" } ] } ] }, { "description": "Pulmonary Function - General Classification", "code_information": [ { "code": "0460", "type": "RC" } ], "standard_charges": [ { "setting": "outpatient", "payers_information": [ { "payer_name": "United Healthcare (UHC)", "plan_name": "DSNP", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "United Healthcare (UHC)", "plan_name": "Medicare Advantage", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" } ] } ] }, { "description": "Pulmonary Function - Visit", "code_information": [ { "code": "0461", "type": "RC" } ], "standard_charges": [ { "setting": "outpatient", "payers_information": [ { "payer_name": "United Healthcare (UHC)", "plan_name": "DSNP", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "United Healthcare (UHC)", "plan_name": "Medicare Advantage", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" } ] } ] }, { "description": "Pulmonary Function - Unit", "code_information": [ { "code": "0462", "type": "RC" } ], "standard_charges": [ { "setting": "outpatient", "payers_information": [ { "payer_name": "United Healthcare (UHC)", "plan_name": "DSNP", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "United Healthcare (UHC)", "plan_name": "Medicare Advantage", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" } ] } ] }, { "description": "Pulmonary Function - Assessment", "code_information": [ { "code": "0463", "type": "RC" } ], "standard_charges": [ { "setting": "outpatient", "payers_information": [ { "payer_name": "United Healthcare (UHC)", "plan_name": "DSNP", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "United Healthcare (UHC)", "plan_name": "Medicare Advantage", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" } ] } ] }, { "description": "Pulmonary Function - Evaluation or Testing", "code_information": [ { "code": "0464", "type": "RC" } ], "standard_charges": [ { "setting": "outpatient", "payers_information": [ { "payer_name": "United Healthcare (UHC)", "plan_name": "DSNP", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "United Healthcare (UHC)", "plan_name": "Medicare Advantage", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" } ] } ] }, { "description": "Pulmonary Function - Treatment", "code_information": [ { "code": "0465", "type": "RC" } ], "standard_charges": [ { "setting": "outpatient", "payers_information": [ { "payer_name": "United Healthcare (UHC)", "plan_name": "DSNP", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "United Healthcare (UHC)", "plan_name": "Medicare Advantage", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" } ] } ] }, { "description": "Pulmonary Function - Continuation", "code_information": [ { "code": "0466", "type": "RC" } ], "standard_charges": [ { "setting": "outpatient", "payers_information": [ { "payer_name": "United Healthcare (UHC)", "plan_name": "DSNP", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "United Healthcare (UHC)", "plan_name": "Medicare Advantage", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" } ] } ] }, { "description": "Pulmonary Function - Observation/Hourly", "code_information": [ { "code": "0467", "type": "RC" } ], "standard_charges": [ { "setting": "outpatient", "payers_information": [ { "payer_name": "United Healthcare (UHC)", "plan_name": "DSNP", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "United Healthcare (UHC)", "plan_name": "Medicare Advantage", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" } ] } ] }, { "description": "Pulmonary Function - Other", "code_information": [ { "code": "0468", "type": "RC" } ], "standard_charges": [ { "setting": "outpatient", "payers_information": [ { "payer_name": "United Healthcare (UHC)", "plan_name": "DSNP", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "United Healthcare (UHC)", "plan_name": "Medicare Advantage", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" } ] } ] }, { "description": "Pulmonary Function - Other", "code_information": [ { "code": "0469", "type": "RC" } ], "standard_charges": [ { "setting": "outpatient", "payers_information": [ { "payer_name": "United Healthcare (UHC)", "plan_name": "DSNP", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "United Healthcare (UHC)", "plan_name": "Medicare Advantage", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" } ] } ] }, { "description": "Audiology - General Classification", "code_information": [ { "code": "0470", "type": "RC" } ], "standard_charges": [ { "setting": "outpatient", "payers_information": [ { "payer_name": "United Healthcare (UHC)", "plan_name": "DSNP", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "United Healthcare (UHC)", "plan_name": "Medicare Advantage", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" } ] } ] }, { "description": "Audiology - Diagnostic", "code_information": [ { "code": "0471", "type": "RC" } ], "standard_charges": [ { "setting": "outpatient", "payers_information": [ { "payer_name": "United Healthcare (UHC)", "plan_name": "DSNP", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "United Healthcare (UHC)", "plan_name": "Medicare Advantage", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" } ] } ] }, { "description": "Audiology - Treatment", "code_information": [ { "code": "0472", "type": "RC" } ], "standard_charges": [ { "setting": "outpatient", "payers_information": [ { "payer_name": "United Healthcare (UHC)", "plan_name": "DSNP", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "United Healthcare (UHC)", "plan_name": "Medicare Advantage", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" } ] } ] }, { "description": "Ambulatory Surgical Care - Assessment", "code_information": [ { "code": "0473", "type": "RC" } ], "standard_charges": [ { "setting": "outpatient", "payers_information": [ { "payer_name": "United Healthcare (UHC)", "plan_name": "DSNP", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "United Healthcare (UHC)", "plan_name": "Medicare Advantage", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" } ] } ] }, { "description": "Ambulatory Surgical Care - Evaluation or Testing", "code_information": [ { "code": "0474", "type": "RC" } ], "standard_charges": [ { "setting": "outpatient", "payers_information": [ { "payer_name": "United Healthcare (UHC)", "plan_name": "DSNP", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "United Healthcare (UHC)", "plan_name": "Medicare Advantage", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" } ] } ] }, { "description": "Ambulatory Surgical Care - Treatment", "code_information": [ { "code": "0475", "type": "RC" } ], "standard_charges": [ { "setting": "outpatient", "payers_information": [ { "payer_name": "United Healthcare (UHC)", "plan_name": "DSNP", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "United Healthcare (UHC)", "plan_name": "Medicare Advantage", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" } ] } ] }, { "description": "Ambulatory Surgical Care - Continuation", "code_information": [ { "code": "0476", "type": "RC" } ], "standard_charges": [ { "setting": "outpatient", "payers_information": [ { "payer_name": "United Healthcare (UHC)", "plan_name": "DSNP", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "United Healthcare (UHC)", "plan_name": "Medicare Advantage", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" } ] } ] }, { "description": "Ambulatory Surgical Care - Observation/Hourly", "code_information": [ { "code": "0477", "type": "RC" } ], "standard_charges": [ { "setting": "outpatient", "payers_information": [ { "payer_name": "United Healthcare (UHC)", "plan_name": "DSNP", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "United Healthcare (UHC)", "plan_name": "Medicare Advantage", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" } ] } ] }, { "description": "Ambulatory Surgical Care - Other", "code_information": [ { "code": "0478", "type": "RC" } ], "standard_charges": [ { "setting": "outpatient", "payers_information": [ { "payer_name": "United Healthcare (UHC)", "plan_name": "DSNP", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "United Healthcare (UHC)", "plan_name": "Medicare Advantage", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" } ] } ] }, { "description": "Audiology - Other", "code_information": [ { "code": "0479", "type": "RC" } ], "standard_charges": [ { "setting": "outpatient", "payers_information": [ { "payer_name": "United Healthcare (UHC)", "plan_name": "DSNP", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "United Healthcare (UHC)", "plan_name": "Medicare Advantage", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" } ] } ] }, { "description": "Cardiology - General Classification", "code_information": [ { "code": "0480", "type": "RC" } ], "standard_charges": [ { "setting": "outpatient", "payers_information": [ { "payer_name": "United Healthcare (UHC)", "plan_name": "DSNP", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "United Healthcare (UHC)", "plan_name": "Medicare Advantage", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" } ] } ] }, { "description": "Cardiology - Cardiac Cath Lab", "code_information": [ { "code": "0481", "type": "RC" } ], "standard_charges": [ { "setting": "outpatient", "payers_information": [ { "payer_name": "United Healthcare (UHC)", "plan_name": "DSNP", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "United Healthcare (UHC)", "plan_name": "Medicare Advantage", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" } ] } ] }, { "description": "Cardiology - Stress Test", "code_information": [ { "code": "0482", "type": "RC" } ], "standard_charges": [ { "setting": "outpatient", "payers_information": [ { "payer_name": "United Healthcare (UHC)", "plan_name": "DSNP", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "United Healthcare (UHC)", "plan_name": "Medicare Advantage", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" } ] } ] }, { "description": "Cardiology - Echocardiology", "code_information": [ { "code": "0483", "type": "RC" } ], "standard_charges": [ { "setting": "outpatient", "payers_information": [ { "payer_name": "United Healthcare (UHC)", "plan_name": "DSNP", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "United Healthcare (UHC)", "plan_name": "Medicare Advantage", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" } ] } ] }, { "description": "Cardiology - Evaluation or Testing", "code_information": [ { "code": "0484", "type": "RC" } ], "standard_charges": [ { "setting": "outpatient", "payers_information": [ { "payer_name": "United Healthcare (UHC)", "plan_name": "DSNP", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "United Healthcare (UHC)", "plan_name": "Medicare Advantage", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" } ] } ] }, { "description": "Cardiology - Treatment", "code_information": [ { "code": "0485", "type": "RC" } ], "standard_charges": [ { "setting": "outpatient", "payers_information": [ { "payer_name": "United Healthcare (UHC)", "plan_name": "DSNP", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "United Healthcare (UHC)", "plan_name": "Medicare Advantage", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" } ] } ] }, { "description": "Cardiology - Continuation", "code_information": [ { "code": "0486", "type": "RC" } ], "standard_charges": [ { "setting": "outpatient", "payers_information": [ { "payer_name": "United Healthcare (UHC)", "plan_name": "DSNP", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "United Healthcare (UHC)", "plan_name": "Medicare Advantage", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" } ] } ] }, { "description": "Cardiology - Observation/Hourly", "code_information": [ { "code": "0487", "type": "RC" } ], "standard_charges": [ { "setting": "outpatient", "payers_information": [ { "payer_name": "United Healthcare (UHC)", "plan_name": "DSNP", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "United Healthcare (UHC)", "plan_name": "Medicare Advantage", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" } ] } ] }, { "description": "Cardiology - Other", "code_information": [ { "code": "0488", "type": "RC" } ], "standard_charges": [ { "setting": "outpatient", "payers_information": [ { "payer_name": "United Healthcare (UHC)", "plan_name": "DSNP", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "United Healthcare (UHC)", "plan_name": "Medicare Advantage", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" } ] } ] }, { "description": "Cardiology - Other", "code_information": [ { "code": "0489", "type": "RC" } ], "standard_charges": [ { "setting": "outpatient", "payers_information": [ { "payer_name": "United Healthcare (UHC)", "plan_name": "DSNP", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "United Healthcare (UHC)", "plan_name": "Medicare Advantage", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" } ] } ] }, { "description": "Ambulatory Surgical Care - General Classification", "code_information": [ { "code": "0490", "type": "RC" } ], "standard_charges": [ { "setting": "outpatient", "payers_information": [ { "payer_name": "United Healthcare (UHC)", "plan_name": "DSNP", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "United Healthcare (UHC)", "plan_name": "Medicare Advantage", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" } ] } ] }, { "description": "Clinic - General Classification", "code_information": [ { "code": "0510", "type": "RC" } ], "standard_charges": [ { "setting": "outpatient", "payers_information": [ { "payer_name": "United Healthcare (UHC)", "plan_name": "DSNP", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "United Healthcare (UHC)", "plan_name": "Medicare Advantage", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" } ] } ] }, { "description": "Clinic - Chronic Pain Center", "code_information": [ { "code": "0511", "type": "RC" } ], "standard_charges": [ { "setting": "outpatient", "payers_information": [ { "payer_name": "United Healthcare (UHC)", "plan_name": "DSNP", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "United Healthcare (UHC)", "plan_name": "Medicare Advantage", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" } ] } ] }, { "description": "Clinic - Dental", "code_information": [ { "code": "0512", "type": "RC" } ], "standard_charges": [ { "setting": "outpatient", "payers_information": [ { "payer_name": "United Healthcare (UHC)", "plan_name": "DSNP", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "United Healthcare (UHC)", "plan_name": "Medicare Advantage", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" } ] } ] }, { "description": "Clinic - Psychiatric", "code_information": [ { "code": "0513", "type": "RC" } ], "standard_charges": [ { "setting": "outpatient", "payers_information": [ { "payer_name": "United Healthcare (UHC)", "plan_name": "DSNP", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "United Healthcare (UHC)", "plan_name": "Medicare Advantage", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" } ] } ] }, { "description": "Clinic - OB-GYN", "code_information": [ { "code": "0514", "type": "RC" } ], "standard_charges": [ { "setting": "outpatient", "payers_information": [ { "payer_name": "United Healthcare (UHC)", "plan_name": "DSNP", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "United Healthcare (UHC)", "plan_name": "Medicare Advantage", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" } ] } ] }, { "description": "Clinic - Pediatric", "code_information": [ { "code": "0515", "type": "RC" } ], "standard_charges": [ { "setting": "outpatient", "payers_information": [ { "payer_name": "United Healthcare (UHC)", "plan_name": "DSNP", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "United Healthcare (UHC)", "plan_name": "Medicare Advantage", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" } ] } ] }, { "description": "Clinic - Urgent Care", "code_information": [ { "code": "0516", "type": "RC" } ], "standard_charges": [ { "setting": "outpatient", "payers_information": [ { "payer_name": "United Healthcare (UHC)", "plan_name": "DSNP", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "United Healthcare (UHC)", "plan_name": "Medicare Advantage", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" } ] } ] }, { "description": "Clinic - Family Practice", "code_information": [ { "code": "0517", "type": "RC" } ], "standard_charges": [ { "setting": "outpatient", "payers_information": [ { "payer_name": "United Healthcare (UHC)", "plan_name": "DSNP", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "United Healthcare (UHC)", "plan_name": "Medicare Advantage", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" } ] } ] }, { "description": "Clinic - Other", "code_information": [ { "code": "0518", "type": "RC" } ], "standard_charges": [ { "setting": "outpatient", "payers_information": [ { "payer_name": "United Healthcare (UHC)", "plan_name": "DSNP", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "United Healthcare (UHC)", "plan_name": "Medicare Advantage", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" } ] } ] }, { "description": "Clinic - Other", "code_information": [ { "code": "0519", "type": "RC" } ], "standard_charges": [ { "setting": "outpatient", "payers_information": [ { "payer_name": "United Healthcare (UHC)", "plan_name": "DSNP", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "United Healthcare (UHC)", "plan_name": "Medicare Advantage", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" } ] } ] }, { "description": "Free-Standing Clinic - General Classification", "code_information": [ { "code": "0520", "type": "RC" } ], "standard_charges": [ { "setting": "outpatient", "payers_information": [ { "payer_name": "United Healthcare (UHC)", "plan_name": "DSNP", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "United Healthcare (UHC)", "plan_name": "Medicare Advantage", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" } ] } ] }, { "description": "Free-Standing Clinic - Clinic visit by member to RHC/FQHC", "code_information": [ { "code": "0521", "type": "RC" } ], "standard_charges": [ { "setting": "outpatient", "payers_information": [ { "payer_name": "United Healthcare (UHC)", "plan_name": "DSNP", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "United Healthcare (UHC)", "plan_name": "Medicare Advantage", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" } ] } ] }, { "description": "Free-Standing Clinic - Home visit by RHC/FQHC practitioner", "code_information": [ { "code": "0522", "type": "RC" } ], "standard_charges": [ { "setting": "outpatient", "payers_information": [ { "payer_name": "United Healthcare (UHC)", "plan_name": "DSNP", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "United Healthcare (UHC)", "plan_name": "Medicare Advantage", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" } ] } ] }, { "description": "Free-Standing Clinic - Family Practice", "code_information": [ { "code": "0523", "type": "RC" } ], "standard_charges": [ { "setting": "outpatient", "payers_information": [ { "payer_name": "United Healthcare (UHC)", "plan_name": "DSNP", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "United Healthcare (UHC)", "plan_name": "Medicare Advantage", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" } ] } ] }, { "description": "Free-Standing Clinic - Visit by RHC/FQHC practitioner to a member in a SNF or Skilled Swing Bed in a covered Part A stay", "code_information": [ { "code": "0524", "type": "RC" } ], "standard_charges": [ { "setting": "outpatient", "payers_information": [ { "payer_name": "United Healthcare (UHC)", "plan_name": "DSNP", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "United Healthcare (UHC)", "plan_name": "Medicare Advantage", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" } ] } ] }, { "description": "Free-Standing Clinic - Visit by RHC/FQHC practitioner to a member in a SNF (not in a covered Part A stay) or NF or ICF MR or other residential facility", "code_information": [ { "code": "0525", "type": "RC" } ], "standard_charges": [ { "setting": "outpatient", "payers_information": [ { "payer_name": "United Healthcare (UHC)", "plan_name": "DSNP", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "United Healthcare (UHC)", "plan_name": "Medicare Advantage", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" } ] } ] }, { "description": "Free-Standing Clinic - Urgent Care", "code_information": [ { "code": "0526", "type": "RC" } ], "standard_charges": [ { "setting": "outpatient", "payers_information": [ { "payer_name": "United Healthcare (UHC)", "plan_name": "DSNP", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "United Healthcare (UHC)", "plan_name": "Medicare Advantage", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" } ] } ] }, { "description": "Free-Standing Clinic - RHC/FQHC Visiting Nurse Service(s) to a member's home when in a home health shortage area", "code_information": [ { "code": "0527", "type": "RC" } ], "standard_charges": [ { "setting": "outpatient", "payers_information": [ { "payer_name": "United Healthcare (UHC)", "plan_name": "DSNP", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "United Healthcare (UHC)", "plan_name": "Medicare Advantage", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" } ] } ] }, { "description": "Free-Standing Clinic - Visit by RHC/FQHC practitioner to other non RHC/FQHC site (e.g., scene of accident)", "code_information": [ { "code": "0528", "type": "RC" } ], "standard_charges": [ { "setting": "outpatient", "payers_information": [ { "payer_name": "United Healthcare (UHC)", "plan_name": "DSNP", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "United Healthcare (UHC)", "plan_name": "Medicare Advantage", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" } ] } ] }, { "description": "Free-Standing Clinic - Other", "code_information": [ { "code": "0529", "type": "RC" } ], "standard_charges": [ { "setting": "outpatient", "payers_information": [ { "payer_name": "United Healthcare (UHC)", "plan_name": "DSNP", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "United Healthcare (UHC)", "plan_name": "Medicare Advantage", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" } ] } ] }, { "description": "Magnetic Resonance Technology (MRT) - General Classification", "code_information": [ { "code": "0610", "type": "RC" } ], "standard_charges": [ { "setting": "outpatient", "payers_information": [ { "payer_name": "United Healthcare (UHC)", "plan_name": "DSNP", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "United Healthcare (UHC)", "plan_name": "Medicare Advantage", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" } ] } ] }, { "description": "Magnetic Resonance Technology (MRT) - Brain/Brainstem", "code_information": [ { "code": "0611", "type": "RC" } ], "standard_charges": [ { "setting": "outpatient", "payers_information": [ { "payer_name": "United Healthcare (UHC)", "plan_name": "DSNP", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "United Healthcare (UHC)", "plan_name": "Medicare Advantage", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" } ] } ] }, { "description": "Magnetic Resonance Technology (MRT) - Spinal Cord/Spine", "code_information": [ { "code": "0612", "type": "RC" } ], "standard_charges": [ { "setting": "outpatient", "payers_information": [ { "payer_name": "United Healthcare (UHC)", "plan_name": "DSNP", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "United Healthcare (UHC)", "plan_name": "Medicare Advantage", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" } ] } ] }, { "description": "Magnetic Resonance Technology (MRT) - MRI - Other", "code_information": [ { "code": "0614", "type": "RC" } ], "standard_charges": [ { "setting": "outpatient", "payers_information": [ { "payer_name": "United Healthcare (UHC)", "plan_name": "DSNP", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "United Healthcare (UHC)", "plan_name": "Medicare Advantage", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" } ] } ] }, { "description": "Magnetic Resonance Technology (MRT) - MRA - Head and Neck", "code_information": [ { "code": "0615", "type": "RC" } ], "standard_charges": [ { "setting": "outpatient", "payers_information": [ { "payer_name": "United Healthcare (UHC)", "plan_name": "DSNP", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "United Healthcare (UHC)", "plan_name": "Medicare Advantage", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" } ] } ] }, { "description": "Magnetic Resonance Technology (MRT) - MRA - Lower Extremities", "code_information": [ { "code": "0616", "type": "RC" } ], "standard_charges": [ { "setting": "outpatient", "payers_information": [ { "payer_name": "United Healthcare (UHC)", "plan_name": "DSNP", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "United Healthcare (UHC)", "plan_name": "Medicare Advantage", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" } ] } ] }, { "description": "Magnetic Resonance Technology (MRT) - MRA - Other", "code_information": [ { "code": "0618", "type": "RC" } ], "standard_charges": [ { "setting": "outpatient", "payers_information": [ { "payer_name": "United Healthcare (UHC)", "plan_name": "DSNP", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "United Healthcare (UHC)", "plan_name": "Medicare Advantage", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" } ] } ] }, { "description": "Magnetic Resonance Technology (MRT) - Other", "code_information": [ { "code": "0619", "type": "RC" } ], "standard_charges": [ { "setting": "outpatient", "payers_information": [ { "payer_name": "United Healthcare (UHC)", "plan_name": "DSNP", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "United Healthcare (UHC)", "plan_name": "Medicare Advantage", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" } ] } ] }, { "description": "Medical Surgical Supplies - Incident to Radiology", "code_information": [ { "code": "0621", "type": "RC" } ], "standard_charges": [ { "setting": "outpatient", "payers_information": [ { "payer_name": "United Healthcare (UHC)", "plan_name": "DSNP", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "United Healthcare (UHC)", "plan_name": "Medicare Advantage", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" } ] } ] }, { "description": "Medical Surgical Supplies - Incident to Other Diagnostic Services", "code_information": [ { "code": "0622", "type": "RC" } ], "standard_charges": [ { "setting": "outpatient", "payers_information": [ { "payer_name": "United Healthcare (UHC)", "plan_name": "DSNP", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "United Healthcare (UHC)", "plan_name": "Medicare Advantage", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" } ] } ] }, { "description": "Medical Surgical Supplies - Surgical Dressings", "code_information": [ { "code": "0623", "type": "RC" } ], "standard_charges": [ { "setting": "outpatient", "payers_information": [ { "payer_name": "United Healthcare (UHC)", "plan_name": "DSNP", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Blue Cross Blue Shield of Montana", "plan_name": "Medicare Advantage", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "United Healthcare (UHC)", "plan_name": "Medicare Advantage", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" } ] } ] }, { "description": "Medical Surgical Supplies - FDA Investigational Devices", "code_information": [ { "code": "0624", "type": "RC" } ], "standard_charges": [ { "setting": "outpatient", "payers_information": [ { "payer_name": "United Healthcare (UHC)", "plan_name": "DSNP", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "United Healthcare (UHC)", "plan_name": "Medicare Advantage", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" } ] } ] }, { "description": "Drugs requiring specific identification-general classification", "code_information": [ { "code": "0630", "type": "RC" } ], "standard_charges": [ { "setting": "outpatient", "payers_information": [ { "payer_name": "United Healthcare (UHC)", "plan_name": "DSNP", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Blue Cross Blue Shield of Montana", "plan_name": "Medicare Advantage", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "United Healthcare (UHC)", "plan_name": "Medicare Advantage", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Blue Cross Blue Shield of Montana", "plan_name": "HealthLink Network", "standard_charge_percentage": 75, "methodology": "percent of total billed charges", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Blue Cross Blue Shield of Montana", "plan_name": "Traditional Network", "standard_charge_percentage": 75, "methodology": "percent of total billed charges", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Blue Cross Blue Shield of Montana", "plan_name": "POS Network", "standard_charge_percentage": 75, "methodology": "percent of total billed charges", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Blue Cross Blue Shield of Montana", "plan_name": "Closed Plan Network", "standard_charge_percentage": 75, "methodology": "percent of total billed charges", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Blue Cross Blue Shield of Montana", "plan_name": "Retail HMO POS Network", "standard_charge_percentage": 75, "methodology": "percent of total billed charges", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Blue Cross Blue Shield of Montana", "plan_name": "Blue Options Network", "standard_charge_percentage": 75, "methodology": "percent of total billed charges", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" } ] } ] }, { "description": "Pharmacy - Single Source Drug", "code_information": [ { "code": "0631", "type": "RC" } ], "standard_charges": [ { "setting": "outpatient", "payers_information": [ { "payer_name": "United Healthcare (UHC)", "plan_name": "DSNP", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Blue Cross Blue Shield of Montana", "plan_name": "Medicare Advantage", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "United Healthcare (UHC)", "plan_name": "Medicare Advantage", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Blue Cross Blue Shield of Montana", "plan_name": "HealthLink Network", "standard_charge_percentage": 75, "methodology": "percent of total billed charges", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Blue Cross Blue Shield of Montana", "plan_name": "Traditional Network", "standard_charge_percentage": 75, "methodology": "percent of total billed charges", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Blue Cross Blue Shield of Montana", "plan_name": "POS Network", "standard_charge_percentage": 75, "methodology": "percent of total billed charges", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Blue Cross Blue Shield of Montana", "plan_name": "Closed Plan Network", "standard_charge_percentage": 75, "methodology": "percent of total billed charges", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Blue Cross Blue Shield of Montana", "plan_name": "Retail HMO POS Network", "standard_charge_percentage": 75, "methodology": "percent of total billed charges", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Blue Cross Blue Shield of Montana", "plan_name": "Blue Options Network", "standard_charge_percentage": 75, "methodology": "percent of total billed charges", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" } ] } ] }, { "description": "Pharmacy - Multiple Source Drug", "code_information": [ { "code": "0632", "type": "RC" } ], "standard_charges": [ { "setting": "outpatient", "payers_information": [ { "payer_name": "United Healthcare (UHC)", "plan_name": "DSNP", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "United Healthcare (UHC)", "plan_name": "Medicare Advantage", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Blue Cross Blue Shield of Montana", "plan_name": "HealthLink Network", "standard_charge_percentage": 75, "methodology": "percent of total billed charges", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Blue Cross Blue Shield of Montana", "plan_name": "Traditional Network", "standard_charge_percentage": 75, "methodology": "percent of total billed charges", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Blue Cross Blue Shield of Montana", "plan_name": "POS Network", "standard_charge_percentage": 75, "methodology": "percent of total billed charges", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Blue Cross Blue Shield of Montana", "plan_name": "Closed Plan Network", "standard_charge_percentage": 75, "methodology": "percent of total billed charges", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Blue Cross Blue Shield of Montana", "plan_name": "Retail HMO POS Network", "standard_charge_percentage": 75, "methodology": "percent of total billed charges", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Blue Cross Blue Shield of Montana", "plan_name": "Blue Options Network", "standard_charge_percentage": 75, "methodology": "percent of total billed charges", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" } ] } ] }, { "description": "Pharmacy - Restrictive Prescription", "code_information": [ { "code": "0633", "type": "RC" } ], "standard_charges": [ { "setting": "outpatient", "payers_information": [ { "payer_name": "United Healthcare (UHC)", "plan_name": "DSNP", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "United Healthcare (UHC)", "plan_name": "Medicare Advantage", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Blue Cross Blue Shield of Montana", "plan_name": "HealthLink Network", "standard_charge_percentage": 75, "methodology": "percent of total billed charges", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Blue Cross Blue Shield of Montana", "plan_name": "Traditional Network", "standard_charge_percentage": 75, "methodology": "percent of total billed charges", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Blue Cross Blue Shield of Montana", "plan_name": "POS Network", "standard_charge_percentage": 75, "methodology": "percent of total billed charges", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Blue Cross Blue Shield of Montana", "plan_name": "Closed Plan Network", "standard_charge_percentage": 75, "methodology": "percent of total billed charges", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Blue Cross Blue Shield of Montana", "plan_name": "Retail HMO POS Network", "standard_charge_percentage": 75, "methodology": "percent of total billed charges", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Blue Cross Blue Shield of Montana", "plan_name": "Blue Options Network", "standard_charge_percentage": 75, "methodology": "percent of total billed charges", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" } ] } ] }, { "description": "Pharmacy - Erythropoietin (EPO) less than 10,000 units", "code_information": [ { "code": "0634", "type": "RC" } ], "standard_charges": [ { "setting": "outpatient", "payers_information": [ { "payer_name": "United Healthcare (UHC)", "plan_name": "DSNP", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Blue Cross Blue Shield of Montana", "plan_name": "Medicare Advantage", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "United Healthcare (UHC)", "plan_name": "Medicare Advantage", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Blue Cross Blue Shield of Montana", "plan_name": "HealthLink Network", "standard_charge_percentage": 75, "methodology": "percent of total billed charges", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Blue Cross Blue Shield of Montana", "plan_name": "Traditional Network", "standard_charge_percentage": 75, "methodology": "percent of total billed charges", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Blue Cross Blue Shield of Montana", "plan_name": "POS Network", "standard_charge_percentage": 75, "methodology": "percent of total billed charges", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Blue Cross Blue Shield of Montana", "plan_name": "Closed Plan Network", "standard_charge_percentage": 75, "methodology": "percent of total billed charges", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Blue Cross Blue Shield of Montana", "plan_name": "Retail HMO POS Network", "standard_charge_percentage": 75, "methodology": "percent of total billed charges", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Blue Cross Blue Shield of Montana", "plan_name": "Blue Options Network", "standard_charge_percentage": 75, "methodology": "percent of total billed charges", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" } ] } ] }, { "description": "Pharmacy - Erythropoietin (EPO) 10,000 or more units", "code_information": [ { "code": "0635", "type": "RC" } ], "standard_charges": [ { "setting": "outpatient", "payers_information": [ { "payer_name": "United Healthcare (UHC)", "plan_name": "DSNP", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Blue Cross Blue Shield of Montana", "plan_name": "Medicare Advantage", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "United Healthcare (UHC)", "plan_name": "Medicare Advantage", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Blue Cross Blue Shield of Montana", "plan_name": "HealthLink Network", "standard_charge_percentage": 75, "methodology": "percent of total billed charges", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Blue Cross Blue Shield of Montana", "plan_name": "Traditional Network", "standard_charge_percentage": 75, "methodology": "percent of total billed charges", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Blue Cross Blue Shield of Montana", "plan_name": "POS Network", "standard_charge_percentage": 75, "methodology": "percent of total billed charges", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Blue Cross Blue Shield of Montana", "plan_name": "Closed Plan Network", "standard_charge_percentage": 75, "methodology": "percent of total billed charges", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Blue Cross Blue Shield of Montana", "plan_name": "Retail HMO POS Network", "standard_charge_percentage": 75, "methodology": "percent of total billed charges", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Blue Cross Blue Shield of Montana", "plan_name": "Blue Options Network", "standard_charge_percentage": 75, "methodology": "percent of total billed charges", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" } ] } ] }, { "description": "Pharmacy - Drugs Requiring Detailed Coding", "code_information": [ { "code": "0636", "type": "RC" } ], "standard_charges": [ { "setting": "outpatient", "payers_information": [ { "payer_name": "United Healthcare (UHC)", "plan_name": "DSNP", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Coventry Health Care", "plan_name": "Workers' Compensation", "standard_charge_percentage": 105, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Coventry Health Care", "plan_name": "Auto Network", "standard_charge_percentage": 105, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Blue Cross Blue Shield of Montana", "plan_name": "Medicare Advantage", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "United Healthcare (UHC)", "plan_name": "Medicare Advantage", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Blue Cross Blue Shield of Montana", "plan_name": "HealthLink Network", "standard_charge_percentage": 75, "methodology": "percent of total billed charges", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Blue Cross Blue Shield of Montana", "plan_name": "Traditional Network", "standard_charge_percentage": 75, "methodology": "percent of total billed charges", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Blue Cross Blue Shield of Montana", "plan_name": "POS Network", "standard_charge_percentage": 75, "methodology": "percent of total billed charges", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Blue Cross Blue Shield of Montana", "plan_name": "Closed Plan Network", "standard_charge_percentage": 75, "methodology": "percent of total billed charges", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Blue Cross Blue Shield of Montana", "plan_name": "Retail HMO POS Network", "standard_charge_percentage": 75, "methodology": "percent of total billed charges", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Blue Cross Blue Shield of Montana", "plan_name": "Blue Options Network", "standard_charge_percentage": 75, "methodology": "percent of total billed charges", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" } ] } ] }, { "description": "Pharmacy - Self-administrable Drugs", "code_information": [ { "code": "0637", "type": "RC" } ], "standard_charges": [ { "setting": "outpatient", "payers_information": [ { "payer_name": "United Healthcare (UHC)", "plan_name": "DSNP", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "United Healthcare (UHC)", "plan_name": "Medicare Advantage", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Blue Cross Blue Shield of Montana", "plan_name": "HealthLink Network", "standard_charge_percentage": 75, "methodology": "percent of total billed charges", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Blue Cross Blue Shield of Montana", "plan_name": "Traditional Network", "standard_charge_percentage": 75, "methodology": "percent of total billed charges", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Blue Cross Blue Shield of Montana", "plan_name": "POS Network", "standard_charge_percentage": 75, "methodology": "percent of total billed charges", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Blue Cross Blue Shield of Montana", "plan_name": "Closed Plan Network", "standard_charge_percentage": 75, "methodology": "percent of total billed charges", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Blue Cross Blue Shield of Montana", "plan_name": "Retail HMO POS Network", "standard_charge_percentage": 75, "methodology": "percent of total billed charges", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Blue Cross Blue Shield of Montana", "plan_name": "Blue Options Network", "standard_charge_percentage": 75, "methodology": "percent of total billed charges", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" } ] } ] }, { "description": "Home IV Therapy Services - General Classification", "code_information": [ { "code": "0640", "type": "RC" } ], "standard_charges": [ { "setting": "outpatient", "payers_information": [ { "payer_name": "United Healthcare (UHC)", "plan_name": "DSNP", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Blue Cross Blue Shield of Montana", "plan_name": "Medicare Advantage", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "United Healthcare (UHC)", "plan_name": "Medicare Advantage", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" } ] } ] }, { "description": "Home IV Therapy Services - Non-routine Nursing, Central Line", "code_information": [ { "code": "0641", "type": "RC" } ], "standard_charges": [ { "setting": "outpatient", "payers_information": [ { "payer_name": "United Healthcare (UHC)", "plan_name": "DSNP", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Blue Cross Blue Shield of Montana", "plan_name": "Medicare Advantage", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "United Healthcare (UHC)", "plan_name": "Medicare Advantage", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" } ] } ] }, { "description": "Home IV Therapy Services - IV Site Care, Central Line", "code_information": [ { "code": "0642", "type": "RC" } ], "standard_charges": [ { "setting": "outpatient", "payers_information": [ { "payer_name": "United Healthcare (UHC)", "plan_name": "DSNP", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Blue Cross Blue Shield of Montana", "plan_name": "Medicare Advantage", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "United Healthcare (UHC)", "plan_name": "Medicare Advantage", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" } ] } ] }, { "description": "Home IV Therapy Services - IV Start/Care, Peripheral Line", "code_information": [ { "code": "0643", "type": "RC" } ], "standard_charges": [ { "setting": "outpatient", "payers_information": [ { "payer_name": "United Healthcare (UHC)", "plan_name": "DSNP", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Blue Cross Blue Shield of Montana", "plan_name": "Medicare Advantage", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "United Healthcare (UHC)", "plan_name": "Medicare Advantage", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" } ] } ] }, { "description": "Home IV Therapy Services - Non-routine Nursing, Peripheral Line", "code_information": [ { "code": "0644", "type": "RC" } ], "standard_charges": [ { "setting": "outpatient", "payers_information": [ { "payer_name": "United Healthcare (UHC)", "plan_name": "DSNP", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Blue Cross Blue Shield of Montana", "plan_name": "Medicare Advantage", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "United Healthcare (UHC)", "plan_name": "Medicare Advantage", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" } ] } ] }, { "description": "Home IV Therapy Services - Training, Patient/Caregiver, Central Line", "code_information": [ { "code": "0645", "type": "RC" } ], "standard_charges": [ { "setting": "outpatient", "payers_information": [ { "payer_name": "United Healthcare (UHC)", "plan_name": "DSNP", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Blue Cross Blue Shield of Montana", "plan_name": "Medicare Advantage", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "United Healthcare (UHC)", "plan_name": "Medicare Advantage", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" } ] } ] }, { "description": "Home IV Therapy Services - Training, Disabled Patient, Central Line", "code_information": [ { "code": "0646", "type": "RC" } ], "standard_charges": [ { "setting": "outpatient", "payers_information": [ { "payer_name": "United Healthcare (UHC)", "plan_name": "DSNP", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Blue Cross Blue Shield of Montana", "plan_name": "Medicare Advantage", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "United Healthcare (UHC)", "plan_name": "Medicare Advantage", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" } ] } ] }, { "description": "Home IV Therapy Services - Training, Patient/Caregiver, Peripheral Line", "code_information": [ { "code": "0647", "type": "RC" } ], "standard_charges": [ { "setting": "outpatient", "payers_information": [ { "payer_name": "United Healthcare (UHC)", "plan_name": "DSNP", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Blue Cross Blue Shield of Montana", "plan_name": "Medicare Advantage", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "United Healthcare (UHC)", "plan_name": "Medicare Advantage", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" } ] } ] }, { "description": "Home IV Therapy Services - Training, Disabled Patient, Peripheral Line", "code_information": [ { "code": "0648", "type": "RC" } ], "standard_charges": [ { "setting": "outpatient", "payers_information": [ { "payer_name": "United Healthcare (UHC)", "plan_name": "DSNP", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Blue Cross Blue Shield of Montana", "plan_name": "Medicare Advantage", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "United Healthcare (UHC)", "plan_name": "Medicare Advantage", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" } ] } ] }, { "description": "Home IV Therapy Services - Other", "code_information": [ { "code": "0649", "type": "RC" } ], "standard_charges": [ { "setting": "outpatient", "payers_information": [ { "payer_name": "United Healthcare (UHC)", "plan_name": "DSNP", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Blue Cross Blue Shield of Montana", "plan_name": "Medicare Advantage", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "United Healthcare (UHC)", "plan_name": "Medicare Advantage", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" } ] } ] }, { "description": "Hospice Services - General Classification", "code_information": [ { "code": "0650", "type": "RC" } ], "standard_charges": [ { "setting": "outpatient", "payers_information": [ { "payer_name": "United Healthcare (UHC)", "plan_name": "DSNP", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "United Healthcare (UHC)", "plan_name": "Medicare Advantage", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" } ] } ] }, { "description": "Hospice Services - Routine Home Care", "code_information": [ { "code": "0651", "type": "RC" } ], "standard_charges": [ { "setting": "outpatient", "payers_information": [ { "payer_name": "United Healthcare (UHC)", "plan_name": "DSNP", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "United Healthcare (UHC)", "plan_name": "Medicare Advantage", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" } ] } ] }, { "description": "Hospice Services - Continuous Home Care", "code_information": [ { "code": "0652", "type": "RC" } ], "standard_charges": [ { "setting": "outpatient", "payers_information": [ { "payer_name": "United Healthcare (UHC)", "plan_name": "DSNP", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "United Healthcare (UHC)", "plan_name": "Medicare Advantage", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" } ] } ] }, { "description": "Hospice Services - Inpatient Respite Care", "code_information": [ { "code": "0655", "type": "RC" } ], "standard_charges": [ { "setting": "outpatient", "payers_information": [ { "payer_name": "United Healthcare (UHC)", "plan_name": "DSNP", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "United Healthcare (UHC)", "plan_name": "Medicare Advantage", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" } ] } ] }, { "description": "Hospice Services - General Inpatient Care (non-respite)", "code_information": [ { "code": "0656", "type": "RC" } ], "standard_charges": [ { "setting": "outpatient", "payers_information": [ { "payer_name": "United Healthcare (UHC)", "plan_name": "DSNP", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "United Healthcare (UHC)", "plan_name": "Medicare Advantage", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" } ] } ] }, { "description": "Hospice Services - Physician Services", "code_information": [ { "code": "0657", "type": "RC" } ], "standard_charges": [ { "setting": "outpatient", "payers_information": [ { "payer_name": "United Healthcare (UHC)", "plan_name": "DSNP", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "United Healthcare (UHC)", "plan_name": "Medicare Advantage", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" } ] } ] }, { "description": "Hospice Services - Hospice Room & Board - Nursing Facility", "code_information": [ { "code": "0658", "type": "RC" } ], "standard_charges": [ { "setting": "outpatient", "payers_information": [ { "payer_name": "United Healthcare (UHC)", "plan_name": "DSNP", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "United Healthcare (UHC)", "plan_name": "Medicare Advantage", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" } ] } ] }, { "description": "Hospice Services - Other", "code_information": [ { "code": "0659", "type": "RC" } ], "standard_charges": [ { "setting": "outpatient", "payers_information": [ { "payer_name": "United Healthcare (UHC)", "plan_name": "DSNP", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "United Healthcare (UHC)", "plan_name": "Medicare Advantage", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" } ] } ] }, { "description": "Respite Care - General Classification", "code_information": [ { "code": "0660", "type": "RC" } ], "standard_charges": [ { "setting": "outpatient", "payers_information": [ { "payer_name": "United Healthcare (UHC)", "plan_name": "DSNP", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "United Healthcare (UHC)", "plan_name": "Medicare Advantage", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" } ] } ] }, { "description": "Respite Care - Hourly Charge/Nursing", "code_information": [ { "code": "0661", "type": "RC" } ], "standard_charges": [ { "setting": "outpatient", "payers_information": [ { "payer_name": "United Healthcare (UHC)", "plan_name": "DSNP", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "United Healthcare (UHC)", "plan_name": "Medicare Advantage", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" } ] } ] }, { "description": "Respite Care - Hourly Charge/Aide/Homemaker/Companion", "code_information": [ { "code": "0662", "type": "RC" } ], "standard_charges": [ { "setting": "outpatient", "payers_information": [ { "payer_name": "United Healthcare (UHC)", "plan_name": "DSNP", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "United Healthcare (UHC)", "plan_name": "Medicare Advantage", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" } ] } ] }, { "description": "Respite Care - Daily Respite Charge", "code_information": [ { "code": "0663", "type": "RC" } ], "standard_charges": [ { "setting": "outpatient", "payers_information": [ { "payer_name": "United Healthcare (UHC)", "plan_name": "DSNP", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "United Healthcare (UHC)", "plan_name": "Medicare Advantage", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" } ] } ] }, { "description": "Respite Care (Hospice) - Evaluation or Testing", "code_information": [ { "code": "0664", "type": "RC" } ], "standard_charges": [ { "setting": "outpatient", "payers_information": [ { "payer_name": "United Healthcare (UHC)", "plan_name": "DSNP", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "United Healthcare (UHC)", "plan_name": "Medicare Advantage", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" } ] } ] }, { "description": "Respite Care (Hospice) - Treatment", "code_information": [ { "code": "0665", "type": "RC" } ], "standard_charges": [ { "setting": "outpatient", "payers_information": [ { "payer_name": "United Healthcare (UHC)", "plan_name": "DSNP", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "United Healthcare (UHC)", "plan_name": "Medicare Advantage", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" } ] } ] }, { "description": "Respite Care (Hospice) - Continuation", "code_information": [ { "code": "0666", "type": "RC" } ], "standard_charges": [ { "setting": "outpatient", "payers_information": [ { "payer_name": "United Healthcare (UHC)", "plan_name": "DSNP", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "United Healthcare (UHC)", "plan_name": "Medicare Advantage", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" } ] } ] }, { "description": "Respite Care (Hospice) - Observation/Hourly", "code_information": [ { "code": "0667", "type": "RC" } ], "standard_charges": [ { "setting": "outpatient", "payers_information": [ { "payer_name": "United Healthcare (UHC)", "plan_name": "DSNP", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "United Healthcare (UHC)", "plan_name": "Medicare Advantage", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" } ] } ] }, { "description": "Respite Care (Hospice) - Other", "code_information": [ { "code": "0668", "type": "RC" } ], "standard_charges": [ { "setting": "outpatient", "payers_information": [ { "payer_name": "United Healthcare (UHC)", "plan_name": "DSNP", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "United Healthcare (UHC)", "plan_name": "Medicare Advantage", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" } ] } ] }, { "description": "Respite Care - Other", "code_information": [ { "code": "0669", "type": "RC" } ], "standard_charges": [ { "setting": "outpatient", "payers_information": [ { "payer_name": "United Healthcare (UHC)", "plan_name": "DSNP", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "United Healthcare (UHC)", "plan_name": "Medicare Advantage", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" } ] } ] }, { "description": "Outpatient Special Residence Charges - General Classification", "code_information": [ { "code": "0670", "type": "RC" } ], "standard_charges": [ { "setting": "outpatient", "payers_information": [ { "payer_name": "United Healthcare (UHC)", "plan_name": "DSNP", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "United Healthcare (UHC)", "plan_name": "Medicare Advantage", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" } ] } ] }, { "description": "Outpatient Special Residence Charges - Hospital Owned", "code_information": [ { "code": "0671", "type": "RC" } ], "standard_charges": [ { "setting": "outpatient", "payers_information": [ { "payer_name": "United Healthcare (UHC)", "plan_name": "DSNP", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "United Healthcare (UHC)", "plan_name": "Medicare Advantage", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" } ] } ] }, { "description": "Outpatient Special Residence Charges - Contracted", "code_information": [ { "code": "0672", "type": "RC" } ], "standard_charges": [ { "setting": "outpatient", "payers_information": [ { "payer_name": "United Healthcare (UHC)", "plan_name": "DSNP", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "United Healthcare (UHC)", "plan_name": "Medicare Advantage", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" } ] } ] }, { "description": "Outpatient Special Residence Charges - Other", "code_information": [ { "code": "0679", "type": "RC" } ], "standard_charges": [ { "setting": "outpatient", "payers_information": [ { "payer_name": "United Healthcare (UHC)", "plan_name": "DSNP", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "United Healthcare (UHC)", "plan_name": "Medicare Advantage", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" } ] } ] }, { "description": "Trauma Response - Level I", "code_information": [ { "code": "0681", "type": "RC" } ], "standard_charges": [ { "setting": "outpatient", "payers_information": [ { "payer_name": "United Healthcare (UHC)", "plan_name": "DSNP", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "United Healthcare (UHC)", "plan_name": "Medicare Advantage", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" } ] } ] }, { "description": "Trauma Response - Level II", "code_information": [ { "code": "0682", "type": "RC" } ], "standard_charges": [ { "setting": "outpatient", "payers_information": [ { "payer_name": "United Healthcare (UHC)", "plan_name": "DSNP", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "United Healthcare (UHC)", "plan_name": "Medicare Advantage", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" } ] } ] }, { "description": "Trauma Response - Level III", "code_information": [ { "code": "0683", "type": "RC" } ], "standard_charges": [ { "setting": "outpatient", "payers_information": [ { "payer_name": "United Healthcare (UHC)", "plan_name": "DSNP", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "United Healthcare (UHC)", "plan_name": "Medicare Advantage", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" } ] } ] }, { "description": "Trauma Response - Level IV", "code_information": [ { "code": "0684", "type": "RC" } ], "standard_charges": [ { "setting": "outpatient", "payers_information": [ { "payer_name": "United Healthcare (UHC)", "plan_name": "DSNP", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "United Healthcare (UHC)", "plan_name": "Medicare Advantage", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" } ] } ] }, { "description": "Trauma Response - Other", "code_information": [ { "code": "0689", "type": "RC" } ], "standard_charges": [ { "setting": "outpatient", "payers_information": [ { "payer_name": "United Healthcare (UHC)", "plan_name": "DSNP", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "United Healthcare (UHC)", "plan_name": "Medicare Advantage", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" } ] } ] }, { "description": "Pre-hospice/Palliative Care Services - General Classification", "code_information": [ { "code": "0690", "type": "RC" } ], "standard_charges": [ { "setting": "outpatient", "payers_information": [ { "payer_name": "United Healthcare (UHC)", "plan_name": "DSNP", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "United Healthcare (UHC)", "plan_name": "Medicare Advantage", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" } ] } ] }, { "description": "Pre-hospice/Palliative Care Services - Visit Charge", "code_information": [ { "code": "0691", "type": "RC" } ], "standard_charges": [ { "setting": "outpatient", "payers_information": [ { "payer_name": "United Healthcare (UHC)", "plan_name": "DSNP", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "United Healthcare (UHC)", "plan_name": "Medicare Advantage", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" } ] } ] }, { "description": "Pre-hospice/Palliative Care Services - Hourly Charge", "code_information": [ { "code": "0692", "type": "RC" } ], "standard_charges": [ { "setting": "outpatient", "payers_information": [ { "payer_name": "United Healthcare (UHC)", "plan_name": "DSNP", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "United Healthcare (UHC)", "plan_name": "Medicare Advantage", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" } ] } ] }, { "description": "Pre-hospice/Palliative Care Services - Evaluation", "code_information": [ { "code": "0693", "type": "RC" } ], "standard_charges": [ { "setting": "outpatient", "payers_information": [ { "payer_name": "United Healthcare (UHC)", "plan_name": "DSNP", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "United Healthcare (UHC)", "plan_name": "Medicare Advantage", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" } ] } ] }, { "description": "Pre-hospice/Palliative Care Services - Consultation and Education", "code_information": [ { "code": "0694", "type": "RC" } ], "standard_charges": [ { "setting": "outpatient", "payers_information": [ { "payer_name": "United Healthcare (UHC)", "plan_name": "DSNP", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "United Healthcare (UHC)", "plan_name": "Medicare Advantage", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" } ] } ] }, { "description": "Pre-hospice/Palliative Care Services - Inpatient Care", "code_information": [ { "code": "0695", "type": "RC" } ], "standard_charges": [ { "setting": "outpatient", "payers_information": [ { "payer_name": "United Healthcare (UHC)", "plan_name": "DSNP", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "United Healthcare (UHC)", "plan_name": "Medicare Advantage", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" } ] } ] }, { "description": "Pre-hospice/Palliative Care Services - Physician Services", "code_information": [ { "code": "0696", "type": "RC" } ], "standard_charges": [ { "setting": "outpatient", "payers_information": [ { "payer_name": "United Healthcare (UHC)", "plan_name": "DSNP", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "United Healthcare (UHC)", "plan_name": "Medicare Advantage", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" } ] } ] }, { "description": "Reserved", "code_information": [ { "code": "0697", "type": "RC" } ], "standard_charges": [ { "setting": "outpatient", "payers_information": [ { "payer_name": "United Healthcare (UHC)", "plan_name": "DSNP", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "United Healthcare (UHC)", "plan_name": "Medicare Advantage", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" } ] } ] }, { "description": "Reserved", "code_information": [ { "code": "0698", "type": "RC" } ], "standard_charges": [ { "setting": "outpatient", "payers_information": [ { "payer_name": "United Healthcare (UHC)", "plan_name": "DSNP", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "United Healthcare (UHC)", "plan_name": "Medicare Advantage", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" } ] } ] }, { "description": "Pre-hospice/Palliative Care Services - Other Pre-hospice/Palliative", "code_information": [ { "code": "0699", "type": "RC" } ], "standard_charges": [ { "setting": "outpatient", "payers_information": [ { "payer_name": "United Healthcare (UHC)", "plan_name": "DSNP", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "United Healthcare (UHC)", "plan_name": "Medicare Advantage", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" } ] } ] }, { "description": "Cast Room - General Classification", "code_information": [ { "code": "0700", "type": "RC" } ], "standard_charges": [ { "setting": "outpatient", "payers_information": [ { "payer_name": "United Healthcare (UHC)", "plan_name": "DSNP", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "United Healthcare (UHC)", "plan_name": "Medicare Advantage", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" } ] } ] }, { "description": "Recovery Room - General Classification", "code_information": [ { "code": "0710", "type": "RC" } ], "standard_charges": [ { "setting": "outpatient", "payers_information": [ { "payer_name": "United Healthcare (UHC)", "plan_name": "DSNP", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "United Healthcare (UHC)", "plan_name": "Medicare Advantage", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" } ] } ] }, { "description": "EKG/ECG (Electrocardiogram) - General Classification", "code_information": [ { "code": "0730", "type": "RC" } ], "standard_charges": [ { "setting": "outpatient", "payers_information": [ { "payer_name": "United Healthcare (UHC)", "plan_name": "DSNP", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "United Healthcare (UHC)", "plan_name": "Medicare Advantage", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" } ] } ] }, { "description": "EKG/ECG (Electrocardiogram) - Holter Monitor", "code_information": [ { "code": "0731", "type": "RC" } ], "standard_charges": [ { "setting": "outpatient", "payers_information": [ { "payer_name": "United Healthcare (UHC)", "plan_name": "DSNP", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "United Healthcare (UHC)", "plan_name": "Medicare Advantage", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" } ] } ] }, { "description": "EKG/ECG (Electrocardiogram) - Telemetry", "code_information": [ { "code": "0732", "type": "RC" } ], "standard_charges": [ { "setting": "outpatient", "payers_information": [ { "payer_name": "United Healthcare (UHC)", "plan_name": "DSNP", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "United Healthcare (UHC)", "plan_name": "Medicare Advantage", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" } ] } ] }, { "description": "EKG/ECG - Assessment", "code_information": [ { "code": "0733", "type": "RC" } ], "standard_charges": [ { "setting": "outpatient", "payers_information": [ { "payer_name": "United Healthcare (UHC)", "plan_name": "DSNP", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "United Healthcare (UHC)", "plan_name": "Medicare Advantage", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" } ] } ] }, { "description": "EKG/ECG - Evaluation or Testing", "code_information": [ { "code": "0734", "type": "RC" } ], "standard_charges": [ { "setting": "outpatient", "payers_information": [ { "payer_name": "United Healthcare (UHC)", "plan_name": "DSNP", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "United Healthcare (UHC)", "plan_name": "Medicare Advantage", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" } ] } ] }, { "description": "EKG/ECG - Treatment", "code_information": [ { "code": "0735", "type": "RC" } ], "standard_charges": [ { "setting": "outpatient", "payers_information": [ { "payer_name": "United Healthcare (UHC)", "plan_name": "DSNP", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "United Healthcare (UHC)", "plan_name": "Medicare Advantage", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" } ] } ] }, { "description": "EKG/ECG - Continuation", "code_information": [ { "code": "0736", "type": "RC" } ], "standard_charges": [ { "setting": "outpatient", "payers_information": [ { "payer_name": "United Healthcare (UHC)", "plan_name": "DSNP", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "United Healthcare (UHC)", "plan_name": "Medicare Advantage", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" } ] } ] }, { "description": "EKG/ECG - Observation/Hourly", "code_information": [ { "code": "0737", "type": "RC" } ], "standard_charges": [ { "setting": "outpatient", "payers_information": [ { "payer_name": "United Healthcare (UHC)", "plan_name": "DSNP", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "United Healthcare (UHC)", "plan_name": "Medicare Advantage", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" } ] } ] }, { "description": "EKG/ECG - Other", "code_information": [ { "code": "0738", "type": "RC" } ], "standard_charges": [ { "setting": "outpatient", "payers_information": [ { "payer_name": "United Healthcare (UHC)", "plan_name": "DSNP", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "United Healthcare (UHC)", "plan_name": "Medicare Advantage", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" } ] } ] }, { "description": "EKG/ECG (Electrocardiogram) - Other", "code_information": [ { "code": "0739", "type": "RC" } ], "standard_charges": [ { "setting": "outpatient", "payers_information": [ { "payer_name": "United Healthcare (UHC)", "plan_name": "DSNP", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "United Healthcare (UHC)", "plan_name": "Medicare Advantage", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" } ] } ] }, { "description": "EEG (Electroencephalogram) - General Classification", "code_information": [ { "code": "0740", "type": "RC" } ], "standard_charges": [ { "setting": "outpatient", "payers_information": [ { "payer_name": "United Healthcare (UHC)", "plan_name": "DSNP", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "United Healthcare (UHC)", "plan_name": "Medicare Advantage", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" } ] } ] }, { "description": "EEG - Visit", "code_information": [ { "code": "0741", "type": "RC" } ], "standard_charges": [ { "setting": "outpatient", "payers_information": [ { "payer_name": "United Healthcare (UHC)", "plan_name": "DSNP", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "United Healthcare (UHC)", "plan_name": "Medicare Advantage", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" } ] } ] }, { "description": "EEG - Unit", "code_information": [ { "code": "0742", "type": "RC" } ], "standard_charges": [ { "setting": "outpatient", "payers_information": [ { "payer_name": "United Healthcare (UHC)", "plan_name": "DSNP", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "United Healthcare (UHC)", "plan_name": "Medicare Advantage", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" } ] } ] }, { "description": "EEG - Assessment", "code_information": [ { "code": "0743", "type": "RC" } ], "standard_charges": [ { "setting": "outpatient", "payers_information": [ { "payer_name": "United Healthcare (UHC)", "plan_name": "DSNP", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "United Healthcare (UHC)", "plan_name": "Medicare Advantage", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" } ] } ] }, { "description": "EEG - Evaluation or Testing", "code_information": [ { "code": "0744", "type": "RC" } ], "standard_charges": [ { "setting": "outpatient", "payers_information": [ { "payer_name": "United Healthcare (UHC)", "plan_name": "DSNP", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "United Healthcare (UHC)", "plan_name": "Medicare Advantage", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" } ] } ] }, { "description": "EEG - Treatment", "code_information": [ { "code": "0745", "type": "RC" } ], "standard_charges": [ { "setting": "outpatient", "payers_information": [ { "payer_name": "United Healthcare (UHC)", "plan_name": "DSNP", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "United Healthcare (UHC)", "plan_name": "Medicare Advantage", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" } ] } ] }, { "description": "EEG - Continuation", "code_information": [ { "code": "0746", "type": "RC" } ], "standard_charges": [ { "setting": "outpatient", "payers_information": [ { "payer_name": "United Healthcare (UHC)", "plan_name": "DSNP", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "United Healthcare (UHC)", "plan_name": "Medicare Advantage", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" } ] } ] }, { "description": "EEG - Observation/Hourly", "code_information": [ { "code": "0747", "type": "RC" } ], "standard_charges": [ { "setting": "outpatient", "payers_information": [ { "payer_name": "United Healthcare (UHC)", "plan_name": "DSNP", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "United Healthcare (UHC)", "plan_name": "Medicare Advantage", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" } ] } ] }, { "description": "EEG - Other", "code_information": [ { "code": "0748", "type": "RC" } ], "standard_charges": [ { "setting": "outpatient", "payers_information": [ { "payer_name": "United Healthcare (UHC)", "plan_name": "DSNP", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "United Healthcare (UHC)", "plan_name": "Medicare Advantage", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" } ] } ] }, { "description": "EEG - Other", "code_information": [ { "code": "0749", "type": "RC" } ], "standard_charges": [ { "setting": "outpatient", "payers_information": [ { "payer_name": "United Healthcare (UHC)", "plan_name": "DSNP", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "United Healthcare (UHC)", "plan_name": "Medicare Advantage", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" } ] } ] }, { "description": "Psychiatric/psychological services-general classification", "code_information": [ { "code": "0910", "type": "RC" } ], "standard_charges": [ { "setting": "outpatient", "payers_information": [ { "payer_name": "United Healthcare (UHC)", "plan_name": "DSNP", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "United Healthcare (UHC)", "plan_name": "Medicare Advantage", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" } ] } ] }, { "description": "Rpr s/n/ax/gen/trk7.6-12.5cm", "code_information": [ { "code": "12004", "type": "HCPCS" } ], "standard_charges": [ { "setting": "outpatient", "payers_information": [ { "payer_name": "United Healthcare (UHC)", "plan_name": "DSNP", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "United Healthcare (UHC)", "plan_name": "Medicare Advantage", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" } ] } ] }, { "description": "Rpr f/e/e/n/l/m 2.5 cm/<", "code_information": [ { "code": "12011", "type": "HCPCS" } ], "standard_charges": [ { "setting": "outpatient", "payers_information": [ { "payer_name": "United Healthcare (UHC)", "plan_name": "DSNP", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "United Healthcare (UHC)", "plan_name": "Medicare Advantage", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" } ] } ] }, { "description": "Rpr f/e/e/n/l/m 2.6-5.0 cm", "code_information": [ { "code": "12013", "type": "HCPCS" } ], "standard_charges": [ { "setting": "outpatient", "payers_information": [ { "payer_name": "United Healthcare (UHC)", "plan_name": "DSNP", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "United Healthcare (UHC)", "plan_name": "Medicare Advantage", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" } ] } ] }, { "description": "Intmd rpr s/a/t/ext 2.6-7.5", "code_information": [ { "code": "12032", "type": "HCPCS" } ], "standard_charges": [ { "setting": "outpatient", "payers_information": [ { "payer_name": "United Healthcare (UHC)", "plan_name": "DSNP", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "United Healthcare (UHC)", "plan_name": "Medicare Advantage", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" } ] } ] }, { "description": "Tis trnfr trunk 10 sq cm/<", "code_information": [ { "code": "14000", "type": "HCPCS" } ], "standard_charges": [ { "setting": "outpatient", "payers_information": [ { "payer_name": "United Healthcare (UHC)", "plan_name": "DSNP", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "United Healthcare (UHC)", "plan_name": "Medicare Advantage", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" } ] } ] }, { "description": "Tis trnfr s/a/l 10 sq cm/<", "code_information": [ { "code": "14020", "type": "HCPCS" } ], "standard_charges": [ { "setting": "outpatient", "payers_information": [ { "payer_name": "United Healthcare (UHC)", "plan_name": "DSNP", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "United Healthcare (UHC)", "plan_name": "Medicare Advantage", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" } ] } ] }, { "description": "Grfg autol fat lipo 50 cc/<", "code_information": [ { "code": "15771", "type": "HCPCS" } ], "standard_charges": [ { "setting": "outpatient", "payers_information": [ { "payer_name": "United Healthcare (UHC)", "plan_name": "DSNP", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "United Healthcare (UHC)", "plan_name": "Medicare Advantage", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" } ] } ] }, { "description": "Grfg autol fat lipo ea addl", "code_information": [ { "code": "15772", "type": "HCPCS" } ], "standard_charges": [ { "setting": "outpatient", "payers_information": [ { "payer_name": "United Healthcare (UHC)", "plan_name": "DSNP", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "United Healthcare (UHC)", "plan_name": "Medicare Advantage", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" } ] } ] }, { "description": "Removal sutr/stapl xreq anes", "code_information": [ { "code": "15853", "type": "HCPCS" } ], "standard_charges": [ { "setting": "outpatient", "payers_information": [ { "payer_name": "United Healthcare (UHC)", "plan_name": "DSNP", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "United Healthcare (UHC)", "plan_name": "Medicare Advantage", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" } ] } ] }, { "description": "Dress/debrid p-thick burn s", "code_information": [ { "code": "16020", "type": "HCPCS" } ], "standard_charges": [ { "setting": "outpatient", "payers_information": [ { "payer_name": "United Healthcare (UHC)", "plan_name": "DSNP", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "United Healthcare (UHC)", "plan_name": "Medicare Advantage", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" } ] } ] }, { "description": "Bx breast 1st lesion strtctc", "code_information": [ { "code": "19081", "type": "HCPCS" } ], "standard_charges": [ { "setting": "outpatient", "payers_information": [ { "payer_name": "United Healthcare (UHC)", "plan_name": "DSNP", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "United Healthcare (UHC)", "plan_name": "Medicare Advantage", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" } ] } ] }, { "description": "Bx breast 1st lesion us imag", "code_information": [ { "code": "19083", "type": "HCPCS" } ], "standard_charges": [ { "setting": "outpatient", "payers_information": [ { "payer_name": "United Healthcare (UHC)", "plan_name": "DSNP", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "United Healthcare (UHC)", "plan_name": "Medicare Advantage", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" } ] } ] }, { "description": "Removal of breast lesion", "code_information": [ { "code": "19120", "type": "HCPCS" } ], "standard_charges": [ { "setting": "outpatient", "payers_information": [ { "payer_name": "United Healthcare (UHC)", "plan_name": "DSNP", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "United Healthcare (UHC)", "plan_name": "Medicare Advantage", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" } ] } ] }, { "description": "Perq device breast 1st imag", "code_information": [ { "code": "19281", "type": "HCPCS" } ], "standard_charges": [ { "setting": "outpatient", "payers_information": [ { "payer_name": "United Healthcare (UHC)", "plan_name": "DSNP", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "United Healthcare (UHC)", "plan_name": "Medicare Advantage", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" } ] } ] }, { "description": "Perq dev breast 1st us imag", "code_information": [ { "code": "19285", "type": "HCPCS" } ], "standard_charges": [ { "setting": "outpatient", "payers_information": [ { "payer_name": "United Healthcare (UHC)", "plan_name": "DSNP", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "United Healthcare (UHC)", "plan_name": "Medicare Advantage", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" } ] } ] }, { "description": "Partial mastectomy", "code_information": [ { "code": "19301", "type": "HCPCS" } ], "standard_charges": [ { "setting": "outpatient", "payers_information": [ { "payer_name": "United Healthcare (UHC)", "plan_name": "DSNP", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "United Healthcare (UHC)", "plan_name": "Medicare Advantage", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" } ] } ] }, { "description": "P-mastectomy w/ln removal", "code_information": [ { "code": "19302", "type": "HCPCS" } ], "standard_charges": [ { "setting": "outpatient", "payers_information": [ { "payer_name": "United Healthcare (UHC)", "plan_name": "DSNP", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "United Healthcare (UHC)", "plan_name": "Medicare Advantage", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" } ] } ] }, { "description": "Mast simple complete", "code_information": [ { "code": "19303", "type": "HCPCS" } ], "standard_charges": [ { "setting": "outpatient", "payers_information": [ { "payer_name": "United Healthcare (UHC)", "plan_name": "DSNP", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "United Healthcare (UHC)", "plan_name": "Medicare Advantage", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" } ] } ] }, { "description": "Mast mod rad", "code_information": [ { "code": "19307", "type": "HCPCS" } ], "standard_charges": [ { "setting": "outpatient", "payers_information": [ { "payer_name": "United Healthcare (UHC)", "plan_name": "DSNP", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "United Healthcare (UHC)", "plan_name": "Medicare Advantage", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" } ] } ] }, { "description": "Bone biopsy trocar/ndl deep", "code_information": [ { "code": "20225", "type": "HCPCS" } ], "standard_charges": [ { "setting": "outpatient", "payers_information": [ { "payer_name": "United Healthcare (UHC)", "plan_name": "DSNP", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "United Healthcare (UHC)", "plan_name": "Medicare Advantage", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" } ] } ] }, { "description": "Drain/inj joint/bursa w/o us", "code_information": [ { "code": "20610", "type": "HCPCS" } ], "standard_charges": [ { "setting": "outpatient", "payers_information": [ { "payer_name": "United Healthcare (UHC)", "plan_name": "DSNP", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "United Healthcare (UHC)", "plan_name": "Medicare Advantage", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" } ] } ] }, { "description": "Removal of implant deep", "code_information": [ { "code": "20680", "type": "HCPCS" } ], "standard_charges": [ { "setting": "outpatient", "payers_information": [ { "payer_name": "United Healthcare (UHC)", "plan_name": "DSNP", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "United Healthcare (UHC)", "plan_name": "Medicare Advantage", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" } ] } ] }, { "description": "Cptr-asst dir ms px", "code_information": [ { "code": "20985", "type": "HCPCS" } ], "standard_charges": [ { "setting": "outpatient", "payers_information": [ { "payer_name": "United Healthcare (UHC)", "plan_name": "DSNP", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "United Healthcare (UHC)", "plan_name": "Medicare Advantage", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" } ] } ] }, { "description": "Exc face tum deep 2 cm/>", "code_information": [ { "code": "21014", "type": "HCPCS" } ], "standard_charges": [ { "setting": "outpatient", "payers_information": [ { "payer_name": "United Healthcare (UHC)", "plan_name": "DSNP", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "United Healthcare (UHC)", "plan_name": "Medicare Advantage", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" } ] } ] }, { "description": "Exc neck les sc 3 cm/>", "code_information": [ { "code": "21552", "type": "HCPCS" } ], "standard_charges": [ { "setting": "outpatient", "payers_information": [ { "payer_name": "United Healthcare (UHC)", "plan_name": "DSNP", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "United Healthcare (UHC)", "plan_name": "Medicare Advantage", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" } ] } ] }, { "description": "Exc back les sc 3 cm/>", "code_information": [ { "code": "21931", "type": "HCPCS" } ], "standard_charges": [ { "setting": "outpatient", "payers_information": [ { "payer_name": "United Healthcare (UHC)", "plan_name": "DSNP", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "United Healthcare (UHC)", "plan_name": "Medicare Advantage", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" } ] } ] }, { "description": "Osteot dsc ant 1vrt sgm lmbr", "code_information": [ { "code": "22224", "type": "HCPCS" } ], "standard_charges": [ { "setting": "outpatient", "payers_information": [ { "payer_name": "United Healthcare (UHC)", "plan_name": "DSNP", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "United Healthcare (UHC)", "plan_name": "Medicare Advantage", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" } ] } ] }, { "description": "Perq vertebral augmentation", "code_information": [ { "code": "22513", "type": "HCPCS" } ], "standard_charges": [ { "setting": "outpatient", "payers_information": [ { "payer_name": "United Healthcare (UHC)", "plan_name": "DSNP", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "United Healthcare (UHC)", "plan_name": "Medicare Advantage", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" } ] } ] }, { "description": "Perq vertebral augmentation", "code_information": [ { "code": "22514", "type": "HCPCS" } ], "standard_charges": [ { "setting": "outpatient", "payers_information": [ { "payer_name": "United Healthcare (UHC)", "plan_name": "DSNP", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "United Healthcare (UHC)", "plan_name": "Medicare Advantage", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" } ] } ] }, { "description": "Perq vertebral augmentation", "code_information": [ { "code": "22515", "type": "HCPCS" } ], "standard_charges": [ { "setting": "outpatient", "payers_information": [ { "payer_name": "United Healthcare (UHC)", "plan_name": "DSNP", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "United Healthcare (UHC)", "plan_name": "Medicare Advantage", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" } ] } ] }, { "description": "Arthrd ant toral/xoral c1-c2", "code_information": [ { "code": "22548", "type": "HCPCS" } ], "standard_charges": [ { "setting": "outpatient", "payers_information": [ { "payer_name": "United Healthcare (UHC)", "plan_name": "DSNP", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "United Healthcare (UHC)", "plan_name": "Medicare Advantage", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" } ] } ] }, { "description": "Arthrd ant ntrbd cervical ea", "code_information": [ { "code": "22552", "type": "HCPCS" } ], "standard_charges": [ { "setting": "outpatient", "payers_information": [ { "payer_name": "United Healthcare (UHC)", "plan_name": "DSNP", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "United Healthcare (UHC)", "plan_name": "Medicare Advantage", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" } ] } ] }, { "description": "Repair rotator cuff chronic", "code_information": [ { "code": "23412", "type": "HCPCS" } ], "standard_charges": [ { "setting": "outpatient", "payers_information": [ { "payer_name": "United Healthcare (UHC)", "plan_name": "DSNP", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "United Healthcare (UHC)", "plan_name": "Medicare Advantage", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" } ] } ] }, { "description": "Optx clavicular fx w/int fix", "code_information": [ { "code": "23515", "type": "HCPCS" } ], "standard_charges": [ { "setting": "outpatient", "payers_information": [ { "payer_name": "United Healthcare (UHC)", "plan_name": "DSNP", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "United Healthcare (UHC)", "plan_name": "Medicare Advantage", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" } ] } ] }, { "description": "Cltx sho dslc w/mnpj wo anes", "code_information": [ { "code": "23650", "type": "HCPCS" } ], "standard_charges": [ { "setting": "outpatient", "payers_information": [ { "payer_name": "United Healthcare (UHC)", "plan_name": "DSNP", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "United Healthcare (UHC)", "plan_name": "Medicare Advantage", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" } ] } ] }, { "description": "Reconstruct elbow lat ligmnt", "code_information": [ { "code": "24344", "type": "HCPCS" } ], "standard_charges": [ { "setting": "outpatient", "payers_information": [ { "payer_name": "United Healthcare (UHC)", "plan_name": "DSNP", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "United Healthcare (UHC)", "plan_name": "Medicare Advantage", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" } ] } ] }, { "description": "Medical Rehabilitation Day Program - Half Day", "code_information": [ { "code": "0931", "type": "RC" } ], "standard_charges": [ { "setting": "outpatient", "payers_information": [ { "payer_name": "United Healthcare (UHC)", "plan_name": "DSNP", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "United Healthcare (UHC)", "plan_name": "Medicare Advantage", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" } ] } ] }, { "description": "Medical Rehabilitation Day Program - Full Day", "code_information": [ { "code": "0932", "type": "RC" } ], "standard_charges": [ { "setting": "outpatient", "payers_information": [ { "payer_name": "United Healthcare (UHC)", "plan_name": "DSNP", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "United Healthcare (UHC)", "plan_name": "Medicare Advantage", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" } ] } ] }, { "description": "Other Diagnostic Radiology - Assessment", "code_information": [ { "code": "0933", "type": "RC" } ], "standard_charges": [ { "setting": "outpatient", "payers_information": [ { "payer_name": "United Healthcare (UHC)", "plan_name": "DSNP", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "United Healthcare (UHC)", "plan_name": "Medicare Advantage", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" } ] } ] }, { "description": "Other Diagnostic Radiology - Evaluation or Testing", "code_information": [ { "code": "0934", "type": "RC" } ], "standard_charges": [ { "setting": "outpatient", "payers_information": [ { "payer_name": "United Healthcare (UHC)", "plan_name": "DSNP", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "United Healthcare (UHC)", "plan_name": "Medicare Advantage", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" } ] } ] }, { "description": "Other Diagnostic Radiology - Treatment", "code_information": [ { "code": "0935", "type": "RC" } ], "standard_charges": [ { "setting": "outpatient", "payers_information": [ { "payer_name": "United Healthcare (UHC)", "plan_name": "DSNP", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "United Healthcare (UHC)", "plan_name": "Medicare Advantage", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" } ] } ] }, { "description": "Other Diagnostic Radiology - Continuation", "code_information": [ { "code": "0936", "type": "RC" } ], "standard_charges": [ { "setting": "outpatient", "payers_information": [ { "payer_name": "United Healthcare (UHC)", "plan_name": "DSNP", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "United Healthcare (UHC)", "plan_name": "Medicare Advantage", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" } ] } ] }, { "description": "Other Diagnostic Radiology - Observation/Hourly", "code_information": [ { "code": "0937", "type": "RC" } ], "standard_charges": [ { "setting": "outpatient", "payers_information": [ { "payer_name": "United Healthcare (UHC)", "plan_name": "DSNP", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "United Healthcare (UHC)", "plan_name": "Medicare Advantage", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" } ] } ] }, { "description": "Other Diagnostic Radiology - Other", "code_information": [ { "code": "0938", "type": "RC" } ], "standard_charges": [ { "setting": "outpatient", "payers_information": [ { "payer_name": "United Healthcare (UHC)", "plan_name": "DSNP", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "United Healthcare (UHC)", "plan_name": "Medicare Advantage", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" } ] } ] }, { "description": "Other Diagnostic Radiology - Other", "code_information": [ { "code": "0939", "type": "RC" } ], "standard_charges": [ { "setting": "outpatient", "payers_information": [ { "payer_name": "United Healthcare (UHC)", "plan_name": "DSNP", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "United Healthcare (UHC)", "plan_name": "Medicare Advantage", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" } ] } ] }, { "description": "Other Therapeutic Services - General Classification", "code_information": [ { "code": "0940", "type": "RC" } ], "standard_charges": [ { "setting": "outpatient", "payers_information": [ { "payer_name": "United Healthcare (UHC)", "plan_name": "DSNP", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "United Healthcare (UHC)", "plan_name": "Medicare Advantage", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" } ] } ] }, { "description": "Other Therapeutic Services - Recreational Therapy", "code_information": [ { "code": "0941", "type": "RC" } ], "standard_charges": [ { "setting": "outpatient", "payers_information": [ { "payer_name": "United Healthcare (UHC)", "plan_name": "DSNP", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "United Healthcare (UHC)", "plan_name": "Medicare Advantage", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" } ] } ] }, { "description": "Other Therapeutic Services - Education/Training", "code_information": [ { "code": "0942", "type": "RC" } ], "standard_charges": [ { "setting": "outpatient", "payers_information": [ { "payer_name": "United Healthcare (UHC)", "plan_name": "DSNP", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "United Healthcare (UHC)", "plan_name": "Medicare Advantage", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Blue Cross Blue Shield of Montana", "plan_name": "HealthLink Network", "standard_charge_percentage": 75, "methodology": "percent of total billed charges", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Blue Cross Blue Shield of Montana", "plan_name": "Traditional Network", "standard_charge_percentage": 75, "methodology": "percent of total billed charges", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Blue Cross Blue Shield of Montana", "plan_name": "POS Network", "standard_charge_percentage": 75, "methodology": "percent of total billed charges", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Blue Cross Blue Shield of Montana", "plan_name": "Closed Plan Network", "standard_charge_percentage": 75, "methodology": "percent of total billed charges", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Blue Cross Blue Shield of Montana", "plan_name": "Retail HMO POS Network", "standard_charge_percentage": 75, "methodology": "percent of total billed charges", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Blue Cross Blue Shield of Montana", "plan_name": "Blue Options Network", "standard_charge_percentage": 75, "methodology": "percent of total billed charges", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" } ] } ] }, { "description": "Other Therapeutic Services - Cardiac Rehabilitation", "code_information": [ { "code": "0943", "type": "RC" } ], "standard_charges": [ { "setting": "outpatient", "payers_information": [ { "payer_name": "United Healthcare (UHC)", "plan_name": "DSNP", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "United Healthcare (UHC)", "plan_name": "Medicare Advantage", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" } ] } ] }, { "description": "Other Therapeutic Services - Drug Rehabilitation", "code_information": [ { "code": "0944", "type": "RC" } ], "standard_charges": [ { "setting": "outpatient", "payers_information": [ { "payer_name": "United Healthcare (UHC)", "plan_name": "DSNP", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "United Healthcare (UHC)", "plan_name": "Medicare Advantage", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" } ] } ] }, { "description": "Other Therapeutic Services - Alcohol Rehabilitation", "code_information": [ { "code": "0945", "type": "RC" } ], "standard_charges": [ { "setting": "outpatient", "payers_information": [ { "payer_name": "United Healthcare (UHC)", "plan_name": "DSNP", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "United Healthcare (UHC)", "plan_name": "Medicare Advantage", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" } ] } ] }, { "description": "Other Therapeutic Services - Complex Medical Equipment - Routine", "code_information": [ { "code": "0946", "type": "RC" } ], "standard_charges": [ { "setting": "outpatient", "payers_information": [ { "payer_name": "United Healthcare (UHC)", "plan_name": "DSNP", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "United Healthcare (UHC)", "plan_name": "Medicare Advantage", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Blue Cross Blue Shield of Montana", "plan_name": "HealthLink Network", "standard_charge_percentage": 75, "methodology": "percent of total billed charges", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Blue Cross Blue Shield of Montana", "plan_name": "Traditional Network", "standard_charge_percentage": 75, "methodology": "percent of total billed charges", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Blue Cross Blue Shield of Montana", "plan_name": "POS Network", "standard_charge_percentage": 75, "methodology": "percent of total billed charges", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Blue Cross Blue Shield of Montana", "plan_name": "Closed Plan Network", "standard_charge_percentage": 75, "methodology": "percent of total billed charges", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Blue Cross Blue Shield of Montana", "plan_name": "Retail HMO POS Network", "standard_charge_percentage": 75, "methodology": "percent of total billed charges", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Blue Cross Blue Shield of Montana", "plan_name": "Blue Options Network", "standard_charge_percentage": 75, "methodology": "percent of total billed charges", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" } ] } ] }, { "description": "Other Therapeutic Services - Complex Medical Equipment - Ancillary", "code_information": [ { "code": "0947", "type": "RC" } ], "standard_charges": [ { "setting": "outpatient", "payers_information": [ { "payer_name": "United Healthcare (UHC)", "plan_name": "DSNP", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "United Healthcare (UHC)", "plan_name": "Medicare Advantage", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Blue Cross Blue Shield of Montana", "plan_name": "HealthLink Network", "standard_charge_percentage": 75, "methodology": "percent of total billed charges", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Blue Cross Blue Shield of Montana", "plan_name": "Traditional Network", "standard_charge_percentage": 75, "methodology": "percent of total billed charges", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Blue Cross Blue Shield of Montana", "plan_name": "POS Network", "standard_charge_percentage": 75, "methodology": "percent of total billed charges", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Blue Cross Blue Shield of Montana", "plan_name": "Closed Plan Network", "standard_charge_percentage": 75, "methodology": "percent of total billed charges", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Blue Cross Blue Shield of Montana", "plan_name": "Retail HMO POS Network", "standard_charge_percentage": 75, "methodology": "percent of total billed charges", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Blue Cross Blue Shield of Montana", "plan_name": "Blue Options Network", "standard_charge_percentage": 75, "methodology": "percent of total billed charges", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" } ] } ] }, { "description": "Other Therapeutic Services - Pulmonary Rehabilitation", "code_information": [ { "code": "0948", "type": "RC" } ], "standard_charges": [ { "setting": "outpatient", "payers_information": [ { "payer_name": "United Healthcare (UHC)", "plan_name": "DSNP", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "United Healthcare (UHC)", "plan_name": "Medicare Advantage", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" } ] } ] }, { "description": "Other Therapeutic Services - Other", "code_information": [ { "code": "0949", "type": "RC" } ], "standard_charges": [ { "setting": "outpatient", "payers_information": [ { "payer_name": "United Healthcare (UHC)", "plan_name": "DSNP", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "United Healthcare (UHC)", "plan_name": "Medicare Advantage", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" } ] } ] }, { "description": "Anesth ear surgery", "code_information": [ { "code": "00120", "type": "HCPCS" } ], "standard_charges": [ { "setting": "outpatient", "payers_information": [ { "payer_name": "United Healthcare (UHC)", "plan_name": "DSNP", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "United Healthcare (UHC)", "plan_name": "Medicare Advantage", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" } ] } ] }, { "description": "Anesth head/neck/ptrunk", "code_information": [ { "code": "00300", "type": "HCPCS" } ], "standard_charges": [ { "setting": "outpatient", "payers_information": [ { "payer_name": "United Healthcare (UHC)", "plan_name": "DSNP", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "United Healthcare (UHC)", "plan_name": "Medicare Advantage", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" } ] } ] }, { "description": "Anesth neck organ 1yr/>", "code_information": [ { "code": "00320", "type": "HCPCS" } ], "standard_charges": [ { "setting": "outpatient", "payers_information": [ { "payer_name": "United Healthcare (UHC)", "plan_name": "DSNP", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "United Healthcare (UHC)", "plan_name": "Medicare Advantage", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" } ] } ] }, { "description": "Anesth neck vessel surgery", "code_information": [ { "code": "00350", "type": "HCPCS" } ], "standard_charges": [ { "setting": "outpatient", "payers_information": [ { "payer_name": "United Healthcare (UHC)", "plan_name": "DSNP", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "United Healthcare (UHC)", "plan_name": "Medicare Advantage", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" } ] } ] }, { "description": "Anesth neck vessel surgery", "code_information": [ { "code": "00352", "type": "HCPCS" } ], "standard_charges": [ { "setting": "outpatient", "payers_information": [ { "payer_name": "United Healthcare (UHC)", "plan_name": "DSNP", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "United Healthcare (UHC)", "plan_name": "Medicare Advantage", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" } ] } ] }, { "description": "Anesth surgery of breast", "code_information": [ { "code": "00402", "type": "HCPCS" } ], "standard_charges": [ { "setting": "outpatient", "payers_information": [ { "payer_name": "United Healthcare (UHC)", "plan_name": "DSNP", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "United Healthcare (UHC)", "plan_name": "Medicare Advantage", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" } ] } ] }, { "description": "Anesth correct heart rhythm", "code_information": [ { "code": "00410", "type": "HCPCS" } ], "standard_charges": [ { "setting": "outpatient", "payers_information": [ { "payer_name": "United Healthcare (UHC)", "plan_name": "DSNP", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "United Healthcare (UHC)", "plan_name": "Medicare Advantage", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" } ] } ] }, { "description": "Anesth surgery of shoulder", "code_information": [ { "code": "00450", "type": "HCPCS" } ], "standard_charges": [ { "setting": "outpatient", "payers_information": [ { "payer_name": "United Healthcare (UHC)", "plan_name": "DSNP", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "United Healthcare (UHC)", "plan_name": "Medicare Advantage", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" } ] } ] }, { "description": "Anesth abdominal wall surg", "code_information": [ { "code": "00730", "type": "HCPCS" } ], "standard_charges": [ { "setting": "outpatient", "payers_information": [ { "payer_name": "United Healthcare (UHC)", "plan_name": "DSNP", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "United Healthcare (UHC)", "plan_name": "Medicare Advantage", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" } ] } ] }, { "description": "Anesth vasectomy", "code_information": [ { "code": "00921", "type": "HCPCS" } ], "standard_charges": [ { "setting": "outpatient", "payers_information": [ { "payer_name": "United Healthcare (UHC)", "plan_name": "DSNP", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "United Healthcare (UHC)", "plan_name": "Medicare Advantage", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" } ] } ] }, { "description": "Fna bx w/us gdn 1st les", "code_information": [ { "code": "10005", "type": "HCPCS" } ], "standard_charges": [ { "setting": "outpatient", "payers_information": [ { "payer_name": "United Healthcare (UHC)", "plan_name": "DSNP", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "United Healthcare (UHC)", "plan_name": "Medicare Advantage", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" } ] } ] }, { "description": "I&d abscess simple/single", "code_information": [ { "code": "10060", "type": "HCPCS" } ], "standard_charges": [ { "setting": "outpatient", "payers_information": [ { "payer_name": "United Healthcare (UHC)", "plan_name": "DSNP", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "United Healthcare (UHC)", "plan_name": "Medicare Advantage", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" } ] } ] }, { "description": "I&d abscess comp/multiple", "code_information": [ { "code": "10061", "type": "HCPCS" } ], "standard_charges": [ { "setting": "outpatient", "payers_information": [ { "payer_name": "United Healthcare (UHC)", "plan_name": "DSNP", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "United Healthcare (UHC)", "plan_name": "Medicare Advantage", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" } ] } ] }, { "description": "Dbrdmt subq tiss each addl", "code_information": [ { "code": "11045", "type": "HCPCS" } ], "standard_charges": [ { "setting": "outpatient", "payers_information": [ { "payer_name": "United Healthcare (UHC)", "plan_name": "DSNP", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "United Healthcare (UHC)", "plan_name": "Medicare Advantage", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" } ] } ] }, { "description": "Exc tr-ext b9+marg >4.0 cm", "code_information": [ { "code": "11406", "type": "HCPCS" } ], "standard_charges": [ { "setting": "outpatient", "payers_information": [ { "payer_name": "United Healthcare (UHC)", "plan_name": "DSNP", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "United Healthcare (UHC)", "plan_name": "Medicare Advantage", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" } ] } ] }, { "description": "Exc h-f-nk-sp b9+marg 1.1-2", "code_information": [ { "code": "11422", "type": "HCPCS" } ], "standard_charges": [ { "setting": "outpatient", "payers_information": [ { "payer_name": "United Healthcare (UHC)", "plan_name": "DSNP", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "United Healthcare (UHC)", "plan_name": "Medicare Advantage", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" } ] } ] }, { "description": "Rpr s/n/ax/gen/trnk 2.5cm/<", "code_information": [ { "code": "12001", "type": "HCPCS" } ], "standard_charges": [ { "setting": "outpatient", "payers_information": [ { "payer_name": "United Healthcare (UHC)", "plan_name": "DSNP", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "United Healthcare (UHC)", "plan_name": "Medicare Advantage", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" } ] } ] }, { "description": "Rpr s/n/ax/gen/trnk2.6-7.5cm", "code_information": [ { "code": "12002", "type": "HCPCS" } ], "standard_charges": [ { "setting": "outpatient", "payers_information": [ { "payer_name": "United Healthcare (UHC)", "plan_name": "DSNP", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "United Healthcare (UHC)", "plan_name": "Medicare Advantage", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" } ] } ] }, { "description": "Removal tunneled cv cath", "code_information": [ { "code": "36589", "type": "HCPCS" } ], "standard_charges": [ { "setting": "outpatient", "payers_information": [ { "payer_name": "United Healthcare (UHC)", "plan_name": "DSNP", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "United Healthcare (UHC)", "plan_name": "Medicare Advantage", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" } ] } ] }, { "description": "Removal tunneled cv cath", "code_information": [ { "code": "36590", "type": "HCPCS" } ], "standard_charges": [ { "setting": "outpatient", "payers_information": [ { "payer_name": "United Healthcare (UHC)", "plan_name": "DSNP", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "United Healthcare (UHC)", "plan_name": "Medicare Advantage", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" } ] } ] }, { "description": "Reposition venous catheter", "code_information": [ { "code": "36597", "type": "HCPCS" } ], "standard_charges": [ { "setting": "outpatient", "payers_information": [ { "payer_name": "United Healthcare (UHC)", "plan_name": "DSNP", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "United Healthcare (UHC)", "plan_name": "Medicare Advantage", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" } ] } ] }, { "description": "Withdrawal of arterial blood", "code_information": [ { "code": "36600", "type": "HCPCS" } ], "standard_charges": [ { "setting": "outpatient", "payers_information": [ { "payer_name": "United Healthcare (UHC)", "plan_name": "DSNP", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "United Healthcare (UHC)", "plan_name": "Medicare Advantage", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" } ] } ] }, { "description": "Alpha-fetoprotein serum", "code_information": [ { "code": "82105", "type": "HCPCS" } ], "standard_charges": [ { "setting": "outpatient", "payers_information": [ { "payer_name": "United Healthcare (UHC)", "plan_name": "DSNP", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "United Healthcare (UHC)", "plan_name": "Medicare Advantage", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" } ] } ] }, { "description": "Assay of ammonia", "code_information": [ { "code": "82140", "type": "HCPCS" } ], "standard_charges": [ { "setting": "outpatient", "payers_information": [ { "payer_name": "United Healthcare (UHC)", "plan_name": "DSNP", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "United Healthcare (UHC)", "plan_name": "Medicare Advantage", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" } ] } ] }, { "description": "Assay of amylase", "code_information": [ { "code": "82150", "type": "HCPCS" } ], "standard_charges": [ { "setting": "outpatient", "payers_information": [ { "payer_name": "United Healthcare (UHC)", "plan_name": "DSNP", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "United Healthcare (UHC)", "plan_name": "Medicare Advantage", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" } ] } ] }, { "description": "Assay of beta-2 protein", "code_information": [ { "code": "82232", "type": "HCPCS" } ], "standard_charges": [ { "setting": "outpatient", "payers_information": [ { "payer_name": "United Healthcare (UHC)", "plan_name": "DSNP", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "United Healthcare (UHC)", "plan_name": "Medicare Advantage", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" } ] } ] }, { "description": "Bilirubin direct", "code_information": [ { "code": "82248", "type": "HCPCS" } ], "standard_charges": [ { "setting": "outpatient", "payers_information": [ { "payer_name": "United Healthcare (UHC)", "plan_name": "DSNP", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "United Healthcare (UHC)", "plan_name": "Medicare Advantage", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" } ] } ] }, { "description": "Occult bld feces 1-3 tests", "code_information": [ { "code": "82272", "type": "HCPCS" } ], "standard_charges": [ { "setting": "outpatient", "payers_information": [ { "payer_name": "United Healthcare (UHC)", "plan_name": "DSNP", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "United Healthcare (UHC)", "plan_name": "Medicare Advantage", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" } ] } ] }, { "description": "Vitamin d 25 hydroxy", "code_information": [ { "code": "82306", "type": "HCPCS" } ], "standard_charges": [ { "setting": "outpatient", "payers_information": [ { "payer_name": "United Healthcare (UHC)", "plan_name": "DSNP", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "United Healthcare (UHC)", "plan_name": "Medicare Advantage", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" } ] } ] }, { "description": "Assay of calcium", "code_information": [ { "code": "82330", "type": "HCPCS" } ], "standard_charges": [ { "setting": "outpatient", "payers_information": [ { "payer_name": "United Healthcare (UHC)", "plan_name": "DSNP", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "National Comp Care", "plan_name": "Workers' Compensation", "standard_charge_percentage": 90, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Coventry Health Care", "plan_name": "Auto Network", "standard_charge_percentage": 90, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Coventry Health Care", "plan_name": "Workers' Compensation", "standard_charge_percentage": 95, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Blue Cross Blue Shield of Montana", "plan_name": "Medicare Advantage", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "United Healthcare (UHC)", "plan_name": "Medicare Advantage", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Allegiance Provider Direct", "plan_name": "Medicare", "standard_charge_percentage": 229.99999999999997, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "PacificSource Health Plans", "plan_name": "PPO (PSN Network and Smart Health Network)", "standard_charge_percentage": 80, "methodology": "percent of total billed charges", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Medicare (CMS)", "plan_name": "Medicare", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "First Choice Health Network fka Health InfoNet", "plan_name": "Commercial", "standard_charge_percentage": 85, "methodology": "percent of total billed charges", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Claritev fka MultiPlan", "plan_name": "Auto Medical Program", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Claritev fka MultiPlan", "plan_name": "Workers' Compensation Program", "standard_charge_percentage": 90, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Claritev fka MultiPlan", "plan_name": "PPO", "standard_charge_percentage": 75, "methodology": "percent of total billed charges", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "First Choice of the Midwest", "plan_name": "PPO", "standard_charge_percentage": 90, "methodology": "percent of total billed charges", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Employee Benefit Management Services (EBMS)", "plan_name": "EBMS SelectCare Network", "standard_charge_percentage": 80, "methodology": "percent of total billed charges", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Medica Insurance Company", "plan_name": "Medicare Cost", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "First Choice Health Network fka Health InfoNet", "plan_name": "Medicare Advantage", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "First Choice Health Network fka Health InfoNet", "plan_name": "Workers Compensation", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Allegiance Provider Direct", "plan_name": "Montana Association of Counties (MACo)", "standard_charge_percentage": 229.99999999999997, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Allegiance Provider Direct", "plan_name": "State of Montana Employee Benefit Plan (Self-Funded)", "standard_charge_percentage": 229.99999999999997, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Allegiance Provider Direct", "plan_name": "Montana Municipal Interlocal Authority (MMIA)", "standard_charge_percentage": 229.99999999999997, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Medicaid (State)", "plan_name": "Medicaid", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Blue Cross Blue Shield of Montana", "plan_name": "HealthLink Network", "standard_charge_percentage": 75, "methodology": "percent of total billed charges", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Blue Cross Blue Shield of Montana", "plan_name": "Traditional Network", "standard_charge_percentage": 75, "methodology": "percent of total billed charges", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Blue Cross Blue Shield of Montana", "plan_name": "POS Network", "standard_charge_percentage": 75, "methodology": "percent of total billed charges", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Blue Cross Blue Shield of Montana", "plan_name": "Closed Plan Network", "standard_charge_percentage": 75, "methodology": "percent of total billed charges", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Blue Cross Blue Shield of Montana", "plan_name": "Retail HMO POS Network", "standard_charge_percentage": 75, "methodology": "percent of total billed charges", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Blue Cross Blue Shield of Montana", "plan_name": "Blue Options Network", "standard_charge_percentage": 75, "methodology": "percent of total billed charges", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "PacificSource Health Plans", "plan_name": "Medicare Advantage", "standard_charge_percentage": 103, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" } ] } ] }, { "description": "Calculus assay quant", "code_information": [ { "code": "82360", "type": "HCPCS" } ], "standard_charges": [ { "setting": "outpatient", "payers_information": [ { "payer_name": "United Healthcare (UHC)", "plan_name": "DSNP", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "United Healthcare (UHC)", "plan_name": "Medicare Advantage", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" } ] } ] }, { "description": "Carcinoembryonic antigen", "code_information": [ { "code": "82378", "type": "HCPCS" } ], "standard_charges": [ { "setting": "outpatient", "payers_information": [ { "payer_name": "United Healthcare (UHC)", "plan_name": "DSNP", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "United Healthcare (UHC)", "plan_name": "Medicare Advantage", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" } ] } ] }, { "description": "Total cortisol", "code_information": [ { "code": "82533", "type": "HCPCS" } ], "standard_charges": [ { "setting": "outpatient", "payers_information": [ { "payer_name": "United Healthcare (UHC)", "plan_name": "DSNP", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "United Healthcare (UHC)", "plan_name": "Medicare Advantage", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" } ] } ] }, { "description": "Assay of ck (cpk)", "code_information": [ { "code": "82550", "type": "HCPCS" } ], "standard_charges": [ { "setting": "outpatient", "payers_information": [ { "payer_name": "United Healthcare (UHC)", "plan_name": "DSNP", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "United Healthcare (UHC)", "plan_name": "Medicare Advantage", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" } ] } ] }, { "description": "Creatine mb fraction", "code_information": [ { "code": "82553", "type": "HCPCS" } ], "standard_charges": [ { "setting": "outpatient", "payers_information": [ { "payer_name": "United Healthcare (UHC)", "plan_name": "DSNP", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "United Healthcare (UHC)", "plan_name": "Medicare Advantage", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" } ] } ] }, { "description": "Assay of creatinine", "code_information": [ { "code": "82565", "type": "HCPCS" } ], "standard_charges": [ { "setting": "outpatient", "payers_information": [ { "payer_name": "United Healthcare (UHC)", "plan_name": "DSNP", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "United Healthcare (UHC)", "plan_name": "Medicare Advantage", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" } ] } ] }, { "description": "Assay of urine creatinine", "code_information": [ { "code": "82570", "type": "HCPCS" } ], "standard_charges": [ { "setting": "outpatient", "payers_information": [ { "payer_name": "United Healthcare (UHC)", "plan_name": "DSNP", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "United Healthcare (UHC)", "plan_name": "Medicare Advantage", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" } ] } ] }, { "description": "Vitamin b-12", "code_information": [ { "code": "82607", "type": "HCPCS" } ], "standard_charges": [ { "setting": "outpatient", "payers_information": [ { "payer_name": "United Healthcare (UHC)", "plan_name": "DSNP", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "United Healthcare (UHC)", "plan_name": "Medicare Advantage", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" } ] } ] }, { "description": "Assay of erythropoietin", "code_information": [ { "code": "82668", "type": "HCPCS" } ], "standard_charges": [ { "setting": "outpatient", "payers_information": [ { "payer_name": "United Healthcare (UHC)", "plan_name": "DSNP", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "United Healthcare (UHC)", "plan_name": "Medicare Advantage", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" } ] } ] }, { "description": "Assay of ferritin", "code_information": [ { "code": "82728", "type": "HCPCS" } ], "standard_charges": [ { "setting": "outpatient", "payers_information": [ { "payer_name": "United Healthcare (UHC)", "plan_name": "DSNP", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "National Comp Care", "plan_name": "Workers' Compensation", "standard_charge_percentage": 90, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Coventry Health Care", "plan_name": "Auto Network", "standard_charge_percentage": 90, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Coventry Health Care", "plan_name": "Workers' Compensation", "standard_charge_percentage": 95, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Blue Cross Blue Shield of Montana", "plan_name": "Medicare Advantage", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "United Healthcare (UHC)", "plan_name": "Medicare Advantage", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Allegiance Provider Direct", "plan_name": "Medicare", "standard_charge_percentage": 229.99999999999997, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "PacificSource Health Plans", "plan_name": "PPO (PSN Network and Smart Health Network)", "standard_charge_percentage": 80, "methodology": "percent of total billed charges", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Medicare (CMS)", "plan_name": "Medicare", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "First Choice Health Network fka Health InfoNet", "plan_name": "Commercial", "standard_charge_percentage": 85, "methodology": "percent of total billed charges", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Claritev fka MultiPlan", "plan_name": "Auto Medical Program", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Claritev fka MultiPlan", "plan_name": "Workers' Compensation Program", "standard_charge_percentage": 90, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Claritev fka MultiPlan", "plan_name": "PPO", "standard_charge_percentage": 75, "methodology": "percent of total billed charges", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "First Choice of the Midwest", "plan_name": "PPO", "standard_charge_percentage": 90, "methodology": "percent of total billed charges", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Employee Benefit Management Services (EBMS)", "plan_name": "EBMS SelectCare Network", "standard_charge_percentage": 80, "methodology": "percent of total billed charges", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Medica Insurance Company", "plan_name": "Medicare Cost", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "First Choice Health Network fka Health InfoNet", "plan_name": "Medicare Advantage", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "First Choice Health Network fka Health InfoNet", "plan_name": "Workers Compensation", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Allegiance Provider Direct", "plan_name": "Montana Association of Counties (MACo)", "standard_charge_percentage": 229.99999999999997, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Allegiance Provider Direct", "plan_name": "State of Montana Employee Benefit Plan (Self-Funded)", "standard_charge_percentage": 229.99999999999997, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Allegiance Provider Direct", "plan_name": "Montana Municipal Interlocal Authority (MMIA)", "standard_charge_percentage": 229.99999999999997, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Medicaid (State)", "plan_name": "Medicaid", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Blue Cross Blue Shield of Montana", "plan_name": "HealthLink Network", "standard_charge_percentage": 75, "methodology": "percent of total billed charges", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Blue Cross Blue Shield of Montana", "plan_name": "Traditional Network", "standard_charge_percentage": 75, "methodology": "percent of total billed charges", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Blue Cross Blue Shield of Montana", "plan_name": "POS Network", "standard_charge_percentage": 75, "methodology": "percent of total billed charges", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Blue Cross Blue Shield of Montana", "plan_name": "Closed Plan Network", "standard_charge_percentage": 75, "methodology": "percent of total billed charges", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Blue Cross Blue Shield of Montana", "plan_name": "Retail HMO POS Network", "standard_charge_percentage": 75, "methodology": "percent of total billed charges", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Blue Cross Blue Shield of Montana", "plan_name": "Blue Options Network", "standard_charge_percentage": 75, "methodology": "percent of total billed charges", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "PacificSource Health Plans", "plan_name": "Medicare Advantage", "standard_charge_percentage": 103, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" } ] } ] }, { "description": "Assay of folic acid serum", "code_information": [ { "code": "82746", "type": "HCPCS" } ], "standard_charges": [ { "setting": "outpatient", "payers_information": [ { "payer_name": "United Healthcare (UHC)", "plan_name": "DSNP", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "United Healthcare (UHC)", "plan_name": "Medicare Advantage", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" } ] } ] }, { "description": "Assay iga/igd/igg/igm each", "code_information": [ { "code": "82784", "type": "HCPCS" } ], "standard_charges": [ { "setting": "outpatient", "payers_information": [ { "payer_name": "United Healthcare (UHC)", "plan_name": "DSNP", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "United Healthcare (UHC)", "plan_name": "Medicare Advantage", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" } ] } ] }, { "description": "Blood gases any combination", "code_information": [ { "code": "82803", "type": "HCPCS" } ], "standard_charges": [ { "setting": "outpatient", "payers_information": [ { "payer_name": "United Healthcare (UHC)", "plan_name": "DSNP", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "National Comp Care", "plan_name": "Workers' Compensation", "standard_charge_percentage": 90, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Coventry Health Care", "plan_name": "Auto Network", "standard_charge_percentage": 90, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Coventry Health Care", "plan_name": "Workers' Compensation", "standard_charge_percentage": 95, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Blue Cross Blue Shield of Montana", "plan_name": "Medicare Advantage", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "United Healthcare (UHC)", "plan_name": "Medicare Advantage", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Allegiance Provider Direct", "plan_name": "Medicare", "standard_charge_percentage": 229.99999999999997, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "PacificSource Health Plans", "plan_name": "PPO (PSN Network and Smart Health Network)", "standard_charge_percentage": 80, "methodology": "percent of total billed charges", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "First Choice Health Network fka Health InfoNet", "plan_name": "Commercial", "standard_charge_percentage": 85, "methodology": "percent of total billed charges", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Medicare (CMS)", "plan_name": "Medicare", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Claritev fka MultiPlan", "plan_name": "Auto Medical Program", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Claritev fka MultiPlan", "plan_name": "Workers' Compensation Program", "standard_charge_percentage": 90, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Claritev fka MultiPlan", "plan_name": "PPO", "standard_charge_percentage": 75, "methodology": "percent of total billed charges", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "First Choice of the Midwest", "plan_name": "PPO", "standard_charge_percentage": 90, "methodology": "percent of total billed charges", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Employee Benefit Management Services (EBMS)", "plan_name": "EBMS SelectCare Network", "standard_charge_percentage": 80, "methodology": "percent of total billed charges", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Medica Insurance Company", "plan_name": "Medicare Cost", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "First Choice Health Network fka Health InfoNet", "plan_name": "Medicare Advantage", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "First Choice Health Network fka Health InfoNet", "plan_name": "Workers Compensation", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Allegiance Provider Direct", "plan_name": "Montana Association of Counties (MACo)", "standard_charge_percentage": 229.99999999999997, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Allegiance Provider Direct", "plan_name": "State of Montana Employee Benefit Plan (Self-Funded)", "standard_charge_percentage": 229.99999999999997, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Allegiance Provider Direct", "plan_name": "Montana Municipal Interlocal Authority (MMIA)", "standard_charge_percentage": 229.99999999999997, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Medicaid (State)", "plan_name": "Medicaid", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Blue Cross Blue Shield of Montana", "plan_name": "HealthLink Network", "standard_charge_percentage": 75, "methodology": "percent of total billed charges", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Blue Cross Blue Shield of Montana", "plan_name": "Traditional Network", "standard_charge_percentage": 75, "methodology": "percent of total billed charges", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Blue Cross Blue Shield of Montana", "plan_name": "POS Network", "standard_charge_percentage": 75, "methodology": "percent of total billed charges", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Blue Cross Blue Shield of Montana", "plan_name": "Closed Plan Network", "standard_charge_percentage": 75, "methodology": "percent of total billed charges", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Blue Cross Blue Shield of Montana", "plan_name": "Retail HMO POS Network", "standard_charge_percentage": 75, "methodology": "percent of total billed charges", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Blue Cross Blue Shield of Montana", "plan_name": "Blue Options Network", "standard_charge_percentage": 75, "methodology": "percent of total billed charges", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "PacificSource Health Plans", "plan_name": "Medicare Advantage", "standard_charge_percentage": 103, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" } ] } ] }, { "description": "Blood gases w/o2 saturation", "code_information": [ { "code": "82805", "type": "HCPCS" } ], "standard_charges": [ { "setting": "outpatient", "payers_information": [ { "payer_name": "United Healthcare (UHC)", "plan_name": "DSNP", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "National Comp Care", "plan_name": "Workers' Compensation", "standard_charge_percentage": 90, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Coventry Health Care", "plan_name": "Auto Network", "standard_charge_percentage": 90, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Coventry Health Care", "plan_name": "Workers' Compensation", "standard_charge_percentage": 95, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Blue Cross Blue Shield of Montana", "plan_name": "Medicare Advantage", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "United Healthcare (UHC)", "plan_name": "Medicare Advantage", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Allegiance Provider Direct", "plan_name": "Medicare", "standard_charge_percentage": 229.99999999999997, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "PacificSource Health Plans", "plan_name": "PPO (PSN Network and Smart Health Network)", "standard_charge_percentage": 80, "methodology": "percent of total billed charges", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "First Choice Health Network fka Health InfoNet", "plan_name": "Commercial", "standard_charge_percentage": 85, "methodology": "percent of total billed charges", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Medicare (CMS)", "plan_name": "Medicare", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Claritev fka MultiPlan", "plan_name": "Workers' Compensation Program", "standard_charge_percentage": 90, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Claritev fka MultiPlan", "plan_name": "Auto Medical Program", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Claritev fka MultiPlan", "plan_name": "PPO", "standard_charge_percentage": 75, "methodology": "percent of total billed charges", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "First Choice of the Midwest", "plan_name": "PPO", "standard_charge_percentage": 90, "methodology": "percent of total billed charges", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Employee Benefit Management Services (EBMS)", "plan_name": "EBMS SelectCare Network", "standard_charge_percentage": 80, "methodology": "percent of total billed charges", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Medica Insurance Company", "plan_name": "Medicare Cost", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "First Choice Health Network fka Health InfoNet", "plan_name": "Medicare Advantage", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "First Choice Health Network fka Health InfoNet", "plan_name": "Workers Compensation", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Allegiance Provider Direct", "plan_name": "Montana Association of Counties (MACo)", "standard_charge_percentage": 229.99999999999997, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Allegiance Provider Direct", "plan_name": "State of Montana Employee Benefit Plan (Self-Funded)", "standard_charge_percentage": 229.99999999999997, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Allegiance Provider Direct", "plan_name": "Montana Municipal Interlocal Authority (MMIA)", "standard_charge_percentage": 229.99999999999997, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Medicaid (State)", "plan_name": "Medicaid", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Blue Cross Blue Shield of Montana", "plan_name": "HealthLink Network", "standard_charge_percentage": 75, "methodology": "percent of total billed charges", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Blue Cross Blue Shield of Montana", "plan_name": "Traditional Network", "standard_charge_percentage": 75, "methodology": "percent of total billed charges", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Blue Cross Blue Shield of Montana", "plan_name": "POS Network", "standard_charge_percentage": 75, "methodology": "percent of total billed charges", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Blue Cross Blue Shield of Montana", "plan_name": "Closed Plan Network", "standard_charge_percentage": 75, "methodology": "percent of total billed charges", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Blue Cross Blue Shield of Montana", "plan_name": "Retail HMO POS Network", "standard_charge_percentage": 75, "methodology": "percent of total billed charges", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Blue Cross Blue Shield of Montana", "plan_name": "Blue Options Network", "standard_charge_percentage": 75, "methodology": "percent of total billed charges", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "PacificSource Health Plans", "plan_name": "Medicare Advantage", "standard_charge_percentage": 103, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" } ] } ] }, { "description": "Glucose other fluid", "code_information": [ { "code": "82945", "type": "HCPCS" } ], "standard_charges": [ { "setting": "outpatient", "payers_information": [ { "payer_name": "United Healthcare (UHC)", "plan_name": "DSNP", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "National Comp Care", "plan_name": "Workers' Compensation", "standard_charge_percentage": 90, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Coventry Health Care", "plan_name": "Auto Network", "standard_charge_percentage": 90, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Coventry Health Care", "plan_name": "Workers' Compensation", "standard_charge_percentage": 95, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Blue Cross Blue Shield of Montana", "plan_name": "Medicare Advantage", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "United Healthcare (UHC)", "plan_name": "Medicare Advantage", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Allegiance Provider Direct", "plan_name": "Medicare", "standard_charge_percentage": 229.99999999999997, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "PacificSource Health Plans", "plan_name": "PPO (PSN Network and Smart Health Network)", "standard_charge_percentage": 80, "methodology": "percent of total billed charges", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Medicare (CMS)", "plan_name": "Medicare", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "First Choice Health Network fka Health InfoNet", "plan_name": "Commercial", "standard_charge_percentage": 85, "methodology": "percent of total billed charges", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Claritev fka MultiPlan", "plan_name": "Auto Medical Program", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Claritev fka MultiPlan", "plan_name": "Workers' Compensation Program", "standard_charge_percentage": 90, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Claritev fka MultiPlan", "plan_name": "PPO", "standard_charge_percentage": 75, "methodology": "percent of total billed charges", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "First Choice of the Midwest", "plan_name": "PPO", "standard_charge_percentage": 90, "methodology": "percent of total billed charges", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Employee Benefit Management Services (EBMS)", "plan_name": "EBMS SelectCare Network", "standard_charge_percentage": 80, "methodology": "percent of total billed charges", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Medica Insurance Company", "plan_name": "Medicare Cost", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "First Choice Health Network fka Health InfoNet", "plan_name": "Medicare Advantage", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "First Choice Health Network fka Health InfoNet", "plan_name": "Workers Compensation", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Allegiance Provider Direct", "plan_name": "Montana Association of Counties (MACo)", "standard_charge_percentage": 229.99999999999997, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Allegiance Provider Direct", "plan_name": "State of Montana Employee Benefit Plan (Self-Funded)", "standard_charge_percentage": 229.99999999999997, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Allegiance Provider Direct", "plan_name": "Montana Municipal Interlocal Authority (MMIA)", "standard_charge_percentage": 229.99999999999997, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Medicaid (State)", "plan_name": "Medicaid", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Blue Cross Blue Shield of Montana", "plan_name": "HealthLink Network", "standard_charge_percentage": 75, "methodology": "percent of total billed charges", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Blue Cross Blue Shield of Montana", "plan_name": "Traditional Network", "standard_charge_percentage": 75, "methodology": "percent of total billed charges", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Blue Cross Blue Shield of Montana", "plan_name": "POS Network", "standard_charge_percentage": 75, "methodology": "percent of total billed charges", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Blue Cross Blue Shield of Montana", "plan_name": "Closed Plan Network", "standard_charge_percentage": 75, "methodology": "percent of total billed charges", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Blue Cross Blue Shield of Montana", "plan_name": "Retail HMO POS Network", "standard_charge_percentage": 75, "methodology": "percent of total billed charges", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Blue Cross Blue Shield of Montana", "plan_name": "Blue Options Network", "standard_charge_percentage": 75, "methodology": "percent of total billed charges", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "PacificSource Health Plans", "plan_name": "Medicare Advantage", "standard_charge_percentage": 103, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" } ] } ] }, { "description": "Assay glucose blood quant", "code_information": [ { "code": "82947", "type": "HCPCS" } ], "standard_charges": [ { "setting": "outpatient", "payers_information": [ { "payer_name": "United Healthcare (UHC)", "plan_name": "DSNP", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "United Healthcare (UHC)", "plan_name": "Medicare Advantage", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" } ] } ] }, { "description": "Reagent strip/blood glucose", "code_information": [ { "code": "82948", "type": "HCPCS" } ], "standard_charges": [ { "setting": "outpatient", "payers_information": [ { "payer_name": "United Healthcare (UHC)", "plan_name": "DSNP", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "National Comp Care", "plan_name": "Workers' Compensation", "standard_charge_percentage": 90, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Coventry Health Care", "plan_name": "Auto Network", "standard_charge_percentage": 90, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Coventry Health Care", "plan_name": "Workers' Compensation", "standard_charge_percentage": 95, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Blue Cross Blue Shield of Montana", "plan_name": "Medicare Advantage", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "United Healthcare (UHC)", "plan_name": "Medicare Advantage", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Allegiance Provider Direct", "plan_name": "Medicare", "standard_charge_percentage": 229.99999999999997, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "PacificSource Health Plans", "plan_name": "PPO (PSN Network and Smart Health Network)", "standard_charge_percentage": 80, "methodology": "percent of total billed charges", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Medicare (CMS)", "plan_name": "Medicare", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "First Choice Health Network fka Health InfoNet", "plan_name": "Commercial", "standard_charge_percentage": 85, "methodology": "percent of total billed charges", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Claritev fka MultiPlan", "plan_name": "Auto Medical Program", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Claritev fka MultiPlan", "plan_name": "Workers' Compensation Program", "standard_charge_percentage": 90, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Claritev fka MultiPlan", "plan_name": "PPO", "standard_charge_percentage": 75, "methodology": "percent of total billed charges", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "First Choice of the Midwest", "plan_name": "PPO", "standard_charge_percentage": 90, "methodology": "percent of total billed charges", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Employee Benefit Management Services (EBMS)", "plan_name": "EBMS SelectCare Network", "standard_charge_percentage": 80, "methodology": "percent of total billed charges", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Medica Insurance Company", "plan_name": "Medicare Cost", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "First Choice Health Network fka Health InfoNet", "plan_name": "Medicare Advantage", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "First Choice Health Network fka Health InfoNet", "plan_name": "Workers Compensation", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Allegiance Provider Direct", "plan_name": "Montana Association of Counties (MACo)", "standard_charge_percentage": 229.99999999999997, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Allegiance Provider Direct", "plan_name": "State of Montana Employee Benefit Plan (Self-Funded)", "standard_charge_percentage": 229.99999999999997, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Allegiance Provider Direct", "plan_name": "Montana Municipal Interlocal Authority (MMIA)", "standard_charge_percentage": 229.99999999999997, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Blue Cross Blue Shield of Montana", "plan_name": "HealthLink Network", "standard_charge_percentage": 75, "methodology": "percent of total billed charges", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Blue Cross Blue Shield of Montana", "plan_name": "Traditional Network", "standard_charge_percentage": 75, "methodology": "percent of total billed charges", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Blue Cross Blue Shield of Montana", "plan_name": "POS Network", "standard_charge_percentage": 75, "methodology": "percent of total billed charges", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Blue Cross Blue Shield of Montana", "plan_name": "Closed Plan Network", "standard_charge_percentage": 75, "methodology": "percent of total billed charges", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Blue Cross Blue Shield of Montana", "plan_name": "Retail HMO POS Network", "standard_charge_percentage": 75, "methodology": "percent of total billed charges", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Blue Cross Blue Shield of Montana", "plan_name": "Blue Options Network", "standard_charge_percentage": 75, "methodology": "percent of total billed charges", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Medicaid (State)", "plan_name": "Medicaid", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "PacificSource Health Plans", "plan_name": "Medicare Advantage", "standard_charge_percentage": 103, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" } ] } ] }, { "description": "Assay of ggt", "code_information": [ { "code": "82977", "type": "HCPCS" } ], "standard_charges": [ { "setting": "outpatient", "payers_information": [ { "payer_name": "United Healthcare (UHC)", "plan_name": "DSNP", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "United Healthcare (UHC)", "plan_name": "Medicare Advantage", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" } ] } ] }, { "description": "Assay of haptoglobin quant", "code_information": [ { "code": "83010", "type": "HCPCS" } ], "standard_charges": [ { "setting": "outpatient", "payers_information": [ { "payer_name": "United Healthcare (UHC)", "plan_name": "DSNP", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "United Healthcare (UHC)", "plan_name": "Medicare Advantage", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" } ] } ] }, { "description": "Hemoglobin glycosylated a1c", "code_information": [ { "code": "83036", "type": "HCPCS" } ], "standard_charges": [ { "setting": "outpatient", "payers_information": [ { "payer_name": "United Healthcare (UHC)", "plan_name": "DSNP", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "National Comp Care", "plan_name": "Workers' Compensation", "standard_charge_percentage": 90, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Coventry Health Care", "plan_name": "Auto Network", "standard_charge_percentage": 90, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Coventry Health Care", "plan_name": "Workers' Compensation", "standard_charge_percentage": 95, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Blue Cross Blue Shield of Montana", "plan_name": "Medicare Advantage", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "United Healthcare (UHC)", "plan_name": "Medicare Advantage", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Allegiance Provider Direct", "plan_name": "Medicare", "standard_charge_percentage": 229.99999999999997, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "PacificSource Health Plans", "plan_name": "PPO (PSN Network and Smart Health Network)", "standard_charge_percentage": 80, "methodology": "percent of total billed charges", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Medicare (CMS)", "plan_name": "Medicare", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "First Choice Health Network fka Health InfoNet", "plan_name": "Commercial", "standard_charge_percentage": 85, "methodology": "percent of total billed charges", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Claritev fka MultiPlan", "plan_name": "Auto Medical Program", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Claritev fka MultiPlan", "plan_name": "Workers' Compensation Program", "standard_charge_percentage": 90, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Claritev fka MultiPlan", "plan_name": "PPO", "standard_charge_percentage": 75, "methodology": "percent of total billed charges", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "First Choice of the Midwest", "plan_name": "PPO", "standard_charge_percentage": 90, "methodology": "percent of total billed charges", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Employee Benefit Management Services (EBMS)", "plan_name": "EBMS SelectCare Network", "standard_charge_percentage": 80, "methodology": "percent of total billed charges", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Medica Insurance Company", "plan_name": "Medicare Cost", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "First Choice Health Network fka Health InfoNet", "plan_name": "Medicare Advantage", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "First Choice Health Network fka Health InfoNet", "plan_name": "Workers Compensation", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Allegiance Provider Direct", "plan_name": "Montana Association of Counties (MACo)", "standard_charge_percentage": 229.99999999999997, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Allegiance Provider Direct", "plan_name": "State of Montana Employee Benefit Plan (Self-Funded)", "standard_charge_percentage": 229.99999999999997, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Allegiance Provider Direct", "plan_name": "Montana Municipal Interlocal Authority (MMIA)", "standard_charge_percentage": 229.99999999999997, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Blue Cross Blue Shield of Montana", "plan_name": "HealthLink Network", "standard_charge_percentage": 75, "methodology": "percent of total billed charges", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Blue Cross Blue Shield of Montana", "plan_name": "Traditional Network", "standard_charge_percentage": 75, "methodology": "percent of total billed charges", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Blue Cross Blue Shield of Montana", "plan_name": "POS Network", "standard_charge_percentage": 75, "methodology": "percent of total billed charges", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Blue Cross Blue Shield of Montana", "plan_name": "Closed Plan Network", "standard_charge_percentage": 75, "methodology": "percent of total billed charges", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Blue Cross Blue Shield of Montana", "plan_name": "Retail HMO POS Network", "standard_charge_percentage": 75, "methodology": "percent of total billed charges", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Blue Cross Blue Shield of Montana", "plan_name": "Blue Options Network", "standard_charge_percentage": 75, "methodology": "percent of total billed charges", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Medicaid (State)", "plan_name": "Medicaid", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "PacificSource Health Plans", "plan_name": "Medicare Advantage", "standard_charge_percentage": 103, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" } ] } ] }, { "description": "Iron binding test", "code_information": [ { "code": "83550", "type": "HCPCS" } ], "standard_charges": [ { "setting": "outpatient", "payers_information": [ { "payer_name": "United Healthcare (UHC)", "plan_name": "DSNP", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "United Healthcare (UHC)", "plan_name": "Medicare Advantage", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" } ] } ] }, { "description": "Assay of lactic acid", "code_information": [ { "code": "83605", "type": "HCPCS" } ], "standard_charges": [ { "setting": "outpatient", "payers_information": [ { "payer_name": "United Healthcare (UHC)", "plan_name": "DSNP", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "United Healthcare (UHC)", "plan_name": "Medicare Advantage", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" } ] } ] }, { "description": "Lactate (ld) (ldh) enzyme", "code_information": [ { "code": "83615", "type": "HCPCS" } ], "standard_charges": [ { "setting": "outpatient", "payers_information": [ { "payer_name": "United Healthcare (UHC)", "plan_name": "DSNP", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "United Healthcare (UHC)", "plan_name": "Medicare Advantage", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" } ] } ] }, { "description": "Assay of lipase", "code_information": [ { "code": "83690", "type": "HCPCS" } ], "standard_charges": [ { "setting": "outpatient", "payers_information": [ { "payer_name": "United Healthcare (UHC)", "plan_name": "DSNP", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "United Healthcare (UHC)", "plan_name": "Medicare Advantage", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" } ] } ] }, { "description": "Assay of magnesium", "code_information": [ { "code": "83735", "type": "HCPCS" } ], "standard_charges": [ { "setting": "outpatient", "payers_information": [ { "payer_name": "United Healthcare (UHC)", "plan_name": "DSNP", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "National Comp Care", "plan_name": "Workers' Compensation", "standard_charge_percentage": 90, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Coventry Health Care", "plan_name": "Auto Network", "standard_charge_percentage": 90, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Coventry Health Care", "plan_name": "Workers' Compensation", "standard_charge_percentage": 95, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Blue Cross Blue Shield of Montana", "plan_name": "Medicare Advantage", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "United Healthcare (UHC)", "plan_name": "Medicare Advantage", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Allegiance Provider Direct", "plan_name": "Medicare", "standard_charge_percentage": 229.99999999999997, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "PacificSource Health Plans", "plan_name": "PPO (PSN Network and Smart Health Network)", "standard_charge_percentage": 80, "methodology": "percent of total billed charges", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "First Choice Health Network fka Health InfoNet", "plan_name": "Commercial", "standard_charge_percentage": 85, "methodology": "percent of total billed charges", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Medicare (CMS)", "plan_name": "Medicare", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Claritev fka MultiPlan", "plan_name": "Auto Medical Program", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Claritev fka MultiPlan", "plan_name": "Workers' Compensation Program", "standard_charge_percentage": 90, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Claritev fka MultiPlan", "plan_name": "PPO", "standard_charge_percentage": 75, "methodology": "percent of total billed charges", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "First Choice of the Midwest", "plan_name": "PPO", "standard_charge_percentage": 90, "methodology": "percent of total billed charges", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Employee Benefit Management Services (EBMS)", "plan_name": "EBMS SelectCare Network", "standard_charge_percentage": 80, "methodology": "percent of total billed charges", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Medica Insurance Company", "plan_name": "Medicare Cost", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "First Choice Health Network fka Health InfoNet", "plan_name": "Medicare Advantage", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "First Choice Health Network fka Health InfoNet", "plan_name": "Workers Compensation", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Allegiance Provider Direct", "plan_name": "Montana Association of Counties (MACo)", "standard_charge_percentage": 229.99999999999997, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Allegiance Provider Direct", "plan_name": "State of Montana Employee Benefit Plan (Self-Funded)", "standard_charge_percentage": 229.99999999999997, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Allegiance Provider Direct", "plan_name": "Montana Municipal Interlocal Authority (MMIA)", "standard_charge_percentage": 229.99999999999997, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Medicaid (State)", "plan_name": "Medicaid", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Blue Cross Blue Shield of Montana", "plan_name": "HealthLink Network", "standard_charge_percentage": 75, "methodology": "percent of total billed charges", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Blue Cross Blue Shield of Montana", "plan_name": "Traditional Network", "standard_charge_percentage": 75, "methodology": "percent of total billed charges", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Blue Cross Blue Shield of Montana", "plan_name": "POS Network", "standard_charge_percentage": 75, "methodology": "percent of total billed charges", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Blue Cross Blue Shield of Montana", "plan_name": "Closed Plan Network", "standard_charge_percentage": 75, "methodology": "percent of total billed charges", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Blue Cross Blue Shield of Montana", "plan_name": "Retail HMO POS Network", "standard_charge_percentage": 75, "methodology": "percent of total billed charges", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Blue Cross Blue Shield of Montana", "plan_name": "Blue Options Network", "standard_charge_percentage": 75, "methodology": "percent of total billed charges", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "PacificSource Health Plans", "plan_name": "Medicare Advantage", "standard_charge_percentage": 103, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" } ] } ] }, { "description": "Assay of natriuretic peptide", "code_information": [ { "code": "83880", "type": "HCPCS" } ], "standard_charges": [ { "setting": "outpatient", "payers_information": [ { "payer_name": "United Healthcare (UHC)", "plan_name": "DSNP", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "National Comp Care", "plan_name": "Workers' Compensation", "standard_charge_percentage": 90, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Coventry Health Care", "plan_name": "Auto Network", "standard_charge_percentage": 90, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Coventry Health Care", "plan_name": "Workers' Compensation", "standard_charge_percentage": 95, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Blue Cross Blue Shield of Montana", "plan_name": "Medicare Advantage", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "United Healthcare (UHC)", "plan_name": "Medicare Advantage", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Allegiance Provider Direct", "plan_name": "Medicare", "standard_charge_percentage": 229.99999999999997, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "PacificSource Health Plans", "plan_name": "PPO (PSN Network and Smart Health Network)", "standard_charge_percentage": 80, "methodology": "percent of total billed charges", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "First Choice Health Network fka Health InfoNet", "plan_name": "Commercial", "standard_charge_percentage": 85, "methodology": "percent of total billed charges", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Medicare (CMS)", "plan_name": "Medicare", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Claritev fka MultiPlan", "plan_name": "Auto Medical Program", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Claritev fka MultiPlan", "plan_name": "Workers' Compensation Program", "standard_charge_percentage": 90, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Claritev fka MultiPlan", "plan_name": "PPO", "standard_charge_percentage": 75, "methodology": "percent of total billed charges", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "First Choice of the Midwest", "plan_name": "PPO", "standard_charge_percentage": 90, "methodology": "percent of total billed charges", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Employee Benefit Management Services (EBMS)", "plan_name": "EBMS SelectCare Network", "standard_charge_percentage": 80, "methodology": "percent of total billed charges", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Medica Insurance Company", "plan_name": "Medicare Cost", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "First Choice Health Network fka Health InfoNet", "plan_name": "Medicare Advantage", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "First Choice Health Network fka Health InfoNet", "plan_name": "Workers Compensation", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Allegiance Provider Direct", "plan_name": "Montana Association of Counties (MACo)", "standard_charge_percentage": 229.99999999999997, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Allegiance Provider Direct", "plan_name": "State of Montana Employee Benefit Plan (Self-Funded)", "standard_charge_percentage": 229.99999999999997, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Allegiance Provider Direct", "plan_name": "Montana Municipal Interlocal Authority (MMIA)", "standard_charge_percentage": 229.99999999999997, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Medicaid (State)", "plan_name": "Medicaid", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Blue Cross Blue Shield of Montana", "plan_name": "HealthLink Network", "standard_charge_percentage": 75, "methodology": "percent of total billed charges", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Blue Cross Blue Shield of Montana", "plan_name": "Traditional Network", "standard_charge_percentage": 75, "methodology": "percent of total billed charges", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Blue Cross Blue Shield of Montana", "plan_name": "POS Network", "standard_charge_percentage": 75, "methodology": "percent of total billed charges", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Blue Cross Blue Shield of Montana", "plan_name": "Closed Plan Network", "standard_charge_percentage": 75, "methodology": "percent of total billed charges", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Blue Cross Blue Shield of Montana", "plan_name": "Retail HMO POS Network", "standard_charge_percentage": 75, "methodology": "percent of total billed charges", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Blue Cross Blue Shield of Montana", "plan_name": "Blue Options Network", "standard_charge_percentage": 75, "methodology": "percent of total billed charges", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "PacificSource Health Plans", "plan_name": "Medicare Advantage", "standard_charge_percentage": 103, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" } ] } ] }, { "description": "Assay of blood osmolality", "code_information": [ { "code": "83930", "type": "HCPCS" } ], "standard_charges": [ { "setting": "outpatient", "payers_information": [ { "payer_name": "United Healthcare (UHC)", "plan_name": "DSNP", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "United Healthcare (UHC)", "plan_name": "Medicare Advantage", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" } ] } ] }, { "description": "Assay of urine osmolality", "code_information": [ { "code": "83935", "type": "HCPCS" } ], "standard_charges": [ { "setting": "outpatient", "payers_information": [ { "payer_name": "United Healthcare (UHC)", "plan_name": "DSNP", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "United Healthcare (UHC)", "plan_name": "Medicare Advantage", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" } ] } ] }, { "description": "Assay of parathormone", "code_information": [ { "code": "83970", "type": "HCPCS" } ], "standard_charges": [ { "setting": "outpatient", "payers_information": [ { "payer_name": "United Healthcare (UHC)", "plan_name": "DSNP", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "United Healthcare (UHC)", "plan_name": "Medicare Advantage", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" } ] } ] }, { "description": "Assay of phosphorus", "code_information": [ { "code": "84100", "type": "HCPCS" } ], "standard_charges": [ { "setting": "outpatient", "payers_information": [ { "payer_name": "United Healthcare (UHC)", "plan_name": "DSNP", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "National Comp Care", "plan_name": "Workers' Compensation", "standard_charge_percentage": 90, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Coventry Health Care", "plan_name": "Auto Network", "standard_charge_percentage": 90, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Coventry Health Care", "plan_name": "Workers' Compensation", "standard_charge_percentage": 95, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Blue Cross Blue Shield of Montana", "plan_name": "Medicare Advantage", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "United Healthcare (UHC)", "plan_name": "Medicare Advantage", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Allegiance Provider Direct", "plan_name": "Medicare", "standard_charge_percentage": 229.99999999999997, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "PacificSource Health Plans", "plan_name": "PPO (PSN Network and Smart Health Network)", "standard_charge_percentage": 80, "methodology": "percent of total billed charges", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "First Choice Health Network fka Health InfoNet", "plan_name": "Commercial", "standard_charge_percentage": 85, "methodology": "percent of total billed charges", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Medicare (CMS)", "plan_name": "Medicare", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Claritev fka MultiPlan", "plan_name": "Auto Medical Program", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Claritev fka MultiPlan", "plan_name": "Workers' Compensation Program", "standard_charge_percentage": 90, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Claritev fka MultiPlan", "plan_name": "PPO", "standard_charge_percentage": 75, "methodology": "percent of total billed charges", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "First Choice of the Midwest", "plan_name": "PPO", "standard_charge_percentage": 90, "methodology": "percent of total billed charges", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Employee Benefit Management Services (EBMS)", "plan_name": "EBMS SelectCare Network", "standard_charge_percentage": 80, "methodology": "percent of total billed charges", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Medica Insurance Company", "plan_name": "Medicare Cost", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "First Choice Health Network fka Health InfoNet", "plan_name": "Medicare Advantage", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "First Choice Health Network fka Health InfoNet", "plan_name": "Workers Compensation", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Allegiance Provider Direct", "plan_name": "Montana Association of Counties (MACo)", "standard_charge_percentage": 229.99999999999997, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Allegiance Provider Direct", "plan_name": "State of Montana Employee Benefit Plan (Self-Funded)", "standard_charge_percentage": 229.99999999999997, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Allegiance Provider Direct", "plan_name": "Montana Municipal Interlocal Authority (MMIA)", "standard_charge_percentage": 229.99999999999997, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Medicaid (State)", "plan_name": "Medicaid", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Blue Cross Blue Shield of Montana", "plan_name": "HealthLink Network", "standard_charge_percentage": 75, "methodology": "percent of total billed charges", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Blue Cross Blue Shield of Montana", "plan_name": "Traditional Network", "standard_charge_percentage": 75, "methodology": "percent of total billed charges", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Blue Cross Blue Shield of Montana", "plan_name": "POS Network", "standard_charge_percentage": 75, "methodology": "percent of total billed charges", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Blue Cross Blue Shield of Montana", "plan_name": "Closed Plan Network", "standard_charge_percentage": 75, "methodology": "percent of total billed charges", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Blue Cross Blue Shield of Montana", "plan_name": "Retail HMO POS Network", "standard_charge_percentage": 75, "methodology": "percent of total billed charges", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Blue Cross Blue Shield of Montana", "plan_name": "Blue Options Network", "standard_charge_percentage": 75, "methodology": "percent of total billed charges", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "PacificSource Health Plans", "plan_name": "Medicare Advantage", "standard_charge_percentage": 103, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" } ] } ] }, { "description": "Assay of serum potassium", "code_information": [ { "code": "84132", "type": "HCPCS" } ], "standard_charges": [ { "setting": "outpatient", "payers_information": [ { "payer_name": "United Healthcare (UHC)", "plan_name": "DSNP", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "United Healthcare (UHC)", "plan_name": "Medicare Advantage", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" } ] } ] }, { "description": "Assay of prealbumin", "code_information": [ { "code": "84134", "type": "HCPCS" } ], "standard_charges": [ { "setting": "outpatient", "payers_information": [ { "payer_name": "United Healthcare (UHC)", "plan_name": "DSNP", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "National Comp Care", "plan_name": "Workers' Compensation", "standard_charge_percentage": 90, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Coventry Health Care", "plan_name": "Auto Network", "standard_charge_percentage": 90, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Coventry Health Care", "plan_name": "Workers' Compensation", "standard_charge_percentage": 95, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Blue Cross Blue Shield of Montana", "plan_name": "Medicare Advantage", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "United Healthcare (UHC)", "plan_name": "Medicare Advantage", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Allegiance Provider Direct", "plan_name": "Medicare", "standard_charge_percentage": 229.99999999999997, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "PacificSource Health Plans", "plan_name": "PPO (PSN Network and Smart Health Network)", "standard_charge_percentage": 80, "methodology": "percent of total billed charges", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Medicare (CMS)", "plan_name": "Medicare", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "First Choice Health Network fka Health InfoNet", "plan_name": "Commercial", "standard_charge_percentage": 85, "methodology": "percent of total billed charges", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Claritev fka MultiPlan", "plan_name": "Auto Medical Program", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Claritev fka MultiPlan", "plan_name": "Workers' Compensation Program", "standard_charge_percentage": 90, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Claritev fka MultiPlan", "plan_name": "PPO", "standard_charge_percentage": 75, "methodology": "percent of total billed charges", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "First Choice of the Midwest", "plan_name": "PPO", "standard_charge_percentage": 90, "methodology": "percent of total billed charges", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Employee Benefit Management Services (EBMS)", "plan_name": "EBMS SelectCare Network", "standard_charge_percentage": 80, "methodology": "percent of total billed charges", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Medica Insurance Company", "plan_name": "Medicare Cost", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "First Choice Health Network fka Health InfoNet", "plan_name": "Medicare Advantage", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "First Choice Health Network fka Health InfoNet", "plan_name": "Workers Compensation", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Allegiance Provider Direct", "plan_name": "Montana Association of Counties (MACo)", "standard_charge_percentage": 229.99999999999997, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Allegiance Provider Direct", "plan_name": "State of Montana Employee Benefit Plan (Self-Funded)", "standard_charge_percentage": 229.99999999999997, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Allegiance Provider Direct", "plan_name": "Montana Municipal Interlocal Authority (MMIA)", "standard_charge_percentage": 229.99999999999997, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Medicaid (State)", "plan_name": "Medicaid", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Blue Cross Blue Shield of Montana", "plan_name": "HealthLink Network", "standard_charge_percentage": 75, "methodology": "percent of total billed charges", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Blue Cross Blue Shield of Montana", "plan_name": "Traditional Network", "standard_charge_percentage": 75, "methodology": "percent of total billed charges", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Blue Cross Blue Shield of Montana", "plan_name": "POS Network", "standard_charge_percentage": 75, "methodology": "percent of total billed charges", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Blue Cross Blue Shield of Montana", "plan_name": "Closed Plan Network", "standard_charge_percentage": 75, "methodology": "percent of total billed charges", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Blue Cross Blue Shield of Montana", "plan_name": "Retail HMO POS Network", "standard_charge_percentage": 75, "methodology": "percent of total billed charges", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Blue Cross Blue Shield of Montana", "plan_name": "Blue Options Network", "standard_charge_percentage": 75, "methodology": "percent of total billed charges", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "PacificSource Health Plans", "plan_name": "Medicare Advantage", "standard_charge_percentage": 103, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" } ] } ] }, { "description": "Procalcitonin (pct)", "code_information": [ { "code": "84145", "type": "HCPCS" } ], "standard_charges": [ { "setting": "outpatient", "payers_information": [ { "payer_name": "United Healthcare (UHC)", "plan_name": "DSNP", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "National Comp Care", "plan_name": "Workers' Compensation", "standard_charge_percentage": 90, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Coventry Health Care", "plan_name": "Auto Network", "standard_charge_percentage": 90, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Coventry Health Care", "plan_name": "Workers' Compensation", "standard_charge_percentage": 95, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Blue Cross Blue Shield of Montana", "plan_name": "Medicare Advantage", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "United Healthcare (UHC)", "plan_name": "Medicare Advantage", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Allegiance Provider Direct", "plan_name": "Medicare", "standard_charge_percentage": 229.99999999999997, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "PacificSource Health Plans", "plan_name": "PPO (PSN Network and Smart Health Network)", "standard_charge_percentage": 80, "methodology": "percent of total billed charges", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "First Choice Health Network fka Health InfoNet", "plan_name": "Commercial", "standard_charge_percentage": 85, "methodology": "percent of total billed charges", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Medicare (CMS)", "plan_name": "Medicare", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Claritev fka MultiPlan", "plan_name": "Auto Medical Program", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Claritev fka MultiPlan", "plan_name": "Workers' Compensation Program", "standard_charge_percentage": 90, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Claritev fka MultiPlan", "plan_name": "PPO", "standard_charge_percentage": 75, "methodology": "percent of total billed charges", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "First Choice of the Midwest", "plan_name": "PPO", "standard_charge_percentage": 90, "methodology": "percent of total billed charges", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Employee Benefit Management Services (EBMS)", "plan_name": "EBMS SelectCare Network", "standard_charge_percentage": 80, "methodology": "percent of total billed charges", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Medica Insurance Company", "plan_name": "Medicare Cost", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "First Choice Health Network fka Health InfoNet", "plan_name": "Medicare Advantage", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "First Choice Health Network fka Health InfoNet", "plan_name": "Workers Compensation", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Allegiance Provider Direct", "plan_name": "Montana Association of Counties (MACo)", "standard_charge_percentage": 229.99999999999997, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Allegiance Provider Direct", "plan_name": "State of Montana Employee Benefit Plan (Self-Funded)", "standard_charge_percentage": 229.99999999999997, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Allegiance Provider Direct", "plan_name": "Montana Municipal Interlocal Authority (MMIA)", "standard_charge_percentage": 229.99999999999997, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Medicaid (State)", "plan_name": "Medicaid", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Blue Cross Blue Shield of Montana", "plan_name": "HealthLink Network", "standard_charge_percentage": 75, "methodology": "percent of total billed charges", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Blue Cross Blue Shield of Montana", "plan_name": "Traditional Network", "standard_charge_percentage": 75, "methodology": "percent of total billed charges", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Blue Cross Blue Shield of Montana", "plan_name": "POS Network", "standard_charge_percentage": 75, "methodology": "percent of total billed charges", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Blue Cross Blue Shield of Montana", "plan_name": "Closed Plan Network", "standard_charge_percentage": 75, "methodology": "percent of total billed charges", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Blue Cross Blue Shield of Montana", "plan_name": "Retail HMO POS Network", "standard_charge_percentage": 75, "methodology": "percent of total billed charges", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Blue Cross Blue Shield of Montana", "plan_name": "Blue Options Network", "standard_charge_percentage": 75, "methodology": "percent of total billed charges", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "PacificSource Health Plans", "plan_name": "Medicare Advantage", "standard_charge_percentage": 103, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" } ] } ] }, { "description": "Assay of psa total", "code_information": [ { "code": "84153", "type": "HCPCS" } ], "standard_charges": [ { "setting": "outpatient", "payers_information": [ { "payer_name": "United Healthcare (UHC)", "plan_name": "DSNP", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "United Healthcare (UHC)", "plan_name": "Medicare Advantage", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" } ] } ] }, { "description": "Assay of protein serum", "code_information": [ { "code": "84155", "type": "HCPCS" } ], "standard_charges": [ { "setting": "outpatient", "payers_information": [ { "payer_name": "United Healthcare (UHC)", "plan_name": "DSNP", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "United Healthcare (UHC)", "plan_name": "Medicare Advantage", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" } ] } ] }, { "description": "Assay of protein urine", "code_information": [ { "code": "84156", "type": "HCPCS" } ], "standard_charges": [ { "setting": "outpatient", "payers_information": [ { "payer_name": "United Healthcare (UHC)", "plan_name": "DSNP", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "United Healthcare (UHC)", "plan_name": "Medicare Advantage", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" } ] } ] }, { "description": "Assay of protein other", "code_information": [ { "code": "84157", "type": "HCPCS" } ], "standard_charges": [ { "setting": "outpatient", "payers_information": [ { "payer_name": "United Healthcare (UHC)", "plan_name": "DSNP", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "United Healthcare (UHC)", "plan_name": "Medicare Advantage", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" } ] } ] }, { "description": "Protein e-phoresis serum", "code_information": [ { "code": "84165", "type": "HCPCS" } ], "standard_charges": [ { "setting": "outpatient", "payers_information": [ { "payer_name": "United Healthcare (UHC)", "plan_name": "DSNP", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "United Healthcare (UHC)", "plan_name": "Medicare Advantage", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" } ] } ] }, { "description": "Assay of serum sodium", "code_information": [ { "code": "84295", "type": "HCPCS" } ], "standard_charges": [ { "setting": "outpatient", "payers_information": [ { "payer_name": "United Healthcare (UHC)", "plan_name": "DSNP", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "United Healthcare (UHC)", "plan_name": "Medicare Advantage", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" } ] } ] }, { "description": "Assay of urine sodium", "code_information": [ { "code": "84300", "type": "HCPCS" } ], "standard_charges": [ { "setting": "outpatient", "payers_information": [ { "payer_name": "United Healthcare (UHC)", "plan_name": "DSNP", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "United Healthcare (UHC)", "plan_name": "Medicare Advantage", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" } ] } ] }, { "description": "Assay of total testosterone", "code_information": [ { "code": "84403", "type": "HCPCS" } ], "standard_charges": [ { "setting": "outpatient", "payers_information": [ { "payer_name": "United Healthcare (UHC)", "plan_name": "DSNP", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "United Healthcare (UHC)", "plan_name": "Medicare Advantage", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" } ] } ] }, { "description": "Us exam of head and neck", "code_information": [ { "code": "76536", "type": "HCPCS" } ], "standard_charges": [ { "setting": "outpatient", "payers_information": [ { "payer_name": "United Healthcare (UHC)", "plan_name": "DSNP", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "United Healthcare (UHC)", "plan_name": "Medicare Advantage", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" } ] } ] }, { "description": "Ultrasound breast complete", "code_information": [ { "code": "76641", "type": "HCPCS" } ], "standard_charges": [ { "setting": "outpatient", "payers_information": [ { "payer_name": "United Healthcare (UHC)", "plan_name": "DSNP", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "United Healthcare (UHC)", "plan_name": "Medicare Advantage", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" } ] } ] }, { "description": "Us exam abdom complete", "code_information": [ { "code": "76700", "type": "HCPCS" } ], "standard_charges": [ { "setting": "outpatient", "payers_information": [ { "payer_name": "United Healthcare (UHC)", "plan_name": "DSNP", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "National Comp Care", "plan_name": "Workers' Compensation", "standard_charge_percentage": 90, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Coventry Health Care", "plan_name": "Auto Network", "standard_charge_percentage": 90, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Coventry Health Care", "plan_name": "Workers' Compensation", "standard_charge_percentage": 95, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Blue Cross Blue Shield of Montana", "plan_name": "Medicare Advantage", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "United Healthcare (UHC)", "plan_name": "Medicare Advantage", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Allegiance Provider Direct", "plan_name": "Medicare", "standard_charge_percentage": 229.99999999999997, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "PacificSource Health Plans", "plan_name": "PPO (PSN Network and Smart Health Network)", "standard_charge_percentage": 80, "methodology": "percent of total billed charges", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Medicare (CMS)", "plan_name": "Medicare", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "First Choice Health Network fka Health InfoNet", "plan_name": "Commercial", "standard_charge_percentage": 85, "methodology": "percent of total billed charges", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Claritev fka MultiPlan", "plan_name": "Auto Medical Program", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Claritev fka MultiPlan", "plan_name": "Workers' Compensation Program", "standard_charge_percentage": 90, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Claritev fka MultiPlan", "plan_name": "PPO", "standard_charge_percentage": 75, "methodology": "percent of total billed charges", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "First Choice of the Midwest", "plan_name": "PPO", "standard_charge_percentage": 90, "methodology": "percent of total billed charges", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Employee Benefit Management Services (EBMS)", "plan_name": "EBMS SelectCare Network", "standard_charge_percentage": 80, "methodology": "percent of total billed charges", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Medica Insurance Company", "plan_name": "Medicare Cost", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "First Choice Health Network fka Health InfoNet", "plan_name": "Medicare Advantage", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "First Choice Health Network fka Health InfoNet", "plan_name": "Workers Compensation", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Allegiance Provider Direct", "plan_name": "Montana Association of Counties (MACo)", "standard_charge_percentage": 229.99999999999997, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Allegiance Provider Direct", "plan_name": "State of Montana Employee Benefit Plan (Self-Funded)", "standard_charge_percentage": 229.99999999999997, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Allegiance Provider Direct", "plan_name": "Montana Municipal Interlocal Authority (MMIA)", "standard_charge_percentage": 229.99999999999997, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Medicaid (State)", "plan_name": "Medicaid", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Blue Cross Blue Shield of Montana", "plan_name": "HealthLink Network", "standard_charge_percentage": 75, "methodology": "percent of total billed charges", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Blue Cross Blue Shield of Montana", "plan_name": "Traditional Network", "standard_charge_percentage": 75, "methodology": "percent of total billed charges", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Blue Cross Blue Shield of Montana", "plan_name": "POS Network", "standard_charge_percentage": 75, "methodology": "percent of total billed charges", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Blue Cross Blue Shield of Montana", "plan_name": "Closed Plan Network", "standard_charge_percentage": 75, "methodology": "percent of total billed charges", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Blue Cross Blue Shield of Montana", "plan_name": "Retail HMO POS Network", "standard_charge_percentage": 75, "methodology": "percent of total billed charges", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Blue Cross Blue Shield of Montana", "plan_name": "Blue Options Network", "standard_charge_percentage": 75, "methodology": "percent of total billed charges", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "PacificSource Health Plans", "plan_name": "Medicare Advantage", "standard_charge_percentage": 103, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" } ] } ] }, { "description": "Echo exam of abdomen", "code_information": [ { "code": "76705", "type": "HCPCS" } ], "standard_charges": [ { "setting": "outpatient", "payers_information": [ { "payer_name": "United Healthcare (UHC)", "plan_name": "DSNP", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "United Healthcare (UHC)", "plan_name": "Medicare Advantage", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" } ] } ] }, { "description": "Us exam abdo back wall comp", "code_information": [ { "code": "76770", "type": "HCPCS" } ], "standard_charges": [ { "setting": "outpatient", "payers_information": [ { "payer_name": "United Healthcare (UHC)", "plan_name": "DSNP", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "United Healthcare (UHC)", "plan_name": "Medicare Advantage", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" } ] } ] }, { "description": "Ob us < 14 wks single fetus", "code_information": [ { "code": "76801", "type": "HCPCS" } ], "standard_charges": [ { "setting": "outpatient", "payers_information": [ { "payer_name": "United Healthcare (UHC)", "plan_name": "DSNP", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "United Healthcare (UHC)", "plan_name": "Medicare Advantage", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" } ] } ] }, { "description": "Ob us >= 14 wks sngl fetus", "code_information": [ { "code": "76805", "type": "HCPCS" } ], "standard_charges": [ { "setting": "outpatient", "payers_information": [ { "payer_name": "United Healthcare (UHC)", "plan_name": "DSNP", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "United Healthcare (UHC)", "plan_name": "Medicare Advantage", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" } ] } ] }, { "description": "Ob us detailed sngl fetus", "code_information": [ { "code": "76811", "type": "HCPCS" } ], "standard_charges": [ { "setting": "outpatient", "payers_information": [ { "payer_name": "United Healthcare (UHC)", "plan_name": "DSNP", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "United Healthcare (UHC)", "plan_name": "Medicare Advantage", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" } ] } ] }, { "description": "Ob us limited fetus(s)", "code_information": [ { "code": "76815", "type": "HCPCS" } ], "standard_charges": [ { "setting": "outpatient", "payers_information": [ { "payer_name": "United Healthcare (UHC)", "plan_name": "DSNP", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "United Healthcare (UHC)", "plan_name": "Medicare Advantage", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" } ] } ] }, { "description": "Transvaginal us obstetric", "code_information": [ { "code": "76817", "type": "HCPCS" } ], "standard_charges": [ { "setting": "outpatient", "payers_information": [ { "payer_name": "United Healthcare (UHC)", "plan_name": "DSNP", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "United Healthcare (UHC)", "plan_name": "Medicare Advantage", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" } ] } ] }, { "description": "Fetal biophys profile w/nst", "code_information": [ { "code": "76818", "type": "HCPCS" } ], "standard_charges": [ { "setting": "outpatient", "payers_information": [ { "payer_name": "United Healthcare (UHC)", "plan_name": "DSNP", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "United Healthcare (UHC)", "plan_name": "Medicare Advantage", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" } ] } ] }, { "description": "Fetal biophys profil w/o nst", "code_information": [ { "code": "76819", "type": "HCPCS" } ], "standard_charges": [ { "setting": "outpatient", "payers_information": [ { "payer_name": "United Healthcare (UHC)", "plan_name": "DSNP", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "United Healthcare (UHC)", "plan_name": "Medicare Advantage", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" } ] } ] }, { "description": "Transvaginal us non-ob", "code_information": [ { "code": "76830", "type": "HCPCS" } ], "standard_charges": [ { "setting": "outpatient", "payers_information": [ { "payer_name": "United Healthcare (UHC)", "plan_name": "DSNP", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "United Healthcare (UHC)", "plan_name": "Medicare Advantage", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" } ] } ] }, { "description": "Us exam pelvic complete", "code_information": [ { "code": "76856", "type": "HCPCS" } ], "standard_charges": [ { "setting": "outpatient", "payers_information": [ { "payer_name": "United Healthcare (UHC)", "plan_name": "DSNP", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "United Healthcare (UHC)", "plan_name": "Medicare Advantage", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" } ] } ] }, { "description": "Us exam scrotum", "code_information": [ { "code": "76870", "type": "HCPCS" } ], "standard_charges": [ { "setting": "outpatient", "payers_information": [ { "payer_name": "United Healthcare (UHC)", "plan_name": "DSNP", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "United Healthcare (UHC)", "plan_name": "Medicare Advantage", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" } ] } ] }, { "description": "Us transrectal", "code_information": [ { "code": "76872", "type": "HCPCS" } ], "standard_charges": [ { "setting": "outpatient", "payers_information": [ { "payer_name": "United Healthcare (UHC)", "plan_name": "DSNP", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "United Healthcare (UHC)", "plan_name": "Medicare Advantage", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" } ] } ] }, { "description": "Us guide vascular access", "code_information": [ { "code": "76937", "type": "HCPCS" } ], "standard_charges": [ { "setting": "outpatient", "payers_information": [ { "payer_name": "United Healthcare (UHC)", "plan_name": "DSNP", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "United Healthcare (UHC)", "plan_name": "Medicare Advantage", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" } ] } ] }, { "description": "Echo guide for transfusion", "code_information": [ { "code": "76941", "type": "HCPCS" } ], "standard_charges": [ { "setting": "outpatient", "payers_information": [ { "payer_name": "United Healthcare (UHC)", "plan_name": "DSNP", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "United Healthcare (UHC)", "plan_name": "Medicare Advantage", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" } ] } ] }, { "description": "Echo guide for biopsy", "code_information": [ { "code": "76942", "type": "HCPCS" } ], "standard_charges": [ { "setting": "outpatient", "payers_information": [ { "payer_name": "United Healthcare (UHC)", "plan_name": "DSNP", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "United Healthcare (UHC)", "plan_name": "Medicare Advantage", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" } ] } ] }, { "description": "Echo examination procedure", "code_information": [ { "code": "76999", "type": "HCPCS" } ], "standard_charges": [ { "setting": "outpatient", "payers_information": [ { "payer_name": "United Healthcare (UHC)", "plan_name": "DSNP", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "United Healthcare (UHC)", "plan_name": "Medicare Advantage", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" } ] } ] }, { "description": "Fluoroguide for vein device", "code_information": [ { "code": "77001", "type": "HCPCS" } ], "standard_charges": [ { "setting": "outpatient", "payers_information": [ { "payer_name": "United Healthcare (UHC)", "plan_name": "DSNP", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "United Healthcare (UHC)", "plan_name": "Medicare Advantage", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" } ] } ] }, { "description": "Needle localization by xray", "code_information": [ { "code": "77002", "type": "HCPCS" } ], "standard_charges": [ { "setting": "outpatient", "payers_information": [ { "payer_name": "United Healthcare (UHC)", "plan_name": "DSNP", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "United Healthcare (UHC)", "plan_name": "Medicare Advantage", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" } ] } ] }, { "description": "Ct scan for needle biopsy", "code_information": [ { "code": "77012", "type": "HCPCS" } ], "standard_charges": [ { "setting": "outpatient", "payers_information": [ { "payer_name": "United Healthcare (UHC)", "plan_name": "DSNP", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "United Healthcare (UHC)", "plan_name": "Medicare Advantage", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" } ] } ] }, { "description": "Dx mammo incl cad uni", "code_information": [ { "code": "77065", "type": "HCPCS" } ], "standard_charges": [ { "setting": "outpatient", "payers_information": [ { "payer_name": "United Healthcare (UHC)", "plan_name": "DSNP", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "United Healthcare (UHC)", "plan_name": "Medicare Advantage", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" } ] } ] }, { "description": "Dx mammo incl cad bi", "code_information": [ { "code": "77066", "type": "HCPCS" } ], "standard_charges": [ { "setting": "outpatient", "payers_information": [ { "payer_name": "United Healthcare (UHC)", "plan_name": "DSNP", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "United Healthcare (UHC)", "plan_name": "Medicare Advantage", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" } ] } ] }, { "description": "Scr mammo bi incl cad", "code_information": [ { "code": "77067", "type": "HCPCS" } ], "standard_charges": [ { "setting": "outpatient", "payers_information": [ { "payer_name": "United Healthcare (UHC)", "plan_name": "DSNP", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "United Healthcare (UHC)", "plan_name": "Medicare Advantage", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" } ] } ] }, { "description": "Dxa bone density axial", "code_information": [ { "code": "77080", "type": "HCPCS" } ], "standard_charges": [ { "setting": "outpatient", "payers_information": [ { "payer_name": "United Healthcare (UHC)", "plan_name": "DSNP", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "United Healthcare (UHC)", "plan_name": "Medicare Advantage", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" } ] } ] }, { "description": "Set radiation therapy field", "code_information": [ { "code": "77280", "type": "HCPCS" } ], "standard_charges": [ { "setting": "outpatient", "payers_information": [ { "payer_name": "United Healthcare (UHC)", "plan_name": "DSNP", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "United Healthcare (UHC)", "plan_name": "Medicare Advantage", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" } ] } ] }, { "description": "Set radiation therapy field", "code_information": [ { "code": "77290", "type": "HCPCS" } ], "standard_charges": [ { "setting": "outpatient", "payers_information": [ { "payer_name": "United Healthcare (UHC)", "plan_name": "DSNP", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "United Healthcare (UHC)", "plan_name": "Medicare Advantage", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" } ] } ] }, { "description": "3-d radiotherapy plan", "code_information": [ { "code": "77295", "type": "HCPCS" } ], "standard_charges": [ { "setting": "outpatient", "payers_information": [ { "payer_name": "United Healthcare (UHC)", "plan_name": "DSNP", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "United Healthcare (UHC)", "plan_name": "Medicare Advantage", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" } ] } ] }, { "description": "Radiation therapy dose plan", "code_information": [ { "code": "77300", "type": "HCPCS" } ], "standard_charges": [ { "setting": "outpatient", "payers_information": [ { "payer_name": "United Healthcare (UHC)", "plan_name": "DSNP", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "United Healthcare (UHC)", "plan_name": "Medicare Advantage", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" } ] } ] }, { "description": "Telethx isodose plan cplx", "code_information": [ { "code": "77307", "type": "HCPCS" } ], "standard_charges": [ { "setting": "outpatient", "payers_information": [ { "payer_name": "United Healthcare (UHC)", "plan_name": "DSNP", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "United Healthcare (UHC)", "plan_name": "Medicare Advantage", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" } ] } ] }, { "description": "Radiation treatment aid(s)", "code_information": [ { "code": "77332", "type": "HCPCS" } ], "standard_charges": [ { "setting": "outpatient", "payers_information": [ { "payer_name": "United Healthcare (UHC)", "plan_name": "DSNP", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "United Healthcare (UHC)", "plan_name": "Medicare Advantage", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" } ] } ] }, { "description": "Radiation treatment aid(s)", "code_information": [ { "code": "77334", "type": "HCPCS" } ], "standard_charges": [ { "setting": "outpatient", "payers_information": [ { "payer_name": "United Healthcare (UHC)", "plan_name": "DSNP", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "United Healthcare (UHC)", "plan_name": "Medicare Advantage", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" } ] } ] }, { "description": "Radiation physics consult", "code_information": [ { "code": "77336", "type": "HCPCS" } ], "standard_charges": [ { "setting": "outpatient", "payers_information": [ { "payer_name": "United Healthcare (UHC)", "plan_name": "DSNP", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "United Healthcare (UHC)", "plan_name": "Medicare Advantage", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" } ] } ] }, { "description": "Design mlc device for imrt", "code_information": [ { "code": "77338", "type": "HCPCS" } ], "standard_charges": [ { "setting": "outpatient", "payers_information": [ { "payer_name": "United Healthcare (UHC)", "plan_name": "DSNP", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "United Healthcare (UHC)", "plan_name": "Medicare Advantage", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" } ] } ] }, { "description": "Ntsty modul rad tx dlvr cplx", "code_information": [ { "code": "77386", "type": "HCPCS" } ], "standard_charges": [ { "setting": "outpatient", "payers_information": [ { "payer_name": "United Healthcare (UHC)", "plan_name": "DSNP", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "United Healthcare (UHC)", "plan_name": "Medicare Advantage", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" } ] } ] }, { "description": "Radiation treatment delivery", "code_information": [ { "code": "77412", "type": "HCPCS" } ], "standard_charges": [ { "setting": "outpatient", "payers_information": [ { "payer_name": "United Healthcare (UHC)", "plan_name": "DSNP", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "United Healthcare (UHC)", "plan_name": "Medicare Advantage", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" } ] } ] }, { "description": "Radiology port images(s)", "code_information": [ { "code": "77417", "type": "HCPCS" } ], "standard_charges": [ { "setting": "outpatient", "payers_information": [ { "payer_name": "United Healthcare (UHC)", "plan_name": "DSNP", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "United Healthcare (UHC)", "plan_name": "Medicare Advantage", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" } ] } ] }, { "description": "Thyroid met imaging body", "code_information": [ { "code": "78018", "type": "HCPCS" } ], "standard_charges": [ { "setting": "outpatient", "payers_information": [ { "payer_name": "United Healthcare (UHC)", "plan_name": "DSNP", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "United Healthcare (UHC)", "plan_name": "Medicare Advantage", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" } ] } ] }, { "description": "Hepatobiliary system imaging", "code_information": [ { "code": "78226", "type": "HCPCS" } ], "standard_charges": [ { "setting": "outpatient", "payers_information": [ { "payer_name": "United Healthcare (UHC)", "plan_name": "DSNP", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "United Healthcare (UHC)", "plan_name": "Medicare Advantage", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" } ] } ] }, { "description": "Gastric emptying imag study", "code_information": [ { "code": "78264", "type": "HCPCS" } ], "standard_charges": [ { "setting": "outpatient", "payers_information": [ { "payer_name": "United Healthcare (UHC)", "plan_name": "DSNP", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "United Healthcare (UHC)", "plan_name": "Medicare Advantage", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" } ] } ] }, { "description": "Bone imaging whole body", "code_information": [ { "code": "78306", "type": "HCPCS" } ], "standard_charges": [ { "setting": "outpatient", "payers_information": [ { "payer_name": "United Healthcare (UHC)", "plan_name": "DSNP", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "United Healthcare (UHC)", "plan_name": "Medicare Advantage", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" } ] } ] }, { "description": "Ht muscle image spect sing", "code_information": [ { "code": "78451", "type": "HCPCS" } ], "standard_charges": [ { "setting": "outpatient", "payers_information": [ { "payer_name": "United Healthcare (UHC)", "plan_name": "DSNP", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "United Healthcare (UHC)", "plan_name": "Medicare Advantage", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" } ] } ] }, { "description": "Ht muscle image spect mult", "code_information": [ { "code": "78452", "type": "HCPCS" } ], "standard_charges": [ { "setting": "outpatient", "payers_information": [ { "payer_name": "United Healthcare (UHC)", "plan_name": "DSNP", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "United Healthcare (UHC)", "plan_name": "Medicare Advantage", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" } ] } ] }, { "description": "Metabolic panel total ca", "code_information": [ { "code": "80048", "type": "HCPCS" } ], "standard_charges": [ { "setting": "outpatient", "payers_information": [ { "payer_name": "United Healthcare (UHC)", "plan_name": "DSNP", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "National Comp Care", "plan_name": "Workers' Compensation", "standard_charge_percentage": 90, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Coventry Health Care", "plan_name": "Auto Network", "standard_charge_percentage": 90, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Coventry Health Care", "plan_name": "Workers' Compensation", "standard_charge_percentage": 95, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Blue Cross Blue Shield of Montana", "plan_name": "Medicare Advantage", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "United Healthcare (UHC)", "plan_name": "Medicare Advantage", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Allegiance Provider Direct", "plan_name": "Medicare", "standard_charge_percentage": 229.99999999999997, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "PacificSource Health Plans", "plan_name": "PPO (PSN Network and Smart Health Network)", "standard_charge_percentage": 80, "methodology": "percent of total billed charges", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "First Choice Health Network fka Health InfoNet", "plan_name": "Commercial", "standard_charge_percentage": 85, "methodology": "percent of total billed charges", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Medicare (CMS)", "plan_name": "Medicare", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Claritev fka MultiPlan", "plan_name": "Workers' Compensation Program", "standard_charge_percentage": 90, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Claritev fka MultiPlan", "plan_name": "Auto Medical Program", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Claritev fka MultiPlan", "plan_name": "PPO", "standard_charge_percentage": 75, "methodology": "percent of total billed charges", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "First Choice of the Midwest", "plan_name": "PPO", "standard_charge_percentage": 90, "methodology": "percent of total billed charges", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Employee Benefit Management Services (EBMS)", "plan_name": "EBMS SelectCare Network", "standard_charge_percentage": 80, "methodology": "percent of total billed charges", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Medica Insurance Company", "plan_name": "Medicare Cost", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "First Choice Health Network fka Health InfoNet", "plan_name": "Medicare Advantage", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "First Choice Health Network fka Health InfoNet", "plan_name": "Workers Compensation", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Allegiance Provider Direct", "plan_name": "Montana Association of Counties (MACo)", "standard_charge_percentage": 229.99999999999997, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Allegiance Provider Direct", "plan_name": "State of Montana Employee Benefit Plan (Self-Funded)", "standard_charge_percentage": 229.99999999999997, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Allegiance Provider Direct", "plan_name": "Montana Municipal Interlocal Authority (MMIA)", "standard_charge_percentage": 229.99999999999997, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Medicaid (State)", "plan_name": "Medicaid", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Blue Cross Blue Shield of Montana", "plan_name": "HealthLink Network", "standard_charge_percentage": 75, "methodology": "percent of total billed charges", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Blue Cross Blue Shield of Montana", "plan_name": "Traditional Network", "standard_charge_percentage": 75, "methodology": "percent of total billed charges", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Blue Cross Blue Shield of Montana", "plan_name": "POS Network", "standard_charge_percentage": 75, "methodology": "percent of total billed charges", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Blue Cross Blue Shield of Montana", "plan_name": "Closed Plan Network", "standard_charge_percentage": 75, "methodology": "percent of total billed charges", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Blue Cross Blue Shield of Montana", "plan_name": "Retail HMO POS Network", "standard_charge_percentage": 75, "methodology": "percent of total billed charges", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Blue Cross Blue Shield of Montana", "plan_name": "Blue Options Network", "standard_charge_percentage": 75, "methodology": "percent of total billed charges", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "PacificSource Health Plans", "plan_name": "Medicare Advantage", "standard_charge_percentage": 103, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" } ] } ] }, { "description": "Comprehen metabolic panel", "code_information": [ { "code": "80053", "type": "HCPCS" } ], "standard_charges": [ { "setting": "outpatient", "payers_information": [ { "payer_name": "United Healthcare (UHC)", "plan_name": "DSNP", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "National Comp Care", "plan_name": "Workers' Compensation", "standard_charge_percentage": 90, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Coventry Health Care", "plan_name": "Auto Network", "standard_charge_percentage": 90, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Coventry Health Care", "plan_name": "Workers' Compensation", "standard_charge_percentage": 95, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Blue Cross Blue Shield of Montana", "plan_name": "Medicare Advantage", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "United Healthcare (UHC)", "plan_name": "Medicare Advantage", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Allegiance Provider Direct", "plan_name": "Medicare", "standard_charge_percentage": 229.99999999999997, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "PacificSource Health Plans", "plan_name": "PPO (PSN Network and Smart Health Network)", "standard_charge_percentage": 80, "methodology": "percent of total billed charges", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "First Choice Health Network fka Health InfoNet", "plan_name": "Commercial", "standard_charge_percentage": 85, "methodology": "percent of total billed charges", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Medicare (CMS)", "plan_name": "Medicare", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Claritev fka MultiPlan", "plan_name": "Workers' Compensation Program", "standard_charge_percentage": 90, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Claritev fka MultiPlan", "plan_name": "Auto Medical Program", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Claritev fka MultiPlan", "plan_name": "PPO", "standard_charge_percentage": 75, "methodology": "percent of total billed charges", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "First Choice of the Midwest", "plan_name": "PPO", "standard_charge_percentage": 90, "methodology": "percent of total billed charges", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Employee Benefit Management Services (EBMS)", "plan_name": "EBMS SelectCare Network", "standard_charge_percentage": 80, "methodology": "percent of total billed charges", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Medica Insurance Company", "plan_name": "Medicare Cost", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "First Choice Health Network fka Health InfoNet", "plan_name": "Medicare Advantage", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "First Choice Health Network fka Health InfoNet", "plan_name": "Workers Compensation", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Allegiance Provider Direct", "plan_name": "Montana Association of Counties (MACo)", "standard_charge_percentage": 229.99999999999997, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Allegiance Provider Direct", "plan_name": "State of Montana Employee Benefit Plan (Self-Funded)", "standard_charge_percentage": 229.99999999999997, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Allegiance Provider Direct", "plan_name": "Montana Municipal Interlocal Authority (MMIA)", "standard_charge_percentage": 229.99999999999997, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Medicaid (State)", "plan_name": "Medicaid", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Blue Cross Blue Shield of Montana", "plan_name": "HealthLink Network", "standard_charge_percentage": 75, "methodology": "percent of total billed charges", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Blue Cross Blue Shield of Montana", "plan_name": "Traditional Network", "standard_charge_percentage": 75, "methodology": "percent of total billed charges", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Blue Cross Blue Shield of Montana", "plan_name": "POS Network", "standard_charge_percentage": 75, "methodology": "percent of total billed charges", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Blue Cross Blue Shield of Montana", "plan_name": "Closed Plan Network", "standard_charge_percentage": 75, "methodology": "percent of total billed charges", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Blue Cross Blue Shield of Montana", "plan_name": "Retail HMO POS Network", "standard_charge_percentage": 75, "methodology": "percent of total billed charges", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Blue Cross Blue Shield of Montana", "plan_name": "Blue Options Network", "standard_charge_percentage": 75, "methodology": "percent of total billed charges", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "PacificSource Health Plans", "plan_name": "Medicare Advantage", "standard_charge_percentage": 103, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" } ] } ] }, { "description": "Lipid panel", "code_information": [ { "code": "80061", "type": "HCPCS" } ], "standard_charges": [ { "setting": "outpatient", "payers_information": [ { "payer_name": "United Healthcare (UHC)", "plan_name": "DSNP", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "United Healthcare (UHC)", "plan_name": "Medicare Advantage", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" } ] } ] }, { "description": "Renal function panel", "code_information": [ { "code": "80069", "type": "HCPCS" } ], "standard_charges": [ { "setting": "outpatient", "payers_information": [ { "payer_name": "United Healthcare (UHC)", "plan_name": "DSNP", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "National Comp Care", "plan_name": "Workers' Compensation", "standard_charge_percentage": 90, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Coventry Health Care", "plan_name": "Auto Network", "standard_charge_percentage": 90, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Coventry Health Care", "plan_name": "Workers' Compensation", "standard_charge_percentage": 95, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Blue Cross Blue Shield of Montana", "plan_name": "Medicare Advantage", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "United Healthcare (UHC)", "plan_name": "Medicare Advantage", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Allegiance Provider Direct", "plan_name": "Medicare", "standard_charge_percentage": 229.99999999999997, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "PacificSource Health Plans", "plan_name": "PPO (PSN Network and Smart Health Network)", "standard_charge_percentage": 80, "methodology": "percent of total billed charges", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "First Choice Health Network fka Health InfoNet", "plan_name": "Commercial", "standard_charge_percentage": 85, "methodology": "percent of total billed charges", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Medicare (CMS)", "plan_name": "Medicare", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Claritev fka MultiPlan", "plan_name": "Workers' Compensation Program", "standard_charge_percentage": 90, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Claritev fka MultiPlan", "plan_name": "Auto Medical Program", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Claritev fka MultiPlan", "plan_name": "PPO", "standard_charge_percentage": 75, "methodology": "percent of total billed charges", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "First Choice of the Midwest", "plan_name": "PPO", "standard_charge_percentage": 90, "methodology": "percent of total billed charges", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Employee Benefit Management Services (EBMS)", "plan_name": "EBMS SelectCare Network", "standard_charge_percentage": 80, "methodology": "percent of total billed charges", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Medica Insurance Company", "plan_name": "Medicare Cost", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "First Choice Health Network fka Health InfoNet", "plan_name": "Medicare Advantage", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "First Choice Health Network fka Health InfoNet", "plan_name": "Workers Compensation", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Allegiance Provider Direct", "plan_name": "Montana Association of Counties (MACo)", "standard_charge_percentage": 229.99999999999997, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Allegiance Provider Direct", "plan_name": "State of Montana Employee Benefit Plan (Self-Funded)", "standard_charge_percentage": 229.99999999999997, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Allegiance Provider Direct", "plan_name": "Montana Municipal Interlocal Authority (MMIA)", "standard_charge_percentage": 229.99999999999997, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Medicaid (State)", "plan_name": "Medicaid", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Blue Cross Blue Shield of Montana", "plan_name": "HealthLink Network", "standard_charge_percentage": 75, "methodology": "percent of total billed charges", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Blue Cross Blue Shield of Montana", "plan_name": "Traditional Network", "standard_charge_percentage": 75, "methodology": "percent of total billed charges", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Blue Cross Blue Shield of Montana", "plan_name": "POS Network", "standard_charge_percentage": 75, "methodology": "percent of total billed charges", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Blue Cross Blue Shield of Montana", "plan_name": "Closed Plan Network", "standard_charge_percentage": 75, "methodology": "percent of total billed charges", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Blue Cross Blue Shield of Montana", "plan_name": "Retail HMO POS Network", "standard_charge_percentage": 75, "methodology": "percent of total billed charges", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Blue Cross Blue Shield of Montana", "plan_name": "Blue Options Network", "standard_charge_percentage": 75, "methodology": "percent of total billed charges", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "PacificSource Health Plans", "plan_name": "Medicare Advantage", "standard_charge_percentage": 103, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" } ] } ] }, { "description": "Acute hepatitis panel", "code_information": [ { "code": "80074", "type": "HCPCS" } ], "standard_charges": [ { "setting": "outpatient", "payers_information": [ { "payer_name": "United Healthcare (UHC)", "plan_name": "DSNP", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "United Healthcare (UHC)", "plan_name": "Medicare Advantage", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" } ] } ] }, { "description": "Hepatic function panel", "code_information": [ { "code": "80076", "type": "HCPCS" } ], "standard_charges": [ { "setting": "outpatient", "payers_information": [ { "payer_name": "United Healthcare (UHC)", "plan_name": "DSNP", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "United Healthcare (UHC)", "plan_name": "Medicare Advantage", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" } ] } ] }, { "description": "Drug assay acetaminophen", "code_information": [ { "code": "80143", "type": "HCPCS" } ], "standard_charges": [ { "setting": "outpatient", "payers_information": [ { "payer_name": "United Healthcare (UHC)", "plan_name": "DSNP", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "United Healthcare (UHC)", "plan_name": "Medicare Advantage", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" } ] } ] }, { "description": "Assay of digoxin free", "code_information": [ { "code": "80163", "type": "HCPCS" } ], "standard_charges": [ { "setting": "outpatient", "payers_information": [ { "payer_name": "United Healthcare (UHC)", "plan_name": "DSNP", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "United Healthcare (UHC)", "plan_name": "Medicare Advantage", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" } ] } ] }, { "description": "Dipropylacetic acid free", "code_information": [ { "code": "80165", "type": "HCPCS" } ], "standard_charges": [ { "setting": "outpatient", "payers_information": [ { "payer_name": "United Healthcare (UHC)", "plan_name": "DSNP", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "United Healthcare (UHC)", "plan_name": "Medicare Advantage", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" } ] } ] }, { "description": "Drug scrn quan levetiracetam", "code_information": [ { "code": "80177", "type": "HCPCS" } ], "standard_charges": [ { "setting": "outpatient", "payers_information": [ { "payer_name": "United Healthcare (UHC)", "plan_name": "DSNP", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "United Healthcare (UHC)", "plan_name": "Medicare Advantage", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" } ] } ] }, { "description": "Microbe susceptible disk", "code_information": [ { "code": "87184", "type": "HCPCS" } ], "standard_charges": [ { "setting": "outpatient", "payers_information": [ { "payer_name": "United Healthcare (UHC)", "plan_name": "DSNP", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "United Healthcare (UHC)", "plan_name": "Medicare Advantage", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" } ] } ] }, { "description": "Microbe susceptible mic", "code_information": [ { "code": "87186", "type": "HCPCS" } ], "standard_charges": [ { "setting": "outpatient", "payers_information": [ { "payer_name": "United Healthcare (UHC)", "plan_name": "DSNP", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "United Healthcare (UHC)", "plan_name": "Medicare Advantage", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" } ] } ] }, { "description": "Smear gram stain", "code_information": [ { "code": "87205", "type": "HCPCS" } ], "standard_charges": [ { "setting": "outpatient", "payers_information": [ { "payer_name": "United Healthcare (UHC)", "plan_name": "DSNP", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "United Healthcare (UHC)", "plan_name": "Medicare Advantage", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" } ] } ] }, { "description": "Smear wet mount saline/ink", "code_information": [ { "code": "87210", "type": "HCPCS" } ], "standard_charges": [ { "setting": "outpatient", "payers_information": [ { "payer_name": "United Healthcare (UHC)", "plan_name": "DSNP", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "United Healthcare (UHC)", "plan_name": "Medicare Advantage", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" } ] } ] }, { "description": "Aspergillus ag ia", "code_information": [ { "code": "87305", "type": "HCPCS" } ], "standard_charges": [ { "setting": "outpatient", "payers_information": [ { "payer_name": "United Healthcare (UHC)", "plan_name": "DSNP", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "United Healthcare (UHC)", "plan_name": "Medicare Advantage", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" } ] } ] }, { "description": "Clostridium ag ia", "code_information": [ { "code": "87324", "type": "HCPCS" } ], "standard_charges": [ { "setting": "outpatient", "payers_information": [ { "payer_name": "United Healthcare (UHC)", "plan_name": "DSNP", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "United Healthcare (UHC)", "plan_name": "Medicare Advantage", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" } ] } ] }, { "description": "Cryptococcus neoform ag ia", "code_information": [ { "code": "87327", "type": "HCPCS" } ], "standard_charges": [ { "setting": "outpatient", "payers_information": [ { "payer_name": "United Healthcare (UHC)", "plan_name": "DSNP", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "United Healthcare (UHC)", "plan_name": "Medicare Advantage", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" } ] } ] }, { "description": "Hepatitis b surface ag ia", "code_information": [ { "code": "87340", "type": "HCPCS" } ], "standard_charges": [ { "setting": "outpatient", "payers_information": [ { "payer_name": "United Healthcare (UHC)", "plan_name": "DSNP", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "National Comp Care", "plan_name": "Workers' Compensation", "standard_charge_percentage": 90, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Coventry Health Care", "plan_name": "Auto Network", "standard_charge_percentage": 90, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Coventry Health Care", "plan_name": "Workers' Compensation", "standard_charge_percentage": 95, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Blue Cross Blue Shield of Montana", "plan_name": "Medicare Advantage", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "United Healthcare (UHC)", "plan_name": "Medicare Advantage", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Allegiance Provider Direct", "plan_name": "Medicare", "standard_charge_percentage": 229.99999999999997, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "PacificSource Health Plans", "plan_name": "PPO (PSN Network and Smart Health Network)", "standard_charge_percentage": 80, "methodology": "percent of total billed charges", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Medicare (CMS)", "plan_name": "Medicare", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "First Choice Health Network fka Health InfoNet", "plan_name": "Commercial", "standard_charge_percentage": 85, "methodology": "percent of total billed charges", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Claritev fka MultiPlan", "plan_name": "Auto Medical Program", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Claritev fka MultiPlan", "plan_name": "Workers' Compensation Program", "standard_charge_percentage": 90, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Claritev fka MultiPlan", "plan_name": "PPO", "standard_charge_percentage": 75, "methodology": "percent of total billed charges", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "First Choice of the Midwest", "plan_name": "PPO", "standard_charge_percentage": 90, "methodology": "percent of total billed charges", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Employee Benefit Management Services (EBMS)", "plan_name": "EBMS SelectCare Network", "standard_charge_percentage": 80, "methodology": "percent of total billed charges", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Medica Insurance Company", "plan_name": "Medicare Cost", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "First Choice Health Network fka Health InfoNet", "plan_name": "Medicare Advantage", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "First Choice Health Network fka Health InfoNet", "plan_name": "Workers Compensation", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Allegiance Provider Direct", "plan_name": "Montana Association of Counties (MACo)", "standard_charge_percentage": 229.99999999999997, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Allegiance Provider Direct", "plan_name": "State of Montana Employee Benefit Plan (Self-Funded)", "standard_charge_percentage": 229.99999999999997, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Allegiance Provider Direct", "plan_name": "Montana Municipal Interlocal Authority (MMIA)", "standard_charge_percentage": 229.99999999999997, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Blue Cross Blue Shield of Montana", "plan_name": "HealthLink Network", "standard_charge_percentage": 75, "methodology": "percent of total billed charges", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Blue Cross Blue Shield of Montana", "plan_name": "Traditional Network", "standard_charge_percentage": 75, "methodology": "percent of total billed charges", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Blue Cross Blue Shield of Montana", "plan_name": "POS Network", "standard_charge_percentage": 75, "methodology": "percent of total billed charges", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Blue Cross Blue Shield of Montana", "plan_name": "Closed Plan Network", "standard_charge_percentage": 75, "methodology": "percent of total billed charges", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Blue Cross Blue Shield of Montana", "plan_name": "Retail HMO POS Network", "standard_charge_percentage": 75, "methodology": "percent of total billed charges", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Blue Cross Blue Shield of Montana", "plan_name": "Blue Options Network", "standard_charge_percentage": 75, "methodology": "percent of total billed charges", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Medicaid (State)", "plan_name": "Medicaid", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "PacificSource Health Plans", "plan_name": "Medicare Advantage", "standard_charge_percentage": 103, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" } ] } ] }, { "description": "Resp syncytial virus ag ia", "code_information": [ { "code": "87420", "type": "HCPCS" } ], "standard_charges": [ { "setting": "outpatient", "payers_information": [ { "payer_name": "United Healthcare (UHC)", "plan_name": "DSNP", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "United Healthcare (UHC)", "plan_name": "Medicare Advantage", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" } ] } ] }, { "description": "Sarscov coronavirus ag ia", "code_information": [ { "code": "87426", "type": "HCPCS" } ], "standard_charges": [ { "setting": "outpatient", "payers_information": [ { "payer_name": "United Healthcare (UHC)", "plan_name": "DSNP", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "United Healthcare (UHC)", "plan_name": "Medicare Advantage", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" } ] } ] }, { "description": "Shiga-like toxin ag ia", "code_information": [ { "code": "87427", "type": "HCPCS" } ], "standard_charges": [ { "setting": "outpatient", "payers_information": [ { "payer_name": "United Healthcare (UHC)", "plan_name": "DSNP", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "United Healthcare (UHC)", "plan_name": "Medicare Advantage", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" } ] } ] }, { "description": "Nos each organism ag ia", "code_information": [ { "code": "87449", "type": "HCPCS" } ], "standard_charges": [ { "setting": "outpatient", "payers_information": [ { "payer_name": "United Healthcare (UHC)", "plan_name": "DSNP", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "United Healthcare (UHC)", "plan_name": "Medicare Advantage", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" } ] } ] }, { "description": "Chlmyd trach dna dir probe", "code_information": [ { "code": "87490", "type": "HCPCS" } ], "standard_charges": [ { "setting": "outpatient", "payers_information": [ { "payer_name": "United Healthcare (UHC)", "plan_name": "DSNP", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "United Healthcare (UHC)", "plan_name": "Medicare Advantage", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" } ] } ] }, { "description": "Chlmyd trach dna amp probe", "code_information": [ { "code": "87491", "type": "HCPCS" } ], "standard_charges": [ { "setting": "outpatient", "payers_information": [ { "payer_name": "United Healthcare (UHC)", "plan_name": "DSNP", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "United Healthcare (UHC)", "plan_name": "Medicare Advantage", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" } ] } ] }, { "description": "Influenza dna amp probe", "code_information": [ { "code": "87502", "type": "HCPCS" } ], "standard_charges": [ { "setting": "outpatient", "payers_information": [ { "payer_name": "United Healthcare (UHC)", "plan_name": "DSNP", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "United Healthcare (UHC)", "plan_name": "Medicare Advantage", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" } ] } ] }, { "description": "Hepatitis c revrs trnscrpj", "code_information": [ { "code": "87522", "type": "HCPCS" } ], "standard_charges": [ { "setting": "outpatient", "payers_information": [ { "payer_name": "United Healthcare (UHC)", "plan_name": "DSNP", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "United Healthcare (UHC)", "plan_name": "Medicare Advantage", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" } ] } ] }, { "description": "Hsv dna amp probe", "code_information": [ { "code": "87529", "type": "HCPCS" } ], "standard_charges": [ { "setting": "outpatient", "payers_information": [ { "payer_name": "United Healthcare (UHC)", "plan_name": "DSNP", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "United Healthcare (UHC)", "plan_name": "Medicare Advantage", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" } ] } ] }, { "description": "Hiv-1 quant&revrse trnscrpj", "code_information": [ { "code": "87536", "type": "HCPCS" } ], "standard_charges": [ { "setting": "outpatient", "payers_information": [ { "payer_name": "United Healthcare (UHC)", "plan_name": "DSNP", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "United Healthcare (UHC)", "plan_name": "Medicare Advantage", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" } ] } ] }, { "description": "Therapeutic exercises", "code_information": [ { "code": "97110", "type": "HCPCS" } ], "standard_charges": [ { "setting": "outpatient", "payers_information": [ { "payer_name": "National Comp Care", "plan_name": "Workers' Compensation", "standard_charge_dollar": 90, "methodology": "fee schedule", "median_amount": 90, "10th_percentile": 90, "90th_percentile": 90, "count": "1 through 10" }, { "payer_name": "Coventry Health Care", "plan_name": "Auto Network", "standard_charge_percentage": 90, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Coventry Health Care", "plan_name": "Workers' Compensation", "standard_charge_percentage": 95, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "United Healthcare (UHC)", "plan_name": "DSNP", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Blue Cross Blue Shield of Montana", "plan_name": "Medicare Advantage", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "United Healthcare (UHC)", "plan_name": "Medicare Advantage", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Allegiance Provider Direct", "plan_name": "Medicare", "standard_charge_percentage": 229.99999999999997, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "PacificSource Health Plans", "plan_name": "PPO (PSN Network and Smart Health Network)", "standard_charge_percentage": 80, "methodology": "percent of total billed charges", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Medicare (CMS)", "plan_name": "Medicare", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "First Choice Health Network fka Health InfoNet", "plan_name": "Commercial", "standard_charge_percentage": 85, "methodology": "percent of total billed charges", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Claritev fka MultiPlan", "plan_name": "Auto Medical Program", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Claritev fka MultiPlan", "plan_name": "Workers' Compensation Program", "standard_charge_percentage": 90, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Claritev fka MultiPlan", "plan_name": "PPO", "standard_charge_percentage": 75, "methodology": "percent of total billed charges", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "First Choice of the Midwest", "plan_name": "PPO", "standard_charge_percentage": 90, "methodology": "percent of total billed charges", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Employee Benefit Management Services (EBMS)", "plan_name": "EBMS SelectCare Network", "standard_charge_percentage": 80, "methodology": "percent of total billed charges", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Medica Insurance Company", "plan_name": "Medicare Cost", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "First Choice Health Network fka Health InfoNet", "plan_name": "Medicare Advantage", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "First Choice Health Network fka Health InfoNet", "plan_name": "Workers Compensation", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Allegiance Provider Direct", "plan_name": "Montana Association of Counties (MACo)", "standard_charge_percentage": 229.99999999999997, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Allegiance Provider Direct", "plan_name": "State of Montana Employee Benefit Plan (Self-Funded)", "standard_charge_percentage": 229.99999999999997, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Allegiance Provider Direct", "plan_name": "Montana Municipal Interlocal Authority (MMIA)", "standard_charge_percentage": 229.99999999999997, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Blue Cross Blue Shield of Montana", "plan_name": "HealthLink Network", "standard_charge_percentage": 75, "methodology": "percent of total billed charges", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Blue Cross Blue Shield of Montana", "plan_name": "Traditional Network", "standard_charge_percentage": 75, "methodology": "percent of total billed charges", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Blue Cross Blue Shield of Montana", "plan_name": "POS Network", "standard_charge_percentage": 75, "methodology": "percent of total billed charges", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Blue Cross Blue Shield of Montana", "plan_name": "Closed Plan Network", "standard_charge_percentage": 75, "methodology": "percent of total billed charges", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Blue Cross Blue Shield of Montana", "plan_name": "Retail HMO POS Network", "standard_charge_percentage": 75, "methodology": "percent of total billed charges", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Blue Cross Blue Shield of Montana", "plan_name": "Blue Options Network", "standard_charge_percentage": 75, "methodology": "percent of total billed charges", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Medicaid (State)", "plan_name": "Medicaid", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "PacificSource Health Plans", "plan_name": "Medicare Advantage", "standard_charge_percentage": 103, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" } ], "minimum": 90, "maximum": 90 } ] }, { "description": "Gait training therapy", "code_information": [ { "code": "97116", "type": "HCPCS" } ], "standard_charges": [ { "setting": "outpatient", "payers_information": [ { "payer_name": "National Comp Care", "plan_name": "Workers' Compensation", "standard_charge_dollar": 90, "methodology": "fee schedule", "median_amount": 90, "10th_percentile": 90, "90th_percentile": 90, "count": "1 through 10" }, { "payer_name": "Coventry Health Care", "plan_name": "Auto Network", "standard_charge_percentage": 90, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Coventry Health Care", "plan_name": "Workers' Compensation", "standard_charge_percentage": 95, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "United Healthcare (UHC)", "plan_name": "DSNP", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Blue Cross Blue Shield of Montana", "plan_name": "Medicare Advantage", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "United Healthcare (UHC)", "plan_name": "Medicare Advantage", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Allegiance Provider Direct", "plan_name": "Medicare", "standard_charge_percentage": 229.99999999999997, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "PacificSource Health Plans", "plan_name": "PPO (PSN Network and Smart Health Network)", "standard_charge_percentage": 80, "methodology": "percent of total billed charges", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Medicare (CMS)", "plan_name": "Medicare", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "First Choice Health Network fka Health InfoNet", "plan_name": "Commercial", "standard_charge_percentage": 85, "methodology": "percent of total billed charges", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Claritev fka MultiPlan", "plan_name": "Auto Medical Program", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Claritev fka MultiPlan", "plan_name": "Workers' Compensation Program", "standard_charge_percentage": 90, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Claritev fka MultiPlan", "plan_name": "PPO", "standard_charge_percentage": 75, "methodology": "percent of total billed charges", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "First Choice of the Midwest", "plan_name": "PPO", "standard_charge_percentage": 90, "methodology": "percent of total billed charges", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Employee Benefit Management Services (EBMS)", "plan_name": "EBMS SelectCare Network", "standard_charge_percentage": 80, "methodology": "percent of total billed charges", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Medica Insurance Company", "plan_name": "Medicare Cost", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "First Choice Health Network fka Health InfoNet", "plan_name": "Medicare Advantage", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "First Choice Health Network fka Health InfoNet", "plan_name": "Workers Compensation", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Allegiance Provider Direct", "plan_name": "Montana Association of Counties (MACo)", "standard_charge_percentage": 229.99999999999997, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Allegiance Provider Direct", "plan_name": "State of Montana Employee Benefit Plan (Self-Funded)", "standard_charge_percentage": 229.99999999999997, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Allegiance Provider Direct", "plan_name": "Montana Municipal Interlocal Authority (MMIA)", "standard_charge_percentage": 229.99999999999997, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Blue Cross Blue Shield of Montana", "plan_name": "HealthLink Network", "standard_charge_percentage": 75, "methodology": "percent of total billed charges", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Blue Cross Blue Shield of Montana", "plan_name": "Traditional Network", "standard_charge_percentage": 75, "methodology": "percent of total billed charges", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Blue Cross Blue Shield of Montana", "plan_name": "POS Network", "standard_charge_percentage": 75, "methodology": "percent of total billed charges", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Blue Cross Blue Shield of Montana", "plan_name": "Closed Plan Network", "standard_charge_percentage": 75, "methodology": "percent of total billed charges", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Blue Cross Blue Shield of Montana", "plan_name": "Retail HMO POS Network", "standard_charge_percentage": 75, "methodology": "percent of total billed charges", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Blue Cross Blue Shield of Montana", "plan_name": "Blue Options Network", "standard_charge_percentage": 75, "methodology": "percent of total billed charges", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Medicaid (State)", "plan_name": "Medicaid", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "PacificSource Health Plans", "plan_name": "Medicare Advantage", "standard_charge_percentage": 103, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" } ], "minimum": 90, "maximum": 90 } ] }, { "description": "Therapeutic activities", "code_information": [ { "code": "97530", "type": "HCPCS" } ], "standard_charges": [ { "setting": "outpatient", "payers_information": [ { "payer_name": "National Comp Care", "plan_name": "Workers' Compensation", "standard_charge_dollar": 90, "methodology": "fee schedule", "median_amount": 90, "10th_percentile": 90, "90th_percentile": 90, "count": "1 through 10" }, { "payer_name": "Coventry Health Care", "plan_name": "Auto Network", "standard_charge_percentage": 90, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Coventry Health Care", "plan_name": "Workers' Compensation", "standard_charge_percentage": 95, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "United Healthcare (UHC)", "plan_name": "DSNP", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Blue Cross Blue Shield of Montana", "plan_name": "Medicare Advantage", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "United Healthcare (UHC)", "plan_name": "Medicare Advantage", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Allegiance Provider Direct", "plan_name": "Medicare", "standard_charge_percentage": 229.99999999999997, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "PacificSource Health Plans", "plan_name": "PPO (PSN Network and Smart Health Network)", "standard_charge_percentage": 80, "methodology": "percent of total billed charges", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Medicare (CMS)", "plan_name": "Medicare", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "First Choice Health Network fka Health InfoNet", "plan_name": "Commercial", "standard_charge_percentage": 85, "methodology": "percent of total billed charges", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Claritev fka MultiPlan", "plan_name": "Auto Medical Program", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Claritev fka MultiPlan", "plan_name": "Workers' Compensation Program", "standard_charge_percentage": 90, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Claritev fka MultiPlan", "plan_name": "PPO", "standard_charge_percentage": 75, "methodology": "percent of total billed charges", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "First Choice of the Midwest", "plan_name": "PPO", "standard_charge_percentage": 90, "methodology": "percent of total billed charges", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Employee Benefit Management Services (EBMS)", "plan_name": "EBMS SelectCare Network", "standard_charge_percentage": 80, "methodology": "percent of total billed charges", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Medica Insurance Company", "plan_name": "Medicare Cost", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "First Choice Health Network fka Health InfoNet", "plan_name": "Medicare Advantage", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "First Choice Health Network fka Health InfoNet", "plan_name": "Workers Compensation", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Allegiance Provider Direct", "plan_name": "Montana Association of Counties (MACo)", "standard_charge_percentage": 229.99999999999997, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Allegiance Provider Direct", "plan_name": "State of Montana Employee Benefit Plan (Self-Funded)", "standard_charge_percentage": 229.99999999999997, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Allegiance Provider Direct", "plan_name": "Montana Municipal Interlocal Authority (MMIA)", "standard_charge_percentage": 229.99999999999997, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Blue Cross Blue Shield of Montana", "plan_name": "HealthLink Network", "standard_charge_percentage": 75, "methodology": "percent of total billed charges", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Blue Cross Blue Shield of Montana", "plan_name": "Traditional Network", "standard_charge_percentage": 75, "methodology": "percent of total billed charges", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Blue Cross Blue Shield of Montana", "plan_name": "POS Network", "standard_charge_percentage": 75, "methodology": "percent of total billed charges", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Blue Cross Blue Shield of Montana", "plan_name": "Closed Plan Network", "standard_charge_percentage": 75, "methodology": "percent of total billed charges", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Blue Cross Blue Shield of Montana", "plan_name": "Retail HMO POS Network", "standard_charge_percentage": 75, "methodology": "percent of total billed charges", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Blue Cross Blue Shield of Montana", "plan_name": "Blue Options Network", "standard_charge_percentage": 75, "methodology": "percent of total billed charges", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Medicaid (State)", "plan_name": "Medicaid", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "PacificSource Health Plans", "plan_name": "Medicare Advantage", "standard_charge_percentage": 103, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" } ], "minimum": 90, "maximum": 90 } ] }, { "description": "Self care mngment training", "code_information": [ { "code": "97535", "type": "HCPCS" } ], "standard_charges": [ { "setting": "outpatient", "payers_information": [ { "payer_name": "National Comp Care", "plan_name": "Workers' Compensation", "standard_charge_dollar": 90, "methodology": "fee schedule", "median_amount": 90, "10th_percentile": 90, "90th_percentile": 90, "count": "1 through 10" }, { "payer_name": "Coventry Health Care", "plan_name": "Auto Network", "standard_charge_percentage": 90, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "United Healthcare (UHC)", "plan_name": "DSNP", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Blue Cross Blue Shield of Montana", "plan_name": "Medicare Advantage", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Coventry Health Care", "plan_name": "Workers' Compensation", "standard_charge_percentage": 95, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "United Healthcare (UHC)", "plan_name": "Medicare Advantage", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Allegiance Provider Direct", "plan_name": "Medicare", "standard_charge_percentage": 229.99999999999997, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "PacificSource Health Plans", "plan_name": "PPO (PSN Network and Smart Health Network)", "standard_charge_percentage": 80, "methodology": "percent of total billed charges", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Medicare (CMS)", "plan_name": "Medicare", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "First Choice Health Network fka Health InfoNet", "plan_name": "Commercial", "standard_charge_percentage": 85, "methodology": "percent of total billed charges", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Claritev fka MultiPlan", "plan_name": "Auto Medical Program", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Claritev fka MultiPlan", "plan_name": "Workers' Compensation Program", "standard_charge_percentage": 90, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Claritev fka MultiPlan", "plan_name": "PPO", "standard_charge_percentage": 75, "methodology": "percent of total billed charges", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "First Choice of the Midwest", "plan_name": "PPO", "standard_charge_percentage": 90, "methodology": "percent of total billed charges", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Employee Benefit Management Services (EBMS)", "plan_name": "EBMS SelectCare Network", "standard_charge_percentage": 80, "methodology": "percent of total billed charges", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Medica Insurance Company", "plan_name": "Medicare Cost", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "First Choice Health Network fka Health InfoNet", "plan_name": "Medicare Advantage", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "First Choice Health Network fka Health InfoNet", "plan_name": "Workers Compensation", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Allegiance Provider Direct", "plan_name": "Montana Association of Counties (MACo)", "standard_charge_percentage": 229.99999999999997, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Allegiance Provider Direct", "plan_name": "State of Montana Employee Benefit Plan (Self-Funded)", "standard_charge_percentage": 229.99999999999997, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Allegiance Provider Direct", "plan_name": "Montana Municipal Interlocal Authority (MMIA)", "standard_charge_percentage": 229.99999999999997, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Blue Cross Blue Shield of Montana", "plan_name": "HealthLink Network", "standard_charge_percentage": 75, "methodology": "percent of total billed charges", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Blue Cross Blue Shield of Montana", "plan_name": "Traditional Network", "standard_charge_percentage": 75, "methodology": "percent of total billed charges", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Blue Cross Blue Shield of Montana", "plan_name": "POS Network", "standard_charge_percentage": 75, "methodology": "percent of total billed charges", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Blue Cross Blue Shield of Montana", "plan_name": "Closed Plan Network", "standard_charge_percentage": 75, "methodology": "percent of total billed charges", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Blue Cross Blue Shield of Montana", "plan_name": "Retail HMO POS Network", "standard_charge_percentage": 75, "methodology": "percent of total billed charges", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Blue Cross Blue Shield of Montana", "plan_name": "Blue Options Network", "standard_charge_percentage": 75, "methodology": "percent of total billed charges", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Medicaid (State)", "plan_name": "Medicaid", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "PacificSource Health Plans", "plan_name": "Medicare Advantage", "standard_charge_percentage": 103, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" } ], "minimum": 90, "maximum": 90 } ] }, { "description": "Community/work reintegration", "code_information": [ { "code": "97537", "type": "HCPCS" } ], "standard_charges": [ { "setting": "outpatient", "payers_information": [ { "payer_name": "National Comp Care", "plan_name": "Workers' Compensation", "standard_charge_dollar": 90, "methodology": "fee schedule", "median_amount": 90, "10th_percentile": 90, "90th_percentile": 90, "count": "1 through 10" }, { "payer_name": "Coventry Health Care", "plan_name": "Auto Network", "standard_charge_percentage": 90, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Coventry Health Care", "plan_name": "Workers' Compensation", "standard_charge_percentage": 95, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Blue Cross Blue Shield of Montana", "plan_name": "Medicare Advantage", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Allegiance Provider Direct", "plan_name": "Medicare", "standard_charge_percentage": 229.99999999999997, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "PacificSource Health Plans", "plan_name": "PPO (PSN Network and Smart Health Network)", "standard_charge_percentage": 80, "methodology": "percent of total billed charges", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "First Choice Health Network fka Health InfoNet", "plan_name": "Commercial", "standard_charge_percentage": 85, "methodology": "percent of total billed charges", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Medicare (CMS)", "plan_name": "Medicare", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Claritev fka MultiPlan", "plan_name": "Workers' Compensation Program", "standard_charge_percentage": 90, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Claritev fka MultiPlan", "plan_name": "Auto Medical Program", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Claritev fka MultiPlan", "plan_name": "PPO", "standard_charge_percentage": 75, "methodology": "percent of total billed charges", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "First Choice of the Midwest", "plan_name": "PPO", "standard_charge_percentage": 90, "methodology": "percent of total billed charges", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Employee Benefit Management Services (EBMS)", "plan_name": "EBMS SelectCare Network", "standard_charge_percentage": 80, "methodology": "percent of total billed charges", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Medica Insurance Company", "plan_name": "Medicare Cost", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "First Choice Health Network fka Health InfoNet", "plan_name": "Medicare Advantage", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "First Choice Health Network fka Health InfoNet", "plan_name": "Workers Compensation", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Allegiance Provider Direct", "plan_name": "Montana Association of Counties (MACo)", "standard_charge_percentage": 229.99999999999997, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Allegiance Provider Direct", "plan_name": "State of Montana Employee Benefit Plan (Self-Funded)", "standard_charge_percentage": 229.99999999999997, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Allegiance Provider Direct", "plan_name": "Montana Municipal Interlocal Authority (MMIA)", "standard_charge_percentage": 229.99999999999997, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Medicaid (State)", "plan_name": "Medicaid", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Blue Cross Blue Shield of Montana", "plan_name": "HealthLink Network", "standard_charge_percentage": 75, "methodology": "percent of total billed charges", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Blue Cross Blue Shield of Montana", "plan_name": "Traditional Network", "standard_charge_percentage": 75, "methodology": "percent of total billed charges", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Blue Cross Blue Shield of Montana", "plan_name": "POS Network", "standard_charge_percentage": 75, "methodology": "percent of total billed charges", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Blue Cross Blue Shield of Montana", "plan_name": "Closed Plan Network", "standard_charge_percentage": 75, "methodology": "percent of total billed charges", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Blue Cross Blue Shield of Montana", "plan_name": "Retail HMO POS Network", "standard_charge_percentage": 75, "methodology": "percent of total billed charges", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Blue Cross Blue Shield of Montana", "plan_name": "Blue Options Network", "standard_charge_percentage": 75, "methodology": "percent of total billed charges", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "PacificSource Health Plans", "plan_name": "Medicare Advantage", "standard_charge_percentage": 103, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" } ], "minimum": 90, "maximum": 90 } ] }, { "description": "Rubeola antibody", "code_information": [ { "code": "86765", "type": "HCPCS" } ], "standard_charges": [ { "setting": "outpatient", "payers_information": [ { "payer_name": "United Healthcare (UHC)", "plan_name": "DSNP", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "United Healthcare (UHC)", "plan_name": "Medicare Advantage", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" } ] } ] }, { "description": "Ot eval low complex 30 min", "code_information": [ { "code": "97165", "type": "HCPCS" } ], "standard_charges": [ { "setting": "outpatient", "payers_information": [ { "payer_name": "National Comp Care", "plan_name": "Workers' Compensation", "standard_charge_dollar": 150, "methodology": "fee schedule", "median_amount": 150, "10th_percentile": 150, "90th_percentile": 150, "count": "1 through 10" }, { "payer_name": "Coventry Health Care", "plan_name": "Auto Network", "standard_charge_percentage": 90, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "United Healthcare (UHC)", "plan_name": "DSNP", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Blue Cross Blue Shield of Montana", "plan_name": "Medicare Advantage", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Coventry Health Care", "plan_name": "Workers' Compensation", "standard_charge_percentage": 95, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "United Healthcare (UHC)", "plan_name": "Medicare Advantage", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Allegiance Provider Direct", "plan_name": "Medicare", "standard_charge_percentage": 229.99999999999997, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "PacificSource Health Plans", "plan_name": "PPO (PSN Network and Smart Health Network)", "standard_charge_percentage": 80, "methodology": "percent of total billed charges", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Medicare (CMS)", "plan_name": "Medicare", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "First Choice Health Network fka Health InfoNet", "plan_name": "Commercial", "standard_charge_percentage": 85, "methodology": "percent of total billed charges", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Claritev fka MultiPlan", "plan_name": "Auto Medical Program", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Claritev fka MultiPlan", "plan_name": "Workers' Compensation Program", "standard_charge_percentage": 90, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Claritev fka MultiPlan", "plan_name": "PPO", "standard_charge_percentage": 75, "methodology": "percent of total billed charges", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "First Choice of the Midwest", "plan_name": "PPO", "standard_charge_percentage": 90, "methodology": "percent of total billed charges", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Employee Benefit Management Services (EBMS)", "plan_name": "EBMS SelectCare Network", "standard_charge_percentage": 80, "methodology": "percent of total billed charges", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Medica Insurance Company", "plan_name": "Medicare Cost", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "First Choice Health Network fka Health InfoNet", "plan_name": "Medicare Advantage", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "First Choice Health Network fka Health InfoNet", "plan_name": "Workers Compensation", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Allegiance Provider Direct", "plan_name": "Montana Association of Counties (MACo)", "standard_charge_percentage": 229.99999999999997, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Allegiance Provider Direct", "plan_name": "State of Montana Employee Benefit Plan (Self-Funded)", "standard_charge_percentage": 229.99999999999997, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Allegiance Provider Direct", "plan_name": "Montana Municipal Interlocal Authority (MMIA)", "standard_charge_percentage": 229.99999999999997, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Blue Cross Blue Shield of Montana", "plan_name": "HealthLink Network", "standard_charge_percentage": 75, "methodology": "percent of total billed charges", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Blue Cross Blue Shield of Montana", "plan_name": "Traditional Network", "standard_charge_percentage": 75, "methodology": "percent of total billed charges", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Blue Cross Blue Shield of Montana", "plan_name": "POS Network", "standard_charge_percentage": 75, "methodology": "percent of total billed charges", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Blue Cross Blue Shield of Montana", "plan_name": "Closed Plan Network", "standard_charge_percentage": 75, "methodology": "percent of total billed charges", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Blue Cross Blue Shield of Montana", "plan_name": "Retail HMO POS Network", "standard_charge_percentage": 75, "methodology": "percent of total billed charges", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Blue Cross Blue Shield of Montana", "plan_name": "Blue Options Network", "standard_charge_percentage": 75, "methodology": "percent of total billed charges", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Medicaid (State)", "plan_name": "Medicaid", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "PacificSource Health Plans", "plan_name": "Medicare Advantage", "standard_charge_percentage": 103, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" } ], "minimum": 150, "maximum": 150 } ] }, { "description": "Ot eval mod complex 45 min", "code_information": [ { "code": "97166", "type": "HCPCS" } ], "standard_charges": [ { "setting": "outpatient", "payers_information": [ { "payer_name": "National Comp Care", "plan_name": "Workers' Compensation", "standard_charge_dollar": 150, "methodology": "fee schedule", "median_amount": 150, "10th_percentile": 150, "90th_percentile": 150, "count": "1 through 10" }, { "payer_name": "Coventry Health Care", "plan_name": "Auto Network", "standard_charge_percentage": 90, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "United Healthcare (UHC)", "plan_name": "DSNP", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Blue Cross Blue Shield of Montana", "plan_name": "Medicare Advantage", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Coventry Health Care", "plan_name": "Workers' Compensation", "standard_charge_percentage": 95, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "United Healthcare (UHC)", "plan_name": "Medicare Advantage", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Allegiance Provider Direct", "plan_name": "Medicare", "standard_charge_percentage": 229.99999999999997, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "PacificSource Health Plans", "plan_name": "PPO (PSN Network and Smart Health Network)", "standard_charge_percentage": 80, "methodology": "percent of total billed charges", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Medicare (CMS)", "plan_name": "Medicare", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "First Choice Health Network fka Health InfoNet", "plan_name": "Commercial", "standard_charge_percentage": 85, "methodology": "percent of total billed charges", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Claritev fka MultiPlan", "plan_name": "Auto Medical Program", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Claritev fka MultiPlan", "plan_name": "Workers' Compensation Program", "standard_charge_percentage": 90, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Claritev fka MultiPlan", "plan_name": "PPO", "standard_charge_percentage": 75, "methodology": "percent of total billed charges", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "First Choice of the Midwest", "plan_name": "PPO", "standard_charge_percentage": 90, "methodology": "percent of total billed charges", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Employee Benefit Management Services (EBMS)", "plan_name": "EBMS SelectCare Network", "standard_charge_percentage": 80, "methodology": "percent of total billed charges", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Medica Insurance Company", "plan_name": "Medicare Cost", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "First Choice Health Network fka Health InfoNet", "plan_name": "Medicare Advantage", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "First Choice Health Network fka Health InfoNet", "plan_name": "Workers Compensation", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Allegiance Provider Direct", "plan_name": "Montana Association of Counties (MACo)", "standard_charge_percentage": 229.99999999999997, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Allegiance Provider Direct", "plan_name": "State of Montana Employee Benefit Plan (Self-Funded)", "standard_charge_percentage": 229.99999999999997, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Allegiance Provider Direct", "plan_name": "Montana Municipal Interlocal Authority (MMIA)", "standard_charge_percentage": 229.99999999999997, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Blue Cross Blue Shield of Montana", "plan_name": "HealthLink Network", "standard_charge_percentage": 75, "methodology": "percent of total billed charges", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Blue Cross Blue Shield of Montana", "plan_name": "Traditional Network", "standard_charge_percentage": 75, "methodology": "percent of total billed charges", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Blue Cross Blue Shield of Montana", "plan_name": "POS Network", "standard_charge_percentage": 75, "methodology": "percent of total billed charges", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Blue Cross Blue Shield of Montana", "plan_name": "Closed Plan Network", "standard_charge_percentage": 75, "methodology": "percent of total billed charges", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Blue Cross Blue Shield of Montana", "plan_name": "Retail HMO POS Network", "standard_charge_percentage": 75, "methodology": "percent of total billed charges", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Blue Cross Blue Shield of Montana", "plan_name": "Blue Options Network", "standard_charge_percentage": 75, "methodology": "percent of total billed charges", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Medicaid (State)", "plan_name": "Medicaid", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "PacificSource Health Plans", "plan_name": "Medicare Advantage", "standard_charge_percentage": 103, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" } ], "minimum": 150, "maximum": 150 } ] }, { "description": "Ot eval high complex 60 min", "code_information": [ { "code": "97167", "type": "HCPCS" } ], "standard_charges": [ { "setting": "outpatient", "payers_information": [ { "payer_name": "National Comp Care", "plan_name": "Workers' Compensation", "standard_charge_dollar": 150, "methodology": "fee schedule", "median_amount": 150, "10th_percentile": 150, "90th_percentile": 150, "count": "1 through 10" }, { "payer_name": "Coventry Health Care", "plan_name": "Auto Network", "standard_charge_percentage": 90, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Coventry Health Care", "plan_name": "Workers' Compensation", "standard_charge_percentage": 95, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Blue Cross Blue Shield of Montana", "plan_name": "Medicare Advantage", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Allegiance Provider Direct", "plan_name": "Medicare", "standard_charge_percentage": 229.99999999999997, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "PacificSource Health Plans", "plan_name": "PPO (PSN Network and Smart Health Network)", "standard_charge_percentage": 80, "methodology": "percent of total billed charges", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Medicare (CMS)", "plan_name": "Medicare", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "First Choice Health Network fka Health InfoNet", "plan_name": "Commercial", "standard_charge_percentage": 85, "methodology": "percent of total billed charges", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Claritev fka MultiPlan", "plan_name": "Auto Medical Program", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Claritev fka MultiPlan", "plan_name": "Workers' Compensation Program", "standard_charge_percentage": 90, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Claritev fka MultiPlan", "plan_name": "PPO", "standard_charge_percentage": 75, "methodology": "percent of total billed charges", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "First Choice of the Midwest", "plan_name": "PPO", "standard_charge_percentage": 90, "methodology": "percent of total billed charges", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Employee Benefit Management Services (EBMS)", "plan_name": "EBMS SelectCare Network", "standard_charge_percentage": 80, "methodology": "percent of total billed charges", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Medica Insurance Company", "plan_name": "Medicare Cost", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "First Choice Health Network fka Health InfoNet", "plan_name": "Medicare Advantage", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "First Choice Health Network fka Health InfoNet", "plan_name": "Workers Compensation", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Allegiance Provider Direct", "plan_name": "Montana Association of Counties (MACo)", "standard_charge_percentage": 229.99999999999997, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Allegiance Provider Direct", "plan_name": "State of Montana Employee Benefit Plan (Self-Funded)", "standard_charge_percentage": 229.99999999999997, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Allegiance Provider Direct", "plan_name": "Montana Municipal Interlocal Authority (MMIA)", "standard_charge_percentage": 229.99999999999997, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Blue Cross Blue Shield of Montana", "plan_name": "HealthLink Network", "standard_charge_percentage": 75, "methodology": "percent of total billed charges", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Blue Cross Blue Shield of Montana", "plan_name": "Traditional Network", "standard_charge_percentage": 75, "methodology": "percent of total billed charges", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Blue Cross Blue Shield of Montana", "plan_name": "POS Network", "standard_charge_percentage": 75, "methodology": "percent of total billed charges", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Blue Cross Blue Shield of Montana", "plan_name": "Closed Plan Network", "standard_charge_percentage": 75, "methodology": "percent of total billed charges", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Blue Cross Blue Shield of Montana", "plan_name": "Retail HMO POS Network", "standard_charge_percentage": 75, "methodology": "percent of total billed charges", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Blue Cross Blue Shield of Montana", "plan_name": "Blue Options Network", "standard_charge_percentage": 75, "methodology": "percent of total billed charges", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Medicaid (State)", "plan_name": "Medicaid", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "PacificSource Health Plans", "plan_name": "Medicare Advantage", "standard_charge_percentage": 103, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" } ], "minimum": 150, "maximum": 150 } ] }, { "description": "Ot re-eval est plan care", "code_information": [ { "code": "97168", "type": "HCPCS" } ], "standard_charges": [ { "setting": "outpatient", "payers_information": [ { "payer_name": "National Comp Care", "plan_name": "Workers' Compensation", "standard_charge_dollar": 150, "methodology": "fee schedule", "median_amount": 150, "10th_percentile": 150, "90th_percentile": 150, "count": "1 through 10" }, { "payer_name": "Coventry Health Care", "plan_name": "Auto Network", "standard_charge_percentage": 90, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Coventry Health Care", "plan_name": "Workers' Compensation", "standard_charge_percentage": 95, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Blue Cross Blue Shield of Montana", "plan_name": "Medicare Advantage", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Allegiance Provider Direct", "plan_name": "Medicare", "standard_charge_percentage": 229.99999999999997, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "PacificSource Health Plans", "plan_name": "PPO (PSN Network and Smart Health Network)", "standard_charge_percentage": 80, "methodology": "percent of total billed charges", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "First Choice Health Network fka Health InfoNet", "plan_name": "Commercial", "standard_charge_percentage": 85, "methodology": "percent of total billed charges", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Medicare (CMS)", "plan_name": "Medicare", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Claritev fka MultiPlan", "plan_name": "Workers' Compensation Program", "standard_charge_percentage": 90, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Claritev fka MultiPlan", "plan_name": "Auto Medical Program", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Claritev fka MultiPlan", "plan_name": "PPO", "standard_charge_percentage": 75, "methodology": "percent of total billed charges", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "First Choice of the Midwest", "plan_name": "PPO", "standard_charge_percentage": 90, "methodology": "percent of total billed charges", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Employee Benefit Management Services (EBMS)", "plan_name": "EBMS SelectCare Network", "standard_charge_percentage": 80, "methodology": "percent of total billed charges", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Medica Insurance Company", "plan_name": "Medicare Cost", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "First Choice Health Network fka Health InfoNet", "plan_name": "Medicare Advantage", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "First Choice Health Network fka Health InfoNet", "plan_name": "Workers Compensation", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Allegiance Provider Direct", "plan_name": "Montana Association of Counties (MACo)", "standard_charge_percentage": 229.99999999999997, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Allegiance Provider Direct", "plan_name": "State of Montana Employee Benefit Plan (Self-Funded)", "standard_charge_percentage": 229.99999999999997, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Allegiance Provider Direct", "plan_name": "Montana Municipal Interlocal Authority (MMIA)", "standard_charge_percentage": 229.99999999999997, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Medicaid (State)", "plan_name": "Medicaid", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Blue Cross Blue Shield of Montana", "plan_name": "HealthLink Network", "standard_charge_percentage": 75, "methodology": "percent of total billed charges", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Blue Cross Blue Shield of Montana", "plan_name": "Traditional Network", "standard_charge_percentage": 75, "methodology": "percent of total billed charges", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Blue Cross Blue Shield of Montana", "plan_name": "POS Network", "standard_charge_percentage": 75, "methodology": "percent of total billed charges", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Blue Cross Blue Shield of Montana", "plan_name": "Closed Plan Network", "standard_charge_percentage": 75, "methodology": "percent of total billed charges", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Blue Cross Blue Shield of Montana", "plan_name": "Retail HMO POS Network", "standard_charge_percentage": 75, "methodology": "percent of total billed charges", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Blue Cross Blue Shield of Montana", "plan_name": "Blue Options Network", "standard_charge_percentage": 75, "methodology": "percent of total billed charges", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "PacificSource Health Plans", "plan_name": "Medicare Advantage", "standard_charge_percentage": 103, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" } ], "minimum": 150, "maximum": 150 } ] }, { "description": "Appl modality 1+estim ea 15", "code_information": [ { "code": "97032", "type": "HCPCS" } ], "standard_charges": [ { "setting": "outpatient", "payers_information": [ { "payer_name": "National Comp Care", "plan_name": "Workers' Compensation", "standard_charge_dollar": 90, "methodology": "fee schedule", "median_amount": 90, "10th_percentile": 90, "90th_percentile": 90, "count": "1 through 10" }, { "payer_name": "Coventry Health Care", "plan_name": "Auto Network", "standard_charge_percentage": 90, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Blue Cross Blue Shield of Montana", "plan_name": "Medicare Advantage", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Coventry Health Care", "plan_name": "Workers' Compensation", "standard_charge_percentage": 95, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Allegiance Provider Direct", "plan_name": "Medicare", "standard_charge_percentage": 229.99999999999997, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "PacificSource Health Plans", "plan_name": "PPO (PSN Network and Smart Health Network)", "standard_charge_percentage": 80, "methodology": "percent of total billed charges", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Medicare (CMS)", "plan_name": "Medicare", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "First Choice Health Network fka Health InfoNet", "plan_name": "Commercial", "standard_charge_percentage": 85, "methodology": "percent of total billed charges", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Claritev fka MultiPlan", "plan_name": "Auto Medical Program", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Claritev fka MultiPlan", "plan_name": "Workers' Compensation Program", "standard_charge_percentage": 90, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Claritev fka MultiPlan", "plan_name": "PPO", "standard_charge_percentage": 75, "methodology": "percent of total billed charges", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "First Choice of the Midwest", "plan_name": "PPO", "standard_charge_percentage": 90, "methodology": "percent of total billed charges", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Employee Benefit Management Services (EBMS)", "plan_name": "EBMS SelectCare Network", "standard_charge_percentage": 80, "methodology": "percent of total billed charges", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Medica Insurance Company", "plan_name": "Medicare Cost", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "First Choice Health Network fka Health InfoNet", "plan_name": "Medicare Advantage", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "First Choice Health Network fka Health InfoNet", "plan_name": "Workers Compensation", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Allegiance Provider Direct", "plan_name": "Montana Association of Counties (MACo)", "standard_charge_percentage": 229.99999999999997, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Allegiance Provider Direct", "plan_name": "State of Montana Employee Benefit Plan (Self-Funded)", "standard_charge_percentage": 229.99999999999997, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Allegiance Provider Direct", "plan_name": "Montana Municipal Interlocal Authority (MMIA)", "standard_charge_percentage": 229.99999999999997, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Blue Cross Blue Shield of Montana", "plan_name": "HealthLink Network", "standard_charge_percentage": 75, "methodology": "percent of total billed charges", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Blue Cross Blue Shield of Montana", "plan_name": "Traditional Network", "standard_charge_percentage": 75, "methodology": "percent of total billed charges", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Blue Cross Blue Shield of Montana", "plan_name": "POS Network", "standard_charge_percentage": 75, "methodology": "percent of total billed charges", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Blue Cross Blue Shield of Montana", "plan_name": "Closed Plan Network", "standard_charge_percentage": 75, "methodology": "percent of total billed charges", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Blue Cross Blue Shield of Montana", "plan_name": "Retail HMO POS Network", "standard_charge_percentage": 75, "methodology": "percent of total billed charges", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Blue Cross Blue Shield of Montana", "plan_name": "Blue Options Network", "standard_charge_percentage": 75, "methodology": "percent of total billed charges", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Medicaid (State)", "plan_name": "Medicaid", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "PacificSource Health Plans", "plan_name": "Medicare Advantage", "standard_charge_percentage": 103, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" } ], "minimum": 90, "maximum": 90 } ] }, { "description": "Neuromuscular reeducation", "code_information": [ { "code": "97112", "type": "HCPCS" } ], "standard_charges": [ { "setting": "outpatient", "payers_information": [ { "payer_name": "National Comp Care", "plan_name": "Workers' Compensation", "standard_charge_dollar": 90, "methodology": "fee schedule", "median_amount": 90, "10th_percentile": 90, "90th_percentile": 90, "count": "1 through 10" }, { "payer_name": "Coventry Health Care", "plan_name": "Auto Network", "standard_charge_percentage": 90, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Coventry Health Care", "plan_name": "Workers' Compensation", "standard_charge_percentage": 95, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "United Healthcare (UHC)", "plan_name": "DSNP", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Blue Cross Blue Shield of Montana", "plan_name": "Medicare Advantage", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "United Healthcare (UHC)", "plan_name": "Medicare Advantage", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Allegiance Provider Direct", "plan_name": "Medicare", "standard_charge_percentage": 229.99999999999997, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "PacificSource Health Plans", "plan_name": "PPO (PSN Network and Smart Health Network)", "standard_charge_percentage": 80, "methodology": "percent of total billed charges", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Medicare (CMS)", "plan_name": "Medicare", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "First Choice Health Network fka Health InfoNet", "plan_name": "Commercial", "standard_charge_percentage": 85, "methodology": "percent of total billed charges", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Claritev fka MultiPlan", "plan_name": "Auto Medical Program", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Claritev fka MultiPlan", "plan_name": "Workers' Compensation Program", "standard_charge_percentage": 90, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Claritev fka MultiPlan", "plan_name": "PPO", "standard_charge_percentage": 75, "methodology": "percent of total billed charges", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "First Choice of the Midwest", "plan_name": "PPO", "standard_charge_percentage": 90, "methodology": "percent of total billed charges", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Employee Benefit Management Services (EBMS)", "plan_name": "EBMS SelectCare Network", "standard_charge_percentage": 80, "methodology": "percent of total billed charges", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Medica Insurance Company", "plan_name": "Medicare Cost", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "First Choice Health Network fka Health InfoNet", "plan_name": "Medicare Advantage", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "First Choice Health Network fka Health InfoNet", "plan_name": "Workers Compensation", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Allegiance Provider Direct", "plan_name": "Montana Association of Counties (MACo)", "standard_charge_percentage": 229.99999999999997, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Allegiance Provider Direct", "plan_name": "State of Montana Employee Benefit Plan (Self-Funded)", "standard_charge_percentage": 229.99999999999997, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Allegiance Provider Direct", "plan_name": "Montana Municipal Interlocal Authority (MMIA)", "standard_charge_percentage": 229.99999999999997, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Blue Cross Blue Shield of Montana", "plan_name": "HealthLink Network", "standard_charge_percentage": 75, "methodology": "percent of total billed charges", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Blue Cross Blue Shield of Montana", "plan_name": "Traditional Network", "standard_charge_percentage": 75, "methodology": "percent of total billed charges", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Blue Cross Blue Shield of Montana", "plan_name": "POS Network", "standard_charge_percentage": 75, "methodology": "percent of total billed charges", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Blue Cross Blue Shield of Montana", "plan_name": "Closed Plan Network", "standard_charge_percentage": 75, "methodology": "percent of total billed charges", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Blue Cross Blue Shield of Montana", "plan_name": "Retail HMO POS Network", "standard_charge_percentage": 75, "methodology": "percent of total billed charges", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Blue Cross Blue Shield of Montana", "plan_name": "Blue Options Network", "standard_charge_percentage": 75, "methodology": "percent of total billed charges", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Medicaid (State)", "plan_name": "Medicaid", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "PacificSource Health Plans", "plan_name": "Medicare Advantage", "standard_charge_percentage": 103, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" } ], "minimum": 90, "maximum": 90 } ] }, { "description": "Aquatic therapy/exercises", "code_information": [ { "code": "97113", "type": "HCPCS" } ], "standard_charges": [ { "setting": "outpatient", "payers_information": [ { "payer_name": "National Comp Care", "plan_name": "Workers' Compensation", "standard_charge_dollar": 90, "methodology": "fee schedule", "median_amount": 90, "10th_percentile": 90, "90th_percentile": 90, "count": "1 through 10" }, { "payer_name": "Coventry Health Care", "plan_name": "Auto Network", "standard_charge_percentage": 90, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Blue Cross Blue Shield of Montana", "plan_name": "Medicare Advantage", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Coventry Health Care", "plan_name": "Workers' Compensation", "standard_charge_percentage": 95, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Allegiance Provider Direct", "plan_name": "Medicare", "standard_charge_percentage": 229.99999999999997, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "PacificSource Health Plans", "plan_name": "PPO (PSN Network and Smart Health Network)", "standard_charge_percentage": 80, "methodology": "percent of total billed charges", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Medicare (CMS)", "plan_name": "Medicare", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "First Choice Health Network fka Health InfoNet", "plan_name": "Commercial", "standard_charge_percentage": 85, "methodology": "percent of total billed charges", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Claritev fka MultiPlan", "plan_name": "Auto Medical Program", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Claritev fka MultiPlan", "plan_name": "Workers' Compensation Program", "standard_charge_percentage": 90, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Claritev fka MultiPlan", "plan_name": "PPO", "standard_charge_percentage": 75, "methodology": "percent of total billed charges", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "First Choice of the Midwest", "plan_name": "PPO", "standard_charge_percentage": 90, "methodology": "percent of total billed charges", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Employee Benefit Management Services (EBMS)", "plan_name": "EBMS SelectCare Network", "standard_charge_percentage": 80, "methodology": "percent of total billed charges", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Medica Insurance Company", "plan_name": "Medicare Cost", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "First Choice Health Network fka Health InfoNet", "plan_name": "Medicare Advantage", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "First Choice Health Network fka Health InfoNet", "plan_name": "Workers Compensation", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Allegiance Provider Direct", "plan_name": "Montana Association of Counties (MACo)", "standard_charge_percentage": 229.99999999999997, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Allegiance Provider Direct", "plan_name": "State of Montana Employee Benefit Plan (Self-Funded)", "standard_charge_percentage": 229.99999999999997, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Allegiance Provider Direct", "plan_name": "Montana Municipal Interlocal Authority (MMIA)", "standard_charge_percentage": 229.99999999999997, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Blue Cross Blue Shield of Montana", "plan_name": "HealthLink Network", "standard_charge_percentage": 75, "methodology": "percent of total billed charges", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Blue Cross Blue Shield of Montana", "plan_name": "Traditional Network", "standard_charge_percentage": 75, "methodology": "percent of total billed charges", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Blue Cross Blue Shield of Montana", "plan_name": "POS Network", "standard_charge_percentage": 75, "methodology": "percent of total billed charges", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Blue Cross Blue Shield of Montana", "plan_name": "Closed Plan Network", "standard_charge_percentage": 75, "methodology": "percent of total billed charges", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Blue Cross Blue Shield of Montana", "plan_name": "Retail HMO POS Network", "standard_charge_percentage": 75, "methodology": "percent of total billed charges", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Blue Cross Blue Shield of Montana", "plan_name": "Blue Options Network", "standard_charge_percentage": 75, "methodology": "percent of total billed charges", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Medicaid (State)", "plan_name": "Medicaid", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "PacificSource Health Plans", "plan_name": "Medicare Advantage", "standard_charge_percentage": 103, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" } ], "minimum": 90, "maximum": 90 } ] }, { "description": "Massage therapy", "code_information": [ { "code": "97124", "type": "HCPCS" } ], "standard_charges": [ { "setting": "outpatient", "payers_information": [ { "payer_name": "National Comp Care", "plan_name": "Workers' Compensation", "standard_charge_dollar": 90, "methodology": "fee schedule", "median_amount": 90, "10th_percentile": 90, "90th_percentile": 90, "count": "1 through 10" }, { "payer_name": "Coventry Health Care", "plan_name": "Auto Network", "standard_charge_percentage": 90, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Coventry Health Care", "plan_name": "Workers' Compensation", "standard_charge_percentage": 95, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Blue Cross Blue Shield of Montana", "plan_name": "Medicare Advantage", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Allegiance Provider Direct", "plan_name": "Medicare", "standard_charge_percentage": 229.99999999999997, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "PacificSource Health Plans", "plan_name": "PPO (PSN Network and Smart Health Network)", "standard_charge_percentage": 80, "methodology": "percent of total billed charges", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Medicare (CMS)", "plan_name": "Medicare", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "First Choice Health Network fka Health InfoNet", "plan_name": "Commercial", "standard_charge_percentage": 85, "methodology": "percent of total billed charges", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Claritev fka MultiPlan", "plan_name": "Auto Medical Program", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Claritev fka MultiPlan", "plan_name": "Workers' Compensation Program", "standard_charge_percentage": 90, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Claritev fka MultiPlan", "plan_name": "PPO", "standard_charge_percentage": 75, "methodology": "percent of total billed charges", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "First Choice of the Midwest", "plan_name": "PPO", "standard_charge_percentage": 90, "methodology": "percent of total billed charges", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Employee Benefit Management Services (EBMS)", "plan_name": "EBMS SelectCare Network", "standard_charge_percentage": 80, "methodology": "percent of total billed charges", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Medica Insurance Company", "plan_name": "Medicare Cost", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "First Choice Health Network fka Health InfoNet", "plan_name": "Medicare Advantage", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "First Choice Health Network fka Health InfoNet", "plan_name": "Workers Compensation", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Allegiance Provider Direct", "plan_name": "Montana Association of Counties (MACo)", "standard_charge_percentage": 229.99999999999997, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Allegiance Provider Direct", "plan_name": "State of Montana Employee Benefit Plan (Self-Funded)", "standard_charge_percentage": 229.99999999999997, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Allegiance Provider Direct", "plan_name": "Montana Municipal Interlocal Authority (MMIA)", "standard_charge_percentage": 229.99999999999997, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Medicaid (State)", "plan_name": "Medicaid", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Blue Cross Blue Shield of Montana", "plan_name": "HealthLink Network", "standard_charge_percentage": 75, "methodology": "percent of total billed charges", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Blue Cross Blue Shield of Montana", "plan_name": "Traditional Network", "standard_charge_percentage": 75, "methodology": "percent of total billed charges", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Blue Cross Blue Shield of Montana", "plan_name": "POS Network", "standard_charge_percentage": 75, "methodology": "percent of total billed charges", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Blue Cross Blue Shield of Montana", "plan_name": "Closed Plan Network", "standard_charge_percentage": 75, "methodology": "percent of total billed charges", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Blue Cross Blue Shield of Montana", "plan_name": "Retail HMO POS Network", "standard_charge_percentage": 75, "methodology": "percent of total billed charges", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Blue Cross Blue Shield of Montana", "plan_name": "Blue Options Network", "standard_charge_percentage": 75, "methodology": "percent of total billed charges", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "PacificSource Health Plans", "plan_name": "Medicare Advantage", "standard_charge_percentage": 103, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" } ], "minimum": 90, "maximum": 90 } ] }, { "description": "Ther ivntj 1st 15 min", "code_information": [ { "code": "97129", "type": "HCPCS" } ], "standard_charges": [ { "setting": "outpatient", "payers_information": [ { "payer_name": "National Comp Care", "plan_name": "Workers' Compensation", "standard_charge_dollar": 90, "methodology": "fee schedule", "median_amount": 90, "10th_percentile": 90, "90th_percentile": 90, "count": "1 through 10" }, { "payer_name": "Coventry Health Care", "plan_name": "Auto Network", "standard_charge_percentage": 90, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Blue Cross Blue Shield of Montana", "plan_name": "Medicare Advantage", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Coventry Health Care", "plan_name": "Workers' Compensation", "standard_charge_percentage": 95, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Allegiance Provider Direct", "plan_name": "Medicare", "standard_charge_percentage": 229.99999999999997, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "PacificSource Health Plans", "plan_name": "PPO (PSN Network and Smart Health Network)", "standard_charge_percentage": 80, "methodology": "percent of total billed charges", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Medicare (CMS)", "plan_name": "Medicare", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "First Choice Health Network fka Health InfoNet", "plan_name": "Commercial", "standard_charge_percentage": 85, "methodology": "percent of total billed charges", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Claritev fka MultiPlan", "plan_name": "Auto Medical Program", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Claritev fka MultiPlan", "plan_name": "Workers' Compensation Program", "standard_charge_percentage": 90, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Claritev fka MultiPlan", "plan_name": "PPO", "standard_charge_percentage": 75, "methodology": "percent of total billed charges", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "First Choice of the Midwest", "plan_name": "PPO", "standard_charge_percentage": 90, "methodology": "percent of total billed charges", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Employee Benefit Management Services (EBMS)", "plan_name": "EBMS SelectCare Network", "standard_charge_percentage": 80, "methodology": "percent of total billed charges", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Medica Insurance Company", "plan_name": "Medicare Cost", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "First Choice Health Network fka Health InfoNet", "plan_name": "Medicare Advantage", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "First Choice Health Network fka Health InfoNet", "plan_name": "Workers Compensation", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Allegiance Provider Direct", "plan_name": "Montana Association of Counties (MACo)", "standard_charge_percentage": 229.99999999999997, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Allegiance Provider Direct", "plan_name": "State of Montana Employee Benefit Plan (Self-Funded)", "standard_charge_percentage": 229.99999999999997, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Allegiance Provider Direct", "plan_name": "Montana Municipal Interlocal Authority (MMIA)", "standard_charge_percentage": 229.99999999999997, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Blue Cross Blue Shield of Montana", "plan_name": "HealthLink Network", "standard_charge_percentage": 75, "methodology": "percent of total billed charges", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Blue Cross Blue Shield of Montana", "plan_name": "Traditional Network", "standard_charge_percentage": 75, "methodology": "percent of total billed charges", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Blue Cross Blue Shield of Montana", "plan_name": "POS Network", "standard_charge_percentage": 75, "methodology": "percent of total billed charges", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Blue Cross Blue Shield of Montana", "plan_name": "Closed Plan Network", "standard_charge_percentage": 75, "methodology": "percent of total billed charges", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Blue Cross Blue Shield of Montana", "plan_name": "Retail HMO POS Network", "standard_charge_percentage": 75, "methodology": "percent of total billed charges", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Blue Cross Blue Shield of Montana", "plan_name": "Blue Options Network", "standard_charge_percentage": 75, "methodology": "percent of total billed charges", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Medicaid (State)", "plan_name": "Medicaid", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "PacificSource Health Plans", "plan_name": "Medicare Advantage", "standard_charge_percentage": 103, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" } ], "minimum": 90, "maximum": 90 } ] }, { "description": "Manual therapy 1/> regions", "code_information": [ { "code": "97140", "type": "HCPCS" } ], "standard_charges": [ { "setting": "outpatient", "payers_information": [ { "payer_name": "National Comp Care", "plan_name": "Workers' Compensation", "standard_charge_dollar": 90, "methodology": "fee schedule", "median_amount": 90, "10th_percentile": 90, "90th_percentile": 90, "count": "1 through 10" }, { "payer_name": "Coventry Health Care", "plan_name": "Auto Network", "standard_charge_percentage": 90, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Blue Cross Blue Shield of Montana", "plan_name": "Medicare Advantage", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Coventry Health Care", "plan_name": "Workers' Compensation", "standard_charge_percentage": 95, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Allegiance Provider Direct", "plan_name": "Medicare", "standard_charge_percentage": 229.99999999999997, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "PacificSource Health Plans", "plan_name": "PPO (PSN Network and Smart Health Network)", "standard_charge_percentage": 80, "methodology": "percent of total billed charges", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Medicare (CMS)", "plan_name": "Medicare", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "First Choice Health Network fka Health InfoNet", "plan_name": "Commercial", "standard_charge_percentage": 85, "methodology": "percent of total billed charges", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Claritev fka MultiPlan", "plan_name": "Auto Medical Program", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Claritev fka MultiPlan", "plan_name": "Workers' Compensation Program", "standard_charge_percentage": 90, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Claritev fka MultiPlan", "plan_name": "PPO", "standard_charge_percentage": 75, "methodology": "percent of total billed charges", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "First Choice of the Midwest", "plan_name": "PPO", "standard_charge_percentage": 90, "methodology": "percent of total billed charges", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Employee Benefit Management Services (EBMS)", "plan_name": "EBMS SelectCare Network", "standard_charge_percentage": 80, "methodology": "percent of total billed charges", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Medica Insurance Company", "plan_name": "Medicare Cost", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "First Choice Health Network fka Health InfoNet", "plan_name": "Medicare Advantage", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "First Choice Health Network fka Health InfoNet", "plan_name": "Workers Compensation", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Allegiance Provider Direct", "plan_name": "Montana Association of Counties (MACo)", "standard_charge_percentage": 229.99999999999997, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Allegiance Provider Direct", "plan_name": "State of Montana Employee Benefit Plan (Self-Funded)", "standard_charge_percentage": 229.99999999999997, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Allegiance Provider Direct", "plan_name": "Montana Municipal Interlocal Authority (MMIA)", "standard_charge_percentage": 229.99999999999997, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Blue Cross Blue Shield of Montana", "plan_name": "HealthLink Network", "standard_charge_percentage": 75, "methodology": "percent of total billed charges", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Blue Cross Blue Shield of Montana", "plan_name": "Traditional Network", "standard_charge_percentage": 75, "methodology": "percent of total billed charges", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Blue Cross Blue Shield of Montana", "plan_name": "POS Network", "standard_charge_percentage": 75, "methodology": "percent of total billed charges", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Blue Cross Blue Shield of Montana", "plan_name": "Closed Plan Network", "standard_charge_percentage": 75, "methodology": "percent of total billed charges", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Blue Cross Blue Shield of Montana", "plan_name": "Retail HMO POS Network", "standard_charge_percentage": 75, "methodology": "percent of total billed charges", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Blue Cross Blue Shield of Montana", "plan_name": "Blue Options Network", "standard_charge_percentage": 75, "methodology": "percent of total billed charges", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Medicaid (State)", "plan_name": "Medicaid", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "PacificSource Health Plans", "plan_name": "Medicare Advantage", "standard_charge_percentage": 103, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" } ], "minimum": 90, "maximum": 90 } ] }, { "description": "Pt eval low complex 20 min", "code_information": [ { "code": "97161", "type": "HCPCS" } ], "standard_charges": [ { "setting": "outpatient", "payers_information": [ { "payer_name": "National Comp Care", "plan_name": "Workers' Compensation", "standard_charge_dollar": 150, "methodology": "fee schedule", "median_amount": 150, "10th_percentile": 150, "90th_percentile": 150, "count": "1 through 10" }, { "payer_name": "Coventry Health Care", "plan_name": "Auto Network", "standard_charge_percentage": 90, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "United Healthcare (UHC)", "plan_name": "DSNP", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Blue Cross Blue Shield of Montana", "plan_name": "Medicare Advantage", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Coventry Health Care", "plan_name": "Workers' Compensation", "standard_charge_percentage": 95, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "United Healthcare (UHC)", "plan_name": "Medicare Advantage", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Allegiance Provider Direct", "plan_name": "Medicare", "standard_charge_percentage": 229.99999999999997, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "PacificSource Health Plans", "plan_name": "PPO (PSN Network and Smart Health Network)", "standard_charge_percentage": 80, "methodology": "percent of total billed charges", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Medicare (CMS)", "plan_name": "Medicare", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "First Choice Health Network fka Health InfoNet", "plan_name": "Commercial", "standard_charge_percentage": 85, "methodology": "percent of total billed charges", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Claritev fka MultiPlan", "plan_name": "Auto Medical Program", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Claritev fka MultiPlan", "plan_name": "Workers' Compensation Program", "standard_charge_percentage": 90, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Claritev fka MultiPlan", "plan_name": "PPO", "standard_charge_percentage": 75, "methodology": "percent of total billed charges", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "First Choice of the Midwest", "plan_name": "PPO", "standard_charge_percentage": 90, "methodology": "percent of total billed charges", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Employee Benefit Management Services (EBMS)", "plan_name": "EBMS SelectCare Network", "standard_charge_percentage": 80, "methodology": "percent of total billed charges", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Medica Insurance Company", "plan_name": "Medicare Cost", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "First Choice Health Network fka Health InfoNet", "plan_name": "Medicare Advantage", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "First Choice Health Network fka Health InfoNet", "plan_name": "Workers Compensation", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Allegiance Provider Direct", "plan_name": "Montana Association of Counties (MACo)", "standard_charge_percentage": 229.99999999999997, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Allegiance Provider Direct", "plan_name": "State of Montana Employee Benefit Plan (Self-Funded)", "standard_charge_percentage": 229.99999999999997, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Allegiance Provider Direct", "plan_name": "Montana Municipal Interlocal Authority (MMIA)", "standard_charge_percentage": 229.99999999999997, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Blue Cross Blue Shield of Montana", "plan_name": "HealthLink Network", "standard_charge_percentage": 75, "methodology": "percent of total billed charges", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Blue Cross Blue Shield of Montana", "plan_name": "Traditional Network", "standard_charge_percentage": 75, "methodology": "percent of total billed charges", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Blue Cross Blue Shield of Montana", "plan_name": "POS Network", "standard_charge_percentage": 75, "methodology": "percent of total billed charges", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Blue Cross Blue Shield of Montana", "plan_name": "Closed Plan Network", "standard_charge_percentage": 75, "methodology": "percent of total billed charges", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Blue Cross Blue Shield of Montana", "plan_name": "Retail HMO POS Network", "standard_charge_percentage": 75, "methodology": "percent of total billed charges", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Blue Cross Blue Shield of Montana", "plan_name": "Blue Options Network", "standard_charge_percentage": 75, "methodology": "percent of total billed charges", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Medicaid (State)", "plan_name": "Medicaid", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "PacificSource Health Plans", "plan_name": "Medicare Advantage", "standard_charge_percentage": 103, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" } ], "minimum": 150, "maximum": 150 } ] }, { "description": "Pt eval mod complex 30 min", "code_information": [ { "code": "97162", "type": "HCPCS" } ], "standard_charges": [ { "setting": "outpatient", "payers_information": [ { "payer_name": "National Comp Care", "plan_name": "Workers' Compensation", "standard_charge_dollar": 150, "methodology": "fee schedule", "median_amount": 150, "10th_percentile": 150, "90th_percentile": 150, "count": "1 through 10" }, { "payer_name": "Coventry Health Care", "plan_name": "Auto Network", "standard_charge_percentage": 90, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "United Healthcare (UHC)", "plan_name": "DSNP", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Blue Cross Blue Shield of Montana", "plan_name": "Medicare Advantage", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Coventry Health Care", "plan_name": "Workers' Compensation", "standard_charge_percentage": 95, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "United Healthcare (UHC)", "plan_name": "Medicare Advantage", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Allegiance Provider Direct", "plan_name": "Medicare", "standard_charge_percentage": 229.99999999999997, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "PacificSource Health Plans", "plan_name": "PPO (PSN Network and Smart Health Network)", "standard_charge_percentage": 80, "methodology": "percent of total billed charges", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Medicare (CMS)", "plan_name": "Medicare", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "First Choice Health Network fka Health InfoNet", "plan_name": "Commercial", "standard_charge_percentage": 85, "methodology": "percent of total billed charges", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Claritev fka MultiPlan", "plan_name": "Auto Medical Program", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Claritev fka MultiPlan", "plan_name": "Workers' Compensation Program", "standard_charge_percentage": 90, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Claritev fka MultiPlan", "plan_name": "PPO", "standard_charge_percentage": 75, "methodology": "percent of total billed charges", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "First Choice of the Midwest", "plan_name": "PPO", "standard_charge_percentage": 90, "methodology": "percent of total billed charges", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Employee Benefit Management Services (EBMS)", "plan_name": "EBMS SelectCare Network", "standard_charge_percentage": 80, "methodology": "percent of total billed charges", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Medica Insurance Company", "plan_name": "Medicare Cost", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "First Choice Health Network fka Health InfoNet", "plan_name": "Medicare Advantage", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "First Choice Health Network fka Health InfoNet", "plan_name": "Workers Compensation", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Allegiance Provider Direct", "plan_name": "Montana Association of Counties (MACo)", "standard_charge_percentage": 229.99999999999997, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Allegiance Provider Direct", "plan_name": "State of Montana Employee Benefit Plan (Self-Funded)", "standard_charge_percentage": 229.99999999999997, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Allegiance Provider Direct", "plan_name": "Montana Municipal Interlocal Authority (MMIA)", "standard_charge_percentage": 229.99999999999997, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Blue Cross Blue Shield of Montana", "plan_name": "HealthLink Network", "standard_charge_percentage": 75, "methodology": "percent of total billed charges", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Blue Cross Blue Shield of Montana", "plan_name": "Traditional Network", "standard_charge_percentage": 75, "methodology": "percent of total billed charges", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Blue Cross Blue Shield of Montana", "plan_name": "POS Network", "standard_charge_percentage": 75, "methodology": "percent of total billed charges", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Blue Cross Blue Shield of Montana", "plan_name": "Closed Plan Network", "standard_charge_percentage": 75, "methodology": "percent of total billed charges", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Blue Cross Blue Shield of Montana", "plan_name": "Retail HMO POS Network", "standard_charge_percentage": 75, "methodology": "percent of total billed charges", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Blue Cross Blue Shield of Montana", "plan_name": "Blue Options Network", "standard_charge_percentage": 75, "methodology": "percent of total billed charges", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Medicaid (State)", "plan_name": "Medicaid", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "PacificSource Health Plans", "plan_name": "Medicare Advantage", "standard_charge_percentage": 103, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" } ], "minimum": 150, "maximum": 150 } ] }, { "description": "Pt eval high complex 45 min", "code_information": [ { "code": "97163", "type": "HCPCS" } ], "standard_charges": [ { "setting": "outpatient", "payers_information": [ { "payer_name": "National Comp Care", "plan_name": "Workers' Compensation", "standard_charge_dollar": 150, "methodology": "fee schedule", "median_amount": 150, "10th_percentile": 150, "90th_percentile": 150, "count": "1 through 10" }, { "payer_name": "Coventry Health Care", "plan_name": "Auto Network", "standard_charge_percentage": 90, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "United Healthcare (UHC)", "plan_name": "DSNP", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Blue Cross Blue Shield of Montana", "plan_name": "Medicare Advantage", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Coventry Health Care", "plan_name": "Workers' Compensation", "standard_charge_percentage": 95, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "United Healthcare (UHC)", "plan_name": "Medicare Advantage", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Allegiance Provider Direct", "plan_name": "Medicare", "standard_charge_percentage": 229.99999999999997, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "PacificSource Health Plans", "plan_name": "PPO (PSN Network and Smart Health Network)", "standard_charge_percentage": 80, "methodology": "percent of total billed charges", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Medicare (CMS)", "plan_name": "Medicare", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "First Choice Health Network fka Health InfoNet", "plan_name": "Commercial", "standard_charge_percentage": 85, "methodology": "percent of total billed charges", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Claritev fka MultiPlan", "plan_name": "Auto Medical Program", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Claritev fka MultiPlan", "plan_name": "Workers' Compensation Program", "standard_charge_percentage": 90, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Claritev fka MultiPlan", "plan_name": "PPO", "standard_charge_percentage": 75, "methodology": "percent of total billed charges", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "First Choice of the Midwest", "plan_name": "PPO", "standard_charge_percentage": 90, "methodology": "percent of total billed charges", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Employee Benefit Management Services (EBMS)", "plan_name": "EBMS SelectCare Network", "standard_charge_percentage": 80, "methodology": "percent of total billed charges", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Medica Insurance Company", "plan_name": "Medicare Cost", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "First Choice Health Network fka Health InfoNet", "plan_name": "Medicare Advantage", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "First Choice Health Network fka Health InfoNet", "plan_name": "Workers Compensation", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Allegiance Provider Direct", "plan_name": "Montana Association of Counties (MACo)", "standard_charge_percentage": 229.99999999999997, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Allegiance Provider Direct", "plan_name": "State of Montana Employee Benefit Plan (Self-Funded)", "standard_charge_percentage": 229.99999999999997, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Allegiance Provider Direct", "plan_name": "Montana Municipal Interlocal Authority (MMIA)", "standard_charge_percentage": 229.99999999999997, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Blue Cross Blue Shield of Montana", "plan_name": "HealthLink Network", "standard_charge_percentage": 75, "methodology": "percent of total billed charges", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Blue Cross Blue Shield of Montana", "plan_name": "Traditional Network", "standard_charge_percentage": 75, "methodology": "percent of total billed charges", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Blue Cross Blue Shield of Montana", "plan_name": "POS Network", "standard_charge_percentage": 75, "methodology": "percent of total billed charges", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Blue Cross Blue Shield of Montana", "plan_name": "Closed Plan Network", "standard_charge_percentage": 75, "methodology": "percent of total billed charges", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Blue Cross Blue Shield of Montana", "plan_name": "Retail HMO POS Network", "standard_charge_percentage": 75, "methodology": "percent of total billed charges", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Blue Cross Blue Shield of Montana", "plan_name": "Blue Options Network", "standard_charge_percentage": 75, "methodology": "percent of total billed charges", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Medicaid (State)", "plan_name": "Medicaid", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "PacificSource Health Plans", "plan_name": "Medicare Advantage", "standard_charge_percentage": 103, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" } ], "minimum": 150, "maximum": 150 } ] }, { "description": "Pt re-eval est plan care", "code_information": [ { "code": "97164", "type": "HCPCS" } ], "standard_charges": [ { "setting": "outpatient", "payers_information": [ { "payer_name": "National Comp Care", "plan_name": "Workers' Compensation", "standard_charge_dollar": 150, "methodology": "fee schedule", "median_amount": 150, "10th_percentile": 150, "90th_percentile": 150, "count": "1 through 10" }, { "payer_name": "Coventry Health Care", "plan_name": "Auto Network", "standard_charge_percentage": 90, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "United Healthcare (UHC)", "plan_name": "DSNP", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Coventry Health Care", "plan_name": "Workers' Compensation", "standard_charge_percentage": 95, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Blue Cross Blue Shield of Montana", "plan_name": "Medicare Advantage", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "United Healthcare (UHC)", "plan_name": "Medicare Advantage", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Allegiance Provider Direct", "plan_name": "Medicare", "standard_charge_percentage": 229.99999999999997, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "PacificSource Health Plans", "plan_name": "PPO (PSN Network and Smart Health Network)", "standard_charge_percentage": 80, "methodology": "percent of total billed charges", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "First Choice Health Network fka Health InfoNet", "plan_name": "Commercial", "standard_charge_percentage": 85, "methodology": "percent of total billed charges", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Medicare (CMS)", "plan_name": "Medicare", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Claritev fka MultiPlan", "plan_name": "Workers' Compensation Program", "standard_charge_percentage": 90, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Claritev fka MultiPlan", "plan_name": "Auto Medical Program", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Claritev fka MultiPlan", "plan_name": "PPO", "standard_charge_percentage": 75, "methodology": "percent of total billed charges", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "First Choice of the Midwest", "plan_name": "PPO", "standard_charge_percentage": 90, "methodology": "percent of total billed charges", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Employee Benefit Management Services (EBMS)", "plan_name": "EBMS SelectCare Network", "standard_charge_percentage": 80, "methodology": "percent of total billed charges", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Medica Insurance Company", "plan_name": "Medicare Cost", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "First Choice Health Network fka Health InfoNet", "plan_name": "Medicare Advantage", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "First Choice Health Network fka Health InfoNet", "plan_name": "Workers Compensation", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Allegiance Provider Direct", "plan_name": "Montana Association of Counties (MACo)", "standard_charge_percentage": 229.99999999999997, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Allegiance Provider Direct", "plan_name": "State of Montana Employee Benefit Plan (Self-Funded)", "standard_charge_percentage": 229.99999999999997, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Allegiance Provider Direct", "plan_name": "Montana Municipal Interlocal Authority (MMIA)", "standard_charge_percentage": 229.99999999999997, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Medicaid (State)", "plan_name": "Medicaid", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Blue Cross Blue Shield of Montana", "plan_name": "HealthLink Network", "standard_charge_percentage": 75, "methodology": "percent of total billed charges", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Blue Cross Blue Shield of Montana", "plan_name": "Traditional Network", "standard_charge_percentage": 75, "methodology": "percent of total billed charges", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Blue Cross Blue Shield of Montana", "plan_name": "POS Network", "standard_charge_percentage": 75, "methodology": "percent of total billed charges", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Blue Cross Blue Shield of Montana", "plan_name": "Closed Plan Network", "standard_charge_percentage": 75, "methodology": "percent of total billed charges", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Blue Cross Blue Shield of Montana", "plan_name": "Retail HMO POS Network", "standard_charge_percentage": 75, "methodology": "percent of total billed charges", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Blue Cross Blue Shield of Montana", "plan_name": "Blue Options Network", "standard_charge_percentage": 75, "methodology": "percent of total billed charges", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "PacificSource Health Plans", "plan_name": "Medicare Advantage", "standard_charge_percentage": 103, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" } ], "minimum": 150, "maximum": 150 } ] }, { "description": "Speech/hearing therapy", "code_information": [ { "code": "92507", "type": "HCPCS" } ], "standard_charges": [ { "setting": "outpatient", "payers_information": [ { "payer_name": "National Comp Care", "plan_name": "Workers' Compensation", "standard_charge_dollar": 90, "methodology": "fee schedule", "median_amount": 90, "10th_percentile": 90, "90th_percentile": 90, "count": "1 through 10" }, { "payer_name": "Coventry Health Care", "plan_name": "Auto Network", "standard_charge_percentage": 90, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "United Healthcare (UHC)", "plan_name": "DSNP", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Blue Cross Blue Shield of Montana", "plan_name": "Medicare Advantage", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Coventry Health Care", "plan_name": "Workers' Compensation", "standard_charge_percentage": 95, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "United Healthcare (UHC)", "plan_name": "Medicare Advantage", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Allegiance Provider Direct", "plan_name": "Medicare", "standard_charge_percentage": 229.99999999999997, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "PacificSource Health Plans", "plan_name": "PPO (PSN Network and Smart Health Network)", "standard_charge_percentage": 80, "methodology": "percent of total billed charges", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Medicare (CMS)", "plan_name": "Medicare", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "First Choice Health Network fka Health InfoNet", "plan_name": "Commercial", "standard_charge_percentage": 85, "methodology": "percent of total billed charges", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Claritev fka MultiPlan", "plan_name": "Auto Medical Program", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Claritev fka MultiPlan", "plan_name": "Workers' Compensation Program", "standard_charge_percentage": 90, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Claritev fka MultiPlan", "plan_name": "PPO", "standard_charge_percentage": 75, "methodology": "percent of total billed charges", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "First Choice of the Midwest", "plan_name": "PPO", "standard_charge_percentage": 90, "methodology": "percent of total billed charges", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Employee Benefit Management Services (EBMS)", "plan_name": "EBMS SelectCare Network", "standard_charge_percentage": 80, "methodology": "percent of total billed charges", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Medica Insurance Company", "plan_name": "Medicare Cost", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "First Choice Health Network fka Health InfoNet", "plan_name": "Medicare Advantage", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "First Choice Health Network fka Health InfoNet", "plan_name": "Workers Compensation", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Allegiance Provider Direct", "plan_name": "Montana Association of Counties (MACo)", "standard_charge_percentage": 229.99999999999997, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Allegiance Provider Direct", "plan_name": "State of Montana Employee Benefit Plan (Self-Funded)", "standard_charge_percentage": 229.99999999999997, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Allegiance Provider Direct", "plan_name": "Montana Municipal Interlocal Authority (MMIA)", "standard_charge_percentage": 229.99999999999997, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Blue Cross Blue Shield of Montana", "plan_name": "HealthLink Network", "standard_charge_percentage": 75, "methodology": "percent of total billed charges", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Blue Cross Blue Shield of Montana", "plan_name": "Traditional Network", "standard_charge_percentage": 75, "methodology": "percent of total billed charges", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Blue Cross Blue Shield of Montana", "plan_name": "POS Network", "standard_charge_percentage": 75, "methodology": "percent of total billed charges", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Blue Cross Blue Shield of Montana", "plan_name": "Closed Plan Network", "standard_charge_percentage": 75, "methodology": "percent of total billed charges", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Blue Cross Blue Shield of Montana", "plan_name": "Retail HMO POS Network", "standard_charge_percentage": 75, "methodology": "percent of total billed charges", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Blue Cross Blue Shield of Montana", "plan_name": "Blue Options Network", "standard_charge_percentage": 75, "methodology": "percent of total billed charges", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Medicaid (State)", "plan_name": "Medicaid", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "PacificSource Health Plans", "plan_name": "Medicare Advantage", "standard_charge_percentage": 103, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" } ], "minimum": 90, "maximum": 90 } ] }, { "description": "Oral function therapy", "code_information": [ { "code": "92526", "type": "HCPCS" } ], "standard_charges": [ { "setting": "outpatient", "payers_information": [ { "payer_name": "National Comp Care", "plan_name": "Workers' Compensation", "standard_charge_dollar": 90, "methodology": "fee schedule", "median_amount": 90, "10th_percentile": 90, "90th_percentile": 90, "count": "1 through 10" }, { "payer_name": "Coventry Health Care", "plan_name": "Auto Network", "standard_charge_percentage": 90, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "United Healthcare (UHC)", "plan_name": "DSNP", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Blue Cross Blue Shield of Montana", "plan_name": "Medicare Advantage", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Coventry Health Care", "plan_name": "Workers' Compensation", "standard_charge_percentage": 95, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "United Healthcare (UHC)", "plan_name": "Medicare Advantage", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Allegiance Provider Direct", "plan_name": "Medicare", "standard_charge_percentage": 229.99999999999997, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "PacificSource Health Plans", "plan_name": "PPO (PSN Network and Smart Health Network)", "standard_charge_percentage": 80, "methodology": "percent of total billed charges", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Medicare (CMS)", "plan_name": "Medicare", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "First Choice Health Network fka Health InfoNet", "plan_name": "Commercial", "standard_charge_percentage": 85, "methodology": "percent of total billed charges", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Claritev fka MultiPlan", "plan_name": "Auto Medical Program", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Claritev fka MultiPlan", "plan_name": "Workers' Compensation Program", "standard_charge_percentage": 90, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Claritev fka MultiPlan", "plan_name": "PPO", "standard_charge_percentage": 75, "methodology": "percent of total billed charges", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "First Choice of the Midwest", "plan_name": "PPO", "standard_charge_percentage": 90, "methodology": "percent of total billed charges", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Employee Benefit Management Services (EBMS)", "plan_name": "EBMS SelectCare Network", "standard_charge_percentage": 80, "methodology": "percent of total billed charges", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Medica Insurance Company", "plan_name": "Medicare Cost", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "First Choice Health Network fka Health InfoNet", "plan_name": "Medicare Advantage", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "First Choice Health Network fka Health InfoNet", "plan_name": "Workers Compensation", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Allegiance Provider Direct", "plan_name": "Montana Association of Counties (MACo)", "standard_charge_percentage": 229.99999999999997, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Allegiance Provider Direct", "plan_name": "State of Montana Employee Benefit Plan (Self-Funded)", "standard_charge_percentage": 229.99999999999997, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Allegiance Provider Direct", "plan_name": "Montana Municipal Interlocal Authority (MMIA)", "standard_charge_percentage": 229.99999999999997, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Blue Cross Blue Shield of Montana", "plan_name": "HealthLink Network", "standard_charge_percentage": 75, "methodology": "percent of total billed charges", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Blue Cross Blue Shield of Montana", "plan_name": "Traditional Network", "standard_charge_percentage": 75, "methodology": "percent of total billed charges", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Blue Cross Blue Shield of Montana", "plan_name": "POS Network", "standard_charge_percentage": 75, "methodology": "percent of total billed charges", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Blue Cross Blue Shield of Montana", "plan_name": "Closed Plan Network", "standard_charge_percentage": 75, "methodology": "percent of total billed charges", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Blue Cross Blue Shield of Montana", "plan_name": "Retail HMO POS Network", "standard_charge_percentage": 75, "methodology": "percent of total billed charges", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Blue Cross Blue Shield of Montana", "plan_name": "Blue Options Network", "standard_charge_percentage": 75, "methodology": "percent of total billed charges", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Medicaid (State)", "plan_name": "Medicaid", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "PacificSource Health Plans", "plan_name": "Medicare Advantage", "standard_charge_percentage": 103, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" } ], "minimum": 90, "maximum": 90 } ] }, { "description": "Oral speech device eval", "code_information": [ { "code": "92597", "type": "HCPCS" } ], "standard_charges": [ { "setting": "outpatient", "payers_information": [ { "payer_name": "National Comp Care", "plan_name": "Workers' Compensation", "standard_charge_dollar": 90, "methodology": "fee schedule", "median_amount": 90, "10th_percentile": 90, "90th_percentile": 90, "count": "1 through 10" } ], "minimum": 90, "maximum": 90 } ] }, { "description": "Ex for nonspeech device rx", "code_information": [ { "code": "92605", "type": "HCPCS" } ], "standard_charges": [ { "setting": "outpatient", "payers_information": [ { "payer_name": "National Comp Care", "plan_name": "Workers' Compensation", "standard_charge_dollar": 90, "methodology": "fee schedule", "median_amount": 90, "10th_percentile": 90, "90th_percentile": 90, "count": "1 through 10" } ], "minimum": 90, "maximum": 90 } ] }, { "description": "Non-speech device service", "code_information": [ { "code": "92606", "type": "HCPCS" } ], "standard_charges": [ { "setting": "outpatient", "payers_information": [ { "payer_name": "National Comp Care", "plan_name": "Workers' Compensation", "standard_charge_dollar": 90, "methodology": "fee schedule", "median_amount": 90, "10th_percentile": 90, "90th_percentile": 90, "count": "1 through 10" } ], "minimum": 90, "maximum": 90 } ] }, { "description": "Ex for speech device rx 1hr", "code_information": [ { "code": "92607", "type": "HCPCS" } ], "standard_charges": [ { "setting": "outpatient", "payers_information": [ { "payer_name": "National Comp Care", "plan_name": "Workers' Compensation", "standard_charge_dollar": 90, "methodology": "fee schedule", "median_amount": 90, "10th_percentile": 90, "90th_percentile": 90, "count": "1 through 10" }, { "payer_name": "Coventry Health Care", "plan_name": "Auto Network", "standard_charge_percentage": 90, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Coventry Health Care", "plan_name": "Workers' Compensation", "standard_charge_percentage": 95, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Blue Cross Blue Shield of Montana", "plan_name": "Medicare Advantage", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Allegiance Provider Direct", "plan_name": "Medicare", "standard_charge_percentage": 229.99999999999997, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "PacificSource Health Plans", "plan_name": "PPO (PSN Network and Smart Health Network)", "standard_charge_percentage": 80, "methodology": "percent of total billed charges", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "First Choice Health Network fka Health InfoNet", "plan_name": "Commercial", "standard_charge_percentage": 85, "methodology": "percent of total billed charges", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Medicare (CMS)", "plan_name": "Medicare", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Claritev fka MultiPlan", "plan_name": "Workers' Compensation Program", "standard_charge_percentage": 90, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Claritev fka MultiPlan", "plan_name": "Auto Medical Program", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Claritev fka MultiPlan", "plan_name": "PPO", "standard_charge_percentage": 75, "methodology": "percent of total billed charges", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "First Choice of the Midwest", "plan_name": "PPO", "standard_charge_percentage": 90, "methodology": "percent of total billed charges", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Employee Benefit Management Services (EBMS)", "plan_name": "EBMS SelectCare Network", "standard_charge_percentage": 80, "methodology": "percent of total billed charges", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Medica Insurance Company", "plan_name": "Medicare Cost", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "First Choice Health Network fka Health InfoNet", "plan_name": "Medicare Advantage", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "First Choice Health Network fka Health InfoNet", "plan_name": "Workers Compensation", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Allegiance Provider Direct", "plan_name": "Montana Association of Counties (MACo)", "standard_charge_percentage": 229.99999999999997, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Allegiance Provider Direct", "plan_name": "State of Montana Employee Benefit Plan (Self-Funded)", "standard_charge_percentage": 229.99999999999997, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Allegiance Provider Direct", "plan_name": "Montana Municipal Interlocal Authority (MMIA)", "standard_charge_percentage": 229.99999999999997, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Medicaid (State)", "plan_name": "Medicaid", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Blue Cross Blue Shield of Montana", "plan_name": "HealthLink Network", "standard_charge_percentage": 75, "methodology": "percent of total billed charges", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Blue Cross Blue Shield of Montana", "plan_name": "Traditional Network", "standard_charge_percentage": 75, "methodology": "percent of total billed charges", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Blue Cross Blue Shield of Montana", "plan_name": "POS Network", "standard_charge_percentage": 75, "methodology": "percent of total billed charges", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Blue Cross Blue Shield of Montana", "plan_name": "Closed Plan Network", "standard_charge_percentage": 75, "methodology": "percent of total billed charges", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Blue Cross Blue Shield of Montana", "plan_name": "Retail HMO POS Network", "standard_charge_percentage": 75, "methodology": "percent of total billed charges", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Blue Cross Blue Shield of Montana", "plan_name": "Blue Options Network", "standard_charge_percentage": 75, "methodology": "percent of total billed charges", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "PacificSource Health Plans", "plan_name": "Medicare Advantage", "standard_charge_percentage": 103, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" } ], "minimum": 90, "maximum": 90 } ] }, { "description": "Treponema pallidum", "code_information": [ { "code": "86780", "type": "HCPCS" } ], "standard_charges": [ { "setting": "outpatient", "payers_information": [ { "payer_name": "United Healthcare (UHC)", "plan_name": "DSNP", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "United Healthcare (UHC)", "plan_name": "Medicare Advantage", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" } ] } ] }, { "description": "Varicella-zoster antibody", "code_information": [ { "code": "86787", "type": "HCPCS" } ], "standard_charges": [ { "setting": "outpatient", "payers_information": [ { "payer_name": "United Healthcare (UHC)", "plan_name": "DSNP", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "United Healthcare (UHC)", "plan_name": "Medicare Advantage", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" } ] } ] }, { "description": "Rbc antibody screen", "code_information": [ { "code": "86850", "type": "HCPCS" } ], "standard_charges": [ { "setting": "outpatient", "payers_information": [ { "payer_name": "United Healthcare (UHC)", "plan_name": "DSNP", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "United Healthcare (UHC)", "plan_name": "Medicare Advantage", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" } ] } ] }, { "description": "Rbc antibody identification", "code_information": [ { "code": "86870", "type": "HCPCS" } ], "standard_charges": [ { "setting": "outpatient", "payers_information": [ { "payer_name": "United Healthcare (UHC)", "plan_name": "DSNP", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "United Healthcare (UHC)", "plan_name": "Medicare Advantage", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" } ] } ] }, { "description": "Coombs test direct", "code_information": [ { "code": "86880", "type": "HCPCS" } ], "standard_charges": [ { "setting": "outpatient", "payers_information": [ { "payer_name": "United Healthcare (UHC)", "plan_name": "DSNP", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "United Healthcare (UHC)", "plan_name": "Medicare Advantage", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" } ] } ] }, { "description": "Blood typing serologic abo", "code_information": [ { "code": "86900", "type": "HCPCS" } ], "standard_charges": [ { "setting": "outpatient", "payers_information": [ { "payer_name": "United Healthcare (UHC)", "plan_name": "DSNP", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "United Healthcare (UHC)", "plan_name": "Medicare Advantage", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" } ] } ] }, { "description": "Blood typing serologic rh(d)", "code_information": [ { "code": "86901", "type": "HCPCS" } ], "standard_charges": [ { "setting": "outpatient", "payers_information": [ { "payer_name": "United Healthcare (UHC)", "plan_name": "DSNP", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "United Healthcare (UHC)", "plan_name": "Medicare Advantage", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" } ] } ] }, { "description": "Blood typing rbc antigens", "code_information": [ { "code": "86905", "type": "HCPCS" } ], "standard_charges": [ { "setting": "outpatient", "payers_information": [ { "payer_name": "United Healthcare (UHC)", "plan_name": "DSNP", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "National Comp Care", "plan_name": "Workers' Compensation", "standard_charge_percentage": 90, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Coventry Health Care", "plan_name": "Auto Network", "standard_charge_percentage": 90, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Coventry Health Care", "plan_name": "Workers' Compensation", "standard_charge_percentage": 95, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Blue Cross Blue Shield of Montana", "plan_name": "Medicare Advantage", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "United Healthcare (UHC)", "plan_name": "Medicare Advantage", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Allegiance Provider Direct", "plan_name": "Medicare", "standard_charge_percentage": 229.99999999999997, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "PacificSource Health Plans", "plan_name": "PPO (PSN Network and Smart Health Network)", "standard_charge_percentage": 80, "methodology": "percent of total billed charges", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "First Choice Health Network fka Health InfoNet", "plan_name": "Commercial", "standard_charge_percentage": 85, "methodology": "percent of total billed charges", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Medicare (CMS)", "plan_name": "Medicare", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Claritev fka MultiPlan", "plan_name": "Workers' Compensation Program", "standard_charge_percentage": 90, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Claritev fka MultiPlan", "plan_name": "Auto Medical Program", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Claritev fka MultiPlan", "plan_name": "PPO", "standard_charge_percentage": 75, "methodology": "percent of total billed charges", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "First Choice of the Midwest", "plan_name": "PPO", "standard_charge_percentage": 90, "methodology": "percent of total billed charges", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Employee Benefit Management Services (EBMS)", "plan_name": "EBMS SelectCare Network", "standard_charge_percentage": 80, "methodology": "percent of total billed charges", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Medica Insurance Company", "plan_name": "Medicare Cost", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "First Choice Health Network fka Health InfoNet", "plan_name": "Medicare Advantage", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "First Choice Health Network fka Health InfoNet", "plan_name": "Workers Compensation", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Allegiance Provider Direct", "plan_name": "Montana Association of Counties (MACo)", "standard_charge_percentage": 229.99999999999997, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Allegiance Provider Direct", "plan_name": "State of Montana Employee Benefit Plan (Self-Funded)", "standard_charge_percentage": 229.99999999999997, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Allegiance Provider Direct", "plan_name": "Montana Municipal Interlocal Authority (MMIA)", "standard_charge_percentage": 229.99999999999997, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Medicaid (State)", "plan_name": "Medicaid", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Blue Cross Blue Shield of Montana", "plan_name": "HealthLink Network", "standard_charge_percentage": 75, "methodology": "percent of total billed charges", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Blue Cross Blue Shield of Montana", "plan_name": "Traditional Network", "standard_charge_percentage": 75, "methodology": "percent of total billed charges", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Blue Cross Blue Shield of Montana", "plan_name": "POS Network", "standard_charge_percentage": 75, "methodology": "percent of total billed charges", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Blue Cross Blue Shield of Montana", "plan_name": "Closed Plan Network", "standard_charge_percentage": 75, "methodology": "percent of total billed charges", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Blue Cross Blue Shield of Montana", "plan_name": "Retail HMO POS Network", "standard_charge_percentage": 75, "methodology": "percent of total billed charges", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Blue Cross Blue Shield of Montana", "plan_name": "Blue Options Network", "standard_charge_percentage": 75, "methodology": "percent of total billed charges", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "PacificSource Health Plans", "plan_name": "Medicare Advantage", "standard_charge_percentage": 103, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" } ] } ] }, { "description": "Bld typing serologic rh phnt", "code_information": [ { "code": "86906", "type": "HCPCS" } ], "standard_charges": [ { "setting": "outpatient", "payers_information": [ { "payer_name": "United Healthcare (UHC)", "plan_name": "DSNP", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "United Healthcare (UHC)", "plan_name": "Medicare Advantage", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" } ] } ] }, { "description": "Compatibility test spin", "code_information": [ { "code": "86920", "type": "HCPCS" } ], "standard_charges": [ { "setting": "outpatient", "payers_information": [ { "payer_name": "United Healthcare (UHC)", "plan_name": "DSNP", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "United Healthcare (UHC)", "plan_name": "Medicare Advantage", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" } ] } ] }, { "description": "Compatibility test antiglob", "code_information": [ { "code": "86922", "type": "HCPCS" } ], "standard_charges": [ { "setting": "outpatient", "payers_information": [ { "payer_name": "United Healthcare (UHC)", "plan_name": "DSNP", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "United Healthcare (UHC)", "plan_name": "Medicare Advantage", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" } ] } ] }, { "description": "Unlisted transfusion med px", "code_information": [ { "code": "86999", "type": "HCPCS" } ], "standard_charges": [ { "setting": "outpatient", "payers_information": [ { "payer_name": "United Healthcare (UHC)", "plan_name": "DSNP", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "United Healthcare (UHC)", "plan_name": "Medicare Advantage", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" } ] } ] }, { "description": "Blood culture for bacteria", "code_information": [ { "code": "87040", "type": "HCPCS" } ], "standard_charges": [ { "setting": "outpatient", "payers_information": [ { "payer_name": "United Healthcare (UHC)", "plan_name": "DSNP", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "National Comp Care", "plan_name": "Workers' Compensation", "standard_charge_percentage": 90, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Coventry Health Care", "plan_name": "Auto Network", "standard_charge_percentage": 90, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Coventry Health Care", "plan_name": "Workers' Compensation", "standard_charge_percentage": 95, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Blue Cross Blue Shield of Montana", "plan_name": "Medicare Advantage", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "United Healthcare (UHC)", "plan_name": "Medicare Advantage", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Allegiance Provider Direct", "plan_name": "Medicare", "standard_charge_percentage": 229.99999999999997, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "PacificSource Health Plans", "plan_name": "PPO (PSN Network and Smart Health Network)", "standard_charge_percentage": 80, "methodology": "percent of total billed charges", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "First Choice Health Network fka Health InfoNet", "plan_name": "Commercial", "standard_charge_percentage": 85, "methodology": "percent of total billed charges", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Medicare (CMS)", "plan_name": "Medicare", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Claritev fka MultiPlan", "plan_name": "Auto Medical Program", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Claritev fka MultiPlan", "plan_name": "Workers' Compensation Program", "standard_charge_percentage": 90, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Claritev fka MultiPlan", "plan_name": "PPO", "standard_charge_percentage": 75, "methodology": "percent of total billed charges", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "First Choice of the Midwest", "plan_name": "PPO", "standard_charge_percentage": 90, "methodology": "percent of total billed charges", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Employee Benefit Management Services (EBMS)", "plan_name": "EBMS SelectCare Network", "standard_charge_percentage": 80, "methodology": "percent of total billed charges", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Medica Insurance Company", "plan_name": "Medicare Cost", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "First Choice Health Network fka Health InfoNet", "plan_name": "Medicare Advantage", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "First Choice Health Network fka Health InfoNet", "plan_name": "Workers Compensation", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Allegiance Provider Direct", "plan_name": "Montana Association of Counties (MACo)", "standard_charge_percentage": 229.99999999999997, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Allegiance Provider Direct", "plan_name": "State of Montana Employee Benefit Plan (Self-Funded)", "standard_charge_percentage": 229.99999999999997, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Allegiance Provider Direct", "plan_name": "Montana Municipal Interlocal Authority (MMIA)", "standard_charge_percentage": 229.99999999999997, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Medicaid (State)", "plan_name": "Medicaid", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Blue Cross Blue Shield of Montana", "plan_name": "HealthLink Network", "standard_charge_percentage": 75, "methodology": "percent of total billed charges", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Blue Cross Blue Shield of Montana", "plan_name": "Traditional Network", "standard_charge_percentage": 75, "methodology": "percent of total billed charges", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Blue Cross Blue Shield of Montana", "plan_name": "POS Network", "standard_charge_percentage": 75, "methodology": "percent of total billed charges", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Blue Cross Blue Shield of Montana", "plan_name": "Closed Plan Network", "standard_charge_percentage": 75, "methodology": "percent of total billed charges", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Blue Cross Blue Shield of Montana", "plan_name": "Retail HMO POS Network", "standard_charge_percentage": 75, "methodology": "percent of total billed charges", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Blue Cross Blue Shield of Montana", "plan_name": "Blue Options Network", "standard_charge_percentage": 75, "methodology": "percent of total billed charges", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "PacificSource Health Plans", "plan_name": "Medicare Advantage", "standard_charge_percentage": 103, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" } ] } ] }, { "description": "Feces culture aerobic bact", "code_information": [ { "code": "87045", "type": "HCPCS" } ], "standard_charges": [ { "setting": "outpatient", "payers_information": [ { "payer_name": "United Healthcare (UHC)", "plan_name": "DSNP", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "United Healthcare (UHC)", "plan_name": "Medicare Advantage", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" } ] } ] }, { "description": "Evaluation of speech fluency", "code_information": [ { "code": "92521", "type": "HCPCS" } ], "standard_charges": [ { "setting": "outpatient", "payers_information": [ { "payer_name": "National Comp Care", "plan_name": "Workers' Compensation", "standard_charge_dollar": 150, "methodology": "fee schedule", "median_amount": 150, "10th_percentile": 150, "90th_percentile": 150, "count": "1 through 10" } ], "minimum": 150, "maximum": 150 } ] }, { "description": "Evaluate speech production", "code_information": [ { "code": "92522", "type": "HCPCS" } ], "standard_charges": [ { "setting": "outpatient", "payers_information": [ { "payer_name": "National Comp Care", "plan_name": "Workers' Compensation", "standard_charge_dollar": 150, "methodology": "fee schedule", "median_amount": 150, "10th_percentile": 150, "90th_percentile": 150, "count": "1 through 10" }, { "payer_name": "Coventry Health Care", "plan_name": "Auto Network", "standard_charge_percentage": 90, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Coventry Health Care", "plan_name": "Workers' Compensation", "standard_charge_percentage": 95, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Blue Cross Blue Shield of Montana", "plan_name": "Medicare Advantage", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Allegiance Provider Direct", "plan_name": "Medicare", "standard_charge_percentage": 229.99999999999997, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "PacificSource Health Plans", "plan_name": "PPO (PSN Network and Smart Health Network)", "standard_charge_percentage": 80, "methodology": "percent of total billed charges", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "First Choice Health Network fka Health InfoNet", "plan_name": "Commercial", "standard_charge_percentage": 85, "methodology": "percent of total billed charges", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Medicare (CMS)", "plan_name": "Medicare", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Claritev fka MultiPlan", "plan_name": "Workers' Compensation Program", "standard_charge_percentage": 90, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Claritev fka MultiPlan", "plan_name": "Auto Medical Program", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Claritev fka MultiPlan", "plan_name": "PPO", "standard_charge_percentage": 75, "methodology": "percent of total billed charges", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "First Choice of the Midwest", "plan_name": "PPO", "standard_charge_percentage": 90, "methodology": "percent of total billed charges", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Employee Benefit Management Services (EBMS)", "plan_name": "EBMS SelectCare Network", "standard_charge_percentage": 80, "methodology": "percent of total billed charges", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Medica Insurance Company", "plan_name": "Medicare Cost", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "First Choice Health Network fka Health InfoNet", "plan_name": "Medicare Advantage", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "First Choice Health Network fka Health InfoNet", "plan_name": "Workers Compensation", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Allegiance Provider Direct", "plan_name": "Montana Association of Counties (MACo)", "standard_charge_percentage": 229.99999999999997, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Allegiance Provider Direct", "plan_name": "State of Montana Employee Benefit Plan (Self-Funded)", "standard_charge_percentage": 229.99999999999997, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Allegiance Provider Direct", "plan_name": "Montana Municipal Interlocal Authority (MMIA)", "standard_charge_percentage": 229.99999999999997, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Medicaid (State)", "plan_name": "Medicaid", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Blue Cross Blue Shield of Montana", "plan_name": "HealthLink Network", "standard_charge_percentage": 75, "methodology": "percent of total billed charges", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Blue Cross Blue Shield of Montana", "plan_name": "Traditional Network", "standard_charge_percentage": 75, "methodology": "percent of total billed charges", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Blue Cross Blue Shield of Montana", "plan_name": "POS Network", "standard_charge_percentage": 75, "methodology": "percent of total billed charges", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Blue Cross Blue Shield of Montana", "plan_name": "Closed Plan Network", "standard_charge_percentage": 75, "methodology": "percent of total billed charges", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Blue Cross Blue Shield of Montana", "plan_name": "Retail HMO POS Network", "standard_charge_percentage": 75, "methodology": "percent of total billed charges", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Blue Cross Blue Shield of Montana", "plan_name": "Blue Options Network", "standard_charge_percentage": 75, "methodology": "percent of total billed charges", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "PacificSource Health Plans", "plan_name": "Medicare Advantage", "standard_charge_percentage": 103, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" } ], "minimum": 150, "maximum": 150 } ] }, { "description": "Speech sound lang comprehen", "code_information": [ { "code": "92523", "type": "HCPCS" } ], "standard_charges": [ { "setting": "outpatient", "payers_information": [ { "payer_name": "National Comp Care", "plan_name": "Workers' Compensation", "standard_charge_dollar": 150, "methodology": "fee schedule", "median_amount": 150, "10th_percentile": 150, "90th_percentile": 150, "count": "1 through 10" }, { "payer_name": "Coventry Health Care", "plan_name": "Auto Network", "standard_charge_percentage": 90, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "United Healthcare (UHC)", "plan_name": "DSNP", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Blue Cross Blue Shield of Montana", "plan_name": "Medicare Advantage", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Coventry Health Care", "plan_name": "Workers' Compensation", "standard_charge_percentage": 95, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "United Healthcare (UHC)", "plan_name": "Medicare Advantage", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Allegiance Provider Direct", "plan_name": "Medicare", "standard_charge_percentage": 229.99999999999997, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "PacificSource Health Plans", "plan_name": "PPO (PSN Network and Smart Health Network)", "standard_charge_percentage": 80, "methodology": "percent of total billed charges", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Medicare (CMS)", "plan_name": "Medicare", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "First Choice Health Network fka Health InfoNet", "plan_name": "Commercial", "standard_charge_percentage": 85, "methodology": "percent of total billed charges", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Claritev fka MultiPlan", "plan_name": "Auto Medical Program", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Claritev fka MultiPlan", "plan_name": "Workers' Compensation Program", "standard_charge_percentage": 90, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Claritev fka MultiPlan", "plan_name": "PPO", "standard_charge_percentage": 75, "methodology": "percent of total billed charges", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "First Choice of the Midwest", "plan_name": "PPO", "standard_charge_percentage": 90, "methodology": "percent of total billed charges", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Employee Benefit Management Services (EBMS)", "plan_name": "EBMS SelectCare Network", "standard_charge_percentage": 80, "methodology": "percent of total billed charges", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Medica Insurance Company", "plan_name": "Medicare Cost", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "First Choice Health Network fka Health InfoNet", "plan_name": "Medicare Advantage", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "First Choice Health Network fka Health InfoNet", "plan_name": "Workers Compensation", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Allegiance Provider Direct", "plan_name": "Montana Association of Counties (MACo)", "standard_charge_percentage": 229.99999999999997, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Allegiance Provider Direct", "plan_name": "State of Montana Employee Benefit Plan (Self-Funded)", "standard_charge_percentage": 229.99999999999997, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Allegiance Provider Direct", "plan_name": "Montana Municipal Interlocal Authority (MMIA)", "standard_charge_percentage": 229.99999999999997, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Blue Cross Blue Shield of Montana", "plan_name": "HealthLink Network", "standard_charge_percentage": 75, "methodology": "percent of total billed charges", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Blue Cross Blue Shield of Montana", "plan_name": "Traditional Network", "standard_charge_percentage": 75, "methodology": "percent of total billed charges", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Blue Cross Blue Shield of Montana", "plan_name": "POS Network", "standard_charge_percentage": 75, "methodology": "percent of total billed charges", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Blue Cross Blue Shield of Montana", "plan_name": "Closed Plan Network", "standard_charge_percentage": 75, "methodology": "percent of total billed charges", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Blue Cross Blue Shield of Montana", "plan_name": "Retail HMO POS Network", "standard_charge_percentage": 75, "methodology": "percent of total billed charges", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Blue Cross Blue Shield of Montana", "plan_name": "Blue Options Network", "standard_charge_percentage": 75, "methodology": "percent of total billed charges", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Medicaid (State)", "plan_name": "Medicaid", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "PacificSource Health Plans", "plan_name": "Medicare Advantage", "standard_charge_percentage": 103, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" } ], "minimum": 150, "maximum": 150 } ] }, { "description": "Behavral qualit analys voice", "code_information": [ { "code": "92524", "type": "HCPCS" } ], "standard_charges": [ { "setting": "outpatient", "payers_information": [ { "payer_name": "National Comp Care", "plan_name": "Workers' Compensation", "standard_charge_dollar": 150, "methodology": "fee schedule", "median_amount": 150, "10th_percentile": 150, "90th_percentile": 150, "count": "1 through 10" }, { "payer_name": "Coventry Health Care", "plan_name": "Auto Network", "standard_charge_percentage": 90, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Coventry Health Care", "plan_name": "Workers' Compensation", "standard_charge_percentage": 95, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Blue Cross Blue Shield of Montana", "plan_name": "Medicare Advantage", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Allegiance Provider Direct", "plan_name": "Medicare", "standard_charge_percentage": 229.99999999999997, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "PacificSource Health Plans", "plan_name": "PPO (PSN Network and Smart Health Network)", "standard_charge_percentage": 80, "methodology": "percent of total billed charges", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Medicare (CMS)", "plan_name": "Medicare", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "First Choice Health Network fka Health InfoNet", "plan_name": "Commercial", "standard_charge_percentage": 85, "methodology": "percent of total billed charges", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Claritev fka MultiPlan", "plan_name": "Auto Medical Program", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Claritev fka MultiPlan", "plan_name": "Workers' Compensation Program", "standard_charge_percentage": 90, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Claritev fka MultiPlan", "plan_name": "PPO", "standard_charge_percentage": 75, "methodology": "percent of total billed charges", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "First Choice of the Midwest", "plan_name": "PPO", "standard_charge_percentage": 90, "methodology": "percent of total billed charges", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Employee Benefit Management Services (EBMS)", "plan_name": "EBMS SelectCare Network", "standard_charge_percentage": 80, "methodology": "percent of total billed charges", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Medica Insurance Company", "plan_name": "Medicare Cost", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "First Choice Health Network fka Health InfoNet", "plan_name": "Medicare Advantage", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "First Choice Health Network fka Health InfoNet", "plan_name": "Workers Compensation", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Allegiance Provider Direct", "plan_name": "Montana Association of Counties (MACo)", "standard_charge_percentage": 229.99999999999997, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Allegiance Provider Direct", "plan_name": "State of Montana Employee Benefit Plan (Self-Funded)", "standard_charge_percentage": 229.99999999999997, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Allegiance Provider Direct", "plan_name": "Montana Municipal Interlocal Authority (MMIA)", "standard_charge_percentage": 229.99999999999997, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Medicaid (State)", "plan_name": "Medicaid", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Blue Cross Blue Shield of Montana", "plan_name": "HealthLink Network", "standard_charge_percentage": 75, "methodology": "percent of total billed charges", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Blue Cross Blue Shield of Montana", "plan_name": "Traditional Network", "standard_charge_percentage": 75, "methodology": "percent of total billed charges", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Blue Cross Blue Shield of Montana", "plan_name": "POS Network", "standard_charge_percentage": 75, "methodology": "percent of total billed charges", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Blue Cross Blue Shield of Montana", "plan_name": "Closed Plan Network", "standard_charge_percentage": 75, "methodology": "percent of total billed charges", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Blue Cross Blue Shield of Montana", "plan_name": "Retail HMO POS Network", "standard_charge_percentage": 75, "methodology": "percent of total billed charges", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Blue Cross Blue Shield of Montana", "plan_name": "Blue Options Network", "standard_charge_percentage": 75, "methodology": "percent of total billed charges", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "PacificSource Health Plans", "plan_name": "Medicare Advantage", "standard_charge_percentage": 103, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" } ], "minimum": 150, "maximum": 150 } ] }, { "description": "Assessment of aphasia", "code_information": [ { "code": "96105", "type": "HCPCS" } ], "standard_charges": [ { "setting": "outpatient", "payers_information": [ { "payer_name": "National Comp Care", "plan_name": "Workers' Compensation", "standard_charge_dollar": 150, "methodology": "fee schedule", "median_amount": 150, "10th_percentile": 150, "90th_percentile": 150, "count": "1 through 10" }, { "payer_name": "Coventry Health Care", "plan_name": "Auto Network", "standard_charge_percentage": 90, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Coventry Health Care", "plan_name": "Workers' Compensation", "standard_charge_percentage": 95, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Blue Cross Blue Shield of Montana", "plan_name": "Medicare Advantage", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Allegiance Provider Direct", "plan_name": "Medicare", "standard_charge_percentage": 229.99999999999997, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "PacificSource Health Plans", "plan_name": "PPO (PSN Network and Smart Health Network)", "standard_charge_percentage": 80, "methodology": "percent of total billed charges", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Medicare (CMS)", "plan_name": "Medicare", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "First Choice Health Network fka Health InfoNet", "plan_name": "Commercial", "standard_charge_percentage": 85, "methodology": "percent of total billed charges", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Claritev fka MultiPlan", "plan_name": "Auto Medical Program", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Claritev fka MultiPlan", "plan_name": "Workers' Compensation Program", "standard_charge_percentage": 90, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Claritev fka MultiPlan", "plan_name": "PPO", "standard_charge_percentage": 75, "methodology": "percent of total billed charges", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "First Choice of the Midwest", "plan_name": "PPO", "standard_charge_percentage": 90, "methodology": "percent of total billed charges", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Employee Benefit Management Services (EBMS)", "plan_name": "EBMS SelectCare Network", "standard_charge_percentage": 80, "methodology": "percent of total billed charges", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Medica Insurance Company", "plan_name": "Medicare Cost", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "First Choice Health Network fka Health InfoNet", "plan_name": "Medicare Advantage", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "First Choice Health Network fka Health InfoNet", "plan_name": "Workers Compensation", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Allegiance Provider Direct", "plan_name": "Montana Association of Counties (MACo)", "standard_charge_percentage": 229.99999999999997, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Allegiance Provider Direct", "plan_name": "State of Montana Employee Benefit Plan (Self-Funded)", "standard_charge_percentage": 229.99999999999997, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Allegiance Provider Direct", "plan_name": "Montana Municipal Interlocal Authority (MMIA)", "standard_charge_percentage": 229.99999999999997, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Medicaid (State)", "plan_name": "Medicaid", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Blue Cross Blue Shield of Montana", "plan_name": "HealthLink Network", "standard_charge_percentage": 75, "methodology": "percent of total billed charges", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Blue Cross Blue Shield of Montana", "plan_name": "Traditional Network", "standard_charge_percentage": 75, "methodology": "percent of total billed charges", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Blue Cross Blue Shield of Montana", "plan_name": "POS Network", "standard_charge_percentage": 75, "methodology": "percent of total billed charges", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Blue Cross Blue Shield of Montana", "plan_name": "Closed Plan Network", "standard_charge_percentage": 75, "methodology": "percent of total billed charges", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Blue Cross Blue Shield of Montana", "plan_name": "Retail HMO POS Network", "standard_charge_percentage": 75, "methodology": "percent of total billed charges", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Blue Cross Blue Shield of Montana", "plan_name": "Blue Options Network", "standard_charge_percentage": 75, "methodology": "percent of total billed charges", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "PacificSource Health Plans", "plan_name": "Medicare Advantage", "standard_charge_percentage": 103, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" } ], "minimum": 150, "maximum": 150 } ] }, { "description": "Stool cultr aerobic bact ea", "code_information": [ { "code": "87046", "type": "HCPCS" } ], "standard_charges": [ { "setting": "outpatient", "payers_information": [ { "payer_name": "United Healthcare (UHC)", "plan_name": "DSNP", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "United Healthcare (UHC)", "plan_name": "Medicare Advantage", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" } ] } ] }, { "description": "Culture othr specimn aerobic", "code_information": [ { "code": "87070", "type": "HCPCS" } ], "standard_charges": [ { "setting": "outpatient", "payers_information": [ { "payer_name": "United Healthcare (UHC)", "plan_name": "DSNP", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "National Comp Care", "plan_name": "Workers' Compensation", "standard_charge_percentage": 90, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Coventry Health Care", "plan_name": "Auto Network", "standard_charge_percentage": 90, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Coventry Health Care", "plan_name": "Workers' Compensation", "standard_charge_percentage": 95, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Blue Cross Blue Shield of Montana", "plan_name": "Medicare Advantage", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "United Healthcare (UHC)", "plan_name": "Medicare Advantage", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Allegiance Provider Direct", "plan_name": "Medicare", "standard_charge_percentage": 229.99999999999997, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "PacificSource Health Plans", "plan_name": "PPO (PSN Network and Smart Health Network)", "standard_charge_percentage": 80, "methodology": "percent of total billed charges", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "First Choice Health Network fka Health InfoNet", "plan_name": "Commercial", "standard_charge_percentage": 85, "methodology": "percent of total billed charges", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Medicare (CMS)", "plan_name": "Medicare", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Claritev fka MultiPlan", "plan_name": "Auto Medical Program", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Claritev fka MultiPlan", "plan_name": "Workers' Compensation Program", "standard_charge_percentage": 90, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Claritev fka MultiPlan", "plan_name": "PPO", "standard_charge_percentage": 75, "methodology": "percent of total billed charges", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "First Choice of the Midwest", "plan_name": "PPO", "standard_charge_percentage": 90, "methodology": "percent of total billed charges", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Employee Benefit Management Services (EBMS)", "plan_name": "EBMS SelectCare Network", "standard_charge_percentage": 80, "methodology": "percent of total billed charges", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Medica Insurance Company", "plan_name": "Medicare Cost", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "First Choice Health Network fka Health InfoNet", "plan_name": "Medicare Advantage", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "First Choice Health Network fka Health InfoNet", "plan_name": "Workers Compensation", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Allegiance Provider Direct", "plan_name": "Montana Association of Counties (MACo)", "standard_charge_percentage": 229.99999999999997, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Allegiance Provider Direct", "plan_name": "State of Montana Employee Benefit Plan (Self-Funded)", "standard_charge_percentage": 229.99999999999997, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Allegiance Provider Direct", "plan_name": "Montana Municipal Interlocal Authority (MMIA)", "standard_charge_percentage": 229.99999999999997, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Medicaid (State)", "plan_name": "Medicaid", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Blue Cross Blue Shield of Montana", "plan_name": "HealthLink Network", "standard_charge_percentage": 75, "methodology": "percent of total billed charges", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Blue Cross Blue Shield of Montana", "plan_name": "Traditional Network", "standard_charge_percentage": 75, "methodology": "percent of total billed charges", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Blue Cross Blue Shield of Montana", "plan_name": "POS Network", "standard_charge_percentage": 75, "methodology": "percent of total billed charges", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Blue Cross Blue Shield of Montana", "plan_name": "Closed Plan Network", "standard_charge_percentage": 75, "methodology": "percent of total billed charges", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Blue Cross Blue Shield of Montana", "plan_name": "Retail HMO POS Network", "standard_charge_percentage": 75, "methodology": "percent of total billed charges", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Blue Cross Blue Shield of Montana", "plan_name": "Blue Options Network", "standard_charge_percentage": 75, "methodology": "percent of total billed charges", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "PacificSource Health Plans", "plan_name": "Medicare Advantage", "standard_charge_percentage": 103, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" } ] } ] }, { "description": "Cultr bacteria except blood", "code_information": [ { "code": "87075", "type": "HCPCS" } ], "standard_charges": [ { "setting": "outpatient", "payers_information": [ { "payer_name": "United Healthcare (UHC)", "plan_name": "DSNP", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "United Healthcare (UHC)", "plan_name": "Medicare Advantage", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" } ] } ] }, { "description": "Ther ivntj ea addl 15 min", "code_information": [ { "code": "97130", "type": "HCPCS" } ], "standard_charges": [ { "setting": "outpatient", "payers_information": [ { "payer_name": "National Comp Care", "plan_name": "Workers' Compensation", "standard_charge_percentage": 90, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Coventry Health Care", "plan_name": "Auto Network", "standard_charge_percentage": 90, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Blue Cross Blue Shield of Montana", "plan_name": "Medicare Advantage", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Coventry Health Care", "plan_name": "Workers' Compensation", "standard_charge_percentage": 95, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Allegiance Provider Direct", "plan_name": "Medicare", "standard_charge_percentage": 229.99999999999997, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "PacificSource Health Plans", "plan_name": "PPO (PSN Network and Smart Health Network)", "standard_charge_percentage": 80, "methodology": "percent of total billed charges", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Medicare (CMS)", "plan_name": "Medicare", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "First Choice Health Network fka Health InfoNet", "plan_name": "Commercial", "standard_charge_percentage": 85, "methodology": "percent of total billed charges", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Claritev fka MultiPlan", "plan_name": "Auto Medical Program", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Claritev fka MultiPlan", "plan_name": "Workers' Compensation Program", "standard_charge_percentage": 90, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Claritev fka MultiPlan", "plan_name": "PPO", "standard_charge_percentage": 75, "methodology": "percent of total billed charges", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "First Choice of the Midwest", "plan_name": "PPO", "standard_charge_percentage": 90, "methodology": "percent of total billed charges", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Employee Benefit Management Services (EBMS)", "plan_name": "EBMS SelectCare Network", "standard_charge_percentage": 80, "methodology": "percent of total billed charges", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Medica Insurance Company", "plan_name": "Medicare Cost", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "First Choice Health Network fka Health InfoNet", "plan_name": "Medicare Advantage", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "First Choice Health Network fka Health InfoNet", "plan_name": "Workers Compensation", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Allegiance Provider Direct", "plan_name": "Montana Association of Counties (MACo)", "standard_charge_percentage": 229.99999999999997, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Allegiance Provider Direct", "plan_name": "State of Montana Employee Benefit Plan (Self-Funded)", "standard_charge_percentage": 229.99999999999997, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Allegiance Provider Direct", "plan_name": "Montana Municipal Interlocal Authority (MMIA)", "standard_charge_percentage": 229.99999999999997, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Blue Cross Blue Shield of Montana", "plan_name": "HealthLink Network", "standard_charge_percentage": 75, "methodology": "percent of total billed charges", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Blue Cross Blue Shield of Montana", "plan_name": "Traditional Network", "standard_charge_percentage": 75, "methodology": "percent of total billed charges", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Blue Cross Blue Shield of Montana", "plan_name": "POS Network", "standard_charge_percentage": 75, "methodology": "percent of total billed charges", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Blue Cross Blue Shield of Montana", "plan_name": "Closed Plan Network", "standard_charge_percentage": 75, "methodology": "percent of total billed charges", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Blue Cross Blue Shield of Montana", "plan_name": "Retail HMO POS Network", "standard_charge_percentage": 75, "methodology": "percent of total billed charges", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Blue Cross Blue Shield of Montana", "plan_name": "Blue Options Network", "standard_charge_percentage": 75, "methodology": "percent of total billed charges", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Medicaid (State)", "plan_name": "Medicaid", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "PacificSource Health Plans", "plan_name": "Medicare Advantage", "standard_charge_percentage": 103, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" } ] } ] }, { "description": "Hemodialysis one evaluation", "code_information": [ { "code": "90935", "type": "HCPCS" } ], "standard_charges": [ { "setting": "outpatient", "payers_information": [ { "payer_name": "National Comp Care", "plan_name": "Workers' Compensation", "standard_charge_percentage": 90, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Coventry Health Care", "plan_name": "Auto Network", "standard_charge_percentage": 90, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "United Healthcare (UHC)", "plan_name": "DSNP", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Blue Cross Blue Shield of Montana", "plan_name": "Medicare Advantage", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Coventry Health Care", "plan_name": "Workers' Compensation", "standard_charge_percentage": 95, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "United Healthcare (UHC)", "plan_name": "Medicare Advantage", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Allegiance Provider Direct", "plan_name": "Medicare", "standard_charge_percentage": 229.99999999999997, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "PacificSource Health Plans", "plan_name": "PPO (PSN Network and Smart Health Network)", "standard_charge_percentage": 80, "methodology": "percent of total billed charges", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Medicare (CMS)", "plan_name": "Medicare", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "First Choice Health Network fka Health InfoNet", "plan_name": "Commercial", "standard_charge_percentage": 85, "methodology": "percent of total billed charges", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Claritev fka MultiPlan", "plan_name": "Auto Medical Program", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Claritev fka MultiPlan", "plan_name": "Workers' Compensation Program", "standard_charge_percentage": 90, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Claritev fka MultiPlan", "plan_name": "PPO", "standard_charge_percentage": 75, "methodology": "percent of total billed charges", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "First Choice of the Midwest", "plan_name": "PPO", "standard_charge_percentage": 90, "methodology": "percent of total billed charges", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Employee Benefit Management Services (EBMS)", "plan_name": "EBMS SelectCare Network", "standard_charge_percentage": 80, "methodology": "percent of total billed charges", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Medica Insurance Company", "plan_name": "Medicare Cost", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "First Choice Health Network fka Health InfoNet", "plan_name": "Medicare Advantage", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "First Choice Health Network fka Health InfoNet", "plan_name": "Workers Compensation", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Allegiance Provider Direct", "plan_name": "Montana Association of Counties (MACo)", "standard_charge_percentage": 229.99999999999997, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Allegiance Provider Direct", "plan_name": "State of Montana Employee Benefit Plan (Self-Funded)", "standard_charge_percentage": 229.99999999999997, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Allegiance Provider Direct", "plan_name": "Montana Municipal Interlocal Authority (MMIA)", "standard_charge_percentage": 229.99999999999997, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Blue Cross Blue Shield of Montana", "plan_name": "HealthLink Network", "standard_charge_percentage": 75, "methodology": "percent of total billed charges", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Blue Cross Blue Shield of Montana", "plan_name": "Traditional Network", "standard_charge_percentage": 75, "methodology": "percent of total billed charges", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Blue Cross Blue Shield of Montana", "plan_name": "POS Network", "standard_charge_percentage": 75, "methodology": "percent of total billed charges", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Blue Cross Blue Shield of Montana", "plan_name": "Closed Plan Network", "standard_charge_percentage": 75, "methodology": "percent of total billed charges", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Blue Cross Blue Shield of Montana", "plan_name": "Retail HMO POS Network", "standard_charge_percentage": 75, "methodology": "percent of total billed charges", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Blue Cross Blue Shield of Montana", "plan_name": "Blue Options Network", "standard_charge_percentage": 75, "methodology": "percent of total billed charges", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Medicaid (State)", "plan_name": "Medicaid", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "PacificSource Health Plans", "plan_name": "Medicare Advantage", "standard_charge_percentage": 103, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" } ] } ] }, { "description": "Unlisted special svc px/rprt", "code_information": [ { "code": "99199", "type": "HCPCS" } ], "standard_charges": [ { "setting": "outpatient", "payers_information": [ { "payer_name": "National Comp Care", "plan_name": "Workers' Compensation", "standard_charge_percentage": 90, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Coventry Health Care", "plan_name": "Auto Network", "standard_charge_percentage": 90, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "United Healthcare (UHC)", "plan_name": "DSNP", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Blue Cross Blue Shield of Montana", "plan_name": "Medicare Advantage", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Coventry Health Care", "plan_name": "Workers' Compensation", "standard_charge_percentage": 95, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "United Healthcare (UHC)", "plan_name": "Medicare Advantage", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Allegiance Provider Direct", "plan_name": "Medicare", "standard_charge_percentage": 229.99999999999997, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "PacificSource Health Plans", "plan_name": "PPO (PSN Network and Smart Health Network)", "standard_charge_percentage": 80, "methodology": "percent of total billed charges", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Medicare (CMS)", "plan_name": "Medicare", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "First Choice Health Network fka Health InfoNet", "plan_name": "Commercial", "standard_charge_percentage": 85, "methodology": "percent of total billed charges", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Claritev fka MultiPlan", "plan_name": "Auto Medical Program", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Claritev fka MultiPlan", "plan_name": "Workers' Compensation Program", "standard_charge_percentage": 90, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Claritev fka MultiPlan", "plan_name": "PPO", "standard_charge_percentage": 75, "methodology": "percent of total billed charges", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "First Choice of the Midwest", "plan_name": "PPO", "standard_charge_percentage": 90, "methodology": "percent of total billed charges", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Employee Benefit Management Services (EBMS)", "plan_name": "EBMS SelectCare Network", "standard_charge_percentage": 80, "methodology": "percent of total billed charges", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Medica Insurance Company", "plan_name": "Medicare Cost", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "First Choice Health Network fka Health InfoNet", "plan_name": "Medicare Advantage", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "First Choice Health Network fka Health InfoNet", "plan_name": "Workers Compensation", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Allegiance Provider Direct", "plan_name": "Montana Association of Counties (MACo)", "standard_charge_percentage": 229.99999999999997, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Allegiance Provider Direct", "plan_name": "State of Montana Employee Benefit Plan (Self-Funded)", "standard_charge_percentage": 229.99999999999997, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Allegiance Provider Direct", "plan_name": "Montana Municipal Interlocal Authority (MMIA)", "standard_charge_percentage": 229.99999999999997, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Blue Cross Blue Shield of Montana", "plan_name": "HealthLink Network", "standard_charge_percentage": 75, "methodology": "percent of total billed charges", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Blue Cross Blue Shield of Montana", "plan_name": "Traditional Network", "standard_charge_percentage": 75, "methodology": "percent of total billed charges", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Blue Cross Blue Shield of Montana", "plan_name": "POS Network", "standard_charge_percentage": 75, "methodology": "percent of total billed charges", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Blue Cross Blue Shield of Montana", "plan_name": "Closed Plan Network", "standard_charge_percentage": 75, "methodology": "percent of total billed charges", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Blue Cross Blue Shield of Montana", "plan_name": "Retail HMO POS Network", "standard_charge_percentage": 75, "methodology": "percent of total billed charges", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Blue Cross Blue Shield of Montana", "plan_name": "Blue Options Network", "standard_charge_percentage": 75, "methodology": "percent of total billed charges", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Medicaid (State)", "plan_name": "Medicaid", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "PacificSource Health Plans", "plan_name": "Medicare Advantage", "standard_charge_percentage": 103, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" } ] } ] }, { "description": "Evaluate swallowing function", "code_information": [ { "code": "92610", "type": "HCPCS" } ], "standard_charges": [ { "setting": "outpatient", "payers_information": [ { "payer_name": "National Comp Care", "plan_name": "Workers' Compensation", "standard_charge_percentage": 90, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Coventry Health Care", "plan_name": "Auto Network", "standard_charge_percentage": 90, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "United Healthcare (UHC)", "plan_name": "DSNP", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Blue Cross Blue Shield of Montana", "plan_name": "Medicare Advantage", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Coventry Health Care", "plan_name": "Workers' Compensation", "standard_charge_percentage": 95, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "United Healthcare (UHC)", "plan_name": "Medicare Advantage", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Allegiance Provider Direct", "plan_name": "Medicare", "standard_charge_percentage": 229.99999999999997, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "PacificSource Health Plans", "plan_name": "PPO (PSN Network and Smart Health Network)", "standard_charge_percentage": 80, "methodology": "percent of total billed charges", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Medicare (CMS)", "plan_name": "Medicare", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "First Choice Health Network fka Health InfoNet", "plan_name": "Commercial", "standard_charge_percentage": 85, "methodology": "percent of total billed charges", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Claritev fka MultiPlan", "plan_name": "Auto Medical Program", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Claritev fka MultiPlan", "plan_name": "Workers' Compensation Program", "standard_charge_percentage": 90, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Claritev fka MultiPlan", "plan_name": "PPO", "standard_charge_percentage": 75, "methodology": "percent of total billed charges", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "First Choice of the Midwest", "plan_name": "PPO", "standard_charge_percentage": 90, "methodology": "percent of total billed charges", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Employee Benefit Management Services (EBMS)", "plan_name": "EBMS SelectCare Network", "standard_charge_percentage": 80, "methodology": "percent of total billed charges", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Medica Insurance Company", "plan_name": "Medicare Cost", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "First Choice Health Network fka Health InfoNet", "plan_name": "Medicare Advantage", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "First Choice Health Network fka Health InfoNet", "plan_name": "Workers Compensation", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Allegiance Provider Direct", "plan_name": "Montana Association of Counties (MACo)", "standard_charge_percentage": 229.99999999999997, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Allegiance Provider Direct", "plan_name": "State of Montana Employee Benefit Plan (Self-Funded)", "standard_charge_percentage": 229.99999999999997, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Allegiance Provider Direct", "plan_name": "Montana Municipal Interlocal Authority (MMIA)", "standard_charge_percentage": 229.99999999999997, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Blue Cross Blue Shield of Montana", "plan_name": "HealthLink Network", "standard_charge_percentage": 75, "methodology": "percent of total billed charges", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Blue Cross Blue Shield of Montana", "plan_name": "Traditional Network", "standard_charge_percentage": 75, "methodology": "percent of total billed charges", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Blue Cross Blue Shield of Montana", "plan_name": "POS Network", "standard_charge_percentage": 75, "methodology": "percent of total billed charges", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Blue Cross Blue Shield of Montana", "plan_name": "Closed Plan Network", "standard_charge_percentage": 75, "methodology": "percent of total billed charges", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Blue Cross Blue Shield of Montana", "plan_name": "Retail HMO POS Network", "standard_charge_percentage": 75, "methodology": "percent of total billed charges", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Blue Cross Blue Shield of Montana", "plan_name": "Blue Options Network", "standard_charge_percentage": 75, "methodology": "percent of total billed charges", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Medicaid (State)", "plan_name": "Medicaid", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "PacificSource Health Plans", "plan_name": "Medicare Advantage", "standard_charge_percentage": 103, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" } ] } ] }, { "description": "Cognitive test by hc pro", "code_information": [ { "code": "96125", "type": "HCPCS" } ], "standard_charges": [ { "setting": "outpatient", "payers_information": [ { "payer_name": "National Comp Care", "plan_name": "Workers' Compensation", "standard_charge_percentage": 90, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Coventry Health Care", "plan_name": "Auto Network", "standard_charge_percentage": 90, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Blue Cross Blue Shield of Montana", "plan_name": "Medicare Advantage", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Coventry Health Care", "plan_name": "Workers' Compensation", "standard_charge_percentage": 95, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Allegiance Provider Direct", "plan_name": "Medicare", "standard_charge_percentage": 229.99999999999997, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "PacificSource Health Plans", "plan_name": "PPO (PSN Network and Smart Health Network)", "standard_charge_percentage": 80, "methodology": "percent of total billed charges", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Medicare (CMS)", "plan_name": "Medicare", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "First Choice Health Network fka Health InfoNet", "plan_name": "Commercial", "standard_charge_percentage": 85, "methodology": "percent of total billed charges", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Claritev fka MultiPlan", "plan_name": "Auto Medical Program", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Claritev fka MultiPlan", "plan_name": "Workers' Compensation Program", "standard_charge_percentage": 90, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Claritev fka MultiPlan", "plan_name": "PPO", "standard_charge_percentage": 75, "methodology": "percent of total billed charges", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "First Choice of the Midwest", "plan_name": "PPO", "standard_charge_percentage": 90, "methodology": "percent of total billed charges", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Employee Benefit Management Services (EBMS)", "plan_name": "EBMS SelectCare Network", "standard_charge_percentage": 80, "methodology": "percent of total billed charges", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Medica Insurance Company", "plan_name": "Medicare Cost", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "First Choice Health Network fka Health InfoNet", "plan_name": "Medicare Advantage", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "First Choice Health Network fka Health InfoNet", "plan_name": "Workers Compensation", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Allegiance Provider Direct", "plan_name": "Montana Association of Counties (MACo)", "standard_charge_percentage": 229.99999999999997, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Allegiance Provider Direct", "plan_name": "State of Montana Employee Benefit Plan (Self-Funded)", "standard_charge_percentage": 229.99999999999997, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Allegiance Provider Direct", "plan_name": "Montana Municipal Interlocal Authority (MMIA)", "standard_charge_percentage": 229.99999999999997, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Blue Cross Blue Shield of Montana", "plan_name": "HealthLink Network", "standard_charge_percentage": 75, "methodology": "percent of total billed charges", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Blue Cross Blue Shield of Montana", "plan_name": "Traditional Network", "standard_charge_percentage": 75, "methodology": "percent of total billed charges", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Blue Cross Blue Shield of Montana", "plan_name": "POS Network", "standard_charge_percentage": 75, "methodology": "percent of total billed charges", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Blue Cross Blue Shield of Montana", "plan_name": "Closed Plan Network", "standard_charge_percentage": 75, "methodology": "percent of total billed charges", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Blue Cross Blue Shield of Montana", "plan_name": "Retail HMO POS Network", "standard_charge_percentage": 75, "methodology": "percent of total billed charges", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Blue Cross Blue Shield of Montana", "plan_name": "Blue Options Network", "standard_charge_percentage": 75, "methodology": "percent of total billed charges", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Medicaid (State)", "plan_name": "Medicaid", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "PacificSource Health Plans", "plan_name": "Medicare Advantage", "standard_charge_percentage": 103, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" } ] } ] }, { "description": "Debride nail 6 or more", "code_information": [ { "code": "11721", "type": "HCPCS" } ], "standard_charges": [ { "setting": "outpatient", "payers_information": [ { "payer_name": "National Comp Care", "plan_name": "Workers' Compensation", "standard_charge_percentage": 90, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Coventry Health Care", "plan_name": "Auto Network", "standard_charge_percentage": 90, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Coventry Health Care", "plan_name": "Workers' Compensation", "standard_charge_percentage": 95, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "TriWest Healthcare Alliance Corporation", "plan_name": "VA CCN", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Blue Cross Blue Shield of Montana", "plan_name": "Medicare Advantage", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Allegiance Provider Direct", "plan_name": "Medicare", "standard_charge_percentage": 229.99999999999997, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "PacificSource Health Plans", "plan_name": "PPO (PSN Network and Smart Health Network)", "standard_charge_percentage": 80, "methodology": "percent of total billed charges", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Medicare (CMS)", "plan_name": "Medicare", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "First Choice Health Network fka Health InfoNet", "plan_name": "Commercial", "standard_charge_percentage": 85, "methodology": "percent of total billed charges", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Claritev fka MultiPlan", "plan_name": "Auto Medical Program", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Claritev fka MultiPlan", "plan_name": "Workers' Compensation Program", "standard_charge_percentage": 90, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Claritev fka MultiPlan", "plan_name": "PPO", "standard_charge_percentage": 75, "methodology": "percent of total billed charges", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "First Choice of the Midwest", "plan_name": "PPO", "standard_charge_percentage": 90, "methodology": "percent of total billed charges", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Employee Benefit Management Services (EBMS)", "plan_name": "EBMS SelectCare Network", "standard_charge_percentage": 80, "methodology": "percent of total billed charges", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Medica Insurance Company", "plan_name": "Medicare Cost", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "First Choice Health Network fka Health InfoNet", "plan_name": "Medicare Advantage", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "First Choice Health Network fka Health InfoNet", "plan_name": "Workers Compensation", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Allegiance Provider Direct", "plan_name": "Montana Association of Counties (MACo)", "standard_charge_percentage": 229.99999999999997, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Allegiance Provider Direct", "plan_name": "State of Montana Employee Benefit Plan (Self-Funded)", "standard_charge_percentage": 229.99999999999997, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Allegiance Provider Direct", "plan_name": "Montana Municipal Interlocal Authority (MMIA)", "standard_charge_percentage": 229.99999999999997, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Medicaid (State)", "plan_name": "Medicaid", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Blue Cross Blue Shield of Montana", "plan_name": "HealthLink Network", "standard_charge_percentage": 75, "methodology": "percent of total billed charges", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Blue Cross Blue Shield of Montana", "plan_name": "Traditional Network", "standard_charge_percentage": 75, "methodology": "percent of total billed charges", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Blue Cross Blue Shield of Montana", "plan_name": "POS Network", "standard_charge_percentage": 75, "methodology": "percent of total billed charges", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Blue Cross Blue Shield of Montana", "plan_name": "Closed Plan Network", "standard_charge_percentage": 75, "methodology": "percent of total billed charges", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Blue Cross Blue Shield of Montana", "plan_name": "Retail HMO POS Network", "standard_charge_percentage": 75, "methodology": "percent of total billed charges", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Blue Cross Blue Shield of Montana", "plan_name": "Blue Options Network", "standard_charge_percentage": 75, "methodology": "percent of total billed charges", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "PacificSource Health Plans", "plan_name": "Medicare Advantage", "standard_charge_percentage": 103, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" } ] } ] }, { "description": "App mdlty 1+ultrasound ea 15", "code_information": [ { "code": "97035", "type": "HCPCS" } ], "standard_charges": [ { "setting": "outpatient", "payers_information": [ { "payer_name": "National Comp Care", "plan_name": "Workers' Compensation", "standard_charge_percentage": 90, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Coventry Health Care", "plan_name": "Auto Network", "standard_charge_percentage": 90, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Coventry Health Care", "plan_name": "Workers' Compensation", "standard_charge_percentage": 95, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Blue Cross Blue Shield of Montana", "plan_name": "Medicare Advantage", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Allegiance Provider Direct", "plan_name": "Medicare", "standard_charge_percentage": 229.99999999999997, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "PacificSource Health Plans", "plan_name": "PPO (PSN Network and Smart Health Network)", "standard_charge_percentage": 80, "methodology": "percent of total billed charges", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Medicare (CMS)", "plan_name": "Medicare", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "First Choice Health Network fka Health InfoNet", "plan_name": "Commercial", "standard_charge_percentage": 85, "methodology": "percent of total billed charges", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Claritev fka MultiPlan", "plan_name": "Auto Medical Program", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Claritev fka MultiPlan", "plan_name": "Workers' Compensation Program", "standard_charge_percentage": 90, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Claritev fka MultiPlan", "plan_name": "PPO", "standard_charge_percentage": 75, "methodology": "percent of total billed charges", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "First Choice of the Midwest", "plan_name": "PPO", "standard_charge_percentage": 90, "methodology": "percent of total billed charges", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Employee Benefit Management Services (EBMS)", "plan_name": "EBMS SelectCare Network", "standard_charge_percentage": 80, "methodology": "percent of total billed charges", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Medica Insurance Company", "plan_name": "Medicare Cost", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "First Choice Health Network fka Health InfoNet", "plan_name": "Medicare Advantage", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "First Choice Health Network fka Health InfoNet", "plan_name": "Workers Compensation", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Allegiance Provider Direct", "plan_name": "Montana Association of Counties (MACo)", "standard_charge_percentage": 229.99999999999997, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Allegiance Provider Direct", "plan_name": "State of Montana Employee Benefit Plan (Self-Funded)", "standard_charge_percentage": 229.99999999999997, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Allegiance Provider Direct", "plan_name": "Montana Municipal Interlocal Authority (MMIA)", "standard_charge_percentage": 229.99999999999997, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Medicaid (State)", "plan_name": "Medicaid", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Blue Cross Blue Shield of Montana", "plan_name": "HealthLink Network", "standard_charge_percentage": 75, "methodology": "percent of total billed charges", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Blue Cross Blue Shield of Montana", "plan_name": "Traditional Network", "standard_charge_percentage": 75, "methodology": "percent of total billed charges", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Blue Cross Blue Shield of Montana", "plan_name": "POS Network", "standard_charge_percentage": 75, "methodology": "percent of total billed charges", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Blue Cross Blue Shield of Montana", "plan_name": "Closed Plan Network", "standard_charge_percentage": 75, "methodology": "percent of total billed charges", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Blue Cross Blue Shield of Montana", "plan_name": "Retail HMO POS Network", "standard_charge_percentage": 75, "methodology": "percent of total billed charges", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Blue Cross Blue Shield of Montana", "plan_name": "Blue Options Network", "standard_charge_percentage": 75, "methodology": "percent of total billed charges", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "PacificSource Health Plans", "plan_name": "Medicare Advantage", "standard_charge_percentage": 103, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" } ] } ] }, { "description": "Glucose blood test", "code_information": [ { "code": "82962", "type": "HCPCS" } ], "standard_charges": [ { "setting": "outpatient", "payers_information": [ { "payer_name": "National Comp Care", "plan_name": "Workers' Compensation", "standard_charge_percentage": 90, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Coventry Health Care", "plan_name": "Auto Network", "standard_charge_percentage": 90, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Coventry Health Care", "plan_name": "Workers' Compensation", "standard_charge_percentage": 95, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Blue Cross Blue Shield of Montana", "plan_name": "Medicare Advantage", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Allegiance Provider Direct", "plan_name": "Medicare", "standard_charge_percentage": 229.99999999999997, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "PacificSource Health Plans", "plan_name": "PPO (PSN Network and Smart Health Network)", "standard_charge_percentage": 80, "methodology": "percent of total billed charges", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Medicare (CMS)", "plan_name": "Medicare", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "First Choice Health Network fka Health InfoNet", "plan_name": "Commercial", "standard_charge_percentage": 85, "methodology": "percent of total billed charges", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Claritev fka MultiPlan", "plan_name": "Auto Medical Program", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Claritev fka MultiPlan", "plan_name": "Workers' Compensation Program", "standard_charge_percentage": 90, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Claritev fka MultiPlan", "plan_name": "PPO", "standard_charge_percentage": 75, "methodology": "percent of total billed charges", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "First Choice of the Midwest", "plan_name": "PPO", "standard_charge_percentage": 90, "methodology": "percent of total billed charges", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Employee Benefit Management Services (EBMS)", "plan_name": "EBMS SelectCare Network", "standard_charge_percentage": 80, "methodology": "percent of total billed charges", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Medica Insurance Company", "plan_name": "Medicare Cost", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "First Choice Health Network fka Health InfoNet", "plan_name": "Medicare Advantage", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "First Choice Health Network fka Health InfoNet", "plan_name": "Workers Compensation", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Allegiance Provider Direct", "plan_name": "Montana Association of Counties (MACo)", "standard_charge_percentage": 229.99999999999997, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Allegiance Provider Direct", "plan_name": "State of Montana Employee Benefit Plan (Self-Funded)", "standard_charge_percentage": 229.99999999999997, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Allegiance Provider Direct", "plan_name": "Montana Municipal Interlocal Authority (MMIA)", "standard_charge_percentage": 229.99999999999997, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Medicaid (State)", "plan_name": "Medicaid", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Blue Cross Blue Shield of Montana", "plan_name": "HealthLink Network", "standard_charge_percentage": 75, "methodology": "percent of total billed charges", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Blue Cross Blue Shield of Montana", "plan_name": "Traditional Network", "standard_charge_percentage": 75, "methodology": "percent of total billed charges", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Blue Cross Blue Shield of Montana", "plan_name": "POS Network", "standard_charge_percentage": 75, "methodology": "percent of total billed charges", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Blue Cross Blue Shield of Montana", "plan_name": "Closed Plan Network", "standard_charge_percentage": 75, "methodology": "percent of total billed charges", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Blue Cross Blue Shield of Montana", "plan_name": "Retail HMO POS Network", "standard_charge_percentage": 75, "methodology": "percent of total billed charges", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Blue Cross Blue Shield of Montana", "plan_name": "Blue Options Network", "standard_charge_percentage": 75, "methodology": "percent of total billed charges", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "PacificSource Health Plans", "plan_name": "Medicare Advantage", "standard_charge_percentage": 103, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" } ] } ] }, { "description": "Physical performance test", "code_information": [ { "code": "97750", "type": "HCPCS" } ], "standard_charges": [ { "setting": "outpatient", "payers_information": [ { "payer_name": "National Comp Care", "plan_name": "Workers' Compensation", "standard_charge_percentage": 90, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Coventry Health Care", "plan_name": "Auto Network", "standard_charge_percentage": 90, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Coventry Health Care", "plan_name": "Workers' Compensation", "standard_charge_percentage": 95, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Blue Cross Blue Shield of Montana", "plan_name": "Medicare Advantage", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Allegiance Provider Direct", "plan_name": "Medicare", "standard_charge_percentage": 229.99999999999997, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "PacificSource Health Plans", "plan_name": "PPO (PSN Network and Smart Health Network)", "standard_charge_percentage": 80, "methodology": "percent of total billed charges", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Medicare (CMS)", "plan_name": "Medicare", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "First Choice Health Network fka Health InfoNet", "plan_name": "Commercial", "standard_charge_percentage": 85, "methodology": "percent of total billed charges", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Claritev fka MultiPlan", "plan_name": "Auto Medical Program", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Claritev fka MultiPlan", "plan_name": "Workers' Compensation Program", "standard_charge_percentage": 90, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Claritev fka MultiPlan", "plan_name": "PPO", "standard_charge_percentage": 75, "methodology": "percent of total billed charges", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "First Choice of the Midwest", "plan_name": "PPO", "standard_charge_percentage": 90, "methodology": "percent of total billed charges", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Employee Benefit Management Services (EBMS)", "plan_name": "EBMS SelectCare Network", "standard_charge_percentage": 80, "methodology": "percent of total billed charges", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Medica Insurance Company", "plan_name": "Medicare Cost", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "First Choice Health Network fka Health InfoNet", "plan_name": "Medicare Advantage", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "First Choice Health Network fka Health InfoNet", "plan_name": "Workers Compensation", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Allegiance Provider Direct", "plan_name": "Montana Association of Counties (MACo)", "standard_charge_percentage": 229.99999999999997, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Allegiance Provider Direct", "plan_name": "State of Montana Employee Benefit Plan (Self-Funded)", "standard_charge_percentage": 229.99999999999997, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Allegiance Provider Direct", "plan_name": "Montana Municipal Interlocal Authority (MMIA)", "standard_charge_percentage": 229.99999999999997, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Medicaid (State)", "plan_name": "Medicaid", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Blue Cross Blue Shield of Montana", "plan_name": "HealthLink Network", "standard_charge_percentage": 75, "methodology": "percent of total billed charges", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Blue Cross Blue Shield of Montana", "plan_name": "Traditional Network", "standard_charge_percentage": 75, "methodology": "percent of total billed charges", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Blue Cross Blue Shield of Montana", "plan_name": "POS Network", "standard_charge_percentage": 75, "methodology": "percent of total billed charges", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Blue Cross Blue Shield of Montana", "plan_name": "Closed Plan Network", "standard_charge_percentage": 75, "methodology": "percent of total billed charges", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Blue Cross Blue Shield of Montana", "plan_name": "Retail HMO POS Network", "standard_charge_percentage": 75, "methodology": "percent of total billed charges", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Blue Cross Blue Shield of Montana", "plan_name": "Blue Options Network", "standard_charge_percentage": 75, "methodology": "percent of total billed charges", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "PacificSource Health Plans", "plan_name": "Medicare Advantage", "standard_charge_percentage": 103, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" } ] } ] }, { "description": "Use of speech device service", "code_information": [ { "code": "92609", "type": "HCPCS" } ], "standard_charges": [ { "setting": "outpatient", "payers_information": [ { "payer_name": "National Comp Care", "plan_name": "Workers' Compensation", "standard_charge_percentage": 90, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Coventry Health Care", "plan_name": "Auto Network", "standard_charge_percentage": 90, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Coventry Health Care", "plan_name": "Workers' Compensation", "standard_charge_percentage": 95, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Blue Cross Blue Shield of Montana", "plan_name": "Medicare Advantage", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Allegiance Provider Direct", "plan_name": "Medicare", "standard_charge_percentage": 229.99999999999997, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "PacificSource Health Plans", "plan_name": "PPO (PSN Network and Smart Health Network)", "standard_charge_percentage": 80, "methodology": "percent of total billed charges", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "First Choice Health Network fka Health InfoNet", "plan_name": "Commercial", "standard_charge_percentage": 85, "methodology": "percent of total billed charges", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Medicare (CMS)", "plan_name": "Medicare", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Claritev fka MultiPlan", "plan_name": "Workers' Compensation Program", "standard_charge_percentage": 90, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Claritev fka MultiPlan", "plan_name": "Auto Medical Program", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Claritev fka MultiPlan", "plan_name": "PPO", "standard_charge_percentage": 75, "methodology": "percent of total billed charges", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "First Choice of the Midwest", "plan_name": "PPO", "standard_charge_percentage": 90, "methodology": "percent of total billed charges", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Employee Benefit Management Services (EBMS)", "plan_name": "EBMS SelectCare Network", "standard_charge_percentage": 80, "methodology": "percent of total billed charges", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Medica Insurance Company", "plan_name": "Medicare Cost", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "First Choice Health Network fka Health InfoNet", "plan_name": "Medicare Advantage", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "First Choice Health Network fka Health InfoNet", "plan_name": "Workers Compensation", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Allegiance Provider Direct", "plan_name": "Montana Association of Counties (MACo)", "standard_charge_percentage": 229.99999999999997, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Allegiance Provider Direct", "plan_name": "State of Montana Employee Benefit Plan (Self-Funded)", "standard_charge_percentage": 229.99999999999997, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Allegiance Provider Direct", "plan_name": "Montana Municipal Interlocal Authority (MMIA)", "standard_charge_percentage": 229.99999999999997, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Medicaid (State)", "plan_name": "Medicaid", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Blue Cross Blue Shield of Montana", "plan_name": "HealthLink Network", "standard_charge_percentage": 75, "methodology": "percent of total billed charges", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Blue Cross Blue Shield of Montana", "plan_name": "Traditional Network", "standard_charge_percentage": 75, "methodology": "percent of total billed charges", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Blue Cross Blue Shield of Montana", "plan_name": "POS Network", "standard_charge_percentage": 75, "methodology": "percent of total billed charges", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Blue Cross Blue Shield of Montana", "plan_name": "Closed Plan Network", "standard_charge_percentage": 75, "methodology": "percent of total billed charges", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Blue Cross Blue Shield of Montana", "plan_name": "Retail HMO POS Network", "standard_charge_percentage": 75, "methodology": "percent of total billed charges", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Blue Cross Blue Shield of Montana", "plan_name": "Blue Options Network", "standard_charge_percentage": 75, "methodology": "percent of total billed charges", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "PacificSource Health Plans", "plan_name": "Medicare Advantage", "standard_charge_percentage": 103, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" } ] } ] }, { "description": "Wheelchair mngment training", "code_information": [ { "code": "97542", "type": "HCPCS" } ], "standard_charges": [ { "setting": "outpatient", "payers_information": [ { "payer_name": "National Comp Care", "plan_name": "Workers' Compensation", "standard_charge_percentage": 90, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Coventry Health Care", "plan_name": "Auto Network", "standard_charge_percentage": 90, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Coventry Health Care", "plan_name": "Workers' Compensation", "standard_charge_percentage": 95, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Blue Cross Blue Shield of Montana", "plan_name": "Medicare Advantage", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Allegiance Provider Direct", "plan_name": "Medicare", "standard_charge_percentage": 229.99999999999997, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "PacificSource Health Plans", "plan_name": "PPO (PSN Network and Smart Health Network)", "standard_charge_percentage": 80, "methodology": "percent of total billed charges", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "First Choice Health Network fka Health InfoNet", "plan_name": "Commercial", "standard_charge_percentage": 85, "methodology": "percent of total billed charges", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Medicare (CMS)", "plan_name": "Medicare", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Claritev fka MultiPlan", "plan_name": "Workers' Compensation Program", "standard_charge_percentage": 90, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Claritev fka MultiPlan", "plan_name": "Auto Medical Program", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Claritev fka MultiPlan", "plan_name": "PPO", "standard_charge_percentage": 75, "methodology": "percent of total billed charges", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "First Choice of the Midwest", "plan_name": "PPO", "standard_charge_percentage": 90, "methodology": "percent of total billed charges", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Employee Benefit Management Services (EBMS)", "plan_name": "EBMS SelectCare Network", "standard_charge_percentage": 80, "methodology": "percent of total billed charges", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Medica Insurance Company", "plan_name": "Medicare Cost", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "First Choice Health Network fka Health InfoNet", "plan_name": "Medicare Advantage", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "First Choice Health Network fka Health InfoNet", "plan_name": "Workers Compensation", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Allegiance Provider Direct", "plan_name": "Montana Association of Counties (MACo)", "standard_charge_percentage": 229.99999999999997, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Allegiance Provider Direct", "plan_name": "State of Montana Employee Benefit Plan (Self-Funded)", "standard_charge_percentage": 229.99999999999997, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Allegiance Provider Direct", "plan_name": "Montana Municipal Interlocal Authority (MMIA)", "standard_charge_percentage": 229.99999999999997, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Medicaid (State)", "plan_name": "Medicaid", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Blue Cross Blue Shield of Montana", "plan_name": "HealthLink Network", "standard_charge_percentage": 75, "methodology": "percent of total billed charges", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Blue Cross Blue Shield of Montana", "plan_name": "Traditional Network", "standard_charge_percentage": 75, "methodology": "percent of total billed charges", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Blue Cross Blue Shield of Montana", "plan_name": "POS Network", "standard_charge_percentage": 75, "methodology": "percent of total billed charges", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Blue Cross Blue Shield of Montana", "plan_name": "Closed Plan Network", "standard_charge_percentage": 75, "methodology": "percent of total billed charges", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Blue Cross Blue Shield of Montana", "plan_name": "Retail HMO POS Network", "standard_charge_percentage": 75, "methodology": "percent of total billed charges", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Blue Cross Blue Shield of Montana", "plan_name": "Blue Options Network", "standard_charge_percentage": 75, "methodology": "percent of total billed charges", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "PacificSource Health Plans", "plan_name": "Medicare Advantage", "standard_charge_percentage": 103, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" } ] } ] }, { "description": "Endoscopy swallow (fees) vid", "code_information": [ { "code": "92612", "type": "HCPCS" } ], "standard_charges": [ { "setting": "outpatient", "payers_information": [ { "payer_name": "National Comp Care", "plan_name": "Workers' Compensation", "standard_charge_percentage": 90, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Coventry Health Care", "plan_name": "Auto Network", "standard_charge_percentage": 90, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Coventry Health Care", "plan_name": "Workers' Compensation", "standard_charge_percentage": 95, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Blue Cross Blue Shield of Montana", "plan_name": "Medicare Advantage", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Allegiance Provider Direct", "plan_name": "Medicare", "standard_charge_percentage": 229.99999999999997, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "PacificSource Health Plans", "plan_name": "PPO (PSN Network and Smart Health Network)", "standard_charge_percentage": 80, "methodology": "percent of total billed charges", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "First Choice Health Network fka Health InfoNet", "plan_name": "Commercial", "standard_charge_percentage": 85, "methodology": "percent of total billed charges", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Medicare (CMS)", "plan_name": "Medicare", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Claritev fka MultiPlan", "plan_name": "Workers' Compensation Program", "standard_charge_percentage": 90, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Claritev fka MultiPlan", "plan_name": "Auto Medical Program", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Claritev fka MultiPlan", "plan_name": "PPO", "standard_charge_percentage": 75, "methodology": "percent of total billed charges", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "First Choice of the Midwest", "plan_name": "PPO", "standard_charge_percentage": 90, "methodology": "percent of total billed charges", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Employee Benefit Management Services (EBMS)", "plan_name": "EBMS SelectCare Network", "standard_charge_percentage": 80, "methodology": "percent of total billed charges", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Medica Insurance Company", "plan_name": "Medicare Cost", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "First Choice Health Network fka Health InfoNet", "plan_name": "Medicare Advantage", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "First Choice Health Network fka Health InfoNet", "plan_name": "Workers Compensation", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Allegiance Provider Direct", "plan_name": "Montana Association of Counties (MACo)", "standard_charge_percentage": 229.99999999999997, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Allegiance Provider Direct", "plan_name": "State of Montana Employee Benefit Plan (Self-Funded)", "standard_charge_percentage": 229.99999999999997, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Allegiance Provider Direct", "plan_name": "Montana Municipal Interlocal Authority (MMIA)", "standard_charge_percentage": 229.99999999999997, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Medicaid (State)", "plan_name": "Medicaid", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Blue Cross Blue Shield of Montana", "plan_name": "HealthLink Network", "standard_charge_percentage": 75, "methodology": "percent of total billed charges", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Blue Cross Blue Shield of Montana", "plan_name": "Traditional Network", "standard_charge_percentage": 75, "methodology": "percent of total billed charges", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Blue Cross Blue Shield of Montana", "plan_name": "POS Network", "standard_charge_percentage": 75, "methodology": "percent of total billed charges", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Blue Cross Blue Shield of Montana", "plan_name": "Closed Plan Network", "standard_charge_percentage": 75, "methodology": "percent of total billed charges", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Blue Cross Blue Shield of Montana", "plan_name": "Retail HMO POS Network", "standard_charge_percentage": 75, "methodology": "percent of total billed charges", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Blue Cross Blue Shield of Montana", "plan_name": "Blue Options Network", "standard_charge_percentage": 75, "methodology": "percent of total billed charges", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "PacificSource Health Plans", "plan_name": "Medicare Advantage", "standard_charge_percentage": 103, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" } ] } ] }, { "description": "Vent mgmt inpat subq day", "code_information": [ { "code": "94003", "type": "HCPCS" } ], "standard_charges": [ { "setting": "outpatient", "payers_information": [ { "payer_name": "National Comp Care", "plan_name": "Workers' Compensation", "standard_charge_percentage": 90, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Coventry Health Care", "plan_name": "Auto Network", "standard_charge_percentage": 90, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Coventry Health Care", "plan_name": "Workers' Compensation", "standard_charge_percentage": 95, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "United Healthcare (UHC)", "plan_name": "DSNP", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Blue Cross Blue Shield of Montana", "plan_name": "Medicare Advantage", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "United Healthcare (UHC)", "plan_name": "Medicare Advantage", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Allegiance Provider Direct", "plan_name": "Medicare", "standard_charge_percentage": 229.99999999999997, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "PacificSource Health Plans", "plan_name": "PPO (PSN Network and Smart Health Network)", "standard_charge_percentage": 80, "methodology": "percent of total billed charges", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "First Choice Health Network fka Health InfoNet", "plan_name": "Commercial", "standard_charge_percentage": 85, "methodology": "percent of total billed charges", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Medicare (CMS)", "plan_name": "Medicare", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Claritev fka MultiPlan", "plan_name": "Workers' Compensation Program", "standard_charge_percentage": 90, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Claritev fka MultiPlan", "plan_name": "Auto Medical Program", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Claritev fka MultiPlan", "plan_name": "PPO", "standard_charge_percentage": 75, "methodology": "percent of total billed charges", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "First Choice of the Midwest", "plan_name": "PPO", "standard_charge_percentage": 90, "methodology": "percent of total billed charges", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Employee Benefit Management Services (EBMS)", "plan_name": "EBMS SelectCare Network", "standard_charge_percentage": 80, "methodology": "percent of total billed charges", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Medica Insurance Company", "plan_name": "Medicare Cost", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "First Choice Health Network fka Health InfoNet", "plan_name": "Medicare Advantage", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "First Choice Health Network fka Health InfoNet", "plan_name": "Workers Compensation", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Allegiance Provider Direct", "plan_name": "Montana Association of Counties (MACo)", "standard_charge_percentage": 229.99999999999997, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Allegiance Provider Direct", "plan_name": "State of Montana Employee Benefit Plan (Self-Funded)", "standard_charge_percentage": 229.99999999999997, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Allegiance Provider Direct", "plan_name": "Montana Municipal Interlocal Authority (MMIA)", "standard_charge_percentage": 229.99999999999997, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Medicaid (State)", "plan_name": "Medicaid", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Blue Cross Blue Shield of Montana", "plan_name": "HealthLink Network", "standard_charge_percentage": 75, "methodology": "percent of total billed charges", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Blue Cross Blue Shield of Montana", "plan_name": "Traditional Network", "standard_charge_percentage": 75, "methodology": "percent of total billed charges", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Blue Cross Blue Shield of Montana", "plan_name": "POS Network", "standard_charge_percentage": 75, "methodology": "percent of total billed charges", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Blue Cross Blue Shield of Montana", "plan_name": "Closed Plan Network", "standard_charge_percentage": 75, "methodology": "percent of total billed charges", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Blue Cross Blue Shield of Montana", "plan_name": "Retail HMO POS Network", "standard_charge_percentage": 75, "methodology": "percent of total billed charges", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Blue Cross Blue Shield of Montana", "plan_name": "Blue Options Network", "standard_charge_percentage": 75, "methodology": "percent of total billed charges", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "PacificSource Health Plans", "plan_name": "Medicare Advantage", "standard_charge_percentage": 103, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" } ] } ] }, { "description": "Orthotic mgmt&traing 1st enc", "code_information": [ { "code": "97760", "type": "HCPCS" } ], "standard_charges": [ { "setting": "outpatient", "payers_information": [ { "payer_name": "National Comp Care", "plan_name": "Workers' Compensation", "standard_charge_percentage": 90, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Coventry Health Care", "plan_name": "Auto Network", "standard_charge_percentage": 90, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Coventry Health Care", "plan_name": "Workers' Compensation", "standard_charge_percentage": 95, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Blue Cross Blue Shield of Montana", "plan_name": "Medicare Advantage", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Allegiance Provider Direct", "plan_name": "Medicare", "standard_charge_percentage": 229.99999999999997, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "PacificSource Health Plans", "plan_name": "PPO (PSN Network and Smart Health Network)", "standard_charge_percentage": 80, "methodology": "percent of total billed charges", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "First Choice Health Network fka Health InfoNet", "plan_name": "Commercial", "standard_charge_percentage": 85, "methodology": "percent of total billed charges", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Medicare (CMS)", "plan_name": "Medicare", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Claritev fka MultiPlan", "plan_name": "Workers' Compensation Program", "standard_charge_percentage": 90, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Claritev fka MultiPlan", "plan_name": "Auto Medical Program", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Claritev fka MultiPlan", "plan_name": "PPO", "standard_charge_percentage": 75, "methodology": "percent of total billed charges", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "First Choice of the Midwest", "plan_name": "PPO", "standard_charge_percentage": 90, "methodology": "percent of total billed charges", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Employee Benefit Management Services (EBMS)", "plan_name": "EBMS SelectCare Network", "standard_charge_percentage": 80, "methodology": "percent of total billed charges", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Medica Insurance Company", "plan_name": "Medicare Cost", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "First Choice Health Network fka Health InfoNet", "plan_name": "Medicare Advantage", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "First Choice Health Network fka Health InfoNet", "plan_name": "Workers Compensation", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Allegiance Provider Direct", "plan_name": "Montana Association of Counties (MACo)", "standard_charge_percentage": 229.99999999999997, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Allegiance Provider Direct", "plan_name": "State of Montana Employee Benefit Plan (Self-Funded)", "standard_charge_percentage": 229.99999999999997, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Allegiance Provider Direct", "plan_name": "Montana Municipal Interlocal Authority (MMIA)", "standard_charge_percentage": 229.99999999999997, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Medicaid (State)", "plan_name": "Medicaid", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Blue Cross Blue Shield of Montana", "plan_name": "HealthLink Network", "standard_charge_percentage": 75, "methodology": "percent of total billed charges", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Blue Cross Blue Shield of Montana", "plan_name": "Traditional Network", "standard_charge_percentage": 75, "methodology": "percent of total billed charges", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Blue Cross Blue Shield of Montana", "plan_name": "POS Network", "standard_charge_percentage": 75, "methodology": "percent of total billed charges", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Blue Cross Blue Shield of Montana", "plan_name": "Closed Plan Network", "standard_charge_percentage": 75, "methodology": "percent of total billed charges", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Blue Cross Blue Shield of Montana", "plan_name": "Retail HMO POS Network", "standard_charge_percentage": 75, "methodology": "percent of total billed charges", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Blue Cross Blue Shield of Montana", "plan_name": "Blue Options Network", "standard_charge_percentage": 75, "methodology": "percent of total billed charges", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "PacificSource Health Plans", "plan_name": "Medicare Advantage", "standard_charge_percentage": 103, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" } ] } ] }, { "description": "Electric stimulation therapy", "code_information": [ { "code": "97014", "type": "HCPCS" } ], "standard_charges": [ { "setting": "outpatient", "payers_information": [ { "payer_name": "National Comp Care", "plan_name": "Workers' Compensation", "standard_charge_percentage": 90, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Coventry Health Care", "plan_name": "Auto Network", "standard_charge_percentage": 90, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Coventry Health Care", "plan_name": "Workers' Compensation", "standard_charge_percentage": 95, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Blue Cross Blue Shield of Montana", "plan_name": "Medicare Advantage", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Allegiance Provider Direct", "plan_name": "Medicare", "standard_charge_percentage": 229.99999999999997, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "PacificSource Health Plans", "plan_name": "PPO (PSN Network and Smart Health Network)", "standard_charge_percentage": 80, "methodology": "percent of total billed charges", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "First Choice Health Network fka Health InfoNet", "plan_name": "Commercial", "standard_charge_percentage": 85, "methodology": "percent of total billed charges", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Medicare (CMS)", "plan_name": "Medicare", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Claritev fka MultiPlan", "plan_name": "Workers' Compensation Program", "standard_charge_percentage": 90, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Claritev fka MultiPlan", "plan_name": "Auto Medical Program", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Claritev fka MultiPlan", "plan_name": "PPO", "standard_charge_percentage": 75, "methodology": "percent of total billed charges", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "First Choice of the Midwest", "plan_name": "PPO", "standard_charge_percentage": 90, "methodology": "percent of total billed charges", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Employee Benefit Management Services (EBMS)", "plan_name": "EBMS SelectCare Network", "standard_charge_percentage": 80, "methodology": "percent of total billed charges", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Medica Insurance Company", "plan_name": "Medicare Cost", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "First Choice Health Network fka Health InfoNet", "plan_name": "Medicare Advantage", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "First Choice Health Network fka Health InfoNet", "plan_name": "Workers Compensation", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Allegiance Provider Direct", "plan_name": "Montana Association of Counties (MACo)", "standard_charge_percentage": 229.99999999999997, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Allegiance Provider Direct", "plan_name": "State of Montana Employee Benefit Plan (Self-Funded)", "standard_charge_percentage": 229.99999999999997, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Allegiance Provider Direct", "plan_name": "Montana Municipal Interlocal Authority (MMIA)", "standard_charge_percentage": 229.99999999999997, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Medicaid (State)", "plan_name": "Medicaid", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Blue Cross Blue Shield of Montana", "plan_name": "HealthLink Network", "standard_charge_percentage": 75, "methodology": "percent of total billed charges", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Blue Cross Blue Shield of Montana", "plan_name": "Traditional Network", "standard_charge_percentage": 75, "methodology": "percent of total billed charges", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Blue Cross Blue Shield of Montana", "plan_name": "POS Network", "standard_charge_percentage": 75, "methodology": "percent of total billed charges", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Blue Cross Blue Shield of Montana", "plan_name": "Closed Plan Network", "standard_charge_percentage": 75, "methodology": "percent of total billed charges", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Blue Cross Blue Shield of Montana", "plan_name": "Retail HMO POS Network", "standard_charge_percentage": 75, "methodology": "percent of total billed charges", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Blue Cross Blue Shield of Montana", "plan_name": "Blue Options Network", "standard_charge_percentage": 75, "methodology": "percent of total billed charges", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "PacificSource Health Plans", "plan_name": "Medicare Advantage", "standard_charge_percentage": 103, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" } ] } ] }, { "description": "Orthc/prostc mgmt sbsq enc", "code_information": [ { "code": "97763", "type": "HCPCS" } ], "standard_charges": [ { "setting": "outpatient", "payers_information": [ { "payer_name": "National Comp Care", "plan_name": "Workers' Compensation", "standard_charge_percentage": 90, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Coventry Health Care", "plan_name": "Auto Network", "standard_charge_percentage": 90, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Coventry Health Care", "plan_name": "Workers' Compensation", "standard_charge_percentage": 95, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Blue Cross Blue Shield of Montana", "plan_name": "Medicare Advantage", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Allegiance Provider Direct", "plan_name": "Medicare", "standard_charge_percentage": 229.99999999999997, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "PacificSource Health Plans", "plan_name": "PPO (PSN Network and Smart Health Network)", "standard_charge_percentage": 80, "methodology": "percent of total billed charges", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "First Choice Health Network fka Health InfoNet", "plan_name": "Commercial", "standard_charge_percentage": 85, "methodology": "percent of total billed charges", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Medicare (CMS)", "plan_name": "Medicare", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Claritev fka MultiPlan", "plan_name": "Workers' Compensation Program", "standard_charge_percentage": 90, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Claritev fka MultiPlan", "plan_name": "Auto Medical Program", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Claritev fka MultiPlan", "plan_name": "PPO", "standard_charge_percentage": 75, "methodology": "percent of total billed charges", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "First Choice of the Midwest", "plan_name": "PPO", "standard_charge_percentage": 90, "methodology": "percent of total billed charges", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Employee Benefit Management Services (EBMS)", "plan_name": "EBMS SelectCare Network", "standard_charge_percentage": 80, "methodology": "percent of total billed charges", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Medica Insurance Company", "plan_name": "Medicare Cost", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "First Choice Health Network fka Health InfoNet", "plan_name": "Medicare Advantage", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "First Choice Health Network fka Health InfoNet", "plan_name": "Workers Compensation", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Allegiance Provider Direct", "plan_name": "Montana Association of Counties (MACo)", "standard_charge_percentage": 229.99999999999997, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Allegiance Provider Direct", "plan_name": "State of Montana Employee Benefit Plan (Self-Funded)", "standard_charge_percentage": 229.99999999999997, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Allegiance Provider Direct", "plan_name": "Montana Municipal Interlocal Authority (MMIA)", "standard_charge_percentage": 229.99999999999997, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Medicaid (State)", "plan_name": "Medicaid", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Blue Cross Blue Shield of Montana", "plan_name": "HealthLink Network", "standard_charge_percentage": 75, "methodology": "percent of total billed charges", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Blue Cross Blue Shield of Montana", "plan_name": "Traditional Network", "standard_charge_percentage": 75, "methodology": "percent of total billed charges", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Blue Cross Blue Shield of Montana", "plan_name": "POS Network", "standard_charge_percentage": 75, "methodology": "percent of total billed charges", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Blue Cross Blue Shield of Montana", "plan_name": "Closed Plan Network", "standard_charge_percentage": 75, "methodology": "percent of total billed charges", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Blue Cross Blue Shield of Montana", "plan_name": "Retail HMO POS Network", "standard_charge_percentage": 75, "methodology": "percent of total billed charges", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Blue Cross Blue Shield of Montana", "plan_name": "Blue Options Network", "standard_charge_percentage": 75, "methodology": "percent of total billed charges", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "PacificSource Health Plans", "plan_name": "Medicare Advantage", "standard_charge_percentage": 103, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" } ] } ] }, { "description": "Complete cbc w/auto diff wbc", "code_information": [ { "code": "85025", "type": "HCPCS" } ], "standard_charges": [ { "setting": "outpatient", "payers_information": [ { "payer_name": "National Comp Care", "plan_name": "Workers' Compensation", "standard_charge_percentage": 90, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Coventry Health Care", "plan_name": "Auto Network", "standard_charge_percentage": 90, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "United Healthcare (UHC)", "plan_name": "DSNP", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Coventry Health Care", "plan_name": "Workers' Compensation", "standard_charge_percentage": 95, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Blue Cross Blue Shield of Montana", "plan_name": "Medicare Advantage", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "United Healthcare (UHC)", "plan_name": "Medicare Advantage", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Allegiance Provider Direct", "plan_name": "Medicare", "standard_charge_percentage": 229.99999999999997, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "PacificSource Health Plans", "plan_name": "PPO (PSN Network and Smart Health Network)", "standard_charge_percentage": 80, "methodology": "percent of total billed charges", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "First Choice Health Network fka Health InfoNet", "plan_name": "Commercial", "standard_charge_percentage": 85, "methodology": "percent of total billed charges", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Medicare (CMS)", "plan_name": "Medicare", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Claritev fka MultiPlan", "plan_name": "Workers' Compensation Program", "standard_charge_percentage": 90, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Claritev fka MultiPlan", "plan_name": "Auto Medical Program", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Claritev fka MultiPlan", "plan_name": "PPO", "standard_charge_percentage": 75, "methodology": "percent of total billed charges", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "First Choice of the Midwest", "plan_name": "PPO", "standard_charge_percentage": 90, "methodology": "percent of total billed charges", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Employee Benefit Management Services (EBMS)", "plan_name": "EBMS SelectCare Network", "standard_charge_percentage": 80, "methodology": "percent of total billed charges", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Medica Insurance Company", "plan_name": "Medicare Cost", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "First Choice Health Network fka Health InfoNet", "plan_name": "Medicare Advantage", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "First Choice Health Network fka Health InfoNet", "plan_name": "Workers Compensation", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Allegiance Provider Direct", "plan_name": "Montana Association of Counties (MACo)", "standard_charge_percentage": 229.99999999999997, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Allegiance Provider Direct", "plan_name": "State of Montana Employee Benefit Plan (Self-Funded)", "standard_charge_percentage": 229.99999999999997, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Allegiance Provider Direct", "plan_name": "Montana Municipal Interlocal Authority (MMIA)", "standard_charge_percentage": 229.99999999999997, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Medicaid (State)", "plan_name": "Medicaid", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Blue Cross Blue Shield of Montana", "plan_name": "HealthLink Network", "standard_charge_percentage": 75, "methodology": "percent of total billed charges", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Blue Cross Blue Shield of Montana", "plan_name": "Traditional Network", "standard_charge_percentage": 75, "methodology": "percent of total billed charges", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Blue Cross Blue Shield of Montana", "plan_name": "POS Network", "standard_charge_percentage": 75, "methodology": "percent of total billed charges", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Blue Cross Blue Shield of Montana", "plan_name": "Closed Plan Network", "standard_charge_percentage": 75, "methodology": "percent of total billed charges", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Blue Cross Blue Shield of Montana", "plan_name": "Retail HMO POS Network", "standard_charge_percentage": 75, "methodology": "percent of total billed charges", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Blue Cross Blue Shield of Montana", "plan_name": "Blue Options Network", "standard_charge_percentage": 75, "methodology": "percent of total billed charges", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "PacificSource Health Plans", "plan_name": "Medicare Advantage", "standard_charge_percentage": 103, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" } ] } ] }, { "description": "Canalith repositioning proc", "code_information": [ { "code": "95992", "type": "HCPCS" } ], "standard_charges": [ { "setting": "outpatient", "payers_information": [ { "payer_name": "National Comp Care", "plan_name": "Workers' Compensation", "standard_charge_percentage": 90, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Coventry Health Care", "plan_name": "Auto Network", "standard_charge_percentage": 90, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Coventry Health Care", "plan_name": "Workers' Compensation", "standard_charge_percentage": 95, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Blue Cross Blue Shield of Montana", "plan_name": "Medicare Advantage", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Allegiance Provider Direct", "plan_name": "Medicare", "standard_charge_percentage": 229.99999999999997, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "PacificSource Health Plans", "plan_name": "PPO (PSN Network and Smart Health Network)", "standard_charge_percentage": 80, "methodology": "percent of total billed charges", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "First Choice Health Network fka Health InfoNet", "plan_name": "Commercial", "standard_charge_percentage": 85, "methodology": "percent of total billed charges", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Medicare (CMS)", "plan_name": "Medicare", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Claritev fka MultiPlan", "plan_name": "Workers' Compensation Program", "standard_charge_percentage": 90, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Claritev fka MultiPlan", "plan_name": "Auto Medical Program", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Claritev fka MultiPlan", "plan_name": "PPO", "standard_charge_percentage": 75, "methodology": "percent of total billed charges", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "First Choice of the Midwest", "plan_name": "PPO", "standard_charge_percentage": 90, "methodology": "percent of total billed charges", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Employee Benefit Management Services (EBMS)", "plan_name": "EBMS SelectCare Network", "standard_charge_percentage": 80, "methodology": "percent of total billed charges", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Medica Insurance Company", "plan_name": "Medicare Cost", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "First Choice Health Network fka Health InfoNet", "plan_name": "Medicare Advantage", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "First Choice Health Network fka Health InfoNet", "plan_name": "Workers Compensation", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Allegiance Provider Direct", "plan_name": "Montana Association of Counties (MACo)", "standard_charge_percentage": 229.99999999999997, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Allegiance Provider Direct", "plan_name": "State of Montana Employee Benefit Plan (Self-Funded)", "standard_charge_percentage": 229.99999999999997, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Allegiance Provider Direct", "plan_name": "Montana Municipal Interlocal Authority (MMIA)", "standard_charge_percentage": 229.99999999999997, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Medicaid (State)", "plan_name": "Medicaid", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Blue Cross Blue Shield of Montana", "plan_name": "HealthLink Network", "standard_charge_percentage": 75, "methodology": "percent of total billed charges", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Blue Cross Blue Shield of Montana", "plan_name": "Traditional Network", "standard_charge_percentage": 75, "methodology": "percent of total billed charges", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Blue Cross Blue Shield of Montana", "plan_name": "POS Network", "standard_charge_percentage": 75, "methodology": "percent of total billed charges", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Blue Cross Blue Shield of Montana", "plan_name": "Closed Plan Network", "standard_charge_percentage": 75, "methodology": "percent of total billed charges", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Blue Cross Blue Shield of Montana", "plan_name": "Retail HMO POS Network", "standard_charge_percentage": 75, "methodology": "percent of total billed charges", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Blue Cross Blue Shield of Montana", "plan_name": "Blue Options Network", "standard_charge_percentage": 75, "methodology": "percent of total billed charges", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "PacificSource Health Plans", "plan_name": "Medicare Advantage", "standard_charge_percentage": 103, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" } ] } ] }, { "description": "Sensory integration", "code_information": [ { "code": "97533", "type": "HCPCS" } ], "standard_charges": [ { "setting": "outpatient", "payers_information": [ { "payer_name": "National Comp Care", "plan_name": "Workers' Compensation", "standard_charge_percentage": 90, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Coventry Health Care", "plan_name": "Auto Network", "standard_charge_percentage": 90, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Coventry Health Care", "plan_name": "Workers' Compensation", "standard_charge_percentage": 95, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Blue Cross Blue Shield of Montana", "plan_name": "Medicare Advantage", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Allegiance Provider Direct", "plan_name": "Medicare", "standard_charge_percentage": 229.99999999999997, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "PacificSource Health Plans", "plan_name": "PPO (PSN Network and Smart Health Network)", "standard_charge_percentage": 80, "methodology": "percent of total billed charges", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "First Choice Health Network fka Health InfoNet", "plan_name": "Commercial", "standard_charge_percentage": 85, "methodology": "percent of total billed charges", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Medicare (CMS)", "plan_name": "Medicare", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Claritev fka MultiPlan", "plan_name": "Workers' Compensation Program", "standard_charge_percentage": 90, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Claritev fka MultiPlan", "plan_name": "Auto Medical Program", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Claritev fka MultiPlan", "plan_name": "PPO", "standard_charge_percentage": 75, "methodology": "percent of total billed charges", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "First Choice of the Midwest", "plan_name": "PPO", "standard_charge_percentage": 90, "methodology": "percent of total billed charges", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Employee Benefit Management Services (EBMS)", "plan_name": "EBMS SelectCare Network", "standard_charge_percentage": 80, "methodology": "percent of total billed charges", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Medica Insurance Company", "plan_name": "Medicare Cost", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "First Choice Health Network fka Health InfoNet", "plan_name": "Medicare Advantage", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "First Choice Health Network fka Health InfoNet", "plan_name": "Workers Compensation", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Allegiance Provider Direct", "plan_name": "Montana Association of Counties (MACo)", "standard_charge_percentage": 229.99999999999997, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Allegiance Provider Direct", "plan_name": "State of Montana Employee Benefit Plan (Self-Funded)", "standard_charge_percentage": 229.99999999999997, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Allegiance Provider Direct", "plan_name": "Montana Municipal Interlocal Authority (MMIA)", "standard_charge_percentage": 229.99999999999997, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Medicaid (State)", "plan_name": "Medicaid", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Blue Cross Blue Shield of Montana", "plan_name": "HealthLink Network", "standard_charge_percentage": 75, "methodology": "percent of total billed charges", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Blue Cross Blue Shield of Montana", "plan_name": "Traditional Network", "standard_charge_percentage": 75, "methodology": "percent of total billed charges", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Blue Cross Blue Shield of Montana", "plan_name": "POS Network", "standard_charge_percentage": 75, "methodology": "percent of total billed charges", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Blue Cross Blue Shield of Montana", "plan_name": "Closed Plan Network", "standard_charge_percentage": 75, "methodology": "percent of total billed charges", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Blue Cross Blue Shield of Montana", "plan_name": "Retail HMO POS Network", "standard_charge_percentage": 75, "methodology": "percent of total billed charges", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Blue Cross Blue Shield of Montana", "plan_name": "Blue Options Network", "standard_charge_percentage": 75, "methodology": "percent of total billed charges", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "PacificSource Health Plans", "plan_name": "Medicare Advantage", "standard_charge_percentage": 103, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" } ] } ] }, { "description": "Ndl insj w/o njx 3+ musc", "code_information": [ { "code": "20561", "type": "HCPCS" } ], "standard_charges": [ { "setting": "outpatient", "payers_information": [ { "payer_name": "National Comp Care", "plan_name": "Workers' Compensation", "standard_charge_percentage": 90, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Coventry Health Care", "plan_name": "Auto Network", "standard_charge_percentage": 90, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Coventry Health Care", "plan_name": "Workers' Compensation", "standard_charge_percentage": 95, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "TriWest Healthcare Alliance Corporation", "plan_name": "VA CCN", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Blue Cross Blue Shield of Montana", "plan_name": "Medicare Advantage", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Allegiance Provider Direct", "plan_name": "Medicare", "standard_charge_percentage": 229.99999999999997, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "PacificSource Health Plans", "plan_name": "PPO (PSN Network and Smart Health Network)", "standard_charge_percentage": 80, "methodology": "percent of total billed charges", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "First Choice Health Network fka Health InfoNet", "plan_name": "Commercial", "standard_charge_percentage": 85, "methodology": "percent of total billed charges", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Medicare (CMS)", "plan_name": "Medicare", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Claritev fka MultiPlan", "plan_name": "Workers' Compensation Program", "standard_charge_percentage": 90, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Claritev fka MultiPlan", "plan_name": "Auto Medical Program", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Claritev fka MultiPlan", "plan_name": "PPO", "standard_charge_percentage": 75, "methodology": "percent of total billed charges", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "First Choice of the Midwest", "plan_name": "PPO", "standard_charge_percentage": 90, "methodology": "percent of total billed charges", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Employee Benefit Management Services (EBMS)", "plan_name": "EBMS SelectCare Network", "standard_charge_percentage": 80, "methodology": "percent of total billed charges", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Medica Insurance Company", "plan_name": "Medicare Cost", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "First Choice Health Network fka Health InfoNet", "plan_name": "Medicare Advantage", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "First Choice Health Network fka Health InfoNet", "plan_name": "Workers Compensation", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Allegiance Provider Direct", "plan_name": "Montana Association of Counties (MACo)", "standard_charge_percentage": 229.99999999999997, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Allegiance Provider Direct", "plan_name": "State of Montana Employee Benefit Plan (Self-Funded)", "standard_charge_percentage": 229.99999999999997, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Allegiance Provider Direct", "plan_name": "Montana Municipal Interlocal Authority (MMIA)", "standard_charge_percentage": 229.99999999999997, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Medicaid (State)", "plan_name": "Medicaid", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Blue Cross Blue Shield of Montana", "plan_name": "HealthLink Network", "standard_charge_percentage": 75, "methodology": "percent of total billed charges", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Blue Cross Blue Shield of Montana", "plan_name": "Traditional Network", "standard_charge_percentage": 75, "methodology": "percent of total billed charges", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Blue Cross Blue Shield of Montana", "plan_name": "POS Network", "standard_charge_percentage": 75, "methodology": "percent of total billed charges", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Blue Cross Blue Shield of Montana", "plan_name": "Closed Plan Network", "standard_charge_percentage": 75, "methodology": "percent of total billed charges", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Blue Cross Blue Shield of Montana", "plan_name": "Retail HMO POS Network", "standard_charge_percentage": 75, "methodology": "percent of total billed charges", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Blue Cross Blue Shield of Montana", "plan_name": "Blue Options Network", "standard_charge_percentage": 75, "methodology": "percent of total billed charges", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "PacificSource Health Plans", "plan_name": "Medicare Advantage", "standard_charge_percentage": 103, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" } ] } ] }, { "description": "Ndl insj w/o njx 1 or 2 musc", "code_information": [ { "code": "20560", "type": "HCPCS" } ], "standard_charges": [ { "setting": "outpatient", "payers_information": [ { "payer_name": "National Comp Care", "plan_name": "Workers' Compensation", "standard_charge_percentage": 90, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Coventry Health Care", "plan_name": "Auto Network", "standard_charge_percentage": 90, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Coventry Health Care", "plan_name": "Workers' Compensation", "standard_charge_percentage": 95, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "TriWest Healthcare Alliance Corporation", "plan_name": "VA CCN", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Blue Cross Blue Shield of Montana", "plan_name": "Medicare Advantage", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Allegiance Provider Direct", "plan_name": "Medicare", "standard_charge_percentage": 229.99999999999997, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "PacificSource Health Plans", "plan_name": "PPO (PSN Network and Smart Health Network)", "standard_charge_percentage": 80, "methodology": "percent of total billed charges", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "First Choice Health Network fka Health InfoNet", "plan_name": "Commercial", "standard_charge_percentage": 85, "methodology": "percent of total billed charges", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Medicare (CMS)", "plan_name": "Medicare", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Claritev fka MultiPlan", "plan_name": "Workers' Compensation Program", "standard_charge_percentage": 90, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Claritev fka MultiPlan", "plan_name": "Auto Medical Program", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Claritev fka MultiPlan", "plan_name": "PPO", "standard_charge_percentage": 75, "methodology": "percent of total billed charges", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "First Choice of the Midwest", "plan_name": "PPO", "standard_charge_percentage": 90, "methodology": "percent of total billed charges", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Employee Benefit Management Services (EBMS)", "plan_name": "EBMS SelectCare Network", "standard_charge_percentage": 80, "methodology": "percent of total billed charges", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Medica Insurance Company", "plan_name": "Medicare Cost", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "First Choice Health Network fka Health InfoNet", "plan_name": "Medicare Advantage", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "First Choice Health Network fka Health InfoNet", "plan_name": "Workers Compensation", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Allegiance Provider Direct", "plan_name": "Montana Association of Counties (MACo)", "standard_charge_percentage": 229.99999999999997, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Allegiance Provider Direct", "plan_name": "State of Montana Employee Benefit Plan (Self-Funded)", "standard_charge_percentage": 229.99999999999997, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Allegiance Provider Direct", "plan_name": "Montana Municipal Interlocal Authority (MMIA)", "standard_charge_percentage": 229.99999999999997, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Medicaid (State)", "plan_name": "Medicaid", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Blue Cross Blue Shield of Montana", "plan_name": "HealthLink Network", "standard_charge_percentage": 75, "methodology": "percent of total billed charges", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Blue Cross Blue Shield of Montana", "plan_name": "Traditional Network", "standard_charge_percentage": 75, "methodology": "percent of total billed charges", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Blue Cross Blue Shield of Montana", "plan_name": "POS Network", "standard_charge_percentage": 75, "methodology": "percent of total billed charges", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Blue Cross Blue Shield of Montana", "plan_name": "Closed Plan Network", "standard_charge_percentage": 75, "methodology": "percent of total billed charges", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Blue Cross Blue Shield of Montana", "plan_name": "Retail HMO POS Network", "standard_charge_percentage": 75, "methodology": "percent of total billed charges", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Blue Cross Blue Shield of Montana", "plan_name": "Blue Options Network", "standard_charge_percentage": 75, "methodology": "percent of total billed charges", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "PacificSource Health Plans", "plan_name": "Medicare Advantage", "standard_charge_percentage": 103, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" } ] } ] }, { "description": "App mdlty 1+iontphrsis ea 15", "code_information": [ { "code": "97033", "type": "HCPCS" } ], "standard_charges": [ { "setting": "outpatient", "payers_information": [ { "payer_name": "National Comp Care", "plan_name": "Workers' Compensation", "standard_charge_percentage": 90, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Coventry Health Care", "plan_name": "Auto Network", "standard_charge_percentage": 90, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Coventry Health Care", "plan_name": "Workers' Compensation", "standard_charge_percentage": 95, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Blue Cross Blue Shield of Montana", "plan_name": "Medicare Advantage", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Allegiance Provider Direct", "plan_name": "Medicare", "standard_charge_percentage": 229.99999999999997, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "PacificSource Health Plans", "plan_name": "PPO (PSN Network and Smart Health Network)", "standard_charge_percentage": 80, "methodology": "percent of total billed charges", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "First Choice Health Network fka Health InfoNet", "plan_name": "Commercial", "standard_charge_percentage": 85, "methodology": "percent of total billed charges", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Medicare (CMS)", "plan_name": "Medicare", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Claritev fka MultiPlan", "plan_name": "Workers' Compensation Program", "standard_charge_percentage": 90, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Claritev fka MultiPlan", "plan_name": "Auto Medical Program", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Claritev fka MultiPlan", "plan_name": "PPO", "standard_charge_percentage": 75, "methodology": "percent of total billed charges", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "First Choice of the Midwest", "plan_name": "PPO", "standard_charge_percentage": 90, "methodology": "percent of total billed charges", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Employee Benefit Management Services (EBMS)", "plan_name": "EBMS SelectCare Network", "standard_charge_percentage": 80, "methodology": "percent of total billed charges", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Medica Insurance Company", "plan_name": "Medicare Cost", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "First Choice Health Network fka Health InfoNet", "plan_name": "Medicare Advantage", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "First Choice Health Network fka Health InfoNet", "plan_name": "Workers Compensation", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Allegiance Provider Direct", "plan_name": "Montana Association of Counties (MACo)", "standard_charge_percentage": 229.99999999999997, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Allegiance Provider Direct", "plan_name": "State of Montana Employee Benefit Plan (Self-Funded)", "standard_charge_percentage": 229.99999999999997, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Allegiance Provider Direct", "plan_name": "Montana Municipal Interlocal Authority (MMIA)", "standard_charge_percentage": 229.99999999999997, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Medicaid (State)", "plan_name": "Medicaid", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Blue Cross Blue Shield of Montana", "plan_name": "HealthLink Network", "standard_charge_percentage": 75, "methodology": "percent of total billed charges", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Blue Cross Blue Shield of Montana", "plan_name": "Traditional Network", "standard_charge_percentage": 75, "methodology": "percent of total billed charges", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Blue Cross Blue Shield of Montana", "plan_name": "POS Network", "standard_charge_percentage": 75, "methodology": "percent of total billed charges", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Blue Cross Blue Shield of Montana", "plan_name": "Closed Plan Network", "standard_charge_percentage": 75, "methodology": "percent of total billed charges", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Blue Cross Blue Shield of Montana", "plan_name": "Retail HMO POS Network", "standard_charge_percentage": 75, "methodology": "percent of total billed charges", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Blue Cross Blue Shield of Montana", "plan_name": "Blue Options Network", "standard_charge_percentage": 75, "methodology": "percent of total billed charges", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "PacificSource Health Plans", "plan_name": "Medicare Advantage", "standard_charge_percentage": 103, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" } ] } ] }, { "description": "Paraffin bath therapy", "code_information": [ { "code": "97018", "type": "HCPCS" } ], "standard_charges": [ { "setting": "outpatient", "payers_information": [ { "payer_name": "National Comp Care", "plan_name": "Workers' Compensation", "standard_charge_percentage": 90, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Coventry Health Care", "plan_name": "Auto Network", "standard_charge_percentage": 90, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Coventry Health Care", "plan_name": "Workers' Compensation", "standard_charge_percentage": 95, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Blue Cross Blue Shield of Montana", "plan_name": "Medicare Advantage", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Allegiance Provider Direct", "plan_name": "Medicare", "standard_charge_percentage": 229.99999999999997, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "PacificSource Health Plans", "plan_name": "PPO (PSN Network and Smart Health Network)", "standard_charge_percentage": 80, "methodology": "percent of total billed charges", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "First Choice Health Network fka Health InfoNet", "plan_name": "Commercial", "standard_charge_percentage": 85, "methodology": "percent of total billed charges", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Medicare (CMS)", "plan_name": "Medicare", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Claritev fka MultiPlan", "plan_name": "Workers' Compensation Program", "standard_charge_percentage": 90, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Claritev fka MultiPlan", "plan_name": "Auto Medical Program", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Claritev fka MultiPlan", "plan_name": "PPO", "standard_charge_percentage": 75, "methodology": "percent of total billed charges", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "First Choice of the Midwest", "plan_name": "PPO", "standard_charge_percentage": 90, "methodology": "percent of total billed charges", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Employee Benefit Management Services (EBMS)", "plan_name": "EBMS SelectCare Network", "standard_charge_percentage": 80, "methodology": "percent of total billed charges", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Medica Insurance Company", "plan_name": "Medicare Cost", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "First Choice Health Network fka Health InfoNet", "plan_name": "Medicare Advantage", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "First Choice Health Network fka Health InfoNet", "plan_name": "Workers Compensation", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Allegiance Provider Direct", "plan_name": "Montana Association of Counties (MACo)", "standard_charge_percentage": 229.99999999999997, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Allegiance Provider Direct", "plan_name": "State of Montana Employee Benefit Plan (Self-Funded)", "standard_charge_percentage": 229.99999999999997, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Allegiance Provider Direct", "plan_name": "Montana Municipal Interlocal Authority (MMIA)", "standard_charge_percentage": 229.99999999999997, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Medicaid (State)", "plan_name": "Medicaid", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Blue Cross Blue Shield of Montana", "plan_name": "HealthLink Network", "standard_charge_percentage": 75, "methodology": "percent of total billed charges", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Blue Cross Blue Shield of Montana", "plan_name": "Traditional Network", "standard_charge_percentage": 75, "methodology": "percent of total billed charges", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Blue Cross Blue Shield of Montana", "plan_name": "POS Network", "standard_charge_percentage": 75, "methodology": "percent of total billed charges", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Blue Cross Blue Shield of Montana", "plan_name": "Closed Plan Network", "standard_charge_percentage": 75, "methodology": "percent of total billed charges", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Blue Cross Blue Shield of Montana", "plan_name": "Retail HMO POS Network", "standard_charge_percentage": 75, "methodology": "percent of total billed charges", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Blue Cross Blue Shield of Montana", "plan_name": "Blue Options Network", "standard_charge_percentage": 75, "methodology": "percent of total billed charges", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "PacificSource Health Plans", "plan_name": "Medicare Advantage", "standard_charge_percentage": 103, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" } ] } ] }, { "description": "Complete cbc automated", "code_information": [ { "code": "85027", "type": "HCPCS" } ], "standard_charges": [ { "setting": "outpatient", "payers_information": [ { "payer_name": "National Comp Care", "plan_name": "Workers' Compensation", "standard_charge_percentage": 90, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Coventry Health Care", "plan_name": "Auto Network", "standard_charge_percentage": 90, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "United Healthcare (UHC)", "plan_name": "DSNP", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Coventry Health Care", "plan_name": "Workers' Compensation", "standard_charge_percentage": 95, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Blue Cross Blue Shield of Montana", "plan_name": "Medicare Advantage", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "United Healthcare (UHC)", "plan_name": "Medicare Advantage", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Allegiance Provider Direct", "plan_name": "Medicare", "standard_charge_percentage": 229.99999999999997, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "PacificSource Health Plans", "plan_name": "PPO (PSN Network and Smart Health Network)", "standard_charge_percentage": 80, "methodology": "percent of total billed charges", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "First Choice Health Network fka Health InfoNet", "plan_name": "Commercial", "standard_charge_percentage": 85, "methodology": "percent of total billed charges", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Medicare (CMS)", "plan_name": "Medicare", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Claritev fka MultiPlan", "plan_name": "Workers' Compensation Program", "standard_charge_percentage": 90, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Claritev fka MultiPlan", "plan_name": "Auto Medical Program", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Claritev fka MultiPlan", "plan_name": "PPO", "standard_charge_percentage": 75, "methodology": "percent of total billed charges", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "First Choice of the Midwest", "plan_name": "PPO", "standard_charge_percentage": 90, "methodology": "percent of total billed charges", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Employee Benefit Management Services (EBMS)", "plan_name": "EBMS SelectCare Network", "standard_charge_percentage": 80, "methodology": "percent of total billed charges", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Medica Insurance Company", "plan_name": "Medicare Cost", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "First Choice Health Network fka Health InfoNet", "plan_name": "Medicare Advantage", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "First Choice Health Network fka Health InfoNet", "plan_name": "Workers Compensation", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Allegiance Provider Direct", "plan_name": "Montana Association of Counties (MACo)", "standard_charge_percentage": 229.99999999999997, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Allegiance Provider Direct", "plan_name": "State of Montana Employee Benefit Plan (Self-Funded)", "standard_charge_percentage": 229.99999999999997, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Allegiance Provider Direct", "plan_name": "Montana Municipal Interlocal Authority (MMIA)", "standard_charge_percentage": 229.99999999999997, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Medicaid (State)", "plan_name": "Medicaid", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Blue Cross Blue Shield of Montana", "plan_name": "HealthLink Network", "standard_charge_percentage": 75, "methodology": "percent of total billed charges", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Blue Cross Blue Shield of Montana", "plan_name": "Traditional Network", "standard_charge_percentage": 75, "methodology": "percent of total billed charges", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Blue Cross Blue Shield of Montana", "plan_name": "POS Network", "standard_charge_percentage": 75, "methodology": "percent of total billed charges", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Blue Cross Blue Shield of Montana", "plan_name": "Closed Plan Network", "standard_charge_percentage": 75, "methodology": "percent of total billed charges", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Blue Cross Blue Shield of Montana", "plan_name": "Retail HMO POS Network", "standard_charge_percentage": 75, "methodology": "percent of total billed charges", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Blue Cross Blue Shield of Montana", "plan_name": "Blue Options Network", "standard_charge_percentage": 75, "methodology": "percent of total billed charges", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "PacificSource Health Plans", "plan_name": "Medicare Advantage", "standard_charge_percentage": 103, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" } ] } ] }, { "description": "Ct head/brain w/o & w/dye", "code_information": [ { "code": "70470", "type": "HCPCS" } ], "standard_charges": [ { "setting": "outpatient", "payers_information": [ { "payer_name": "National Comp Care", "plan_name": "Workers' Compensation", "standard_charge_percentage": 90, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Coventry Health Care", "plan_name": "Auto Network", "standard_charge_percentage": 90, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Coventry Health Care", "plan_name": "Workers' Compensation", "standard_charge_percentage": 95, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "TriWest Healthcare Alliance Corporation", "plan_name": "VA CCN", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Blue Cross Blue Shield of Montana", "plan_name": "Medicare Advantage", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Allegiance Provider Direct", "plan_name": "Medicare", "standard_charge_percentage": 229.99999999999997, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "PacificSource Health Plans", "plan_name": "PPO (PSN Network and Smart Health Network)", "standard_charge_percentage": 80, "methodology": "percent of total billed charges", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "First Choice Health Network fka Health InfoNet", "plan_name": "Commercial", "standard_charge_percentage": 85, "methodology": "percent of total billed charges", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Medicare (CMS)", "plan_name": "Medicare", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Claritev fka MultiPlan", "plan_name": "Workers' Compensation Program", "standard_charge_percentage": 90, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Claritev fka MultiPlan", "plan_name": "Auto Medical Program", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Claritev fka MultiPlan", "plan_name": "PPO", "standard_charge_percentage": 75, "methodology": "percent of total billed charges", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "First Choice of the Midwest", "plan_name": "PPO", "standard_charge_percentage": 90, "methodology": "percent of total billed charges", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Employee Benefit Management Services (EBMS)", "plan_name": "EBMS SelectCare Network", "standard_charge_percentage": 80, "methodology": "percent of total billed charges", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Medica Insurance Company", "plan_name": "Medicare Cost", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "First Choice Health Network fka Health InfoNet", "plan_name": "Medicare Advantage", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "First Choice Health Network fka Health InfoNet", "plan_name": "Workers Compensation", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Allegiance Provider Direct", "plan_name": "Montana Association of Counties (MACo)", "standard_charge_percentage": 229.99999999999997, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Allegiance Provider Direct", "plan_name": "State of Montana Employee Benefit Plan (Self-Funded)", "standard_charge_percentage": 229.99999999999997, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Allegiance Provider Direct", "plan_name": "Montana Municipal Interlocal Authority (MMIA)", "standard_charge_percentage": 229.99999999999997, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Medicaid (State)", "plan_name": "Medicaid", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Blue Cross Blue Shield of Montana", "plan_name": "HealthLink Network", "standard_charge_percentage": 75, "methodology": "percent of total billed charges", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Blue Cross Blue Shield of Montana", "plan_name": "Traditional Network", "standard_charge_percentage": 75, "methodology": "percent of total billed charges", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Blue Cross Blue Shield of Montana", "plan_name": "POS Network", "standard_charge_percentage": 75, "methodology": "percent of total billed charges", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Blue Cross Blue Shield of Montana", "plan_name": "Closed Plan Network", "standard_charge_percentage": 75, "methodology": "percent of total billed charges", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Blue Cross Blue Shield of Montana", "plan_name": "Retail HMO POS Network", "standard_charge_percentage": 75, "methodology": "percent of total billed charges", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Blue Cross Blue Shield of Montana", "plan_name": "Blue Options Network", "standard_charge_percentage": 75, "methodology": "percent of total billed charges", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "PacificSource Health Plans", "plan_name": "Medicare Advantage", "standard_charge_percentage": 103, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" } ] } ] }, { "description": "Extremity study", "code_information": [ { "code": "93970", "type": "HCPCS" } ], "standard_charges": [ { "setting": "outpatient", "payers_information": [ { "payer_name": "National Comp Care", "plan_name": "Workers' Compensation", "standard_charge_percentage": 90, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Coventry Health Care", "plan_name": "Auto Network", "standard_charge_percentage": 90, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "United Healthcare (UHC)", "plan_name": "DSNP", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Coventry Health Care", "plan_name": "Workers' Compensation", "standard_charge_percentage": 95, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Blue Cross Blue Shield of Montana", "plan_name": "Medicare Advantage", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "United Healthcare (UHC)", "plan_name": "Medicare Advantage", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Allegiance Provider Direct", "plan_name": "Medicare", "standard_charge_percentage": 229.99999999999997, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "PacificSource Health Plans", "plan_name": "PPO (PSN Network and Smart Health Network)", "standard_charge_percentage": 80, "methodology": "percent of total billed charges", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "First Choice Health Network fka Health InfoNet", "plan_name": "Commercial", "standard_charge_percentage": 85, "methodology": "percent of total billed charges", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Medicare (CMS)", "plan_name": "Medicare", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Claritev fka MultiPlan", "plan_name": "Workers' Compensation Program", "standard_charge_percentage": 90, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Claritev fka MultiPlan", "plan_name": "Auto Medical Program", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Claritev fka MultiPlan", "plan_name": "PPO", "standard_charge_percentage": 75, "methodology": "percent of total billed charges", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "First Choice of the Midwest", "plan_name": "PPO", "standard_charge_percentage": 90, "methodology": "percent of total billed charges", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Employee Benefit Management Services (EBMS)", "plan_name": "EBMS SelectCare Network", "standard_charge_percentage": 80, "methodology": "percent of total billed charges", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Medica Insurance Company", "plan_name": "Medicare Cost", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "First Choice Health Network fka Health InfoNet", "plan_name": "Medicare Advantage", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "First Choice Health Network fka Health InfoNet", "plan_name": "Workers Compensation", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Allegiance Provider Direct", "plan_name": "Montana Association of Counties (MACo)", "standard_charge_percentage": 229.99999999999997, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Allegiance Provider Direct", "plan_name": "State of Montana Employee Benefit Plan (Self-Funded)", "standard_charge_percentage": 229.99999999999997, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Allegiance Provider Direct", "plan_name": "Montana Municipal Interlocal Authority (MMIA)", "standard_charge_percentage": 229.99999999999997, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Medicaid (State)", "plan_name": "Medicaid", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Blue Cross Blue Shield of Montana", "plan_name": "HealthLink Network", "standard_charge_percentage": 75, "methodology": "percent of total billed charges", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Blue Cross Blue Shield of Montana", "plan_name": "Traditional Network", "standard_charge_percentage": 75, "methodology": "percent of total billed charges", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Blue Cross Blue Shield of Montana", "plan_name": "POS Network", "standard_charge_percentage": 75, "methodology": "percent of total billed charges", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Blue Cross Blue Shield of Montana", "plan_name": "Closed Plan Network", "standard_charge_percentage": 75, "methodology": "percent of total billed charges", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Blue Cross Blue Shield of Montana", "plan_name": "Retail HMO POS Network", "standard_charge_percentage": 75, "methodology": "percent of total billed charges", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Blue Cross Blue Shield of Montana", "plan_name": "Blue Options Network", "standard_charge_percentage": 75, "methodology": "percent of total billed charges", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "PacificSource Health Plans", "plan_name": "Medicare Advantage", "standard_charge_percentage": 103, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" } ] } ] }, { "description": "Vent mgmt inpat init day", "code_information": [ { "code": "94002", "type": "HCPCS" } ], "standard_charges": [ { "setting": "outpatient", "payers_information": [ { "payer_name": "National Comp Care", "plan_name": "Workers' Compensation", "standard_charge_percentage": 90, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Coventry Health Care", "plan_name": "Auto Network", "standard_charge_percentage": 90, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "United Healthcare (UHC)", "plan_name": "DSNP", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Coventry Health Care", "plan_name": "Workers' Compensation", "standard_charge_percentage": 95, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Blue Cross Blue Shield of Montana", "plan_name": "Medicare Advantage", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "United Healthcare (UHC)", "plan_name": "Medicare Advantage", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Allegiance Provider Direct", "plan_name": "Medicare", "standard_charge_percentage": 229.99999999999997, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "PacificSource Health Plans", "plan_name": "PPO (PSN Network and Smart Health Network)", "standard_charge_percentage": 80, "methodology": "percent of total billed charges", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "First Choice Health Network fka Health InfoNet", "plan_name": "Commercial", "standard_charge_percentage": 85, "methodology": "percent of total billed charges", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Medicare (CMS)", "plan_name": "Medicare", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Claritev fka MultiPlan", "plan_name": "Workers' Compensation Program", "standard_charge_percentage": 90, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Claritev fka MultiPlan", "plan_name": "Auto Medical Program", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Claritev fka MultiPlan", "plan_name": "PPO", "standard_charge_percentage": 75, "methodology": "percent of total billed charges", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "First Choice of the Midwest", "plan_name": "PPO", "standard_charge_percentage": 90, "methodology": "percent of total billed charges", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Employee Benefit Management Services (EBMS)", "plan_name": "EBMS SelectCare Network", "standard_charge_percentage": 80, "methodology": "percent of total billed charges", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Medica Insurance Company", "plan_name": "Medicare Cost", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "First Choice Health Network fka Health InfoNet", "plan_name": "Medicare Advantage", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "First Choice Health Network fka Health InfoNet", "plan_name": "Workers Compensation", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Allegiance Provider Direct", "plan_name": "Montana Association of Counties (MACo)", "standard_charge_percentage": 229.99999999999997, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Allegiance Provider Direct", "plan_name": "State of Montana Employee Benefit Plan (Self-Funded)", "standard_charge_percentage": 229.99999999999997, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Allegiance Provider Direct", "plan_name": "Montana Municipal Interlocal Authority (MMIA)", "standard_charge_percentage": 229.99999999999997, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Medicaid (State)", "plan_name": "Medicaid", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Blue Cross Blue Shield of Montana", "plan_name": "HealthLink Network", "standard_charge_percentage": 75, "methodology": "percent of total billed charges", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Blue Cross Blue Shield of Montana", "plan_name": "Traditional Network", "standard_charge_percentage": 75, "methodology": "percent of total billed charges", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Blue Cross Blue Shield of Montana", "plan_name": "POS Network", "standard_charge_percentage": 75, "methodology": "percent of total billed charges", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Blue Cross Blue Shield of Montana", "plan_name": "Closed Plan Network", "standard_charge_percentage": 75, "methodology": "percent of total billed charges", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Blue Cross Blue Shield of Montana", "plan_name": "Retail HMO POS Network", "standard_charge_percentage": 75, "methodology": "percent of total billed charges", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Blue Cross Blue Shield of Montana", "plan_name": "Blue Options Network", "standard_charge_percentage": 75, "methodology": "percent of total billed charges", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "PacificSource Health Plans", "plan_name": "Medicare Advantage", "standard_charge_percentage": 103, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" } ] } ] }, { "description": "Resp virus 12-25 targets", "code_information": [ { "code": "87633", "type": "HCPCS" } ], "standard_charges": [ { "setting": "outpatient", "payers_information": [ { "payer_name": "National Comp Care", "plan_name": "Workers' Compensation", "standard_charge_percentage": 90, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Coventry Health Care", "plan_name": "Auto Network", "standard_charge_percentage": 90, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Coventry Health Care", "plan_name": "Workers' Compensation", "standard_charge_percentage": 95, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Blue Cross Blue Shield of Montana", "plan_name": "Medicare Advantage", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Allegiance Provider Direct", "plan_name": "Medicare", "standard_charge_percentage": 229.99999999999997, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "PacificSource Health Plans", "plan_name": "PPO (PSN Network and Smart Health Network)", "standard_charge_percentage": 80, "methodology": "percent of total billed charges", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "First Choice Health Network fka Health InfoNet", "plan_name": "Commercial", "standard_charge_percentage": 85, "methodology": "percent of total billed charges", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Medicare (CMS)", "plan_name": "Medicare", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Claritev fka MultiPlan", "plan_name": "Workers' Compensation Program", "standard_charge_percentage": 90, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Claritev fka MultiPlan", "plan_name": "Auto Medical Program", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Claritev fka MultiPlan", "plan_name": "PPO", "standard_charge_percentage": 75, "methodology": "percent of total billed charges", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "First Choice of the Midwest", "plan_name": "PPO", "standard_charge_percentage": 90, "methodology": "percent of total billed charges", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Employee Benefit Management Services (EBMS)", "plan_name": "EBMS SelectCare Network", "standard_charge_percentage": 80, "methodology": "percent of total billed charges", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Medica Insurance Company", "plan_name": "Medicare Cost", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "First Choice Health Network fka Health InfoNet", "plan_name": "Medicare Advantage", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "First Choice Health Network fka Health InfoNet", "plan_name": "Workers Compensation", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Allegiance Provider Direct", "plan_name": "Montana Association of Counties (MACo)", "standard_charge_percentage": 229.99999999999997, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Allegiance Provider Direct", "plan_name": "State of Montana Employee Benefit Plan (Self-Funded)", "standard_charge_percentage": 229.99999999999997, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Allegiance Provider Direct", "plan_name": "Montana Municipal Interlocal Authority (MMIA)", "standard_charge_percentage": 229.99999999999997, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Medicaid (State)", "plan_name": "Medicaid", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Blue Cross Blue Shield of Montana", "plan_name": "HealthLink Network", "standard_charge_percentage": 75, "methodology": "percent of total billed charges", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Blue Cross Blue Shield of Montana", "plan_name": "Traditional Network", "standard_charge_percentage": 75, "methodology": "percent of total billed charges", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Blue Cross Blue Shield of Montana", "plan_name": "POS Network", "standard_charge_percentage": 75, "methodology": "percent of total billed charges", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Blue Cross Blue Shield of Montana", "plan_name": "Closed Plan Network", "standard_charge_percentage": 75, "methodology": "percent of total billed charges", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Blue Cross Blue Shield of Montana", "plan_name": "Retail HMO POS Network", "standard_charge_percentage": 75, "methodology": "percent of total billed charges", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Blue Cross Blue Shield of Montana", "plan_name": "Blue Options Network", "standard_charge_percentage": 75, "methodology": "percent of total billed charges", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "PacificSource Health Plans", "plan_name": "Medicare Advantage", "standard_charge_percentage": 103, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" } ] } ] }, { "description": "Sbsq hosp ip/obs moderate 35", "code_information": [ { "code": "99232", "type": "HCPCS" } ], "standard_charges": [ { "setting": "outpatient", "payers_information": [ { "payer_name": "National Comp Care", "plan_name": "Workers' Compensation", "standard_charge_percentage": 90, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Coventry Health Care", "plan_name": "Auto Network", "standard_charge_percentage": 90, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Coventry Health Care", "plan_name": "Workers' Compensation", "standard_charge_percentage": 95, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Blue Cross Blue Shield of Montana", "plan_name": "Medicare Advantage", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Allegiance Provider Direct", "plan_name": "Medicare", "standard_charge_percentage": 229.99999999999997, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "PacificSource Health Plans", "plan_name": "PPO (PSN Network and Smart Health Network)", "standard_charge_percentage": 80, "methodology": "percent of total billed charges", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "First Choice Health Network fka Health InfoNet", "plan_name": "Commercial", "standard_charge_percentage": 85, "methodology": "percent of total billed charges", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Medicare (CMS)", "plan_name": "Medicare", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Claritev fka MultiPlan", "plan_name": "Auto Medical Program", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Claritev fka MultiPlan", "plan_name": "Workers' Compensation Program", "standard_charge_percentage": 90, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Claritev fka MultiPlan", "plan_name": "PPO", "standard_charge_percentage": 75, "methodology": "percent of total billed charges", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "First Choice of the Midwest", "plan_name": "PPO", "standard_charge_percentage": 90, "methodology": "percent of total billed charges", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Employee Benefit Management Services (EBMS)", "plan_name": "EBMS SelectCare Network", "standard_charge_percentage": 80, "methodology": "percent of total billed charges", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Medica Insurance Company", "plan_name": "Medicare Cost", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "First Choice Health Network fka Health InfoNet", "plan_name": "Medicare Advantage", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "First Choice Health Network fka Health InfoNet", "plan_name": "Workers Compensation", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Allegiance Provider Direct", "plan_name": "Montana Association of Counties (MACo)", "standard_charge_percentage": 229.99999999999997, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Allegiance Provider Direct", "plan_name": "State of Montana Employee Benefit Plan (Self-Funded)", "standard_charge_percentage": 229.99999999999997, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Allegiance Provider Direct", "plan_name": "Montana Municipal Interlocal Authority (MMIA)", "standard_charge_percentage": 229.99999999999997, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Medicaid (State)", "plan_name": "Medicaid", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Blue Cross Blue Shield of Montana", "plan_name": "HealthLink Network", "standard_charge_percentage": 75, "methodology": "percent of total billed charges", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Blue Cross Blue Shield of Montana", "plan_name": "Traditional Network", "standard_charge_percentage": 75, "methodology": "percent of total billed charges", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Blue Cross Blue Shield of Montana", "plan_name": "POS Network", "standard_charge_percentage": 75, "methodology": "percent of total billed charges", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Blue Cross Blue Shield of Montana", "plan_name": "Closed Plan Network", "standard_charge_percentage": 75, "methodology": "percent of total billed charges", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Blue Cross Blue Shield of Montana", "plan_name": "Retail HMO POS Network", "standard_charge_percentage": 75, "methodology": "percent of total billed charges", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Blue Cross Blue Shield of Montana", "plan_name": "Blue Options Network", "standard_charge_percentage": 75, "methodology": "percent of total billed charges", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "PacificSource Health Plans", "plan_name": "Medicare Advantage", "standard_charge_percentage": 103, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" } ] } ] }, { "description": "Application of finger splint", "code_information": [ { "code": "29130", "type": "HCPCS" } ], "standard_charges": [ { "setting": "outpatient", "payers_information": [ { "payer_name": "National Comp Care", "plan_name": "Workers' Compensation", "standard_charge_percentage": 90, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Coventry Health Care", "plan_name": "Auto Network", "standard_charge_percentage": 90, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Coventry Health Care", "plan_name": "Workers' Compensation", "standard_charge_percentage": 95, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "TriWest Healthcare Alliance Corporation", "plan_name": "VA CCN", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Blue Cross Blue Shield of Montana", "plan_name": "Medicare Advantage", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Allegiance Provider Direct", "plan_name": "Medicare", "standard_charge_percentage": 229.99999999999997, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "PacificSource Health Plans", "plan_name": "PPO (PSN Network and Smart Health Network)", "standard_charge_percentage": 80, "methodology": "percent of total billed charges", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "First Choice Health Network fka Health InfoNet", "plan_name": "Commercial", "standard_charge_percentage": 85, "methodology": "percent of total billed charges", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Medicare (CMS)", "plan_name": "Medicare", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Claritev fka MultiPlan", "plan_name": "Auto Medical Program", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Claritev fka MultiPlan", "plan_name": "Workers' Compensation Program", "standard_charge_percentage": 90, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Claritev fka MultiPlan", "plan_name": "PPO", "standard_charge_percentage": 75, "methodology": "percent of total billed charges", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "First Choice of the Midwest", "plan_name": "PPO", "standard_charge_percentage": 90, "methodology": "percent of total billed charges", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Employee Benefit Management Services (EBMS)", "plan_name": "EBMS SelectCare Network", "standard_charge_percentage": 80, "methodology": "percent of total billed charges", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Medica Insurance Company", "plan_name": "Medicare Cost", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "First Choice Health Network fka Health InfoNet", "plan_name": "Medicare Advantage", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "First Choice Health Network fka Health InfoNet", "plan_name": "Workers Compensation", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Allegiance Provider Direct", "plan_name": "Montana Association of Counties (MACo)", "standard_charge_percentage": 229.99999999999997, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Allegiance Provider Direct", "plan_name": "State of Montana Employee Benefit Plan (Self-Funded)", "standard_charge_percentage": 229.99999999999997, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Allegiance Provider Direct", "plan_name": "Montana Municipal Interlocal Authority (MMIA)", "standard_charge_percentage": 229.99999999999997, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Medicaid (State)", "plan_name": "Medicaid", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Blue Cross Blue Shield of Montana", "plan_name": "HealthLink Network", "standard_charge_percentage": 75, "methodology": "percent of total billed charges", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Blue Cross Blue Shield of Montana", "plan_name": "Traditional Network", "standard_charge_percentage": 75, "methodology": "percent of total billed charges", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Blue Cross Blue Shield of Montana", "plan_name": "POS Network", "standard_charge_percentage": 75, "methodology": "percent of total billed charges", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Blue Cross Blue Shield of Montana", "plan_name": "Closed Plan Network", "standard_charge_percentage": 75, "methodology": "percent of total billed charges", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Blue Cross Blue Shield of Montana", "plan_name": "Retail HMO POS Network", "standard_charge_percentage": 75, "methodology": "percent of total billed charges", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Blue Cross Blue Shield of Montana", "plan_name": "Blue Options Network", "standard_charge_percentage": 75, "methodology": "percent of total billed charges", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "PacificSource Health Plans", "plan_name": "Medicare Advantage", "standard_charge_percentage": 103, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" } ] } ] }, { "description": "Prosthetic traing 1st enc", "code_information": [ { "code": "97761", "type": "HCPCS" } ], "standard_charges": [ { "setting": "outpatient", "payers_information": [ { "payer_name": "National Comp Care", "plan_name": "Workers' Compensation", "standard_charge_percentage": 90, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Coventry Health Care", "plan_name": "Auto Network", "standard_charge_percentage": 90, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Coventry Health Care", "plan_name": "Workers' Compensation", "standard_charge_percentage": 95, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Blue Cross Blue Shield of Montana", "plan_name": "Medicare Advantage", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Allegiance Provider Direct", "plan_name": "Medicare", "standard_charge_percentage": 229.99999999999997, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "PacificSource Health Plans", "plan_name": "PPO (PSN Network and Smart Health Network)", "standard_charge_percentage": 80, "methodology": "percent of total billed charges", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "First Choice Health Network fka Health InfoNet", "plan_name": "Commercial", "standard_charge_percentage": 85, "methodology": "percent of total billed charges", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Medicare (CMS)", "plan_name": "Medicare", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Claritev fka MultiPlan", "plan_name": "Auto Medical Program", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Claritev fka MultiPlan", "plan_name": "Workers' Compensation Program", "standard_charge_percentage": 90, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Claritev fka MultiPlan", "plan_name": "PPO", "standard_charge_percentage": 75, "methodology": "percent of total billed charges", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "First Choice of the Midwest", "plan_name": "PPO", "standard_charge_percentage": 90, "methodology": "percent of total billed charges", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Employee Benefit Management Services (EBMS)", "plan_name": "EBMS SelectCare Network", "standard_charge_percentage": 80, "methodology": "percent of total billed charges", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Medica Insurance Company", "plan_name": "Medicare Cost", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "First Choice Health Network fka Health InfoNet", "plan_name": "Medicare Advantage", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "First Choice Health Network fka Health InfoNet", "plan_name": "Workers Compensation", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Allegiance Provider Direct", "plan_name": "Montana Association of Counties (MACo)", "standard_charge_percentage": 229.99999999999997, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Allegiance Provider Direct", "plan_name": "State of Montana Employee Benefit Plan (Self-Funded)", "standard_charge_percentage": 229.99999999999997, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Allegiance Provider Direct", "plan_name": "Montana Municipal Interlocal Authority (MMIA)", "standard_charge_percentage": 229.99999999999997, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Medicaid (State)", "plan_name": "Medicaid", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Blue Cross Blue Shield of Montana", "plan_name": "HealthLink Network", "standard_charge_percentage": 75, "methodology": "percent of total billed charges", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Blue Cross Blue Shield of Montana", "plan_name": "Traditional Network", "standard_charge_percentage": 75, "methodology": "percent of total billed charges", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Blue Cross Blue Shield of Montana", "plan_name": "POS Network", "standard_charge_percentage": 75, "methodology": "percent of total billed charges", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Blue Cross Blue Shield of Montana", "plan_name": "Closed Plan Network", "standard_charge_percentage": 75, "methodology": "percent of total billed charges", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Blue Cross Blue Shield of Montana", "plan_name": "Retail HMO POS Network", "standard_charge_percentage": 75, "methodology": "percent of total billed charges", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Blue Cross Blue Shield of Montana", "plan_name": "Blue Options Network", "standard_charge_percentage": 75, "methodology": "percent of total billed charges", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "PacificSource Health Plans", "plan_name": "Medicare Advantage", "standard_charge_percentage": 103, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" } ] } ] }, { "description": "Culture anaerobe ident each", "code_information": [ { "code": "87076", "type": "HCPCS" } ], "standard_charges": [ { "setting": "outpatient", "payers_information": [ { "payer_name": "United Healthcare (UHC)", "plan_name": "DSNP", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "United Healthcare (UHC)", "plan_name": "Medicare Advantage", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" } ] } ] }, { "description": "Mechanical traction therapy", "code_information": [ { "code": "97012", "type": "HCPCS" } ], "standard_charges": [ { "setting": "outpatient", "payers_information": [ { "payer_name": "National Comp Care", "plan_name": "Workers' Compensation", "standard_charge_percentage": 90, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Coventry Health Care", "plan_name": "Auto Network", "standard_charge_percentage": 90, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Coventry Health Care", "plan_name": "Workers' Compensation", "standard_charge_percentage": 95, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Blue Cross Blue Shield of Montana", "plan_name": "Medicare Advantage", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Allegiance Provider Direct", "plan_name": "Medicare", "standard_charge_percentage": 229.99999999999997, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "PacificSource Health Plans", "plan_name": "PPO (PSN Network and Smart Health Network)", "standard_charge_percentage": 80, "methodology": "percent of total billed charges", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "First Choice Health Network fka Health InfoNet", "plan_name": "Commercial", "standard_charge_percentage": 85, "methodology": "percent of total billed charges", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Medicare (CMS)", "plan_name": "Medicare", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Claritev fka MultiPlan", "plan_name": "Auto Medical Program", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Claritev fka MultiPlan", "plan_name": "Workers' Compensation Program", "standard_charge_percentage": 90, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Claritev fka MultiPlan", "plan_name": "PPO", "standard_charge_percentage": 75, "methodology": "percent of total billed charges", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "First Choice of the Midwest", "plan_name": "PPO", "standard_charge_percentage": 90, "methodology": "percent of total billed charges", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Employee Benefit Management Services (EBMS)", "plan_name": "EBMS SelectCare Network", "standard_charge_percentage": 80, "methodology": "percent of total billed charges", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Medica Insurance Company", "plan_name": "Medicare Cost", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "First Choice Health Network fka Health InfoNet", "plan_name": "Medicare Advantage", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "First Choice Health Network fka Health InfoNet", "plan_name": "Workers Compensation", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Allegiance Provider Direct", "plan_name": "Montana Association of Counties (MACo)", "standard_charge_percentage": 229.99999999999997, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Allegiance Provider Direct", "plan_name": "State of Montana Employee Benefit Plan (Self-Funded)", "standard_charge_percentage": 229.99999999999997, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Allegiance Provider Direct", "plan_name": "Montana Municipal Interlocal Authority (MMIA)", "standard_charge_percentage": 229.99999999999997, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Medicaid (State)", "plan_name": "Medicaid", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Blue Cross Blue Shield of Montana", "plan_name": "HealthLink Network", "standard_charge_percentage": 75, "methodology": "percent of total billed charges", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Blue Cross Blue Shield of Montana", "plan_name": "Traditional Network", "standard_charge_percentage": 75, "methodology": "percent of total billed charges", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Blue Cross Blue Shield of Montana", "plan_name": "POS Network", "standard_charge_percentage": 75, "methodology": "percent of total billed charges", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Blue Cross Blue Shield of Montana", "plan_name": "Closed Plan Network", "standard_charge_percentage": 75, "methodology": "percent of total billed charges", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Blue Cross Blue Shield of Montana", "plan_name": "Retail HMO POS Network", "standard_charge_percentage": 75, "methodology": "percent of total billed charges", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Blue Cross Blue Shield of Montana", "plan_name": "Blue Options Network", "standard_charge_percentage": 75, "methodology": "percent of total billed charges", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "PacificSource Health Plans", "plan_name": "Medicare Advantage", "standard_charge_percentage": 103, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" } ] } ] }, { "description": "Mri lumbar spine w/o & w/dye", "code_information": [ { "code": "72158", "type": "HCPCS" } ], "standard_charges": [ { "setting": "outpatient", "payers_information": [ { "payer_name": "National Comp Care", "plan_name": "Workers' Compensation", "standard_charge_percentage": 90, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Coventry Health Care", "plan_name": "Auto Network", "standard_charge_percentage": 90, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Coventry Health Care", "plan_name": "Workers' Compensation", "standard_charge_percentage": 95, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "TriWest Healthcare Alliance Corporation", "plan_name": "VA CCN", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Blue Cross Blue Shield of Montana", "plan_name": "Medicare Advantage", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Allegiance Provider Direct", "plan_name": "Medicare", "standard_charge_percentage": 229.99999999999997, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "PacificSource Health Plans", "plan_name": "PPO (PSN Network and Smart Health Network)", "standard_charge_percentage": 80, "methodology": "percent of total billed charges", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "First Choice Health Network fka Health InfoNet", "plan_name": "Commercial", "standard_charge_percentage": 85, "methodology": "percent of total billed charges", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Medicare (CMS)", "plan_name": "Medicare", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Claritev fka MultiPlan", "plan_name": "Auto Medical Program", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Claritev fka MultiPlan", "plan_name": "Workers' Compensation Program", "standard_charge_percentage": 90, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Claritev fka MultiPlan", "plan_name": "PPO", "standard_charge_percentage": 75, "methodology": "percent of total billed charges", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "First Choice of the Midwest", "plan_name": "PPO", "standard_charge_percentage": 90, "methodology": "percent of total billed charges", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Employee Benefit Management Services (EBMS)", "plan_name": "EBMS SelectCare Network", "standard_charge_percentage": 80, "methodology": "percent of total billed charges", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Medica Insurance Company", "plan_name": "Medicare Cost", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "First Choice Health Network fka Health InfoNet", "plan_name": "Medicare Advantage", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "First Choice Health Network fka Health InfoNet", "plan_name": "Workers Compensation", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Allegiance Provider Direct", "plan_name": "Montana Association of Counties (MACo)", "standard_charge_percentage": 229.99999999999997, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Allegiance Provider Direct", "plan_name": "State of Montana Employee Benefit Plan (Self-Funded)", "standard_charge_percentage": 229.99999999999997, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Allegiance Provider Direct", "plan_name": "Montana Municipal Interlocal Authority (MMIA)", "standard_charge_percentage": 229.99999999999997, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Medicaid (State)", "plan_name": "Medicaid", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Blue Cross Blue Shield of Montana", "plan_name": "HealthLink Network", "standard_charge_percentage": 75, "methodology": "percent of total billed charges", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Blue Cross Blue Shield of Montana", "plan_name": "Traditional Network", "standard_charge_percentage": 75, "methodology": "percent of total billed charges", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Blue Cross Blue Shield of Montana", "plan_name": "POS Network", "standard_charge_percentage": 75, "methodology": "percent of total billed charges", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Blue Cross Blue Shield of Montana", "plan_name": "Closed Plan Network", "standard_charge_percentage": 75, "methodology": "percent of total billed charges", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Blue Cross Blue Shield of Montana", "plan_name": "Retail HMO POS Network", "standard_charge_percentage": 75, "methodology": "percent of total billed charges", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Blue Cross Blue Shield of Montana", "plan_name": "Blue Options Network", "standard_charge_percentage": 75, "methodology": "percent of total billed charges", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "PacificSource Health Plans", "plan_name": "Medicare Advantage", "standard_charge_percentage": 103, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" } ] } ] }, { "description": "Unlisted e&m service", "code_information": [ { "code": "99499", "type": "HCPCS" } ], "standard_charges": [ { "setting": "outpatient", "payers_information": [ { "payer_name": "National Comp Care", "plan_name": "Workers' Compensation", "standard_charge_percentage": 90, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Coventry Health Care", "plan_name": "Auto Network", "standard_charge_percentage": 90, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Coventry Health Care", "plan_name": "Workers' Compensation", "standard_charge_percentage": 95, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Blue Cross Blue Shield of Montana", "plan_name": "Medicare Advantage", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Allegiance Provider Direct", "plan_name": "Medicare", "standard_charge_percentage": 229.99999999999997, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "PacificSource Health Plans", "plan_name": "PPO (PSN Network and Smart Health Network)", "standard_charge_percentage": 80, "methodology": "percent of total billed charges", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "First Choice Health Network fka Health InfoNet", "plan_name": "Commercial", "standard_charge_percentage": 85, "methodology": "percent of total billed charges", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Medicare (CMS)", "plan_name": "Medicare", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Claritev fka MultiPlan", "plan_name": "Auto Medical Program", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Claritev fka MultiPlan", "plan_name": "Workers' Compensation Program", "standard_charge_percentage": 90, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Claritev fka MultiPlan", "plan_name": "PPO", "standard_charge_percentage": 75, "methodology": "percent of total billed charges", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "First Choice of the Midwest", "plan_name": "PPO", "standard_charge_percentage": 90, "methodology": "percent of total billed charges", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Employee Benefit Management Services (EBMS)", "plan_name": "EBMS SelectCare Network", "standard_charge_percentage": 80, "methodology": "percent of total billed charges", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Medica Insurance Company", "plan_name": "Medicare Cost", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "First Choice Health Network fka Health InfoNet", "plan_name": "Medicare Advantage", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "First Choice Health Network fka Health InfoNet", "plan_name": "Workers Compensation", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Allegiance Provider Direct", "plan_name": "Montana Association of Counties (MACo)", "standard_charge_percentage": 229.99999999999997, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Allegiance Provider Direct", "plan_name": "State of Montana Employee Benefit Plan (Self-Funded)", "standard_charge_percentage": 229.99999999999997, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Allegiance Provider Direct", "plan_name": "Montana Municipal Interlocal Authority (MMIA)", "standard_charge_percentage": 229.99999999999997, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Medicaid (State)", "plan_name": "Medicaid", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Blue Cross Blue Shield of Montana", "plan_name": "HealthLink Network", "standard_charge_percentage": 75, "methodology": "percent of total billed charges", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Blue Cross Blue Shield of Montana", "plan_name": "Traditional Network", "standard_charge_percentage": 75, "methodology": "percent of total billed charges", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Blue Cross Blue Shield of Montana", "plan_name": "POS Network", "standard_charge_percentage": 75, "methodology": "percent of total billed charges", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Blue Cross Blue Shield of Montana", "plan_name": "Closed Plan Network", "standard_charge_percentage": 75, "methodology": "percent of total billed charges", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Blue Cross Blue Shield of Montana", "plan_name": "Retail HMO POS Network", "standard_charge_percentage": 75, "methodology": "percent of total billed charges", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Blue Cross Blue Shield of Montana", "plan_name": "Blue Options Network", "standard_charge_percentage": 75, "methodology": "percent of total billed charges", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "PacificSource Health Plans", "plan_name": "Medicare Advantage", "standard_charge_percentage": 103, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" } ] } ] }, { "description": "Caregiver traing 1st 30 min", "code_information": [ { "code": "97550", "type": "HCPCS" } ], "standard_charges": [ { "setting": "outpatient", "payers_information": [ { "payer_name": "National Comp Care", "plan_name": "Workers' Compensation", "standard_charge_percentage": 90, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Coventry Health Care", "plan_name": "Auto Network", "standard_charge_percentage": 90, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Coventry Health Care", "plan_name": "Workers' Compensation", "standard_charge_percentage": 95, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Blue Cross Blue Shield of Montana", "plan_name": "Medicare Advantage", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Allegiance Provider Direct", "plan_name": "Medicare", "standard_charge_percentage": 229.99999999999997, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "PacificSource Health Plans", "plan_name": "PPO (PSN Network and Smart Health Network)", "standard_charge_percentage": 80, "methodology": "percent of total billed charges", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "First Choice Health Network fka Health InfoNet", "plan_name": "Commercial", "standard_charge_percentage": 85, "methodology": "percent of total billed charges", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Medicare (CMS)", "plan_name": "Medicare", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Claritev fka MultiPlan", "plan_name": "Auto Medical Program", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Claritev fka MultiPlan", "plan_name": "Workers' Compensation Program", "standard_charge_percentage": 90, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Claritev fka MultiPlan", "plan_name": "PPO", "standard_charge_percentage": 75, "methodology": "percent of total billed charges", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "First Choice of the Midwest", "plan_name": "PPO", "standard_charge_percentage": 90, "methodology": "percent of total billed charges", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Employee Benefit Management Services (EBMS)", "plan_name": "EBMS SelectCare Network", "standard_charge_percentage": 80, "methodology": "percent of total billed charges", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Medica Insurance Company", "plan_name": "Medicare Cost", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "First Choice Health Network fka Health InfoNet", "plan_name": "Medicare Advantage", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "First Choice Health Network fka Health InfoNet", "plan_name": "Workers Compensation", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Allegiance Provider Direct", "plan_name": "Montana Association of Counties (MACo)", "standard_charge_percentage": 229.99999999999997, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Allegiance Provider Direct", "plan_name": "State of Montana Employee Benefit Plan (Self-Funded)", "standard_charge_percentage": 229.99999999999997, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Allegiance Provider Direct", "plan_name": "Montana Municipal Interlocal Authority (MMIA)", "standard_charge_percentage": 229.99999999999997, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Medicaid (State)", "plan_name": "Medicaid", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Blue Cross Blue Shield of Montana", "plan_name": "HealthLink Network", "standard_charge_percentage": 75, "methodology": "percent of total billed charges", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Blue Cross Blue Shield of Montana", "plan_name": "Traditional Network", "standard_charge_percentage": 75, "methodology": "percent of total billed charges", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Blue Cross Blue Shield of Montana", "plan_name": "POS Network", "standard_charge_percentage": 75, "methodology": "percent of total billed charges", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Blue Cross Blue Shield of Montana", "plan_name": "Closed Plan Network", "standard_charge_percentage": 75, "methodology": "percent of total billed charges", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Blue Cross Blue Shield of Montana", "plan_name": "Retail HMO POS Network", "standard_charge_percentage": 75, "methodology": "percent of total billed charges", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Blue Cross Blue Shield of Montana", "plan_name": "Blue Options Network", "standard_charge_percentage": 75, "methodology": "percent of total billed charges", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "PacificSource Health Plans", "plan_name": "Medicare Advantage", "standard_charge_percentage": 103, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" } ] } ] }, { "description": "Prothrombin time", "code_information": [ { "code": "85610", "type": "HCPCS" } ], "standard_charges": [ { "setting": "outpatient", "payers_information": [ { "payer_name": "National Comp Care", "plan_name": "Workers' Compensation", "standard_charge_percentage": 90, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Coventry Health Care", "plan_name": "Auto Network", "standard_charge_percentage": 90, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "United Healthcare (UHC)", "plan_name": "DSNP", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Coventry Health Care", "plan_name": "Workers' Compensation", "standard_charge_percentage": 95, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Blue Cross Blue Shield of Montana", "plan_name": "Medicare Advantage", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "United Healthcare (UHC)", "plan_name": "Medicare Advantage", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Allegiance Provider Direct", "plan_name": "Medicare", "standard_charge_percentage": 229.99999999999997, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "PacificSource Health Plans", "plan_name": "PPO (PSN Network and Smart Health Network)", "standard_charge_percentage": 80, "methodology": "percent of total billed charges", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "First Choice Health Network fka Health InfoNet", "plan_name": "Commercial", "standard_charge_percentage": 85, "methodology": "percent of total billed charges", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Medicare (CMS)", "plan_name": "Medicare", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Claritev fka MultiPlan", "plan_name": "Auto Medical Program", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Claritev fka MultiPlan", "plan_name": "Workers' Compensation Program", "standard_charge_percentage": 90, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Claritev fka MultiPlan", "plan_name": "PPO", "standard_charge_percentage": 75, "methodology": "percent of total billed charges", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "First Choice of the Midwest", "plan_name": "PPO", "standard_charge_percentage": 90, "methodology": "percent of total billed charges", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Employee Benefit Management Services (EBMS)", "plan_name": "EBMS SelectCare Network", "standard_charge_percentage": 80, "methodology": "percent of total billed charges", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Medica Insurance Company", "plan_name": "Medicare Cost", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "First Choice Health Network fka Health InfoNet", "plan_name": "Medicare Advantage", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "First Choice Health Network fka Health InfoNet", "plan_name": "Workers Compensation", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Allegiance Provider Direct", "plan_name": "Montana Association of Counties (MACo)", "standard_charge_percentage": 229.99999999999997, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Allegiance Provider Direct", "plan_name": "State of Montana Employee Benefit Plan (Self-Funded)", "standard_charge_percentage": 229.99999999999997, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Allegiance Provider Direct", "plan_name": "Montana Municipal Interlocal Authority (MMIA)", "standard_charge_percentage": 229.99999999999997, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Medicaid (State)", "plan_name": "Medicaid", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Blue Cross Blue Shield of Montana", "plan_name": "HealthLink Network", "standard_charge_percentage": 75, "methodology": "percent of total billed charges", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Blue Cross Blue Shield of Montana", "plan_name": "Traditional Network", "standard_charge_percentage": 75, "methodology": "percent of total billed charges", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Blue Cross Blue Shield of Montana", "plan_name": "POS Network", "standard_charge_percentage": 75, "methodology": "percent of total billed charges", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Blue Cross Blue Shield of Montana", "plan_name": "Closed Plan Network", "standard_charge_percentage": 75, "methodology": "percent of total billed charges", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Blue Cross Blue Shield of Montana", "plan_name": "Retail HMO POS Network", "standard_charge_percentage": 75, "methodology": "percent of total billed charges", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Blue Cross Blue Shield of Montana", "plan_name": "Blue Options Network", "standard_charge_percentage": 75, "methodology": "percent of total billed charges", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "PacificSource Health Plans", "plan_name": "Medicare Advantage", "standard_charge_percentage": 103, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" } ] } ] }, { "description": "Sbsq hosp ip/obs sf/low 25", "code_information": [ { "code": "99231", "type": "HCPCS" } ], "standard_charges": [ { "setting": "outpatient", "payers_information": [ { "payer_name": "National Comp Care", "plan_name": "Workers' Compensation", "standard_charge_percentage": 90, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Coventry Health Care", "plan_name": "Auto Network", "standard_charge_percentage": 90, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Coventry Health Care", "plan_name": "Workers' Compensation", "standard_charge_percentage": 95, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Blue Cross Blue Shield of Montana", "plan_name": "Medicare Advantage", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Allegiance Provider Direct", "plan_name": "Medicare", "standard_charge_percentage": 229.99999999999997, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "PacificSource Health Plans", "plan_name": "PPO (PSN Network and Smart Health Network)", "standard_charge_percentage": 80, "methodology": "percent of total billed charges", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "First Choice Health Network fka Health InfoNet", "plan_name": "Commercial", "standard_charge_percentage": 85, "methodology": "percent of total billed charges", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Medicare (CMS)", "plan_name": "Medicare", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Claritev fka MultiPlan", "plan_name": "Auto Medical Program", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Claritev fka MultiPlan", "plan_name": "Workers' Compensation Program", "standard_charge_percentage": 90, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Claritev fka MultiPlan", "plan_name": "PPO", "standard_charge_percentage": 75, "methodology": "percent of total billed charges", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "First Choice of the Midwest", "plan_name": "PPO", "standard_charge_percentage": 90, "methodology": "percent of total billed charges", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Employee Benefit Management Services (EBMS)", "plan_name": "EBMS SelectCare Network", "standard_charge_percentage": 80, "methodology": "percent of total billed charges", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Medica Insurance Company", "plan_name": "Medicare Cost", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "First Choice Health Network fka Health InfoNet", "plan_name": "Medicare Advantage", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "First Choice Health Network fka Health InfoNet", "plan_name": "Workers Compensation", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Allegiance Provider Direct", "plan_name": "Montana Association of Counties (MACo)", "standard_charge_percentage": 229.99999999999997, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Allegiance Provider Direct", "plan_name": "State of Montana Employee Benefit Plan (Self-Funded)", "standard_charge_percentage": 229.99999999999997, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Allegiance Provider Direct", "plan_name": "Montana Municipal Interlocal Authority (MMIA)", "standard_charge_percentage": 229.99999999999997, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Medicaid (State)", "plan_name": "Medicaid", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Blue Cross Blue Shield of Montana", "plan_name": "HealthLink Network", "standard_charge_percentage": 75, "methodology": "percent of total billed charges", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Blue Cross Blue Shield of Montana", "plan_name": "Traditional Network", "standard_charge_percentage": 75, "methodology": "percent of total billed charges", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Blue Cross Blue Shield of Montana", "plan_name": "POS Network", "standard_charge_percentage": 75, "methodology": "percent of total billed charges", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Blue Cross Blue Shield of Montana", "plan_name": "Closed Plan Network", "standard_charge_percentage": 75, "methodology": "percent of total billed charges", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Blue Cross Blue Shield of Montana", "plan_name": "Retail HMO POS Network", "standard_charge_percentage": 75, "methodology": "percent of total billed charges", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Blue Cross Blue Shield of Montana", "plan_name": "Blue Options Network", "standard_charge_percentage": 75, "methodology": "percent of total billed charges", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "PacificSource Health Plans", "plan_name": "Medicare Advantage", "standard_charge_percentage": 103, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" } ] } ] }, { "description": "Sars-cov-2 covid-19 amp prb", "code_information": [ { "code": "87635", "type": "HCPCS" } ], "standard_charges": [ { "setting": "outpatient", "payers_information": [ { "payer_name": "National Comp Care", "plan_name": "Workers' Compensation", "standard_charge_percentage": 90, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Coventry Health Care", "plan_name": "Auto Network", "standard_charge_percentage": 90, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "United Healthcare (UHC)", "plan_name": "DSNP", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Coventry Health Care", "plan_name": "Workers' Compensation", "standard_charge_percentage": 95, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Blue Cross Blue Shield of Montana", "plan_name": "Medicare Advantage", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "United Healthcare (UHC)", "plan_name": "Medicare Advantage", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Allegiance Provider Direct", "plan_name": "Medicare", "standard_charge_percentage": 229.99999999999997, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "PacificSource Health Plans", "plan_name": "PPO (PSN Network and Smart Health Network)", "standard_charge_percentage": 80, "methodology": "percent of total billed charges", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "First Choice Health Network fka Health InfoNet", "plan_name": "Commercial", "standard_charge_percentage": 85, "methodology": "percent of total billed charges", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Medicare (CMS)", "plan_name": "Medicare", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Claritev fka MultiPlan", "plan_name": "Auto Medical Program", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Claritev fka MultiPlan", "plan_name": "Workers' Compensation Program", "standard_charge_percentage": 90, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Claritev fka MultiPlan", "plan_name": "PPO", "standard_charge_percentage": 75, "methodology": "percent of total billed charges", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "First Choice of the Midwest", "plan_name": "PPO", "standard_charge_percentage": 90, "methodology": "percent of total billed charges", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Employee Benefit Management Services (EBMS)", "plan_name": "EBMS SelectCare Network", "standard_charge_percentage": 80, "methodology": "percent of total billed charges", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Medica Insurance Company", "plan_name": "Medicare Cost", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "First Choice Health Network fka Health InfoNet", "plan_name": "Medicare Advantage", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "First Choice Health Network fka Health InfoNet", "plan_name": "Workers Compensation", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Allegiance Provider Direct", "plan_name": "Montana Association of Counties (MACo)", "standard_charge_percentage": 229.99999999999997, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Allegiance Provider Direct", "plan_name": "State of Montana Employee Benefit Plan (Self-Funded)", "standard_charge_percentage": 229.99999999999997, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Allegiance Provider Direct", "plan_name": "Montana Municipal Interlocal Authority (MMIA)", "standard_charge_percentage": 229.99999999999997, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Medicaid (State)", "plan_name": "Medicaid", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Blue Cross Blue Shield of Montana", "plan_name": "HealthLink Network", "standard_charge_percentage": 75, "methodology": "percent of total billed charges", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Blue Cross Blue Shield of Montana", "plan_name": "Traditional Network", "standard_charge_percentage": 75, "methodology": "percent of total billed charges", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Blue Cross Blue Shield of Montana", "plan_name": "POS Network", "standard_charge_percentage": 75, "methodology": "percent of total billed charges", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Blue Cross Blue Shield of Montana", "plan_name": "Closed Plan Network", "standard_charge_percentage": 75, "methodology": "percent of total billed charges", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Blue Cross Blue Shield of Montana", "plan_name": "Retail HMO POS Network", "standard_charge_percentage": 75, "methodology": "percent of total billed charges", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Blue Cross Blue Shield of Montana", "plan_name": "Blue Options Network", "standard_charge_percentage": 75, "methodology": "percent of total billed charges", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "PacificSource Health Plans", "plan_name": "Medicare Advantage", "standard_charge_percentage": 103, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" } ] } ] }, { "description": "C-reactive protein", "code_information": [ { "code": "86140", "type": "HCPCS" } ], "standard_charges": [ { "setting": "outpatient", "payers_information": [ { "payer_name": "National Comp Care", "plan_name": "Workers' Compensation", "standard_charge_percentage": 90, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Coventry Health Care", "plan_name": "Auto Network", "standard_charge_percentage": 90, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "United Healthcare (UHC)", "plan_name": "DSNP", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Coventry Health Care", "plan_name": "Workers' Compensation", "standard_charge_percentage": 95, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Blue Cross Blue Shield of Montana", "plan_name": "Medicare Advantage", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "United Healthcare (UHC)", "plan_name": "Medicare Advantage", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Allegiance Provider Direct", "plan_name": "Medicare", "standard_charge_percentage": 229.99999999999997, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "PacificSource Health Plans", "plan_name": "PPO (PSN Network and Smart Health Network)", "standard_charge_percentage": 80, "methodology": "percent of total billed charges", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "First Choice Health Network fka Health InfoNet", "plan_name": "Commercial", "standard_charge_percentage": 85, "methodology": "percent of total billed charges", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Medicare (CMS)", "plan_name": "Medicare", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Claritev fka MultiPlan", "plan_name": "Auto Medical Program", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Claritev fka MultiPlan", "plan_name": "Workers' Compensation Program", "standard_charge_percentage": 90, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Claritev fka MultiPlan", "plan_name": "PPO", "standard_charge_percentage": 75, "methodology": "percent of total billed charges", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "First Choice of the Midwest", "plan_name": "PPO", "standard_charge_percentage": 90, "methodology": "percent of total billed charges", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Employee Benefit Management Services (EBMS)", "plan_name": "EBMS SelectCare Network", "standard_charge_percentage": 80, "methodology": "percent of total billed charges", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Medica Insurance Company", "plan_name": "Medicare Cost", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "First Choice Health Network fka Health InfoNet", "plan_name": "Medicare Advantage", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "First Choice Health Network fka Health InfoNet", "plan_name": "Workers Compensation", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Allegiance Provider Direct", "plan_name": "Montana Association of Counties (MACo)", "standard_charge_percentage": 229.99999999999997, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Allegiance Provider Direct", "plan_name": "State of Montana Employee Benefit Plan (Self-Funded)", "standard_charge_percentage": 229.99999999999997, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Allegiance Provider Direct", "plan_name": "Montana Municipal Interlocal Authority (MMIA)", "standard_charge_percentage": 229.99999999999997, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Medicaid (State)", "plan_name": "Medicaid", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Blue Cross Blue Shield of Montana", "plan_name": "HealthLink Network", "standard_charge_percentage": 75, "methodology": "percent of total billed charges", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Blue Cross Blue Shield of Montana", "plan_name": "Traditional Network", "standard_charge_percentage": 75, "methodology": "percent of total billed charges", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Blue Cross Blue Shield of Montana", "plan_name": "POS Network", "standard_charge_percentage": 75, "methodology": "percent of total billed charges", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Blue Cross Blue Shield of Montana", "plan_name": "Closed Plan Network", "standard_charge_percentage": 75, "methodology": "percent of total billed charges", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Blue Cross Blue Shield of Montana", "plan_name": "Retail HMO POS Network", "standard_charge_percentage": 75, "methodology": "percent of total billed charges", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Blue Cross Blue Shield of Montana", "plan_name": "Blue Options Network", "standard_charge_percentage": 75, "methodology": "percent of total billed charges", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "PacificSource Health Plans", "plan_name": "Medicare Advantage", "standard_charge_percentage": 103, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" } ] } ] }, { "description": "C diff amplified probe", "code_information": [ { "code": "87493", "type": "HCPCS" } ], "standard_charges": [ { "setting": "outpatient", "payers_information": [ { "payer_name": "National Comp Care", "plan_name": "Workers' Compensation", "standard_charge_percentage": 90, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Coventry Health Care", "plan_name": "Auto Network", "standard_charge_percentage": 90, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Coventry Health Care", "plan_name": "Workers' Compensation", "standard_charge_percentage": 95, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Blue Cross Blue Shield of Montana", "plan_name": "Medicare Advantage", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Allegiance Provider Direct", "plan_name": "Medicare", "standard_charge_percentage": 229.99999999999997, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "PacificSource Health Plans", "plan_name": "PPO (PSN Network and Smart Health Network)", "standard_charge_percentage": 80, "methodology": "percent of total billed charges", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "First Choice Health Network fka Health InfoNet", "plan_name": "Commercial", "standard_charge_percentage": 85, "methodology": "percent of total billed charges", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Medicare (CMS)", "plan_name": "Medicare", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Claritev fka MultiPlan", "plan_name": "Auto Medical Program", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Claritev fka MultiPlan", "plan_name": "Workers' Compensation Program", "standard_charge_percentage": 90, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Claritev fka MultiPlan", "plan_name": "PPO", "standard_charge_percentage": 75, "methodology": "percent of total billed charges", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "First Choice of the Midwest", "plan_name": "PPO", "standard_charge_percentage": 90, "methodology": "percent of total billed charges", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Employee Benefit Management Services (EBMS)", "plan_name": "EBMS SelectCare Network", "standard_charge_percentage": 80, "methodology": "percent of total billed charges", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Medica Insurance Company", "plan_name": "Medicare Cost", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "First Choice Health Network fka Health InfoNet", "plan_name": "Medicare Advantage", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "First Choice Health Network fka Health InfoNet", "plan_name": "Workers Compensation", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Allegiance Provider Direct", "plan_name": "Montana Association of Counties (MACo)", "standard_charge_percentage": 229.99999999999997, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Allegiance Provider Direct", "plan_name": "State of Montana Employee Benefit Plan (Self-Funded)", "standard_charge_percentage": 229.99999999999997, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Allegiance Provider Direct", "plan_name": "Montana Municipal Interlocal Authority (MMIA)", "standard_charge_percentage": 229.99999999999997, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Medicaid (State)", "plan_name": "Medicaid", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Blue Cross Blue Shield of Montana", "plan_name": "HealthLink Network", "standard_charge_percentage": 75, "methodology": "percent of total billed charges", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Blue Cross Blue Shield of Montana", "plan_name": "Traditional Network", "standard_charge_percentage": 75, "methodology": "percent of total billed charges", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Blue Cross Blue Shield of Montana", "plan_name": "POS Network", "standard_charge_percentage": 75, "methodology": "percent of total billed charges", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Blue Cross Blue Shield of Montana", "plan_name": "Closed Plan Network", "standard_charge_percentage": 75, "methodology": "percent of total billed charges", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Blue Cross Blue Shield of Montana", "plan_name": "Retail HMO POS Network", "standard_charge_percentage": 75, "methodology": "percent of total billed charges", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Blue Cross Blue Shield of Montana", "plan_name": "Blue Options Network", "standard_charge_percentage": 75, "methodology": "percent of total billed charges", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "PacificSource Health Plans", "plan_name": "Medicare Advantage", "standard_charge_percentage": 103, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" } ] } ] }, { "description": "Assay thyroid stim hormone", "code_information": [ { "code": "84443", "type": "HCPCS" } ], "standard_charges": [ { "setting": "outpatient", "payers_information": [ { "payer_name": "National Comp Care", "plan_name": "Workers' Compensation", "standard_charge_percentage": 90, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Coventry Health Care", "plan_name": "Auto Network", "standard_charge_percentage": 90, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "United Healthcare (UHC)", "plan_name": "DSNP", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Coventry Health Care", "plan_name": "Workers' Compensation", "standard_charge_percentage": 95, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Blue Cross Blue Shield of Montana", "plan_name": "Medicare Advantage", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "United Healthcare (UHC)", "plan_name": "Medicare Advantage", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Allegiance Provider Direct", "plan_name": "Medicare", "standard_charge_percentage": 229.99999999999997, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "PacificSource Health Plans", "plan_name": "PPO (PSN Network and Smart Health Network)", "standard_charge_percentage": 80, "methodology": "percent of total billed charges", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "First Choice Health Network fka Health InfoNet", "plan_name": "Commercial", "standard_charge_percentage": 85, "methodology": "percent of total billed charges", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Medicare (CMS)", "plan_name": "Medicare", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Claritev fka MultiPlan", "plan_name": "Auto Medical Program", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Claritev fka MultiPlan", "plan_name": "Workers' Compensation Program", "standard_charge_percentage": 90, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Claritev fka MultiPlan", "plan_name": "PPO", "standard_charge_percentage": 75, "methodology": "percent of total billed charges", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "First Choice of the Midwest", "plan_name": "PPO", "standard_charge_percentage": 90, "methodology": "percent of total billed charges", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Employee Benefit Management Services (EBMS)", "plan_name": "EBMS SelectCare Network", "standard_charge_percentage": 80, "methodology": "percent of total billed charges", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Medica Insurance Company", "plan_name": "Medicare Cost", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "First Choice Health Network fka Health InfoNet", "plan_name": "Medicare Advantage", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "First Choice Health Network fka Health InfoNet", "plan_name": "Workers Compensation", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Allegiance Provider Direct", "plan_name": "Montana Association of Counties (MACo)", "standard_charge_percentage": 229.99999999999997, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Allegiance Provider Direct", "plan_name": "State of Montana Employee Benefit Plan (Self-Funded)", "standard_charge_percentage": 229.99999999999997, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Allegiance Provider Direct", "plan_name": "Montana Municipal Interlocal Authority (MMIA)", "standard_charge_percentage": 229.99999999999997, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Medicaid (State)", "plan_name": "Medicaid", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Blue Cross Blue Shield of Montana", "plan_name": "HealthLink Network", "standard_charge_percentage": 75, "methodology": "percent of total billed charges", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Blue Cross Blue Shield of Montana", "plan_name": "Traditional Network", "standard_charge_percentage": 75, "methodology": "percent of total billed charges", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Blue Cross Blue Shield of Montana", "plan_name": "POS Network", "standard_charge_percentage": 75, "methodology": "percent of total billed charges", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Blue Cross Blue Shield of Montana", "plan_name": "Closed Plan Network", "standard_charge_percentage": 75, "methodology": "percent of total billed charges", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Blue Cross Blue Shield of Montana", "plan_name": "Retail HMO POS Network", "standard_charge_percentage": 75, "methodology": "percent of total billed charges", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Blue Cross Blue Shield of Montana", "plan_name": "Blue Options Network", "standard_charge_percentage": 75, "methodology": "percent of total billed charges", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "PacificSource Health Plans", "plan_name": "Medicare Advantage", "standard_charge_percentage": 103, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" } ] } ] }, { "description": "Apply forearm splint", "code_information": [ { "code": "29126", "type": "HCPCS" } ], "standard_charges": [ { "setting": "outpatient", "payers_information": [ { "payer_name": "National Comp Care", "plan_name": "Workers' Compensation", "standard_charge_percentage": 90, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Coventry Health Care", "plan_name": "Auto Network", "standard_charge_percentage": 90, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Coventry Health Care", "plan_name": "Workers' Compensation", "standard_charge_percentage": 95, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "TriWest Healthcare Alliance Corporation", "plan_name": "VA CCN", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Blue Cross Blue Shield of Montana", "plan_name": "Medicare Advantage", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Allegiance Provider Direct", "plan_name": "Medicare", "standard_charge_percentage": 229.99999999999997, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "PacificSource Health Plans", "plan_name": "PPO (PSN Network and Smart Health Network)", "standard_charge_percentage": 80, "methodology": "percent of total billed charges", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Medicare (CMS)", "plan_name": "Medicare", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "First Choice Health Network fka Health InfoNet", "plan_name": "Commercial", "standard_charge_percentage": 85, "methodology": "percent of total billed charges", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Claritev fka MultiPlan", "plan_name": "Auto Medical Program", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Claritev fka MultiPlan", "plan_name": "Workers' Compensation Program", "standard_charge_percentage": 90, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Claritev fka MultiPlan", "plan_name": "PPO", "standard_charge_percentage": 75, "methodology": "percent of total billed charges", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "First Choice of the Midwest", "plan_name": "PPO", "standard_charge_percentage": 90, "methodology": "percent of total billed charges", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Employee Benefit Management Services (EBMS)", "plan_name": "EBMS SelectCare Network", "standard_charge_percentage": 80, "methodology": "percent of total billed charges", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Medica Insurance Company", "plan_name": "Medicare Cost", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "First Choice Health Network fka Health InfoNet", "plan_name": "Medicare Advantage", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "First Choice Health Network fka Health InfoNet", "plan_name": "Workers Compensation", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Allegiance Provider Direct", "plan_name": "Montana Association of Counties (MACo)", "standard_charge_percentage": 229.99999999999997, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Allegiance Provider Direct", "plan_name": "State of Montana Employee Benefit Plan (Self-Funded)", "standard_charge_percentage": 229.99999999999997, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Allegiance Provider Direct", "plan_name": "Montana Municipal Interlocal Authority (MMIA)", "standard_charge_percentage": 229.99999999999997, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Medicaid (State)", "plan_name": "Medicaid", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Blue Cross Blue Shield of Montana", "plan_name": "HealthLink Network", "standard_charge_percentage": 75, "methodology": "percent of total billed charges", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Blue Cross Blue Shield of Montana", "plan_name": "Traditional Network", "standard_charge_percentage": 75, "methodology": "percent of total billed charges", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Blue Cross Blue Shield of Montana", "plan_name": "POS Network", "standard_charge_percentage": 75, "methodology": "percent of total billed charges", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Blue Cross Blue Shield of Montana", "plan_name": "Closed Plan Network", "standard_charge_percentage": 75, "methodology": "percent of total billed charges", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Blue Cross Blue Shield of Montana", "plan_name": "Retail HMO POS Network", "standard_charge_percentage": 75, "methodology": "percent of total billed charges", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Blue Cross Blue Shield of Montana", "plan_name": "Blue Options Network", "standard_charge_percentage": 75, "methodology": "percent of total billed charges", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "PacificSource Health Plans", "plan_name": "Medicare Advantage", "standard_charge_percentage": 103, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" } ] } ] }, { "description": "Extremity study", "code_information": [ { "code": "93971", "type": "HCPCS" } ], "standard_charges": [ { "setting": "outpatient", "payers_information": [ { "payer_name": "National Comp Care", "plan_name": "Workers' Compensation", "standard_charge_percentage": 90, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Coventry Health Care", "plan_name": "Auto Network", "standard_charge_percentage": 90, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "United Healthcare (UHC)", "plan_name": "DSNP", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Coventry Health Care", "plan_name": "Workers' Compensation", "standard_charge_percentage": 95, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Blue Cross Blue Shield of Montana", "plan_name": "Medicare Advantage", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "United Healthcare (UHC)", "plan_name": "Medicare Advantage", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Allegiance Provider Direct", "plan_name": "Medicare", "standard_charge_percentage": 229.99999999999997, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "PacificSource Health Plans", "plan_name": "PPO (PSN Network and Smart Health Network)", "standard_charge_percentage": 80, "methodology": "percent of total billed charges", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Medicare (CMS)", "plan_name": "Medicare", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "First Choice Health Network fka Health InfoNet", "plan_name": "Commercial", "standard_charge_percentage": 85, "methodology": "percent of total billed charges", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Claritev fka MultiPlan", "plan_name": "Auto Medical Program", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Claritev fka MultiPlan", "plan_name": "Workers' Compensation Program", "standard_charge_percentage": 90, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Claritev fka MultiPlan", "plan_name": "PPO", "standard_charge_percentage": 75, "methodology": "percent of total billed charges", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "First Choice of the Midwest", "plan_name": "PPO", "standard_charge_percentage": 90, "methodology": "percent of total billed charges", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Employee Benefit Management Services (EBMS)", "plan_name": "EBMS SelectCare Network", "standard_charge_percentage": 80, "methodology": "percent of total billed charges", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Medica Insurance Company", "plan_name": "Medicare Cost", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "First Choice Health Network fka Health InfoNet", "plan_name": "Medicare Advantage", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "First Choice Health Network fka Health InfoNet", "plan_name": "Workers Compensation", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Allegiance Provider Direct", "plan_name": "Montana Association of Counties (MACo)", "standard_charge_percentage": 229.99999999999997, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Allegiance Provider Direct", "plan_name": "State of Montana Employee Benefit Plan (Self-Funded)", "standard_charge_percentage": 229.99999999999997, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Allegiance Provider Direct", "plan_name": "Montana Municipal Interlocal Authority (MMIA)", "standard_charge_percentage": 229.99999999999997, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Medicaid (State)", "plan_name": "Medicaid", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Blue Cross Blue Shield of Montana", "plan_name": "HealthLink Network", "standard_charge_percentage": 75, "methodology": "percent of total billed charges", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Blue Cross Blue Shield of Montana", "plan_name": "Traditional Network", "standard_charge_percentage": 75, "methodology": "percent of total billed charges", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Blue Cross Blue Shield of Montana", "plan_name": "POS Network", "standard_charge_percentage": 75, "methodology": "percent of total billed charges", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Blue Cross Blue Shield of Montana", "plan_name": "Closed Plan Network", "standard_charge_percentage": 75, "methodology": "percent of total billed charges", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Blue Cross Blue Shield of Montana", "plan_name": "Retail HMO POS Network", "standard_charge_percentage": 75, "methodology": "percent of total billed charges", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Blue Cross Blue Shield of Montana", "plan_name": "Blue Options Network", "standard_charge_percentage": 75, "methodology": "percent of total billed charges", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "PacificSource Health Plans", "plan_name": "Medicare Advantage", "standard_charge_percentage": 103, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" } ] } ] }, { "description": "Lower extremity study", "code_information": [ { "code": "93926", "type": "HCPCS" } ], "standard_charges": [ { "setting": "outpatient", "payers_information": [ { "payer_name": "National Comp Care", "plan_name": "Workers' Compensation", "standard_charge_percentage": 90, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Coventry Health Care", "plan_name": "Auto Network", "standard_charge_percentage": 90, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "United Healthcare (UHC)", "plan_name": "DSNP", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Coventry Health Care", "plan_name": "Workers' Compensation", "standard_charge_percentage": 95, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Blue Cross Blue Shield of Montana", "plan_name": "Medicare Advantage", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "United Healthcare (UHC)", "plan_name": "Medicare Advantage", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Allegiance Provider Direct", "plan_name": "Medicare", "standard_charge_percentage": 229.99999999999997, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "PacificSource Health Plans", "plan_name": "PPO (PSN Network and Smart Health Network)", "standard_charge_percentage": 80, "methodology": "percent of total billed charges", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Medicare (CMS)", "plan_name": "Medicare", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "First Choice Health Network fka Health InfoNet", "plan_name": "Commercial", "standard_charge_percentage": 85, "methodology": "percent of total billed charges", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Claritev fka MultiPlan", "plan_name": "Auto Medical Program", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Claritev fka MultiPlan", "plan_name": "Workers' Compensation Program", "standard_charge_percentage": 90, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Claritev fka MultiPlan", "plan_name": "PPO", "standard_charge_percentage": 75, "methodology": "percent of total billed charges", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "First Choice of the Midwest", "plan_name": "PPO", "standard_charge_percentage": 90, "methodology": "percent of total billed charges", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Employee Benefit Management Services (EBMS)", "plan_name": "EBMS SelectCare Network", "standard_charge_percentage": 80, "methodology": "percent of total billed charges", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Medica Insurance Company", "plan_name": "Medicare Cost", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "First Choice Health Network fka Health InfoNet", "plan_name": "Medicare Advantage", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "First Choice Health Network fka Health InfoNet", "plan_name": "Workers Compensation", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Allegiance Provider Direct", "plan_name": "Montana Association of Counties (MACo)", "standard_charge_percentage": 229.99999999999997, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Allegiance Provider Direct", "plan_name": "State of Montana Employee Benefit Plan (Self-Funded)", "standard_charge_percentage": 229.99999999999997, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Allegiance Provider Direct", "plan_name": "Montana Municipal Interlocal Authority (MMIA)", "standard_charge_percentage": 229.99999999999997, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Medicaid (State)", "plan_name": "Medicaid", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Blue Cross Blue Shield of Montana", "plan_name": "HealthLink Network", "standard_charge_percentage": 75, "methodology": "percent of total billed charges", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Blue Cross Blue Shield of Montana", "plan_name": "Traditional Network", "standard_charge_percentage": 75, "methodology": "percent of total billed charges", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Blue Cross Blue Shield of Montana", "plan_name": "POS Network", "standard_charge_percentage": 75, "methodology": "percent of total billed charges", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Blue Cross Blue Shield of Montana", "plan_name": "Closed Plan Network", "standard_charge_percentage": 75, "methodology": "percent of total billed charges", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Blue Cross Blue Shield of Montana", "plan_name": "Retail HMO POS Network", "standard_charge_percentage": 75, "methodology": "percent of total billed charges", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Blue Cross Blue Shield of Montana", "plan_name": "Blue Options Network", "standard_charge_percentage": 75, "methodology": "percent of total billed charges", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "PacificSource Health Plans", "plan_name": "Medicare Advantage", "standard_charge_percentage": 103, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" } ] } ] }, { "description": "Urine culture/colony count", "code_information": [ { "code": "87086", "type": "HCPCS" } ], "standard_charges": [ { "setting": "outpatient", "payers_information": [ { "payer_name": "National Comp Care", "plan_name": "Workers' Compensation", "standard_charge_percentage": 90, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "United Healthcare (UHC)", "plan_name": "DSNP", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Coventry Health Care", "plan_name": "Auto Network", "standard_charge_percentage": 90, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Coventry Health Care", "plan_name": "Workers' Compensation", "standard_charge_percentage": 95, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Blue Cross Blue Shield of Montana", "plan_name": "Medicare Advantage", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "United Healthcare (UHC)", "plan_name": "Medicare Advantage", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Allegiance Provider Direct", "plan_name": "Medicare", "standard_charge_percentage": 229.99999999999997, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "PacificSource Health Plans", "plan_name": "PPO (PSN Network and Smart Health Network)", "standard_charge_percentage": 80, "methodology": "percent of total billed charges", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Medicare (CMS)", "plan_name": "Medicare", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "First Choice Health Network fka Health InfoNet", "plan_name": "Commercial", "standard_charge_percentage": 85, "methodology": "percent of total billed charges", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Claritev fka MultiPlan", "plan_name": "Auto Medical Program", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Claritev fka MultiPlan", "plan_name": "Workers' Compensation Program", "standard_charge_percentage": 90, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Claritev fka MultiPlan", "plan_name": "PPO", "standard_charge_percentage": 75, "methodology": "percent of total billed charges", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "First Choice of the Midwest", "plan_name": "PPO", "standard_charge_percentage": 90, "methodology": "percent of total billed charges", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Employee Benefit Management Services (EBMS)", "plan_name": "EBMS SelectCare Network", "standard_charge_percentage": 80, "methodology": "percent of total billed charges", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Medica Insurance Company", "plan_name": "Medicare Cost", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "First Choice Health Network fka Health InfoNet", "plan_name": "Medicare Advantage", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "First Choice Health Network fka Health InfoNet", "plan_name": "Workers Compensation", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Allegiance Provider Direct", "plan_name": "Montana Association of Counties (MACo)", "standard_charge_percentage": 229.99999999999997, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Allegiance Provider Direct", "plan_name": "State of Montana Employee Benefit Plan (Self-Funded)", "standard_charge_percentage": 229.99999999999997, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Allegiance Provider Direct", "plan_name": "Montana Municipal Interlocal Authority (MMIA)", "standard_charge_percentage": 229.99999999999997, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Medicaid (State)", "plan_name": "Medicaid", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Blue Cross Blue Shield of Montana", "plan_name": "HealthLink Network", "standard_charge_percentage": 75, "methodology": "percent of total billed charges", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Blue Cross Blue Shield of Montana", "plan_name": "Traditional Network", "standard_charge_percentage": 75, "methodology": "percent of total billed charges", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Blue Cross Blue Shield of Montana", "plan_name": "POS Network", "standard_charge_percentage": 75, "methodology": "percent of total billed charges", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Blue Cross Blue Shield of Montana", "plan_name": "Closed Plan Network", "standard_charge_percentage": 75, "methodology": "percent of total billed charges", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Blue Cross Blue Shield of Montana", "plan_name": "Retail HMO POS Network", "standard_charge_percentage": 75, "methodology": "percent of total billed charges", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Blue Cross Blue Shield of Montana", "plan_name": "Blue Options Network", "standard_charge_percentage": 75, "methodology": "percent of total billed charges", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "PacificSource Health Plans", "plan_name": "Medicare Advantage", "standard_charge_percentage": 103, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" } ] } ] }, { "description": "Culture aerobic identify", "code_information": [ { "code": "87077", "type": "HCPCS" } ], "standard_charges": [ { "setting": "outpatient", "payers_information": [ { "payer_name": "United Healthcare (UHC)", "plan_name": "DSNP", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "United Healthcare (UHC)", "plan_name": "Medicare Advantage", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" } ] } ] }, { "description": "Av fuse uppr arm basilic", "code_information": [ { "code": "36819", "type": "HCPCS" } ], "standard_charges": [ { "setting": "outpatient", "payers_information": [ { "payer_name": "United Healthcare (UHC)", "plan_name": "DSNP", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "United Healthcare (UHC)", "plan_name": "Medicare Advantage", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" } ] } ] }, { "description": "Av fusion direct any site", "code_information": [ { "code": "36821", "type": "HCPCS" } ], "standard_charges": [ { "setting": "outpatient", "payers_information": [ { "payer_name": "United Healthcare (UHC)", "plan_name": "DSNP", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "United Healthcare (UHC)", "plan_name": "Medicare Advantage", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" } ] } ] }, { "description": "Artery-vein nonautograft", "code_information": [ { "code": "36830", "type": "HCPCS" } ], "standard_charges": [ { "setting": "outpatient", "payers_information": [ { "payer_name": "United Healthcare (UHC)", "plan_name": "DSNP", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "United Healthcare (UHC)", "plan_name": "Medicare Advantage", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" } ] } ] }, { "description": "Av fistula revision open", "code_information": [ { "code": "36832", "type": "HCPCS" } ], "standard_charges": [ { "setting": "outpatient", "payers_information": [ { "payer_name": "United Healthcare (UHC)", "plan_name": "DSNP", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "United Healthcare (UHC)", "plan_name": "Medicare Advantage", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" } ] } ] }, { "description": "Intro cath dialysis circuit", "code_information": [ { "code": "36901", "type": "HCPCS" } ], "standard_charges": [ { "setting": "outpatient", "payers_information": [ { "payer_name": "United Healthcare (UHC)", "plan_name": "DSNP", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "United Healthcare (UHC)", "plan_name": "Medicare Advantage", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" } ] } ] }, { "description": "Intro cath dialysis circuit", "code_information": [ { "code": "36902", "type": "HCPCS" } ], "standard_charges": [ { "setting": "outpatient", "payers_information": [ { "payer_name": "United Healthcare (UHC)", "plan_name": "DSNP", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "United Healthcare (UHC)", "plan_name": "Medicare Advantage", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" } ] } ] }, { "description": "Intro cath dialysis circuit", "code_information": [ { "code": "36903", "type": "HCPCS" } ], "standard_charges": [ { "setting": "outpatient", "payers_information": [ { "payer_name": "United Healthcare (UHC)", "plan_name": "DSNP", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "United Healthcare (UHC)", "plan_name": "Medicare Advantage", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" } ] } ] }, { "description": "Thrmbc/nfs dialysis circuit", "code_information": [ { "code": "36905", "type": "HCPCS" } ], "standard_charges": [ { "setting": "outpatient", "payers_information": [ { "payer_name": "United Healthcare (UHC)", "plan_name": "DSNP", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "United Healthcare (UHC)", "plan_name": "Medicare Advantage", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" } ] } ] }, { "description": "Thrmbc/nfs dialysis circuit", "code_information": [ { "code": "36906", "type": "HCPCS" } ], "standard_charges": [ { "setting": "outpatient", "payers_information": [ { "payer_name": "United Healthcare (UHC)", "plan_name": "DSNP", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "United Healthcare (UHC)", "plan_name": "Medicare Advantage", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" } ] } ] }, { "description": "Balo angiop ctr dialysis seg", "code_information": [ { "code": "36907", "type": "HCPCS" } ], "standard_charges": [ { "setting": "outpatient", "payers_information": [ { "payer_name": "United Healthcare (UHC)", "plan_name": "DSNP", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "United Healthcare (UHC)", "plan_name": "Medicare Advantage", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" } ] } ] }, { "description": "Dialysis circuit embolj", "code_information": [ { "code": "36909", "type": "HCPCS" } ], "standard_charges": [ { "setting": "outpatient", "payers_information": [ { "payer_name": "United Healthcare (UHC)", "plan_name": "DSNP", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "United Healthcare (UHC)", "plan_name": "Medicare Advantage", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" } ] } ] }, { "description": "Rem endovas vena cava filter", "code_information": [ { "code": "37193", "type": "HCPCS" } ], "standard_charges": [ { "setting": "outpatient", "payers_information": [ { "payer_name": "United Healthcare (UHC)", "plan_name": "DSNP", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "United Healthcare (UHC)", "plan_name": "Medicare Advantage", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" } ] } ] }, { "description": "Thrombolytic art therapy", "code_information": [ { "code": "37211", "type": "HCPCS" } ], "standard_charges": [ { "setting": "outpatient", "payers_information": [ { "payer_name": "United Healthcare (UHC)", "plan_name": "DSNP", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "United Healthcare (UHC)", "plan_name": "Medicare Advantage", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" } ] } ] }, { "description": "Fem/popl revas w/tla", "code_information": [ { "code": "37224", "type": "HCPCS" } ], "standard_charges": [ { "setting": "outpatient", "payers_information": [ { "payer_name": "United Healthcare (UHC)", "plan_name": "DSNP", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "United Healthcare (UHC)", "plan_name": "Medicare Advantage", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" } ] } ] }, { "description": "Fem/popl revas w/ather", "code_information": [ { "code": "37225", "type": "HCPCS" } ], "standard_charges": [ { "setting": "outpatient", "payers_information": [ { "payer_name": "United Healthcare (UHC)", "plan_name": "DSNP", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "United Healthcare (UHC)", "plan_name": "Medicare Advantage", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" } ] } ] }, { "description": "Tib/per revasc w/tla", "code_information": [ { "code": "37228", "type": "HCPCS" } ], "standard_charges": [ { "setting": "outpatient", "payers_information": [ { "payer_name": "United Healthcare (UHC)", "plan_name": "DSNP", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "United Healthcare (UHC)", "plan_name": "Medicare Advantage", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" } ] } ] }, { "description": "Tib/per revasc w/ather", "code_information": [ { "code": "37229", "type": "HCPCS" } ], "standard_charges": [ { "setting": "outpatient", "payers_information": [ { "payer_name": "United Healthcare (UHC)", "plan_name": "DSNP", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "United Healthcare (UHC)", "plan_name": "Medicare Advantage", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" } ] } ] }, { "description": "Tib/per revasc add-on", "code_information": [ { "code": "37232", "type": "HCPCS" } ], "standard_charges": [ { "setting": "outpatient", "payers_information": [ { "payer_name": "United Healthcare (UHC)", "plan_name": "DSNP", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "United Healthcare (UHC)", "plan_name": "Medicare Advantage", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" } ] } ] }, { "description": "Tibper revasc w/ather add-on", "code_information": [ { "code": "37233", "type": "HCPCS" } ], "standard_charges": [ { "setting": "outpatient", "payers_information": [ { "payer_name": "United Healthcare (UHC)", "plan_name": "DSNP", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "United Healthcare (UHC)", "plan_name": "Medicare Advantage", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" } ] } ] }, { "description": "Open/perq place stent same", "code_information": [ { "code": "37238", "type": "HCPCS" } ], "standard_charges": [ { "setting": "outpatient", "payers_information": [ { "payer_name": "United Healthcare (UHC)", "plan_name": "DSNP", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "United Healthcare (UHC)", "plan_name": "Medicare Advantage", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" } ] } ] }, { "description": "Open/perq place stent ea add", "code_information": [ { "code": "37239", "type": "HCPCS" } ], "standard_charges": [ { "setting": "outpatient", "payers_information": [ { "payer_name": "United Healthcare (UHC)", "plan_name": "DSNP", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "United Healthcare (UHC)", "plan_name": "Medicare Advantage", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" } ] } ] }, { "description": "Vasc embolize/occlude organ", "code_information": [ { "code": "37243", "type": "HCPCS" } ], "standard_charges": [ { "setting": "outpatient", "payers_information": [ { "payer_name": "United Healthcare (UHC)", "plan_name": "DSNP", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "United Healthcare (UHC)", "plan_name": "Medicare Advantage", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" } ] } ] }, { "description": "Trluml balo angiop 1st art", "code_information": [ { "code": "37246", "type": "HCPCS" } ], "standard_charges": [ { "setting": "outpatient", "payers_information": [ { "payer_name": "United Healthcare (UHC)", "plan_name": "DSNP", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "United Healthcare (UHC)", "plan_name": "Medicare Advantage", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" } ] } ] }, { "description": "Intrvasc us noncoronary 1st", "code_information": [ { "code": "37252", "type": "HCPCS" } ], "standard_charges": [ { "setting": "outpatient", "payers_information": [ { "payer_name": "United Healthcare (UHC)", "plan_name": "DSNP", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "United Healthcare (UHC)", "plan_name": "Medicare Advantage", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" } ] } ] }, { "description": "2d oral/facial photo image", "code_information": [ { "code": "D0703", "type": "HCPCS" } ], "standard_charges": [ { "setting": "outpatient", "payers_information": [ { "payer_name": "United Healthcare (UHC)", "plan_name": "DSNP", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "United Healthcare (UHC)", "plan_name": "Medicare Advantage", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" } ] } ] }, { "description": "Admin influenza virus vac", "code_information": [ { "code": "G0008", "type": "HCPCS" } ], "standard_charges": [ { "setting": "outpatient", "payers_information": [ { "payer_name": "United Healthcare (UHC)", "plan_name": "DSNP", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "United Healthcare (UHC)", "plan_name": "Medicare Advantage", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" } ] } ] }, { "description": "Unsched dialysis esrd pt hos", "code_information": [ { "code": "G0257", "type": "HCPCS" } ], "standard_charges": [ { "setting": "outpatient", "payers_information": [ { "payer_name": "United Healthcare (UHC)", "plan_name": "DSNP", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "United Healthcare (UHC)", "plan_name": "Medicare Advantage", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" } ] } ] }, { "description": "Hospital observation per hr", "code_information": [ { "code": "G0378", "type": "HCPCS" } ], "standard_charges": [ { "setting": "outpatient", "payers_information": [ { "payer_name": "United Healthcare (UHC)", "plan_name": "DSNP", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "United Healthcare (UHC)", "plan_name": "Medicare Advantage", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" } ] } ] }, { "description": "Direct refer hospital observ", "code_information": [ { "code": "G0379", "type": "HCPCS" } ], "standard_charges": [ { "setting": "outpatient", "payers_information": [ { "payer_name": "United Healthcare (UHC)", "plan_name": "DSNP", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "United Healthcare (UHC)", "plan_name": "Medicare Advantage", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" } ] } ] }, { "description": "Trauma respons w/hosp criti", "code_information": [ { "code": "G0390", "type": "HCPCS" } ], "standard_charges": [ { "setting": "outpatient", "payers_information": [ { "payer_name": "United Healthcare (UHC)", "plan_name": "DSNP", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "United Healthcare (UHC)", "plan_name": "Medicare Advantage", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" } ] } ] }, { "description": "Hospital outpt clinic visit", "code_information": [ { "code": "G0463", "type": "HCPCS" } ], "standard_charges": [ { "setting": "outpatient", "payers_information": [ { "payer_name": "United Healthcare (UHC)", "plan_name": "DSNP", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "United Healthcare (UHC)", "plan_name": "Medicare Advantage", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" } ] } ] }, { "description": "Drug test def 1-7 classes", "code_information": [ { "code": "G0480", "type": "HCPCS" } ], "standard_charges": [ { "setting": "outpatient", "payers_information": [ { "payer_name": "United Healthcare (UHC)", "plan_name": "DSNP", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "United Healthcare (UHC)", "plan_name": "Medicare Advantage", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" } ] } ] }, { "description": "Inj, acetaminophen (nos)", "code_information": [ { "code": "J0131", "type": "HCPCS" }, { "code": "36000-0372-40", "type": "NDC" } ], "standard_charges": [ { "setting": "outpatient", "payers_information": [ { "payer_name": "United Healthcare (UHC)", "plan_name": "DSNP", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "United Healthcare (UHC)", "plan_name": "Medicare Advantage", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" } ] } ], "drug_information": { "unit": 65, "type": "ML" } }, { "description": "Adrenalin epinephrine inject", "code_information": [ { "code": "J0171", "type": "HCPCS" }, { "code": "00093-5985-27", "type": "NDC" } ], "standard_charges": [ { "setting": "outpatient", "payers_information": [ { "payer_name": "United Healthcare (UHC)", "plan_name": "DSNP", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "United Healthcare (UHC)", "plan_name": "Medicare Advantage", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" } ] } ], "drug_information": { "unit": 2, "type": "EA" } }, { "description": "Ampicillin 500 mg inj", "code_information": [ { "code": "J0290", "type": "HCPCS" }, { "code": "00409-3718-01", "type": "NDC" } ], "standard_charges": [ { "setting": "outpatient", "payers_information": [ { "payer_name": "United Healthcare (UHC)", "plan_name": "DSNP", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "United Healthcare (UHC)", "plan_name": "Medicare Advantage", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" } ] } ], "drug_information": { "unit": 10, "type": "EA" } }, { "description": "Ampicillin sulbactam 1.5 gm", "code_information": [ { "code": "J0295", "type": "HCPCS" }, { "code": "00049-0013-83", "type": "NDC" } ], "standard_charges": [ { "setting": "outpatient", "payers_information": [ { "payer_name": "United Healthcare (UHC)", "plan_name": "DSNP", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "United Healthcare (UHC)", "plan_name": "Medicare Advantage", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" } ] } ], "drug_information": { "unit": 1, "type": "EA" } }, { "description": "Succinycholine chloride inj", "code_information": [ { "code": "J0330", "type": "HCPCS" }, { "code": "00143-9338-25", "type": "NDC" } ], "standard_charges": [ { "setting": "outpatient", "payers_information": [ { "payer_name": "United Healthcare (UHC)", "plan_name": "DSNP", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "United Healthcare (UHC)", "plan_name": "Medicare Advantage", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" } ] } ], "drug_information": { "unit": 10, "type": "ML" } }, { "description": "Hydralazine hcl injection", "code_information": [ { "code": "J0360", "type": "HCPCS" }, { "code": "00641-6231-25", "type": "NDC" } ], "standard_charges": [ { "setting": "outpatient", "payers_information": [ { "payer_name": "United Healthcare (UHC)", "plan_name": "DSNP", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "United Healthcare (UHC)", "plan_name": "Medicare Advantage", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" } ] } ], "drug_information": { "unit": 1, "type": "ML" } }, { "description": "Azithromycin", "code_information": [ { "code": "J0456", "type": "HCPCS" }, { "code": "00069-3150-83", "type": "NDC" } ], "standard_charges": [ { "setting": "outpatient", "payers_information": [ { "payer_name": "United Healthcare (UHC)", "plan_name": "DSNP", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "United Healthcare (UHC)", "plan_name": "Medicare Advantage", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" } ] } ], "drug_information": { "unit": 1, "type": "EA" } }, { "description": "Atropine sulfate injection", "code_information": [ { "code": "J0461", "type": "HCPCS" }, { "code": "16729-0512-43", "type": "NDC" } ], "standard_charges": [ { "setting": "outpatient", "payers_information": [ { "payer_name": "United Healthcare (UHC)", "plan_name": "DSNP", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "United Healthcare (UHC)", "plan_name": "Medicare Advantage", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" } ] } ], "drug_information": { "unit": 20, "type": "ML" } }, { "description": "Dicyclomine injection", "code_information": [ { "code": "J0500", "type": "HCPCS" }, { "code": "00517-1980-05", "type": "NDC" } ], "standard_charges": [ { "setting": "outpatient", "payers_information": [ { "payer_name": "United Healthcare (UHC)", "plan_name": "DSNP", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "United Healthcare (UHC)", "plan_name": "Medicare Advantage", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" } ] } ], "drug_information": { "unit": 2, "type": "ML" } }, { "description": "Bivalirudin", "code_information": [ { "code": "J0583", "type": "HCPCS" }, { "code": "00338-9572-24", "type": "NDC" } ], "standard_charges": [ { "setting": "outpatient", "payers_information": [ { "payer_name": "United Healthcare (UHC)", "plan_name": "DSNP", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "United Healthcare (UHC)", "plan_name": "Medicare Advantage", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" } ] } ], "drug_information": { "unit": 50, "type": "ML" } }, { "description": "Calcium glucon (fresenius)", "code_information": [ { "code": "J0612", "type": "HCPCS" }, { "code": "00143-9180-25", "type": "NDC" } ], "standard_charges": [ { "setting": "outpatient", "payers_information": [ { "payer_name": "United Healthcare (UHC)", "plan_name": "DSNP", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "United Healthcare (UHC)", "plan_name": "Medicare Advantage", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" } ] } ], "drug_information": { "unit": 10, "type": "ML" } }, { "description": "Inj, bupivacaine, nos, 0.5mg", "code_information": [ { "code": "J0665", "type": "HCPCS" }, { "code": "00143-9328-10", "type": "NDC" } ], "standard_charges": [ { "setting": "outpatient", "payers_information": [ { "payer_name": "United Healthcare (UHC)", "plan_name": "DSNP", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "United Healthcare (UHC)", "plan_name": "Medicare Advantage", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" } ] } ], "drug_information": { "unit": 50, "type": "ML" } }, { "description": "Cefazolin sodium injection", "code_information": [ { "code": "J0690", "type": "HCPCS" }, { "code": "00143-9261-10", "type": "NDC" } ], "standard_charges": [ { "setting": "outpatient", "payers_information": [ { "payer_name": "United Healthcare (UHC)", "plan_name": "DSNP", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "United Healthcare (UHC)", "plan_name": "Medicare Advantage", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" } ] } ], "drug_information": { "unit": 10, "type": "EA" } }, { "description": "Cefepime hcl for injection", "code_information": [ { "code": "J0692", "type": "HCPCS" }, { "code": "00409-9566-10", "type": "NDC" } ], "standard_charges": [ { "setting": "outpatient", "payers_information": [ { "payer_name": "United Healthcare (UHC)", "plan_name": "DSNP", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "United Healthcare (UHC)", "plan_name": "Medicare Advantage", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" } ] } ], "drug_information": { "unit": 10, "type": "EA" } }, { "description": "Cefoxitin sodium injection", "code_information": [ { "code": "J0694", "type": "HCPCS" }, { "code": "00264-3123-11", "type": "NDC" } ], "standard_charges": [ { "setting": "outpatient", "payers_information": [ { "payer_name": "United Healthcare (UHC)", "plan_name": "DSNP", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "United Healthcare (UHC)", "plan_name": "Medicare Advantage", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" } ] } ], "drug_information": { "unit": 1, "type": "EA" } }, { "description": "Ceftriaxone sodium injection", "code_information": [ { "code": "J0696", "type": "HCPCS" }, { "code": "00143-9678-01", "type": "NDC" } ], "standard_charges": [ { "setting": "outpatient", "payers_information": [ { "payer_name": "United Healthcare (UHC)", "plan_name": "DSNP", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "United Healthcare (UHC)", "plan_name": "Medicare Advantage", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" } ] } ], "drug_information": { "unit": 1, "type": "EA" } }, { "description": "Ceftaroline fosamil inj", "code_information": [ { "code": "J0712", "type": "HCPCS" } ], "standard_charges": [ { "setting": "outpatient", "payers_information": [ { "payer_name": "United Healthcare (UHC)", "plan_name": "DSNP", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "United Healthcare (UHC)", "plan_name": "Medicare Advantage", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "First Choice of the Midwest", "plan_name": "PPO", "standard_charge_percentage": 90, "methodology": "percent of total billed charges", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" } ] } ] }, { "description": "Inj ceftazidime per 500 mg", "code_information": [ { "code": "J0713", "type": "HCPCS" }, { "code": "00409-5082-16", "type": "NDC" } ], "standard_charges": [ { "setting": "outpatient", "payers_information": [ { "payer_name": "United Healthcare (UHC)", "plan_name": "DSNP", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "United Healthcare (UHC)", "plan_name": "Medicare Advantage", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" } ] } ], "drug_information": { "unit": 1, "type": "EA" } }, { "description": "Ciprofloxacin iv", "code_information": [ { "code": "J0744", "type": "HCPCS" }, { "code": "00409-2300-24", "type": "NDC" } ], "standard_charges": [ { "setting": "outpatient", "payers_information": [ { "payer_name": "United Healthcare (UHC)", "plan_name": "DSNP", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "United Healthcare (UHC)", "plan_name": "Medicare Advantage", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" } ] } ], "drug_information": { "unit": 100, "type": "ML" } }, { "description": "Dexamethasone sodium phos", "code_information": [ { "code": "J1100", "type": "HCPCS" }, { "code": "00641-0367-21", "type": "NDC" } ], "standard_charges": [ { "setting": "outpatient", "payers_information": [ { "payer_name": "United Healthcare (UHC)", "plan_name": "DSNP", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "United Healthcare (UHC)", "plan_name": "Medicare Advantage", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" } ] } ], "drug_information": { "unit": 1, "type": "ML" } }, { "description": "Hydromorphone injection", "code_information": [ { "code": "J1170", "type": "HCPCS" }, { "code": "00409-1283-05", "type": "NDC" } ], "standard_charges": [ { "setting": "outpatient", "payers_information": [ { "payer_name": "United Healthcare (UHC)", "plan_name": "DSNP", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "United Healthcare (UHC)", "plan_name": "Medicare Advantage", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" } ] } ], "drug_information": { "unit": 0.5, "type": "ML" } }, { "description": "Injection, hydromorphone, 0.1 mg", "code_information": [ { "code": "J1171", "type": "HCPCS" }, { "code": "00409-1283-31", "type": "NDC" } ], "standard_charges": [ { "setting": "outpatient", "payers_information": [ { "payer_name": "United Healthcare (UHC)", "plan_name": "DSNP", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "United Healthcare (UHC)", "plan_name": "Medicare Advantage", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "First Choice of the Midwest", "plan_name": "PPO", "standard_charge_percentage": 90, "methodology": "percent of total billed charges", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" } ] } ], "drug_information": { "unit": 1, "type": "ML" } }, { "description": "Inj tbo filgrastim 1 microg", "code_information": [ { "code": "J1447", "type": "HCPCS" }, { "code": "63459-0918-59", "type": "NDC" } ], "standard_charges": [ { "setting": "outpatient", "payers_information": [ { "payer_name": "United Healthcare (UHC)", "plan_name": "DSNP", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "United Healthcare (UHC)", "plan_name": "Medicare Advantage", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "First Choice of the Midwest", "plan_name": "PPO", "standard_charge_percentage": 90, "methodology": "percent of total billed charges", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" } ] } ], "drug_information": { "unit": 1, "type": "ML" } }, { "description": "Fluconazole", "code_information": [ { "code": "J1450", "type": "HCPCS" }, { "code": "00338-6045-37", "type": "NDC" } ], "standard_charges": [ { "setting": "outpatient", "payers_information": [ { "payer_name": "United Healthcare (UHC)", "plan_name": "DSNP", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "United Healthcare (UHC)", "plan_name": "Medicare Advantage", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" } ] } ], "drug_information": { "unit": 200, "type": "ML" } }, { "description": "Garamycin gentamicin inj", "code_information": [ { "code": "J1580", "type": "HCPCS" }, { "code": "00143-9128-25", "type": "NDC" } ], "standard_charges": [ { "setting": "outpatient", "payers_information": [ { "payer_name": "United Healthcare (UHC)", "plan_name": "DSNP", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "United Healthcare (UHC)", "plan_name": "Medicare Advantage", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" } ] } ], "drug_information": { "unit": 2, "type": "ML" } }, { "description": "Glucagon hydrochloride/1 mg", "code_information": [ { "code": "J1610", "type": "HCPCS" }, { "code": "00002-8031-01", "type": "NDC" } ], "standard_charges": [ { "setting": "outpatient", "payers_information": [ { "payer_name": "United Healthcare (UHC)", "plan_name": "DSNP", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "United Healthcare (UHC)", "plan_name": "Medicare Advantage", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "First Choice of the Midwest", "plan_name": "PPO", "standard_charge_percentage": 90, "methodology": "percent of total billed charges", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" } ] } ], "drug_information": { "unit": 1, "type": "EA" } }, { "description": "Haloperidol injection", "code_information": [ { "code": "J1630", "type": "HCPCS" }, { "code": "00143-9319-25", "type": "NDC" } ], "standard_charges": [ { "setting": "outpatient", "payers_information": [ { "payer_name": "United Healthcare (UHC)", "plan_name": "DSNP", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "United Healthcare (UHC)", "plan_name": "Medicare Advantage", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" } ] } ], "drug_information": { "unit": 1, "type": "ML" } }, { "description": "Inj heparin sodium per 1000u", "code_information": [ { "code": "J1644", "type": "HCPCS" }, { "code": "00264-5705-05", "type": "NDC" } ], "standard_charges": [ { "setting": "outpatient", "payers_information": [ { "payer_name": "United Healthcare (UHC)", "plan_name": "DSNP", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "United Healthcare (UHC)", "plan_name": "Medicare Advantage", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" } ] } ], "drug_information": { "unit": 0.5, "type": "ML" } }, { "description": "Insulin injection", "code_information": [ { "code": "J1815", "type": "HCPCS" }, { "code": "00002-7511-01", "type": "NDC" } ], "standard_charges": [ { "setting": "outpatient", "payers_information": [ { "payer_name": "United Healthcare (UHC)", "plan_name": "DSNP", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "United Healthcare (UHC)", "plan_name": "Medicare Advantage", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" } ] } ], "drug_information": { "unit": 10, "type": "ML" } }, { "description": "Ketorolac tromethamine inj", "code_information": [ { "code": "J1885", "type": "HCPCS" }, { "code": "00338-0069-10", "type": "NDC" } ], "standard_charges": [ { "setting": "outpatient", "payers_information": [ { "payer_name": "United Healthcare (UHC)", "plan_name": "DSNP", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "United Healthcare (UHC)", "plan_name": "Medicare Advantage", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "First Choice of the Midwest", "plan_name": "PPO", "standard_charge_percentage": 90, "methodology": "percent of total billed charges", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" } ] } ], "drug_information": { "unit": 1, "type": "ML" } }, { "description": "Furosemide injection", "code_information": [ { "code": "J1940", "type": "HCPCS" }, { "code": "00143-9155-25", "type": "NDC" } ], "standard_charges": [ { "setting": "outpatient", "payers_information": [ { "payer_name": "United Healthcare (UHC)", "plan_name": "DSNP", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "United Healthcare (UHC)", "plan_name": "Medicare Advantage", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" } ] } ], "drug_information": { "unit": 2, "type": "ML" } }, { "description": "Levetiracetam injection", "code_information": [ { "code": "J1953", "type": "HCPCS" }, { "code": "00143-9673-25", "type": "NDC" } ], "standard_charges": [ { "setting": "outpatient", "payers_information": [ { "payer_name": "United Healthcare (UHC)", "plan_name": "DSNP", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "United Healthcare (UHC)", "plan_name": "Medicare Advantage", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" } ] } ], "drug_information": { "unit": 5, "type": "ML" } }, { "description": "Levofloxacin injection", "code_information": [ { "code": "J1956", "type": "HCPCS" }, { "code": "00143-9315-24", "type": "NDC" } ], "standard_charges": [ { "setting": "outpatient", "payers_information": [ { "payer_name": "United Healthcare (UHC)", "plan_name": "DSNP", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "United Healthcare (UHC)", "plan_name": "Medicare Advantage", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" } ] } ], "drug_information": { "unit": 50, "type": "ML" } }, { "description": "Lidocaine injection", "code_information": [ { "code": "J2001", "type": "HCPCS" }, { "code": "00264-9594-10", "type": "NDC" } ], "standard_charges": [ { "setting": "outpatient", "payers_information": [ { "payer_name": "United Healthcare (UHC)", "plan_name": "DSNP", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "United Healthcare (UHC)", "plan_name": "Medicare Advantage", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" } ] } ], "drug_information": { "unit": 500, "type": "ML" } }, { "description": "Injection, lidocaine hydrochloride, 1 mg", "code_information": [ { "code": "J2003", "type": "HCPCS" }, { "code": "00143-9172-10", "type": "NDC" } ], "standard_charges": [ { "setting": "outpatient", "payers_information": [ { "payer_name": "United Healthcare (UHC)", "plan_name": "DSNP", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "United Healthcare (UHC)", "plan_name": "Medicare Advantage", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" } ] } ], "drug_information": { "unit": 20, "type": "ML" } }, { "description": "Linezolid injection", "code_information": [ { "code": "J2020", "type": "HCPCS" }, { "code": "00009-5137-01", "type": "NDC" } ], "standard_charges": [ { "setting": "outpatient", "payers_information": [ { "payer_name": "United Healthcare (UHC)", "plan_name": "DSNP", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "United Healthcare (UHC)", "plan_name": "Medicare Advantage", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" } ] } ], "drug_information": { "unit": 100, "type": "ML" } }, { "description": "Lorazepam injection", "code_information": [ { "code": "J2060", "type": "HCPCS" }, { "code": "00409-1539-31", "type": "NDC" } ], "standard_charges": [ { "setting": "outpatient", "payers_information": [ { "payer_name": "United Healthcare (UHC)", "plan_name": "DSNP", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "United Healthcare (UHC)", "plan_name": "Medicare Advantage", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" } ] } ], "drug_information": { "unit": 1, "type": "ML" } }, { "description": "Meperidine hydrochl /100 mg", "code_information": [ { "code": "J2175", "type": "HCPCS" }, { "code": "00338-2691-75", "type": "NDC" } ], "standard_charges": [ { "setting": "outpatient", "payers_information": [ { "payer_name": "United Healthcare (UHC)", "plan_name": "DSNP", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "United Healthcare (UHC)", "plan_name": "Medicare Advantage", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" } ] } ], "drug_information": { "unit": 50, "type": "ML" } }, { "description": "Meropenem", "code_information": [ { "code": "J2185", "type": "HCPCS" }, { "code": "00069-0313-10", "type": "NDC" } ], "standard_charges": [ { "setting": "outpatient", "payers_information": [ { "payer_name": "United Healthcare (UHC)", "plan_name": "DSNP", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "United Healthcare (UHC)", "plan_name": "Medicare Advantage", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" } ] } ], "drug_information": { "unit": 10, "type": "EA" } }, { "description": "Inj midazolam hydrochloride", "code_information": [ { "code": "J2250", "type": "HCPCS" }, { "code": "00409-0001-25", "type": "NDC" } ], "standard_charges": [ { "setting": "outpatient", "payers_information": [ { "payer_name": "United Healthcare (UHC)", "plan_name": "DSNP", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "United Healthcare (UHC)", "plan_name": "Medicare Advantage", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" } ] } ], "drug_information": { "unit": 2, "type": "ML" } }, { "description": "Morphine sulfate injection", "code_information": [ { "code": "J2270", "type": "HCPCS" }, { "code": "00406-1521-53", "type": "NDC" } ], "standard_charges": [ { "setting": "outpatient", "payers_information": [ { "payer_name": "United Healthcare (UHC)", "plan_name": "DSNP", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "United Healthcare (UHC)", "plan_name": "Medicare Advantage", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" } ] } ], "drug_information": { "unit": 5, "type": "GM" } }, { "description": "Inj naloxone hydrochloride", "code_information": [ { "code": "J2310", "type": "HCPCS" }, { "code": "00409-1215-01", "type": "NDC" } ], "standard_charges": [ { "setting": "outpatient", "payers_information": [ { "payer_name": "United Healthcare (UHC)", "plan_name": "DSNP", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "United Healthcare (UHC)", "plan_name": "Medicare Advantage", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" } ] } ], "drug_information": { "unit": 1, "type": "ML" } }, { "description": "Octreotide inj, non-depot", "code_information": [ { "code": "J2354", "type": "HCPCS" }, { "code": "00078-0180-01", "type": "NDC" } ], "standard_charges": [ { "setting": "outpatient", "payers_information": [ { "payer_name": "United Healthcare (UHC)", "plan_name": "DSNP", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "United Healthcare (UHC)", "plan_name": "Medicare Advantage", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" } ] } ], "drug_information": { "unit": 1, "type": "ML" } }, { "description": "Inj phenylephrine hcl 20 mcg", "code_information": [ { "code": "J2371", "type": "HCPCS" }, { "code": "00641-6188-10", "type": "NDC" } ], "standard_charges": [ { "setting": "outpatient", "payers_information": [ { "payer_name": "United Healthcare (UHC)", "plan_name": "DSNP", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "United Healthcare (UHC)", "plan_name": "Medicare Advantage", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" } ] } ], "drug_information": { "unit": 5, "type": "ML" } }, { "description": "Ondansetron hcl injection", "code_information": [ { "code": "J2405", "type": "HCPCS" }, { "code": "00143-9890-10", "type": "NDC" } ], "standard_charges": [ { "setting": "outpatient", "payers_information": [ { "payer_name": "United Healthcare (UHC)", "plan_name": "DSNP", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "United Healthcare (UHC)", "plan_name": "Medicare Advantage", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" } ] } ], "drug_information": { "unit": 20, "type": "ML" } }, { "description": "Papaverin hcl injection", "code_information": [ { "code": "J2440", "type": "HCPCS" }, { "code": "00517-4002-25", "type": "NDC" } ], "standard_charges": [ { "setting": "outpatient", "payers_information": [ { "payer_name": "United Healthcare (UHC)", "plan_name": "DSNP", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "United Healthcare (UHC)", "plan_name": "Medicare Advantage", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" } ] } ], "drug_information": { "unit": 2, "type": "ML" } }, { "description": "Injection, pantoprazole sodium, 40 mg", "code_information": [ { "code": "J2470", "type": "HCPCS" }, { "code": "00143-9300-10", "type": "NDC" } ], "standard_charges": [ { "setting": "outpatient", "payers_information": [ { "payer_name": "United Healthcare (UHC)", "plan_name": "DSNP", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "United Healthcare (UHC)", "plan_name": "Medicare Advantage", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" } ] } ], "drug_information": { "unit": 10, "type": "EA" } }, { "description": "Piperacillin/tazobactam", "code_information": [ { "code": "J2543", "type": "HCPCS" }, { "code": "00206-8852-16", "type": "NDC" } ], "standard_charges": [ { "setting": "outpatient", "payers_information": [ { "payer_name": "United Healthcare (UHC)", "plan_name": "DSNP", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "United Healthcare (UHC)", "plan_name": "Medicare Advantage", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" } ] } ], "drug_information": { "unit": 1, "type": "EA" } }, { "description": "Phenobarbital sodium inj", "code_information": [ { "code": "J2560", "type": "HCPCS" }, { "code": "00641-0476-21", "type": "NDC" } ], "standard_charges": [ { "setting": "outpatient", "payers_information": [ { "payer_name": "United Healthcare (UHC)", "plan_name": "DSNP", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "United Healthcare (UHC)", "plan_name": "Medicare Advantage", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" } ] } ], "drug_information": { "unit": 1, "type": "ML" } }, { "description": "Inj, vasopressin, 1 unit", "code_information": [ { "code": "J2598", "type": "HCPCS" }, { "code": "00548-9701-00", "type": "NDC" } ], "standard_charges": [ { "setting": "outpatient", "payers_information": [ { "payer_name": "United Healthcare (UHC)", "plan_name": "DSNP", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "United Healthcare (UHC)", "plan_name": "Medicare Advantage", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" } ] } ], "drug_information": { "unit": 1, "type": "ML" } }, { "description": "Post chmbr intraocular lens", "code_information": [ { "code": "V2632", "type": "HCPCS" } ], "standard_charges": [ { "setting": "outpatient", "payers_information": [ { "payer_name": "United Healthcare (UHC)", "plan_name": "DSNP", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "United Healthcare (UHC)", "plan_name": "Medicare Advantage", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" } ] } ] }, { "description": "Corneal tissue processing", "code_information": [ { "code": "V2785", "type": "HCPCS" } ], "standard_charges": [ { "setting": "outpatient", "payers_information": [ { "payer_name": "United Healthcare (UHC)", "plan_name": "DSNP", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "United Healthcare (UHC)", "plan_name": "Medicare Advantage", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" } ] } ] }, { "description": "USE OF HOSP,EXAM.OR TREAT.RM.", "code_information": [ { "code": "Z7500", "type": "HCPCS" } ], "standard_charges": [ { "setting": "outpatient", "payers_information": [ { "payer_name": "United Healthcare (UHC)", "plan_name": "DSNP", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "United Healthcare (UHC)", "plan_name": "Medicare Advantage", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" } ] } ] }, { "description": "USE OF EMERGENCY ROOM", "code_information": [ { "code": "Z7502", "type": "HCPCS" } ], "standard_charges": [ { "setting": "outpatient", "payers_information": [ { "payer_name": "United Healthcare (UHC)", "plan_name": "DSNP", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "United Healthcare (UHC)", "plan_name": "Medicare Advantage", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" } ] } ] }, { "description": "USE OF OPER ROOM OR CYST ROOM-FIRST HOUR", "code_information": [ { "code": "Z7506", "type": "HCPCS" } ], "standard_charges": [ { "setting": "outpatient", "payers_information": [ { "payer_name": "United Healthcare (UHC)", "plan_name": "DSNP", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "United Healthcare (UHC)", "plan_name": "Medicare Advantage", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" } ] } ] }, { "description": "USE OF OP OR CYSTO RM 1ST SUBSEQ HALF HR", "code_information": [ { "code": "Z7508", "type": "HCPCS" } ], "standard_charges": [ { "setting": "outpatient", "payers_information": [ { "payer_name": "United Healthcare (UHC)", "plan_name": "DSNP", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "United Healthcare (UHC)", "plan_name": "Medicare Advantage", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" } ] } ] }, { "description": "USE OP OR CYSTO RM SEC SUBS HALF HOUR", "code_information": [ { "code": "Z7510", "type": "HCPCS" } ], "standard_charges": [ { "setting": "outpatient", "payers_information": [ { "payer_name": "United Healthcare (UHC)", "plan_name": "DSNP", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "United Healthcare (UHC)", "plan_name": "Medicare Advantage", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" } ] } ] }, { "description": "USE OF RECOVERY ROOM", "code_information": [ { "code": "Z7512", "type": "HCPCS" } ], "standard_charges": [ { "setting": "outpatient", "payers_information": [ { "payer_name": "United Healthcare (UHC)", "plan_name": "DSNP", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "United Healthcare (UHC)", "plan_name": "Medicare Advantage", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" } ] } ] }, { "description": "PAY FOR RM AND BOARD AND GEN NURSING CAR", "code_information": [ { "code": "Z7514", "type": "HCPCS" } ], "standard_charges": [ { "setting": "outpatient", "payers_information": [ { "payer_name": "United Healthcare (UHC)", "plan_name": "DSNP", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "United Healthcare (UHC)", "plan_name": "Medicare Advantage", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" } ] } ] }, { "description": "MISC DRUGS AND MED SUPPLIES, ADMIN STAT", "code_information": [ { "code": "Z7610", "type": "HCPCS" } ], "standard_charges": [ { "setting": "outpatient", "payers_information": [ { "payer_name": "United Healthcare (UHC)", "plan_name": "DSNP", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "United Healthcare (UHC)", "plan_name": "Medicare Advantage", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" } ] } ] }, { "description": "INITIAL INFANT HEAR-SCREEN-HOSP/INP", "code_information": [ { "code": "Z9725", "type": "HCPCS" } ], "standard_charges": [ { "setting": "outpatient", "payers_information": [ { "payer_name": "United Healthcare (UHC)", "plan_name": "DSNP", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "United Healthcare (UHC)", "plan_name": "Medicare Advantage", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" } ] } ] }, { "description": "Skilled Nursing - General Classification", "code_information": [ { "code": "0550", "type": "RC" } ], "standard_charges": [ { "setting": "outpatient", "payers_information": [ { "payer_name": "Blue Cross Blue Shield of Montana", "plan_name": "Medicare Advantage", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" } ] } ] }, { "description": "Skilled Nursing - Visit Charge", "code_information": [ { "code": "0551", "type": "RC" } ], "standard_charges": [ { "setting": "outpatient", "payers_information": [ { "payer_name": "Blue Cross Blue Shield of Montana", "plan_name": "Medicare Advantage", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" } ] } ] }, { "description": "Skilled Nursing - Evaluation or Testing", "code_information": [ { "code": "0554", "type": "RC" } ], "standard_charges": [ { "setting": "outpatient", "payers_information": [ { "payer_name": "Blue Cross Blue Shield of Montana", "plan_name": "Medicare Advantage", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" } ] } ] }, { "description": "Skilled Nursing - Observation/Hourly", "code_information": [ { "code": "0557", "type": "RC" } ], "standard_charges": [ { "setting": "outpatient", "payers_information": [ { "payer_name": "Blue Cross Blue Shield of Montana", "plan_name": "Medicare Advantage", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" } ] } ] }, { "description": "Skilled Nursing - Other", "code_information": [ { "code": "0558", "type": "RC" } ], "standard_charges": [ { "setting": "outpatient", "payers_information": [ { "payer_name": "Blue Cross Blue Shield of Montana", "plan_name": "Medicare Advantage", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" } ] } ] }, { "description": "Skilled Nursing - Other", "code_information": [ { "code": "0559", "type": "RC" } ], "standard_charges": [ { "setting": "outpatient", "payers_information": [ { "payer_name": "Blue Cross Blue Shield of Montana", "plan_name": "Medicare Advantage", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" } ] } ] }, { "description": "Home Health (HH) - Medical Social Services - Visit Charge", "code_information": [ { "code": "0561", "type": "RC" } ], "standard_charges": [ { "setting": "outpatient", "payers_information": [ { "payer_name": "Blue Cross Blue Shield of Montana", "plan_name": "Medicare Advantage", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" } ] } ] }, { "description": "Leave of Absence - General Classification", "code_information": [ { "code": "0180", "type": "RC" } ], "standard_charges": [ { "setting": "inpatient", "payers_information": [ { "payer_name": "TriWest Healthcare Alliance Corporation", "plan_name": "VA CCN", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Blue Cross Blue Shield of Montana", "plan_name": "Medicare Advantage", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "First Choice of the Midwest", "plan_name": "PPO", "standard_charge_percentage": 90, "methodology": "percent of total billed charges", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Employee Benefit Management Services (EBMS)", "plan_name": "EBMS SelectCare Network", "standard_charge_percentage": 80, "methodology": "percent of total billed charges", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Claritev fka MultiPlan", "plan_name": "Workers' Compensation Program", "standard_charge_percentage": 90, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Claritev fka MultiPlan", "plan_name": "Auto Medical Program", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Allegiance Provider Direct", "plan_name": "Medicare", "standard_charge_percentage": 229.99999999999997, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Claritev fka MultiPlan", "plan_name": "PPO", "standard_charge_percentage": 75, "methodology": "percent of total billed charges", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Medica Insurance Company", "plan_name": "Medicare Cost", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Medicare (CMS)", "plan_name": "Medicare", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "National Comp Care", "plan_name": "Workers' Compensation", "standard_charge_dollar": 1800, "methodology": "per diem", "median_amount": 1800, "10th_percentile": 1800, "90th_percentile": 1800, "count": "1 through 10" }, { "payer_name": "First Choice Health Network fka Health InfoNet", "plan_name": "Commercial", "standard_charge_percentage": 85, "methodology": "percent of total billed charges", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "First Choice Health Network fka Health InfoNet", "plan_name": "Workers Compensation", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Allegiance Provider Direct", "plan_name": "State of Montana Employee Benefit Plan (Self-Funded)", "standard_charge_percentage": 229.99999999999997, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Allegiance Provider Direct", "plan_name": "Montana Municipal Interlocal Authority (MMIA)", "standard_charge_percentage": 229.99999999999997, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Allegiance Provider Direct", "plan_name": "Montana Association of Counties (MACo)", "standard_charge_percentage": 229.99999999999997, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "First Choice Health Network fka Health InfoNet", "plan_name": "Medicare Advantage", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "TriWest Healthcare Alliance Corporation", "plan_name": "TRICARE Prime", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "TriWest Healthcare Alliance Corporation", "plan_name": "TRICARE Select", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Blue Cross Blue Shield of Montana", "plan_name": "HealthLink Network", "standard_charge_percentage": 75, "methodology": "percent of total billed charges", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Blue Cross Blue Shield of Montana", "plan_name": "Traditional Network", "standard_charge_percentage": 75, "methodology": "percent of total billed charges", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Blue Cross Blue Shield of Montana", "plan_name": "POS Network", "standard_charge_percentage": 75, "methodology": "percent of total billed charges", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Blue Cross Blue Shield of Montana", "plan_name": "Closed Plan Network", "standard_charge_percentage": 75, "methodology": "percent of total billed charges", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Blue Cross Blue Shield of Montana", "plan_name": "Retail HMO POS Network", "standard_charge_percentage": 75, "methodology": "percent of total billed charges", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Blue Cross Blue Shield of Montana", "plan_name": "Blue Options Network", "standard_charge_percentage": 75, "methodology": "percent of total billed charges", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "PacificSource Health Plans", "plan_name": "Medicare Advantage", "standard_charge_percentage": 103, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" } ], "minimum": 1800, "maximum": 1800 } ] }, { "description": "Room & Board - Semi-private (Two Beds) - Psychiatric", "code_information": [ { "code": "0124", "type": "RC" } ], "standard_charges": [ { "setting": "inpatient", "payers_information": [ { "payer_name": "Allegiance Provider Direct", "plan_name": "PPO", "standard_charge_dollar": 1900, "methodology": "per diem", "median_amount": 1900, "10th_percentile": 1900, "90th_percentile": 1900, "count": "1 through 10" } ], "minimum": 1900, "maximum": 1900 } ] }, { "description": "Room & Board - Semi-private (Two Beds) - Detoxification", "code_information": [ { "code": "0126", "type": "RC" } ], "standard_charges": [ { "setting": "inpatient", "payers_information": [ { "payer_name": "Allegiance Provider Direct", "plan_name": "PPO", "standard_charge_dollar": 1900, "methodology": "per diem", "median_amount": 1900, "10th_percentile": 1900, "90th_percentile": 1900, "count": "1 through 10" } ], "minimum": 1900, "maximum": 1900 } ] }, { "description": "Room & Board - Three and Four Beds - Psychiatric", "code_information": [ { "code": "0134", "type": "RC" } ], "standard_charges": [ { "setting": "inpatient", "payers_information": [ { "payer_name": "Allegiance Provider Direct", "plan_name": "PPO", "standard_charge_dollar": 1900, "methodology": "per diem", "median_amount": 1900, "10th_percentile": 1900, "90th_percentile": 1900, "count": "1 through 10" } ], "minimum": 1900, "maximum": 1900 } ] }, { "description": "Room & Board - Three and Four Beds - Detoxification", "code_information": [ { "code": "0136", "type": "RC" } ], "standard_charges": [ { "setting": "inpatient", "payers_information": [ { "payer_name": "Allegiance Provider Direct", "plan_name": "PPO", "standard_charge_dollar": 1900, "methodology": "per diem", "median_amount": 1900, "10th_percentile": 1900, "90th_percentile": 1900, "count": "1 through 10" } ], "minimum": 1900, "maximum": 1900 } ] }, { "description": "Room & Board - Deluxe Private - Psychiatric", "code_information": [ { "code": "0144", "type": "RC" } ], "standard_charges": [ { "setting": "inpatient", "payers_information": [ { "payer_name": "Allegiance Provider Direct", "plan_name": "PPO", "standard_charge_dollar": 1900, "methodology": "per diem", "median_amount": 1900, "10th_percentile": 1900, "90th_percentile": 1900, "count": "1 through 10" } ], "minimum": 1900, "maximum": 1900 } ] }, { "description": "Room & Board - Deluxe Private - Detoxification", "code_information": [ { "code": "0146", "type": "RC" } ], "standard_charges": [ { "setting": "inpatient", "payers_information": [ { "payer_name": "Allegiance Provider Direct", "plan_name": "PPO", "standard_charge_dollar": 1900, "methodology": "per diem", "median_amount": 1900, "10th_percentile": 1900, "90th_percentile": 1900, "count": "1 through 10" } ], "minimum": 1900, "maximum": 1900 } ] }, { "description": "Room & Board - Ward - Psychiatric", "code_information": [ { "code": "0154", "type": "RC" } ], "standard_charges": [ { "setting": "inpatient", "payers_information": [ { "payer_name": "Allegiance Provider Direct", "plan_name": "PPO", "standard_charge_dollar": 1900, "methodology": "per diem", "median_amount": 1900, "10th_percentile": 1900, "90th_percentile": 1900, "count": "1 through 10" } ], "minimum": 1900, "maximum": 1900 } ] }, { "description": "Room & Board - Ward - Detoxification", "code_information": [ { "code": "0156", "type": "RC" } ], "standard_charges": [ { "setting": "inpatient", "payers_information": [ { "payer_name": "Allegiance Provider Direct", "plan_name": "PPO", "standard_charge_dollar": 1900, "methodology": "per diem", "median_amount": 1900, "10th_percentile": 1900, "90th_percentile": 1900, "count": "1 through 10" } ], "minimum": 1900, "maximum": 1900 } ] }, { "description": "Intensive Care Unit - Psychiatric", "code_information": [ { "code": "0204", "type": "RC" } ], "standard_charges": [ { "setting": "inpatient", "payers_information": [ { "payer_name": "Allegiance Provider Direct", "plan_name": "PPO", "standard_charge_dollar": 2350, "methodology": "per diem", "median_amount": 2350, "10th_percentile": 2350, "90th_percentile": 2350, "count": "1 through 10" } ], "minimum": 2350, "maximum": 2350 } ] }, { "description": "Coronary Care Unit - Heart Transplant", "code_information": [ { "code": "0213", "type": "RC" } ], "standard_charges": [ { "setting": "inpatient", "payers_information": [ { "payer_name": "Allegiance Provider Direct", "plan_name": "PPO", "standard_charge_dollar": 2350, "methodology": "per diem", "median_amount": 2350, "10th_percentile": 2350, "90th_percentile": 2350, "count": "1 through 10" } ], "minimum": 2350, "maximum": 2350 } ] }, { "description": "Durable Medical Equipment (other than renal) - General Classification", "code_information": [ { "code": "0290", "type": "RC" } ], "standard_charges": [ { "setting": "outpatient", "payers_information": [ { "payer_name": "Blue Cross Blue Shield of Montana", "plan_name": "Medicare Advantage", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" } ] } ] }, { "description": "Durable Medical Equipment (other than renal) - Rental", "code_information": [ { "code": "0291", "type": "RC" } ], "standard_charges": [ { "setting": "outpatient", "payers_information": [ { "payer_name": "Blue Cross Blue Shield of Montana", "plan_name": "Medicare Advantage", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" } ] } ] }, { "description": "Durable Medical Equipment (other than renal) - Purchase of new DME", "code_information": [ { "code": "0292", "type": "RC" } ], "standard_charges": [ { "setting": "outpatient", "payers_information": [ { "payer_name": "Blue Cross Blue Shield of Montana", "plan_name": "Medicare Advantage", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" } ] } ] }, { "description": "Durable Medical Equipment (other than renal) - Purchase of used DME", "code_information": [ { "code": "0293", "type": "RC" } ], "standard_charges": [ { "setting": "outpatient", "payers_information": [ { "payer_name": "Blue Cross Blue Shield of Montana", "plan_name": "Medicare Advantage", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" } ] } ] }, { "description": "Durable Medical Equipment (other than renal) - Supplies/Drugs for DME", "code_information": [ { "code": "0294", "type": "RC" } ], "standard_charges": [ { "setting": "outpatient", "payers_information": [ { "payer_name": "Blue Cross Blue Shield of Montana", "plan_name": "Medicare Advantage", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" } ] } ] }, { "description": "Durable Medical Equipment (Other than Oxygen) - Treatment", "code_information": [ { "code": "0295", "type": "RC" } ], "standard_charges": [ { "setting": "outpatient", "payers_information": [ { "payer_name": "Blue Cross Blue Shield of Montana", "plan_name": "Medicare Advantage", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" } ] } ] }, { "description": "Durable Medical Equipment (Other than Oxygen) - Continuation", "code_information": [ { "code": "0296", "type": "RC" } ], "standard_charges": [ { "setting": "outpatient", "payers_information": [ { "payer_name": "Blue Cross Blue Shield of Montana", "plan_name": "Medicare Advantage", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" } ] } ] }, { "description": "Durable Medical Equipment (Other than Oxygen) - Observation/Hourly", "code_information": [ { "code": "0297", "type": "RC" } ], "standard_charges": [ { "setting": "outpatient", "payers_information": [ { "payer_name": "Blue Cross Blue Shield of Montana", "plan_name": "Medicare Advantage", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" } ] } ] }, { "description": "Durable Medical Equipment (Other than Oxygen) - Other", "code_information": [ { "code": "0298", "type": "RC" } ], "standard_charges": [ { "setting": "outpatient", "payers_information": [ { "payer_name": "Blue Cross Blue Shield of Montana", "plan_name": "Medicare Advantage", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" } ] } ] }, { "description": "Durable Medical Equipment (other than renal) - Other", "code_information": [ { "code": "0299", "type": "RC" } ], "standard_charges": [ { "setting": "outpatient", "payers_information": [ { "payer_name": "Blue Cross Blue Shield of Montana", "plan_name": "Medicare Advantage", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" } ] } ] }, { "description": "Home Health (HH) Aide - Visit Charge", "code_information": [ { "code": "0571", "type": "RC" } ], "standard_charges": [ { "setting": "outpatient", "payers_information": [ { "payer_name": "Blue Cross Blue Shield of Montana", "plan_name": "Medicare Advantage", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" } ] } ] }, { "description": "1st hosp ip/obs high 75", "code_information": [ { "code": "99223", "type": "HCPCS" } ], "standard_charges": [ { "setting": "outpatient", "payers_information": [ { "payer_name": "National Comp Care", "plan_name": "Workers' Compensation", "standard_charge_percentage": 90, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Coventry Health Care", "plan_name": "Auto Network", "standard_charge_percentage": 90, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Coventry Health Care", "plan_name": "Workers' Compensation", "standard_charge_percentage": 95, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Blue Cross Blue Shield of Montana", "plan_name": "Medicare Advantage", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Allegiance Provider Direct", "plan_name": "Medicare", "standard_charge_percentage": 229.99999999999997, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "PacificSource Health Plans", "plan_name": "PPO (PSN Network and Smart Health Network)", "standard_charge_percentage": 80, "methodology": "percent of total billed charges", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Medicare (CMS)", "plan_name": "Medicare", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "First Choice Health Network fka Health InfoNet", "plan_name": "Commercial", "standard_charge_percentage": 85, "methodology": "percent of total billed charges", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Claritev fka MultiPlan", "plan_name": "Auto Medical Program", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Claritev fka MultiPlan", "plan_name": "Workers' Compensation Program", "standard_charge_percentage": 90, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Claritev fka MultiPlan", "plan_name": "PPO", "standard_charge_percentage": 75, "methodology": "percent of total billed charges", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "First Choice of the Midwest", "plan_name": "PPO", "standard_charge_percentage": 90, "methodology": "percent of total billed charges", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Employee Benefit Management Services (EBMS)", "plan_name": "EBMS SelectCare Network", "standard_charge_percentage": 80, "methodology": "percent of total billed charges", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Medica Insurance Company", "plan_name": "Medicare Cost", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "First Choice Health Network fka Health InfoNet", "plan_name": "Medicare Advantage", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "First Choice Health Network fka Health InfoNet", "plan_name": "Workers Compensation", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Allegiance Provider Direct", "plan_name": "Montana Association of Counties (MACo)", "standard_charge_percentage": 229.99999999999997, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Allegiance Provider Direct", "plan_name": "State of Montana Employee Benefit Plan (Self-Funded)", "standard_charge_percentage": 229.99999999999997, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Allegiance Provider Direct", "plan_name": "Montana Municipal Interlocal Authority (MMIA)", "standard_charge_percentage": 229.99999999999997, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Medicaid (State)", "plan_name": "Medicaid", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Blue Cross Blue Shield of Montana", "plan_name": "HealthLink Network", "standard_charge_percentage": 75, "methodology": "percent of total billed charges", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Blue Cross Blue Shield of Montana", "plan_name": "Traditional Network", "standard_charge_percentage": 75, "methodology": "percent of total billed charges", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Blue Cross Blue Shield of Montana", "plan_name": "POS Network", "standard_charge_percentage": 75, "methodology": "percent of total billed charges", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Blue Cross Blue Shield of Montana", "plan_name": "Closed Plan Network", "standard_charge_percentage": 75, "methodology": "percent of total billed charges", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Blue Cross Blue Shield of Montana", "plan_name": "Retail HMO POS Network", "standard_charge_percentage": 75, "methodology": "percent of total billed charges", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Blue Cross Blue Shield of Montana", "plan_name": "Blue Options Network", "standard_charge_percentage": 75, "methodology": "percent of total billed charges", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "PacificSource Health Plans", "plan_name": "Medicare Advantage", "standard_charge_percentage": 103, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" } ] } ] }, { "description": "Free assay (ft-3)", "code_information": [ { "code": "84481", "type": "HCPCS" } ], "standard_charges": [ { "setting": "outpatient", "payers_information": [ { "payer_name": "National Comp Care", "plan_name": "Workers' Compensation", "standard_charge_percentage": 90, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Coventry Health Care", "plan_name": "Auto Network", "standard_charge_percentage": 90, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "United Healthcare (UHC)", "plan_name": "DSNP", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Coventry Health Care", "plan_name": "Workers' Compensation", "standard_charge_percentage": 95, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Blue Cross Blue Shield of Montana", "plan_name": "Medicare Advantage", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "United Healthcare (UHC)", "plan_name": "Medicare Advantage", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Allegiance Provider Direct", "plan_name": "Medicare", "standard_charge_percentage": 229.99999999999997, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "PacificSource Health Plans", "plan_name": "PPO (PSN Network and Smart Health Network)", "standard_charge_percentage": 80, "methodology": "percent of total billed charges", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Medicare (CMS)", "plan_name": "Medicare", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "First Choice Health Network fka Health InfoNet", "plan_name": "Commercial", "standard_charge_percentage": 85, "methodology": "percent of total billed charges", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Claritev fka MultiPlan", "plan_name": "Auto Medical Program", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Claritev fka MultiPlan", "plan_name": "Workers' Compensation Program", "standard_charge_percentage": 90, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Claritev fka MultiPlan", "plan_name": "PPO", "standard_charge_percentage": 75, "methodology": "percent of total billed charges", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "First Choice of the Midwest", "plan_name": "PPO", "standard_charge_percentage": 90, "methodology": "percent of total billed charges", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Employee Benefit Management Services (EBMS)", "plan_name": "EBMS SelectCare Network", "standard_charge_percentage": 80, "methodology": "percent of total billed charges", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Medica Insurance Company", "plan_name": "Medicare Cost", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "First Choice Health Network fka Health InfoNet", "plan_name": "Medicare Advantage", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "First Choice Health Network fka Health InfoNet", "plan_name": "Workers Compensation", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Allegiance Provider Direct", "plan_name": "Montana Association of Counties (MACo)", "standard_charge_percentage": 229.99999999999997, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Allegiance Provider Direct", "plan_name": "State of Montana Employee Benefit Plan (Self-Funded)", "standard_charge_percentage": 229.99999999999997, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Allegiance Provider Direct", "plan_name": "Montana Municipal Interlocal Authority (MMIA)", "standard_charge_percentage": 229.99999999999997, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Blue Cross Blue Shield of Montana", "plan_name": "HealthLink Network", "standard_charge_percentage": 75, "methodology": "percent of total billed charges", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Blue Cross Blue Shield of Montana", "plan_name": "Traditional Network", "standard_charge_percentage": 75, "methodology": "percent of total billed charges", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Blue Cross Blue Shield of Montana", "plan_name": "POS Network", "standard_charge_percentage": 75, "methodology": "percent of total billed charges", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Blue Cross Blue Shield of Montana", "plan_name": "Closed Plan Network", "standard_charge_percentage": 75, "methodology": "percent of total billed charges", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Blue Cross Blue Shield of Montana", "plan_name": "Retail HMO POS Network", "standard_charge_percentage": 75, "methodology": "percent of total billed charges", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Blue Cross Blue Shield of Montana", "plan_name": "Blue Options Network", "standard_charge_percentage": 75, "methodology": "percent of total billed charges", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Medicaid (State)", "plan_name": "Medicaid", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "PacificSource Health Plans", "plan_name": "Medicare Advantage", "standard_charge_percentage": 103, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" } ] } ] }, { "description": "Urine bacteria culture", "code_information": [ { "code": "87088", "type": "HCPCS" } ], "standard_charges": [ { "setting": "outpatient", "payers_information": [ { "payer_name": "United Healthcare (UHC)", "plan_name": "DSNP", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "United Healthcare (UHC)", "plan_name": "Medicare Advantage", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" } ] } ] }, { "description": "Skin fungi culture", "code_information": [ { "code": "87101", "type": "HCPCS" } ], "standard_charges": [ { "setting": "outpatient", "payers_information": [ { "payer_name": "United Healthcare (UHC)", "plan_name": "DSNP", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "United Healthcare (UHC)", "plan_name": "Medicare Advantage", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" } ] } ] }, { "description": "Home Health (HH) Aide - Other", "code_information": [ { "code": "0579", "type": "RC" } ], "standard_charges": [ { "setting": "outpatient", "payers_information": [ { "payer_name": "Blue Cross Blue Shield of Montana", "plan_name": "Medicare Advantage", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" } ] } ] }, { "description": "Home Health (HH) - Oxygen - General Classification", "code_information": [ { "code": "0600", "type": "RC" } ], "standard_charges": [ { "setting": "outpatient", "payers_information": [ { "payer_name": "Blue Cross Blue Shield of Montana", "plan_name": "Medicare Advantage", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" } ] } ] }, { "description": "Home Health (HH) - Oxygen - Stat Equip/Supply/Content", "code_information": [ { "code": "0601", "type": "RC" } ], "standard_charges": [ { "setting": "outpatient", "payers_information": [ { "payer_name": "Blue Cross Blue Shield of Montana", "plan_name": "Medicare Advantage", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" } ] } ] }, { "description": "Home Health (HH) - Oxygen - Stat Equip/Supply<1 LPM", "code_information": [ { "code": "0602", "type": "RC" } ], "standard_charges": [ { "setting": "outpatient", "payers_information": [ { "payer_name": "Blue Cross Blue Shield of Montana", "plan_name": "Medicare Advantage", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" } ] } ] }, { "description": "Home Health (HH) - Oxygen - Stat Equip/Supply>4 LPM", "code_information": [ { "code": "0603", "type": "RC" } ], "standard_charges": [ { "setting": "outpatient", "payers_information": [ { "payer_name": "Blue Cross Blue Shield of Montana", "plan_name": "Medicare Advantage", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" } ] } ] }, { "description": "Home Health (HH) - Oxygen - Portable Add-on", "code_information": [ { "code": "0604", "type": "RC" } ], "standard_charges": [ { "setting": "outpatient", "payers_information": [ { "payer_name": "Blue Cross Blue Shield of Montana", "plan_name": "Medicare Advantage", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" } ] } ] }, { "description": "Miscellaneous Dialysis - Home Dialysis Aid Visit", "code_information": [ { "code": "0882", "type": "RC" } ], "standard_charges": [ { "setting": "outpatient", "payers_information": [ { "payer_name": "Blue Cross Blue Shield of Montana", "plan_name": "HealthLink Network", "standard_charge_percentage": 75, "methodology": "percent of total billed charges", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Blue Cross Blue Shield of Montana", "plan_name": "Traditional Network", "standard_charge_percentage": 75, "methodology": "percent of total billed charges", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Blue Cross Blue Shield of Montana", "plan_name": "POS Network", "standard_charge_percentage": 75, "methodology": "percent of total billed charges", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Blue Cross Blue Shield of Montana", "plan_name": "Closed Plan Network", "standard_charge_percentage": 75, "methodology": "percent of total billed charges", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Blue Cross Blue Shield of Montana", "plan_name": "Retail HMO POS Network", "standard_charge_percentage": 75, "methodology": "percent of total billed charges", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Blue Cross Blue Shield of Montana", "plan_name": "Blue Options Network", "standard_charge_percentage": 75, "methodology": "percent of total billed charges", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" } ] } ] }, { "description": "Professional Fees - General Classification", "code_information": [ { "code": "0960", "type": "RC" } ], "standard_charges": [ { "setting": "outpatient", "payers_information": [ { "payer_name": "Blue Cross Blue Shield of Montana", "plan_name": "HealthLink Network", "standard_charge_percentage": 75, "methodology": "percent of total billed charges", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Blue Cross Blue Shield of Montana", "plan_name": "Traditional Network", "standard_charge_percentage": 75, "methodology": "percent of total billed charges", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Blue Cross Blue Shield of Montana", "plan_name": "POS Network", "standard_charge_percentage": 75, "methodology": "percent of total billed charges", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Blue Cross Blue Shield of Montana", "plan_name": "Closed Plan Network", "standard_charge_percentage": 75, "methodology": "percent of total billed charges", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Blue Cross Blue Shield of Montana", "plan_name": "Retail HMO POS Network", "standard_charge_percentage": 75, "methodology": "percent of total billed charges", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Blue Cross Blue Shield of Montana", "plan_name": "Blue Options Network", "standard_charge_percentage": 75, "methodology": "percent of total billed charges", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" } ] } ] }, { "description": "Professional Fees - Psychiatric", "code_information": [ { "code": "0961", "type": "RC" } ], "standard_charges": [ { "setting": "outpatient", "payers_information": [ { "payer_name": "Blue Cross Blue Shield of Montana", "plan_name": "HealthLink Network", "standard_charge_percentage": 75, "methodology": "percent of total billed charges", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Blue Cross Blue Shield of Montana", "plan_name": "Traditional Network", "standard_charge_percentage": 75, "methodology": "percent of total billed charges", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Blue Cross Blue Shield of Montana", "plan_name": "POS Network", "standard_charge_percentage": 75, "methodology": "percent of total billed charges", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Blue Cross Blue Shield of Montana", "plan_name": "Closed Plan Network", "standard_charge_percentage": 75, "methodology": "percent of total billed charges", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Blue Cross Blue Shield of Montana", "plan_name": "Retail HMO POS Network", "standard_charge_percentage": 75, "methodology": "percent of total billed charges", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Blue Cross Blue Shield of Montana", "plan_name": "Blue Options Network", "standard_charge_percentage": 75, "methodology": "percent of total billed charges", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" } ] } ] }, { "description": "Professional Fees - Ophthalmology", "code_information": [ { "code": "0962", "type": "RC" } ], "standard_charges": [ { "setting": "outpatient", "payers_information": [ { "payer_name": "Blue Cross Blue Shield of Montana", "plan_name": "HealthLink Network", "standard_charge_percentage": 75, "methodology": "percent of total billed charges", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Blue Cross Blue Shield of Montana", "plan_name": "Traditional Network", "standard_charge_percentage": 75, "methodology": "percent of total billed charges", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Blue Cross Blue Shield of Montana", "plan_name": "POS Network", "standard_charge_percentage": 75, "methodology": "percent of total billed charges", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Blue Cross Blue Shield of Montana", "plan_name": "Closed Plan Network", "standard_charge_percentage": 75, "methodology": "percent of total billed charges", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Blue Cross Blue Shield of Montana", "plan_name": "Retail HMO POS Network", "standard_charge_percentage": 75, "methodology": "percent of total billed charges", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Blue Cross Blue Shield of Montana", "plan_name": "Blue Options Network", "standard_charge_percentage": 75, "methodology": "percent of total billed charges", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" } ] } ] }, { "description": "Professional Fees - Anesthesiologist (MD)", "code_information": [ { "code": "0963", "type": "RC" } ], "standard_charges": [ { "setting": "outpatient", "payers_information": [ { "payer_name": "Blue Cross Blue Shield of Montana", "plan_name": "HealthLink Network", "standard_charge_percentage": 75, "methodology": "percent of total billed charges", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Blue Cross Blue Shield of Montana", "plan_name": "Traditional Network", "standard_charge_percentage": 75, "methodology": "percent of total billed charges", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Blue Cross Blue Shield of Montana", "plan_name": "POS Network", "standard_charge_percentage": 75, "methodology": "percent of total billed charges", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Blue Cross Blue Shield of Montana", "plan_name": "Closed Plan Network", "standard_charge_percentage": 75, "methodology": "percent of total billed charges", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Blue Cross Blue Shield of Montana", "plan_name": "Retail HMO POS Network", "standard_charge_percentage": 75, "methodology": "percent of total billed charges", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Blue Cross Blue Shield of Montana", "plan_name": "Blue Options Network", "standard_charge_percentage": 75, "methodology": "percent of total billed charges", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" } ] } ] }, { "description": "Professional Fees - Anesthetist (CRNA)", "code_information": [ { "code": "0964", "type": "RC" } ], "standard_charges": [ { "setting": "outpatient", "payers_information": [ { "payer_name": "Blue Cross Blue Shield of Montana", "plan_name": "HealthLink Network", "standard_charge_percentage": 75, "methodology": "percent of total billed charges", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Blue Cross Blue Shield of Montana", "plan_name": "Traditional Network", "standard_charge_percentage": 75, "methodology": "percent of total billed charges", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Blue Cross Blue Shield of Montana", "plan_name": "POS Network", "standard_charge_percentage": 75, "methodology": "percent of total billed charges", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Blue Cross Blue Shield of Montana", "plan_name": "Closed Plan Network", "standard_charge_percentage": 75, "methodology": "percent of total billed charges", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Blue Cross Blue Shield of Montana", "plan_name": "Retail HMO POS Network", "standard_charge_percentage": 75, "methodology": "percent of total billed charges", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Blue Cross Blue Shield of Montana", "plan_name": "Blue Options Network", "standard_charge_percentage": 75, "methodology": "percent of total billed charges", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" } ] } ] }, { "description": "Professional Fees – General Classification - Treatment", "code_information": [ { "code": "0965", "type": "RC" } ], "standard_charges": [ { "setting": "outpatient", "payers_information": [ { "payer_name": "Blue Cross Blue Shield of Montana", "plan_name": "HealthLink Network", "standard_charge_percentage": 75, "methodology": "percent of total billed charges", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Blue Cross Blue Shield of Montana", "plan_name": "Traditional Network", "standard_charge_percentage": 75, "methodology": "percent of total billed charges", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Blue Cross Blue Shield of Montana", "plan_name": "POS Network", "standard_charge_percentage": 75, "methodology": "percent of total billed charges", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Blue Cross Blue Shield of Montana", "plan_name": "Closed Plan Network", "standard_charge_percentage": 75, "methodology": "percent of total billed charges", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Blue Cross Blue Shield of Montana", "plan_name": "Retail HMO POS Network", "standard_charge_percentage": 75, "methodology": "percent of total billed charges", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Blue Cross Blue Shield of Montana", "plan_name": "Blue Options Network", "standard_charge_percentage": 75, "methodology": "percent of total billed charges", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" } ] } ] }, { "description": "Professional Fees – General Classification - Continuation", "code_information": [ { "code": "0966", "type": "RC" } ], "standard_charges": [ { "setting": "outpatient", "payers_information": [ { "payer_name": "Blue Cross Blue Shield of Montana", "plan_name": "HealthLink Network", "standard_charge_percentage": 75, "methodology": "percent of total billed charges", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Blue Cross Blue Shield of Montana", "plan_name": "Traditional Network", "standard_charge_percentage": 75, "methodology": "percent of total billed charges", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Blue Cross Blue Shield of Montana", "plan_name": "POS Network", "standard_charge_percentage": 75, "methodology": "percent of total billed charges", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Blue Cross Blue Shield of Montana", "plan_name": "Closed Plan Network", "standard_charge_percentage": 75, "methodology": "percent of total billed charges", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Blue Cross Blue Shield of Montana", "plan_name": "Retail HMO POS Network", "standard_charge_percentage": 75, "methodology": "percent of total billed charges", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Blue Cross Blue Shield of Montana", "plan_name": "Blue Options Network", "standard_charge_percentage": 75, "methodology": "percent of total billed charges", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" } ] } ] }, { "description": "Professional Fees – General Classification - Observation/Hourly", "code_information": [ { "code": "0967", "type": "RC" } ], "standard_charges": [ { "setting": "outpatient", "payers_information": [ { "payer_name": "Blue Cross Blue Shield of Montana", "plan_name": "HealthLink Network", "standard_charge_percentage": 75, "methodology": "percent of total billed charges", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Blue Cross Blue Shield of Montana", "plan_name": "Traditional Network", "standard_charge_percentage": 75, "methodology": "percent of total billed charges", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Blue Cross Blue Shield of Montana", "plan_name": "POS Network", "standard_charge_percentage": 75, "methodology": "percent of total billed charges", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Blue Cross Blue Shield of Montana", "plan_name": "Closed Plan Network", "standard_charge_percentage": 75, "methodology": "percent of total billed charges", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Blue Cross Blue Shield of Montana", "plan_name": "Retail HMO POS Network", "standard_charge_percentage": 75, "methodology": "percent of total billed charges", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Blue Cross Blue Shield of Montana", "plan_name": "Blue Options Network", "standard_charge_percentage": 75, "methodology": "percent of total billed charges", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" } ] } ] }, { "description": "Professional Fees – General Classification - Other", "code_information": [ { "code": "0968", "type": "RC" } ], "standard_charges": [ { "setting": "outpatient", "payers_information": [ { "payer_name": "Blue Cross Blue Shield of Montana", "plan_name": "HealthLink Network", "standard_charge_percentage": 75, "methodology": "percent of total billed charges", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Blue Cross Blue Shield of Montana", "plan_name": "Traditional Network", "standard_charge_percentage": 75, "methodology": "percent of total billed charges", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Blue Cross Blue Shield of Montana", "plan_name": "POS Network", "standard_charge_percentage": 75, "methodology": "percent of total billed charges", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Blue Cross Blue Shield of Montana", "plan_name": "Closed Plan Network", "standard_charge_percentage": 75, "methodology": "percent of total billed charges", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Blue Cross Blue Shield of Montana", "plan_name": "Retail HMO POS Network", "standard_charge_percentage": 75, "methodology": "percent of total billed charges", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Blue Cross Blue Shield of Montana", "plan_name": "Blue Options Network", "standard_charge_percentage": 75, "methodology": "percent of total billed charges", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" } ] } ] }, { "description": "Professional Fees - Other Professional Fees", "code_information": [ { "code": "0969", "type": "RC" } ], "standard_charges": [ { "setting": "outpatient", "payers_information": [ { "payer_name": "Blue Cross Blue Shield of Montana", "plan_name": "HealthLink Network", "standard_charge_percentage": 75, "methodology": "percent of total billed charges", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Blue Cross Blue Shield of Montana", "plan_name": "Traditional Network", "standard_charge_percentage": 75, "methodology": "percent of total billed charges", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Blue Cross Blue Shield of Montana", "plan_name": "POS Network", "standard_charge_percentage": 75, "methodology": "percent of total billed charges", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Blue Cross Blue Shield of Montana", "plan_name": "Closed Plan Network", "standard_charge_percentage": 75, "methodology": "percent of total billed charges", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Blue Cross Blue Shield of Montana", "plan_name": "Retail HMO POS Network", "standard_charge_percentage": 75, "methodology": "percent of total billed charges", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Blue Cross Blue Shield of Montana", "plan_name": "Blue Options Network", "standard_charge_percentage": 75, "methodology": "percent of total billed charges", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" } ] } ] }, { "description": "Anesthetist - General Classification", "code_information": [ { "code": "0970", "type": "RC" } ], "standard_charges": [ { "setting": "outpatient", "payers_information": [ { "payer_name": "Blue Cross Blue Shield of Montana", "plan_name": "HealthLink Network", "standard_charge_percentage": 75, "methodology": "percent of total billed charges", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Blue Cross Blue Shield of Montana", "plan_name": "Traditional Network", "standard_charge_percentage": 75, "methodology": "percent of total billed charges", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Blue Cross Blue Shield of Montana", "plan_name": "POS Network", "standard_charge_percentage": 75, "methodology": "percent of total billed charges", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Blue Cross Blue Shield of Montana", "plan_name": "Closed Plan Network", "standard_charge_percentage": 75, "methodology": "percent of total billed charges", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Blue Cross Blue Shield of Montana", "plan_name": "Retail HMO POS Network", "standard_charge_percentage": 75, "methodology": "percent of total billed charges", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Blue Cross Blue Shield of Montana", "plan_name": "Blue Options Network", "standard_charge_percentage": 75, "methodology": "percent of total billed charges", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" } ] } ] }, { "description": "Professional Fees - Laboratory", "code_information": [ { "code": "0971", "type": "RC" } ], "standard_charges": [ { "setting": "outpatient", "payers_information": [ { "payer_name": "Blue Cross Blue Shield of Montana", "plan_name": "HealthLink Network", "standard_charge_percentage": 75, "methodology": "percent of total billed charges", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Blue Cross Blue Shield of Montana", "plan_name": "Traditional Network", "standard_charge_percentage": 75, "methodology": "percent of total billed charges", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Blue Cross Blue Shield of Montana", "plan_name": "POS Network", "standard_charge_percentage": 75, "methodology": "percent of total billed charges", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Blue Cross Blue Shield of Montana", "plan_name": "Closed Plan Network", "standard_charge_percentage": 75, "methodology": "percent of total billed charges", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Blue Cross Blue Shield of Montana", "plan_name": "Retail HMO POS Network", "standard_charge_percentage": 75, "methodology": "percent of total billed charges", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Blue Cross Blue Shield of Montana", "plan_name": "Blue Options Network", "standard_charge_percentage": 75, "methodology": "percent of total billed charges", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" } ] } ] }, { "description": "Professional Fees - Radiology - Diagnostic", "code_information": [ { "code": "0972", "type": "RC" } ], "standard_charges": [ { "setting": "outpatient", "payers_information": [ { "payer_name": "Blue Cross Blue Shield of Montana", "plan_name": "HealthLink Network", "standard_charge_percentage": 75, "methodology": "percent of total billed charges", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Blue Cross Blue Shield of Montana", "plan_name": "Traditional Network", "standard_charge_percentage": 75, "methodology": "percent of total billed charges", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Blue Cross Blue Shield of Montana", "plan_name": "POS Network", "standard_charge_percentage": 75, "methodology": "percent of total billed charges", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Blue Cross Blue Shield of Montana", "plan_name": "Closed Plan Network", "standard_charge_percentage": 75, "methodology": "percent of total billed charges", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Blue Cross Blue Shield of Montana", "plan_name": "Retail HMO POS Network", "standard_charge_percentage": 75, "methodology": "percent of total billed charges", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Blue Cross Blue Shield of Montana", "plan_name": "Blue Options Network", "standard_charge_percentage": 75, "methodology": "percent of total billed charges", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" } ] } ] }, { "description": "Professional Fees - Radiology - Therapeutic", "code_information": [ { "code": "0973", "type": "RC" } ], "standard_charges": [ { "setting": "outpatient", "payers_information": [ { "payer_name": "Blue Cross Blue Shield of Montana", "plan_name": "HealthLink Network", "standard_charge_percentage": 75, "methodology": "percent of total billed charges", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Blue Cross Blue Shield of Montana", "plan_name": "Traditional Network", "standard_charge_percentage": 75, "methodology": "percent of total billed charges", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Blue Cross Blue Shield of Montana", "plan_name": "POS Network", "standard_charge_percentage": 75, "methodology": "percent of total billed charges", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Blue Cross Blue Shield of Montana", "plan_name": "Closed Plan Network", "standard_charge_percentage": 75, "methodology": "percent of total billed charges", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Blue Cross Blue Shield of Montana", "plan_name": "Retail HMO POS Network", "standard_charge_percentage": 75, "methodology": "percent of total billed charges", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Blue Cross Blue Shield of Montana", "plan_name": "Blue Options Network", "standard_charge_percentage": 75, "methodology": "percent of total billed charges", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" } ] } ] }, { "description": "Professional Fees - Radiology - Nuclear Medicine", "code_information": [ { "code": "0974", "type": "RC" } ], "standard_charges": [ { "setting": "outpatient", "payers_information": [ { "payer_name": "Blue Cross Blue Shield of Montana", "plan_name": "HealthLink Network", "standard_charge_percentage": 75, "methodology": "percent of total billed charges", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Blue Cross Blue Shield of Montana", "plan_name": "Traditional Network", "standard_charge_percentage": 75, "methodology": "percent of total billed charges", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Blue Cross Blue Shield of Montana", "plan_name": "POS Network", "standard_charge_percentage": 75, "methodology": "percent of total billed charges", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Blue Cross Blue Shield of Montana", "plan_name": "Closed Plan Network", "standard_charge_percentage": 75, "methodology": "percent of total billed charges", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Blue Cross Blue Shield of Montana", "plan_name": "Retail HMO POS Network", "standard_charge_percentage": 75, "methodology": "percent of total billed charges", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Blue Cross Blue Shield of Montana", "plan_name": "Blue Options Network", "standard_charge_percentage": 75, "methodology": "percent of total billed charges", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" } ] } ] }, { "description": "Professional Fees - Operating Room", "code_information": [ { "code": "0975", "type": "RC" } ], "standard_charges": [ { "setting": "outpatient", "payers_information": [ { "payer_name": "Blue Cross Blue Shield of Montana", "plan_name": "HealthLink Network", "standard_charge_percentage": 75, "methodology": "percent of total billed charges", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Blue Cross Blue Shield of Montana", "plan_name": "Traditional Network", "standard_charge_percentage": 75, "methodology": "percent of total billed charges", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Blue Cross Blue Shield of Montana", "plan_name": "POS Network", "standard_charge_percentage": 75, "methodology": "percent of total billed charges", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Blue Cross Blue Shield of Montana", "plan_name": "Closed Plan Network", "standard_charge_percentage": 75, "methodology": "percent of total billed charges", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Blue Cross Blue Shield of Montana", "plan_name": "Retail HMO POS Network", "standard_charge_percentage": 75, "methodology": "percent of total billed charges", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Blue Cross Blue Shield of Montana", "plan_name": "Blue Options Network", "standard_charge_percentage": 75, "methodology": "percent of total billed charges", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" } ] } ] }, { "description": "Professional Fees - Respiratory Therapy", "code_information": [ { "code": "0976", "type": "RC" } ], "standard_charges": [ { "setting": "outpatient", "payers_information": [ { "payer_name": "Blue Cross Blue Shield of Montana", "plan_name": "HealthLink Network", "standard_charge_percentage": 75, "methodology": "percent of total billed charges", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Blue Cross Blue Shield of Montana", "plan_name": "Traditional Network", "standard_charge_percentage": 75, "methodology": "percent of total billed charges", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Blue Cross Blue Shield of Montana", "plan_name": "POS Network", "standard_charge_percentage": 75, "methodology": "percent of total billed charges", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Blue Cross Blue Shield of Montana", "plan_name": "Closed Plan Network", "standard_charge_percentage": 75, "methodology": "percent of total billed charges", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Blue Cross Blue Shield of Montana", "plan_name": "Retail HMO POS Network", "standard_charge_percentage": 75, "methodology": "percent of total billed charges", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Blue Cross Blue Shield of Montana", "plan_name": "Blue Options Network", "standard_charge_percentage": 75, "methodology": "percent of total billed charges", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" } ] } ] }, { "description": "Professional Fees - Physical Therapy", "code_information": [ { "code": "0977", "type": "RC" } ], "standard_charges": [ { "setting": "outpatient", "payers_information": [ { "payer_name": "Blue Cross Blue Shield of Montana", "plan_name": "HealthLink Network", "standard_charge_percentage": 75, "methodology": "percent of total billed charges", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Blue Cross Blue Shield of Montana", "plan_name": "Traditional Network", "standard_charge_percentage": 75, "methodology": "percent of total billed charges", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Blue Cross Blue Shield of Montana", "plan_name": "POS Network", "standard_charge_percentage": 75, "methodology": "percent of total billed charges", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Blue Cross Blue Shield of Montana", "plan_name": "Closed Plan Network", "standard_charge_percentage": 75, "methodology": "percent of total billed charges", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Blue Cross Blue Shield of Montana", "plan_name": "Retail HMO POS Network", "standard_charge_percentage": 75, "methodology": "percent of total billed charges", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Blue Cross Blue Shield of Montana", "plan_name": "Blue Options Network", "standard_charge_percentage": 75, "methodology": "percent of total billed charges", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" } ] } ] }, { "description": "Professional Fees - Occupational Therapy", "code_information": [ { "code": "0978", "type": "RC" } ], "standard_charges": [ { "setting": "outpatient", "payers_information": [ { "payer_name": "Blue Cross Blue Shield of Montana", "plan_name": "HealthLink Network", "standard_charge_percentage": 75, "methodology": "percent of total billed charges", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Blue Cross Blue Shield of Montana", "plan_name": "Traditional Network", "standard_charge_percentage": 75, "methodology": "percent of total billed charges", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Blue Cross Blue Shield of Montana", "plan_name": "POS Network", "standard_charge_percentage": 75, "methodology": "percent of total billed charges", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Blue Cross Blue Shield of Montana", "plan_name": "Closed Plan Network", "standard_charge_percentage": 75, "methodology": "percent of total billed charges", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Blue Cross Blue Shield of Montana", "plan_name": "Retail HMO POS Network", "standard_charge_percentage": 75, "methodology": "percent of total billed charges", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Blue Cross Blue Shield of Montana", "plan_name": "Blue Options Network", "standard_charge_percentage": 75, "methodology": "percent of total billed charges", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" } ] } ] }, { "description": "Professional Fees - Speech Pathology", "code_information": [ { "code": "0979", "type": "RC" } ], "standard_charges": [ { "setting": "outpatient", "payers_information": [ { "payer_name": "Blue Cross Blue Shield of Montana", "plan_name": "HealthLink Network", "standard_charge_percentage": 75, "methodology": "percent of total billed charges", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Blue Cross Blue Shield of Montana", "plan_name": "Traditional Network", "standard_charge_percentage": 75, "methodology": "percent of total billed charges", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Blue Cross Blue Shield of Montana", "plan_name": "POS Network", "standard_charge_percentage": 75, "methodology": "percent of total billed charges", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Blue Cross Blue Shield of Montana", "plan_name": "Closed Plan Network", "standard_charge_percentage": 75, "methodology": "percent of total billed charges", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Blue Cross Blue Shield of Montana", "plan_name": "Retail HMO POS Network", "standard_charge_percentage": 75, "methodology": "percent of total billed charges", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Blue Cross Blue Shield of Montana", "plan_name": "Blue Options Network", "standard_charge_percentage": 75, "methodology": "percent of total billed charges", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" } ] } ] }, { "description": "Professional Fees – Outpatient/Other - General Classification", "code_information": [ { "code": "0980", "type": "RC" } ], "standard_charges": [ { "setting": "outpatient", "payers_information": [ { "payer_name": "Blue Cross Blue Shield of Montana", "plan_name": "HealthLink Network", "standard_charge_percentage": 75, "methodology": "percent of total billed charges", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Blue Cross Blue Shield of Montana", "plan_name": "Traditional Network", "standard_charge_percentage": 75, "methodology": "percent of total billed charges", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Blue Cross Blue Shield of Montana", "plan_name": "POS Network", "standard_charge_percentage": 75, "methodology": "percent of total billed charges", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Blue Cross Blue Shield of Montana", "plan_name": "Closed Plan Network", "standard_charge_percentage": 75, "methodology": "percent of total billed charges", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Blue Cross Blue Shield of Montana", "plan_name": "Retail HMO POS Network", "standard_charge_percentage": 75, "methodology": "percent of total billed charges", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Blue Cross Blue Shield of Montana", "plan_name": "Blue Options Network", "standard_charge_percentage": 75, "methodology": "percent of total billed charges", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" } ] } ] }, { "description": "Professional Fees - Emergency Room", "code_information": [ { "code": "0981", "type": "RC" } ], "standard_charges": [ { "setting": "outpatient", "payers_information": [ { "payer_name": "Blue Cross Blue Shield of Montana", "plan_name": "HealthLink Network", "standard_charge_percentage": 75, "methodology": "percent of total billed charges", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Blue Cross Blue Shield of Montana", "plan_name": "Traditional Network", "standard_charge_percentage": 75, "methodology": "percent of total billed charges", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Blue Cross Blue Shield of Montana", "plan_name": "POS Network", "standard_charge_percentage": 75, "methodology": "percent of total billed charges", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Blue Cross Blue Shield of Montana", "plan_name": "Closed Plan Network", "standard_charge_percentage": 75, "methodology": "percent of total billed charges", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Blue Cross Blue Shield of Montana", "plan_name": "Retail HMO POS Network", "standard_charge_percentage": 75, "methodology": "percent of total billed charges", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Blue Cross Blue Shield of Montana", "plan_name": "Blue Options Network", "standard_charge_percentage": 75, "methodology": "percent of total billed charges", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" } ] } ] }, { "description": "Professional Fees - Outpatient Services", "code_information": [ { "code": "0982", "type": "RC" } ], "standard_charges": [ { "setting": "outpatient", "payers_information": [ { "payer_name": "Blue Cross Blue Shield of Montana", "plan_name": "HealthLink Network", "standard_charge_percentage": 75, "methodology": "percent of total billed charges", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Blue Cross Blue Shield of Montana", "plan_name": "Traditional Network", "standard_charge_percentage": 75, "methodology": "percent of total billed charges", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Blue Cross Blue Shield of Montana", "plan_name": "POS Network", "standard_charge_percentage": 75, "methodology": "percent of total billed charges", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Blue Cross Blue Shield of Montana", "plan_name": "Closed Plan Network", "standard_charge_percentage": 75, "methodology": "percent of total billed charges", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Blue Cross Blue Shield of Montana", "plan_name": "Retail HMO POS Network", "standard_charge_percentage": 75, "methodology": "percent of total billed charges", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Blue Cross Blue Shield of Montana", "plan_name": "Blue Options Network", "standard_charge_percentage": 75, "methodology": "percent of total billed charges", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" } ] } ] }, { "description": "Professional Fees - Clinic", "code_information": [ { "code": "0983", "type": "RC" } ], "standard_charges": [ { "setting": "outpatient", "payers_information": [ { "payer_name": "Blue Cross Blue Shield of Montana", "plan_name": "HealthLink Network", "standard_charge_percentage": 75, "methodology": "percent of total billed charges", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Blue Cross Blue Shield of Montana", "plan_name": "Traditional Network", "standard_charge_percentage": 75, "methodology": "percent of total billed charges", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Blue Cross Blue Shield of Montana", "plan_name": "POS Network", "standard_charge_percentage": 75, "methodology": "percent of total billed charges", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Blue Cross Blue Shield of Montana", "plan_name": "Closed Plan Network", "standard_charge_percentage": 75, "methodology": "percent of total billed charges", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Blue Cross Blue Shield of Montana", "plan_name": "Retail HMO POS Network", "standard_charge_percentage": 75, "methodology": "percent of total billed charges", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Blue Cross Blue Shield of Montana", "plan_name": "Blue Options Network", "standard_charge_percentage": 75, "methodology": "percent of total billed charges", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" } ] } ] }, { "description": "Professional Fees - Medical Social Services", "code_information": [ { "code": "0984", "type": "RC" } ], "standard_charges": [ { "setting": "outpatient", "payers_information": [ { "payer_name": "Blue Cross Blue Shield of Montana", "plan_name": "HealthLink Network", "standard_charge_percentage": 75, "methodology": "percent of total billed charges", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Blue Cross Blue Shield of Montana", "plan_name": "Traditional Network", "standard_charge_percentage": 75, "methodology": "percent of total billed charges", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Blue Cross Blue Shield of Montana", "plan_name": "POS Network", "standard_charge_percentage": 75, "methodology": "percent of total billed charges", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Blue Cross Blue Shield of Montana", "plan_name": "Closed Plan Network", "standard_charge_percentage": 75, "methodology": "percent of total billed charges", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Blue Cross Blue Shield of Montana", "plan_name": "Retail HMO POS Network", "standard_charge_percentage": 75, "methodology": "percent of total billed charges", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Blue Cross Blue Shield of Montana", "plan_name": "Blue Options Network", "standard_charge_percentage": 75, "methodology": "percent of total billed charges", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" } ] } ] }, { "description": "Professional Fees - EKG", "code_information": [ { "code": "0985", "type": "RC" } ], "standard_charges": [ { "setting": "outpatient", "payers_information": [ { "payer_name": "Blue Cross Blue Shield of Montana", "plan_name": "HealthLink Network", "standard_charge_percentage": 75, "methodology": "percent of total billed charges", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Blue Cross Blue Shield of Montana", "plan_name": "Traditional Network", "standard_charge_percentage": 75, "methodology": "percent of total billed charges", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Blue Cross Blue Shield of Montana", "plan_name": "POS Network", "standard_charge_percentage": 75, "methodology": "percent of total billed charges", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Blue Cross Blue Shield of Montana", "plan_name": "Closed Plan Network", "standard_charge_percentage": 75, "methodology": "percent of total billed charges", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Blue Cross Blue Shield of Montana", "plan_name": "Retail HMO POS Network", "standard_charge_percentage": 75, "methodology": "percent of total billed charges", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Blue Cross Blue Shield of Montana", "plan_name": "Blue Options Network", "standard_charge_percentage": 75, "methodology": "percent of total billed charges", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" } ] } ] }, { "description": "Professional Fees - EEG", "code_information": [ { "code": "0986", "type": "RC" } ], "standard_charges": [ { "setting": "outpatient", "payers_information": [ { "payer_name": "Blue Cross Blue Shield of Montana", "plan_name": "HealthLink Network", "standard_charge_percentage": 75, "methodology": "percent of total billed charges", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Blue Cross Blue Shield of Montana", "plan_name": "Traditional Network", "standard_charge_percentage": 75, "methodology": "percent of total billed charges", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Blue Cross Blue Shield of Montana", "plan_name": "POS Network", "standard_charge_percentage": 75, "methodology": "percent of total billed charges", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Blue Cross Blue Shield of Montana", "plan_name": "Closed Plan Network", "standard_charge_percentage": 75, "methodology": "percent of total billed charges", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Blue Cross Blue Shield of Montana", "plan_name": "Retail HMO POS Network", "standard_charge_percentage": 75, "methodology": "percent of total billed charges", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Blue Cross Blue Shield of Montana", "plan_name": "Blue Options Network", "standard_charge_percentage": 75, "methodology": "percent of total billed charges", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" } ] } ] }, { "description": "Professional Fees - Hospital Visit", "code_information": [ { "code": "0987", "type": "RC" } ], "standard_charges": [ { "setting": "outpatient", "payers_information": [ { "payer_name": "Blue Cross Blue Shield of Montana", "plan_name": "HealthLink Network", "standard_charge_percentage": 75, "methodology": "percent of total billed charges", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Blue Cross Blue Shield of Montana", "plan_name": "Traditional Network", "standard_charge_percentage": 75, "methodology": "percent of total billed charges", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Blue Cross Blue Shield of Montana", "plan_name": "POS Network", "standard_charge_percentage": 75, "methodology": "percent of total billed charges", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Blue Cross Blue Shield of Montana", "plan_name": "Closed Plan Network", "standard_charge_percentage": 75, "methodology": "percent of total billed charges", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Blue Cross Blue Shield of Montana", "plan_name": "Retail HMO POS Network", "standard_charge_percentage": 75, "methodology": "percent of total billed charges", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Blue Cross Blue Shield of Montana", "plan_name": "Blue Options Network", "standard_charge_percentage": 75, "methodology": "percent of total billed charges", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" } ] } ] }, { "description": "Professional Fees - Consultation", "code_information": [ { "code": "0988", "type": "RC" } ], "standard_charges": [ { "setting": "outpatient", "payers_information": [ { "payer_name": "Blue Cross Blue Shield of Montana", "plan_name": "HealthLink Network", "standard_charge_percentage": 75, "methodology": "percent of total billed charges", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Blue Cross Blue Shield of Montana", "plan_name": "Traditional Network", "standard_charge_percentage": 75, "methodology": "percent of total billed charges", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Blue Cross Blue Shield of Montana", "plan_name": "POS Network", "standard_charge_percentage": 75, "methodology": "percent of total billed charges", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Blue Cross Blue Shield of Montana", "plan_name": "Closed Plan Network", "standard_charge_percentage": 75, "methodology": "percent of total billed charges", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Blue Cross Blue Shield of Montana", "plan_name": "Retail HMO POS Network", "standard_charge_percentage": 75, "methodology": "percent of total billed charges", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Blue Cross Blue Shield of Montana", "plan_name": "Blue Options Network", "standard_charge_percentage": 75, "methodology": "percent of total billed charges", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" } ] } ] }, { "description": "Professional Fees - Private Duty Nurse", "code_information": [ { "code": "0989", "type": "RC" } ], "standard_charges": [ { "setting": "outpatient", "payers_information": [ { "payer_name": "Blue Cross Blue Shield of Montana", "plan_name": "HealthLink Network", "standard_charge_percentage": 75, "methodology": "percent of total billed charges", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Blue Cross Blue Shield of Montana", "plan_name": "Traditional Network", "standard_charge_percentage": 75, "methodology": "percent of total billed charges", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Blue Cross Blue Shield of Montana", "plan_name": "POS Network", "standard_charge_percentage": 75, "methodology": "percent of total billed charges", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Blue Cross Blue Shield of Montana", "plan_name": "Closed Plan Network", "standard_charge_percentage": 75, "methodology": "percent of total billed charges", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Blue Cross Blue Shield of Montana", "plan_name": "Retail HMO POS Network", "standard_charge_percentage": 75, "methodology": "percent of total billed charges", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Blue Cross Blue Shield of Montana", "plan_name": "Blue Options Network", "standard_charge_percentage": 75, "methodology": "percent of total billed charges", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" } ] } ] }, { "description": "Fungi identification yeast", "code_information": [ { "code": "87106", "type": "HCPCS" } ], "standard_charges": [ { "setting": "outpatient", "payers_information": [ { "payer_name": "United Healthcare (UHC)", "plan_name": "DSNP", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "United Healthcare (UHC)", "plan_name": "Medicare Advantage", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" } ] } ] }, { "description": "Mycobacteria culture", "code_information": [ { "code": "87116", "type": "HCPCS" } ], "standard_charges": [ { "setting": "outpatient", "payers_information": [ { "payer_name": "United Healthcare (UHC)", "plan_name": "DSNP", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "United Healthcare (UHC)", "plan_name": "Medicare Advantage", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" } ] } ] }, { "description": "Culture type immunologic", "code_information": [ { "code": "87147", "type": "HCPCS" } ], "standard_charges": [ { "setting": "outpatient", "payers_information": [ { "payer_name": "United Healthcare (UHC)", "plan_name": "DSNP", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "United Healthcare (UHC)", "plan_name": "Medicare Advantage", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" } ] } ] }, { "description": "Dna/rna amplified probe", "code_information": [ { "code": "87150", "type": "HCPCS" } ], "standard_charges": [ { "setting": "outpatient", "payers_information": [ { "payer_name": "United Healthcare (UHC)", "plan_name": "DSNP", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "United Healthcare (UHC)", "plan_name": "Medicare Advantage", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" } ] } ] }, { "description": "Rbc sed rate nonautomated", "code_information": [ { "code": "85651", "type": "HCPCS" } ], "standard_charges": [ { "setting": "outpatient", "payers_information": [ { "payer_name": "United Healthcare (UHC)", "plan_name": "DSNP", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "United Healthcare (UHC)", "plan_name": "Medicare Advantage", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" } ] } ] }, { "description": "Medical/Surgical Supplies and Devices - Prosthetic/Orthotic Devices", "code_information": [ { "code": "0274", "type": "RC" } ], "standard_charges": [ { "setting": "inpatient", "payers_information": [ { "payer_name": "Coventry Health Care", "plan_name": "Workers' Compensation", "standard_charge_percentage": 105, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Coventry Health Care", "plan_name": "Auto Network", "standard_charge_percentage": 105, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" } ] } ] }, { "description": "Medical/Surgical Supplies and Devices - Pacemaker", "code_information": [ { "code": "0275", "type": "RC" } ], "standard_charges": [ { "setting": "inpatient", "payers_information": [ { "payer_name": "Coventry Health Care", "plan_name": "Workers' Compensation", "standard_charge_percentage": 105, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Coventry Health Care", "plan_name": "Auto Network", "standard_charge_percentage": 105, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Blue Cross Blue Shield of Montana", "plan_name": "HealthLink Network", "standard_charge_percentage": 75, "methodology": "percent of total billed charges", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Blue Cross Blue Shield of Montana", "plan_name": "Traditional Network", "standard_charge_percentage": 75, "methodology": "percent of total billed charges", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Blue Cross Blue Shield of Montana", "plan_name": "POS Network", "standard_charge_percentage": 75, "methodology": "percent of total billed charges", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Blue Cross Blue Shield of Montana", "plan_name": "Closed Plan Network", "standard_charge_percentage": 75, "methodology": "percent of total billed charges", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Blue Cross Blue Shield of Montana", "plan_name": "Retail HMO POS Network", "standard_charge_percentage": 75, "methodology": "percent of total billed charges", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Blue Cross Blue Shield of Montana", "plan_name": "Blue Options Network", "standard_charge_percentage": 75, "methodology": "percent of total billed charges", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" } ] } ] }, { "description": "Medical/Surgical Supplies and Devices - Other Implants", "code_information": [ { "code": "0278", "type": "RC" } ], "standard_charges": [ { "setting": "inpatient", "payers_information": [ { "payer_name": "Coventry Health Care", "plan_name": "Workers' Compensation", "standard_charge_percentage": 105, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Coventry Health Care", "plan_name": "Auto Network", "standard_charge_percentage": 105, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" } ] } ] }, { "description": "Thromboplastin time partial", "code_information": [ { "code": "85730", "type": "HCPCS" } ], "standard_charges": [ { "setting": "outpatient", "payers_information": [ { "payer_name": "United Healthcare (UHC)", "plan_name": "DSNP", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "United Healthcare (UHC)", "plan_name": "Medicare Advantage", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" } ] } ] }, { "description": "Platelet antibodies", "code_information": [ { "code": "86022", "type": "HCPCS" } ], "standard_charges": [ { "setting": "outpatient", "payers_information": [ { "payer_name": "United Healthcare (UHC)", "plan_name": "DSNP", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "United Healthcare (UHC)", "plan_name": "Medicare Advantage", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" } ] } ] }, { "description": "M.tuberculo dna amp probe", "code_information": [ { "code": "87556", "type": "HCPCS" } ], "standard_charges": [ { "setting": "outpatient", "payers_information": [ { "payer_name": "United Healthcare (UHC)", "plan_name": "DSNP", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "United Healthcare (UHC)", "plan_name": "Medicare Advantage", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" } ] } ] }, { "description": "N.gonorrhoeae dna amp prob", "code_information": [ { "code": "87591", "type": "HCPCS" } ], "standard_charges": [ { "setting": "outpatient", "payers_information": [ { "payer_name": "United Healthcare (UHC)", "plan_name": "DSNP", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "United Healthcare (UHC)", "plan_name": "Medicare Advantage", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" } ] } ] }, { "description": "Assay of total thyroxine", "code_information": [ { "code": "84436", "type": "HCPCS" } ], "standard_charges": [ { "setting": "outpatient", "payers_information": [ { "payer_name": "United Healthcare (UHC)", "plan_name": "DSNP", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "United Healthcare (UHC)", "plan_name": "Medicare Advantage", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" } ] } ] }, { "description": "Assay of free thyroxine", "code_information": [ { "code": "84439", "type": "HCPCS" } ], "standard_charges": [ { "setting": "outpatient", "payers_information": [ { "payer_name": "United Healthcare (UHC)", "plan_name": "DSNP", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "United Healthcare (UHC)", "plan_name": "Medicare Advantage", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" } ] } ] }, { "description": "Assay of transferrin", "code_information": [ { "code": "84466", "type": "HCPCS" } ], "standard_charges": [ { "setting": "outpatient", "payers_information": [ { "payer_name": "United Healthcare (UHC)", "plan_name": "DSNP", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "United Healthcare (UHC)", "plan_name": "Medicare Advantage", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" } ] } ] }, { "description": "Assay of triglycerides", "code_information": [ { "code": "84478", "type": "HCPCS" } ], "standard_charges": [ { "setting": "outpatient", "payers_information": [ { "payer_name": "United Healthcare (UHC)", "plan_name": "DSNP", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "United Healthcare (UHC)", "plan_name": "Medicare Advantage", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" } ] } ] }, { "description": "Assay of thyroid (t3 or t4)", "code_information": [ { "code": "84479", "type": "HCPCS" } ], "standard_charges": [ { "setting": "outpatient", "payers_information": [ { "payer_name": "United Healthcare (UHC)", "plan_name": "DSNP", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "United Healthcare (UHC)", "plan_name": "Medicare Advantage", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" } ] } ] }, { "description": "Assay triiodothyronine (t3)", "code_information": [ { "code": "84480", "type": "HCPCS" } ], "standard_charges": [ { "setting": "outpatient", "payers_information": [ { "payer_name": "United Healthcare (UHC)", "plan_name": "DSNP", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "United Healthcare (UHC)", "plan_name": "Medicare Advantage", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" } ] } ] }, { "description": "Assay of troponin quant", "code_information": [ { "code": "84484", "type": "HCPCS" } ], "standard_charges": [ { "setting": "outpatient", "payers_information": [ { "payer_name": "United Healthcare (UHC)", "plan_name": "DSNP", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "United Healthcare (UHC)", "plan_name": "Medicare Advantage", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" } ] } ] }, { "description": "Assay of urea nitrogen", "code_information": [ { "code": "84520", "type": "HCPCS" } ], "standard_charges": [ { "setting": "outpatient", "payers_information": [ { "payer_name": "United Healthcare (UHC)", "plan_name": "DSNP", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "United Healthcare (UHC)", "plan_name": "Medicare Advantage", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" } ] } ] }, { "description": "Assay of blood/uric acid", "code_information": [ { "code": "84550", "type": "HCPCS" } ], "standard_charges": [ { "setting": "outpatient", "payers_information": [ { "payer_name": "United Healthcare (UHC)", "plan_name": "DSNP", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "United Healthcare (UHC)", "plan_name": "Medicare Advantage", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" } ] } ] }, { "description": "Chorionic gonadotropin test", "code_information": [ { "code": "84702", "type": "HCPCS" } ], "standard_charges": [ { "setting": "outpatient", "payers_information": [ { "payer_name": "United Healthcare (UHC)", "plan_name": "DSNP", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "United Healthcare (UHC)", "plan_name": "Medicare Advantage", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" } ] } ] }, { "description": "Chorionic gonadotropin assay", "code_information": [ { "code": "84703", "type": "HCPCS" } ], "standard_charges": [ { "setting": "outpatient", "payers_information": [ { "payer_name": "United Healthcare (UHC)", "plan_name": "DSNP", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "United Healthcare (UHC)", "plan_name": "Medicare Advantage", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" } ] } ] }, { "description": "Bl smear w/diff wbc count", "code_information": [ { "code": "85007", "type": "HCPCS" } ], "standard_charges": [ { "setting": "outpatient", "payers_information": [ { "payer_name": "United Healthcare (UHC)", "plan_name": "DSNP", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "United Healthcare (UHC)", "plan_name": "Medicare Advantage", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" } ] } ] }, { "description": "Bl smear w/o diff wbc count", "code_information": [ { "code": "85008", "type": "HCPCS" } ], "standard_charges": [ { "setting": "outpatient", "payers_information": [ { "payer_name": "United Healthcare (UHC)", "plan_name": "DSNP", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "United Healthcare (UHC)", "plan_name": "Medicare Advantage", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" } ] } ] }, { "description": "Hematocrit", "code_information": [ { "code": "85014", "type": "HCPCS" } ], "standard_charges": [ { "setting": "outpatient", "payers_information": [ { "payer_name": "United Healthcare (UHC)", "plan_name": "DSNP", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "United Healthcare (UHC)", "plan_name": "Medicare Advantage", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" } ] } ] }, { "description": "Hemoglobin", "code_information": [ { "code": "85018", "type": "HCPCS" } ], "standard_charges": [ { "setting": "outpatient", "payers_information": [ { "payer_name": "United Healthcare (UHC)", "plan_name": "DSNP", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "United Healthcare (UHC)", "plan_name": "Medicare Advantage", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" } ] } ] }, { "description": "Manual reticulocyte count", "code_information": [ { "code": "85044", "type": "HCPCS" } ], "standard_charges": [ { "setting": "outpatient", "payers_information": [ { "payer_name": "United Healthcare (UHC)", "plan_name": "DSNP", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "United Healthcare (UHC)", "plan_name": "Medicare Advantage", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" } ] } ] }, { "description": "Automated platelet count", "code_information": [ { "code": "85049", "type": "HCPCS" } ], "standard_charges": [ { "setting": "outpatient", "payers_information": [ { "payer_name": "United Healthcare (UHC)", "plan_name": "DSNP", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "United Healthcare (UHC)", "plan_name": "Medicare Advantage", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" } ] } ] }, { "description": "Bone marrow interpretation", "code_information": [ { "code": "85097", "type": "HCPCS" } ], "standard_charges": [ { "setting": "outpatient", "payers_information": [ { "payer_name": "United Healthcare (UHC)", "plan_name": "DSNP", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "United Healthcare (UHC)", "plan_name": "Medicare Advantage", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" } ] } ] }, { "description": "Coagulation time activated", "code_information": [ { "code": "85347", "type": "HCPCS" } ], "standard_charges": [ { "setting": "outpatient", "payers_information": [ { "payer_name": "United Healthcare (UHC)", "plan_name": "DSNP", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "United Healthcare (UHC)", "plan_name": "Medicare Advantage", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" } ] } ] }, { "description": "Fibrin degradation products", "code_information": [ { "code": "85362", "type": "HCPCS" } ], "standard_charges": [ { "setting": "outpatient", "payers_information": [ { "payer_name": "United Healthcare (UHC)", "plan_name": "DSNP", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "United Healthcare (UHC)", "plan_name": "Medicare Advantage", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" } ] } ] }, { "description": "Fibrin degradation quant", "code_information": [ { "code": "85379", "type": "HCPCS" } ], "standard_charges": [ { "setting": "outpatient", "payers_information": [ { "payer_name": "United Healthcare (UHC)", "plan_name": "DSNP", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "United Healthcare (UHC)", "plan_name": "Medicare Advantage", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" } ] } ] }, { "description": "Fibrinogen activity", "code_information": [ { "code": "85384", "type": "HCPCS" } ], "standard_charges": [ { "setting": "outpatient", "payers_information": [ { "payer_name": "United Healthcare (UHC)", "plan_name": "DSNP", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "United Healthcare (UHC)", "plan_name": "Medicare Advantage", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" } ] } ] }, { "description": "Blood platelet aggregation", "code_information": [ { "code": "85576", "type": "HCPCS" } ], "standard_charges": [ { "setting": "outpatient", "payers_information": [ { "payer_name": "United Healthcare (UHC)", "plan_name": "DSNP", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "United Healthcare (UHC)", "plan_name": "Medicare Advantage", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" } ] } ] }, { "description": "Antinuclear antibodies", "code_information": [ { "code": "86038", "type": "HCPCS" } ], "standard_charges": [ { "setting": "outpatient", "payers_information": [ { "payer_name": "United Healthcare (UHC)", "plan_name": "DSNP", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "United Healthcare (UHC)", "plan_name": "Medicare Advantage", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" } ] } ] }, { "description": "Dna antibody native", "code_information": [ { "code": "86225", "type": "HCPCS" } ], "standard_charges": [ { "setting": "outpatient", "payers_information": [ { "payer_name": "United Healthcare (UHC)", "plan_name": "DSNP", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "United Healthcare (UHC)", "plan_name": "Medicare Advantage", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" } ] } ] }, { "description": "Nuclear antigen antibody", "code_information": [ { "code": "86235", "type": "HCPCS" } ], "standard_charges": [ { "setting": "outpatient", "payers_information": [ { "payer_name": "United Healthcare (UHC)", "plan_name": "DSNP", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "United Healthcare (UHC)", "plan_name": "Medicare Advantage", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" } ] } ] }, { "description": "Fluorescent antibody titer", "code_information": [ { "code": "86256", "type": "HCPCS" } ], "standard_charges": [ { "setting": "outpatient", "payers_information": [ { "payer_name": "United Healthcare (UHC)", "plan_name": "DSNP", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "United Healthcare (UHC)", "plan_name": "Medicare Advantage", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" } ] } ] }, { "description": "Immunoassay tumor ca 15-3", "code_information": [ { "code": "86300", "type": "HCPCS" } ], "standard_charges": [ { "setting": "outpatient", "payers_information": [ { "payer_name": "United Healthcare (UHC)", "plan_name": "DSNP", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "United Healthcare (UHC)", "plan_name": "Medicare Advantage", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" } ] } ] }, { "description": "Immunoassay tumor ca 19-9", "code_information": [ { "code": "86301", "type": "HCPCS" } ], "standard_charges": [ { "setting": "outpatient", "payers_information": [ { "payer_name": "United Healthcare (UHC)", "plan_name": "DSNP", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "United Healthcare (UHC)", "plan_name": "Medicare Advantage", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" } ] } ] }, { "description": "Immunoassay tumor ca 125", "code_information": [ { "code": "86304", "type": "HCPCS" } ], "standard_charges": [ { "setting": "outpatient", "payers_information": [ { "payer_name": "United Healthcare (UHC)", "plan_name": "DSNP", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "United Healthcare (UHC)", "plan_name": "Medicare Advantage", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" } ] } ] }, { "description": "Strep a dna dir probe", "code_information": [ { "code": "87650", "type": "HCPCS" } ], "standard_charges": [ { "setting": "outpatient", "payers_information": [ { "payer_name": "United Healthcare (UHC)", "plan_name": "DSNP", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "United Healthcare (UHC)", "plan_name": "Medicare Advantage", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" } ] } ] }, { "description": "Strep a dna amp probe", "code_information": [ { "code": "87651", "type": "HCPCS" } ], "standard_charges": [ { "setting": "outpatient", "payers_information": [ { "payer_name": "United Healthcare (UHC)", "plan_name": "DSNP", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "United Healthcare (UHC)", "plan_name": "Medicare Advantage", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" } ] } ] }, { "description": "Influenza assay w/optic", "code_information": [ { "code": "87804", "type": "HCPCS" } ], "standard_charges": [ { "setting": "outpatient", "payers_information": [ { "payer_name": "United Healthcare (UHC)", "plan_name": "DSNP", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "United Healthcare (UHC)", "plan_name": "Medicare Advantage", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" } ] } ] }, { "description": "Hiv ag w/hiv1&2 antb w/optic", "code_information": [ { "code": "87806", "type": "HCPCS" } ], "standard_charges": [ { "setting": "outpatient", "payers_information": [ { "payer_name": "United Healthcare (UHC)", "plan_name": "DSNP", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "United Healthcare (UHC)", "plan_name": "Medicare Advantage", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" } ] } ] }, { "description": "Sars-cov-2 covid19 w/optic", "code_information": [ { "code": "87811", "type": "HCPCS" } ], "standard_charges": [ { "setting": "outpatient", "payers_information": [ { "payer_name": "United Healthcare (UHC)", "plan_name": "DSNP", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "United Healthcare (UHC)", "plan_name": "Medicare Advantage", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" } ] } ] }, { "description": "Strep a assay w/optic", "code_information": [ { "code": "87880", "type": "HCPCS" } ], "standard_charges": [ { "setting": "outpatient", "payers_information": [ { "payer_name": "United Healthcare (UHC)", "plan_name": "DSNP", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "United Healthcare (UHC)", "plan_name": "Medicare Advantage", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" } ] } ] }, { "description": "Cytopath concentrate tech", "code_information": [ { "code": "88108", "type": "HCPCS" } ], "standard_charges": [ { "setting": "outpatient", "payers_information": [ { "payer_name": "United Healthcare (UHC)", "plan_name": "DSNP", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "United Healthcare (UHC)", "plan_name": "Medicare Advantage", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" } ] } ] }, { "description": "Cytopath cell enhance tech", "code_information": [ { "code": "88112", "type": "HCPCS" } ], "standard_charges": [ { "setting": "outpatient", "payers_information": [ { "payer_name": "United Healthcare (UHC)", "plan_name": "DSNP", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "United Healthcare (UHC)", "plan_name": "Medicare Advantage", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" } ] } ] }, { "description": "Cytopath smear other source", "code_information": [ { "code": "88161", "type": "HCPCS" } ], "standard_charges": [ { "setting": "outpatient", "payers_information": [ { "payer_name": "United Healthcare (UHC)", "plan_name": "DSNP", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "United Healthcare (UHC)", "plan_name": "Medicare Advantage", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" } ] } ] }, { "description": "Cytopath eval fna report", "code_information": [ { "code": "88173", "type": "HCPCS" } ], "standard_charges": [ { "setting": "outpatient", "payers_information": [ { "payer_name": "United Healthcare (UHC)", "plan_name": "DSNP", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "United Healthcare (UHC)", "plan_name": "Medicare Advantage", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" } ] } ] }, { "description": "Surgical path gross", "code_information": [ { "code": "88300", "type": "HCPCS" } ], "standard_charges": [ { "setting": "outpatient", "payers_information": [ { "payer_name": "United Healthcare (UHC)", "plan_name": "DSNP", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "United Healthcare (UHC)", "plan_name": "Medicare Advantage", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" } ] } ] }, { "description": "Tissue exam by pathologist", "code_information": [ { "code": "88302", "type": "HCPCS" } ], "standard_charges": [ { "setting": "outpatient", "payers_information": [ { "payer_name": "United Healthcare (UHC)", "plan_name": "DSNP", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "United Healthcare (UHC)", "plan_name": "Medicare Advantage", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" } ] } ] }, { "description": "Tissue exam by pathologist", "code_information": [ { "code": "88304", "type": "HCPCS" } ], "standard_charges": [ { "setting": "outpatient", "payers_information": [ { "payer_name": "United Healthcare (UHC)", "plan_name": "DSNP", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "United Healthcare (UHC)", "plan_name": "Medicare Advantage", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" } ] } ] }, { "description": "Tissue exam by pathologist", "code_information": [ { "code": "88305", "type": "HCPCS" } ], "standard_charges": [ { "setting": "outpatient", "payers_information": [ { "payer_name": "United Healthcare (UHC)", "plan_name": "DSNP", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "United Healthcare (UHC)", "plan_name": "Medicare Advantage", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" } ] } ] }, { "description": "Tissue exam by pathologist", "code_information": [ { "code": "88307", "type": "HCPCS" } ], "standard_charges": [ { "setting": "outpatient", "payers_information": [ { "payer_name": "United Healthcare (UHC)", "plan_name": "DSNP", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "United Healthcare (UHC)", "plan_name": "Medicare Advantage", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" } ] } ] }, { "description": "Tissue exam by pathologist", "code_information": [ { "code": "88309", "type": "HCPCS" } ], "standard_charges": [ { "setting": "outpatient", "payers_information": [ { "payer_name": "United Healthcare (UHC)", "plan_name": "DSNP", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "United Healthcare (UHC)", "plan_name": "Medicare Advantage", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" } ] } ] }, { "description": "Decalcify tissue", "code_information": [ { "code": "88311", "type": "HCPCS" } ], "standard_charges": [ { "setting": "outpatient", "payers_information": [ { "payer_name": "United Healthcare (UHC)", "plan_name": "DSNP", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "United Healthcare (UHC)", "plan_name": "Medicare Advantage", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" } ] } ] }, { "description": "Special stains group 1", "code_information": [ { "code": "88312", "type": "HCPCS" } ], "standard_charges": [ { "setting": "outpatient", "payers_information": [ { "payer_name": "United Healthcare (UHC)", "plan_name": "DSNP", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "United Healthcare (UHC)", "plan_name": "Medicare Advantage", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" } ] } ] }, { "description": "Special stains group 2", "code_information": [ { "code": "88313", "type": "HCPCS" } ], "standard_charges": [ { "setting": "outpatient", "payers_information": [ { "payer_name": "United Healthcare (UHC)", "plan_name": "DSNP", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "United Healthcare (UHC)", "plan_name": "Medicare Advantage", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" } ] } ] }, { "description": "Path consltj drg surg", "code_information": [ { "code": "88329", "type": "HCPCS" } ], "standard_charges": [ { "setting": "outpatient", "payers_information": [ { "payer_name": "United Healthcare (UHC)", "plan_name": "DSNP", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "United Healthcare (UHC)", "plan_name": "Medicare Advantage", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" } ] } ] }, { "description": "Path consltj surg 1 blk 1spc", "code_information": [ { "code": "88331", "type": "HCPCS" } ], "standard_charges": [ { "setting": "outpatient", "payers_information": [ { "payer_name": "United Healthcare (UHC)", "plan_name": "DSNP", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "United Healthcare (UHC)", "plan_name": "Medicare Advantage", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" } ] } ] }, { "description": "Imhchem/imcytchm ea add antb", "code_information": [ { "code": "88341", "type": "HCPCS" } ], "standard_charges": [ { "setting": "outpatient", "payers_information": [ { "payer_name": "United Healthcare (UHC)", "plan_name": "DSNP", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "United Healthcare (UHC)", "plan_name": "Medicare Advantage", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" } ] } ] }, { "description": "Imhchem/imcytchm 1st antb", "code_information": [ { "code": "88342", "type": "HCPCS" } ], "standard_charges": [ { "setting": "outpatient", "payers_information": [ { "payer_name": "United Healthcare (UHC)", "plan_name": "DSNP", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "United Healthcare (UHC)", "plan_name": "Medicare Advantage", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" } ] } ] }, { "description": "Body fluid cell count", "code_information": [ { "code": "89050", "type": "HCPCS" } ], "standard_charges": [ { "setting": "outpatient", "payers_information": [ { "payer_name": "United Healthcare (UHC)", "plan_name": "DSNP", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "United Healthcare (UHC)", "plan_name": "Medicare Advantage", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" } ] } ] }, { "description": "Body fluid cell count", "code_information": [ { "code": "89051", "type": "HCPCS" } ], "standard_charges": [ { "setting": "outpatient", "payers_information": [ { "payer_name": "United Healthcare (UHC)", "plan_name": "DSNP", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "United Healthcare (UHC)", "plan_name": "Medicare Advantage", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" } ] } ] }, { "description": "Immunization admin", "code_information": [ { "code": "90471", "type": "HCPCS" } ], "standard_charges": [ { "setting": "outpatient", "payers_information": [ { "payer_name": "United Healthcare (UHC)", "plan_name": "DSNP", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "United Healthcare (UHC)", "plan_name": "Medicare Advantage", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" } ] } ] }, { "description": "Rabies vaccine im", "code_information": [ { "code": "90675", "type": "HCPCS" } ], "standard_charges": [ { "setting": "outpatient", "payers_information": [ { "payer_name": "United Healthcare (UHC)", "plan_name": "DSNP", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "United Healthcare (UHC)", "plan_name": "Medicare Advantage", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "First Choice of the Midwest", "plan_name": "PPO", "standard_charge_percentage": 90, "methodology": "percent of total billed charges", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" } ] } ] }, { "description": "Tdap vaccine 7 yrs/> im", "code_information": [ { "code": "90715", "type": "HCPCS" } ], "standard_charges": [ { "setting": "outpatient", "payers_information": [ { "payer_name": "United Healthcare (UHC)", "plan_name": "DSNP", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "United Healthcare (UHC)", "plan_name": "Medicare Advantage", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" } ] } ] }, { "description": "Group psychotherapy", "code_information": [ { "code": "90853", "type": "HCPCS" } ], "standard_charges": [ { "setting": "outpatient", "payers_information": [ { "payer_name": "United Healthcare (UHC)", "plan_name": "DSNP", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "United Healthcare (UHC)", "plan_name": "Medicare Advantage", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" } ] } ] }, { "description": "Extended visual field xm", "code_information": [ { "code": "92083", "type": "HCPCS" } ], "standard_charges": [ { "setting": "outpatient", "payers_information": [ { "payer_name": "United Healthcare (UHC)", "plan_name": "DSNP", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "United Healthcare (UHC)", "plan_name": "Medicare Advantage", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" } ] } ] }, { "description": "Cmptr ophth img optic nerve", "code_information": [ { "code": "92133", "type": "HCPCS" } ], "standard_charges": [ { "setting": "outpatient", "payers_information": [ { "payer_name": "United Healthcare (UHC)", "plan_name": "DSNP", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "United Healthcare (UHC)", "plan_name": "Medicare Advantage", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" } ] } ] }, { "description": "Cptr ophth dx img post segmt", "code_information": [ { "code": "92134", "type": "HCPCS" } ], "standard_charges": [ { "setting": "outpatient", "payers_information": [ { "payer_name": "United Healthcare (UHC)", "plan_name": "DSNP", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "United Healthcare (UHC)", "plan_name": "Medicare Advantage", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" } ] } ] }, { "description": "Fundus photography w/i&r", "code_information": [ { "code": "92250", "type": "HCPCS" } ], "standard_charges": [ { "setting": "outpatient", "payers_information": [ { "payer_name": "United Healthcare (UHC)", "plan_name": "DSNP", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "United Healthcare (UHC)", "plan_name": "Medicare Advantage", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" } ] } ] }, { "description": "Motion fluoroscopy/swallow", "code_information": [ { "code": "92611", "type": "HCPCS" } ], "standard_charges": [ { "setting": "outpatient", "payers_information": [ { "payer_name": "United Healthcare (UHC)", "plan_name": "DSNP", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "United Healthcare (UHC)", "plan_name": "Medicare Advantage", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" } ] } ] }, { "description": "Aep neurodiagnostic i&r", "code_information": [ { "code": "92653", "type": "HCPCS" } ], "standard_charges": [ { "setting": "outpatient", "payers_information": [ { "payer_name": "United Healthcare (UHC)", "plan_name": "DSNP", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "United Healthcare (UHC)", "plan_name": "Medicare Advantage", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" } ] } ] }, { "description": "Prq card stent w/angio 1 vsl", "code_information": [ { "code": "92928", "type": "HCPCS" } ], "standard_charges": [ { "setting": "outpatient", "payers_information": [ { "payer_name": "United Healthcare (UHC)", "plan_name": "DSNP", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "United Healthcare (UHC)", "plan_name": "Medicare Advantage", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" } ] } ] }, { "description": "Prq card stent w/angio addl", "code_information": [ { "code": "92929", "type": "HCPCS" } ], "standard_charges": [ { "setting": "outpatient", "payers_information": [ { "payer_name": "United Healthcare (UHC)", "plan_name": "DSNP", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "United Healthcare (UHC)", "plan_name": "Medicare Advantage", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" } ] } ] }, { "description": "Prq revasc byp graft 1 vsl", "code_information": [ { "code": "92937", "type": "HCPCS" } ], "standard_charges": [ { "setting": "outpatient", "payers_information": [ { "payer_name": "United Healthcare (UHC)", "plan_name": "DSNP", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "United Healthcare (UHC)", "plan_name": "Medicare Advantage", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" } ] } ] }, { "description": "Heart/lung resuscitation cpr", "code_information": [ { "code": "92950", "type": "HCPCS" } ], "standard_charges": [ { "setting": "outpatient", "payers_information": [ { "payer_name": "United Healthcare (UHC)", "plan_name": "DSNP", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "United Healthcare (UHC)", "plan_name": "Medicare Advantage", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" } ] } ] }, { "description": "Cardioversion electric ext", "code_information": [ { "code": "92960", "type": "HCPCS" } ], "standard_charges": [ { "setting": "outpatient", "payers_information": [ { "payer_name": "United Healthcare (UHC)", "plan_name": "DSNP", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "United Healthcare (UHC)", "plan_name": "Medicare Advantage", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" } ] } ] }, { "description": "Endoluminl ivus oct c 1st", "code_information": [ { "code": "92978", "type": "HCPCS" } ], "standard_charges": [ { "setting": "outpatient", "payers_information": [ { "payer_name": "United Healthcare (UHC)", "plan_name": "DSNP", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "United Healthcare (UHC)", "plan_name": "Medicare Advantage", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" } ] } ] }, { "description": "Electrocardiogram tracing", "code_information": [ { "code": "93005", "type": "HCPCS" } ], "standard_charges": [ { "setting": "outpatient", "payers_information": [ { "payer_name": "United Healthcare (UHC)", "plan_name": "DSNP", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "United Healthcare (UHC)", "plan_name": "Medicare Advantage", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" } ] } ] }, { "description": "Cardiovascular stress test", "code_information": [ { "code": "93017", "type": "HCPCS" } ], "standard_charges": [ { "setting": "outpatient", "payers_information": [ { "payer_name": "United Healthcare (UHC)", "plan_name": "DSNP", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "United Healthcare (UHC)", "plan_name": "Medicare Advantage", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" } ] } ] }, { "description": "Ecg monit/reprt up to 48 hrs", "code_information": [ { "code": "93225", "type": "HCPCS" } ], "standard_charges": [ { "setting": "outpatient", "payers_information": [ { "payer_name": "United Healthcare (UHC)", "plan_name": "DSNP", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "United Healthcare (UHC)", "plan_name": "Medicare Advantage", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" } ] } ] }, { "description": "Ecg monit/reprt up to 48 hrs", "code_information": [ { "code": "93226", "type": "HCPCS" } ], "standard_charges": [ { "setting": "outpatient", "payers_information": [ { "payer_name": "United Healthcare (UHC)", "plan_name": "DSNP", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "United Healthcare (UHC)", "plan_name": "Medicare Advantage", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" } ] } ] }, { "description": "Tte w/doppler complete", "code_information": [ { "code": "93306", "type": "HCPCS" } ], "standard_charges": [ { "setting": "outpatient", "payers_information": [ { "payer_name": "United Healthcare (UHC)", "plan_name": "DSNP", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "United Healthcare (UHC)", "plan_name": "Medicare Advantage", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" } ] } ] }, { "description": "Tte f-up or lmtd", "code_information": [ { "code": "93308", "type": "HCPCS" } ], "standard_charges": [ { "setting": "outpatient", "payers_information": [ { "payer_name": "United Healthcare (UHC)", "plan_name": "DSNP", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "United Healthcare (UHC)", "plan_name": "Medicare Advantage", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" } ] } ] }, { "description": "Echo transesophageal", "code_information": [ { "code": "93312", "type": "HCPCS" } ], "standard_charges": [ { "setting": "outpatient", "payers_information": [ { "payer_name": "United Healthcare (UHC)", "plan_name": "DSNP", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "United Healthcare (UHC)", "plan_name": "Medicare Advantage", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" } ] } ] }, { "description": "Coronary artery angio s&i", "code_information": [ { "code": "93454", "type": "HCPCS" } ], "standard_charges": [ { "setting": "outpatient", "payers_information": [ { "payer_name": "United Healthcare (UHC)", "plan_name": "DSNP", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "United Healthcare (UHC)", "plan_name": "Medicare Advantage", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" } ] } ] }, { "description": "L hrt artery/ventricle angio", "code_information": [ { "code": "93458", "type": "HCPCS" } ], "standard_charges": [ { "setting": "outpatient", "payers_information": [ { "payer_name": "United Healthcare (UHC)", "plan_name": "DSNP", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "United Healthcare (UHC)", "plan_name": "Medicare Advantage", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" } ] } ] }, { "description": "L hrt art/grft angio", "code_information": [ { "code": "93459", "type": "HCPCS" } ], "standard_charges": [ { "setting": "outpatient", "payers_information": [ { "payer_name": "United Healthcare (UHC)", "plan_name": "DSNP", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "United Healthcare (UHC)", "plan_name": "Medicare Advantage", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" } ] } ] }, { "description": "R&l hrt art/ventricle angio", "code_information": [ { "code": "93460", "type": "HCPCS" } ], "standard_charges": [ { "setting": "outpatient", "payers_information": [ { "payer_name": "United Healthcare (UHC)", "plan_name": "DSNP", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "United Healthcare (UHC)", "plan_name": "Medicare Advantage", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" } ] } ] }, { "description": "Heart flow reserve measure", "code_information": [ { "code": "93571", "type": "HCPCS" } ], "standard_charges": [ { "setting": "outpatient", "payers_information": [ { "payer_name": "United Healthcare (UHC)", "plan_name": "DSNP", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "United Healthcare (UHC)", "plan_name": "Medicare Advantage", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" } ] } ] }, { "description": "Heart flow reserve measure", "code_information": [ { "code": "93572", "type": "HCPCS" } ], "standard_charges": [ { "setting": "outpatient", "payers_information": [ { "payer_name": "United Healthcare (UHC)", "plan_name": "DSNP", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "United Healthcare (UHC)", "plan_name": "Medicare Advantage", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" } ] } ] }, { "description": "Cardiac rehab/monitor", "code_information": [ { "code": "93798", "type": "HCPCS" } ], "standard_charges": [ { "setting": "outpatient", "payers_information": [ { "payer_name": "United Healthcare (UHC)", "plan_name": "DSNP", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "United Healthcare (UHC)", "plan_name": "Medicare Advantage", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" } ] } ] }, { "description": "Extracranial bilat study", "code_information": [ { "code": "93880", "type": "HCPCS" } ], "standard_charges": [ { "setting": "outpatient", "payers_information": [ { "payer_name": "United Healthcare (UHC)", "plan_name": "DSNP", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "United Healthcare (UHC)", "plan_name": "Medicare Advantage", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" } ] } ] }, { "description": "Lower extremity study", "code_information": [ { "code": "93925", "type": "HCPCS" } ], "standard_charges": [ { "setting": "outpatient", "payers_information": [ { "payer_name": "United Healthcare (UHC)", "plan_name": "DSNP", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "United Healthcare (UHC)", "plan_name": "Medicare Advantage", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" } ] } ] }, { "description": "Upper extremity study", "code_information": [ { "code": "93930", "type": "HCPCS" } ], "standard_charges": [ { "setting": "outpatient", "payers_information": [ { "payer_name": "United Healthcare (UHC)", "plan_name": "DSNP", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "United Healthcare (UHC)", "plan_name": "Medicare Advantage", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" } ] } ] }, { "description": "Dup-scan hemo compl bi std", "code_information": [ { "code": "93985", "type": "HCPCS" } ], "standard_charges": [ { "setting": "outpatient", "payers_information": [ { "payer_name": "United Healthcare (UHC)", "plan_name": "DSNP", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "United Healthcare (UHC)", "plan_name": "Medicare Advantage", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" } ] } ] }, { "description": "Doppler flow testing", "code_information": [ { "code": "93990", "type": "HCPCS" } ], "standard_charges": [ { "setting": "outpatient", "payers_information": [ { "payer_name": "United Healthcare (UHC)", "plan_name": "DSNP", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "United Healthcare (UHC)", "plan_name": "Medicare Advantage", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" } ] } ] }, { "description": "Evaluation of wheezing", "code_information": [ { "code": "94060", "type": "HCPCS" } ], "standard_charges": [ { "setting": "outpatient", "payers_information": [ { "payer_name": "United Healthcare (UHC)", "plan_name": "DSNP", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "United Healthcare (UHC)", "plan_name": "Medicare Advantage", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" } ] } ] }, { "description": "Airway inhalation treatment", "code_information": [ { "code": "94640", "type": "HCPCS" } ], "standard_charges": [ { "setting": "outpatient", "payers_information": [ { "payer_name": "United Healthcare (UHC)", "plan_name": "DSNP", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "United Healthcare (UHC)", "plan_name": "Medicare Advantage", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" } ] } ] }, { "description": "Pos airway pressure cpap", "code_information": [ { "code": "94660", "type": "HCPCS" } ], "standard_charges": [ { "setting": "outpatient", "payers_information": [ { "payer_name": "United Healthcare (UHC)", "plan_name": "DSNP", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "United Healthcare (UHC)", "plan_name": "Medicare Advantage", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" } ] } ] }, { "description": "Measure blood oxygen level", "code_information": [ { "code": "94760", "type": "HCPCS" } ], "standard_charges": [ { "setting": "outpatient", "payers_information": [ { "payer_name": "United Healthcare (UHC)", "plan_name": "DSNP", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "United Healthcare (UHC)", "plan_name": "Medicare Advantage", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" } ] } ] }, { "description": "Measure blood oxygen level", "code_information": [ { "code": "94761", "type": "HCPCS" } ], "standard_charges": [ { "setting": "outpatient", "payers_information": [ { "payer_name": "United Healthcare (UHC)", "plan_name": "DSNP", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "United Healthcare (UHC)", "plan_name": "Medicare Advantage", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" } ] } ] }, { "description": "Unlisted pulmonary svc/px", "code_information": [ { "code": "94799", "type": "HCPCS" } ], "standard_charges": [ { "setting": "outpatient", "payers_information": [ { "payer_name": "United Healthcare (UHC)", "plan_name": "DSNP", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "United Healthcare (UHC)", "plan_name": "Medicare Advantage", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" } ] } ] }, { "description": "Eeg awake and drowsy", "code_information": [ { "code": "95816", "type": "HCPCS" } ], "standard_charges": [ { "setting": "outpatient", "payers_information": [ { "payer_name": "United Healthcare (UHC)", "plan_name": "DSNP", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "United Healthcare (UHC)", "plan_name": "Medicare Advantage", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" } ] } ] }, { "description": "Eeg awake and asleep", "code_information": [ { "code": "95819", "type": "HCPCS" } ], "standard_charges": [ { "setting": "outpatient", "payers_information": [ { "payer_name": "United Healthcare (UHC)", "plan_name": "DSNP", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "United Healthcare (UHC)", "plan_name": "Medicare Advantage", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" } ] } ] }, { "description": "Musc test done w/n test comp", "code_information": [ { "code": "95886", "type": "HCPCS" } ], "standard_charges": [ { "setting": "outpatient", "payers_information": [ { "payer_name": "United Healthcare (UHC)", "plan_name": "DSNP", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "United Healthcare (UHC)", "plan_name": "Medicare Advantage", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" } ] } ] }, { "description": "Nrv cndj test 13/> studies", "code_information": [ { "code": "95913", "type": "HCPCS" } ], "standard_charges": [ { "setting": "outpatient", "payers_information": [ { "payer_name": "United Healthcare (UHC)", "plan_name": "DSNP", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "United Healthcare (UHC)", "plan_name": "Medicare Advantage", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" } ] } ] }, { "description": "Hydration iv infusion init", "code_information": [ { "code": "96360", "type": "HCPCS" } ], "standard_charges": [ { "setting": "outpatient", "payers_information": [ { "payer_name": "United Healthcare (UHC)", "plan_name": "DSNP", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "United Healthcare (UHC)", "plan_name": "Medicare Advantage", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" } ] } ] }, { "description": "Hydrate iv infusion add-on", "code_information": [ { "code": "96361", "type": "HCPCS" } ], "standard_charges": [ { "setting": "outpatient", "payers_information": [ { "payer_name": "United Healthcare (UHC)", "plan_name": "DSNP", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "United Healthcare (UHC)", "plan_name": "Medicare Advantage", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" } ] } ] }, { "description": "Ther/proph/diag iv inf init", "code_information": [ { "code": "96365", "type": "HCPCS" } ], "standard_charges": [ { "setting": "outpatient", "payers_information": [ { "payer_name": "United Healthcare (UHC)", "plan_name": "DSNP", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "United Healthcare (UHC)", "plan_name": "Medicare Advantage", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" } ] } ] }, { "description": "Ther/proph/diag iv inf addon", "code_information": [ { "code": "96366", "type": "HCPCS" } ], "standard_charges": [ { "setting": "outpatient", "payers_information": [ { "payer_name": "United Healthcare (UHC)", "plan_name": "DSNP", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "United Healthcare (UHC)", "plan_name": "Medicare Advantage", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" } ] } ] }, { "description": "Tx/proph/dg addl seq iv inf", "code_information": [ { "code": "96367", "type": "HCPCS" } ], "standard_charges": [ { "setting": "outpatient", "payers_information": [ { "payer_name": "United Healthcare (UHC)", "plan_name": "DSNP", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "United Healthcare (UHC)", "plan_name": "Medicare Advantage", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" } ] } ] }, { "description": "Ther/diag concurrent inf", "code_information": [ { "code": "96368", "type": "HCPCS" } ], "standard_charges": [ { "setting": "outpatient", "payers_information": [ { "payer_name": "United Healthcare (UHC)", "plan_name": "DSNP", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "United Healthcare (UHC)", "plan_name": "Medicare Advantage", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" } ] } ] }, { "description": "Ther/proph/diag inj sc/im", "code_information": [ { "code": "96372", "type": "HCPCS" } ], "standard_charges": [ { "setting": "outpatient", "payers_information": [ { "payer_name": "United Healthcare (UHC)", "plan_name": "DSNP", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "United Healthcare (UHC)", "plan_name": "Medicare Advantage", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" } ] } ] }, { "description": "Ther/proph/diag inj iv push", "code_information": [ { "code": "96374", "type": "HCPCS" } ], "standard_charges": [ { "setting": "outpatient", "payers_information": [ { "payer_name": "United Healthcare (UHC)", "plan_name": "DSNP", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "United Healthcare (UHC)", "plan_name": "Medicare Advantage", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" } ] } ] }, { "description": "Tx/pro/dx inj new drug addon", "code_information": [ { "code": "96375", "type": "HCPCS" } ], "standard_charges": [ { "setting": "outpatient", "payers_information": [ { "payer_name": "United Healthcare (UHC)", "plan_name": "DSNP", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "United Healthcare (UHC)", "plan_name": "Medicare Advantage", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" } ] } ] }, { "description": "Tx/pro/dx inj same drug adon", "code_information": [ { "code": "96376", "type": "HCPCS" } ], "standard_charges": [ { "setting": "outpatient", "payers_information": [ { "payer_name": "United Healthcare (UHC)", "plan_name": "DSNP", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "United Healthcare (UHC)", "plan_name": "Medicare Advantage", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" } ] } ] }, { "description": "Mod sed same phys/qhp 5/>yrs", "code_information": [ { "code": "99152", "type": "HCPCS" } ], "standard_charges": [ { "setting": "outpatient", "payers_information": [ { "payer_name": "United Healthcare (UHC)", "plan_name": "DSNP", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "United Healthcare (UHC)", "plan_name": "Medicare Advantage", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" } ] } ] }, { "description": "Mod sed same phys/qhp ea", "code_information": [ { "code": "99153", "type": "HCPCS" } ], "standard_charges": [ { "setting": "outpatient", "payers_information": [ { "payer_name": "United Healthcare (UHC)", "plan_name": "DSNP", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "United Healthcare (UHC)", "plan_name": "Medicare Advantage", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" } ] } ] }, { "description": "Mod sed other phys/qhp ea", "code_information": [ { "code": "99157", "type": "HCPCS" } ], "standard_charges": [ { "setting": "outpatient", "payers_information": [ { "payer_name": "United Healthcare (UHC)", "plan_name": "DSNP", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "United Healthcare (UHC)", "plan_name": "Medicare Advantage", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" } ] } ] }, { "description": "Emr dpt vst mayx req phy/qhp", "code_information": [ { "code": "99281", "type": "HCPCS" } ], "standard_charges": [ { "setting": "outpatient", "payers_information": [ { "payer_name": "United Healthcare (UHC)", "plan_name": "DSNP", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "United Healthcare (UHC)", "plan_name": "Medicare Advantage", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" } ] } ] }, { "description": "Emergency dept visit sf mdm", "code_information": [ { "code": "99282", "type": "HCPCS" } ], "standard_charges": [ { "setting": "outpatient", "payers_information": [ { "payer_name": "United Healthcare (UHC)", "plan_name": "DSNP", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "United Healthcare (UHC)", "plan_name": "Medicare Advantage", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" } ] } ] }, { "description": "Emergency dept visit low mdm", "code_information": [ { "code": "99283", "type": "HCPCS" } ], "standard_charges": [ { "setting": "outpatient", "payers_information": [ { "payer_name": "United Healthcare (UHC)", "plan_name": "DSNP", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "United Healthcare (UHC)", "plan_name": "Medicare Advantage", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" } ] } ] }, { "description": "Emergency dept visit mod mdm", "code_information": [ { "code": "99284", "type": "HCPCS" } ], "standard_charges": [ { "setting": "outpatient", "payers_information": [ { "payer_name": "United Healthcare (UHC)", "plan_name": "DSNP", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "United Healthcare (UHC)", "plan_name": "Medicare Advantage", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" } ] } ] }, { "description": "Emergency dept visit hi mdm", "code_information": [ { "code": "99285", "type": "HCPCS" } ], "standard_charges": [ { "setting": "outpatient", "payers_information": [ { "payer_name": "United Healthcare (UHC)", "plan_name": "DSNP", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "United Healthcare (UHC)", "plan_name": "Medicare Advantage", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" } ] } ] }, { "description": "Critical care first hour", "code_information": [ { "code": "99291", "type": "HCPCS" } ], "standard_charges": [ { "setting": "outpatient", "payers_information": [ { "payer_name": "United Healthcare (UHC)", "plan_name": "DSNP", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "United Healthcare (UHC)", "plan_name": "Medicare Advantage", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" } ] } ] }, { "description": "Ct perfusion w/contrast cbf", "code_information": [ { "code": "0042T", "type": "HCPCS" } ], "standard_charges": [ { "setting": "outpatient", "payers_information": [ { "payer_name": "United Healthcare (UHC)", "plan_name": "DSNP", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "United Healthcare (UHC)", "plan_name": "Medicare Advantage", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" } ] } ] }, { "description": "Bone srgry cmptr fluor image", "code_information": [ { "code": "0054T", "type": "HCPCS" } ], "standard_charges": [ { "setting": "outpatient", "payers_information": [ { "payer_name": "United Healthcare (UHC)", "plan_name": "DSNP", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "United Healthcare (UHC)", "plan_name": "Medicare Advantage", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" } ] } ] }, { "description": "Insj ant sgm aq drg dev 1+", "code_information": [ { "code": "0671T", "type": "HCPCS" } ], "standard_charges": [ { "setting": "outpatient", "payers_information": [ { "payer_name": "United Healthcare (UHC)", "plan_name": "DSNP", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "United Healthcare (UHC)", "plan_name": "Medicare Advantage", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" } ] } ] }, { "description": "Sterile water/saline, 10 ml", "code_information": [ { "code": "A4216", "type": "HCPCS" }, { "code": "00019-1188-75", "type": "NDC" } ], "standard_charges": [ { "setting": "outpatient", "payers_information": [ { "payer_name": "United Healthcare (UHC)", "plan_name": "DSNP", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "United Healthcare (UHC)", "plan_name": "Medicare Advantage", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" } ] } ], "drug_information": { "unit": 50, "type": "ML" } }, { "description": "Sterile water/saline, 500 ml", "code_information": [ { "code": "A4217", "type": "HCPCS" }, { "code": "00019-1188-27", "type": "NDC" } ], "standard_charges": [ { "setting": "outpatient", "payers_information": [ { "payer_name": "United Healthcare (UHC)", "plan_name": "DSNP", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "United Healthcare (UHC)", "plan_name": "Medicare Advantage", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" } ] } ], "drug_information": { "unit": 125, "type": "ML" } }, { "description": "Fem urinary collect pouch", "code_information": [ { "code": "A4328", "type": "HCPCS" } ], "standard_charges": [ { "setting": "outpatient", "payers_information": [ { "payer_name": "United Healthcare (UHC)", "plan_name": "DSNP", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "United Healthcare (UHC)", "plan_name": "Medicare Advantage", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" } ] } ] }, { "description": "Bedside drainage bag", "code_information": [ { "code": "A4357", "type": "HCPCS" } ], "standard_charges": [ { "setting": "outpatient", "payers_information": [ { "payer_name": "United Healthcare (UHC)", "plan_name": "DSNP", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "United Healthcare (UHC)", "plan_name": "Medicare Advantage", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" } ] } ] }, { "description": "Implantable tissue marker", "code_information": [ { "code": "A4648", "type": "HCPCS" } ], "standard_charges": [ { "setting": "outpatient", "payers_information": [ { "payer_name": "United Healthcare (UHC)", "plan_name": "DSNP", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "United Healthcare (UHC)", "plan_name": "Medicare Advantage", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" } ] } ] }, { "description": "Surgical supplies", "code_information": [ { "code": "A4649", "type": "HCPCS" } ], "standard_charges": [ { "setting": "outpatient", "payers_information": [ { "payer_name": "United Healthcare (UHC)", "plan_name": "DSNP", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "United Healthcare (UHC)", "plan_name": "Medicare Advantage", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" } ] } ] }, { "description": "Clsd ostomy pouch w/flange", "code_information": [ { "code": "A5054", "type": "HCPCS" } ], "standard_charges": [ { "setting": "outpatient", "payers_information": [ { "payer_name": "United Healthcare (UHC)", "plan_name": "DSNP", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "United Healthcare (UHC)", "plan_name": "Medicare Advantage", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" } ] } ] }, { "description": "Foam drg <=16 sq in w/border", "code_information": [ { "code": "A6212", "type": "HCPCS" } ], "standard_charges": [ { "setting": "outpatient", "payers_information": [ { "payer_name": "United Healthcare (UHC)", "plan_name": "DSNP", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "United Healthcare (UHC)", "plan_name": "Medicare Advantage", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" } ] } ] }, { "description": "Sterile gauze>16 <= 48 sq in", "code_information": [ { "code": "A6403", "type": "HCPCS" } ], "standard_charges": [ { "setting": "outpatient", "payers_information": [ { "payer_name": "United Healthcare (UHC)", "plan_name": "DSNP", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "United Healthcare (UHC)", "plan_name": "Medicare Advantage", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" } ] } ] }, { "description": "Tc99m medronate", "code_information": [ { "code": "A9503", "type": "HCPCS" } ], "standard_charges": [ { "setting": "outpatient", "payers_information": [ { "payer_name": "United Healthcare (UHC)", "plan_name": "DSNP", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "United Healthcare (UHC)", "plan_name": "Medicare Advantage", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" } ] } ] }, { "description": "I131 iodide cap, rx", "code_information": [ { "code": "A9517", "type": "HCPCS" } ], "standard_charges": [ { "setting": "outpatient", "payers_information": [ { "payer_name": "United Healthcare (UHC)", "plan_name": "DSNP", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "United Healthcare (UHC)", "plan_name": "Medicare Advantage", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "First Choice of the Midwest", "plan_name": "PPO", "standard_charge_percentage": 90, "methodology": "percent of total billed charges", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" } ] } ] }, { "description": "Tc99m mebrofenin", "code_information": [ { "code": "A9537", "type": "HCPCS" } ], "standard_charges": [ { "setting": "outpatient", "payers_information": [ { "payer_name": "United Healthcare (UHC)", "plan_name": "DSNP", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "United Healthcare (UHC)", "plan_name": "Medicare Advantage", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" } ] } ] }, { "description": "Tc99m succimer", "code_information": [ { "code": "A9551", "type": "HCPCS" } ], "standard_charges": [ { "setting": "outpatient", "payers_information": [ { "payer_name": "United Healthcare (UHC)", "plan_name": "DSNP", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "United Healthcare (UHC)", "plan_name": "Medicare Advantage", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" } ] } ] }, { "description": "Gad-base mr contrast nos,1ml", "code_information": [ { "code": "A9579", "type": "HCPCS" } ], "standard_charges": [ { "setting": "outpatient", "payers_information": [ { "payer_name": "United Healthcare (UHC)", "plan_name": "DSNP", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "United Healthcare (UHC)", "plan_name": "Medicare Advantage", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" } ] } ] }, { "description": "Anchor/screw for opposing bone-to-bone or soft tissue-to-bone (implantable)", "code_information": [ { "code": "C1713", "type": "HCPCS" } ], "standard_charges": [ { "setting": "outpatient", "payers_information": [ { "payer_name": "United Healthcare (UHC)", "plan_name": "DSNP", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "United Healthcare (UHC)", "plan_name": "Medicare Advantage", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" } ] } ] }, { "description": "Catheter, transluminal atherectomy, directional", "code_information": [ { "code": "C1714", "type": "HCPCS" } ], "standard_charges": [ { "setting": "outpatient", "payers_information": [ { "payer_name": "United Healthcare (UHC)", "plan_name": "DSNP", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "United Healthcare (UHC)", "plan_name": "Medicare Advantage", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" } ] } ] }, { "description": "Catheter, transluminal angioplasty, non-laser (may include guidance, infusion/perfusion capability)", "code_information": [ { "code": "C1725", "type": "HCPCS" } ], "standard_charges": [ { "setting": "outpatient", "payers_information": [ { "payer_name": "United Healthcare (UHC)", "plan_name": "DSNP", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "United Healthcare (UHC)", "plan_name": "Medicare Advantage", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" } ] } ] }, { "description": "Catheter, balloon dilatation, non-vascular", "code_information": [ { "code": "C1726", "type": "HCPCS" } ], "standard_charges": [ { "setting": "outpatient", "payers_information": [ { "payer_name": "United Healthcare (UHC)", "plan_name": "DSNP", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "United Healthcare (UHC)", "plan_name": "Medicare Advantage", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" } ] } ] }, { "description": "Catheter, drainage", "code_information": [ { "code": "C1729", "type": "HCPCS" } ], "standard_charges": [ { "setting": "outpatient", "payers_information": [ { "payer_name": "United Healthcare (UHC)", "plan_name": "DSNP", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "United Healthcare (UHC)", "plan_name": "Medicare Advantage", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" } ] } ] }, { "description": "Catheter, electrophysiology, diagnostic, other than 3d mapping (19 or fewer electrodes)", "code_information": [ { "code": "C1730", "type": "HCPCS" } ], "standard_charges": [ { "setting": "outpatient", "payers_information": [ { "payer_name": "United Healthcare (UHC)", "plan_name": "DSNP", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "United Healthcare (UHC)", "plan_name": "Medicare Advantage", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" } ] } ] }, { "description": "Endoscope, single-use (i.e. disposable), urinary tract, imaging/illumination device (insertable)", "code_information": [ { "code": "C1747", "type": "HCPCS" } ], "standard_charges": [ { "setting": "outpatient", "payers_information": [ { "payer_name": "United Healthcare (UHC)", "plan_name": "DSNP", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "United Healthcare (UHC)", "plan_name": "Medicare Advantage", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" } ] } ] }, { "description": "Catheter, hemodialysis/peritoneal, long-term", "code_information": [ { "code": "C1750", "type": "HCPCS" } ], "standard_charges": [ { "setting": "outpatient", "payers_information": [ { "payer_name": "United Healthcare (UHC)", "plan_name": "DSNP", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "United Healthcare (UHC)", "plan_name": "Medicare Advantage", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" } ] } ] }, { "description": "Catheter, infusion, inserted peripherally, centrally or midline (other than hemodialysis)", "code_information": [ { "code": "C1751", "type": "HCPCS" } ], "standard_charges": [ { "setting": "outpatient", "payers_information": [ { "payer_name": "United Healthcare (UHC)", "plan_name": "DSNP", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "United Healthcare (UHC)", "plan_name": "Medicare Advantage", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" } ] } ] }, { "description": "Catheter, intravascular ultrasound", "code_information": [ { "code": "C1753", "type": "HCPCS" } ], "standard_charges": [ { "setting": "outpatient", "payers_information": [ { "payer_name": "United Healthcare (UHC)", "plan_name": "DSNP", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "United Healthcare (UHC)", "plan_name": "Medicare Advantage", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" } ] } ] }, { "description": "Catheter, thrombectomy/embolectomy", "code_information": [ { "code": "C1757", "type": "HCPCS" } ], "standard_charges": [ { "setting": "outpatient", "payers_information": [ { "payer_name": "United Healthcare (UHC)", "plan_name": "DSNP", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "United Healthcare (UHC)", "plan_name": "Medicare Advantage", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" } ] } ] }, { "description": "Catheter, ureteral", "code_information": [ { "code": "C1758", "type": "HCPCS" } ], "standard_charges": [ { "setting": "outpatient", "payers_information": [ { "payer_name": "United Healthcare (UHC)", "plan_name": "DSNP", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "United Healthcare (UHC)", "plan_name": "Medicare Advantage", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" } ] } ] }, { "description": "Inj, propofol, 10 mg", "code_information": [ { "code": "J2704", "type": "HCPCS" }, { "code": "00069-0209-10", "type": "NDC" } ], "standard_charges": [ { "setting": "outpatient", "payers_information": [ { "payer_name": "United Healthcare (UHC)", "plan_name": "DSNP", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "United Healthcare (UHC)", "plan_name": "Medicare Advantage", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" } ] } ], "drug_information": { "unit": 20, "type": "ML" } }, { "description": "Neostigmine methylslfte inj", "code_information": [ { "code": "J2710", "type": "HCPCS" }, { "code": "00517-1133-01", "type": "NDC" } ], "standard_charges": [ { "setting": "outpatient", "payers_information": [ { "payer_name": "United Healthcare (UHC)", "plan_name": "DSNP", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "United Healthcare (UHC)", "plan_name": "Medicare Advantage", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" } ] } ], "drug_information": { "unit": 10, "type": "ML" } }, { "description": "Inj protamine sulfate/10 mg", "code_information": [ { "code": "J2720", "type": "HCPCS" }, { "code": "49452-6109-01", "type": "NDC" } ], "standard_charges": [ { "setting": "outpatient", "payers_information": [ { "payer_name": "United Healthcare (UHC)", "plan_name": "DSNP", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "United Healthcare (UHC)", "plan_name": "Medicare Advantage", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" } ] } ], "drug_information": { "unit": 5, "type": "GM" } }, { "description": "Metoclopramide hcl injection", "code_information": [ { "code": "J2765", "type": "HCPCS" }, { "code": "00409-3414-11", "type": "NDC" } ], "standard_charges": [ { "setting": "outpatient", "payers_information": [ { "payer_name": "United Healthcare (UHC)", "plan_name": "DSNP", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "United Healthcare (UHC)", "plan_name": "Medicare Advantage", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" } ] } ], "drug_information": { "unit": 2, "type": "ML" } }, { "description": "Regadenoson injection", "code_information": [ { "code": "J2785", "type": "HCPCS" } ], "standard_charges": [ { "setting": "outpatient", "payers_information": [ { "payer_name": "United Healthcare (UHC)", "plan_name": "DSNP", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "United Healthcare (UHC)", "plan_name": "Medicare Advantage", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" } ] } ] }, { "description": "Rho d immune globulin inj", "code_information": [ { "code": "J2790", "type": "HCPCS" }, { "code": "00562-7805-00", "type": "NDC" } ], "standard_charges": [ { "setting": "outpatient", "payers_information": [ { "payer_name": "United Healthcare (UHC)", "plan_name": "DSNP", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "United Healthcare (UHC)", "plan_name": "Medicare Advantage", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" } ] } ], "drug_information": { "unit": 1, "type": "EA" } }, { "description": "Ropivacaine hcl injection", "code_information": [ { "code": "J2795", "type": "HCPCS" }, { "code": "00143-9263-10", "type": "NDC" } ], "standard_charges": [ { "setting": "outpatient", "payers_information": [ { "payer_name": "United Healthcare (UHC)", "plan_name": "DSNP", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "United Healthcare (UHC)", "plan_name": "Medicare Advantage", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" } ] } ], "drug_information": { "unit": 20, "type": "ML" } }, { "description": "Na ferric gluconate complex", "code_information": [ { "code": "J2916", "type": "HCPCS" }, { "code": "00143-9298-10", "type": "NDC" } ], "standard_charges": [ { "setting": "outpatient", "payers_information": [ { "payer_name": "United Healthcare (UHC)", "plan_name": "DSNP", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "United Healthcare (UHC)", "plan_name": "Medicare Advantage", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" } ] } ], "drug_information": { "unit": 5, "type": "ML" } }, { "description": "Injection, methylprednisolone sodium succinate, 5 mg", "code_information": [ { "code": "J2919", "type": "HCPCS" }, { "code": "00009-0039-06", "type": "NDC" } ], "standard_charges": [ { "setting": "outpatient", "payers_information": [ { "payer_name": "United Healthcare (UHC)", "plan_name": "DSNP", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "United Healthcare (UHC)", "plan_name": "Medicare Advantage", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "First Choice of the Midwest", "plan_name": "PPO", "standard_charge_percentage": 90, "methodology": "percent of total billed charges", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" } ] } ], "drug_information": { "unit": 25, "type": "EA" } }, { "description": "Methylprednisolone injection", "code_information": [ { "code": "J2920", "type": "HCPCS" }, { "code": "00143-9753-25", "type": "NDC" } ], "standard_charges": [ { "setting": "outpatient", "payers_information": [ { "payer_name": "United Healthcare (UHC)", "plan_name": "DSNP", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "United Healthcare (UHC)", "plan_name": "Medicare Advantage", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" } ] } ], "drug_information": { "unit": 25, "type": "EA" } }, { "description": "Methylprednisolone injection", "code_information": [ { "code": "J2930", "type": "HCPCS" }, { "code": "00009-0698-01", "type": "NDC" } ], "standard_charges": [ { "setting": "outpatient", "payers_information": [ { "payer_name": "United Healthcare (UHC)", "plan_name": "DSNP", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "United Healthcare (UHC)", "plan_name": "Medicare Advantage", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" } ] } ], "drug_information": { "unit": 1, "type": "EA" } }, { "description": "Alteplase recombinant", "code_information": [ { "code": "J2997", "type": "HCPCS" }, { "code": "50242-0041-10", "type": "NDC" } ], "standard_charges": [ { "setting": "outpatient", "payers_information": [ { "payer_name": "United Healthcare (UHC)", "plan_name": "DSNP", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "TriWest Healthcare Alliance Corporation", "plan_name": "VA CCN", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "United Healthcare (UHC)", "plan_name": "Medicare Advantage", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "First Choice of the Midwest", "plan_name": "PPO", "standard_charge_percentage": 90, "methodology": "percent of total billed charges", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Claritev fka MultiPlan", "plan_name": "PPO", "standard_charge_percentage": 75, "methodology": "percent of total billed charges", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Blue Cross Blue Shield of Montana", "plan_name": "HealthLink Network", "standard_charge_percentage": 75, "methodology": "percent of total billed charges", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Blue Cross Blue Shield of Montana", "plan_name": "Traditional Network", "standard_charge_percentage": 75, "methodology": "percent of total billed charges", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Blue Cross Blue Shield of Montana", "plan_name": "POS Network", "standard_charge_percentage": 75, "methodology": "percent of total billed charges", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Blue Cross Blue Shield of Montana", "plan_name": "Closed Plan Network", "standard_charge_percentage": 75, "methodology": "percent of total billed charges", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Blue Cross Blue Shield of Montana", "plan_name": "Retail HMO POS Network", "standard_charge_percentage": 75, "methodology": "percent of total billed charges", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Blue Cross Blue Shield of Montana", "plan_name": "Blue Options Network", "standard_charge_percentage": 75, "methodology": "percent of total billed charges", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "First Choice Health Network fka Health InfoNet", "plan_name": "Medicare Advantage", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Allegiance Provider Direct", "plan_name": "Medicare", "standard_charge_percentage": 229.99999999999997, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Allegiance Provider Direct", "plan_name": "State of Montana Employee Benefit Plan (Self-Funded)", "standard_charge_percentage": 229.99999999999997, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Allegiance Provider Direct", "plan_name": "Montana Municipal Interlocal Authority (MMIA)", "standard_charge_percentage": 229.99999999999997, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "PacificSource Health Plans", "plan_name": "PPO (PSN Network and Smart Health Network)", "standard_charge_percentage": 80, "methodology": "percent of total billed charges", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Medica Insurance Company", "plan_name": "Medicare Cost", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" } ] } ], "drug_information": { "unit": 10, "type": "EA" } }, { "description": "Fentanyl citrate injection", "code_information": [ { "code": "J3010", "type": "HCPCS" }, { "code": "00406-1130-52", "type": "NDC" } ], "standard_charges": [ { "setting": "outpatient", "payers_information": [ { "payer_name": "United Healthcare (UHC)", "plan_name": "DSNP", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "United Healthcare (UHC)", "plan_name": "Medicare Advantage", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" } ] } ], "drug_information": { "unit": 1, "type": "EA" } }, { "description": "Terbutaline sulfate inj", "code_information": [ { "code": "J3105", "type": "HCPCS" }, { "code": "00143-9375-10", "type": "NDC" } ], "standard_charges": [ { "setting": "outpatient", "payers_information": [ { "payer_name": "United Healthcare (UHC)", "plan_name": "DSNP", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "United Healthcare (UHC)", "plan_name": "Medicare Advantage", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" } ] } ], "drug_information": { "unit": 1, "type": "ML" } }, { "description": "Diazepam injection", "code_information": [ { "code": "J3360", "type": "HCPCS" }, { "code": "00409-1273-32", "type": "NDC" } ], "standard_charges": [ { "setting": "outpatient", "payers_information": [ { "payer_name": "United Healthcare (UHC)", "plan_name": "DSNP", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "United Healthcare (UHC)", "plan_name": "Medicare Advantage", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" } ] } ], "drug_information": { "unit": 2, "type": "ML" } }, { "description": "Vancomycin hcl injection", "code_information": [ { "code": "J3370", "type": "HCPCS" }, { "code": "00143-9161-25", "type": "NDC" } ], "standard_charges": [ { "setting": "outpatient", "payers_information": [ { "payer_name": "United Healthcare (UHC)", "plan_name": "DSNP", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "United Healthcare (UHC)", "plan_name": "Medicare Advantage", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" } ] } ], "drug_information": { "unit": 25, "type": "EA" } }, { "description": "Hyaluronidase injection", "code_information": [ { "code": "J3470", "type": "HCPCS" }, { "code": "00548-9090-10", "type": "NDC" } ], "standard_charges": [ { "setting": "outpatient", "payers_information": [ { "payer_name": "United Healthcare (UHC)", "plan_name": "DSNP", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "United Healthcare (UHC)", "plan_name": "Medicare Advantage", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" } ] } ], "drug_information": { "unit": 10, "type": "EA" } }, { "description": "Hyaluronidase recombinant", "code_information": [ { "code": "J3473", "type": "HCPCS" }, { "code": "18657-0117-04", "type": "NDC" } ], "standard_charges": [ { "setting": "outpatient", "payers_information": [ { "payer_name": "United Healthcare (UHC)", "plan_name": "DSNP", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "United Healthcare (UHC)", "plan_name": "Medicare Advantage", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" } ] } ], "drug_information": { "unit": 1, "type": "ML" } }, { "description": "Inj magnesium sulfate", "code_information": [ { "code": "J3475", "type": "HCPCS" }, { "code": "00264-4204-52", "type": "NDC" } ], "standard_charges": [ { "setting": "outpatient", "payers_information": [ { "payer_name": "United Healthcare (UHC)", "plan_name": "DSNP", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "United Healthcare (UHC)", "plan_name": "Medicare Advantage", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" } ] } ], "drug_information": { "unit": 50, "type": "ML" } }, { "description": "Inj potassium chloride", "code_information": [ { "code": "J3480", "type": "HCPCS" }, { "code": "00264-1940-20", "type": "NDC" } ], "standard_charges": [ { "setting": "outpatient", "payers_information": [ { "payer_name": "United Healthcare (UHC)", "plan_name": "DSNP", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "United Healthcare (UHC)", "plan_name": "Medicare Advantage", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" } ] } ], "drug_information": { "unit": 250, "type": "ML" } }, { "description": "Drugs unclassified injection", "code_information": [ { "code": "J3490", "type": "HCPCS" }, { "code": "00004-0350-09", "type": "NDC" } ], "standard_charges": [ { "setting": "outpatient", "payers_information": [ { "payer_name": "United Healthcare (UHC)", "plan_name": "DSNP", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "United Healthcare (UHC)", "plan_name": "Medicare Advantage", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" } ] } ], "drug_information": { "unit": 1, "type": "ML" } }, { "description": "Normal saline solution infus", "code_information": [ { "code": "J7030", "type": "HCPCS" }, { "code": "00264-7800-00", "type": "NDC" } ], "standard_charges": [ { "setting": "outpatient", "payers_information": [ { "payer_name": "United Healthcare (UHC)", "plan_name": "DSNP", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "United Healthcare (UHC)", "plan_name": "Medicare Advantage", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" } ] } ], "drug_information": { "unit": 1000, "type": "ML" } }, { "description": "Normal saline solution infus", "code_information": [ { "code": "J7040", "type": "HCPCS" }, { "code": "00264-5802-00", "type": "NDC" } ], "standard_charges": [ { "setting": "outpatient", "payers_information": [ { "payer_name": "United Healthcare (UHC)", "plan_name": "DSNP", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "United Healthcare (UHC)", "plan_name": "Medicare Advantage", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" } ] } ], "drug_information": { "unit": 1000, "type": "ML" } }, { "description": "5% dextrose/normal saline", "code_information": [ { "code": "J7042", "type": "HCPCS" }, { "code": "00264-7610-00", "type": "NDC" } ], "standard_charges": [ { "setting": "outpatient", "payers_information": [ { "payer_name": "United Healthcare (UHC)", "plan_name": "DSNP", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "United Healthcare (UHC)", "plan_name": "Medicare Advantage", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" } ] } ], "drug_information": { "unit": 1000, "type": "ML" } }, { "description": "Normal saline solution infus", "code_information": [ { "code": "J7050", "type": "HCPCS" }, { "code": "00264-1800-32", "type": "NDC" } ], "standard_charges": [ { "setting": "outpatient", "payers_information": [ { "payer_name": "United Healthcare (UHC)", "plan_name": "DSNP", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "United Healthcare (UHC)", "plan_name": "Medicare Advantage", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" } ] } ], "drug_information": { "unit": 100, "type": "ML" } }, { "description": "5% dextrose/water", "code_information": [ { "code": "J7060", "type": "HCPCS" }, { "code": "00264-1510-31", "type": "NDC" } ], "standard_charges": [ { "setting": "outpatient", "payers_information": [ { "payer_name": "United Healthcare (UHC)", "plan_name": "DSNP", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "United Healthcare (UHC)", "plan_name": "Medicare Advantage", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" } ] } ], "drug_information": { "unit": 50, "type": "ML" } }, { "description": "Ringers lactate infusion", "code_information": [ { "code": "J7120", "type": "HCPCS" }, { "code": "00264-7750-00", "type": "NDC" } ], "standard_charges": [ { "setting": "outpatient", "payers_information": [ { "payer_name": "United Healthcare (UHC)", "plan_name": "DSNP", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "United Healthcare (UHC)", "plan_name": "Medicare Advantage", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" } ] } ], "drug_information": { "unit": 1000, "type": "ML" } }, { "description": "Tacrolimus imme rel oral 1mg", "code_information": [ { "code": "J7507", "type": "HCPCS" }, { "code": "00378-2045-01", "type": "NDC" } ], "standard_charges": [ { "setting": "outpatient", "payers_information": [ { "payer_name": "United Healthcare (UHC)", "plan_name": "DSNP", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "United Healthcare (UHC)", "plan_name": "Medicare Advantage", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" } ] } ], "drug_information": { "unit": 100, "type": "EA" } }, { "description": "Prednisolone oral per 5 mg", "code_information": [ { "code": "J7510", "type": "HCPCS" }, { "code": "00093-6118-87", "type": "NDC" } ], "standard_charges": [ { "setting": "outpatient", "payers_information": [ { "payer_name": "United Healthcare (UHC)", "plan_name": "DSNP", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "United Healthcare (UHC)", "plan_name": "Medicare Advantage", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" } ] } ], "drug_information": { "unit": 240, "type": "ML" } }, { "description": "Prednisone ir or dr oral 1mg", "code_information": [ { "code": "J7512", "type": "HCPCS" }, { "code": "00054-0017-20", "type": "NDC" } ], "standard_charges": [ { "setting": "outpatient", "payers_information": [ { "payer_name": "United Healthcare (UHC)", "plan_name": "DSNP", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "United Healthcare (UHC)", "plan_name": "Medicare Advantage", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" } ] } ], "drug_information": { "unit": 100, "type": "EA" } }, { "description": "Mycophenolate mofetil oral", "code_information": [ { "code": "J7517", "type": "HCPCS" }, { "code": "00004-0259-01", "type": "NDC" } ], "standard_charges": [ { "setting": "outpatient", "payers_information": [ { "payer_name": "United Healthcare (UHC)", "plan_name": "DSNP", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "United Healthcare (UHC)", "plan_name": "Medicare Advantage", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" } ] } ], "drug_information": { "unit": 100, "type": "EA" } }, { "description": "Non-inhalation drug for dme", "code_information": [ { "code": "J7799", "type": "HCPCS" }, { "code": "00264-2303-50", "type": "NDC" } ], "standard_charges": [ { "setting": "outpatient", "payers_information": [ { "payer_name": "United Healthcare (UHC)", "plan_name": "DSNP", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "United Healthcare (UHC)", "plan_name": "Medicare Advantage", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" } ] } ], "drug_information": { "unit": 2000, "type": "ML" } }, { "description": "Oral prescrip drug non chemo", "code_information": [ { "code": "J8499", "type": "HCPCS" }, { "code": "00004-0038-22", "type": "NDC" } ], "standard_charges": [ { "setting": "outpatient", "payers_information": [ { "payer_name": "United Healthcare (UHC)", "plan_name": "DSNP", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "United Healthcare (UHC)", "plan_name": "Medicare Advantage", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" } ] } ], "drug_information": { "unit": 60, "type": "EA" } }, { "description": "Oral dexamethasone", "code_information": [ { "code": "J8540", "type": "HCPCS" }, { "code": "00054-3176-44", "type": "NDC" } ], "standard_charges": [ { "setting": "outpatient", "payers_information": [ { "payer_name": "United Healthcare (UHC)", "plan_name": "DSNP", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "United Healthcare (UHC)", "plan_name": "Medicare Advantage", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" } ] } ], "drug_information": { "unit": 30, "type": "ML" } }, { "description": "Bevacizumab injection", "code_information": [ { "code": "J9035", "type": "HCPCS" }, { "code": "50242-0060-01", "type": "NDC" } ], "standard_charges": [ { "setting": "outpatient", "payers_information": [ { "payer_name": "United Healthcare (UHC)", "plan_name": "DSNP", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "United Healthcare (UHC)", "plan_name": "Medicare Advantage", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "First Choice of the Midwest", "plan_name": "PPO", "standard_charge_percentage": 90, "methodology": "percent of total billed charges", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" } ] } ], "drug_information": { "unit": 4, "type": "ML" } }, { "description": "Mitomycin injection", "code_information": [ { "code": "J9280", "type": "HCPCS" }, { "code": "00143-9135-01", "type": "NDC" } ], "standard_charges": [ { "setting": "outpatient", "payers_information": [ { "payer_name": "United Healthcare (UHC)", "plan_name": "DSNP", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "United Healthcare (UHC)", "plan_name": "Medicare Advantage", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "First Choice of the Midwest", "plan_name": "PPO", "standard_charge_percentage": 90, "methodology": "percent of total billed charges", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" } ] } ], "drug_information": { "unit": 1, "type": "EA" } }, { "description": "Lumbar orthosis, flexible, provides lumbar support, posterior extends from L-1 to below L-5 vertebra, produces intracavitary pressure to reduce load on the intervertebral discs, includes straps, closures, may include pendulous abdomen design, shoulder straps, stays, prefabricated, off-the-shelf", "code_information": [ { "code": "L0625", "type": "HCPCS" } ], "standard_charges": [ { "setting": "outpatient", "payers_information": [ { "payer_name": "United Healthcare (UHC)", "plan_name": "DSNP", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "United Healthcare (UHC)", "plan_name": "Medicare Advantage", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" } ] } ] }, { "description": "Injectable bulking agent, collagen implant, urinary tract, 2.5 ml syringe, includes shipping and necessary supplies", "code_information": [ { "code": "L8603", "type": "HCPCS" } ], "standard_charges": [ { "setting": "outpatient", "payers_information": [ { "payer_name": "United Healthcare (UHC)", "plan_name": "DSNP", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "United Healthcare (UHC)", "plan_name": "Medicare Advantage", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" } ] } ] }, { "description": "Ocular implant", "code_information": [ { "code": "L8610", "type": "HCPCS" } ], "standard_charges": [ { "setting": "outpatient", "payers_information": [ { "payer_name": "United Healthcare (UHC)", "plan_name": "DSNP", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "United Healthcare (UHC)", "plan_name": "Medicare Advantage", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" } ] } ] }, { "description": "Prosthetic implant, not otherwise specified", "code_information": [ { "code": "L8699", "type": "HCPCS" } ], "standard_charges": [ { "setting": "outpatient", "payers_information": [ { "payer_name": "United Healthcare (UHC)", "plan_name": "DSNP", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "United Healthcare (UHC)", "plan_name": "Medicare Advantage", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" } ] } ] }, { "description": "Rbc leukocytes reduced", "code_information": [ { "code": "P9016", "type": "HCPCS" } ], "standard_charges": [ { "setting": "outpatient", "payers_information": [ { "payer_name": "United Healthcare (UHC)", "plan_name": "DSNP", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "United Healthcare (UHC)", "plan_name": "Medicare Advantage", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" } ] } ] }, { "description": "Platelets, pheresis", "code_information": [ { "code": "P9034", "type": "HCPCS" } ], "standard_charges": [ { "setting": "outpatient", "payers_information": [ { "payer_name": "United Healthcare (UHC)", "plan_name": "DSNP", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "United Healthcare (UHC)", "plan_name": "Medicare Advantage", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" } ] } ] }, { "description": "Albumin (human), 25%, 20 ml", "code_information": [ { "code": "P9046", "type": "HCPCS" } ], "standard_charges": [ { "setting": "outpatient", "payers_information": [ { "payer_name": "United Healthcare (UHC)", "plan_name": "DSNP", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "United Healthcare (UHC)", "plan_name": "Medicare Advantage", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "First Choice of the Midwest", "plan_name": "PPO", "standard_charge_percentage": 90, "methodology": "percent of total billed charges", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" } ] } ] }, { "description": "Hocm 350-399mg/ml iodine,1ml", "code_information": [ { "code": "Q9963", "type": "HCPCS" } ], "standard_charges": [ { "setting": "outpatient", "payers_information": [ { "payer_name": "United Healthcare (UHC)", "plan_name": "DSNP", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "United Healthcare (UHC)", "plan_name": "Medicare Advantage", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" } ] } ] }, { "description": "Locm 200-299mg/ml iodine,1ml", "code_information": [ { "code": "Q9966", "type": "HCPCS" } ], "standard_charges": [ { "setting": "outpatient", "payers_information": [ { "payer_name": "United Healthcare (UHC)", "plan_name": "DSNP", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "United Healthcare (UHC)", "plan_name": "Medicare Advantage", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" } ] } ] }, { "description": "Locm 300-399mg/ml iodine,1ml", "code_information": [ { "code": "Q9967", "type": "HCPCS" } ], "standard_charges": [ { "setting": "outpatient", "payers_information": [ { "payer_name": "United Healthcare (UHC)", "plan_name": "DSNP", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "United Healthcare (UHC)", "plan_name": "Medicare Advantage", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" } ] } ] }, { "description": "Visualization adjunct", "code_information": [ { "code": "Q9968", "type": "HCPCS" } ], "standard_charges": [ { "setting": "outpatient", "payers_information": [ { "payer_name": "United Healthcare (UHC)", "plan_name": "DSNP", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "United Healthcare (UHC)", "plan_name": "Medicare Advantage", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "First Choice of the Midwest", "plan_name": "PPO", "standard_charge_percentage": 90, "methodology": "percent of total billed charges", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" } ] } ] }, { "description": "Finasteride, 5 mg", "code_information": [ { "code": "S0138", "type": "HCPCS" } ], "standard_charges": [ { "setting": "outpatient", "payers_information": [ { "payer_name": "United Healthcare (UHC)", "plan_name": "DSNP", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "United Healthcare (UHC)", "plan_name": "Medicare Advantage", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" } ] } ] }, { "description": "Anter chamber intraocul lens", "code_information": [ { "code": "V2630", "type": "HCPCS" } ], "standard_charges": [ { "setting": "outpatient", "payers_information": [ { "payer_name": "United Healthcare (UHC)", "plan_name": "DSNP", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "United Healthcare (UHC)", "plan_name": "Medicare Advantage", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" } ] } ] }, { "description": "Closure device, vascular (implantable/insertable)", "code_information": [ { "code": "C1760", "type": "HCPCS" } ], "standard_charges": [ { "setting": "outpatient", "payers_information": [ { "payer_name": "United Healthcare (UHC)", "plan_name": "DSNP", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "United Healthcare (UHC)", "plan_name": "Medicare Advantage", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" } ] } ] }, { "description": "Catheter, transluminal intravascular lithotripsy, coronary", "code_information": [ { "code": "C1761", "type": "HCPCS" } ], "standard_charges": [ { "setting": "outpatient", "payers_information": [ { "payer_name": "United Healthcare (UHC)", "plan_name": "DSNP", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "United Healthcare (UHC)", "plan_name": "Medicare Advantage", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" } ] } ] }, { "description": "Connective tissue, human (includes fascia lata)", "code_information": [ { "code": "C1762", "type": "HCPCS" } ], "standard_charges": [ { "setting": "outpatient", "payers_information": [ { "payer_name": "United Healthcare (UHC)", "plan_name": "DSNP", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "United Healthcare (UHC)", "plan_name": "Medicare Advantage", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" } ] } ] }, { "description": "Connective tissue, non-human (includes synthetic)", "code_information": [ { "code": "C1763", "type": "HCPCS" } ], "standard_charges": [ { "setting": "outpatient", "payers_information": [ { "payer_name": "United Healthcare (UHC)", "plan_name": "DSNP", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "United Healthcare (UHC)", "plan_name": "Medicare Advantage", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" } ] } ] }, { "description": "Introducer/sheath, guiding, intracardiac electrophysiological, steerable, other than peel-away", "code_information": [ { "code": "C1766", "type": "HCPCS" } ], "standard_charges": [ { "setting": "outpatient", "payers_information": [ { "payer_name": "United Healthcare (UHC)", "plan_name": "DSNP", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "United Healthcare (UHC)", "plan_name": "Medicare Advantage", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" } ] } ] }, { "description": "Graft, vascular", "code_information": [ { "code": "C1768", "type": "HCPCS" } ], "standard_charges": [ { "setting": "outpatient", "payers_information": [ { "payer_name": "United Healthcare (UHC)", "plan_name": "DSNP", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "United Healthcare (UHC)", "plan_name": "Medicare Advantage", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" } ] } ] }, { "description": "Guide wire", "code_information": [ { "code": "C1769", "type": "HCPCS" } ], "standard_charges": [ { "setting": "outpatient", "payers_information": [ { "payer_name": "United Healthcare (UHC)", "plan_name": "DSNP", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "United Healthcare (UHC)", "plan_name": "Medicare Advantage", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" } ] } ] }, { "description": "Repair device, urinary, incontinence, with sling graft", "code_information": [ { "code": "C1771", "type": "HCPCS" } ], "standard_charges": [ { "setting": "outpatient", "payers_information": [ { "payer_name": "United Healthcare (UHC)", "plan_name": "DSNP", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "United Healthcare (UHC)", "plan_name": "Medicare Advantage", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" } ] } ] }, { "description": "Joint device (implantable)", "code_information": [ { "code": "C1776", "type": "HCPCS" } ], "standard_charges": [ { "setting": "outpatient", "payers_information": [ { "payer_name": "United Healthcare (UHC)", "plan_name": "DSNP", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "United Healthcare (UHC)", "plan_name": "Medicare Advantage", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" } ] } ] }, { "description": "Lens, intraocular (new technology)", "code_information": [ { "code": "C1780", "type": "HCPCS" } ], "standard_charges": [ { "setting": "outpatient", "payers_information": [ { "payer_name": "United Healthcare (UHC)", "plan_name": "DSNP", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "United Healthcare (UHC)", "plan_name": "Medicare Advantage", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" } ] } ] }, { "description": "Mesh (implantable)", "code_information": [ { "code": "C1781", "type": "HCPCS" } ], "standard_charges": [ { "setting": "outpatient", "payers_information": [ { "payer_name": "United Healthcare (UHC)", "plan_name": "DSNP", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "United Healthcare (UHC)", "plan_name": "Medicare Advantage", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" } ] } ] }, { "description": "OCULAR IMP, AQUEOUS DRAIN DE", "code_information": [ { "code": "C1783", "type": "HCPCS" } ], "standard_charges": [ { "setting": "outpatient", "payers_information": [ { "payer_name": "United Healthcare (UHC)", "plan_name": "DSNP", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "United Healthcare (UHC)", "plan_name": "Medicare Advantage", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" } ] } ] }, { "description": "Pacemaker, dual chamber, rate-responsive (implantable)", "code_information": [ { "code": "C1785", "type": "HCPCS" } ], "standard_charges": [ { "setting": "outpatient", "payers_information": [ { "payer_name": "United Healthcare (UHC)", "plan_name": "DSNP", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "United Healthcare (UHC)", "plan_name": "Medicare Advantage", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" } ] } ] }, { "description": "Port, indwelling (implantable)", "code_information": [ { "code": "C1788", "type": "HCPCS" } ], "standard_charges": [ { "setting": "outpatient", "payers_information": [ { "payer_name": "United Healthcare (UHC)", "plan_name": "DSNP", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "United Healthcare (UHC)", "plan_name": "Medicare Advantage", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" } ] } ] }, { "description": "Prosthesis, urinary sphincter (implantable)", "code_information": [ { "code": "C1815", "type": "HCPCS" } ], "standard_charges": [ { "setting": "outpatient", "payers_information": [ { "payer_name": "United Healthcare (UHC)", "plan_name": "DSNP", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "United Healthcare (UHC)", "plan_name": "Medicare Advantage", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" } ] } ] }, { "description": "Surgical tissue localization and excision device (implantable)", "code_information": [ { "code": "C1819", "type": "HCPCS" } ], "standard_charges": [ { "setting": "outpatient", "payers_information": [ { "payer_name": "United Healthcare (UHC)", "plan_name": "DSNP", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "United Healthcare (UHC)", "plan_name": "Medicare Advantage", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" } ] } ] }, { "description": "Powered bone marrow biopsy needle", "code_information": [ { "code": "C1830", "type": "HCPCS" } ], "standard_charges": [ { "setting": "outpatient", "payers_information": [ { "payer_name": "United Healthcare (UHC)", "plan_name": "DSNP", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "United Healthcare (UHC)", "plan_name": "Medicare Advantage", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" } ] } ] }, { "description": "Stent, coated/covered, with delivery system", "code_information": [ { "code": "C1874", "type": "HCPCS" } ], "standard_charges": [ { "setting": "outpatient", "payers_information": [ { "payer_name": "United Healthcare (UHC)", "plan_name": "DSNP", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "United Healthcare (UHC)", "plan_name": "Medicare Advantage", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" } ] } ] }, { "description": "Stent, non-coated/non-covered, with delivery system", "code_information": [ { "code": "C1876", "type": "HCPCS" } ], "standard_charges": [ { "setting": "outpatient", "payers_information": [ { "payer_name": "United Healthcare (UHC)", "plan_name": "DSNP", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "United Healthcare (UHC)", "plan_name": "Medicare Advantage", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" } ] } ] }, { "description": "Cardioverter-defibrillator, other than single or dual chamber (implantable)", "code_information": [ { "code": "C1882", "type": "HCPCS" } ], "standard_charges": [ { "setting": "outpatient", "payers_information": [ { "payer_name": "United Healthcare (UHC)", "plan_name": "DSNP", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "United Healthcare (UHC)", "plan_name": "Medicare Advantage", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" } ] } ] }, { "description": "Embolization protective system", "code_information": [ { "code": "C1884", "type": "HCPCS" } ], "standard_charges": [ { "setting": "outpatient", "payers_information": [ { "payer_name": "United Healthcare (UHC)", "plan_name": "DSNP", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "United Healthcare (UHC)", "plan_name": "Medicare Advantage", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" } ] } ] }, { "description": "Catheter, guiding (may include infusion/perfusion capability)", "code_information": [ { "code": "C1887", "type": "HCPCS" } ], "standard_charges": [ { "setting": "outpatient", "payers_information": [ { "payer_name": "United Healthcare (UHC)", "plan_name": "DSNP", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "United Healthcare (UHC)", "plan_name": "Medicare Advantage", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" } ] } ] }, { "description": "Implantable/insertable device, not otherwise classified", "code_information": [ { "code": "C1889", "type": "HCPCS" } ], "standard_charges": [ { "setting": "outpatient", "payers_information": [ { "payer_name": "United Healthcare (UHC)", "plan_name": "DSNP", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "United Healthcare (UHC)", "plan_name": "Medicare Advantage", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" } ] } ] }, { "description": "Introducer/sheath, other than guiding, other than intracardiac electrophysiological, non-laser", "code_information": [ { "code": "C1894", "type": "HCPCS" } ], "standard_charges": [ { "setting": "outpatient", "payers_information": [ { "payer_name": "United Healthcare (UHC)", "plan_name": "DSNP", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "United Healthcare (UHC)", "plan_name": "Medicare Advantage", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" } ] } ] }, { "description": "Lead, pacemaker, other than transvenous vdd single pass", "code_information": [ { "code": "C1898", "type": "HCPCS" } ], "standard_charges": [ { "setting": "outpatient", "payers_information": [ { "payer_name": "United Healthcare (UHC)", "plan_name": "DSNP", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "United Healthcare (UHC)", "plan_name": "Medicare Advantage", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" } ] } ] }, { "description": "Stent, non-coronary, temporary, without delivery system", "code_information": [ { "code": "C2617", "type": "HCPCS" } ], "standard_charges": [ { "setting": "outpatient", "payers_information": [ { "payer_name": "United Healthcare (UHC)", "plan_name": "DSNP", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "United Healthcare (UHC)", "plan_name": "Medicare Advantage", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" } ] } ] }, { "description": "Catheter, transluminal angioplasty, drug-coated, non-laser", "code_information": [ { "code": "C2623", "type": "HCPCS" } ], "standard_charges": [ { "setting": "outpatient", "payers_information": [ { "payer_name": "United Healthcare (UHC)", "plan_name": "DSNP", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "United Healthcare (UHC)", "plan_name": "Medicare Advantage", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" } ] } ] }, { "description": "PROTONIX IV 40 MG", "code_information": [ { "code": "C9113", "type": "HCPCS" } ], "standard_charges": [ { "setting": "outpatient", "payers_information": [ { "payer_name": "United Healthcare (UHC)", "plan_name": "DSNP", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "United Healthcare (UHC)", "plan_name": "Medicare Advantage", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" } ] } ] }, { "description": "INJ, BUPIVACAINE LIPOSOME", "code_information": [ { "code": "C9290", "type": "HCPCS" } ], "standard_charges": [ { "setting": "outpatient", "payers_information": [ { "payer_name": "United Healthcare (UHC)", "plan_name": "DSNP", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "United Healthcare (UHC)", "plan_name": "Medicare Advantage", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" } ] } ] }, { "description": "Revascularization, endovascular, open or percutaneous, lower extremity artery(ies), except tibial/peroneal; with intravascular lithotripsy, and transluminal stent placement(s), includes angioplasty within the same vessel(s), when performed", "code_information": [ { "code": "C9765", "type": "HCPCS" } ], "standard_charges": [ { "setting": "outpatient", "payers_information": [ { "payer_name": "United Healthcare (UHC)", "plan_name": "DSNP", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "United Healthcare (UHC)", "plan_name": "Medicare Advantage", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" } ] } ] }, { "description": "Intraoperative near-infrared fluorescence imaging of major extra-hepatic bile duct(s) (e.g., cystic duct, common bile duct and common hepatic duct) with intravenous administration of indocyanine green (icg) (list separately in addition to code for primary procedure)", "code_information": [ { "code": "C9776", "type": "HCPCS" } ], "standard_charges": [ { "setting": "outpatient", "payers_information": [ { "payer_name": "United Healthcare (UHC)", "plan_name": "DSNP", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "United Healthcare (UHC)", "plan_name": "Medicare Advantage", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" } ] } ] }, { "description": "Hospital outpatient clinic visit specimen collection for severe acute respiratory syndrome coronavirus 2 (sars-cov-2) (coronavirus disease [covid-19]), any specimen source", "code_information": [ { "code": "C9803", "type": "HCPCS" } ], "standard_charges": [ { "setting": "outpatient", "payers_information": [ { "payer_name": "United Healthcare (UHC)", "plan_name": "DSNP", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "United Healthcare (UHC)", "plan_name": "Medicare Advantage", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" } ] } ] }, { "description": "Caries risk assess high risk", "code_information": [ { "code": "D0603", "type": "HCPCS" } ], "standard_charges": [ { "setting": "outpatient", "payers_information": [ { "payer_name": "United Healthcare (UHC)", "plan_name": "DSNP", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "United Healthcare (UHC)", "plan_name": "Medicare Advantage", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" } ] } ] }, { "description": "Antigen test pub hlth pathog", "code_information": [ { "code": "D0604", "type": "HCPCS" } ], "standard_charges": [ { "setting": "outpatient", "payers_information": [ { "payer_name": "United Healthcare (UHC)", "plan_name": "DSNP", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "United Healthcare (UHC)", "plan_name": "Medicare Advantage", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" } ] } ] }, { "description": "Heart Transplant or Implant of Heart Assist System with MCC", "code_information": [ { "code": "1", "type": "LOCAL" } ], "standard_charges": [ { "setting": "inpatient", "payers_information": [ { "payer_name": "TriWest Healthcare Alliance Corporation", "plan_name": "VA CCN", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Blue Cross Blue Shield of Montana", "plan_name": "Medicare Advantage", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "United Healthcare (UHC)", "plan_name": "Medicare Advantage", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "First Choice of the Midwest", "plan_name": "PPO", "standard_charge_percentage": 90, "methodology": "percent of total billed charges", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "United Healthcare (UHC)", "plan_name": "DSNP", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Employee Benefit Management Services (EBMS)", "plan_name": "EBMS SelectCare Network", "standard_charge_percentage": 80, "methodology": "percent of total billed charges", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Allegiance Provider Direct", "plan_name": "Medicare", "standard_charge_percentage": 229.99999999999997, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Claritev fka MultiPlan", "plan_name": "PPO", "standard_charge_percentage": 75, "methodology": "percent of total billed charges", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Medica Insurance Company", "plan_name": "Medicare Cost", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Medicare (CMS)", "plan_name": "Medicare", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Indian Health Services (IHS)", "plan_name": "Commercial", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "First Choice Health Network fka Health InfoNet", "plan_name": "Commercial", "standard_charge_percentage": 85, "methodology": "percent of total billed charges", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Humana Insurance Company", "plan_name": "Humana Medicare Advantage HMO", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Humana Insurance Company", "plan_name": "Humana Medicare Advantage PPO", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Humana Insurance Company", "plan_name": "Humana Medicare Advantage PFFS", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "First Choice Health Network fka Health InfoNet", "plan_name": "Workers Compensation", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Allegiance Provider Direct", "plan_name": "State of Montana Employee Benefit Plan (Self-Funded)", "standard_charge_percentage": 229.99999999999997, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Allegiance Provider Direct", "plan_name": "Montana Municipal Interlocal Authority (MMIA)", "standard_charge_percentage": 229.99999999999997, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Allegiance Provider Direct", "plan_name": "Montana Association of Counties (MACo)", "standard_charge_percentage": 229.99999999999997, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "First Choice Health Network fka Health InfoNet", "plan_name": "Medicare Advantage", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "TriWest Healthcare Alliance Corporation", "plan_name": "TRICARE Prime", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "TriWest Healthcare Alliance Corporation", "plan_name": "TRICARE Select", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Blue Cross Blue Shield of Montana", "plan_name": "HealthLink Network", "standard_charge_percentage": 75, "methodology": "percent of total billed charges", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Blue Cross Blue Shield of Montana", "plan_name": "Traditional Network", "standard_charge_percentage": 75, "methodology": "percent of total billed charges", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Blue Cross Blue Shield of Montana", "plan_name": "POS Network", "standard_charge_percentage": 75, "methodology": "percent of total billed charges", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Blue Cross Blue Shield of Montana", "plan_name": "Closed Plan Network", "standard_charge_percentage": 75, "methodology": "percent of total billed charges", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Blue Cross Blue Shield of Montana", "plan_name": "Retail HMO POS Network", "standard_charge_percentage": 75, "methodology": "percent of total billed charges", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Blue Cross Blue Shield of Montana", "plan_name": "Blue Options Network", "standard_charge_percentage": 75, "methodology": "percent of total billed charges", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "PacificSource Health Plans", "plan_name": "Medicare Advantage", "standard_charge_percentage": 103, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" } ] } ] }, { "description": "Pancreas Transplant", "code_information": [ { "code": "10", "type": "LOCAL" } ], "standard_charges": [ { "setting": "inpatient", "payers_information": [ { "payer_name": "TriWest Healthcare Alliance Corporation", "plan_name": "VA CCN", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Blue Cross Blue Shield of Montana", "plan_name": "Medicare Advantage", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "United Healthcare (UHC)", "plan_name": "Medicare Advantage", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "First Choice of the Midwest", "plan_name": "PPO", "standard_charge_percentage": 90, "methodology": "percent of total billed charges", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "United Healthcare (UHC)", "plan_name": "DSNP", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Employee Benefit Management Services (EBMS)", "plan_name": "EBMS SelectCare Network", "standard_charge_percentage": 80, "methodology": "percent of total billed charges", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Allegiance Provider Direct", "plan_name": "Medicare", "standard_charge_percentage": 229.99999999999997, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Claritev fka MultiPlan", "plan_name": "PPO", "standard_charge_percentage": 75, "methodology": "percent of total billed charges", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Medica Insurance Company", "plan_name": "Medicare Cost", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Medicare (CMS)", "plan_name": "Medicare", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Indian Health Services (IHS)", "plan_name": "Commercial", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "First Choice Health Network fka Health InfoNet", "plan_name": "Commercial", "standard_charge_percentage": 85, "methodology": "percent of total billed charges", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Humana Insurance Company", "plan_name": "Humana Medicare Advantage HMO", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Humana Insurance Company", "plan_name": "Humana Medicare Advantage PPO", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Humana Insurance Company", "plan_name": "Humana Medicare Advantage PFFS", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "First Choice Health Network fka Health InfoNet", "plan_name": "Workers Compensation", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Allegiance Provider Direct", "plan_name": "State of Montana Employee Benefit Plan (Self-Funded)", "standard_charge_percentage": 229.99999999999997, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Allegiance Provider Direct", "plan_name": "Montana Municipal Interlocal Authority (MMIA)", "standard_charge_percentage": 229.99999999999997, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Allegiance Provider Direct", "plan_name": "Montana Association of Counties (MACo)", "standard_charge_percentage": 229.99999999999997, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "First Choice Health Network fka Health InfoNet", "plan_name": "Medicare Advantage", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "TriWest Healthcare Alliance Corporation", "plan_name": "TRICARE Prime", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "TriWest Healthcare Alliance Corporation", "plan_name": "TRICARE Select", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Blue Cross Blue Shield of Montana", "plan_name": "HealthLink Network", "standard_charge_percentage": 75, "methodology": "percent of total billed charges", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Blue Cross Blue Shield of Montana", "plan_name": "Traditional Network", "standard_charge_percentage": 75, "methodology": "percent of total billed charges", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Blue Cross Blue Shield of Montana", "plan_name": "POS Network", "standard_charge_percentage": 75, "methodology": "percent of total billed charges", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Blue Cross Blue Shield of Montana", "plan_name": "Closed Plan Network", "standard_charge_percentage": 75, "methodology": "percent of total billed charges", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Blue Cross Blue Shield of Montana", "plan_name": "Retail HMO POS Network", "standard_charge_percentage": 75, "methodology": "percent of total billed charges", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Blue Cross Blue Shield of Montana", "plan_name": "Blue Options Network", "standard_charge_percentage": 75, "methodology": "percent of total billed charges", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "PacificSource Health Plans", "plan_name": "Medicare Advantage", "standard_charge_percentage": 103, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" } ] } ] }, { "description": "Seizures with MCC", "code_information": [ { "code": "100", "type": "LOCAL" } ], "standard_charges": [ { "setting": "inpatient", "payers_information": [ { "payer_name": "TriWest Healthcare Alliance Corporation", "plan_name": "VA CCN", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Blue Cross Blue Shield of Montana", "plan_name": "Medicare Advantage", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "United Healthcare (UHC)", "plan_name": "Medicare Advantage", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "First Choice of the Midwest", "plan_name": "PPO", "standard_charge_percentage": 90, "methodology": "percent of total billed charges", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "United Healthcare (UHC)", "plan_name": "DSNP", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Employee Benefit Management Services (EBMS)", "plan_name": "EBMS SelectCare Network", "standard_charge_percentage": 80, "methodology": "percent of total billed charges", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Claritev fka MultiPlan", "plan_name": "PPO", "standard_charge_percentage": 75, "methodology": "percent of total billed charges", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Allegiance Provider Direct", "plan_name": "Medicare", "standard_charge_percentage": 229.99999999999997, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Medicare (CMS)", "plan_name": "Medicare", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Medica Insurance Company", "plan_name": "Medicare Cost", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "First Choice Health Network fka Health InfoNet", "plan_name": "Commercial", "standard_charge_percentage": 85, "methodology": "percent of total billed charges", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "First Choice Health Network fka Health InfoNet", "plan_name": "Workers Compensation", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Indian Health Services (IHS)", "plan_name": "Commercial", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Humana Insurance Company", "plan_name": "Humana Medicare Advantage HMO", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Humana Insurance Company", "plan_name": "Humana Medicare Advantage PPO", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Humana Insurance Company", "plan_name": "Humana Medicare Advantage PFFS", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Allegiance Provider Direct", "plan_name": "State of Montana Employee Benefit Plan (Self-Funded)", "standard_charge_percentage": 229.99999999999997, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Allegiance Provider Direct", "plan_name": "Montana Municipal Interlocal Authority (MMIA)", "standard_charge_percentage": 229.99999999999997, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Allegiance Provider Direct", "plan_name": "Montana Association of Counties (MACo)", "standard_charge_percentage": 229.99999999999997, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "First Choice Health Network fka Health InfoNet", "plan_name": "Medicare Advantage", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "TriWest Healthcare Alliance Corporation", "plan_name": "TRICARE Prime", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "TriWest Healthcare Alliance Corporation", "plan_name": "TRICARE Select", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Blue Cross Blue Shield of Montana", "plan_name": "HealthLink Network", "standard_charge_percentage": 75, "methodology": "percent of total billed charges", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Blue Cross Blue Shield of Montana", "plan_name": "Traditional Network", "standard_charge_percentage": 75, "methodology": "percent of total billed charges", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Blue Cross Blue Shield of Montana", "plan_name": "POS Network", "standard_charge_percentage": 75, "methodology": "percent of total billed charges", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Blue Cross Blue Shield of Montana", "plan_name": "Closed Plan Network", "standard_charge_percentage": 75, "methodology": "percent of total billed charges", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Blue Cross Blue Shield of Montana", "plan_name": "Retail HMO POS Network", "standard_charge_percentage": 75, "methodology": "percent of total billed charges", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Blue Cross Blue Shield of Montana", "plan_name": "Blue Options Network", "standard_charge_percentage": 75, "methodology": "percent of total billed charges", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "PacificSource Health Plans", "plan_name": "Medicare Advantage", "standard_charge_percentage": 103, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" } ] } ] }, { "description": "Seizures without MCC", "code_information": [ { "code": "101", "type": "LOCAL" } ], "standard_charges": [ { "setting": "inpatient", "payers_information": [ { "payer_name": "TriWest Healthcare Alliance Corporation", "plan_name": "VA CCN", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Blue Cross Blue Shield of Montana", "plan_name": "Medicare Advantage", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "United Healthcare (UHC)", "plan_name": "Medicare Advantage", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "First Choice of the Midwest", "plan_name": "PPO", "standard_charge_percentage": 90, "methodology": "percent of total billed charges", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "United Healthcare (UHC)", "plan_name": "DSNP", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Employee Benefit Management Services (EBMS)", "plan_name": "EBMS SelectCare Network", "standard_charge_percentage": 80, "methodology": "percent of total billed charges", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Claritev fka MultiPlan", "plan_name": "PPO", "standard_charge_percentage": 75, "methodology": "percent of total billed charges", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Allegiance Provider Direct", "plan_name": "Medicare", "standard_charge_percentage": 229.99999999999997, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Medicare (CMS)", "plan_name": "Medicare", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Medica Insurance Company", "plan_name": "Medicare Cost", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "First Choice Health Network fka Health InfoNet", "plan_name": "Commercial", "standard_charge_percentage": 85, "methodology": "percent of total billed charges", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "First Choice Health Network fka Health InfoNet", "plan_name": "Workers Compensation", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Indian Health Services (IHS)", "plan_name": "Commercial", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Humana Insurance Company", "plan_name": "Humana Medicare Advantage HMO", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Humana Insurance Company", "plan_name": "Humana Medicare Advantage PPO", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Humana Insurance Company", "plan_name": "Humana Medicare Advantage PFFS", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Allegiance Provider Direct", "plan_name": "State of Montana Employee Benefit Plan (Self-Funded)", "standard_charge_percentage": 229.99999999999997, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Allegiance Provider Direct", "plan_name": "Montana Municipal Interlocal Authority (MMIA)", "standard_charge_percentage": 229.99999999999997, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Allegiance Provider Direct", "plan_name": "Montana Association of Counties (MACo)", "standard_charge_percentage": 229.99999999999997, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "First Choice Health Network fka Health InfoNet", "plan_name": "Medicare Advantage", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "TriWest Healthcare Alliance Corporation", "plan_name": "TRICARE Prime", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "TriWest Healthcare Alliance Corporation", "plan_name": "TRICARE Select", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Blue Cross Blue Shield of Montana", "plan_name": "HealthLink Network", "standard_charge_percentage": 75, "methodology": "percent of total billed charges", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Blue Cross Blue Shield of Montana", "plan_name": "Traditional Network", "standard_charge_percentage": 75, "methodology": "percent of total billed charges", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Blue Cross Blue Shield of Montana", "plan_name": "POS Network", "standard_charge_percentage": 75, "methodology": "percent of total billed charges", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Blue Cross Blue Shield of Montana", "plan_name": "Closed Plan Network", "standard_charge_percentage": 75, "methodology": "percent of total billed charges", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Blue Cross Blue Shield of Montana", "plan_name": "Retail HMO POS Network", "standard_charge_percentage": 75, "methodology": "percent of total billed charges", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Blue Cross Blue Shield of Montana", "plan_name": "Blue Options Network", "standard_charge_percentage": 75, "methodology": "percent of total billed charges", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "PacificSource Health Plans", "plan_name": "Medicare Advantage", "standard_charge_percentage": 103, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" } ] } ] }, { "description": "Headaches with MCC*", "code_information": [ { "code": "102", "type": "LOCAL" } ], "standard_charges": [ { "setting": "inpatient", "payers_information": [ { "payer_name": "TriWest Healthcare Alliance Corporation", "plan_name": "VA CCN", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Blue Cross Blue Shield of Montana", "plan_name": "Medicare Advantage", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "United Healthcare (UHC)", "plan_name": "Medicare Advantage", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "First Choice of the Midwest", "plan_name": "PPO", "standard_charge_percentage": 90, "methodology": "percent of total billed charges", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "United Healthcare (UHC)", "plan_name": "DSNP", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Employee Benefit Management Services (EBMS)", "plan_name": "EBMS SelectCare Network", "standard_charge_percentage": 80, "methodology": "percent of total billed charges", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Claritev fka MultiPlan", "plan_name": "PPO", "standard_charge_percentage": 75, "methodology": "percent of total billed charges", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Allegiance Provider Direct", "plan_name": "Medicare", "standard_charge_percentage": 229.99999999999997, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Medicare (CMS)", "plan_name": "Medicare", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Medica Insurance Company", "plan_name": "Medicare Cost", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "First Choice Health Network fka Health InfoNet", "plan_name": "Commercial", "standard_charge_percentage": 85, "methodology": "percent of total billed charges", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "First Choice Health Network fka Health InfoNet", "plan_name": "Workers Compensation", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Indian Health Services (IHS)", "plan_name": "Commercial", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Humana Insurance Company", "plan_name": "Humana Medicare Advantage HMO", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Humana Insurance Company", "plan_name": "Humana Medicare Advantage PPO", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Humana Insurance Company", "plan_name": "Humana Medicare Advantage PFFS", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Allegiance Provider Direct", "plan_name": "State of Montana Employee Benefit Plan (Self-Funded)", "standard_charge_percentage": 229.99999999999997, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Allegiance Provider Direct", "plan_name": "Montana Municipal Interlocal Authority (MMIA)", "standard_charge_percentage": 229.99999999999997, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Allegiance Provider Direct", "plan_name": "Montana Association of Counties (MACo)", "standard_charge_percentage": 229.99999999999997, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "First Choice Health Network fka Health InfoNet", "plan_name": "Medicare Advantage", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "TriWest Healthcare Alliance Corporation", "plan_name": "TRICARE Prime", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "TriWest Healthcare Alliance Corporation", "plan_name": "TRICARE Select", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Blue Cross Blue Shield of Montana", "plan_name": "HealthLink Network", "standard_charge_percentage": 75, "methodology": "percent of total billed charges", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Blue Cross Blue Shield of Montana", "plan_name": "Traditional Network", "standard_charge_percentage": 75, "methodology": "percent of total billed charges", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Blue Cross Blue Shield of Montana", "plan_name": "POS Network", "standard_charge_percentage": 75, "methodology": "percent of total billed charges", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Blue Cross Blue Shield of Montana", "plan_name": "Closed Plan Network", "standard_charge_percentage": 75, "methodology": "percent of total billed charges", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Blue Cross Blue Shield of Montana", "plan_name": "Retail HMO POS Network", "standard_charge_percentage": 75, "methodology": "percent of total billed charges", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Blue Cross Blue Shield of Montana", "plan_name": "Blue Options Network", "standard_charge_percentage": 75, "methodology": "percent of total billed charges", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "PacificSource Health Plans", "plan_name": "Medicare Advantage", "standard_charge_percentage": 103, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" } ] } ] }, { "description": "Headaches without MCC*", "code_information": [ { "code": "103", "type": "LOCAL" } ], "standard_charges": [ { "setting": "inpatient", "payers_information": [ { "payer_name": "TriWest Healthcare Alliance Corporation", "plan_name": "VA CCN", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Blue Cross Blue Shield of Montana", "plan_name": "Medicare Advantage", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "United Healthcare (UHC)", "plan_name": "Medicare Advantage", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "First Choice of the Midwest", "plan_name": "PPO", "standard_charge_percentage": 90, "methodology": "percent of total billed charges", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "United Healthcare (UHC)", "plan_name": "DSNP", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Employee Benefit Management Services (EBMS)", "plan_name": "EBMS SelectCare Network", "standard_charge_percentage": 80, "methodology": "percent of total billed charges", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Claritev fka MultiPlan", "plan_name": "PPO", "standard_charge_percentage": 75, "methodology": "percent of total billed charges", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Allegiance Provider Direct", "plan_name": "Medicare", "standard_charge_percentage": 229.99999999999997, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Medicare (CMS)", "plan_name": "Medicare", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Medica Insurance Company", "plan_name": "Medicare Cost", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "First Choice Health Network fka Health InfoNet", "plan_name": "Commercial", "standard_charge_percentage": 85, "methodology": "percent of total billed charges", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "First Choice Health Network fka Health InfoNet", "plan_name": "Workers Compensation", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Indian Health Services (IHS)", "plan_name": "Commercial", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Humana Insurance Company", "plan_name": "Humana Medicare Advantage HMO", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Humana Insurance Company", "plan_name": "Humana Medicare Advantage PPO", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Humana Insurance Company", "plan_name": "Humana Medicare Advantage PFFS", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Allegiance Provider Direct", "plan_name": "State of Montana Employee Benefit Plan (Self-Funded)", "standard_charge_percentage": 229.99999999999997, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Allegiance Provider Direct", "plan_name": "Montana Municipal Interlocal Authority (MMIA)", "standard_charge_percentage": 229.99999999999997, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Allegiance Provider Direct", "plan_name": "Montana Association of Counties (MACo)", "standard_charge_percentage": 229.99999999999997, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "First Choice Health Network fka Health InfoNet", "plan_name": "Medicare Advantage", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "TriWest Healthcare Alliance Corporation", "plan_name": "TRICARE Prime", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "TriWest Healthcare Alliance Corporation", "plan_name": "TRICARE Select", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Blue Cross Blue Shield of Montana", "plan_name": "HealthLink Network", "standard_charge_percentage": 75, "methodology": "percent of total billed charges", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Blue Cross Blue Shield of Montana", "plan_name": "Traditional Network", "standard_charge_percentage": 75, "methodology": "percent of total billed charges", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Blue Cross Blue Shield of Montana", "plan_name": "POS Network", "standard_charge_percentage": 75, "methodology": "percent of total billed charges", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Blue Cross Blue Shield of Montana", "plan_name": "Closed Plan Network", "standard_charge_percentage": 75, "methodology": "percent of total billed charges", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Blue Cross Blue Shield of Montana", "plan_name": "Retail HMO POS Network", "standard_charge_percentage": 75, "methodology": "percent of total billed charges", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Blue Cross Blue Shield of Montana", "plan_name": "Blue Options Network", "standard_charge_percentage": 75, "methodology": "percent of total billed charges", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "PacificSource Health Plans", "plan_name": "Medicare Advantage", "standard_charge_percentage": 103, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" } ] } ] }, { "description": "INJECTION, ADALIMUMAB, 20 MG", "code_information": [ { "code": "J0135", "type": "HCPCS" }, { "code": "00074-0124-02", "type": "NDC" } ], "standard_charges": [ { "setting": "outpatient", "payers_information": [ { "payer_name": "TriWest Healthcare Alliance Corporation", "plan_name": "VA CCN", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Claritev fka MultiPlan", "plan_name": "PPO", "standard_charge_percentage": 75, "methodology": "percent of total billed charges", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Blue Cross Blue Shield of Montana", "plan_name": "HealthLink Network", "standard_charge_percentage": 75, "methodology": "percent of total billed charges", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Blue Cross Blue Shield of Montana", "plan_name": "Traditional Network", "standard_charge_percentage": 75, "methodology": "percent of total billed charges", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Blue Cross Blue Shield of Montana", "plan_name": "POS Network", "standard_charge_percentage": 75, "methodology": "percent of total billed charges", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Blue Cross Blue Shield of Montana", "plan_name": "Closed Plan Network", "standard_charge_percentage": 75, "methodology": "percent of total billed charges", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Blue Cross Blue Shield of Montana", "plan_name": "Retail HMO POS Network", "standard_charge_percentage": 75, "methodology": "percent of total billed charges", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Blue Cross Blue Shield of Montana", "plan_name": "Blue Options Network", "standard_charge_percentage": 75, "methodology": "percent of total billed charges", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "First Choice Health Network fka Health InfoNet", "plan_name": "Medicare Advantage", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Allegiance Provider Direct", "plan_name": "Medicare", "standard_charge_percentage": 229.99999999999997, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Allegiance Provider Direct", "plan_name": "State of Montana Employee Benefit Plan (Self-Funded)", "standard_charge_percentage": 229.99999999999997, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Allegiance Provider Direct", "plan_name": "Montana Municipal Interlocal Authority (MMIA)", "standard_charge_percentage": 229.99999999999997, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "PacificSource Health Plans", "plan_name": "PPO (PSN Network and Smart Health Network)", "standard_charge_percentage": 80, "methodology": "percent of total billed charges", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Medica Insurance Company", "plan_name": "Medicare Cost", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" } ] } ], "drug_information": { "unit": 2, "type": "EA" } }, { "description": "Inj ivig privigen 500 mg", "code_information": [ { "code": "J1459", "type": "HCPCS" }, { "code": "44206-0436-05", "type": "NDC" } ], "standard_charges": [ { "setting": "outpatient", "payers_information": [ { "payer_name": "TriWest Healthcare Alliance Corporation", "plan_name": "VA CCN", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "First Choice of the Midwest", "plan_name": "PPO", "standard_charge_percentage": 90, "methodology": "percent of total billed charges", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Claritev fka MultiPlan", "plan_name": "PPO", "standard_charge_percentage": 75, "methodology": "percent of total billed charges", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Blue Cross Blue Shield of Montana", "plan_name": "HealthLink Network", "standard_charge_percentage": 75, "methodology": "percent of total billed charges", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Blue Cross Blue Shield of Montana", "plan_name": "Traditional Network", "standard_charge_percentage": 75, "methodology": "percent of total billed charges", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Blue Cross Blue Shield of Montana", "plan_name": "POS Network", "standard_charge_percentage": 75, "methodology": "percent of total billed charges", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Blue Cross Blue Shield of Montana", "plan_name": "Closed Plan Network", "standard_charge_percentage": 75, "methodology": "percent of total billed charges", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Blue Cross Blue Shield of Montana", "plan_name": "Retail HMO POS Network", "standard_charge_percentage": 75, "methodology": "percent of total billed charges", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Blue Cross Blue Shield of Montana", "plan_name": "Blue Options Network", "standard_charge_percentage": 75, "methodology": "percent of total billed charges", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "First Choice Health Network fka Health InfoNet", "plan_name": "Medicare Advantage", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Allegiance Provider Direct", "plan_name": "Medicare", "standard_charge_percentage": 229.99999999999997, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Allegiance Provider Direct", "plan_name": "State of Montana Employee Benefit Plan (Self-Funded)", "standard_charge_percentage": 229.99999999999997, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Allegiance Provider Direct", "plan_name": "Montana Municipal Interlocal Authority (MMIA)", "standard_charge_percentage": 229.99999999999997, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "PacificSource Health Plans", "plan_name": "PPO (PSN Network and Smart Health Network)", "standard_charge_percentage": 80, "methodology": "percent of total billed charges", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Medica Insurance Company", "plan_name": "Medicare Cost", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" } ] } ], "drug_information": { "unit": 1, "type": "ML" } }, { "description": "Gamunex-c/gammaked", "code_information": [ { "code": "J1561", "type": "HCPCS" }, { "code": "13533-0800-12", "type": "NDC" } ], "standard_charges": [ { "setting": "outpatient", "payers_information": [ { "payer_name": "TriWest Healthcare Alliance Corporation", "plan_name": "VA CCN", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "First Choice of the Midwest", "plan_name": "PPO", "standard_charge_percentage": 90, "methodology": "percent of total billed charges", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Claritev fka MultiPlan", "plan_name": "PPO", "standard_charge_percentage": 75, "methodology": "percent of total billed charges", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Blue Cross Blue Shield of Montana", "plan_name": "HealthLink Network", "standard_charge_percentage": 75, "methodology": "percent of total billed charges", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Blue Cross Blue Shield of Montana", "plan_name": "Traditional Network", "standard_charge_percentage": 75, "methodology": "percent of total billed charges", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Blue Cross Blue Shield of Montana", "plan_name": "POS Network", "standard_charge_percentage": 75, "methodology": "percent of total billed charges", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Blue Cross Blue Shield of Montana", "plan_name": "Closed Plan Network", "standard_charge_percentage": 75, "methodology": "percent of total billed charges", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Blue Cross Blue Shield of Montana", "plan_name": "Retail HMO POS Network", "standard_charge_percentage": 75, "methodology": "percent of total billed charges", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Blue Cross Blue Shield of Montana", "plan_name": "Blue Options Network", "standard_charge_percentage": 75, "methodology": "percent of total billed charges", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "First Choice Health Network fka Health InfoNet", "plan_name": "Medicare Advantage", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Allegiance Provider Direct", "plan_name": "Medicare", "standard_charge_percentage": 229.99999999999997, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Allegiance Provider Direct", "plan_name": "State of Montana Employee Benefit Plan (Self-Funded)", "standard_charge_percentage": 229.99999999999997, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Allegiance Provider Direct", "plan_name": "Montana Municipal Interlocal Authority (MMIA)", "standard_charge_percentage": 229.99999999999997, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "PacificSource Health Plans", "plan_name": "PPO (PSN Network and Smart Health Network)", "standard_charge_percentage": 80, "methodology": "percent of total billed charges", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Medica Insurance Company", "plan_name": "Medicare Cost", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" } ] } ], "drug_information": { "unit": 10, "type": "ML" } }, { "description": "Octagam injection", "code_information": [ { "code": "J1568", "type": "HCPCS" }, { "code": "00069-6002-02", "type": "NDC" } ], "standard_charges": [ { "setting": "outpatient", "payers_information": [ { "payer_name": "TriWest Healthcare Alliance Corporation", "plan_name": "VA CCN", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "First Choice of the Midwest", "plan_name": "PPO", "standard_charge_percentage": 90, "methodology": "percent of total billed charges", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Claritev fka MultiPlan", "plan_name": "PPO", "standard_charge_percentage": 75, "methodology": "percent of total billed charges", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Blue Cross Blue Shield of Montana", "plan_name": "HealthLink Network", "standard_charge_percentage": 75, "methodology": "percent of total billed charges", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Blue Cross Blue Shield of Montana", "plan_name": "Traditional Network", "standard_charge_percentage": 75, "methodology": "percent of total billed charges", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Blue Cross Blue Shield of Montana", "plan_name": "POS Network", "standard_charge_percentage": 75, "methodology": "percent of total billed charges", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Blue Cross Blue Shield of Montana", "plan_name": "Closed Plan Network", "standard_charge_percentage": 75, "methodology": "percent of total billed charges", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Blue Cross Blue Shield of Montana", "plan_name": "Retail HMO POS Network", "standard_charge_percentage": 75, "methodology": "percent of total billed charges", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Blue Cross Blue Shield of Montana", "plan_name": "Blue Options Network", "standard_charge_percentage": 75, "methodology": "percent of total billed charges", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "First Choice Health Network fka Health InfoNet", "plan_name": "Medicare Advantage", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Allegiance Provider Direct", "plan_name": "Medicare", "standard_charge_percentage": 229.99999999999997, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Allegiance Provider Direct", "plan_name": "State of Montana Employee Benefit Plan (Self-Funded)", "standard_charge_percentage": 229.99999999999997, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Allegiance Provider Direct", "plan_name": "Montana Municipal Interlocal Authority (MMIA)", "standard_charge_percentage": 229.99999999999997, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "PacificSource Health Plans", "plan_name": "PPO (PSN Network and Smart Health Network)", "standard_charge_percentage": 80, "methodology": "percent of total billed charges", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Medica Insurance Company", "plan_name": "Medicare Cost", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" } ] } ], "drug_information": { "unit": 20, "type": "ML" } }, { "description": "Romiplostim injection", "code_information": [ { "code": "J2796", "type": "HCPCS" }, { "code": "55513-0221-01", "type": "NDC" } ], "standard_charges": [ { "setting": "outpatient", "payers_information": [ { "payer_name": "TriWest Healthcare Alliance Corporation", "plan_name": "VA CCN", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Claritev fka MultiPlan", "plan_name": "PPO", "standard_charge_percentage": 75, "methodology": "percent of total billed charges", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Blue Cross Blue Shield of Montana", "plan_name": "HealthLink Network", "standard_charge_percentage": 75, "methodology": "percent of total billed charges", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Blue Cross Blue Shield of Montana", "plan_name": "Traditional Network", "standard_charge_percentage": 75, "methodology": "percent of total billed charges", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Blue Cross Blue Shield of Montana", "plan_name": "POS Network", "standard_charge_percentage": 75, "methodology": "percent of total billed charges", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Blue Cross Blue Shield of Montana", "plan_name": "Closed Plan Network", "standard_charge_percentage": 75, "methodology": "percent of total billed charges", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Blue Cross Blue Shield of Montana", "plan_name": "Retail HMO POS Network", "standard_charge_percentage": 75, "methodology": "percent of total billed charges", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Blue Cross Blue Shield of Montana", "plan_name": "Blue Options Network", "standard_charge_percentage": 75, "methodology": "percent of total billed charges", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "First Choice Health Network fka Health InfoNet", "plan_name": "Medicare Advantage", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Allegiance Provider Direct", "plan_name": "Medicare", "standard_charge_percentage": 229.99999999999997, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Allegiance Provider Direct", "plan_name": "State of Montana Employee Benefit Plan (Self-Funded)", "standard_charge_percentage": 229.99999999999997, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Allegiance Provider Direct", "plan_name": "Montana Municipal Interlocal Authority (MMIA)", "standard_charge_percentage": 229.99999999999997, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "PacificSource Health Plans", "plan_name": "PPO (PSN Network and Smart Health Network)", "standard_charge_percentage": 80, "methodology": "percent of total billed charges", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Medica Insurance Company", "plan_name": "Medicare Cost", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" } ] } ], "drug_information": { "unit": 1, "type": "EA" } }, { "description": "Inpatient Renal Dialysis - General Classification", "code_information": [ { "code": "0800", "type": "RC" } ], "standard_charges": [ { "setting": "both", "payers_information": [ { "payer_name": "TriWest Healthcare Alliance Corporation", "plan_name": "VA CCN", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Montana Health Cooperative dba Mountain Health Co-Op HPN Product", "plan_name": "MT Connected Care", "standard_charge_dollar": 600, "methodology": "fee schedule", "median_amount": 600, "10th_percentile": 600, "90th_percentile": 600, "count": "1 through 10" }, { "payer_name": "Montana Health Cooperative dba Mountain Health Co-Op HPN Product", "plan_name": "MT Access Care", "standard_charge_dollar": 600, "methodology": "fee schedule", "median_amount": 600, "10th_percentile": 600, "90th_percentile": 600, "count": "1 through 10" } ], "minimum": 600, "maximum": 600 } ] }, { "description": "Home/res vst new sf mdm 15", "code_information": [ { "code": "99341", "type": "HCPCS" } ], "standard_charges": [ { "setting": "outpatient", "payers_information": [ { "payer_name": "Blue Cross Blue Shield of Montana", "plan_name": "Medicare Advantage", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" } ] } ] }, { "description": "Home/res vst new low mdm 30", "code_information": [ { "code": "99342", "type": "HCPCS" } ], "standard_charges": [ { "setting": "outpatient", "payers_information": [ { "payer_name": "Blue Cross Blue Shield of Montana", "plan_name": "Medicare Advantage", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" } ] } ] }, { "description": "HOME VISIT NEW PATIENT", "code_information": [ { "code": "99343", "type": "HCPCS" } ], "standard_charges": [ { "setting": "outpatient", "payers_information": [ { "payer_name": "Blue Cross Blue Shield of Montana", "plan_name": "Medicare Advantage", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" } ] } ] }, { "description": "Home/res vst new mod mdm 60", "code_information": [ { "code": "99344", "type": "HCPCS" } ], "standard_charges": [ { "setting": "outpatient", "payers_information": [ { "payer_name": "Blue Cross Blue Shield of Montana", "plan_name": "Medicare Advantage", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" } ] } ] }, { "description": "Home/res vst new high mdm 75", "code_information": [ { "code": "99345", "type": "HCPCS" } ], "standard_charges": [ { "setting": "outpatient", "payers_information": [ { "payer_name": "Blue Cross Blue Shield of Montana", "plan_name": "Medicare Advantage", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" } ] } ] }, { "description": "Home/res vst est sf mdm 20", "code_information": [ { "code": "99347", "type": "HCPCS" } ], "standard_charges": [ { "setting": "outpatient", "payers_information": [ { "payer_name": "Blue Cross Blue Shield of Montana", "plan_name": "Medicare Advantage", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" } ] } ] }, { "description": "Home/res vst est low mdm 30", "code_information": [ { "code": "99348", "type": "HCPCS" } ], "standard_charges": [ { "setting": "outpatient", "payers_information": [ { "payer_name": "Blue Cross Blue Shield of Montana", "plan_name": "Medicare Advantage", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" } ] } ] }, { "description": "Home/res vst est mod mdm 40", "code_information": [ { "code": "99349", "type": "HCPCS" } ], "standard_charges": [ { "setting": "outpatient", "payers_information": [ { "payer_name": "Blue Cross Blue Shield of Montana", "plan_name": "Medicare Advantage", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" } ] } ] }, { "description": "Home/res vst est high mdm 60", "code_information": [ { "code": "99350", "type": "HCPCS" } ], "standard_charges": [ { "setting": "outpatient", "payers_information": [ { "payer_name": "Blue Cross Blue Shield of Montana", "plan_name": "Medicare Advantage", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" } ] } ] }, { "description": "Home visit resp therapy", "code_information": [ { "code": "99503", "type": "HCPCS" } ], "standard_charges": [ { "setting": "outpatient", "payers_information": [ { "payer_name": "Blue Cross Blue Shield of Montana", "plan_name": "Medicare Advantage", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" } ] } ] }, { "description": "Home visit mech ventilator", "code_information": [ { "code": "99504", "type": "HCPCS" } ], "standard_charges": [ { "setting": "outpatient", "payers_information": [ { "payer_name": "Blue Cross Blue Shield of Montana", "plan_name": "Medicare Advantage", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" } ] } ] }, { "description": "Home visit stoma care", "code_information": [ { "code": "99505", "type": "HCPCS" } ], "standard_charges": [ { "setting": "outpatient", "payers_information": [ { "payer_name": "Blue Cross Blue Shield of Montana", "plan_name": "Medicare Advantage", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" } ] } ] }, { "description": "Home visit im injection", "code_information": [ { "code": "99506", "type": "HCPCS" } ], "standard_charges": [ { "setting": "outpatient", "payers_information": [ { "payer_name": "Blue Cross Blue Shield of Montana", "plan_name": "Medicare Advantage", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" } ] } ] }, { "description": "Home visit cath maintain", "code_information": [ { "code": "99507", "type": "HCPCS" } ], "standard_charges": [ { "setting": "outpatient", "payers_information": [ { "payer_name": "Blue Cross Blue Shield of Montana", "plan_name": "Medicare Advantage", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" } ] } ] }, { "description": "Home visit day life activity", "code_information": [ { "code": "99509", "type": "HCPCS" } ], "standard_charges": [ { "setting": "outpatient", "payers_information": [ { "payer_name": "Blue Cross Blue Shield of Montana", "plan_name": "Medicare Advantage", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" } ] } ] }, { "description": "Home visit fecal/enema mgmt", "code_information": [ { "code": "99511", "type": "HCPCS" } ], "standard_charges": [ { "setting": "outpatient", "payers_information": [ { "payer_name": "Blue Cross Blue Shield of Montana", "plan_name": "Medicare Advantage", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" } ] } ] }, { "description": "Home visit for hemodialysis", "code_information": [ { "code": "99512", "type": "HCPCS" } ], "standard_charges": [ { "setting": "outpatient", "payers_information": [ { "payer_name": "Blue Cross Blue Shield of Montana", "plan_name": "Medicare Advantage", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" } ] } ] }, { "description": "Unlisted home visit svc/px", "code_information": [ { "code": "99600", "type": "HCPCS" } ], "standard_charges": [ { "setting": "outpatient", "payers_information": [ { "payer_name": "Blue Cross Blue Shield of Montana", "plan_name": "Medicare Advantage", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" } ] } ] }, { "description": "Home nfs visit <2 hrs", "code_information": [ { "code": "99601", "type": "HCPCS" } ], "standard_charges": [ { "setting": "outpatient", "payers_information": [ { "payer_name": "Blue Cross Blue Shield of Montana", "plan_name": "Medicare Advantage", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" } ] } ] }, { "description": "Home nfs visit each addl hr", "code_information": [ { "code": "99602", "type": "HCPCS" } ], "standard_charges": [ { "setting": "outpatient", "payers_information": [ { "payer_name": "Blue Cross Blue Shield of Montana", "plan_name": "Medicare Advantage", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" } ] } ] }, { "description": "Unlisted modality", "code_information": [ { "code": "97039", "type": "HCPCS" } ], "standard_charges": [ { "setting": "outpatient", "payers_information": [ { "payer_name": "Blue Cross Blue Shield of Montana", "plan_name": "Medicare Advantage", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" } ] } ] }, { "description": "Work hardening", "code_information": [ { "code": "97545", "type": "HCPCS" } ], "standard_charges": [ { "setting": "outpatient", "payers_information": [ { "payer_name": "Blue Cross Blue Shield of Montana", "plan_name": "Medicare Advantage", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" } ] } ] }, { "description": "Work hardening add-on", "code_information": [ { "code": "97546", "type": "HCPCS" } ], "standard_charges": [ { "setting": "outpatient", "payers_information": [ { "payer_name": "Blue Cross Blue Shield of Montana", "plan_name": "Medicare Advantage", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" } ] } ] }, { "description": "Speech/hearing therapy", "code_information": [ { "code": "92508", "type": "HCPCS" } ], "standard_charges": [ { "setting": "outpatient", "payers_information": [ { "payer_name": "Blue Cross Blue Shield of Montana", "plan_name": "Medicare Advantage", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" } ] } ] }, { "description": "Family psytx w/pt 50 min", "code_information": [ { "code": "90847", "type": "HCPCS" } ], "standard_charges": [ { "setting": "outpatient", "payers_information": [ { "payer_name": "Blue Cross Blue Shield of Montana", "plan_name": "Medicare Advantage", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" } ] } ] }, { "description": "Medical/Surgical Supplies and Devices - Non-sterile Supply", "code_information": [ { "code": "0271", "type": "RC" } ], "standard_charges": [ { "setting": "outpatient", "payers_information": [ { "payer_name": "Blue Cross Blue Shield of Montana", "plan_name": "Medicare Advantage", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" } ] } ] }, { "description": "Medical/Surgical Supplies and Devices - Sterile Supply", "code_information": [ { "code": "0272", "type": "RC" } ], "standard_charges": [ { "setting": "outpatient", "payers_information": [ { "payer_name": "Blue Cross Blue Shield of Montana", "plan_name": "Medicare Advantage", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" } ] } ] }, { "description": "Medical/Surgical Supplies and Devices - Other", "code_information": [ { "code": "0279", "type": "RC" } ], "standard_charges": [ { "setting": "outpatient", "payers_information": [ { "payer_name": "Blue Cross Blue Shield of Montana", "plan_name": "Medicare Advantage", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" } ] } ] }, { "description": "Hemodialysis - Outpatient or Home - Hemodialysis Composite or Other Rate", "code_information": [ { "code": "0821", "type": "RC" } ], "standard_charges": [ { "setting": "outpatient", "payers_information": [ { "payer_name": "Blue Cross Blue Shield of Montana", "plan_name": "Medicare Advantage", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "TriWest Healthcare Alliance Corporation", "plan_name": "VA CCN", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" } ] } ] }, { "description": "Dialysis training complete", "code_information": [ { "code": "90989", "type": "HCPCS" } ], "standard_charges": [ { "setting": "outpatient", "payers_information": [ { "payer_name": "Blue Cross Blue Shield of Montana", "plan_name": "Medicare Advantage", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" } ] } ] }, { "description": "Continuous Ambulatory Peritoneal Dialysis (CAPD) - Outpatient or Home - CAPD/Composite or Other Rate", "code_information": [ { "code": "0841", "type": "RC" } ], "standard_charges": [ { "setting": "outpatient", "payers_information": [ { "payer_name": "Blue Cross Blue Shield of Montana", "plan_name": "Medicare Advantage", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" } ] } ] }, { "description": "Continuous Cycling Peritoneal Dialysis (CCPD) - Outpatient or Home - CCPD/Composite or Other Rate", "code_information": [ { "code": "0851", "type": "RC" } ], "standard_charges": [ { "setting": "outpatient", "payers_information": [ { "payer_name": "Blue Cross Blue Shield of Montana", "plan_name": "Medicare Advantage", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" } ] } ] }, { "description": "Mouth Procedures with CC/MCC", "code_information": [ { "code": "137", "type": "LOCAL" } ], "standard_charges": [ { "setting": "inpatient", "payers_information": [ { "payer_name": "Blue Cross Blue Shield of Montana", "plan_name": "Medicare Advantage", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "United Healthcare (UHC)", "plan_name": "Medicare Advantage", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "First Choice of the Midwest", "plan_name": "PPO", "standard_charge_percentage": 90, "methodology": "percent of total billed charges", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "United Healthcare (UHC)", "plan_name": "DSNP", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Employee Benefit Management Services (EBMS)", "plan_name": "EBMS SelectCare Network", "standard_charge_percentage": 80, "methodology": "percent of total billed charges", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Claritev fka MultiPlan", "plan_name": "PPO", "standard_charge_percentage": 75, "methodology": "percent of total billed charges", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Allegiance Provider Direct", "plan_name": "Medicare", "standard_charge_percentage": 229.99999999999997, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Medicare (CMS)", "plan_name": "Medicare", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Medica Insurance Company", "plan_name": "Medicare Cost", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "First Choice Health Network fka Health InfoNet", "plan_name": "Commercial", "standard_charge_percentage": 85, "methodology": "percent of total billed charges", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "First Choice Health Network fka Health InfoNet", "plan_name": "Workers Compensation", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Indian Health Services (IHS)", "plan_name": "Commercial", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Humana Insurance Company", "plan_name": "Humana Medicare Advantage HMO", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Humana Insurance Company", "plan_name": "Humana Medicare Advantage PPO", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Humana Insurance Company", "plan_name": "Humana Medicare Advantage PFFS", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Allegiance Provider Direct", "plan_name": "State of Montana Employee Benefit Plan (Self-Funded)", "standard_charge_percentage": 229.99999999999997, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Allegiance Provider Direct", "plan_name": "Montana Municipal Interlocal Authority (MMIA)", "standard_charge_percentage": 229.99999999999997, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Allegiance Provider Direct", "plan_name": "Montana Association of Counties (MACo)", "standard_charge_percentage": 229.99999999999997, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "First Choice Health Network fka Health InfoNet", "plan_name": "Medicare Advantage", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "TriWest Healthcare Alliance Corporation", "plan_name": "TRICARE Prime", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "TriWest Healthcare Alliance Corporation", "plan_name": "TRICARE Select", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Blue Cross Blue Shield of Montana", "plan_name": "HealthLink Network", "standard_charge_percentage": 75, "methodology": "percent of total billed charges", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Blue Cross Blue Shield of Montana", "plan_name": "Traditional Network", "standard_charge_percentage": 75, "methodology": "percent of total billed charges", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Blue Cross Blue Shield of Montana", "plan_name": "POS Network", "standard_charge_percentage": 75, "methodology": "percent of total billed charges", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Blue Cross Blue Shield of Montana", "plan_name": "Closed Plan Network", "standard_charge_percentage": 75, "methodology": "percent of total billed charges", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Blue Cross Blue Shield of Montana", "plan_name": "Retail HMO POS Network", "standard_charge_percentage": 75, "methodology": "percent of total billed charges", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Blue Cross Blue Shield of Montana", "plan_name": "Blue Options Network", "standard_charge_percentage": 75, "methodology": "percent of total billed charges", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "PacificSource Health Plans", "plan_name": "Medicare Advantage", "standard_charge_percentage": 103, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" } ] } ] }, { "description": "Mouth Procedures without CC/MCC", "code_information": [ { "code": "138", "type": "LOCAL" } ], "standard_charges": [ { "setting": "inpatient", "payers_information": [ { "payer_name": "Blue Cross Blue Shield of Montana", "plan_name": "Medicare Advantage", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "United Healthcare (UHC)", "plan_name": "Medicare Advantage", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "First Choice of the Midwest", "plan_name": "PPO", "standard_charge_percentage": 90, "methodology": "percent of total billed charges", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "United Healthcare (UHC)", "plan_name": "DSNP", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Employee Benefit Management Services (EBMS)", "plan_name": "EBMS SelectCare Network", "standard_charge_percentage": 80, "methodology": "percent of total billed charges", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Claritev fka MultiPlan", "plan_name": "PPO", "standard_charge_percentage": 75, "methodology": "percent of total billed charges", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Allegiance Provider Direct", "plan_name": "Medicare", "standard_charge_percentage": 229.99999999999997, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Medicare (CMS)", "plan_name": "Medicare", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Medica Insurance Company", "plan_name": "Medicare Cost", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "First Choice Health Network fka Health InfoNet", "plan_name": "Commercial", "standard_charge_percentage": 85, "methodology": "percent of total billed charges", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "First Choice Health Network fka Health InfoNet", "plan_name": "Workers Compensation", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Indian Health Services (IHS)", "plan_name": "Commercial", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Humana Insurance Company", "plan_name": "Humana Medicare Advantage HMO", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Humana Insurance Company", "plan_name": "Humana Medicare Advantage PPO", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Humana Insurance Company", "plan_name": "Humana Medicare Advantage PFFS", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Allegiance Provider Direct", "plan_name": "State of Montana Employee Benefit Plan (Self-Funded)", "standard_charge_percentage": 229.99999999999997, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Allegiance Provider Direct", "plan_name": "Montana Municipal Interlocal Authority (MMIA)", "standard_charge_percentage": 229.99999999999997, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Allegiance Provider Direct", "plan_name": "Montana Association of Counties (MACo)", "standard_charge_percentage": 229.99999999999997, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "First Choice Health Network fka Health InfoNet", "plan_name": "Medicare Advantage", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "TriWest Healthcare Alliance Corporation", "plan_name": "TRICARE Prime", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "TriWest Healthcare Alliance Corporation", "plan_name": "TRICARE Select", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "PacificSource Health Plans", "plan_name": "Medicare Advantage", "standard_charge_percentage": 103, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" } ] } ] }, { "description": "Salivary Gland Procedures", "code_information": [ { "code": "139", "type": "LOCAL" } ], "standard_charges": [ { "setting": "inpatient", "payers_information": [ { "payer_name": "Blue Cross Blue Shield of Montana", "plan_name": "Medicare Advantage", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "United Healthcare (UHC)", "plan_name": "Medicare Advantage", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "First Choice of the Midwest", "plan_name": "PPO", "standard_charge_percentage": 90, "methodology": "percent of total billed charges", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "United Healthcare (UHC)", "plan_name": "DSNP", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Employee Benefit Management Services (EBMS)", "plan_name": "EBMS SelectCare Network", "standard_charge_percentage": 80, "methodology": "percent of total billed charges", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Claritev fka MultiPlan", "plan_name": "PPO", "standard_charge_percentage": 75, "methodology": "percent of total billed charges", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Allegiance Provider Direct", "plan_name": "Medicare", "standard_charge_percentage": 229.99999999999997, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Medicare (CMS)", "plan_name": "Medicare", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Medica Insurance Company", "plan_name": "Medicare Cost", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "First Choice Health Network fka Health InfoNet", "plan_name": "Commercial", "standard_charge_percentage": 85, "methodology": "percent of total billed charges", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "First Choice Health Network fka Health InfoNet", "plan_name": "Workers Compensation", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Indian Health Services (IHS)", "plan_name": "Commercial", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Humana Insurance Company", "plan_name": "Humana Medicare Advantage HMO", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Humana Insurance Company", "plan_name": "Humana Medicare Advantage PPO", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Humana Insurance Company", "plan_name": "Humana Medicare Advantage PFFS", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Allegiance Provider Direct", "plan_name": "State of Montana Employee Benefit Plan (Self-Funded)", "standard_charge_percentage": 229.99999999999997, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Allegiance Provider Direct", "plan_name": "Montana Municipal Interlocal Authority (MMIA)", "standard_charge_percentage": 229.99999999999997, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Allegiance Provider Direct", "plan_name": "Montana Association of Counties (MACo)", "standard_charge_percentage": 229.99999999999997, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "First Choice Health Network fka Health InfoNet", "plan_name": "Medicare Advantage", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "TriWest Healthcare Alliance Corporation", "plan_name": "TRICARE Prime", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "TriWest Healthcare Alliance Corporation", "plan_name": "TRICARE Select", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Blue Cross Blue Shield of Montana", "plan_name": "HealthLink Network", "standard_charge_percentage": 75, "methodology": "percent of total billed charges", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Blue Cross Blue Shield of Montana", "plan_name": "Traditional Network", "standard_charge_percentage": 75, "methodology": "percent of total billed charges", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Blue Cross Blue Shield of Montana", "plan_name": "POS Network", "standard_charge_percentage": 75, "methodology": "percent of total billed charges", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Blue Cross Blue Shield of Montana", "plan_name": "Closed Plan Network", "standard_charge_percentage": 75, "methodology": "percent of total billed charges", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Blue Cross Blue Shield of Montana", "plan_name": "Retail HMO POS Network", "standard_charge_percentage": 75, "methodology": "percent of total billed charges", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Blue Cross Blue Shield of Montana", "plan_name": "Blue Options Network", "standard_charge_percentage": 75, "methodology": "percent of total billed charges", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "PacificSource Health Plans", "plan_name": "Medicare Advantage", "standard_charge_percentage": 103, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" } ] } ] }, { "description": "Major Head and Neck Procedures with MCC", "code_information": [ { "code": "140", "type": "LOCAL" } ], "standard_charges": [ { "setting": "inpatient", "payers_information": [ { "payer_name": "Blue Cross Blue Shield of Montana", "plan_name": "Medicare Advantage", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "United Healthcare (UHC)", "plan_name": "Medicare Advantage", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "First Choice of the Midwest", "plan_name": "PPO", "standard_charge_percentage": 90, "methodology": "percent of total billed charges", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "United Healthcare (UHC)", "plan_name": "DSNP", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Employee Benefit Management Services (EBMS)", "plan_name": "EBMS SelectCare Network", "standard_charge_percentage": 80, "methodology": "percent of total billed charges", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Claritev fka MultiPlan", "plan_name": "PPO", "standard_charge_percentage": 75, "methodology": "percent of total billed charges", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Allegiance Provider Direct", "plan_name": "Medicare", "standard_charge_percentage": 229.99999999999997, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Medicare (CMS)", "plan_name": "Medicare", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Medica Insurance Company", "plan_name": "Medicare Cost", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "First Choice Health Network fka Health InfoNet", "plan_name": "Commercial", "standard_charge_percentage": 85, "methodology": "percent of total billed charges", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "First Choice Health Network fka Health InfoNet", "plan_name": "Workers Compensation", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Indian Health Services (IHS)", "plan_name": "Commercial", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Humana Insurance Company", "plan_name": "Humana Medicare Advantage HMO", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Humana Insurance Company", "plan_name": "Humana Medicare Advantage PPO", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Humana Insurance Company", "plan_name": "Humana Medicare Advantage PFFS", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Allegiance Provider Direct", "plan_name": "State of Montana Employee Benefit Plan (Self-Funded)", "standard_charge_percentage": 229.99999999999997, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Allegiance Provider Direct", "plan_name": "Montana Municipal Interlocal Authority (MMIA)", "standard_charge_percentage": 229.99999999999997, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Allegiance Provider Direct", "plan_name": "Montana Association of Counties (MACo)", "standard_charge_percentage": 229.99999999999997, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "First Choice Health Network fka Health InfoNet", "plan_name": "Medicare Advantage", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "TriWest Healthcare Alliance Corporation", "plan_name": "TRICARE Prime", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "TriWest Healthcare Alliance Corporation", "plan_name": "TRICARE Select", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Blue Cross Blue Shield of Montana", "plan_name": "HealthLink Network", "standard_charge_percentage": 75, "methodology": "percent of total billed charges", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Blue Cross Blue Shield of Montana", "plan_name": "Traditional Network", "standard_charge_percentage": 75, "methodology": "percent of total billed charges", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Blue Cross Blue Shield of Montana", "plan_name": "POS Network", "standard_charge_percentage": 75, "methodology": "percent of total billed charges", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Blue Cross Blue Shield of Montana", "plan_name": "Closed Plan Network", "standard_charge_percentage": 75, "methodology": "percent of total billed charges", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Blue Cross Blue Shield of Montana", "plan_name": "Retail HMO POS Network", "standard_charge_percentage": 75, "methodology": "percent of total billed charges", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Blue Cross Blue Shield of Montana", "plan_name": "Blue Options Network", "standard_charge_percentage": 75, "methodology": "percent of total billed charges", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "PacificSource Health Plans", "plan_name": "Medicare Advantage", "standard_charge_percentage": 103, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" } ] } ] }, { "description": "Major Head and Neck Procedures with CC", "code_information": [ { "code": "141", "type": "LOCAL" } ], "standard_charges": [ { "setting": "inpatient", "payers_information": [ { "payer_name": "Blue Cross Blue Shield of Montana", "plan_name": "Medicare Advantage", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "United Healthcare (UHC)", "plan_name": "Medicare Advantage", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "First Choice of the Midwest", "plan_name": "PPO", "standard_charge_percentage": 90, "methodology": "percent of total billed charges", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "United Healthcare (UHC)", "plan_name": "DSNP", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Employee Benefit Management Services (EBMS)", "plan_name": "EBMS SelectCare Network", "standard_charge_percentage": 80, "methodology": "percent of total billed charges", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Claritev fka MultiPlan", "plan_name": "PPO", "standard_charge_percentage": 75, "methodology": "percent of total billed charges", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Allegiance Provider Direct", "plan_name": "Medicare", "standard_charge_percentage": 229.99999999999997, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Medicare (CMS)", "plan_name": "Medicare", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Medica Insurance Company", "plan_name": "Medicare Cost", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "First Choice Health Network fka Health InfoNet", "plan_name": "Commercial", "standard_charge_percentage": 85, "methodology": "percent of total billed charges", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "First Choice Health Network fka Health InfoNet", "plan_name": "Workers Compensation", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Indian Health Services (IHS)", "plan_name": "Commercial", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Humana Insurance Company", "plan_name": "Humana Medicare Advantage HMO", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Humana Insurance Company", "plan_name": "Humana Medicare Advantage PPO", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Humana Insurance Company", "plan_name": "Humana Medicare Advantage PFFS", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Allegiance Provider Direct", "plan_name": "State of Montana Employee Benefit Plan (Self-Funded)", "standard_charge_percentage": 229.99999999999997, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Allegiance Provider Direct", "plan_name": "Montana Municipal Interlocal Authority (MMIA)", "standard_charge_percentage": 229.99999999999997, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Allegiance Provider Direct", "plan_name": "Montana Association of Counties (MACo)", "standard_charge_percentage": 229.99999999999997, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "First Choice Health Network fka Health InfoNet", "plan_name": "Medicare Advantage", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "TriWest Healthcare Alliance Corporation", "plan_name": "TRICARE Prime", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "TriWest Healthcare Alliance Corporation", "plan_name": "TRICARE Select", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Blue Cross Blue Shield of Montana", "plan_name": "HealthLink Network", "standard_charge_percentage": 75, "methodology": "percent of total billed charges", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Blue Cross Blue Shield of Montana", "plan_name": "Traditional Network", "standard_charge_percentage": 75, "methodology": "percent of total billed charges", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Blue Cross Blue Shield of Montana", "plan_name": "POS Network", "standard_charge_percentage": 75, "methodology": "percent of total billed charges", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Blue Cross Blue Shield of Montana", "plan_name": "Closed Plan Network", "standard_charge_percentage": 75, "methodology": "percent of total billed charges", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Blue Cross Blue Shield of Montana", "plan_name": "Retail HMO POS Network", "standard_charge_percentage": 75, "methodology": "percent of total billed charges", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Blue Cross Blue Shield of Montana", "plan_name": "Blue Options Network", "standard_charge_percentage": 75, "methodology": "percent of total billed charges", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "PacificSource Health Plans", "plan_name": "Medicare Advantage", "standard_charge_percentage": 103, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" } ] } ] }, { "description": "Major Head and Neck Procedures without CC/MCC", "code_information": [ { "code": "142", "type": "LOCAL" } ], "standard_charges": [ { "setting": "inpatient", "payers_information": [ { "payer_name": "Blue Cross Blue Shield of Montana", "plan_name": "Medicare Advantage", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "United Healthcare (UHC)", "plan_name": "Medicare Advantage", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "First Choice of the Midwest", "plan_name": "PPO", "standard_charge_percentage": 90, "methodology": "percent of total billed charges", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "United Healthcare (UHC)", "plan_name": "DSNP", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Employee Benefit Management Services (EBMS)", "plan_name": "EBMS SelectCare Network", "standard_charge_percentage": 80, "methodology": "percent of total billed charges", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Claritev fka MultiPlan", "plan_name": "PPO", "standard_charge_percentage": 75, "methodology": "percent of total billed charges", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Allegiance Provider Direct", "plan_name": "Medicare", "standard_charge_percentage": 229.99999999999997, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Medicare (CMS)", "plan_name": "Medicare", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Medica Insurance Company", "plan_name": "Medicare Cost", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "First Choice Health Network fka Health InfoNet", "plan_name": "Commercial", "standard_charge_percentage": 85, "methodology": "percent of total billed charges", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "First Choice Health Network fka Health InfoNet", "plan_name": "Workers Compensation", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Indian Health Services (IHS)", "plan_name": "Commercial", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Humana Insurance Company", "plan_name": "Humana Medicare Advantage HMO", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Humana Insurance Company", "plan_name": "Humana Medicare Advantage PPO", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Humana Insurance Company", "plan_name": "Humana Medicare Advantage PFFS", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Allegiance Provider Direct", "plan_name": "State of Montana Employee Benefit Plan (Self-Funded)", "standard_charge_percentage": 229.99999999999997, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Allegiance Provider Direct", "plan_name": "Montana Municipal Interlocal Authority (MMIA)", "standard_charge_percentage": 229.99999999999997, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Allegiance Provider Direct", "plan_name": "Montana Association of Counties (MACo)", "standard_charge_percentage": 229.99999999999997, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "First Choice Health Network fka Health InfoNet", "plan_name": "Medicare Advantage", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "TriWest Healthcare Alliance Corporation", "plan_name": "TRICARE Prime", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "TriWest Healthcare Alliance Corporation", "plan_name": "TRICARE Select", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Blue Cross Blue Shield of Montana", "plan_name": "HealthLink Network", "standard_charge_percentage": 75, "methodology": "percent of total billed charges", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Blue Cross Blue Shield of Montana", "plan_name": "Traditional Network", "standard_charge_percentage": 75, "methodology": "percent of total billed charges", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Blue Cross Blue Shield of Montana", "plan_name": "POS Network", "standard_charge_percentage": 75, "methodology": "percent of total billed charges", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Blue Cross Blue Shield of Montana", "plan_name": "Closed Plan Network", "standard_charge_percentage": 75, "methodology": "percent of total billed charges", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Blue Cross Blue Shield of Montana", "plan_name": "Retail HMO POS Network", "standard_charge_percentage": 75, "methodology": "percent of total billed charges", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Blue Cross Blue Shield of Montana", "plan_name": "Blue Options Network", "standard_charge_percentage": 75, "methodology": "percent of total billed charges", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "PacificSource Health Plans", "plan_name": "Medicare Advantage", "standard_charge_percentage": 103, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" } ] } ] }, { "description": "Other Ear, Nose, Mouth and Throat O.R. Procedures with MCC", "code_information": [ { "code": "143", "type": "LOCAL" } ], "standard_charges": [ { "setting": "inpatient", "payers_information": [ { "payer_name": "Blue Cross Blue Shield of Montana", "plan_name": "Medicare Advantage", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "United Healthcare (UHC)", "plan_name": "Medicare Advantage", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "First Choice of the Midwest", "plan_name": "PPO", "standard_charge_percentage": 90, "methodology": "percent of total billed charges", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "United Healthcare (UHC)", "plan_name": "DSNP", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Employee Benefit Management Services (EBMS)", "plan_name": "EBMS SelectCare Network", "standard_charge_percentage": 80, "methodology": "percent of total billed charges", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Claritev fka MultiPlan", "plan_name": "PPO", "standard_charge_percentage": 75, "methodology": "percent of total billed charges", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Allegiance Provider Direct", "plan_name": "Medicare", "standard_charge_percentage": 229.99999999999997, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Medicare (CMS)", "plan_name": "Medicare", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Medica Insurance Company", "plan_name": "Medicare Cost", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "First Choice Health Network fka Health InfoNet", "plan_name": "Commercial", "standard_charge_percentage": 85, "methodology": "percent of total billed charges", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "First Choice Health Network fka Health InfoNet", "plan_name": "Workers Compensation", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Indian Health Services (IHS)", "plan_name": "Commercial", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Humana Insurance Company", "plan_name": "Humana Medicare Advantage HMO", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Humana Insurance Company", "plan_name": "Humana Medicare Advantage PPO", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Humana Insurance Company", "plan_name": "Humana Medicare Advantage PFFS", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Allegiance Provider Direct", "plan_name": "State of Montana Employee Benefit Plan (Self-Funded)", "standard_charge_percentage": 229.99999999999997, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Allegiance Provider Direct", "plan_name": "Montana Municipal Interlocal Authority (MMIA)", "standard_charge_percentage": 229.99999999999997, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Allegiance Provider Direct", "plan_name": "Montana Association of Counties (MACo)", "standard_charge_percentage": 229.99999999999997, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "First Choice Health Network fka Health InfoNet", "plan_name": "Medicare Advantage", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "TriWest Healthcare Alliance Corporation", "plan_name": "TRICARE Prime", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "TriWest Healthcare Alliance Corporation", "plan_name": "TRICARE Select", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Blue Cross Blue Shield of Montana", "plan_name": "HealthLink Network", "standard_charge_percentage": 75, "methodology": "percent of total billed charges", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Blue Cross Blue Shield of Montana", "plan_name": "Traditional Network", "standard_charge_percentage": 75, "methodology": "percent of total billed charges", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Blue Cross Blue Shield of Montana", "plan_name": "POS Network", "standard_charge_percentage": 75, "methodology": "percent of total billed charges", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Blue Cross Blue Shield of Montana", "plan_name": "Closed Plan Network", "standard_charge_percentage": 75, "methodology": "percent of total billed charges", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Blue Cross Blue Shield of Montana", "plan_name": "Retail HMO POS Network", "standard_charge_percentage": 75, "methodology": "percent of total billed charges", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Blue Cross Blue Shield of Montana", "plan_name": "Blue Options Network", "standard_charge_percentage": 75, "methodology": "percent of total billed charges", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "PacificSource Health Plans", "plan_name": "Medicare Advantage", "standard_charge_percentage": 103, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" } ] } ] }, { "description": "Other Ear, Nose, Mouth and Throat O.R. Procedures with CC", "code_information": [ { "code": "144", "type": "LOCAL" } ], "standard_charges": [ { "setting": "inpatient", "payers_information": [ { "payer_name": "Blue Cross Blue Shield of Montana", "plan_name": "Medicare Advantage", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "United Healthcare (UHC)", "plan_name": "Medicare Advantage", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "First Choice of the Midwest", "plan_name": "PPO", "standard_charge_percentage": 90, "methodology": "percent of total billed charges", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "United Healthcare (UHC)", "plan_name": "DSNP", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Employee Benefit Management Services (EBMS)", "plan_name": "EBMS SelectCare Network", "standard_charge_percentage": 80, "methodology": "percent of total billed charges", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Claritev fka MultiPlan", "plan_name": "PPO", "standard_charge_percentage": 75, "methodology": "percent of total billed charges", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Allegiance Provider Direct", "plan_name": "Medicare", "standard_charge_percentage": 229.99999999999997, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Medicare (CMS)", "plan_name": "Medicare", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Medica Insurance Company", "plan_name": "Medicare Cost", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "First Choice Health Network fka Health InfoNet", "plan_name": "Commercial", "standard_charge_percentage": 85, "methodology": "percent of total billed charges", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "First Choice Health Network fka Health InfoNet", "plan_name": "Workers Compensation", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Indian Health Services (IHS)", "plan_name": "Commercial", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Humana Insurance Company", "plan_name": "Humana Medicare Advantage HMO", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Humana Insurance Company", "plan_name": "Humana Medicare Advantage PPO", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Humana Insurance Company", "plan_name": "Humana Medicare Advantage PFFS", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Allegiance Provider Direct", "plan_name": "State of Montana Employee Benefit Plan (Self-Funded)", "standard_charge_percentage": 229.99999999999997, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Allegiance Provider Direct", "plan_name": "Montana Municipal Interlocal Authority (MMIA)", "standard_charge_percentage": 229.99999999999997, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Allegiance Provider Direct", "plan_name": "Montana Association of Counties (MACo)", "standard_charge_percentage": 229.99999999999997, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "First Choice Health Network fka Health InfoNet", "plan_name": "Medicare Advantage", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "TriWest Healthcare Alliance Corporation", "plan_name": "TRICARE Prime", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "TriWest Healthcare Alliance Corporation", "plan_name": "TRICARE Select", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Blue Cross Blue Shield of Montana", "plan_name": "HealthLink Network", "standard_charge_percentage": 75, "methodology": "percent of total billed charges", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Blue Cross Blue Shield of Montana", "plan_name": "Traditional Network", "standard_charge_percentage": 75, "methodology": "percent of total billed charges", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Blue Cross Blue Shield of Montana", "plan_name": "POS Network", "standard_charge_percentage": 75, "methodology": "percent of total billed charges", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Blue Cross Blue Shield of Montana", "plan_name": "Closed Plan Network", "standard_charge_percentage": 75, "methodology": "percent of total billed charges", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Blue Cross Blue Shield of Montana", "plan_name": "Retail HMO POS Network", "standard_charge_percentage": 75, "methodology": "percent of total billed charges", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Blue Cross Blue Shield of Montana", "plan_name": "Blue Options Network", "standard_charge_percentage": 75, "methodology": "percent of total billed charges", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "PacificSource Health Plans", "plan_name": "Medicare Advantage", "standard_charge_percentage": 103, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" } ] } ] }, { "description": "Other Ear, Nose, Mouth and Throat O.R. Procedures without CC/MCC", "code_information": [ { "code": "145", "type": "LOCAL" } ], "standard_charges": [ { "setting": "inpatient", "payers_information": [ { "payer_name": "Blue Cross Blue Shield of Montana", "plan_name": "Medicare Advantage", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "United Healthcare (UHC)", "plan_name": "Medicare Advantage", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "First Choice of the Midwest", "plan_name": "PPO", "standard_charge_percentage": 90, "methodology": "percent of total billed charges", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "United Healthcare (UHC)", "plan_name": "DSNP", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Employee Benefit Management Services (EBMS)", "plan_name": "EBMS SelectCare Network", "standard_charge_percentage": 80, "methodology": "percent of total billed charges", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Claritev fka MultiPlan", "plan_name": "PPO", "standard_charge_percentage": 75, "methodology": "percent of total billed charges", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Allegiance Provider Direct", "plan_name": "Medicare", "standard_charge_percentage": 229.99999999999997, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Medicare (CMS)", "plan_name": "Medicare", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Medica Insurance Company", "plan_name": "Medicare Cost", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "First Choice Health Network fka Health InfoNet", "plan_name": "Commercial", "standard_charge_percentage": 85, "methodology": "percent of total billed charges", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "First Choice Health Network fka Health InfoNet", "plan_name": "Workers Compensation", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Indian Health Services (IHS)", "plan_name": "Commercial", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Humana Insurance Company", "plan_name": "Humana Medicare Advantage HMO", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Humana Insurance Company", "plan_name": "Humana Medicare Advantage PPO", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Humana Insurance Company", "plan_name": "Humana Medicare Advantage PFFS", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Allegiance Provider Direct", "plan_name": "State of Montana Employee Benefit Plan (Self-Funded)", "standard_charge_percentage": 229.99999999999997, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Allegiance Provider Direct", "plan_name": "Montana Municipal Interlocal Authority (MMIA)", "standard_charge_percentage": 229.99999999999997, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Allegiance Provider Direct", "plan_name": "Montana Association of Counties (MACo)", "standard_charge_percentage": 229.99999999999997, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "First Choice Health Network fka Health InfoNet", "plan_name": "Medicare Advantage", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "TriWest Healthcare Alliance Corporation", "plan_name": "TRICARE Prime", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "TriWest Healthcare Alliance Corporation", "plan_name": "TRICARE Select", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Blue Cross Blue Shield of Montana", "plan_name": "HealthLink Network", "standard_charge_percentage": 75, "methodology": "percent of total billed charges", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Blue Cross Blue Shield of Montana", "plan_name": "Traditional Network", "standard_charge_percentage": 75, "methodology": "percent of total billed charges", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Blue Cross Blue Shield of Montana", "plan_name": "POS Network", "standard_charge_percentage": 75, "methodology": "percent of total billed charges", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Blue Cross Blue Shield of Montana", "plan_name": "Closed Plan Network", "standard_charge_percentage": 75, "methodology": "percent of total billed charges", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Blue Cross Blue Shield of Montana", "plan_name": "Retail HMO POS Network", "standard_charge_percentage": 75, "methodology": "percent of total billed charges", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Blue Cross Blue Shield of Montana", "plan_name": "Blue Options Network", "standard_charge_percentage": 75, "methodology": "percent of total billed charges", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "PacificSource Health Plans", "plan_name": "Medicare Advantage", "standard_charge_percentage": 103, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" } ] } ] }, { "description": "Ear, Nose, Mouth and Throat Malignancy with MCC*", "code_information": [ { "code": "146", "type": "LOCAL" } ], "standard_charges": [ { "setting": "inpatient", "payers_information": [ { "payer_name": "Blue Cross Blue Shield of Montana", "plan_name": "Medicare Advantage", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "United Healthcare (UHC)", "plan_name": "Medicare Advantage", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "First Choice of the Midwest", "plan_name": "PPO", "standard_charge_percentage": 90, "methodology": "percent of total billed charges", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "United Healthcare (UHC)", "plan_name": "DSNP", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Employee Benefit Management Services (EBMS)", "plan_name": "EBMS SelectCare Network", "standard_charge_percentage": 80, "methodology": "percent of total billed charges", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Claritev fka MultiPlan", "plan_name": "PPO", "standard_charge_percentage": 75, "methodology": "percent of total billed charges", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Allegiance Provider Direct", "plan_name": "Medicare", "standard_charge_percentage": 229.99999999999997, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Medicare (CMS)", "plan_name": "Medicare", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Medica Insurance Company", "plan_name": "Medicare Cost", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "First Choice Health Network fka Health InfoNet", "plan_name": "Commercial", "standard_charge_percentage": 85, "methodology": "percent of total billed charges", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "First Choice Health Network fka Health InfoNet", "plan_name": "Workers Compensation", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Indian Health Services (IHS)", "plan_name": "Commercial", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Humana Insurance Company", "plan_name": "Humana Medicare Advantage HMO", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Humana Insurance Company", "plan_name": "Humana Medicare Advantage PPO", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Humana Insurance Company", "plan_name": "Humana Medicare Advantage PFFS", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Allegiance Provider Direct", "plan_name": "State of Montana Employee Benefit Plan (Self-Funded)", "standard_charge_percentage": 229.99999999999997, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Allegiance Provider Direct", "plan_name": "Montana Municipal Interlocal Authority (MMIA)", "standard_charge_percentage": 229.99999999999997, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Allegiance Provider Direct", "plan_name": "Montana Association of Counties (MACo)", "standard_charge_percentage": 229.99999999999997, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "First Choice Health Network fka Health InfoNet", "plan_name": "Medicare Advantage", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "TriWest Healthcare Alliance Corporation", "plan_name": "TRICARE Prime", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "TriWest Healthcare Alliance Corporation", "plan_name": "TRICARE Select", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Blue Cross Blue Shield of Montana", "plan_name": "HealthLink Network", "standard_charge_percentage": 75, "methodology": "percent of total billed charges", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Blue Cross Blue Shield of Montana", "plan_name": "Traditional Network", "standard_charge_percentage": 75, "methodology": "percent of total billed charges", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Blue Cross Blue Shield of Montana", "plan_name": "POS Network", "standard_charge_percentage": 75, "methodology": "percent of total billed charges", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Blue Cross Blue Shield of Montana", "plan_name": "Closed Plan Network", "standard_charge_percentage": 75, "methodology": "percent of total billed charges", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Blue Cross Blue Shield of Montana", "plan_name": "Retail HMO POS Network", "standard_charge_percentage": 75, "methodology": "percent of total billed charges", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Blue Cross Blue Shield of Montana", "plan_name": "Blue Options Network", "standard_charge_percentage": 75, "methodology": "percent of total billed charges", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "PacificSource Health Plans", "plan_name": "Medicare Advantage", "standard_charge_percentage": 103, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" } ] } ] }, { "description": "Ear, Nose, Mouth and Throat Malignancy with CC*", "code_information": [ { "code": "147", "type": "LOCAL" } ], "standard_charges": [ { "setting": "inpatient", "payers_information": [ { "payer_name": "Blue Cross Blue Shield of Montana", "plan_name": "Medicare Advantage", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "United Healthcare (UHC)", "plan_name": "Medicare Advantage", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "First Choice of the Midwest", "plan_name": "PPO", "standard_charge_percentage": 90, "methodology": "percent of total billed charges", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "United Healthcare (UHC)", "plan_name": "DSNP", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Employee Benefit Management Services (EBMS)", "plan_name": "EBMS SelectCare Network", "standard_charge_percentage": 80, "methodology": "percent of total billed charges", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Claritev fka MultiPlan", "plan_name": "PPO", "standard_charge_percentage": 75, "methodology": "percent of total billed charges", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Allegiance Provider Direct", "plan_name": "Medicare", "standard_charge_percentage": 229.99999999999997, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Medicare (CMS)", "plan_name": "Medicare", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Medica Insurance Company", "plan_name": "Medicare Cost", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "First Choice Health Network fka Health InfoNet", "plan_name": "Commercial", "standard_charge_percentage": 85, "methodology": "percent of total billed charges", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "First Choice Health Network fka Health InfoNet", "plan_name": "Workers Compensation", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Indian Health Services (IHS)", "plan_name": "Commercial", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Humana Insurance Company", "plan_name": "Humana Medicare Advantage HMO", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Humana Insurance Company", "plan_name": "Humana Medicare Advantage PPO", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Humana Insurance Company", "plan_name": "Humana Medicare Advantage PFFS", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Allegiance Provider Direct", "plan_name": "State of Montana Employee Benefit Plan (Self-Funded)", "standard_charge_percentage": 229.99999999999997, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Allegiance Provider Direct", "plan_name": "Montana Municipal Interlocal Authority (MMIA)", "standard_charge_percentage": 229.99999999999997, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Allegiance Provider Direct", "plan_name": "Montana Association of Counties (MACo)", "standard_charge_percentage": 229.99999999999997, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "First Choice Health Network fka Health InfoNet", "plan_name": "Medicare Advantage", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "TriWest Healthcare Alliance Corporation", "plan_name": "TRICARE Prime", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "TriWest Healthcare Alliance Corporation", "plan_name": "TRICARE Select", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Blue Cross Blue Shield of Montana", "plan_name": "HealthLink Network", "standard_charge_percentage": 75, "methodology": "percent of total billed charges", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Blue Cross Blue Shield of Montana", "plan_name": "Traditional Network", "standard_charge_percentage": 75, "methodology": "percent of total billed charges", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Blue Cross Blue Shield of Montana", "plan_name": "POS Network", "standard_charge_percentage": 75, "methodology": "percent of total billed charges", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Blue Cross Blue Shield of Montana", "plan_name": "Closed Plan Network", "standard_charge_percentage": 75, "methodology": "percent of total billed charges", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Blue Cross Blue Shield of Montana", "plan_name": "Retail HMO POS Network", "standard_charge_percentage": 75, "methodology": "percent of total billed charges", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Blue Cross Blue Shield of Montana", "plan_name": "Blue Options Network", "standard_charge_percentage": 75, "methodology": "percent of total billed charges", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "PacificSource Health Plans", "plan_name": "Medicare Advantage", "standard_charge_percentage": 103, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" } ] } ] }, { "description": "Ear, Nose, Mouth and Throat Malignancy without CC/MCC*", "code_information": [ { "code": "148", "type": "LOCAL" } ], "standard_charges": [ { "setting": "inpatient", "payers_information": [ { "payer_name": "Blue Cross Blue Shield of Montana", "plan_name": "Medicare Advantage", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "United Healthcare (UHC)", "plan_name": "Medicare Advantage", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "First Choice of the Midwest", "plan_name": "PPO", "standard_charge_percentage": 90, "methodology": "percent of total billed charges", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "United Healthcare (UHC)", "plan_name": "DSNP", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Employee Benefit Management Services (EBMS)", "plan_name": "EBMS SelectCare Network", "standard_charge_percentage": 80, "methodology": "percent of total billed charges", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Claritev fka MultiPlan", "plan_name": "PPO", "standard_charge_percentage": 75, "methodology": "percent of total billed charges", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Allegiance Provider Direct", "plan_name": "Medicare", "standard_charge_percentage": 229.99999999999997, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Medicare (CMS)", "plan_name": "Medicare", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Medica Insurance Company", "plan_name": "Medicare Cost", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "First Choice Health Network fka Health InfoNet", "plan_name": "Commercial", "standard_charge_percentage": 85, "methodology": "percent of total billed charges", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "First Choice Health Network fka Health InfoNet", "plan_name": "Workers Compensation", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Indian Health Services (IHS)", "plan_name": "Commercial", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Humana Insurance Company", "plan_name": "Humana Medicare Advantage HMO", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Humana Insurance Company", "plan_name": "Humana Medicare Advantage PPO", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Humana Insurance Company", "plan_name": "Humana Medicare Advantage PFFS", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Allegiance Provider Direct", "plan_name": "State of Montana Employee Benefit Plan (Self-Funded)", "standard_charge_percentage": 229.99999999999997, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Allegiance Provider Direct", "plan_name": "Montana Municipal Interlocal Authority (MMIA)", "standard_charge_percentage": 229.99999999999997, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Allegiance Provider Direct", "plan_name": "Montana Association of Counties (MACo)", "standard_charge_percentage": 229.99999999999997, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "First Choice Health Network fka Health InfoNet", "plan_name": "Medicare Advantage", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "TriWest Healthcare Alliance Corporation", "plan_name": "TRICARE Prime", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "TriWest Healthcare Alliance Corporation", "plan_name": "TRICARE Select", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "PacificSource Health Plans", "plan_name": "Medicare Advantage", "standard_charge_percentage": 103, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" } ] } ] }, { "description": "Dysequilibrium", "code_information": [ { "code": "149", "type": "LOCAL" } ], "standard_charges": [ { "setting": "inpatient", "payers_information": [ { "payer_name": "Blue Cross Blue Shield of Montana", "plan_name": "Medicare Advantage", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "United Healthcare (UHC)", "plan_name": "Medicare Advantage", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "First Choice of the Midwest", "plan_name": "PPO", "standard_charge_percentage": 90, "methodology": "percent of total billed charges", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "United Healthcare (UHC)", "plan_name": "DSNP", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Employee Benefit Management Services (EBMS)", "plan_name": "EBMS SelectCare Network", "standard_charge_percentage": 80, "methodology": "percent of total billed charges", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Claritev fka MultiPlan", "plan_name": "PPO", "standard_charge_percentage": 75, "methodology": "percent of total billed charges", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Allegiance Provider Direct", "plan_name": "Medicare", "standard_charge_percentage": 229.99999999999997, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Medicare (CMS)", "plan_name": "Medicare", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Medica Insurance Company", "plan_name": "Medicare Cost", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "First Choice Health Network fka Health InfoNet", "plan_name": "Commercial", "standard_charge_percentage": 85, "methodology": "percent of total billed charges", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "First Choice Health Network fka Health InfoNet", "plan_name": "Workers Compensation", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Indian Health Services (IHS)", "plan_name": "Commercial", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Humana Insurance Company", "plan_name": "Humana Medicare Advantage HMO", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Humana Insurance Company", "plan_name": "Humana Medicare Advantage PPO", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Humana Insurance Company", "plan_name": "Humana Medicare Advantage PFFS", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Allegiance Provider Direct", "plan_name": "State of Montana Employee Benefit Plan (Self-Funded)", "standard_charge_percentage": 229.99999999999997, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Allegiance Provider Direct", "plan_name": "Montana Municipal Interlocal Authority (MMIA)", "standard_charge_percentage": 229.99999999999997, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Allegiance Provider Direct", "plan_name": "Montana Association of Counties (MACo)", "standard_charge_percentage": 229.99999999999997, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "First Choice Health Network fka Health InfoNet", "plan_name": "Medicare Advantage", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "TriWest Healthcare Alliance Corporation", "plan_name": "TRICARE Prime", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "TriWest Healthcare Alliance Corporation", "plan_name": "TRICARE Select", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Blue Cross Blue Shield of Montana", "plan_name": "HealthLink Network", "standard_charge_percentage": 75, "methodology": "percent of total billed charges", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Blue Cross Blue Shield of Montana", "plan_name": "Traditional Network", "standard_charge_percentage": 75, "methodology": "percent of total billed charges", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Blue Cross Blue Shield of Montana", "plan_name": "POS Network", "standard_charge_percentage": 75, "methodology": "percent of total billed charges", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Blue Cross Blue Shield of Montana", "plan_name": "Closed Plan Network", "standard_charge_percentage": 75, "methodology": "percent of total billed charges", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Blue Cross Blue Shield of Montana", "plan_name": "Retail HMO POS Network", "standard_charge_percentage": 75, "methodology": "percent of total billed charges", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Blue Cross Blue Shield of Montana", "plan_name": "Blue Options Network", "standard_charge_percentage": 75, "methodology": "percent of total billed charges", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "PacificSource Health Plans", "plan_name": "Medicare Advantage", "standard_charge_percentage": 103, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" } ] } ] }, { "description": "Epistaxis with MCC", "code_information": [ { "code": "150", "type": "LOCAL" } ], "standard_charges": [ { "setting": "inpatient", "payers_information": [ { "payer_name": "Blue Cross Blue Shield of Montana", "plan_name": "Medicare Advantage", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "United Healthcare (UHC)", "plan_name": "Medicare Advantage", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "First Choice of the Midwest", "plan_name": "PPO", "standard_charge_percentage": 90, "methodology": "percent of total billed charges", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "United Healthcare (UHC)", "plan_name": "DSNP", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Employee Benefit Management Services (EBMS)", "plan_name": "EBMS SelectCare Network", "standard_charge_percentage": 80, "methodology": "percent of total billed charges", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Claritev fka MultiPlan", "plan_name": "PPO", "standard_charge_percentage": 75, "methodology": "percent of total billed charges", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Allegiance Provider Direct", "plan_name": "Medicare", "standard_charge_percentage": 229.99999999999997, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Medicare (CMS)", "plan_name": "Medicare", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Medica Insurance Company", "plan_name": "Medicare Cost", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "First Choice Health Network fka Health InfoNet", "plan_name": "Commercial", "standard_charge_percentage": 85, "methodology": "percent of total billed charges", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Indian Health Services (IHS)", "plan_name": "Commercial", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "First Choice Health Network fka Health InfoNet", "plan_name": "Workers Compensation", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Humana Insurance Company", "plan_name": "Humana Medicare Advantage HMO", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Humana Insurance Company", "plan_name": "Humana Medicare Advantage PPO", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Humana Insurance Company", "plan_name": "Humana Medicare Advantage PFFS", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Allegiance Provider Direct", "plan_name": "State of Montana Employee Benefit Plan (Self-Funded)", "standard_charge_percentage": 229.99999999999997, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Allegiance Provider Direct", "plan_name": "Montana Municipal Interlocal Authority (MMIA)", "standard_charge_percentage": 229.99999999999997, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Allegiance Provider Direct", "plan_name": "Montana Association of Counties (MACo)", "standard_charge_percentage": 229.99999999999997, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "First Choice Health Network fka Health InfoNet", "plan_name": "Medicare Advantage", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "TriWest Healthcare Alliance Corporation", "plan_name": "TRICARE Prime", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "TriWest Healthcare Alliance Corporation", "plan_name": "TRICARE Select", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Blue Cross Blue Shield of Montana", "plan_name": "HealthLink Network", "standard_charge_percentage": 75, "methodology": "percent of total billed charges", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Blue Cross Blue Shield of Montana", "plan_name": "Traditional Network", "standard_charge_percentage": 75, "methodology": "percent of total billed charges", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Blue Cross Blue Shield of Montana", "plan_name": "POS Network", "standard_charge_percentage": 75, "methodology": "percent of total billed charges", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Blue Cross Blue Shield of Montana", "plan_name": "Closed Plan Network", "standard_charge_percentage": 75, "methodology": "percent of total billed charges", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Blue Cross Blue Shield of Montana", "plan_name": "Retail HMO POS Network", "standard_charge_percentage": 75, "methodology": "percent of total billed charges", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Blue Cross Blue Shield of Montana", "plan_name": "Blue Options Network", "standard_charge_percentage": 75, "methodology": "percent of total billed charges", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "PacificSource Health Plans", "plan_name": "Medicare Advantage", "standard_charge_percentage": 103, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" } ] } ] }, { "description": "Epistaxis without MCC", "code_information": [ { "code": "151", "type": "LOCAL" } ], "standard_charges": [ { "setting": "inpatient", "payers_information": [ { "payer_name": "Blue Cross Blue Shield of Montana", "plan_name": "Medicare Advantage", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "United Healthcare (UHC)", "plan_name": "Medicare Advantage", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "First Choice of the Midwest", "plan_name": "PPO", "standard_charge_percentage": 90, "methodology": "percent of total billed charges", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "United Healthcare (UHC)", "plan_name": "DSNP", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Employee Benefit Management Services (EBMS)", "plan_name": "EBMS SelectCare Network", "standard_charge_percentage": 80, "methodology": "percent of total billed charges", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Claritev fka MultiPlan", "plan_name": "PPO", "standard_charge_percentage": 75, "methodology": "percent of total billed charges", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Allegiance Provider Direct", "plan_name": "Medicare", "standard_charge_percentage": 229.99999999999997, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Medicare (CMS)", "plan_name": "Medicare", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Medica Insurance Company", "plan_name": "Medicare Cost", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "First Choice Health Network fka Health InfoNet", "plan_name": "Commercial", "standard_charge_percentage": 85, "methodology": "percent of total billed charges", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Indian Health Services (IHS)", "plan_name": "Commercial", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "First Choice Health Network fka Health InfoNet", "plan_name": "Workers Compensation", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Humana Insurance Company", "plan_name": "Humana Medicare Advantage HMO", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Humana Insurance Company", "plan_name": "Humana Medicare Advantage PPO", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Humana Insurance Company", "plan_name": "Humana Medicare Advantage PFFS", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Allegiance Provider Direct", "plan_name": "State of Montana Employee Benefit Plan (Self-Funded)", "standard_charge_percentage": 229.99999999999997, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Allegiance Provider Direct", "plan_name": "Montana Municipal Interlocal Authority (MMIA)", "standard_charge_percentage": 229.99999999999997, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Allegiance Provider Direct", "plan_name": "Montana Association of Counties (MACo)", "standard_charge_percentage": 229.99999999999997, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "First Choice Health Network fka Health InfoNet", "plan_name": "Medicare Advantage", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "TriWest Healthcare Alliance Corporation", "plan_name": "TRICARE Prime", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "TriWest Healthcare Alliance Corporation", "plan_name": "TRICARE Select", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Blue Cross Blue Shield of Montana", "plan_name": "HealthLink Network", "standard_charge_percentage": 75, "methodology": "percent of total billed charges", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Blue Cross Blue Shield of Montana", "plan_name": "Traditional Network", "standard_charge_percentage": 75, "methodology": "percent of total billed charges", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Blue Cross Blue Shield of Montana", "plan_name": "POS Network", "standard_charge_percentage": 75, "methodology": "percent of total billed charges", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Blue Cross Blue Shield of Montana", "plan_name": "Closed Plan Network", "standard_charge_percentage": 75, "methodology": "percent of total billed charges", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Blue Cross Blue Shield of Montana", "plan_name": "Retail HMO POS Network", "standard_charge_percentage": 75, "methodology": "percent of total billed charges", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Blue Cross Blue Shield of Montana", "plan_name": "Blue Options Network", "standard_charge_percentage": 75, "methodology": "percent of total billed charges", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "PacificSource Health Plans", "plan_name": "Medicare Advantage", "standard_charge_percentage": 103, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" } ] } ] }, { "description": "Otitis Media and URI with MCC", "code_information": [ { "code": "152", "type": "LOCAL" } ], "standard_charges": [ { "setting": "inpatient", "payers_information": [ { "payer_name": "Blue Cross Blue Shield of Montana", "plan_name": "Medicare Advantage", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "United Healthcare (UHC)", "plan_name": "Medicare Advantage", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "First Choice of the Midwest", "plan_name": "PPO", "standard_charge_percentage": 90, "methodology": "percent of total billed charges", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "United Healthcare (UHC)", "plan_name": "DSNP", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Employee Benefit Management Services (EBMS)", "plan_name": "EBMS SelectCare Network", "standard_charge_percentage": 80, "methodology": "percent of total billed charges", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Claritev fka MultiPlan", "plan_name": "PPO", "standard_charge_percentage": 75, "methodology": "percent of total billed charges", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Allegiance Provider Direct", "plan_name": "Medicare", "standard_charge_percentage": 229.99999999999997, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Medicare (CMS)", "plan_name": "Medicare", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Medica Insurance Company", "plan_name": "Medicare Cost", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "First Choice Health Network fka Health InfoNet", "plan_name": "Commercial", "standard_charge_percentage": 85, "methodology": "percent of total billed charges", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Indian Health Services (IHS)", "plan_name": "Commercial", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "First Choice Health Network fka Health InfoNet", "plan_name": "Workers Compensation", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Humana Insurance Company", "plan_name": "Humana Medicare Advantage HMO", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Humana Insurance Company", "plan_name": "Humana Medicare Advantage PPO", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Humana Insurance Company", "plan_name": "Humana Medicare Advantage PFFS", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Allegiance Provider Direct", "plan_name": "State of Montana Employee Benefit Plan (Self-Funded)", "standard_charge_percentage": 229.99999999999997, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Allegiance Provider Direct", "plan_name": "Montana Municipal Interlocal Authority (MMIA)", "standard_charge_percentage": 229.99999999999997, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Allegiance Provider Direct", "plan_name": "Montana Association of Counties (MACo)", "standard_charge_percentage": 229.99999999999997, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "First Choice Health Network fka Health InfoNet", "plan_name": "Medicare Advantage", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "TriWest Healthcare Alliance Corporation", "plan_name": "TRICARE Prime", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "TriWest Healthcare Alliance Corporation", "plan_name": "TRICARE Select", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Blue Cross Blue Shield of Montana", "plan_name": "HealthLink Network", "standard_charge_percentage": 75, "methodology": "percent of total billed charges", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Blue Cross Blue Shield of Montana", "plan_name": "Traditional Network", "standard_charge_percentage": 75, "methodology": "percent of total billed charges", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Blue Cross Blue Shield of Montana", "plan_name": "POS Network", "standard_charge_percentage": 75, "methodology": "percent of total billed charges", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Blue Cross Blue Shield of Montana", "plan_name": "Closed Plan Network", "standard_charge_percentage": 75, "methodology": "percent of total billed charges", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Blue Cross Blue Shield of Montana", "plan_name": "Retail HMO POS Network", "standard_charge_percentage": 75, "methodology": "percent of total billed charges", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Blue Cross Blue Shield of Montana", "plan_name": "Blue Options Network", "standard_charge_percentage": 75, "methodology": "percent of total billed charges", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "PacificSource Health Plans", "plan_name": "Medicare Advantage", "standard_charge_percentage": 103, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" } ] } ] }, { "description": "Otitis Media and URI without MCC", "code_information": [ { "code": "153", "type": "LOCAL" } ], "standard_charges": [ { "setting": "inpatient", "payers_information": [ { "payer_name": "Blue Cross Blue Shield of Montana", "plan_name": "Medicare Advantage", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "United Healthcare (UHC)", "plan_name": "Medicare Advantage", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "First Choice of the Midwest", "plan_name": "PPO", "standard_charge_percentage": 90, "methodology": "percent of total billed charges", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "United Healthcare (UHC)", "plan_name": "DSNP", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Employee Benefit Management Services (EBMS)", "plan_name": "EBMS SelectCare Network", "standard_charge_percentage": 80, "methodology": "percent of total billed charges", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Claritev fka MultiPlan", "plan_name": "PPO", "standard_charge_percentage": 75, "methodology": "percent of total billed charges", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Allegiance Provider Direct", "plan_name": "Medicare", "standard_charge_percentage": 229.99999999999997, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Medicare (CMS)", "plan_name": "Medicare", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Medica Insurance Company", "plan_name": "Medicare Cost", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "First Choice Health Network fka Health InfoNet", "plan_name": "Commercial", "standard_charge_percentage": 85, "methodology": "percent of total billed charges", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Indian Health Services (IHS)", "plan_name": "Commercial", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "First Choice Health Network fka Health InfoNet", "plan_name": "Workers Compensation", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Humana Insurance Company", "plan_name": "Humana Medicare Advantage HMO", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Humana Insurance Company", "plan_name": "Humana Medicare Advantage PPO", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Humana Insurance Company", "plan_name": "Humana Medicare Advantage PFFS", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Allegiance Provider Direct", "plan_name": "State of Montana Employee Benefit Plan (Self-Funded)", "standard_charge_percentage": 229.99999999999997, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Allegiance Provider Direct", "plan_name": "Montana Municipal Interlocal Authority (MMIA)", "standard_charge_percentage": 229.99999999999997, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Allegiance Provider Direct", "plan_name": "Montana Association of Counties (MACo)", "standard_charge_percentage": 229.99999999999997, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "First Choice Health Network fka Health InfoNet", "plan_name": "Medicare Advantage", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "TriWest Healthcare Alliance Corporation", "plan_name": "TRICARE Prime", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "TriWest Healthcare Alliance Corporation", "plan_name": "TRICARE Select", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Blue Cross Blue Shield of Montana", "plan_name": "HealthLink Network", "standard_charge_percentage": 75, "methodology": "percent of total billed charges", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Blue Cross Blue Shield of Montana", "plan_name": "Traditional Network", "standard_charge_percentage": 75, "methodology": "percent of total billed charges", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Blue Cross Blue Shield of Montana", "plan_name": "POS Network", "standard_charge_percentage": 75, "methodology": "percent of total billed charges", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Blue Cross Blue Shield of Montana", "plan_name": "Closed Plan Network", "standard_charge_percentage": 75, "methodology": "percent of total billed charges", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Blue Cross Blue Shield of Montana", "plan_name": "Retail HMO POS Network", "standard_charge_percentage": 75, "methodology": "percent of total billed charges", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Blue Cross Blue Shield of Montana", "plan_name": "Blue Options Network", "standard_charge_percentage": 75, "methodology": "percent of total billed charges", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "PacificSource Health Plans", "plan_name": "Medicare Advantage", "standard_charge_percentage": 103, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" } ] } ] }, { "description": "Other Ear, Nose, Mouth and Throat Diagnoses with MCC", "code_information": [ { "code": "154", "type": "LOCAL" } ], "standard_charges": [ { "setting": "inpatient", "payers_information": [ { "payer_name": "Blue Cross Blue Shield of Montana", "plan_name": "Medicare Advantage", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "United Healthcare (UHC)", "plan_name": "Medicare Advantage", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "First Choice of the Midwest", "plan_name": "PPO", "standard_charge_percentage": 90, "methodology": "percent of total billed charges", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "United Healthcare (UHC)", "plan_name": "DSNP", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Employee Benefit Management Services (EBMS)", "plan_name": "EBMS SelectCare Network", "standard_charge_percentage": 80, "methodology": "percent of total billed charges", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Claritev fka MultiPlan", "plan_name": "PPO", "standard_charge_percentage": 75, "methodology": "percent of total billed charges", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Allegiance Provider Direct", "plan_name": "Medicare", "standard_charge_percentage": 229.99999999999997, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Medicare (CMS)", "plan_name": "Medicare", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Medica Insurance Company", "plan_name": "Medicare Cost", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "First Choice Health Network fka Health InfoNet", "plan_name": "Commercial", "standard_charge_percentage": 85, "methodology": "percent of total billed charges", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Indian Health Services (IHS)", "plan_name": "Commercial", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "First Choice Health Network fka Health InfoNet", "plan_name": "Workers Compensation", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Humana Insurance Company", "plan_name": "Humana Medicare Advantage HMO", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Humana Insurance Company", "plan_name": "Humana Medicare Advantage PPO", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Humana Insurance Company", "plan_name": "Humana Medicare Advantage PFFS", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Allegiance Provider Direct", "plan_name": "State of Montana Employee Benefit Plan (Self-Funded)", "standard_charge_percentage": 229.99999999999997, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Allegiance Provider Direct", "plan_name": "Montana Municipal Interlocal Authority (MMIA)", "standard_charge_percentage": 229.99999999999997, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Allegiance Provider Direct", "plan_name": "Montana Association of Counties (MACo)", "standard_charge_percentage": 229.99999999999997, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "First Choice Health Network fka Health InfoNet", "plan_name": "Medicare Advantage", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "TriWest Healthcare Alliance Corporation", "plan_name": "TRICARE Prime", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "TriWest Healthcare Alliance Corporation", "plan_name": "TRICARE Select", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Blue Cross Blue Shield of Montana", "plan_name": "HealthLink Network", "standard_charge_percentage": 75, "methodology": "percent of total billed charges", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Blue Cross Blue Shield of Montana", "plan_name": "Traditional Network", "standard_charge_percentage": 75, "methodology": "percent of total billed charges", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Blue Cross Blue Shield of Montana", "plan_name": "POS Network", "standard_charge_percentage": 75, "methodology": "percent of total billed charges", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Blue Cross Blue Shield of Montana", "plan_name": "Closed Plan Network", "standard_charge_percentage": 75, "methodology": "percent of total billed charges", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Blue Cross Blue Shield of Montana", "plan_name": "Retail HMO POS Network", "standard_charge_percentage": 75, "methodology": "percent of total billed charges", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Blue Cross Blue Shield of Montana", "plan_name": "Blue Options Network", "standard_charge_percentage": 75, "methodology": "percent of total billed charges", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "PacificSource Health Plans", "plan_name": "Medicare Advantage", "standard_charge_percentage": 103, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" } ] } ] }, { "description": "Other Ear, Nose, Mouth and Throat Diagnoses with CC", "code_information": [ { "code": "155", "type": "LOCAL" } ], "standard_charges": [ { "setting": "inpatient", "payers_information": [ { "payer_name": "Blue Cross Blue Shield of Montana", "plan_name": "Medicare Advantage", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "United Healthcare (UHC)", "plan_name": "Medicare Advantage", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "First Choice of the Midwest", "plan_name": "PPO", "standard_charge_percentage": 90, "methodology": "percent of total billed charges", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "United Healthcare (UHC)", "plan_name": "DSNP", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Employee Benefit Management Services (EBMS)", "plan_name": "EBMS SelectCare Network", "standard_charge_percentage": 80, "methodology": "percent of total billed charges", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Claritev fka MultiPlan", "plan_name": "PPO", "standard_charge_percentage": 75, "methodology": "percent of total billed charges", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Allegiance Provider Direct", "plan_name": "Medicare", "standard_charge_percentage": 229.99999999999997, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Medicare (CMS)", "plan_name": "Medicare", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Medica Insurance Company", "plan_name": "Medicare Cost", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "First Choice Health Network fka Health InfoNet", "plan_name": "Commercial", "standard_charge_percentage": 85, "methodology": "percent of total billed charges", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Indian Health Services (IHS)", "plan_name": "Commercial", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "First Choice Health Network fka Health InfoNet", "plan_name": "Workers Compensation", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Humana Insurance Company", "plan_name": "Humana Medicare Advantage HMO", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Humana Insurance Company", "plan_name": "Humana Medicare Advantage PPO", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Humana Insurance Company", "plan_name": "Humana Medicare Advantage PFFS", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Allegiance Provider Direct", "plan_name": "State of Montana Employee Benefit Plan (Self-Funded)", "standard_charge_percentage": 229.99999999999997, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Allegiance Provider Direct", "plan_name": "Montana Municipal Interlocal Authority (MMIA)", "standard_charge_percentage": 229.99999999999997, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Allegiance Provider Direct", "plan_name": "Montana Association of Counties (MACo)", "standard_charge_percentage": 229.99999999999997, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "First Choice Health Network fka Health InfoNet", "plan_name": "Medicare Advantage", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "TriWest Healthcare Alliance Corporation", "plan_name": "TRICARE Prime", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "TriWest Healthcare Alliance Corporation", "plan_name": "TRICARE Select", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Blue Cross Blue Shield of Montana", "plan_name": "HealthLink Network", "standard_charge_percentage": 75, "methodology": "percent of total billed charges", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Blue Cross Blue Shield of Montana", "plan_name": "Traditional Network", "standard_charge_percentage": 75, "methodology": "percent of total billed charges", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Blue Cross Blue Shield of Montana", "plan_name": "POS Network", "standard_charge_percentage": 75, "methodology": "percent of total billed charges", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Blue Cross Blue Shield of Montana", "plan_name": "Closed Plan Network", "standard_charge_percentage": 75, "methodology": "percent of total billed charges", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Blue Cross Blue Shield of Montana", "plan_name": "Retail HMO POS Network", "standard_charge_percentage": 75, "methodology": "percent of total billed charges", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Blue Cross Blue Shield of Montana", "plan_name": "Blue Options Network", "standard_charge_percentage": 75, "methodology": "percent of total billed charges", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "PacificSource Health Plans", "plan_name": "Medicare Advantage", "standard_charge_percentage": 103, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" } ] } ] }, { "description": "Other Ear, Nose, Mouth and Throat Diagnoses without CC/MCC", "code_information": [ { "code": "156", "type": "LOCAL" } ], "standard_charges": [ { "setting": "inpatient", "payers_information": [ { "payer_name": "Blue Cross Blue Shield of Montana", "plan_name": "Medicare Advantage", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "United Healthcare (UHC)", "plan_name": "Medicare Advantage", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "First Choice of the Midwest", "plan_name": "PPO", "standard_charge_percentage": 90, "methodology": "percent of total billed charges", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "United Healthcare (UHC)", "plan_name": "DSNP", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Employee Benefit Management Services (EBMS)", "plan_name": "EBMS SelectCare Network", "standard_charge_percentage": 80, "methodology": "percent of total billed charges", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Claritev fka MultiPlan", "plan_name": "PPO", "standard_charge_percentage": 75, "methodology": "percent of total billed charges", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Allegiance Provider Direct", "plan_name": "Medicare", "standard_charge_percentage": 229.99999999999997, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Medicare (CMS)", "plan_name": "Medicare", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Medica Insurance Company", "plan_name": "Medicare Cost", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "First Choice Health Network fka Health InfoNet", "plan_name": "Commercial", "standard_charge_percentage": 85, "methodology": "percent of total billed charges", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Indian Health Services (IHS)", "plan_name": "Commercial", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "First Choice Health Network fka Health InfoNet", "plan_name": "Workers Compensation", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Humana Insurance Company", "plan_name": "Humana Medicare Advantage HMO", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Humana Insurance Company", "plan_name": "Humana Medicare Advantage PPO", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Humana Insurance Company", "plan_name": "Humana Medicare Advantage PFFS", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Allegiance Provider Direct", "plan_name": "State of Montana Employee Benefit Plan (Self-Funded)", "standard_charge_percentage": 229.99999999999997, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Allegiance Provider Direct", "plan_name": "Montana Municipal Interlocal Authority (MMIA)", "standard_charge_percentage": 229.99999999999997, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Allegiance Provider Direct", "plan_name": "Montana Association of Counties (MACo)", "standard_charge_percentage": 229.99999999999997, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "First Choice Health Network fka Health InfoNet", "plan_name": "Medicare Advantage", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "TriWest Healthcare Alliance Corporation", "plan_name": "TRICARE Prime", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "TriWest Healthcare Alliance Corporation", "plan_name": "TRICARE Select", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Blue Cross Blue Shield of Montana", "plan_name": "HealthLink Network", "standard_charge_percentage": 75, "methodology": "percent of total billed charges", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Blue Cross Blue Shield of Montana", "plan_name": "Traditional Network", "standard_charge_percentage": 75, "methodology": "percent of total billed charges", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Blue Cross Blue Shield of Montana", "plan_name": "POS Network", "standard_charge_percentage": 75, "methodology": "percent of total billed charges", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Blue Cross Blue Shield of Montana", "plan_name": "Closed Plan Network", "standard_charge_percentage": 75, "methodology": "percent of total billed charges", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Blue Cross Blue Shield of Montana", "plan_name": "Retail HMO POS Network", "standard_charge_percentage": 75, "methodology": "percent of total billed charges", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Blue Cross Blue Shield of Montana", "plan_name": "Blue Options Network", "standard_charge_percentage": 75, "methodology": "percent of total billed charges", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "PacificSource Health Plans", "plan_name": "Medicare Advantage", "standard_charge_percentage": 103, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" } ] } ] }, { "description": "Dental and Oral Diseases with MCC", "code_information": [ { "code": "157", "type": "LOCAL" } ], "standard_charges": [ { "setting": "inpatient", "payers_information": [ { "payer_name": "Blue Cross Blue Shield of Montana", "plan_name": "Medicare Advantage", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "United Healthcare (UHC)", "plan_name": "Medicare Advantage", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "First Choice of the Midwest", "plan_name": "PPO", "standard_charge_percentage": 90, "methodology": "percent of total billed charges", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "United Healthcare (UHC)", "plan_name": "DSNP", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Employee Benefit Management Services (EBMS)", "plan_name": "EBMS SelectCare Network", "standard_charge_percentage": 80, "methodology": "percent of total billed charges", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Claritev fka MultiPlan", "plan_name": "PPO", "standard_charge_percentage": 75, "methodology": "percent of total billed charges", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Allegiance Provider Direct", "plan_name": "Medicare", "standard_charge_percentage": 229.99999999999997, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Medicare (CMS)", "plan_name": "Medicare", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Medica Insurance Company", "plan_name": "Medicare Cost", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "First Choice Health Network fka Health InfoNet", "plan_name": "Commercial", "standard_charge_percentage": 85, "methodology": "percent of total billed charges", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Indian Health Services (IHS)", "plan_name": "Commercial", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "First Choice Health Network fka Health InfoNet", "plan_name": "Workers Compensation", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Humana Insurance Company", "plan_name": "Humana Medicare Advantage HMO", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Humana Insurance Company", "plan_name": "Humana Medicare Advantage PPO", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Humana Insurance Company", "plan_name": "Humana Medicare Advantage PFFS", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Allegiance Provider Direct", "plan_name": "State of Montana Employee Benefit Plan (Self-Funded)", "standard_charge_percentage": 229.99999999999997, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Allegiance Provider Direct", "plan_name": "Montana Municipal Interlocal Authority (MMIA)", "standard_charge_percentage": 229.99999999999997, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Allegiance Provider Direct", "plan_name": "Montana Association of Counties (MACo)", "standard_charge_percentage": 229.99999999999997, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "First Choice Health Network fka Health InfoNet", "plan_name": "Medicare Advantage", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "TriWest Healthcare Alliance Corporation", "plan_name": "TRICARE Prime", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "TriWest Healthcare Alliance Corporation", "plan_name": "TRICARE Select", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Blue Cross Blue Shield of Montana", "plan_name": "HealthLink Network", "standard_charge_percentage": 75, "methodology": "percent of total billed charges", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Blue Cross Blue Shield of Montana", "plan_name": "Traditional Network", "standard_charge_percentage": 75, "methodology": "percent of total billed charges", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Blue Cross Blue Shield of Montana", "plan_name": "POS Network", "standard_charge_percentage": 75, "methodology": "percent of total billed charges", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Blue Cross Blue Shield of Montana", "plan_name": "Closed Plan Network", "standard_charge_percentage": 75, "methodology": "percent of total billed charges", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Blue Cross Blue Shield of Montana", "plan_name": "Retail HMO POS Network", "standard_charge_percentage": 75, "methodology": "percent of total billed charges", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Blue Cross Blue Shield of Montana", "plan_name": "Blue Options Network", "standard_charge_percentage": 75, "methodology": "percent of total billed charges", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "PacificSource Health Plans", "plan_name": "Medicare Advantage", "standard_charge_percentage": 103, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" } ] } ] }, { "description": "Dental and Oral Diseases with CC", "code_information": [ { "code": "158", "type": "LOCAL" } ], "standard_charges": [ { "setting": "inpatient", "payers_information": [ { "payer_name": "Blue Cross Blue Shield of Montana", "plan_name": "Medicare Advantage", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "United Healthcare (UHC)", "plan_name": "Medicare Advantage", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "First Choice of the Midwest", "plan_name": "PPO", "standard_charge_percentage": 90, "methodology": "percent of total billed charges", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "United Healthcare (UHC)", "plan_name": "DSNP", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Employee Benefit Management Services (EBMS)", "plan_name": "EBMS SelectCare Network", "standard_charge_percentage": 80, "methodology": "percent of total billed charges", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Claritev fka MultiPlan", "plan_name": "PPO", "standard_charge_percentage": 75, "methodology": "percent of total billed charges", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Allegiance Provider Direct", "plan_name": "Medicare", "standard_charge_percentage": 229.99999999999997, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Medicare (CMS)", "plan_name": "Medicare", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Medica Insurance Company", "plan_name": "Medicare Cost", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "First Choice Health Network fka Health InfoNet", "plan_name": "Commercial", "standard_charge_percentage": 85, "methodology": "percent of total billed charges", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Indian Health Services (IHS)", "plan_name": "Commercial", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "First Choice Health Network fka Health InfoNet", "plan_name": "Workers Compensation", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Humana Insurance Company", "plan_name": "Humana Medicare Advantage HMO", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Humana Insurance Company", "plan_name": "Humana Medicare Advantage PPO", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Humana Insurance Company", "plan_name": "Humana Medicare Advantage PFFS", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Allegiance Provider Direct", "plan_name": "State of Montana Employee Benefit Plan (Self-Funded)", "standard_charge_percentage": 229.99999999999997, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Allegiance Provider Direct", "plan_name": "Montana Municipal Interlocal Authority (MMIA)", "standard_charge_percentage": 229.99999999999997, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Allegiance Provider Direct", "plan_name": "Montana Association of Counties (MACo)", "standard_charge_percentage": 229.99999999999997, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "First Choice Health Network fka Health InfoNet", "plan_name": "Medicare Advantage", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "TriWest Healthcare Alliance Corporation", "plan_name": "TRICARE Prime", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "TriWest Healthcare Alliance Corporation", "plan_name": "TRICARE Select", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "PacificSource Health Plans", "plan_name": "Medicare Advantage", "standard_charge_percentage": 103, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" } ] } ] }, { "description": "Dental and Oral Diseases without CC/MCC", "code_information": [ { "code": "159", "type": "LOCAL" } ], "standard_charges": [ { "setting": "inpatient", "payers_information": [ { "payer_name": "Blue Cross Blue Shield of Montana", "plan_name": "Medicare Advantage", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "United Healthcare (UHC)", "plan_name": "Medicare Advantage", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "First Choice of the Midwest", "plan_name": "PPO", "standard_charge_percentage": 90, "methodology": "percent of total billed charges", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "United Healthcare (UHC)", "plan_name": "DSNP", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Employee Benefit Management Services (EBMS)", "plan_name": "EBMS SelectCare Network", "standard_charge_percentage": 80, "methodology": "percent of total billed charges", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Claritev fka MultiPlan", "plan_name": "PPO", "standard_charge_percentage": 75, "methodology": "percent of total billed charges", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Allegiance Provider Direct", "plan_name": "Medicare", "standard_charge_percentage": 229.99999999999997, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Medicare (CMS)", "plan_name": "Medicare", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Medica Insurance Company", "plan_name": "Medicare Cost", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "First Choice Health Network fka Health InfoNet", "plan_name": "Commercial", "standard_charge_percentage": 85, "methodology": "percent of total billed charges", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Indian Health Services (IHS)", "plan_name": "Commercial", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "First Choice Health Network fka Health InfoNet", "plan_name": "Workers Compensation", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Humana Insurance Company", "plan_name": "Humana Medicare Advantage HMO", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Humana Insurance Company", "plan_name": "Humana Medicare Advantage PPO", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Humana Insurance Company", "plan_name": "Humana Medicare Advantage PFFS", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Allegiance Provider Direct", "plan_name": "State of Montana Employee Benefit Plan (Self-Funded)", "standard_charge_percentage": 229.99999999999997, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Allegiance Provider Direct", "plan_name": "Montana Municipal Interlocal Authority (MMIA)", "standard_charge_percentage": 229.99999999999997, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Allegiance Provider Direct", "plan_name": "Montana Association of Counties (MACo)", "standard_charge_percentage": 229.99999999999997, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "First Choice Health Network fka Health InfoNet", "plan_name": "Medicare Advantage", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "TriWest Healthcare Alliance Corporation", "plan_name": "TRICARE Prime", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "TriWest Healthcare Alliance Corporation", "plan_name": "TRICARE Select", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Blue Cross Blue Shield of Montana", "plan_name": "HealthLink Network", "standard_charge_percentage": 75, "methodology": "percent of total billed charges", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Blue Cross Blue Shield of Montana", "plan_name": "Traditional Network", "standard_charge_percentage": 75, "methodology": "percent of total billed charges", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Blue Cross Blue Shield of Montana", "plan_name": "POS Network", "standard_charge_percentage": 75, "methodology": "percent of total billed charges", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Blue Cross Blue Shield of Montana", "plan_name": "Closed Plan Network", "standard_charge_percentage": 75, "methodology": "percent of total billed charges", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Blue Cross Blue Shield of Montana", "plan_name": "Retail HMO POS Network", "standard_charge_percentage": 75, "methodology": "percent of total billed charges", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Blue Cross Blue Shield of Montana", "plan_name": "Blue Options Network", "standard_charge_percentage": 75, "methodology": "percent of total billed charges", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "PacificSource Health Plans", "plan_name": "Medicare Advantage", "standard_charge_percentage": 103, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" } ] } ] }, { "description": "Major Chest Procedures with MCC", "code_information": [ { "code": "163", "type": "LOCAL" } ], "standard_charges": [ { "setting": "inpatient", "payers_information": [ { "payer_name": "Blue Cross Blue Shield of Montana", "plan_name": "Medicare Advantage", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "United Healthcare (UHC)", "plan_name": "Medicare Advantage", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "First Choice of the Midwest", "plan_name": "PPO", "standard_charge_percentage": 90, "methodology": "percent of total billed charges", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "United Healthcare (UHC)", "plan_name": "DSNP", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Employee Benefit Management Services (EBMS)", "plan_name": "EBMS SelectCare Network", "standard_charge_percentage": 80, "methodology": "percent of total billed charges", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Claritev fka MultiPlan", "plan_name": "PPO", "standard_charge_percentage": 75, "methodology": "percent of total billed charges", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Allegiance Provider Direct", "plan_name": "Medicare", "standard_charge_percentage": 229.99999999999997, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Medicare (CMS)", "plan_name": "Medicare", "standard_charge_percentage": 100, "methodology": "fee schedule", "median_amount": 83256.13, "10th_percentile": 60539.65, "90th_percentile": 123831.1, "count": "1 through 10" }, { "payer_name": "Medica Insurance Company", "plan_name": "Medicare Cost", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "First Choice Health Network fka Health InfoNet", "plan_name": "Commercial", "standard_charge_percentage": 85, "methodology": "percent of total billed charges", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Indian Health Services (IHS)", "plan_name": "Commercial", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "First Choice Health Network fka Health InfoNet", "plan_name": "Workers Compensation", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Humana Insurance Company", "plan_name": "Humana Medicare Advantage HMO", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Humana Insurance Company", "plan_name": "Humana Medicare Advantage PPO", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Humana Insurance Company", "plan_name": "Humana Medicare Advantage PFFS", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Allegiance Provider Direct", "plan_name": "State of Montana Employee Benefit Plan (Self-Funded)", "standard_charge_percentage": 229.99999999999997, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Allegiance Provider Direct", "plan_name": "Montana Municipal Interlocal Authority (MMIA)", "standard_charge_percentage": 229.99999999999997, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Allegiance Provider Direct", "plan_name": "Montana Association of Counties (MACo)", "standard_charge_percentage": 229.99999999999997, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "First Choice Health Network fka Health InfoNet", "plan_name": "Medicare Advantage", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "TriWest Healthcare Alliance Corporation", "plan_name": "TRICARE Prime", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "TriWest Healthcare Alliance Corporation", "plan_name": "TRICARE Select", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Blue Cross Blue Shield of Montana", "plan_name": "HealthLink Network", "standard_charge_percentage": 75, "methodology": "percent of total billed charges", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Blue Cross Blue Shield of Montana", "plan_name": "Traditional Network", "standard_charge_percentage": 75, "methodology": "percent of total billed charges", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Blue Cross Blue Shield of Montana", "plan_name": "POS Network", "standard_charge_percentage": 75, "methodology": "percent of total billed charges", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Blue Cross Blue Shield of Montana", "plan_name": "Closed Plan Network", "standard_charge_percentage": 75, "methodology": "percent of total billed charges", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Blue Cross Blue Shield of Montana", "plan_name": "Retail HMO POS Network", "standard_charge_percentage": 75, "methodology": "percent of total billed charges", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Blue Cross Blue Shield of Montana", "plan_name": "Blue Options Network", "standard_charge_percentage": 75, "methodology": "percent of total billed charges", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "PacificSource Health Plans", "plan_name": "Medicare Advantage", "standard_charge_percentage": 103, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" } ], "minimum": 83256.13, "maximum": 83256.13 } ] }, { "description": "Major Chest Procedures with CC", "code_information": [ { "code": "164", "type": "LOCAL" } ], "standard_charges": [ { "setting": "inpatient", "payers_information": [ { "payer_name": "Blue Cross Blue Shield of Montana", "plan_name": "Medicare Advantage", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "United Healthcare (UHC)", "plan_name": "Medicare Advantage", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "First Choice of the Midwest", "plan_name": "PPO", "standard_charge_percentage": 90, "methodology": "percent of total billed charges", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "United Healthcare (UHC)", "plan_name": "DSNP", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Employee Benefit Management Services (EBMS)", "plan_name": "EBMS SelectCare Network", "standard_charge_percentage": 80, "methodology": "percent of total billed charges", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Claritev fka MultiPlan", "plan_name": "PPO", "standard_charge_percentage": 75, "methodology": "percent of total billed charges", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Allegiance Provider Direct", "plan_name": "Medicare", "standard_charge_percentage": 229.99999999999997, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Medicare (CMS)", "plan_name": "Medicare", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Medica Insurance Company", "plan_name": "Medicare Cost", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "First Choice Health Network fka Health InfoNet", "plan_name": "Commercial", "standard_charge_percentage": 85, "methodology": "percent of total billed charges", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Indian Health Services (IHS)", "plan_name": "Commercial", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "First Choice Health Network fka Health InfoNet", "plan_name": "Workers Compensation", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Humana Insurance Company", "plan_name": "Humana Medicare Advantage HMO", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Humana Insurance Company", "plan_name": "Humana Medicare Advantage PPO", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Humana Insurance Company", "plan_name": "Humana Medicare Advantage PFFS", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Allegiance Provider Direct", "plan_name": "State of Montana Employee Benefit Plan (Self-Funded)", "standard_charge_percentage": 229.99999999999997, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Allegiance Provider Direct", "plan_name": "Montana Municipal Interlocal Authority (MMIA)", "standard_charge_percentage": 229.99999999999997, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Allegiance Provider Direct", "plan_name": "Montana Association of Counties (MACo)", "standard_charge_percentage": 229.99999999999997, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "First Choice Health Network fka Health InfoNet", "plan_name": "Medicare Advantage", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "TriWest Healthcare Alliance Corporation", "plan_name": "TRICARE Prime", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "TriWest Healthcare Alliance Corporation", "plan_name": "TRICARE Select", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Blue Cross Blue Shield of Montana", "plan_name": "HealthLink Network", "standard_charge_percentage": 75, "methodology": "percent of total billed charges", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Blue Cross Blue Shield of Montana", "plan_name": "Traditional Network", "standard_charge_percentage": 75, "methodology": "percent of total billed charges", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Blue Cross Blue Shield of Montana", "plan_name": "POS Network", "standard_charge_percentage": 75, "methodology": "percent of total billed charges", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Blue Cross Blue Shield of Montana", "plan_name": "Closed Plan Network", "standard_charge_percentage": 75, "methodology": "percent of total billed charges", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Blue Cross Blue Shield of Montana", "plan_name": "Retail HMO POS Network", "standard_charge_percentage": 75, "methodology": "percent of total billed charges", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Blue Cross Blue Shield of Montana", "plan_name": "Blue Options Network", "standard_charge_percentage": 75, "methodology": "percent of total billed charges", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "PacificSource Health Plans", "plan_name": "Medicare Advantage", "standard_charge_percentage": 103, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" } ] } ] }, { "description": "Major Chest Procedures without CC/MCC", "code_information": [ { "code": "165", "type": "LOCAL" } ], "standard_charges": [ { "setting": "inpatient", "payers_information": [ { "payer_name": "Blue Cross Blue Shield of Montana", "plan_name": "Medicare Advantage", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "United Healthcare (UHC)", "plan_name": "Medicare Advantage", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "First Choice of the Midwest", "plan_name": "PPO", "standard_charge_percentage": 90, "methodology": "percent of total billed charges", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "United Healthcare (UHC)", "plan_name": "DSNP", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Employee Benefit Management Services (EBMS)", "plan_name": "EBMS SelectCare Network", "standard_charge_percentage": 80, "methodology": "percent of total billed charges", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Claritev fka MultiPlan", "plan_name": "PPO", "standard_charge_percentage": 75, "methodology": "percent of total billed charges", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Allegiance Provider Direct", "plan_name": "Medicare", "standard_charge_percentage": 229.99999999999997, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Medicare (CMS)", "plan_name": "Medicare", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Medica Insurance Company", "plan_name": "Medicare Cost", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "First Choice Health Network fka Health InfoNet", "plan_name": "Commercial", "standard_charge_percentage": 85, "methodology": "percent of total billed charges", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Indian Health Services (IHS)", "plan_name": "Commercial", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "First Choice Health Network fka Health InfoNet", "plan_name": "Workers Compensation", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Humana Insurance Company", "plan_name": "Humana Medicare Advantage HMO", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Humana Insurance Company", "plan_name": "Humana Medicare Advantage PPO", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Humana Insurance Company", "plan_name": "Humana Medicare Advantage PFFS", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Allegiance Provider Direct", "plan_name": "State of Montana Employee Benefit Plan (Self-Funded)", "standard_charge_percentage": 229.99999999999997, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Allegiance Provider Direct", "plan_name": "Montana Municipal Interlocal Authority (MMIA)", "standard_charge_percentage": 229.99999999999997, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Allegiance Provider Direct", "plan_name": "Montana Association of Counties (MACo)", "standard_charge_percentage": 229.99999999999997, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "First Choice Health Network fka Health InfoNet", "plan_name": "Medicare Advantage", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "TriWest Healthcare Alliance Corporation", "plan_name": "TRICARE Prime", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "TriWest Healthcare Alliance Corporation", "plan_name": "TRICARE Select", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Blue Cross Blue Shield of Montana", "plan_name": "HealthLink Network", "standard_charge_percentage": 75, "methodology": "percent of total billed charges", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Blue Cross Blue Shield of Montana", "plan_name": "Traditional Network", "standard_charge_percentage": 75, "methodology": "percent of total billed charges", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Blue Cross Blue Shield of Montana", "plan_name": "POS Network", "standard_charge_percentage": 75, "methodology": "percent of total billed charges", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Blue Cross Blue Shield of Montana", "plan_name": "Closed Plan Network", "standard_charge_percentage": 75, "methodology": "percent of total billed charges", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Blue Cross Blue Shield of Montana", "plan_name": "Retail HMO POS Network", "standard_charge_percentage": 75, "methodology": "percent of total billed charges", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Blue Cross Blue Shield of Montana", "plan_name": "Blue Options Network", "standard_charge_percentage": 75, "methodology": "percent of total billed charges", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "PacificSource Health Plans", "plan_name": "Medicare Advantage", "standard_charge_percentage": 103, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" } ] } ] }, { "description": "Other Respiratory System O.R. Procedures with MCC", "code_information": [ { "code": "166", "type": "LOCAL" } ], "standard_charges": [ { "setting": "inpatient", "payers_information": [ { "payer_name": "Blue Cross Blue Shield of Montana", "plan_name": "Medicare Advantage", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "United Healthcare (UHC)", "plan_name": "Medicare Advantage", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "First Choice of the Midwest", "plan_name": "PPO", "standard_charge_percentage": 90, "methodology": "percent of total billed charges", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "United Healthcare (UHC)", "plan_name": "DSNP", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Employee Benefit Management Services (EBMS)", "plan_name": "EBMS SelectCare Network", "standard_charge_percentage": 80, "methodology": "percent of total billed charges", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Claritev fka MultiPlan", "plan_name": "PPO", "standard_charge_percentage": 75, "methodology": "percent of total billed charges", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Allegiance Provider Direct", "plan_name": "Medicare", "standard_charge_percentage": 229.99999999999997, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Medicare (CMS)", "plan_name": "Medicare", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Medica Insurance Company", "plan_name": "Medicare Cost", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "First Choice Health Network fka Health InfoNet", "plan_name": "Commercial", "standard_charge_percentage": 85, "methodology": "percent of total billed charges", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Indian Health Services (IHS)", "plan_name": "Commercial", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "First Choice Health Network fka Health InfoNet", "plan_name": "Workers Compensation", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Humana Insurance Company", "plan_name": "Humana Medicare Advantage HMO", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Humana Insurance Company", "plan_name": "Humana Medicare Advantage PPO", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Humana Insurance Company", "plan_name": "Humana Medicare Advantage PFFS", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Allegiance Provider Direct", "plan_name": "State of Montana Employee Benefit Plan (Self-Funded)", "standard_charge_percentage": 229.99999999999997, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Allegiance Provider Direct", "plan_name": "Montana Municipal Interlocal Authority (MMIA)", "standard_charge_percentage": 229.99999999999997, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Allegiance Provider Direct", "plan_name": "Montana Association of Counties (MACo)", "standard_charge_percentage": 229.99999999999997, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "First Choice Health Network fka Health InfoNet", "plan_name": "Medicare Advantage", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "TriWest Healthcare Alliance Corporation", "plan_name": "TRICARE Prime", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "TriWest Healthcare Alliance Corporation", "plan_name": "TRICARE Select", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Blue Cross Blue Shield of Montana", "plan_name": "HealthLink Network", "standard_charge_percentage": 75, "methodology": "percent of total billed charges", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Blue Cross Blue Shield of Montana", "plan_name": "Traditional Network", "standard_charge_percentage": 75, "methodology": "percent of total billed charges", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Blue Cross Blue Shield of Montana", "plan_name": "POS Network", "standard_charge_percentage": 75, "methodology": "percent of total billed charges", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Blue Cross Blue Shield of Montana", "plan_name": "Closed Plan Network", "standard_charge_percentage": 75, "methodology": "percent of total billed charges", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Blue Cross Blue Shield of Montana", "plan_name": "Retail HMO POS Network", "standard_charge_percentage": 75, "methodology": "percent of total billed charges", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Blue Cross Blue Shield of Montana", "plan_name": "Blue Options Network", "standard_charge_percentage": 75, "methodology": "percent of total billed charges", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "PacificSource Health Plans", "plan_name": "Medicare Advantage", "standard_charge_percentage": 103, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" } ] } ] }, { "description": "Other Respiratory System O.R. Procedures with CC", "code_information": [ { "code": "167", "type": "LOCAL" } ], "standard_charges": [ { "setting": "inpatient", "payers_information": [ { "payer_name": "Blue Cross Blue Shield of Montana", "plan_name": "Medicare Advantage", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "United Healthcare (UHC)", "plan_name": "Medicare Advantage", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "First Choice of the Midwest", "plan_name": "PPO", "standard_charge_percentage": 90, "methodology": "percent of total billed charges", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "United Healthcare (UHC)", "plan_name": "DSNP", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Employee Benefit Management Services (EBMS)", "plan_name": "EBMS SelectCare Network", "standard_charge_percentage": 80, "methodology": "percent of total billed charges", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Claritev fka MultiPlan", "plan_name": "PPO", "standard_charge_percentage": 75, "methodology": "percent of total billed charges", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Allegiance Provider Direct", "plan_name": "Medicare", "standard_charge_percentage": 229.99999999999997, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Medicare (CMS)", "plan_name": "Medicare", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Medica Insurance Company", "plan_name": "Medicare Cost", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "First Choice Health Network fka Health InfoNet", "plan_name": "Commercial", "standard_charge_percentage": 85, "methodology": "percent of total billed charges", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Indian Health Services (IHS)", "plan_name": "Commercial", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "First Choice Health Network fka Health InfoNet", "plan_name": "Workers Compensation", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Humana Insurance Company", "plan_name": "Humana Medicare Advantage HMO", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Humana Insurance Company", "plan_name": "Humana Medicare Advantage PPO", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Humana Insurance Company", "plan_name": "Humana Medicare Advantage PFFS", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Allegiance Provider Direct", "plan_name": "State of Montana Employee Benefit Plan (Self-Funded)", "standard_charge_percentage": 229.99999999999997, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Allegiance Provider Direct", "plan_name": "Montana Municipal Interlocal Authority (MMIA)", "standard_charge_percentage": 229.99999999999997, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Allegiance Provider Direct", "plan_name": "Montana Association of Counties (MACo)", "standard_charge_percentage": 229.99999999999997, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "First Choice Health Network fka Health InfoNet", "plan_name": "Medicare Advantage", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "TriWest Healthcare Alliance Corporation", "plan_name": "TRICARE Prime", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "TriWest Healthcare Alliance Corporation", "plan_name": "TRICARE Select", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Blue Cross Blue Shield of Montana", "plan_name": "HealthLink Network", "standard_charge_percentage": 75, "methodology": "percent of total billed charges", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Blue Cross Blue Shield of Montana", "plan_name": "Traditional Network", "standard_charge_percentage": 75, "methodology": "percent of total billed charges", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Blue Cross Blue Shield of Montana", "plan_name": "POS Network", "standard_charge_percentage": 75, "methodology": "percent of total billed charges", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Blue Cross Blue Shield of Montana", "plan_name": "Closed Plan Network", "standard_charge_percentage": 75, "methodology": "percent of total billed charges", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Blue Cross Blue Shield of Montana", "plan_name": "Retail HMO POS Network", "standard_charge_percentage": 75, "methodology": "percent of total billed charges", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Blue Cross Blue Shield of Montana", "plan_name": "Blue Options Network", "standard_charge_percentage": 75, "methodology": "percent of total billed charges", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "PacificSource Health Plans", "plan_name": "Medicare Advantage", "standard_charge_percentage": 103, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" } ] } ] }, { "description": "Other Respiratory System O.R. Procedures without CC/MCC", "code_information": [ { "code": "168", "type": "LOCAL" } ], "standard_charges": [ { "setting": "inpatient", "payers_information": [ { "payer_name": "Blue Cross Blue Shield of Montana", "plan_name": "Medicare Advantage", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "United Healthcare (UHC)", "plan_name": "Medicare Advantage", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "First Choice of the Midwest", "plan_name": "PPO", "standard_charge_percentage": 90, "methodology": "percent of total billed charges", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "United Healthcare (UHC)", "plan_name": "DSNP", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Employee Benefit Management Services (EBMS)", "plan_name": "EBMS SelectCare Network", "standard_charge_percentage": 80, "methodology": "percent of total billed charges", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Claritev fka MultiPlan", "plan_name": "PPO", "standard_charge_percentage": 75, "methodology": "percent of total billed charges", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Allegiance Provider Direct", "plan_name": "Medicare", "standard_charge_percentage": 229.99999999999997, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Medicare (CMS)", "plan_name": "Medicare", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Medica Insurance Company", "plan_name": "Medicare Cost", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "First Choice Health Network fka Health InfoNet", "plan_name": "Commercial", "standard_charge_percentage": 85, "methodology": "percent of total billed charges", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Indian Health Services (IHS)", "plan_name": "Commercial", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "First Choice Health Network fka Health InfoNet", "plan_name": "Workers Compensation", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Humana Insurance Company", "plan_name": "Humana Medicare Advantage HMO", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Humana Insurance Company", "plan_name": "Humana Medicare Advantage PPO", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Humana Insurance Company", "plan_name": "Humana Medicare Advantage PFFS", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Allegiance Provider Direct", "plan_name": "State of Montana Employee Benefit Plan (Self-Funded)", "standard_charge_percentage": 229.99999999999997, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Allegiance Provider Direct", "plan_name": "Montana Municipal Interlocal Authority (MMIA)", "standard_charge_percentage": 229.99999999999997, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Allegiance Provider Direct", "plan_name": "Montana Association of Counties (MACo)", "standard_charge_percentage": 229.99999999999997, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "First Choice Health Network fka Health InfoNet", "plan_name": "Medicare Advantage", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "TriWest Healthcare Alliance Corporation", "plan_name": "TRICARE Prime", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "TriWest Healthcare Alliance Corporation", "plan_name": "TRICARE Select", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Blue Cross Blue Shield of Montana", "plan_name": "HealthLink Network", "standard_charge_percentage": 75, "methodology": "percent of total billed charges", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Blue Cross Blue Shield of Montana", "plan_name": "Traditional Network", "standard_charge_percentage": 75, "methodology": "percent of total billed charges", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Blue Cross Blue Shield of Montana", "plan_name": "POS Network", "standard_charge_percentage": 75, "methodology": "percent of total billed charges", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Blue Cross Blue Shield of Montana", "plan_name": "Closed Plan Network", "standard_charge_percentage": 75, "methodology": "percent of total billed charges", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Blue Cross Blue Shield of Montana", "plan_name": "Retail HMO POS Network", "standard_charge_percentage": 75, "methodology": "percent of total billed charges", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Blue Cross Blue Shield of Montana", "plan_name": "Blue Options Network", "standard_charge_percentage": 75, "methodology": "percent of total billed charges", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "PacificSource Health Plans", "plan_name": "Medicare Advantage", "standard_charge_percentage": 103, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" } ] } ] }, { "description": "Ultrasound Accelerated and Other Thrombolysis with Principal Diagnosis Pulmonary Embolism", "code_information": [ { "code": "173", "type": "LOCAL" } ], "standard_charges": [ { "setting": "inpatient", "payers_information": [ { "payer_name": "Blue Cross Blue Shield of Montana", "plan_name": "Medicare Advantage", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "United Healthcare (UHC)", "plan_name": "Medicare Advantage", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "First Choice of the Midwest", "plan_name": "PPO", "standard_charge_percentage": 90, "methodology": "percent of total billed charges", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "United Healthcare (UHC)", "plan_name": "DSNP", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Employee Benefit Management Services (EBMS)", "plan_name": "EBMS SelectCare Network", "standard_charge_percentage": 80, "methodology": "percent of total billed charges", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Claritev fka MultiPlan", "plan_name": "PPO", "standard_charge_percentage": 75, "methodology": "percent of total billed charges", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Allegiance Provider Direct", "plan_name": "Medicare", "standard_charge_percentage": 229.99999999999997, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Medicare (CMS)", "plan_name": "Medicare", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Medica Insurance Company", "plan_name": "Medicare Cost", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "First Choice Health Network fka Health InfoNet", "plan_name": "Commercial", "standard_charge_percentage": 85, "methodology": "percent of total billed charges", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Indian Health Services (IHS)", "plan_name": "Commercial", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "First Choice Health Network fka Health InfoNet", "plan_name": "Workers Compensation", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Humana Insurance Company", "plan_name": "Humana Medicare Advantage HMO", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Humana Insurance Company", "plan_name": "Humana Medicare Advantage PPO", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Humana Insurance Company", "plan_name": "Humana Medicare Advantage PFFS", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Allegiance Provider Direct", "plan_name": "State of Montana Employee Benefit Plan (Self-Funded)", "standard_charge_percentage": 229.99999999999997, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Allegiance Provider Direct", "plan_name": "Montana Municipal Interlocal Authority (MMIA)", "standard_charge_percentage": 229.99999999999997, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Allegiance Provider Direct", "plan_name": "Montana Association of Counties (MACo)", "standard_charge_percentage": 229.99999999999997, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "First Choice Health Network fka Health InfoNet", "plan_name": "Medicare Advantage", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "TriWest Healthcare Alliance Corporation", "plan_name": "TRICARE Prime", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "TriWest Healthcare Alliance Corporation", "plan_name": "TRICARE Select", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Blue Cross Blue Shield of Montana", "plan_name": "HealthLink Network", "standard_charge_percentage": 75, "methodology": "percent of total billed charges", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Blue Cross Blue Shield of Montana", "plan_name": "Traditional Network", "standard_charge_percentage": 75, "methodology": "percent of total billed charges", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Blue Cross Blue Shield of Montana", "plan_name": "POS Network", "standard_charge_percentage": 75, "methodology": "percent of total billed charges", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Blue Cross Blue Shield of Montana", "plan_name": "Closed Plan Network", "standard_charge_percentage": 75, "methodology": "percent of total billed charges", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Blue Cross Blue Shield of Montana", "plan_name": "Retail HMO POS Network", "standard_charge_percentage": 75, "methodology": "percent of total billed charges", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Blue Cross Blue Shield of Montana", "plan_name": "Blue Options Network", "standard_charge_percentage": 75, "methodology": "percent of total billed charges", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "PacificSource Health Plans", "plan_name": "Medicare Advantage", "standard_charge_percentage": 103, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" } ] } ] }, { "description": "Pulmonary Embolism with MCC or Acute Cor Pulmonale", "code_information": [ { "code": "175", "type": "LOCAL" } ], "standard_charges": [ { "setting": "inpatient", "payers_information": [ { "payer_name": "Blue Cross Blue Shield of Montana", "plan_name": "Medicare Advantage", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "United Healthcare (UHC)", "plan_name": "Medicare Advantage", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "First Choice of the Midwest", "plan_name": "PPO", "standard_charge_percentage": 90, "methodology": "percent of total billed charges", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "United Healthcare (UHC)", "plan_name": "DSNP", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Employee Benefit Management Services (EBMS)", "plan_name": "EBMS SelectCare Network", "standard_charge_percentage": 80, "methodology": "percent of total billed charges", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Claritev fka MultiPlan", "plan_name": "PPO", "standard_charge_percentage": 75, "methodology": "percent of total billed charges", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Allegiance Provider Direct", "plan_name": "Medicare", "standard_charge_percentage": 229.99999999999997, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Medicare (CMS)", "plan_name": "Medicare", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Medica Insurance Company", "plan_name": "Medicare Cost", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "First Choice Health Network fka Health InfoNet", "plan_name": "Commercial", "standard_charge_percentage": 85, "methodology": "percent of total billed charges", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Indian Health Services (IHS)", "plan_name": "Commercial", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "First Choice Health Network fka Health InfoNet", "plan_name": "Workers Compensation", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Humana Insurance Company", "plan_name": "Humana Medicare Advantage HMO", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Humana Insurance Company", "plan_name": "Humana Medicare Advantage PPO", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Humana Insurance Company", "plan_name": "Humana Medicare Advantage PFFS", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Allegiance Provider Direct", "plan_name": "State of Montana Employee Benefit Plan (Self-Funded)", "standard_charge_percentage": 229.99999999999997, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Allegiance Provider Direct", "plan_name": "Montana Municipal Interlocal Authority (MMIA)", "standard_charge_percentage": 229.99999999999997, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Allegiance Provider Direct", "plan_name": "Montana Association of Counties (MACo)", "standard_charge_percentage": 229.99999999999997, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "First Choice Health Network fka Health InfoNet", "plan_name": "Medicare Advantage", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "TriWest Healthcare Alliance Corporation", "plan_name": "TRICARE Prime", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "TriWest Healthcare Alliance Corporation", "plan_name": "TRICARE Select", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Blue Cross Blue Shield of Montana", "plan_name": "HealthLink Network", "standard_charge_percentage": 75, "methodology": "percent of total billed charges", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Blue Cross Blue Shield of Montana", "plan_name": "Traditional Network", "standard_charge_percentage": 75, "methodology": "percent of total billed charges", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Blue Cross Blue Shield of Montana", "plan_name": "POS Network", "standard_charge_percentage": 75, "methodology": "percent of total billed charges", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Blue Cross Blue Shield of Montana", "plan_name": "Closed Plan Network", "standard_charge_percentage": 75, "methodology": "percent of total billed charges", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Blue Cross Blue Shield of Montana", "plan_name": "Retail HMO POS Network", "standard_charge_percentage": 75, "methodology": "percent of total billed charges", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Blue Cross Blue Shield of Montana", "plan_name": "Blue Options Network", "standard_charge_percentage": 75, "methodology": "percent of total billed charges", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "PacificSource Health Plans", "plan_name": "Medicare Advantage", "standard_charge_percentage": 103, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" } ] } ] }, { "description": "Pulmonary Embolism without MCC", "code_information": [ { "code": "176", "type": "LOCAL" } ], "standard_charges": [ { "setting": "inpatient", "payers_information": [ { "payer_name": "Blue Cross Blue Shield of Montana", "plan_name": "Medicare Advantage", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "United Healthcare (UHC)", "plan_name": "Medicare Advantage", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "First Choice of the Midwest", "plan_name": "PPO", "standard_charge_percentage": 90, "methodology": "percent of total billed charges", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "United Healthcare (UHC)", "plan_name": "DSNP", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Employee Benefit Management Services (EBMS)", "plan_name": "EBMS SelectCare Network", "standard_charge_percentage": 80, "methodology": "percent of total billed charges", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Claritev fka MultiPlan", "plan_name": "PPO", "standard_charge_percentage": 75, "methodology": "percent of total billed charges", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Allegiance Provider Direct", "plan_name": "Medicare", "standard_charge_percentage": 229.99999999999997, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Medicare (CMS)", "plan_name": "Medicare", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Medica Insurance Company", "plan_name": "Medicare Cost", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "First Choice Health Network fka Health InfoNet", "plan_name": "Commercial", "standard_charge_percentage": 85, "methodology": "percent of total billed charges", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Indian Health Services (IHS)", "plan_name": "Commercial", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "First Choice Health Network fka Health InfoNet", "plan_name": "Workers Compensation", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Humana Insurance Company", "plan_name": "Humana Medicare Advantage HMO", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Humana Insurance Company", "plan_name": "Humana Medicare Advantage PPO", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Humana Insurance Company", "plan_name": "Humana Medicare Advantage PFFS", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Allegiance Provider Direct", "plan_name": "State of Montana Employee Benefit Plan (Self-Funded)", "standard_charge_percentage": 229.99999999999997, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Allegiance Provider Direct", "plan_name": "Montana Municipal Interlocal Authority (MMIA)", "standard_charge_percentage": 229.99999999999997, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Allegiance Provider Direct", "plan_name": "Montana Association of Counties (MACo)", "standard_charge_percentage": 229.99999999999997, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "First Choice Health Network fka Health InfoNet", "plan_name": "Medicare Advantage", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "TriWest Healthcare Alliance Corporation", "plan_name": "TRICARE Prime", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "TriWest Healthcare Alliance Corporation", "plan_name": "TRICARE Select", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Blue Cross Blue Shield of Montana", "plan_name": "HealthLink Network", "standard_charge_percentage": 75, "methodology": "percent of total billed charges", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Blue Cross Blue Shield of Montana", "plan_name": "Traditional Network", "standard_charge_percentage": 75, "methodology": "percent of total billed charges", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Blue Cross Blue Shield of Montana", "plan_name": "POS Network", "standard_charge_percentage": 75, "methodology": "percent of total billed charges", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Blue Cross Blue Shield of Montana", "plan_name": "Closed Plan Network", "standard_charge_percentage": 75, "methodology": "percent of total billed charges", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Blue Cross Blue Shield of Montana", "plan_name": "Retail HMO POS Network", "standard_charge_percentage": 75, "methodology": "percent of total billed charges", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Blue Cross Blue Shield of Montana", "plan_name": "Blue Options Network", "standard_charge_percentage": 75, "methodology": "percent of total billed charges", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "PacificSource Health Plans", "plan_name": "Medicare Advantage", "standard_charge_percentage": 103, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" } ] } ] }, { "description": "Respiratory Infections and Inflammations with MCC*", "code_information": [ { "code": "177", "type": "LOCAL" } ], "standard_charges": [ { "setting": "inpatient", "payers_information": [ { "payer_name": "Blue Cross Blue Shield of Montana", "plan_name": "Medicare Advantage", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "United Healthcare (UHC)", "plan_name": "Medicare Advantage", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "First Choice of the Midwest", "plan_name": "PPO", "standard_charge_percentage": 90, "methodology": "percent of total billed charges", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "United Healthcare (UHC)", "plan_name": "DSNP", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Employee Benefit Management Services (EBMS)", "plan_name": "EBMS SelectCare Network", "standard_charge_percentage": 80, "methodology": "percent of total billed charges", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Claritev fka MultiPlan", "plan_name": "PPO", "standard_charge_percentage": 75, "methodology": "percent of total billed charges", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Allegiance Provider Direct", "plan_name": "Medicare", "standard_charge_percentage": 229.99999999999997, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Medicare (CMS)", "plan_name": "Medicare", "standard_charge_percentage": 100, "methodology": "fee schedule", "median_amount": 38443.88, "10th_percentile": 38443.88, "90th_percentile": 38443.88, "count": "1 through 10" }, { "payer_name": "Medica Insurance Company", "plan_name": "Medicare Cost", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "First Choice Health Network fka Health InfoNet", "plan_name": "Commercial", "standard_charge_percentage": 85, "methodology": "percent of total billed charges", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Indian Health Services (IHS)", "plan_name": "Commercial", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "First Choice Health Network fka Health InfoNet", "plan_name": "Workers Compensation", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Humana Insurance Company", "plan_name": "Humana Medicare Advantage HMO", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Humana Insurance Company", "plan_name": "Humana Medicare Advantage PPO", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Humana Insurance Company", "plan_name": "Humana Medicare Advantage PFFS", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Allegiance Provider Direct", "plan_name": "State of Montana Employee Benefit Plan (Self-Funded)", "standard_charge_percentage": 229.99999999999997, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Allegiance Provider Direct", "plan_name": "Montana Municipal Interlocal Authority (MMIA)", "standard_charge_percentage": 229.99999999999997, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Allegiance Provider Direct", "plan_name": "Montana Association of Counties (MACo)", "standard_charge_percentage": 229.99999999999997, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "First Choice Health Network fka Health InfoNet", "plan_name": "Medicare Advantage", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "TriWest Healthcare Alliance Corporation", "plan_name": "TRICARE Prime", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "TriWest Healthcare Alliance Corporation", "plan_name": "TRICARE Select", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Blue Cross Blue Shield of Montana", "plan_name": "HealthLink Network", "standard_charge_percentage": 75, "methodology": "percent of total billed charges", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Blue Cross Blue Shield of Montana", "plan_name": "Traditional Network", "standard_charge_percentage": 75, "methodology": "percent of total billed charges", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Blue Cross Blue Shield of Montana", "plan_name": "POS Network", "standard_charge_percentage": 75, "methodology": "percent of total billed charges", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Blue Cross Blue Shield of Montana", "plan_name": "Closed Plan Network", "standard_charge_percentage": 75, "methodology": "percent of total billed charges", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Blue Cross Blue Shield of Montana", "plan_name": "Retail HMO POS Network", "standard_charge_percentage": 75, "methodology": "percent of total billed charges", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Blue Cross Blue Shield of Montana", "plan_name": "Blue Options Network", "standard_charge_percentage": 75, "methodology": "percent of total billed charges", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "PacificSource Health Plans", "plan_name": "Medicare Advantage", "standard_charge_percentage": 103, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" } ], "minimum": 38443.88, "maximum": 38443.88 } ] }, { "description": "Respiratory Infections and Inflammations with CC*", "code_information": [ { "code": "178", "type": "LOCAL" } ], "standard_charges": [ { "setting": "inpatient", "payers_information": [ { "payer_name": "Blue Cross Blue Shield of Montana", "plan_name": "Medicare Advantage", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "United Healthcare (UHC)", "plan_name": "Medicare Advantage", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "First Choice of the Midwest", "plan_name": "PPO", "standard_charge_percentage": 90, "methodology": "percent of total billed charges", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "United Healthcare (UHC)", "plan_name": "DSNP", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Employee Benefit Management Services (EBMS)", "plan_name": "EBMS SelectCare Network", "standard_charge_percentage": 80, "methodology": "percent of total billed charges", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Claritev fka MultiPlan", "plan_name": "PPO", "standard_charge_percentage": 75, "methodology": "percent of total billed charges", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Allegiance Provider Direct", "plan_name": "Medicare", "standard_charge_percentage": 229.99999999999997, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Medicare (CMS)", "plan_name": "Medicare", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Medica Insurance Company", "plan_name": "Medicare Cost", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "First Choice Health Network fka Health InfoNet", "plan_name": "Commercial", "standard_charge_percentage": 85, "methodology": "percent of total billed charges", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Indian Health Services (IHS)", "plan_name": "Commercial", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "First Choice Health Network fka Health InfoNet", "plan_name": "Workers Compensation", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Humana Insurance Company", "plan_name": "Humana Medicare Advantage HMO", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Humana Insurance Company", "plan_name": "Humana Medicare Advantage PPO", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Humana Insurance Company", "plan_name": "Humana Medicare Advantage PFFS", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Allegiance Provider Direct", "plan_name": "State of Montana Employee Benefit Plan (Self-Funded)", "standard_charge_percentage": 229.99999999999997, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Allegiance Provider Direct", "plan_name": "Montana Municipal Interlocal Authority (MMIA)", "standard_charge_percentage": 229.99999999999997, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Allegiance Provider Direct", "plan_name": "Montana Association of Counties (MACo)", "standard_charge_percentage": 229.99999999999997, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "First Choice Health Network fka Health InfoNet", "plan_name": "Medicare Advantage", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "TriWest Healthcare Alliance Corporation", "plan_name": "TRICARE Prime", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "TriWest Healthcare Alliance Corporation", "plan_name": "TRICARE Select", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Blue Cross Blue Shield of Montana", "plan_name": "HealthLink Network", "standard_charge_percentage": 75, "methodology": "percent of total billed charges", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Blue Cross Blue Shield of Montana", "plan_name": "Traditional Network", "standard_charge_percentage": 75, "methodology": "percent of total billed charges", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Blue Cross Blue Shield of Montana", "plan_name": "POS Network", "standard_charge_percentage": 75, "methodology": "percent of total billed charges", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Blue Cross Blue Shield of Montana", "plan_name": "Closed Plan Network", "standard_charge_percentage": 75, "methodology": "percent of total billed charges", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Blue Cross Blue Shield of Montana", "plan_name": "Retail HMO POS Network", "standard_charge_percentage": 75, "methodology": "percent of total billed charges", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Blue Cross Blue Shield of Montana", "plan_name": "Blue Options Network", "standard_charge_percentage": 75, "methodology": "percent of total billed charges", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "PacificSource Health Plans", "plan_name": "Medicare Advantage", "standard_charge_percentage": 103, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" } ] } ] }, { "description": "Respiratory Infections and Inflammations without CC/MCC*", "code_information": [ { "code": "179", "type": "LOCAL" } ], "standard_charges": [ { "setting": "inpatient", "payers_information": [ { "payer_name": "Blue Cross Blue Shield of Montana", "plan_name": "Medicare Advantage", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "United Healthcare (UHC)", "plan_name": "Medicare Advantage", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "First Choice of the Midwest", "plan_name": "PPO", "standard_charge_percentage": 90, "methodology": "percent of total billed charges", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "United Healthcare (UHC)", "plan_name": "DSNP", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Employee Benefit Management Services (EBMS)", "plan_name": "EBMS SelectCare Network", "standard_charge_percentage": 80, "methodology": "percent of total billed charges", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Claritev fka MultiPlan", "plan_name": "PPO", "standard_charge_percentage": 75, "methodology": "percent of total billed charges", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Allegiance Provider Direct", "plan_name": "Medicare", "standard_charge_percentage": 229.99999999999997, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Medicare (CMS)", "plan_name": "Medicare", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Medica Insurance Company", "plan_name": "Medicare Cost", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "First Choice Health Network fka Health InfoNet", "plan_name": "Commercial", "standard_charge_percentage": 85, "methodology": "percent of total billed charges", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Indian Health Services (IHS)", "plan_name": "Commercial", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "First Choice Health Network fka Health InfoNet", "plan_name": "Workers Compensation", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Humana Insurance Company", "plan_name": "Humana Medicare Advantage HMO", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Humana Insurance Company", "plan_name": "Humana Medicare Advantage PPO", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Humana Insurance Company", "plan_name": "Humana Medicare Advantage PFFS", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Allegiance Provider Direct", "plan_name": "State of Montana Employee Benefit Plan (Self-Funded)", "standard_charge_percentage": 229.99999999999997, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Allegiance Provider Direct", "plan_name": "Montana Municipal Interlocal Authority (MMIA)", "standard_charge_percentage": 229.99999999999997, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Allegiance Provider Direct", "plan_name": "Montana Association of Counties (MACo)", "standard_charge_percentage": 229.99999999999997, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "First Choice Health Network fka Health InfoNet", "plan_name": "Medicare Advantage", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "TriWest Healthcare Alliance Corporation", "plan_name": "TRICARE Prime", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "TriWest Healthcare Alliance Corporation", "plan_name": "TRICARE Select", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Blue Cross Blue Shield of Montana", "plan_name": "HealthLink Network", "standard_charge_percentage": 75, "methodology": "percent of total billed charges", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Blue Cross Blue Shield of Montana", "plan_name": "Traditional Network", "standard_charge_percentage": 75, "methodology": "percent of total billed charges", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Blue Cross Blue Shield of Montana", "plan_name": "POS Network", "standard_charge_percentage": 75, "methodology": "percent of total billed charges", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Blue Cross Blue Shield of Montana", "plan_name": "Closed Plan Network", "standard_charge_percentage": 75, "methodology": "percent of total billed charges", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Blue Cross Blue Shield of Montana", "plan_name": "Retail HMO POS Network", "standard_charge_percentage": 75, "methodology": "percent of total billed charges", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Blue Cross Blue Shield of Montana", "plan_name": "Blue Options Network", "standard_charge_percentage": 75, "methodology": "percent of total billed charges", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "PacificSource Health Plans", "plan_name": "Medicare Advantage", "standard_charge_percentage": 103, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" } ] } ] }, { "description": "Respiratory Neoplasms with MCC", "code_information": [ { "code": "180", "type": "LOCAL" } ], "standard_charges": [ { "setting": "inpatient", "payers_information": [ { "payer_name": "Blue Cross Blue Shield of Montana", "plan_name": "Medicare Advantage", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "United Healthcare (UHC)", "plan_name": "Medicare Advantage", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "First Choice of the Midwest", "plan_name": "PPO", "standard_charge_percentage": 90, "methodology": "percent of total billed charges", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "United Healthcare (UHC)", "plan_name": "DSNP", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Employee Benefit Management Services (EBMS)", "plan_name": "EBMS SelectCare Network", "standard_charge_percentage": 80, "methodology": "percent of total billed charges", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Claritev fka MultiPlan", "plan_name": "PPO", "standard_charge_percentage": 75, "methodology": "percent of total billed charges", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Allegiance Provider Direct", "plan_name": "Medicare", "standard_charge_percentage": 229.99999999999997, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Medicare (CMS)", "plan_name": "Medicare", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Medica Insurance Company", "plan_name": "Medicare Cost", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "First Choice Health Network fka Health InfoNet", "plan_name": "Commercial", "standard_charge_percentage": 85, "methodology": "percent of total billed charges", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Indian Health Services (IHS)", "plan_name": "Commercial", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "First Choice Health Network fka Health InfoNet", "plan_name": "Workers Compensation", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Humana Insurance Company", "plan_name": "Humana Medicare Advantage HMO", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Humana Insurance Company", "plan_name": "Humana Medicare Advantage PPO", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Humana Insurance Company", "plan_name": "Humana Medicare Advantage PFFS", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Allegiance Provider Direct", "plan_name": "State of Montana Employee Benefit Plan (Self-Funded)", "standard_charge_percentage": 229.99999999999997, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Allegiance Provider Direct", "plan_name": "Montana Municipal Interlocal Authority (MMIA)", "standard_charge_percentage": 229.99999999999997, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Allegiance Provider Direct", "plan_name": "Montana Association of Counties (MACo)", "standard_charge_percentage": 229.99999999999997, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "First Choice Health Network fka Health InfoNet", "plan_name": "Medicare Advantage", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "TriWest Healthcare Alliance Corporation", "plan_name": "TRICARE Prime", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "TriWest Healthcare Alliance Corporation", "plan_name": "TRICARE Select", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Blue Cross Blue Shield of Montana", "plan_name": "HealthLink Network", "standard_charge_percentage": 75, "methodology": "percent of total billed charges", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Blue Cross Blue Shield of Montana", "plan_name": "Traditional Network", "standard_charge_percentage": 75, "methodology": "percent of total billed charges", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Blue Cross Blue Shield of Montana", "plan_name": "POS Network", "standard_charge_percentage": 75, "methodology": "percent of total billed charges", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Blue Cross Blue Shield of Montana", "plan_name": "Closed Plan Network", "standard_charge_percentage": 75, "methodology": "percent of total billed charges", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Blue Cross Blue Shield of Montana", "plan_name": "Retail HMO POS Network", "standard_charge_percentage": 75, "methodology": "percent of total billed charges", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Blue Cross Blue Shield of Montana", "plan_name": "Blue Options Network", "standard_charge_percentage": 75, "methodology": "percent of total billed charges", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "PacificSource Health Plans", "plan_name": "Medicare Advantage", "standard_charge_percentage": 103, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" } ] } ] }, { "description": "Respiratory Neoplasms with CC", "code_information": [ { "code": "181", "type": "LOCAL" } ], "standard_charges": [ { "setting": "inpatient", "payers_information": [ { "payer_name": "Blue Cross Blue Shield of Montana", "plan_name": "Medicare Advantage", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "United Healthcare (UHC)", "plan_name": "Medicare Advantage", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "First Choice of the Midwest", "plan_name": "PPO", "standard_charge_percentage": 90, "methodology": "percent of total billed charges", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "United Healthcare (UHC)", "plan_name": "DSNP", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Employee Benefit Management Services (EBMS)", "plan_name": "EBMS SelectCare Network", "standard_charge_percentage": 80, "methodology": "percent of total billed charges", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Claritev fka MultiPlan", "plan_name": "PPO", "standard_charge_percentage": 75, "methodology": "percent of total billed charges", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Allegiance Provider Direct", "plan_name": "Medicare", "standard_charge_percentage": 229.99999999999997, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Medicare (CMS)", "plan_name": "Medicare", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Medica Insurance Company", "plan_name": "Medicare Cost", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "First Choice Health Network fka Health InfoNet", "plan_name": "Commercial", "standard_charge_percentage": 85, "methodology": "percent of total billed charges", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Indian Health Services (IHS)", "plan_name": "Commercial", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "First Choice Health Network fka Health InfoNet", "plan_name": "Workers Compensation", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Humana Insurance Company", "plan_name": "Humana Medicare Advantage HMO", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Humana Insurance Company", "plan_name": "Humana Medicare Advantage PPO", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Humana Insurance Company", "plan_name": "Humana Medicare Advantage PFFS", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Allegiance Provider Direct", "plan_name": "State of Montana Employee Benefit Plan (Self-Funded)", "standard_charge_percentage": 229.99999999999997, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Allegiance Provider Direct", "plan_name": "Montana Municipal Interlocal Authority (MMIA)", "standard_charge_percentage": 229.99999999999997, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Allegiance Provider Direct", "plan_name": "Montana Association of Counties (MACo)", "standard_charge_percentage": 229.99999999999997, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "First Choice Health Network fka Health InfoNet", "plan_name": "Medicare Advantage", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "TriWest Healthcare Alliance Corporation", "plan_name": "TRICARE Prime", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "TriWest Healthcare Alliance Corporation", "plan_name": "TRICARE Select", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Blue Cross Blue Shield of Montana", "plan_name": "HealthLink Network", "standard_charge_percentage": 75, "methodology": "percent of total billed charges", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Blue Cross Blue Shield of Montana", "plan_name": "Traditional Network", "standard_charge_percentage": 75, "methodology": "percent of total billed charges", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Blue Cross Blue Shield of Montana", "plan_name": "POS Network", "standard_charge_percentage": 75, "methodology": "percent of total billed charges", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Blue Cross Blue Shield of Montana", "plan_name": "Closed Plan Network", "standard_charge_percentage": 75, "methodology": "percent of total billed charges", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Blue Cross Blue Shield of Montana", "plan_name": "Retail HMO POS Network", "standard_charge_percentage": 75, "methodology": "percent of total billed charges", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Blue Cross Blue Shield of Montana", "plan_name": "Blue Options Network", "standard_charge_percentage": 75, "methodology": "percent of total billed charges", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "PacificSource Health Plans", "plan_name": "Medicare Advantage", "standard_charge_percentage": 103, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" } ] } ] }, { "description": "Respiratory Neoplasms without CC/MCC", "code_information": [ { "code": "182", "type": "LOCAL" } ], "standard_charges": [ { "setting": "inpatient", "payers_information": [ { "payer_name": "Blue Cross Blue Shield of Montana", "plan_name": "Medicare Advantage", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "United Healthcare (UHC)", "plan_name": "Medicare Advantage", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "First Choice of the Midwest", "plan_name": "PPO", "standard_charge_percentage": 90, "methodology": "percent of total billed charges", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "United Healthcare (UHC)", "plan_name": "DSNP", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Employee Benefit Management Services (EBMS)", "plan_name": "EBMS SelectCare Network", "standard_charge_percentage": 80, "methodology": "percent of total billed charges", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Claritev fka MultiPlan", "plan_name": "PPO", "standard_charge_percentage": 75, "methodology": "percent of total billed charges", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Allegiance Provider Direct", "plan_name": "Medicare", "standard_charge_percentage": 229.99999999999997, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Medicare (CMS)", "plan_name": "Medicare", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Medica Insurance Company", "plan_name": "Medicare Cost", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Indian Health Services (IHS)", "plan_name": "Commercial", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Humana Insurance Company", "plan_name": "Humana Medicare Advantage HMO", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Humana Insurance Company", "plan_name": "Humana Medicare Advantage PPO", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Humana Insurance Company", "plan_name": "Humana Medicare Advantage PFFS", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "First Choice Health Network fka Health InfoNet", "plan_name": "Commercial", "standard_charge_percentage": 85, "methodology": "percent of total billed charges", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "First Choice Health Network fka Health InfoNet", "plan_name": "Workers Compensation", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Allegiance Provider Direct", "plan_name": "State of Montana Employee Benefit Plan (Self-Funded)", "standard_charge_percentage": 229.99999999999997, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Allegiance Provider Direct", "plan_name": "Montana Municipal Interlocal Authority (MMIA)", "standard_charge_percentage": 229.99999999999997, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Allegiance Provider Direct", "plan_name": "Montana Association of Counties (MACo)", "standard_charge_percentage": 229.99999999999997, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "First Choice Health Network fka Health InfoNet", "plan_name": "Medicare Advantage", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "TriWest Healthcare Alliance Corporation", "plan_name": "TRICARE Prime", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "TriWest Healthcare Alliance Corporation", "plan_name": "TRICARE Select", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Blue Cross Blue Shield of Montana", "plan_name": "HealthLink Network", "standard_charge_percentage": 75, "methodology": "percent of total billed charges", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Blue Cross Blue Shield of Montana", "plan_name": "Traditional Network", "standard_charge_percentage": 75, "methodology": "percent of total billed charges", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Blue Cross Blue Shield of Montana", "plan_name": "POS Network", "standard_charge_percentage": 75, "methodology": "percent of total billed charges", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Blue Cross Blue Shield of Montana", "plan_name": "Closed Plan Network", "standard_charge_percentage": 75, "methodology": "percent of total billed charges", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Blue Cross Blue Shield of Montana", "plan_name": "Retail HMO POS Network", "standard_charge_percentage": 75, "methodology": "percent of total billed charges", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Blue Cross Blue Shield of Montana", "plan_name": "Blue Options Network", "standard_charge_percentage": 75, "methodology": "percent of total billed charges", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "PacificSource Health Plans", "plan_name": "Medicare Advantage", "standard_charge_percentage": 103, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" } ] } ] }, { "description": "Major Chest Trauma with MCC", "code_information": [ { "code": "183", "type": "LOCAL" } ], "standard_charges": [ { "setting": "inpatient", "payers_information": [ { "payer_name": "Blue Cross Blue Shield of Montana", "plan_name": "Medicare Advantage", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "United Healthcare (UHC)", "plan_name": "Medicare Advantage", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "First Choice of the Midwest", "plan_name": "PPO", "standard_charge_percentage": 90, "methodology": "percent of total billed charges", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "United Healthcare (UHC)", "plan_name": "DSNP", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Employee Benefit Management Services (EBMS)", "plan_name": "EBMS SelectCare Network", "standard_charge_percentage": 80, "methodology": "percent of total billed charges", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Claritev fka MultiPlan", "plan_name": "PPO", "standard_charge_percentage": 75, "methodology": "percent of total billed charges", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Allegiance Provider Direct", "plan_name": "Medicare", "standard_charge_percentage": 229.99999999999997, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Medicare (CMS)", "plan_name": "Medicare", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Medica Insurance Company", "plan_name": "Medicare Cost", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Indian Health Services (IHS)", "plan_name": "Commercial", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Humana Insurance Company", "plan_name": "Humana Medicare Advantage HMO", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Humana Insurance Company", "plan_name": "Humana Medicare Advantage PPO", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Humana Insurance Company", "plan_name": "Humana Medicare Advantage PFFS", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "First Choice Health Network fka Health InfoNet", "plan_name": "Commercial", "standard_charge_percentage": 85, "methodology": "percent of total billed charges", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "First Choice Health Network fka Health InfoNet", "plan_name": "Workers Compensation", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Allegiance Provider Direct", "plan_name": "State of Montana Employee Benefit Plan (Self-Funded)", "standard_charge_percentage": 229.99999999999997, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Allegiance Provider Direct", "plan_name": "Montana Municipal Interlocal Authority (MMIA)", "standard_charge_percentage": 229.99999999999997, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Allegiance Provider Direct", "plan_name": "Montana Association of Counties (MACo)", "standard_charge_percentage": 229.99999999999997, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "First Choice Health Network fka Health InfoNet", "plan_name": "Medicare Advantage", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "TriWest Healthcare Alliance Corporation", "plan_name": "TRICARE Prime", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "TriWest Healthcare Alliance Corporation", "plan_name": "TRICARE Select", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Blue Cross Blue Shield of Montana", "plan_name": "HealthLink Network", "standard_charge_percentage": 75, "methodology": "percent of total billed charges", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Blue Cross Blue Shield of Montana", "plan_name": "Traditional Network", "standard_charge_percentage": 75, "methodology": "percent of total billed charges", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Blue Cross Blue Shield of Montana", "plan_name": "POS Network", "standard_charge_percentage": 75, "methodology": "percent of total billed charges", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Blue Cross Blue Shield of Montana", "plan_name": "Closed Plan Network", "standard_charge_percentage": 75, "methodology": "percent of total billed charges", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Blue Cross Blue Shield of Montana", "plan_name": "Retail HMO POS Network", "standard_charge_percentage": 75, "methodology": "percent of total billed charges", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Blue Cross Blue Shield of Montana", "plan_name": "Blue Options Network", "standard_charge_percentage": 75, "methodology": "percent of total billed charges", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "PacificSource Health Plans", "plan_name": "Medicare Advantage", "standard_charge_percentage": 103, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" } ] } ] }, { "description": "Major Chest Trauma with CC", "code_information": [ { "code": "184", "type": "LOCAL" } ], "standard_charges": [ { "setting": "inpatient", "payers_information": [ { "payer_name": "Blue Cross Blue Shield of Montana", "plan_name": "Medicare Advantage", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "United Healthcare (UHC)", "plan_name": "Medicare Advantage", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "First Choice of the Midwest", "plan_name": "PPO", "standard_charge_percentage": 90, "methodology": "percent of total billed charges", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "United Healthcare (UHC)", "plan_name": "DSNP", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Employee Benefit Management Services (EBMS)", "plan_name": "EBMS SelectCare Network", "standard_charge_percentage": 80, "methodology": "percent of total billed charges", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Claritev fka MultiPlan", "plan_name": "PPO", "standard_charge_percentage": 75, "methodology": "percent of total billed charges", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Allegiance Provider Direct", "plan_name": "Medicare", "standard_charge_percentage": 229.99999999999997, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Medicare (CMS)", "plan_name": "Medicare", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Medica Insurance Company", "plan_name": "Medicare Cost", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Indian Health Services (IHS)", "plan_name": "Commercial", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Humana Insurance Company", "plan_name": "Humana Medicare Advantage HMO", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Humana Insurance Company", "plan_name": "Humana Medicare Advantage PPO", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Humana Insurance Company", "plan_name": "Humana Medicare Advantage PFFS", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "First Choice Health Network fka Health InfoNet", "plan_name": "Commercial", "standard_charge_percentage": 85, "methodology": "percent of total billed charges", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "First Choice Health Network fka Health InfoNet", "plan_name": "Workers Compensation", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Allegiance Provider Direct", "plan_name": "State of Montana Employee Benefit Plan (Self-Funded)", "standard_charge_percentage": 229.99999999999997, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Allegiance Provider Direct", "plan_name": "Montana Municipal Interlocal Authority (MMIA)", "standard_charge_percentage": 229.99999999999997, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Allegiance Provider Direct", "plan_name": "Montana Association of Counties (MACo)", "standard_charge_percentage": 229.99999999999997, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "First Choice Health Network fka Health InfoNet", "plan_name": "Medicare Advantage", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "TriWest Healthcare Alliance Corporation", "plan_name": "TRICARE Prime", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "TriWest Healthcare Alliance Corporation", "plan_name": "TRICARE Select", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Blue Cross Blue Shield of Montana", "plan_name": "HealthLink Network", "standard_charge_percentage": 75, "methodology": "percent of total billed charges", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Blue Cross Blue Shield of Montana", "plan_name": "Traditional Network", "standard_charge_percentage": 75, "methodology": "percent of total billed charges", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Blue Cross Blue Shield of Montana", "plan_name": "POS Network", "standard_charge_percentage": 75, "methodology": "percent of total billed charges", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Blue Cross Blue Shield of Montana", "plan_name": "Closed Plan Network", "standard_charge_percentage": 75, "methodology": "percent of total billed charges", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Blue Cross Blue Shield of Montana", "plan_name": "Retail HMO POS Network", "standard_charge_percentage": 75, "methodology": "percent of total billed charges", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Blue Cross Blue Shield of Montana", "plan_name": "Blue Options Network", "standard_charge_percentage": 75, "methodology": "percent of total billed charges", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "PacificSource Health Plans", "plan_name": "Medicare Advantage", "standard_charge_percentage": 103, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" } ] } ] }, { "description": "Major Chest Trauma without CC/MCC", "code_information": [ { "code": "185", "type": "LOCAL" } ], "standard_charges": [ { "setting": "inpatient", "payers_information": [ { "payer_name": "Blue Cross Blue Shield of Montana", "plan_name": "Medicare Advantage", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "United Healthcare (UHC)", "plan_name": "Medicare Advantage", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "First Choice of the Midwest", "plan_name": "PPO", "standard_charge_percentage": 90, "methodology": "percent of total billed charges", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "United Healthcare (UHC)", "plan_name": "DSNP", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Employee Benefit Management Services (EBMS)", "plan_name": "EBMS SelectCare Network", "standard_charge_percentage": 80, "methodology": "percent of total billed charges", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Claritev fka MultiPlan", "plan_name": "PPO", "standard_charge_percentage": 75, "methodology": "percent of total billed charges", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Allegiance Provider Direct", "plan_name": "Medicare", "standard_charge_percentage": 229.99999999999997, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Medicare (CMS)", "plan_name": "Medicare", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Medica Insurance Company", "plan_name": "Medicare Cost", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Indian Health Services (IHS)", "plan_name": "Commercial", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Humana Insurance Company", "plan_name": "Humana Medicare Advantage HMO", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Humana Insurance Company", "plan_name": "Humana Medicare Advantage PPO", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Humana Insurance Company", "plan_name": "Humana Medicare Advantage PFFS", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "First Choice Health Network fka Health InfoNet", "plan_name": "Commercial", "standard_charge_percentage": 85, "methodology": "percent of total billed charges", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "First Choice Health Network fka Health InfoNet", "plan_name": "Workers Compensation", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Allegiance Provider Direct", "plan_name": "State of Montana Employee Benefit Plan (Self-Funded)", "standard_charge_percentage": 229.99999999999997, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Allegiance Provider Direct", "plan_name": "Montana Municipal Interlocal Authority (MMIA)", "standard_charge_percentage": 229.99999999999997, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Allegiance Provider Direct", "plan_name": "Montana Association of Counties (MACo)", "standard_charge_percentage": 229.99999999999997, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "First Choice Health Network fka Health InfoNet", "plan_name": "Medicare Advantage", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "TriWest Healthcare Alliance Corporation", "plan_name": "TRICARE Prime", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "TriWest Healthcare Alliance Corporation", "plan_name": "TRICARE Select", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Blue Cross Blue Shield of Montana", "plan_name": "HealthLink Network", "standard_charge_percentage": 75, "methodology": "percent of total billed charges", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Blue Cross Blue Shield of Montana", "plan_name": "Traditional Network", "standard_charge_percentage": 75, "methodology": "percent of total billed charges", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Blue Cross Blue Shield of Montana", "plan_name": "POS Network", "standard_charge_percentage": 75, "methodology": "percent of total billed charges", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Blue Cross Blue Shield of Montana", "plan_name": "Closed Plan Network", "standard_charge_percentage": 75, "methodology": "percent of total billed charges", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Blue Cross Blue Shield of Montana", "plan_name": "Retail HMO POS Network", "standard_charge_percentage": 75, "methodology": "percent of total billed charges", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Blue Cross Blue Shield of Montana", "plan_name": "Blue Options Network", "standard_charge_percentage": 75, "methodology": "percent of total billed charges", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "PacificSource Health Plans", "plan_name": "Medicare Advantage", "standard_charge_percentage": 103, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" } ] } ] }, { "description": "Pleural Effusion with MCC", "code_information": [ { "code": "186", "type": "LOCAL" } ], "standard_charges": [ { "setting": "inpatient", "payers_information": [ { "payer_name": "Blue Cross Blue Shield of Montana", "plan_name": "Medicare Advantage", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "United Healthcare (UHC)", "plan_name": "Medicare Advantage", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "First Choice of the Midwest", "plan_name": "PPO", "standard_charge_percentage": 90, "methodology": "percent of total billed charges", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "United Healthcare (UHC)", "plan_name": "DSNP", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Employee Benefit Management Services (EBMS)", "plan_name": "EBMS SelectCare Network", "standard_charge_percentage": 80, "methodology": "percent of total billed charges", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Claritev fka MultiPlan", "plan_name": "PPO", "standard_charge_percentage": 75, "methodology": "percent of total billed charges", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Allegiance Provider Direct", "plan_name": "Medicare", "standard_charge_percentage": 229.99999999999997, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Medicare (CMS)", "plan_name": "Medicare", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Medica Insurance Company", "plan_name": "Medicare Cost", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Indian Health Services (IHS)", "plan_name": "Commercial", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Humana Insurance Company", "plan_name": "Humana Medicare Advantage HMO", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Humana Insurance Company", "plan_name": "Humana Medicare Advantage PPO", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Humana Insurance Company", "plan_name": "Humana Medicare Advantage PFFS", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "First Choice Health Network fka Health InfoNet", "plan_name": "Commercial", "standard_charge_percentage": 85, "methodology": "percent of total billed charges", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "First Choice Health Network fka Health InfoNet", "plan_name": "Workers Compensation", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Allegiance Provider Direct", "plan_name": "State of Montana Employee Benefit Plan (Self-Funded)", "standard_charge_percentage": 229.99999999999997, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Allegiance Provider Direct", "plan_name": "Montana Municipal Interlocal Authority (MMIA)", "standard_charge_percentage": 229.99999999999997, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Allegiance Provider Direct", "plan_name": "Montana Association of Counties (MACo)", "standard_charge_percentage": 229.99999999999997, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "First Choice Health Network fka Health InfoNet", "plan_name": "Medicare Advantage", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "TriWest Healthcare Alliance Corporation", "plan_name": "TRICARE Prime", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "TriWest Healthcare Alliance Corporation", "plan_name": "TRICARE Select", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Blue Cross Blue Shield of Montana", "plan_name": "HealthLink Network", "standard_charge_percentage": 75, "methodology": "percent of total billed charges", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Blue Cross Blue Shield of Montana", "plan_name": "Traditional Network", "standard_charge_percentage": 75, "methodology": "percent of total billed charges", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Blue Cross Blue Shield of Montana", "plan_name": "POS Network", "standard_charge_percentage": 75, "methodology": "percent of total billed charges", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Blue Cross Blue Shield of Montana", "plan_name": "Closed Plan Network", "standard_charge_percentage": 75, "methodology": "percent of total billed charges", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Blue Cross Blue Shield of Montana", "plan_name": "Retail HMO POS Network", "standard_charge_percentage": 75, "methodology": "percent of total billed charges", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Blue Cross Blue Shield of Montana", "plan_name": "Blue Options Network", "standard_charge_percentage": 75, "methodology": "percent of total billed charges", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "PacificSource Health Plans", "plan_name": "Medicare Advantage", "standard_charge_percentage": 103, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" } ] } ] }, { "description": "Pleural Effusion with CC", "code_information": [ { "code": "187", "type": "LOCAL" } ], "standard_charges": [ { "setting": "inpatient", "payers_information": [ { "payer_name": "Blue Cross Blue Shield of Montana", "plan_name": "Medicare Advantage", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "United Healthcare (UHC)", "plan_name": "Medicare Advantage", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "First Choice of the Midwest", "plan_name": "PPO", "standard_charge_percentage": 90, "methodology": "percent of total billed charges", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "United Healthcare (UHC)", "plan_name": "DSNP", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Employee Benefit Management Services (EBMS)", "plan_name": "EBMS SelectCare Network", "standard_charge_percentage": 80, "methodology": "percent of total billed charges", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Claritev fka MultiPlan", "plan_name": "PPO", "standard_charge_percentage": 75, "methodology": "percent of total billed charges", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Allegiance Provider Direct", "plan_name": "Medicare", "standard_charge_percentage": 229.99999999999997, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Medicare (CMS)", "plan_name": "Medicare", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Medica Insurance Company", "plan_name": "Medicare Cost", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Indian Health Services (IHS)", "plan_name": "Commercial", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Humana Insurance Company", "plan_name": "Humana Medicare Advantage HMO", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Humana Insurance Company", "plan_name": "Humana Medicare Advantage PPO", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Humana Insurance Company", "plan_name": "Humana Medicare Advantage PFFS", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "First Choice Health Network fka Health InfoNet", "plan_name": "Commercial", "standard_charge_percentage": 85, "methodology": "percent of total billed charges", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "First Choice Health Network fka Health InfoNet", "plan_name": "Workers Compensation", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Allegiance Provider Direct", "plan_name": "State of Montana Employee Benefit Plan (Self-Funded)", "standard_charge_percentage": 229.99999999999997, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Allegiance Provider Direct", "plan_name": "Montana Municipal Interlocal Authority (MMIA)", "standard_charge_percentage": 229.99999999999997, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Allegiance Provider Direct", "plan_name": "Montana Association of Counties (MACo)", "standard_charge_percentage": 229.99999999999997, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "First Choice Health Network fka Health InfoNet", "plan_name": "Medicare Advantage", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "TriWest Healthcare Alliance Corporation", "plan_name": "TRICARE Prime", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "TriWest Healthcare Alliance Corporation", "plan_name": "TRICARE Select", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Blue Cross Blue Shield of Montana", "plan_name": "HealthLink Network", "standard_charge_percentage": 75, "methodology": "percent of total billed charges", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Blue Cross Blue Shield of Montana", "plan_name": "Traditional Network", "standard_charge_percentage": 75, "methodology": "percent of total billed charges", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Blue Cross Blue Shield of Montana", "plan_name": "POS Network", "standard_charge_percentage": 75, "methodology": "percent of total billed charges", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Blue Cross Blue Shield of Montana", "plan_name": "Closed Plan Network", "standard_charge_percentage": 75, "methodology": "percent of total billed charges", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Blue Cross Blue Shield of Montana", "plan_name": "Retail HMO POS Network", "standard_charge_percentage": 75, "methodology": "percent of total billed charges", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Blue Cross Blue Shield of Montana", "plan_name": "Blue Options Network", "standard_charge_percentage": 75, "methodology": "percent of total billed charges", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "PacificSource Health Plans", "plan_name": "Medicare Advantage", "standard_charge_percentage": 103, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" } ] } ] }, { "description": "Pleural Effusion without CC/MCC", "code_information": [ { "code": "188", "type": "LOCAL" } ], "standard_charges": [ { "setting": "inpatient", "payers_information": [ { "payer_name": "Blue Cross Blue Shield of Montana", "plan_name": "Medicare Advantage", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "United Healthcare (UHC)", "plan_name": "Medicare Advantage", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "First Choice of the Midwest", "plan_name": "PPO", "standard_charge_percentage": 90, "methodology": "percent of total billed charges", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "United Healthcare (UHC)", "plan_name": "DSNP", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Employee Benefit Management Services (EBMS)", "plan_name": "EBMS SelectCare Network", "standard_charge_percentage": 80, "methodology": "percent of total billed charges", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Claritev fka MultiPlan", "plan_name": "PPO", "standard_charge_percentage": 75, "methodology": "percent of total billed charges", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Allegiance Provider Direct", "plan_name": "Medicare", "standard_charge_percentage": 229.99999999999997, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Medicare (CMS)", "plan_name": "Medicare", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Medica Insurance Company", "plan_name": "Medicare Cost", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Indian Health Services (IHS)", "plan_name": "Commercial", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Humana Insurance Company", "plan_name": "Humana Medicare Advantage HMO", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Humana Insurance Company", "plan_name": "Humana Medicare Advantage PPO", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Humana Insurance Company", "plan_name": "Humana Medicare Advantage PFFS", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "First Choice Health Network fka Health InfoNet", "plan_name": "Commercial", "standard_charge_percentage": 85, "methodology": "percent of total billed charges", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "First Choice Health Network fka Health InfoNet", "plan_name": "Workers Compensation", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Allegiance Provider Direct", "plan_name": "State of Montana Employee Benefit Plan (Self-Funded)", "standard_charge_percentage": 229.99999999999997, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Allegiance Provider Direct", "plan_name": "Montana Municipal Interlocal Authority (MMIA)", "standard_charge_percentage": 229.99999999999997, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Allegiance Provider Direct", "plan_name": "Montana Association of Counties (MACo)", "standard_charge_percentage": 229.99999999999997, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "First Choice Health Network fka Health InfoNet", "plan_name": "Medicare Advantage", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "TriWest Healthcare Alliance Corporation", "plan_name": "TRICARE Prime", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "TriWest Healthcare Alliance Corporation", "plan_name": "TRICARE Select", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Blue Cross Blue Shield of Montana", "plan_name": "HealthLink Network", "standard_charge_percentage": 75, "methodology": "percent of total billed charges", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Blue Cross Blue Shield of Montana", "plan_name": "Traditional Network", "standard_charge_percentage": 75, "methodology": "percent of total billed charges", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Blue Cross Blue Shield of Montana", "plan_name": "POS Network", "standard_charge_percentage": 75, "methodology": "percent of total billed charges", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Blue Cross Blue Shield of Montana", "plan_name": "Closed Plan Network", "standard_charge_percentage": 75, "methodology": "percent of total billed charges", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Blue Cross Blue Shield of Montana", "plan_name": "Retail HMO POS Network", "standard_charge_percentage": 75, "methodology": "percent of total billed charges", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Blue Cross Blue Shield of Montana", "plan_name": "Blue Options Network", "standard_charge_percentage": 75, "methodology": "percent of total billed charges", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "PacificSource Health Plans", "plan_name": "Medicare Advantage", "standard_charge_percentage": 103, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" } ] } ] }, { "description": "Pulmonary Edema and Respiratory Failure", "code_information": [ { "code": "189", "type": "LOCAL" } ], "standard_charges": [ { "setting": "inpatient", "payers_information": [ { "payer_name": "Blue Cross Blue Shield of Montana", "plan_name": "Medicare Advantage", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "United Healthcare (UHC)", "plan_name": "Medicare Advantage", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "First Choice of the Midwest", "plan_name": "PPO", "standard_charge_percentage": 90, "methodology": "percent of total billed charges", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "United Healthcare (UHC)", "plan_name": "DSNP", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Employee Benefit Management Services (EBMS)", "plan_name": "EBMS SelectCare Network", "standard_charge_percentage": 80, "methodology": "percent of total billed charges", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Claritev fka MultiPlan", "plan_name": "PPO", "standard_charge_percentage": 75, "methodology": "percent of total billed charges", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Allegiance Provider Direct", "plan_name": "Medicare", "standard_charge_percentage": 229.99999999999997, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Medicare (CMS)", "plan_name": "Medicare", "standard_charge_percentage": 100, "methodology": "fee schedule", "median_amount": 44021.35, "10th_percentile": 29323.32, "90th_percentile": 44021.35, "count": "30" }, { "payer_name": "Medica Insurance Company", "plan_name": "Medicare Cost", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Indian Health Services (IHS)", "plan_name": "Commercial", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Humana Insurance Company", "plan_name": "Humana Medicare Advantage HMO", "standard_charge_percentage": 100, "methodology": "fee schedule", "median_amount": 25134.28, "10th_percentile": 25134.28, "90th_percentile": 25134.28, "count": "1 through 10" }, { "payer_name": "Humana Insurance Company", "plan_name": "Humana Medicare Advantage PPO", "standard_charge_percentage": 100, "methodology": "fee schedule", "median_amount": 25134.28, "10th_percentile": 25134.28, "90th_percentile": 25134.28, "count": "1 through 10" }, { "payer_name": "Humana Insurance Company", "plan_name": "Humana Medicare Advantage PFFS", "standard_charge_percentage": 100, "methodology": "fee schedule", "median_amount": 25134.28, "10th_percentile": 25134.28, "90th_percentile": 25134.28, "count": "1 through 10" }, { "payer_name": "First Choice Health Network fka Health InfoNet", "plan_name": "Commercial", "standard_charge_percentage": 85, "methodology": "percent of total billed charges", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "First Choice Health Network fka Health InfoNet", "plan_name": "Workers Compensation", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Allegiance Provider Direct", "plan_name": "State of Montana Employee Benefit Plan (Self-Funded)", "standard_charge_percentage": 229.99999999999997, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Allegiance Provider Direct", "plan_name": "Montana Municipal Interlocal Authority (MMIA)", "standard_charge_percentage": 229.99999999999997, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Allegiance Provider Direct", "plan_name": "Montana Association of Counties (MACo)", "standard_charge_percentage": 229.99999999999997, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "First Choice Health Network fka Health InfoNet", "plan_name": "Medicare Advantage", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "TriWest Healthcare Alliance Corporation", "plan_name": "TRICARE Prime", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "TriWest Healthcare Alliance Corporation", "plan_name": "TRICARE Select", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Blue Cross Blue Shield of Montana", "plan_name": "HealthLink Network", "standard_charge_percentage": 75, "methodology": "percent of total billed charges", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Blue Cross Blue Shield of Montana", "plan_name": "Traditional Network", "standard_charge_percentage": 75, "methodology": "percent of total billed charges", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Blue Cross Blue Shield of Montana", "plan_name": "POS Network", "standard_charge_percentage": 75, "methodology": "percent of total billed charges", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Blue Cross Blue Shield of Montana", "plan_name": "Closed Plan Network", "standard_charge_percentage": 75, "methodology": "percent of total billed charges", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Blue Cross Blue Shield of Montana", "plan_name": "Retail HMO POS Network", "standard_charge_percentage": 75, "methodology": "percent of total billed charges", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Blue Cross Blue Shield of Montana", "plan_name": "Blue Options Network", "standard_charge_percentage": 75, "methodology": "percent of total billed charges", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "PacificSource Health Plans", "plan_name": "Medicare Advantage", "standard_charge_percentage": 103, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" } ], "minimum": 25134.28, "maximum": 44021.35 } ] }, { "description": "Chronic Obstructive Pulmonary Disease with MCC*", "code_information": [ { "code": "190", "type": "LOCAL" } ], "standard_charges": [ { "setting": "inpatient", "payers_information": [ { "payer_name": "Blue Cross Blue Shield of Montana", "plan_name": "Medicare Advantage", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "United Healthcare (UHC)", "plan_name": "Medicare Advantage", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "First Choice of the Midwest", "plan_name": "PPO", "standard_charge_percentage": 90, "methodology": "percent of total billed charges", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "United Healthcare (UHC)", "plan_name": "DSNP", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Employee Benefit Management Services (EBMS)", "plan_name": "EBMS SelectCare Network", "standard_charge_percentage": 80, "methodology": "percent of total billed charges", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Claritev fka MultiPlan", "plan_name": "PPO", "standard_charge_percentage": 75, "methodology": "percent of total billed charges", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Allegiance Provider Direct", "plan_name": "Medicare", "standard_charge_percentage": 229.99999999999997, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Medicare (CMS)", "plan_name": "Medicare", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Medica Insurance Company", "plan_name": "Medicare Cost", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Indian Health Services (IHS)", "plan_name": "Commercial", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Humana Insurance Company", "plan_name": "Humana Medicare Advantage HMO", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Humana Insurance Company", "plan_name": "Humana Medicare Advantage PPO", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Humana Insurance Company", "plan_name": "Humana Medicare Advantage PFFS", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "First Choice Health Network fka Health InfoNet", "plan_name": "Commercial", "standard_charge_percentage": 85, "methodology": "percent of total billed charges", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "First Choice Health Network fka Health InfoNet", "plan_name": "Workers Compensation", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Allegiance Provider Direct", "plan_name": "State of Montana Employee Benefit Plan (Self-Funded)", "standard_charge_percentage": 229.99999999999997, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Allegiance Provider Direct", "plan_name": "Montana Municipal Interlocal Authority (MMIA)", "standard_charge_percentage": 229.99999999999997, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Allegiance Provider Direct", "plan_name": "Montana Association of Counties (MACo)", "standard_charge_percentage": 229.99999999999997, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "First Choice Health Network fka Health InfoNet", "plan_name": "Medicare Advantage", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "TriWest Healthcare Alliance Corporation", "plan_name": "TRICARE Prime", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "TriWest Healthcare Alliance Corporation", "plan_name": "TRICARE Select", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Blue Cross Blue Shield of Montana", "plan_name": "HealthLink Network", "standard_charge_percentage": 75, "methodology": "percent of total billed charges", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Blue Cross Blue Shield of Montana", "plan_name": "Traditional Network", "standard_charge_percentage": 75, "methodology": "percent of total billed charges", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Blue Cross Blue Shield of Montana", "plan_name": "POS Network", "standard_charge_percentage": 75, "methodology": "percent of total billed charges", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Blue Cross Blue Shield of Montana", "plan_name": "Closed Plan Network", "standard_charge_percentage": 75, "methodology": "percent of total billed charges", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Blue Cross Blue Shield of Montana", "plan_name": "Retail HMO POS Network", "standard_charge_percentage": 75, "methodology": "percent of total billed charges", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Blue Cross Blue Shield of Montana", "plan_name": "Blue Options Network", "standard_charge_percentage": 75, "methodology": "percent of total billed charges", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "PacificSource Health Plans", "plan_name": "Medicare Advantage", "standard_charge_percentage": 103, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" } ] } ] }, { "description": "Heart Transplant or Implant of Heart Assist System without MCC", "code_information": [ { "code": "2", "type": "LOCAL" } ], "standard_charges": [ { "setting": "inpatient", "payers_information": [ { "payer_name": "Blue Cross Blue Shield of Montana", "plan_name": "Medicare Advantage", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "United Healthcare (UHC)", "plan_name": "Medicare Advantage", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "First Choice of the Midwest", "plan_name": "PPO", "standard_charge_percentage": 90, "methodology": "percent of total billed charges", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "United Healthcare (UHC)", "plan_name": "DSNP", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Employee Benefit Management Services (EBMS)", "plan_name": "EBMS SelectCare Network", "standard_charge_percentage": 80, "methodology": "percent of total billed charges", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Allegiance Provider Direct", "plan_name": "Medicare", "standard_charge_percentage": 229.99999999999997, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Claritev fka MultiPlan", "plan_name": "PPO", "standard_charge_percentage": 75, "methodology": "percent of total billed charges", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Medica Insurance Company", "plan_name": "Medicare Cost", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Medicare (CMS)", "plan_name": "Medicare", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Indian Health Services (IHS)", "plan_name": "Commercial", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "First Choice Health Network fka Health InfoNet", "plan_name": "Commercial", "standard_charge_percentage": 85, "methodology": "percent of total billed charges", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Humana Insurance Company", "plan_name": "Humana Medicare Advantage HMO", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Humana Insurance Company", "plan_name": "Humana Medicare Advantage PPO", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Humana Insurance Company", "plan_name": "Humana Medicare Advantage PFFS", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "First Choice Health Network fka Health InfoNet", "plan_name": "Workers Compensation", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Allegiance Provider Direct", "plan_name": "State of Montana Employee Benefit Plan (Self-Funded)", "standard_charge_percentage": 229.99999999999997, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Allegiance Provider Direct", "plan_name": "Montana Municipal Interlocal Authority (MMIA)", "standard_charge_percentage": 229.99999999999997, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Allegiance Provider Direct", "plan_name": "Montana Association of Counties (MACo)", "standard_charge_percentage": 229.99999999999997, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "First Choice Health Network fka Health InfoNet", "plan_name": "Medicare Advantage", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "TriWest Healthcare Alliance Corporation", "plan_name": "TRICARE Prime", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "TriWest Healthcare Alliance Corporation", "plan_name": "TRICARE Select", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Blue Cross Blue Shield of Montana", "plan_name": "HealthLink Network", "standard_charge_percentage": 75, "methodology": "percent of total billed charges", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Blue Cross Blue Shield of Montana", "plan_name": "Traditional Network", "standard_charge_percentage": 75, "methodology": "percent of total billed charges", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Blue Cross Blue Shield of Montana", "plan_name": "POS Network", "standard_charge_percentage": 75, "methodology": "percent of total billed charges", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Blue Cross Blue Shield of Montana", "plan_name": "Closed Plan Network", "standard_charge_percentage": 75, "methodology": "percent of total billed charges", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Blue Cross Blue Shield of Montana", "plan_name": "Retail HMO POS Network", "standard_charge_percentage": 75, "methodology": "percent of total billed charges", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Blue Cross Blue Shield of Montana", "plan_name": "Blue Options Network", "standard_charge_percentage": 75, "methodology": "percent of total billed charges", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "PacificSource Health Plans", "plan_name": "Medicare Advantage", "standard_charge_percentage": 103, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" } ] } ] }, { "description": "ECMO or Tracheostomy with MV >96 Hours or Principal Diagnosis Except Face, Mouth and Neck with Major O.R. Procedures", "code_information": [ { "code": "3", "type": "LOCAL" } ], "standard_charges": [ { "setting": "inpatient", "payers_information": [ { "payer_name": "Blue Cross Blue Shield of Montana", "plan_name": "Medicare Advantage", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "United Healthcare (UHC)", "plan_name": "Medicare Advantage", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "First Choice of the Midwest", "plan_name": "PPO", "standard_charge_percentage": 90, "methodology": "percent of total billed charges", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "United Healthcare (UHC)", "plan_name": "DSNP", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Employee Benefit Management Services (EBMS)", "plan_name": "EBMS SelectCare Network", "standard_charge_percentage": 80, "methodology": "percent of total billed charges", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Allegiance Provider Direct", "plan_name": "Medicare", "standard_charge_percentage": 229.99999999999997, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Claritev fka MultiPlan", "plan_name": "PPO", "standard_charge_percentage": 75, "methodology": "percent of total billed charges", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Medica Insurance Company", "plan_name": "Medicare Cost", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Medicare (CMS)", "plan_name": "Medicare", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Indian Health Services (IHS)", "plan_name": "Commercial", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "First Choice Health Network fka Health InfoNet", "plan_name": "Commercial", "standard_charge_percentage": 85, "methodology": "percent of total billed charges", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Humana Insurance Company", "plan_name": "Humana Medicare Advantage HMO", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Humana Insurance Company", "plan_name": "Humana Medicare Advantage PPO", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Humana Insurance Company", "plan_name": "Humana Medicare Advantage PFFS", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "First Choice Health Network fka Health InfoNet", "plan_name": "Workers Compensation", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Allegiance Provider Direct", "plan_name": "State of Montana Employee Benefit Plan (Self-Funded)", "standard_charge_percentage": 229.99999999999997, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Allegiance Provider Direct", "plan_name": "Montana Municipal Interlocal Authority (MMIA)", "standard_charge_percentage": 229.99999999999997, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Allegiance Provider Direct", "plan_name": "Montana Association of Counties (MACo)", "standard_charge_percentage": 229.99999999999997, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "First Choice Health Network fka Health InfoNet", "plan_name": "Medicare Advantage", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "TriWest Healthcare Alliance Corporation", "plan_name": "TRICARE Prime", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "TriWest Healthcare Alliance Corporation", "plan_name": "TRICARE Select", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Blue Cross Blue Shield of Montana", "plan_name": "HealthLink Network", "standard_charge_percentage": 75, "methodology": "percent of total billed charges", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Blue Cross Blue Shield of Montana", "plan_name": "Traditional Network", "standard_charge_percentage": 75, "methodology": "percent of total billed charges", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Blue Cross Blue Shield of Montana", "plan_name": "POS Network", "standard_charge_percentage": 75, "methodology": "percent of total billed charges", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Blue Cross Blue Shield of Montana", "plan_name": "Closed Plan Network", "standard_charge_percentage": 75, "methodology": "percent of total billed charges", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Blue Cross Blue Shield of Montana", "plan_name": "Retail HMO POS Network", "standard_charge_percentage": 75, "methodology": "percent of total billed charges", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Blue Cross Blue Shield of Montana", "plan_name": "Blue Options Network", "standard_charge_percentage": 75, "methodology": "percent of total billed charges", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "PacificSource Health Plans", "plan_name": "Medicare Advantage", "standard_charge_percentage": 103, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" } ] } ] }, { "description": "Tracheostomy with MV >96 Hours or Principal Diagnosis Except Face, Mouth and Neck without Major O.R. Procedures", "code_information": [ { "code": "4", "type": "LOCAL" } ], "standard_charges": [ { "setting": "inpatient", "payers_information": [ { "payer_name": "Blue Cross Blue Shield of Montana", "plan_name": "Medicare Advantage", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "United Healthcare (UHC)", "plan_name": "Medicare Advantage", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "First Choice of the Midwest", "plan_name": "PPO", "standard_charge_percentage": 90, "methodology": "percent of total billed charges", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "United Healthcare (UHC)", "plan_name": "DSNP", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Employee Benefit Management Services (EBMS)", "plan_name": "EBMS SelectCare Network", "standard_charge_percentage": 80, "methodology": "percent of total billed charges", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Allegiance Provider Direct", "plan_name": "Medicare", "standard_charge_percentage": 229.99999999999997, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Claritev fka MultiPlan", "plan_name": "PPO", "standard_charge_percentage": 75, "methodology": "percent of total billed charges", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Medica Insurance Company", "plan_name": "Medicare Cost", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Medicare (CMS)", "plan_name": "Medicare", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Indian Health Services (IHS)", "plan_name": "Commercial", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "First Choice Health Network fka Health InfoNet", "plan_name": "Commercial", "standard_charge_percentage": 85, "methodology": "percent of total billed charges", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Humana Insurance Company", "plan_name": "Humana Medicare Advantage HMO", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Humana Insurance Company", "plan_name": "Humana Medicare Advantage PPO", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Humana Insurance Company", "plan_name": "Humana Medicare Advantage PFFS", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "First Choice Health Network fka Health InfoNet", "plan_name": "Workers Compensation", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Allegiance Provider Direct", "plan_name": "State of Montana Employee Benefit Plan (Self-Funded)", "standard_charge_percentage": 229.99999999999997, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Allegiance Provider Direct", "plan_name": "Montana Municipal Interlocal Authority (MMIA)", "standard_charge_percentage": 229.99999999999997, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Allegiance Provider Direct", "plan_name": "Montana Association of Counties (MACo)", "standard_charge_percentage": 229.99999999999997, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "First Choice Health Network fka Health InfoNet", "plan_name": "Medicare Advantage", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "TriWest Healthcare Alliance Corporation", "plan_name": "TRICARE Prime", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "TriWest Healthcare Alliance Corporation", "plan_name": "TRICARE Select", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Blue Cross Blue Shield of Montana", "plan_name": "HealthLink Network", "standard_charge_percentage": 75, "methodology": "percent of total billed charges", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Blue Cross Blue Shield of Montana", "plan_name": "Traditional Network", "standard_charge_percentage": 75, "methodology": "percent of total billed charges", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Blue Cross Blue Shield of Montana", "plan_name": "POS Network", "standard_charge_percentage": 75, "methodology": "percent of total billed charges", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Blue Cross Blue Shield of Montana", "plan_name": "Closed Plan Network", "standard_charge_percentage": 75, "methodology": "percent of total billed charges", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Blue Cross Blue Shield of Montana", "plan_name": "Retail HMO POS Network", "standard_charge_percentage": 75, "methodology": "percent of total billed charges", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Blue Cross Blue Shield of Montana", "plan_name": "Blue Options Network", "standard_charge_percentage": 75, "methodology": "percent of total billed charges", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "PacificSource Health Plans", "plan_name": "Medicare Advantage", "standard_charge_percentage": 103, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" } ] } ] }, { "description": "Liver Transplant with MCC or Intestinal Transplant", "code_information": [ { "code": "5", "type": "LOCAL" } ], "standard_charges": [ { "setting": "inpatient", "payers_information": [ { "payer_name": "Blue Cross Blue Shield of Montana", "plan_name": "Medicare Advantage", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "United Healthcare (UHC)", "plan_name": "Medicare Advantage", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "First Choice of the Midwest", "plan_name": "PPO", "standard_charge_percentage": 90, "methodology": "percent of total billed charges", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "United Healthcare (UHC)", "plan_name": "DSNP", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Employee Benefit Management Services (EBMS)", "plan_name": "EBMS SelectCare Network", "standard_charge_percentage": 80, "methodology": "percent of total billed charges", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Allegiance Provider Direct", "plan_name": "Medicare", "standard_charge_percentage": 229.99999999999997, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Claritev fka MultiPlan", "plan_name": "PPO", "standard_charge_percentage": 75, "methodology": "percent of total billed charges", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Medica Insurance Company", "plan_name": "Medicare Cost", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Medicare (CMS)", "plan_name": "Medicare", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Indian Health Services (IHS)", "plan_name": "Commercial", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "First Choice Health Network fka Health InfoNet", "plan_name": "Commercial", "standard_charge_percentage": 85, "methodology": "percent of total billed charges", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Humana Insurance Company", "plan_name": "Humana Medicare Advantage HMO", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Humana Insurance Company", "plan_name": "Humana Medicare Advantage PPO", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Humana Insurance Company", "plan_name": "Humana Medicare Advantage PFFS", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "First Choice Health Network fka Health InfoNet", "plan_name": "Workers Compensation", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Allegiance Provider Direct", "plan_name": "State of Montana Employee Benefit Plan (Self-Funded)", "standard_charge_percentage": 229.99999999999997, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Allegiance Provider Direct", "plan_name": "Montana Municipal Interlocal Authority (MMIA)", "standard_charge_percentage": 229.99999999999997, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Allegiance Provider Direct", "plan_name": "Montana Association of Counties (MACo)", "standard_charge_percentage": 229.99999999999997, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "First Choice Health Network fka Health InfoNet", "plan_name": "Medicare Advantage", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "TriWest Healthcare Alliance Corporation", "plan_name": "TRICARE Prime", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "TriWest Healthcare Alliance Corporation", "plan_name": "TRICARE Select", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Blue Cross Blue Shield of Montana", "plan_name": "HealthLink Network", "standard_charge_percentage": 75, "methodology": "percent of total billed charges", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Blue Cross Blue Shield of Montana", "plan_name": "Traditional Network", "standard_charge_percentage": 75, "methodology": "percent of total billed charges", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Blue Cross Blue Shield of Montana", "plan_name": "POS Network", "standard_charge_percentage": 75, "methodology": "percent of total billed charges", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Blue Cross Blue Shield of Montana", "plan_name": "Closed Plan Network", "standard_charge_percentage": 75, "methodology": "percent of total billed charges", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Blue Cross Blue Shield of Montana", "plan_name": "Retail HMO POS Network", "standard_charge_percentage": 75, "methodology": "percent of total billed charges", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Blue Cross Blue Shield of Montana", "plan_name": "Blue Options Network", "standard_charge_percentage": 75, "methodology": "percent of total billed charges", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "PacificSource Health Plans", "plan_name": "Medicare Advantage", "standard_charge_percentage": 103, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" } ] } ] }, { "description": "Liver Transplant without MCC", "code_information": [ { "code": "6", "type": "LOCAL" } ], "standard_charges": [ { "setting": "inpatient", "payers_information": [ { "payer_name": "Blue Cross Blue Shield of Montana", "plan_name": "Medicare Advantage", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "United Healthcare (UHC)", "plan_name": "Medicare Advantage", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "First Choice of the Midwest", "plan_name": "PPO", "standard_charge_percentage": 90, "methodology": "percent of total billed charges", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "United Healthcare (UHC)", "plan_name": "DSNP", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Employee Benefit Management Services (EBMS)", "plan_name": "EBMS SelectCare Network", "standard_charge_percentage": 80, "methodology": "percent of total billed charges", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Allegiance Provider Direct", "plan_name": "Medicare", "standard_charge_percentage": 229.99999999999997, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Claritev fka MultiPlan", "plan_name": "PPO", "standard_charge_percentage": 75, "methodology": "percent of total billed charges", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Medica Insurance Company", "plan_name": "Medicare Cost", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Medicare (CMS)", "plan_name": "Medicare", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Indian Health Services (IHS)", "plan_name": "Commercial", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "First Choice Health Network fka Health InfoNet", "plan_name": "Commercial", "standard_charge_percentage": 85, "methodology": "percent of total billed charges", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Humana Insurance Company", "plan_name": "Humana Medicare Advantage HMO", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Humana Insurance Company", "plan_name": "Humana Medicare Advantage PPO", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Humana Insurance Company", "plan_name": "Humana Medicare Advantage PFFS", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "First Choice Health Network fka Health InfoNet", "plan_name": "Workers Compensation", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Allegiance Provider Direct", "plan_name": "State of Montana Employee Benefit Plan (Self-Funded)", "standard_charge_percentage": 229.99999999999997, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Allegiance Provider Direct", "plan_name": "Montana Municipal Interlocal Authority (MMIA)", "standard_charge_percentage": 229.99999999999997, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Allegiance Provider Direct", "plan_name": "Montana Association of Counties (MACo)", "standard_charge_percentage": 229.99999999999997, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "First Choice Health Network fka Health InfoNet", "plan_name": "Medicare Advantage", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "TriWest Healthcare Alliance Corporation", "plan_name": "TRICARE Prime", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "TriWest Healthcare Alliance Corporation", "plan_name": "TRICARE Select", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Blue Cross Blue Shield of Montana", "plan_name": "HealthLink Network", "standard_charge_percentage": 75, "methodology": "percent of total billed charges", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Blue Cross Blue Shield of Montana", "plan_name": "Traditional Network", "standard_charge_percentage": 75, "methodology": "percent of total billed charges", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Blue Cross Blue Shield of Montana", "plan_name": "POS Network", "standard_charge_percentage": 75, "methodology": "percent of total billed charges", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Blue Cross Blue Shield of Montana", "plan_name": "Closed Plan Network", "standard_charge_percentage": 75, "methodology": "percent of total billed charges", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Blue Cross Blue Shield of Montana", "plan_name": "Retail HMO POS Network", "standard_charge_percentage": 75, "methodology": "percent of total billed charges", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Blue Cross Blue Shield of Montana", "plan_name": "Blue Options Network", "standard_charge_percentage": 75, "methodology": "percent of total billed charges", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "PacificSource Health Plans", "plan_name": "Medicare Advantage", "standard_charge_percentage": 103, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" } ] } ] }, { "description": "Lung Transplant", "code_information": [ { "code": "7", "type": "LOCAL" } ], "standard_charges": [ { "setting": "inpatient", "payers_information": [ { "payer_name": "Blue Cross Blue Shield of Montana", "plan_name": "Medicare Advantage", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "United Healthcare (UHC)", "plan_name": "Medicare Advantage", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "First Choice of the Midwest", "plan_name": "PPO", "standard_charge_percentage": 90, "methodology": "percent of total billed charges", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "United Healthcare (UHC)", "plan_name": "DSNP", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Employee Benefit Management Services (EBMS)", "plan_name": "EBMS SelectCare Network", "standard_charge_percentage": 80, "methodology": "percent of total billed charges", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Allegiance Provider Direct", "plan_name": "Medicare", "standard_charge_percentage": 229.99999999999997, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Claritev fka MultiPlan", "plan_name": "PPO", "standard_charge_percentage": 75, "methodology": "percent of total billed charges", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Medica Insurance Company", "plan_name": "Medicare Cost", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Medicare (CMS)", "plan_name": "Medicare", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Indian Health Services (IHS)", "plan_name": "Commercial", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "First Choice Health Network fka Health InfoNet", "plan_name": "Commercial", "standard_charge_percentage": 85, "methodology": "percent of total billed charges", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Humana Insurance Company", "plan_name": "Humana Medicare Advantage HMO", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Humana Insurance Company", "plan_name": "Humana Medicare Advantage PPO", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Humana Insurance Company", "plan_name": "Humana Medicare Advantage PFFS", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "First Choice Health Network fka Health InfoNet", "plan_name": "Workers Compensation", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Allegiance Provider Direct", "plan_name": "State of Montana Employee Benefit Plan (Self-Funded)", "standard_charge_percentage": 229.99999999999997, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Allegiance Provider Direct", "plan_name": "Montana Municipal Interlocal Authority (MMIA)", "standard_charge_percentage": 229.99999999999997, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Allegiance Provider Direct", "plan_name": "Montana Association of Counties (MACo)", "standard_charge_percentage": 229.99999999999997, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "First Choice Health Network fka Health InfoNet", "plan_name": "Medicare Advantage", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "TriWest Healthcare Alliance Corporation", "plan_name": "TRICARE Prime", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "TriWest Healthcare Alliance Corporation", "plan_name": "TRICARE Select", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Blue Cross Blue Shield of Montana", "plan_name": "HealthLink Network", "standard_charge_percentage": 75, "methodology": "percent of total billed charges", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Blue Cross Blue Shield of Montana", "plan_name": "Traditional Network", "standard_charge_percentage": 75, "methodology": "percent of total billed charges", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Blue Cross Blue Shield of Montana", "plan_name": "POS Network", "standard_charge_percentage": 75, "methodology": "percent of total billed charges", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Blue Cross Blue Shield of Montana", "plan_name": "Closed Plan Network", "standard_charge_percentage": 75, "methodology": "percent of total billed charges", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Blue Cross Blue Shield of Montana", "plan_name": "Retail HMO POS Network", "standard_charge_percentage": 75, "methodology": "percent of total billed charges", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Blue Cross Blue Shield of Montana", "plan_name": "Blue Options Network", "standard_charge_percentage": 75, "methodology": "percent of total billed charges", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "PacificSource Health Plans", "plan_name": "Medicare Advantage", "standard_charge_percentage": 103, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" } ] } ] }, { "description": "Simultaneous Pancreas and Kidney Transplant", "code_information": [ { "code": "8", "type": "LOCAL" } ], "standard_charges": [ { "setting": "inpatient", "payers_information": [ { "payer_name": "Blue Cross Blue Shield of Montana", "plan_name": "Medicare Advantage", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "United Healthcare (UHC)", "plan_name": "Medicare Advantage", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "First Choice of the Midwest", "plan_name": "PPO", "standard_charge_percentage": 90, "methodology": "percent of total billed charges", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "United Healthcare (UHC)", "plan_name": "DSNP", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Employee Benefit Management Services (EBMS)", "plan_name": "EBMS SelectCare Network", "standard_charge_percentage": 80, "methodology": "percent of total billed charges", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Allegiance Provider Direct", "plan_name": "Medicare", "standard_charge_percentage": 229.99999999999997, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Claritev fka MultiPlan", "plan_name": "PPO", "standard_charge_percentage": 75, "methodology": "percent of total billed charges", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Medica Insurance Company", "plan_name": "Medicare Cost", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Medicare (CMS)", "plan_name": "Medicare", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Indian Health Services (IHS)", "plan_name": "Commercial", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "First Choice Health Network fka Health InfoNet", "plan_name": "Commercial", "standard_charge_percentage": 85, "methodology": "percent of total billed charges", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Humana Insurance Company", "plan_name": "Humana Medicare Advantage HMO", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Humana Insurance Company", "plan_name": "Humana Medicare Advantage PPO", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Humana Insurance Company", "plan_name": "Humana Medicare Advantage PFFS", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "First Choice Health Network fka Health InfoNet", "plan_name": "Workers Compensation", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Allegiance Provider Direct", "plan_name": "State of Montana Employee Benefit Plan (Self-Funded)", "standard_charge_percentage": 229.99999999999997, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Allegiance Provider Direct", "plan_name": "Montana Municipal Interlocal Authority (MMIA)", "standard_charge_percentage": 229.99999999999997, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Allegiance Provider Direct", "plan_name": "Montana Association of Counties (MACo)", "standard_charge_percentage": 229.99999999999997, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "First Choice Health Network fka Health InfoNet", "plan_name": "Medicare Advantage", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "TriWest Healthcare Alliance Corporation", "plan_name": "TRICARE Prime", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "TriWest Healthcare Alliance Corporation", "plan_name": "TRICARE Select", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Blue Cross Blue Shield of Montana", "plan_name": "HealthLink Network", "standard_charge_percentage": 75, "methodology": "percent of total billed charges", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Blue Cross Blue Shield of Montana", "plan_name": "Traditional Network", "standard_charge_percentage": 75, "methodology": "percent of total billed charges", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Blue Cross Blue Shield of Montana", "plan_name": "POS Network", "standard_charge_percentage": 75, "methodology": "percent of total billed charges", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Blue Cross Blue Shield of Montana", "plan_name": "Closed Plan Network", "standard_charge_percentage": 75, "methodology": "percent of total billed charges", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Blue Cross Blue Shield of Montana", "plan_name": "Retail HMO POS Network", "standard_charge_percentage": 75, "methodology": "percent of total billed charges", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Blue Cross Blue Shield of Montana", "plan_name": "Blue Options Network", "standard_charge_percentage": 75, "methodology": "percent of total billed charges", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "PacificSource Health Plans", "plan_name": "Medicare Advantage", "standard_charge_percentage": 103, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" } ] } ] }, { "description": "Tracheostomy for Face, Mouth and Neck Diagnoses or Laryngectomy with MCC", "code_information": [ { "code": "11", "type": "LOCAL" } ], "standard_charges": [ { "setting": "inpatient", "payers_information": [ { "payer_name": "Blue Cross Blue Shield of Montana", "plan_name": "Medicare Advantage", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "United Healthcare (UHC)", "plan_name": "Medicare Advantage", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "First Choice of the Midwest", "plan_name": "PPO", "standard_charge_percentage": 90, "methodology": "percent of total billed charges", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "United Healthcare (UHC)", "plan_name": "DSNP", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Employee Benefit Management Services (EBMS)", "plan_name": "EBMS SelectCare Network", "standard_charge_percentage": 80, "methodology": "percent of total billed charges", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Allegiance Provider Direct", "plan_name": "Medicare", "standard_charge_percentage": 229.99999999999997, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Claritev fka MultiPlan", "plan_name": "PPO", "standard_charge_percentage": 75, "methodology": "percent of total billed charges", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Medica Insurance Company", "plan_name": "Medicare Cost", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Medicare (CMS)", "plan_name": "Medicare", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Indian Health Services (IHS)", "plan_name": "Commercial", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "First Choice Health Network fka Health InfoNet", "plan_name": "Commercial", "standard_charge_percentage": 85, "methodology": "percent of total billed charges", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Humana Insurance Company", "plan_name": "Humana Medicare Advantage HMO", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Humana Insurance Company", "plan_name": "Humana Medicare Advantage PPO", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Humana Insurance Company", "plan_name": "Humana Medicare Advantage PFFS", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "First Choice Health Network fka Health InfoNet", "plan_name": "Workers Compensation", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Allegiance Provider Direct", "plan_name": "State of Montana Employee Benefit Plan (Self-Funded)", "standard_charge_percentage": 229.99999999999997, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Allegiance Provider Direct", "plan_name": "Montana Municipal Interlocal Authority (MMIA)", "standard_charge_percentage": 229.99999999999997, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Allegiance Provider Direct", "plan_name": "Montana Association of Counties (MACo)", "standard_charge_percentage": 229.99999999999997, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "First Choice Health Network fka Health InfoNet", "plan_name": "Medicare Advantage", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "TriWest Healthcare Alliance Corporation", "plan_name": "TRICARE Prime", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "TriWest Healthcare Alliance Corporation", "plan_name": "TRICARE Select", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Blue Cross Blue Shield of Montana", "plan_name": "HealthLink Network", "standard_charge_percentage": 75, "methodology": "percent of total billed charges", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Blue Cross Blue Shield of Montana", "plan_name": "Traditional Network", "standard_charge_percentage": 75, "methodology": "percent of total billed charges", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Blue Cross Blue Shield of Montana", "plan_name": "POS Network", "standard_charge_percentage": 75, "methodology": "percent of total billed charges", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Blue Cross Blue Shield of Montana", "plan_name": "Closed Plan Network", "standard_charge_percentage": 75, "methodology": "percent of total billed charges", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Blue Cross Blue Shield of Montana", "plan_name": "Retail HMO POS Network", "standard_charge_percentage": 75, "methodology": "percent of total billed charges", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Blue Cross Blue Shield of Montana", "plan_name": "Blue Options Network", "standard_charge_percentage": 75, "methodology": "percent of total billed charges", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "PacificSource Health Plans", "plan_name": "Medicare Advantage", "standard_charge_percentage": 103, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" } ] } ] }, { "description": "Tracheostomy for Face, Mouth and Neck Diagnoses or Laryngectomy with CC", "code_information": [ { "code": "12", "type": "LOCAL" } ], "standard_charges": [ { "setting": "inpatient", "payers_information": [ { "payer_name": "Blue Cross Blue Shield of Montana", "plan_name": "Medicare Advantage", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "United Healthcare (UHC)", "plan_name": "Medicare Advantage", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "First Choice of the Midwest", "plan_name": "PPO", "standard_charge_percentage": 90, "methodology": "percent of total billed charges", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "United Healthcare (UHC)", "plan_name": "DSNP", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Employee Benefit Management Services (EBMS)", "plan_name": "EBMS SelectCare Network", "standard_charge_percentage": 80, "methodology": "percent of total billed charges", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Allegiance Provider Direct", "plan_name": "Medicare", "standard_charge_percentage": 229.99999999999997, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Claritev fka MultiPlan", "plan_name": "PPO", "standard_charge_percentage": 75, "methodology": "percent of total billed charges", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Medica Insurance Company", "plan_name": "Medicare Cost", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Medicare (CMS)", "plan_name": "Medicare", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Indian Health Services (IHS)", "plan_name": "Commercial", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "First Choice Health Network fka Health InfoNet", "plan_name": "Commercial", "standard_charge_percentage": 85, "methodology": "percent of total billed charges", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Humana Insurance Company", "plan_name": "Humana Medicare Advantage HMO", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Humana Insurance Company", "plan_name": "Humana Medicare Advantage PPO", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Humana Insurance Company", "plan_name": "Humana Medicare Advantage PFFS", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "First Choice Health Network fka Health InfoNet", "plan_name": "Workers Compensation", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Allegiance Provider Direct", "plan_name": "State of Montana Employee Benefit Plan (Self-Funded)", "standard_charge_percentage": 229.99999999999997, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Allegiance Provider Direct", "plan_name": "Montana Municipal Interlocal Authority (MMIA)", "standard_charge_percentage": 229.99999999999997, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Allegiance Provider Direct", "plan_name": "Montana Association of Counties (MACo)", "standard_charge_percentage": 229.99999999999997, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "First Choice Health Network fka Health InfoNet", "plan_name": "Medicare Advantage", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "TriWest Healthcare Alliance Corporation", "plan_name": "TRICARE Prime", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "TriWest Healthcare Alliance Corporation", "plan_name": "TRICARE Select", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Blue Cross Blue Shield of Montana", "plan_name": "HealthLink Network", "standard_charge_percentage": 75, "methodology": "percent of total billed charges", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Blue Cross Blue Shield of Montana", "plan_name": "Traditional Network", "standard_charge_percentage": 75, "methodology": "percent of total billed charges", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Blue Cross Blue Shield of Montana", "plan_name": "POS Network", "standard_charge_percentage": 75, "methodology": "percent of total billed charges", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Blue Cross Blue Shield of Montana", "plan_name": "Closed Plan Network", "standard_charge_percentage": 75, "methodology": "percent of total billed charges", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Blue Cross Blue Shield of Montana", "plan_name": "Retail HMO POS Network", "standard_charge_percentage": 75, "methodology": "percent of total billed charges", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Blue Cross Blue Shield of Montana", "plan_name": "Blue Options Network", "standard_charge_percentage": 75, "methodology": "percent of total billed charges", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "PacificSource Health Plans", "plan_name": "Medicare Advantage", "standard_charge_percentage": 103, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" } ] } ] }, { "description": "Tracheostomy for Face, Mouth and Neck Diagnoses or Laryngectomy without CC/MCC", "code_information": [ { "code": "13", "type": "LOCAL" } ], "standard_charges": [ { "setting": "inpatient", "payers_information": [ { "payer_name": "Blue Cross Blue Shield of Montana", "plan_name": "Medicare Advantage", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "United Healthcare (UHC)", "plan_name": "Medicare Advantage", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "First Choice of the Midwest", "plan_name": "PPO", "standard_charge_percentage": 90, "methodology": "percent of total billed charges", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "United Healthcare (UHC)", "plan_name": "DSNP", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Employee Benefit Management Services (EBMS)", "plan_name": "EBMS SelectCare Network", "standard_charge_percentage": 80, "methodology": "percent of total billed charges", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Allegiance Provider Direct", "plan_name": "Medicare", "standard_charge_percentage": 229.99999999999997, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Claritev fka MultiPlan", "plan_name": "PPO", "standard_charge_percentage": 75, "methodology": "percent of total billed charges", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Medica Insurance Company", "plan_name": "Medicare Cost", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Medicare (CMS)", "plan_name": "Medicare", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Indian Health Services (IHS)", "plan_name": "Commercial", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "First Choice Health Network fka Health InfoNet", "plan_name": "Commercial", "standard_charge_percentage": 85, "methodology": "percent of total billed charges", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Humana Insurance Company", "plan_name": "Humana Medicare Advantage HMO", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Humana Insurance Company", "plan_name": "Humana Medicare Advantage PPO", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Humana Insurance Company", "plan_name": "Humana Medicare Advantage PFFS", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "First Choice Health Network fka Health InfoNet", "plan_name": "Workers Compensation", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Allegiance Provider Direct", "plan_name": "State of Montana Employee Benefit Plan (Self-Funded)", "standard_charge_percentage": 229.99999999999997, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Allegiance Provider Direct", "plan_name": "Montana Municipal Interlocal Authority (MMIA)", "standard_charge_percentage": 229.99999999999997, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Allegiance Provider Direct", "plan_name": "Montana Association of Counties (MACo)", "standard_charge_percentage": 229.99999999999997, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "First Choice Health Network fka Health InfoNet", "plan_name": "Medicare Advantage", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "TriWest Healthcare Alliance Corporation", "plan_name": "TRICARE Prime", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "TriWest Healthcare Alliance Corporation", "plan_name": "TRICARE Select", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Blue Cross Blue Shield of Montana", "plan_name": "HealthLink Network", "standard_charge_percentage": 75, "methodology": "percent of total billed charges", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Blue Cross Blue Shield of Montana", "plan_name": "Traditional Network", "standard_charge_percentage": 75, "methodology": "percent of total billed charges", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Blue Cross Blue Shield of Montana", "plan_name": "POS Network", "standard_charge_percentage": 75, "methodology": "percent of total billed charges", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Blue Cross Blue Shield of Montana", "plan_name": "Closed Plan Network", "standard_charge_percentage": 75, "methodology": "percent of total billed charges", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Blue Cross Blue Shield of Montana", "plan_name": "Retail HMO POS Network", "standard_charge_percentage": 75, "methodology": "percent of total billed charges", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Blue Cross Blue Shield of Montana", "plan_name": "Blue Options Network", "standard_charge_percentage": 75, "methodology": "percent of total billed charges", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "PacificSource Health Plans", "plan_name": "Medicare Advantage", "standard_charge_percentage": 103, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" } ] } ] }, { "description": "Allogeneic Bone Marrow Transplant", "code_information": [ { "code": "14", "type": "LOCAL" } ], "standard_charges": [ { "setting": "inpatient", "payers_information": [ { "payer_name": "Blue Cross Blue Shield of Montana", "plan_name": "Medicare Advantage", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "United Healthcare (UHC)", "plan_name": "Medicare Advantage", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "First Choice of the Midwest", "plan_name": "PPO", "standard_charge_percentage": 90, "methodology": "percent of total billed charges", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "United Healthcare (UHC)", "plan_name": "DSNP", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Employee Benefit Management Services (EBMS)", "plan_name": "EBMS SelectCare Network", "standard_charge_percentage": 80, "methodology": "percent of total billed charges", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Allegiance Provider Direct", "plan_name": "Medicare", "standard_charge_percentage": 229.99999999999997, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Claritev fka MultiPlan", "plan_name": "PPO", "standard_charge_percentage": 75, "methodology": "percent of total billed charges", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Medica Insurance Company", "plan_name": "Medicare Cost", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Medicare (CMS)", "plan_name": "Medicare", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Indian Health Services (IHS)", "plan_name": "Commercial", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "First Choice Health Network fka Health InfoNet", "plan_name": "Commercial", "standard_charge_percentage": 85, "methodology": "percent of total billed charges", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Humana Insurance Company", "plan_name": "Humana Medicare Advantage HMO", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Humana Insurance Company", "plan_name": "Humana Medicare Advantage PPO", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Humana Insurance Company", "plan_name": "Humana Medicare Advantage PFFS", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "First Choice Health Network fka Health InfoNet", "plan_name": "Workers Compensation", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Allegiance Provider Direct", "plan_name": "State of Montana Employee Benefit Plan (Self-Funded)", "standard_charge_percentage": 229.99999999999997, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Allegiance Provider Direct", "plan_name": "Montana Municipal Interlocal Authority (MMIA)", "standard_charge_percentage": 229.99999999999997, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Allegiance Provider Direct", "plan_name": "Montana Association of Counties (MACo)", "standard_charge_percentage": 229.99999999999997, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "First Choice Health Network fka Health InfoNet", "plan_name": "Medicare Advantage", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "TriWest Healthcare Alliance Corporation", "plan_name": "TRICARE Prime", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "TriWest Healthcare Alliance Corporation", "plan_name": "TRICARE Select", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Blue Cross Blue Shield of Montana", "plan_name": "HealthLink Network", "standard_charge_percentage": 75, "methodology": "percent of total billed charges", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Blue Cross Blue Shield of Montana", "plan_name": "Traditional Network", "standard_charge_percentage": 75, "methodology": "percent of total billed charges", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Blue Cross Blue Shield of Montana", "plan_name": "POS Network", "standard_charge_percentage": 75, "methodology": "percent of total billed charges", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Blue Cross Blue Shield of Montana", "plan_name": "Closed Plan Network", "standard_charge_percentage": 75, "methodology": "percent of total billed charges", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Blue Cross Blue Shield of Montana", "plan_name": "Retail HMO POS Network", "standard_charge_percentage": 75, "methodology": "percent of total billed charges", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Blue Cross Blue Shield of Montana", "plan_name": "Blue Options Network", "standard_charge_percentage": 75, "methodology": "percent of total billed charges", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "PacificSource Health Plans", "plan_name": "Medicare Advantage", "standard_charge_percentage": 103, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" } ] } ] }, { "description": "Autologous Bone Marrow Transplant with CC/MCC", "code_information": [ { "code": "16", "type": "LOCAL" } ], "standard_charges": [ { "setting": "inpatient", "payers_information": [ { "payer_name": "Blue Cross Blue Shield of Montana", "plan_name": "Medicare Advantage", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "United Healthcare (UHC)", "plan_name": "Medicare Advantage", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "First Choice of the Midwest", "plan_name": "PPO", "standard_charge_percentage": 90, "methodology": "percent of total billed charges", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "United Healthcare (UHC)", "plan_name": "DSNP", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Employee Benefit Management Services (EBMS)", "plan_name": "EBMS SelectCare Network", "standard_charge_percentage": 80, "methodology": "percent of total billed charges", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Allegiance Provider Direct", "plan_name": "Medicare", "standard_charge_percentage": 229.99999999999997, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Claritev fka MultiPlan", "plan_name": "PPO", "standard_charge_percentage": 75, "methodology": "percent of total billed charges", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Medica Insurance Company", "plan_name": "Medicare Cost", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Medicare (CMS)", "plan_name": "Medicare", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Indian Health Services (IHS)", "plan_name": "Commercial", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "First Choice Health Network fka Health InfoNet", "plan_name": "Commercial", "standard_charge_percentage": 85, "methodology": "percent of total billed charges", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Humana Insurance Company", "plan_name": "Humana Medicare Advantage HMO", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Humana Insurance Company", "plan_name": "Humana Medicare Advantage PPO", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Humana Insurance Company", "plan_name": "Humana Medicare Advantage PFFS", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "First Choice Health Network fka Health InfoNet", "plan_name": "Workers Compensation", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Allegiance Provider Direct", "plan_name": "State of Montana Employee Benefit Plan (Self-Funded)", "standard_charge_percentage": 229.99999999999997, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Allegiance Provider Direct", "plan_name": "Montana Municipal Interlocal Authority (MMIA)", "standard_charge_percentage": 229.99999999999997, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Allegiance Provider Direct", "plan_name": "Montana Association of Counties (MACo)", "standard_charge_percentage": 229.99999999999997, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "First Choice Health Network fka Health InfoNet", "plan_name": "Medicare Advantage", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "TriWest Healthcare Alliance Corporation", "plan_name": "TRICARE Prime", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "TriWest Healthcare Alliance Corporation", "plan_name": "TRICARE Select", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Blue Cross Blue Shield of Montana", "plan_name": "HealthLink Network", "standard_charge_percentage": 75, "methodology": "percent of total billed charges", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Blue Cross Blue Shield of Montana", "plan_name": "Traditional Network", "standard_charge_percentage": 75, "methodology": "percent of total billed charges", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Blue Cross Blue Shield of Montana", "plan_name": "POS Network", "standard_charge_percentage": 75, "methodology": "percent of total billed charges", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Blue Cross Blue Shield of Montana", "plan_name": "Closed Plan Network", "standard_charge_percentage": 75, "methodology": "percent of total billed charges", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Blue Cross Blue Shield of Montana", "plan_name": "Retail HMO POS Network", "standard_charge_percentage": 75, "methodology": "percent of total billed charges", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Blue Cross Blue Shield of Montana", "plan_name": "Blue Options Network", "standard_charge_percentage": 75, "methodology": "percent of total billed charges", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "PacificSource Health Plans", "plan_name": "Medicare Advantage", "standard_charge_percentage": 103, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" } ] } ] }, { "description": "Autologous Bone Marrow Transplant without CC/MCC", "code_information": [ { "code": "17", "type": "LOCAL" } ], "standard_charges": [ { "setting": "inpatient", "payers_information": [ { "payer_name": "Blue Cross Blue Shield of Montana", "plan_name": "Medicare Advantage", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "United Healthcare (UHC)", "plan_name": "Medicare Advantage", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "First Choice of the Midwest", "plan_name": "PPO", "standard_charge_percentage": 90, "methodology": "percent of total billed charges", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "United Healthcare (UHC)", "plan_name": "DSNP", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Employee Benefit Management Services (EBMS)", "plan_name": "EBMS SelectCare Network", "standard_charge_percentage": 80, "methodology": "percent of total billed charges", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Allegiance Provider Direct", "plan_name": "Medicare", "standard_charge_percentage": 229.99999999999997, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Claritev fka MultiPlan", "plan_name": "PPO", "standard_charge_percentage": 75, "methodology": "percent of total billed charges", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Medica Insurance Company", "plan_name": "Medicare Cost", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Medicare (CMS)", "plan_name": "Medicare", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Indian Health Services (IHS)", "plan_name": "Commercial", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "First Choice Health Network fka Health InfoNet", "plan_name": "Commercial", "standard_charge_percentage": 85, "methodology": "percent of total billed charges", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Humana Insurance Company", "plan_name": "Humana Medicare Advantage HMO", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Humana Insurance Company", "plan_name": "Humana Medicare Advantage PPO", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Humana Insurance Company", "plan_name": "Humana Medicare Advantage PFFS", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "First Choice Health Network fka Health InfoNet", "plan_name": "Workers Compensation", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Allegiance Provider Direct", "plan_name": "State of Montana Employee Benefit Plan (Self-Funded)", "standard_charge_percentage": 229.99999999999997, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Allegiance Provider Direct", "plan_name": "Montana Municipal Interlocal Authority (MMIA)", "standard_charge_percentage": 229.99999999999997, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Allegiance Provider Direct", "plan_name": "Montana Association of Counties (MACo)", "standard_charge_percentage": 229.99999999999997, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "First Choice Health Network fka Health InfoNet", "plan_name": "Medicare Advantage", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "TriWest Healthcare Alliance Corporation", "plan_name": "TRICARE Prime", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "TriWest Healthcare Alliance Corporation", "plan_name": "TRICARE Select", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Blue Cross Blue Shield of Montana", "plan_name": "HealthLink Network", "standard_charge_percentage": 75, "methodology": "percent of total billed charges", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Blue Cross Blue Shield of Montana", "plan_name": "Traditional Network", "standard_charge_percentage": 75, "methodology": "percent of total billed charges", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Blue Cross Blue Shield of Montana", "plan_name": "POS Network", "standard_charge_percentage": 75, "methodology": "percent of total billed charges", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Blue Cross Blue Shield of Montana", "plan_name": "Closed Plan Network", "standard_charge_percentage": 75, "methodology": "percent of total billed charges", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Blue Cross Blue Shield of Montana", "plan_name": "Retail HMO POS Network", "standard_charge_percentage": 75, "methodology": "percent of total billed charges", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Blue Cross Blue Shield of Montana", "plan_name": "Blue Options Network", "standard_charge_percentage": 75, "methodology": "percent of total billed charges", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "PacificSource Health Plans", "plan_name": "Medicare Advantage", "standard_charge_percentage": 103, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" } ] } ] }, { "description": "Chimeric Antigen Receptor (CAR) T-Cell and Other Immunotherapies", "code_information": [ { "code": "18", "type": "LOCAL" } ], "standard_charges": [ { "setting": "inpatient", "payers_information": [ { "payer_name": "Blue Cross Blue Shield of Montana", "plan_name": "Medicare Advantage", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "United Healthcare (UHC)", "plan_name": "Medicare Advantage", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "First Choice of the Midwest", "plan_name": "PPO", "standard_charge_percentage": 90, "methodology": "percent of total billed charges", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "United Healthcare (UHC)", "plan_name": "DSNP", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Employee Benefit Management Services (EBMS)", "plan_name": "EBMS SelectCare Network", "standard_charge_percentage": 80, "methodology": "percent of total billed charges", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Allegiance Provider Direct", "plan_name": "Medicare", "standard_charge_percentage": 229.99999999999997, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Claritev fka MultiPlan", "plan_name": "PPO", "standard_charge_percentage": 75, "methodology": "percent of total billed charges", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Medica Insurance Company", "plan_name": "Medicare Cost", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Medicare (CMS)", "plan_name": "Medicare", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Indian Health Services (IHS)", "plan_name": "Commercial", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "First Choice Health Network fka Health InfoNet", "plan_name": "Commercial", "standard_charge_percentage": 85, "methodology": "percent of total billed charges", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Humana Insurance Company", "plan_name": "Humana Medicare Advantage HMO", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Humana Insurance Company", "plan_name": "Humana Medicare Advantage PPO", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Humana Insurance Company", "plan_name": "Humana Medicare Advantage PFFS", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "First Choice Health Network fka Health InfoNet", "plan_name": "Workers Compensation", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Allegiance Provider Direct", "plan_name": "State of Montana Employee Benefit Plan (Self-Funded)", "standard_charge_percentage": 229.99999999999997, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Allegiance Provider Direct", "plan_name": "Montana Municipal Interlocal Authority (MMIA)", "standard_charge_percentage": 229.99999999999997, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Allegiance Provider Direct", "plan_name": "Montana Association of Counties (MACo)", "standard_charge_percentage": 229.99999999999997, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "First Choice Health Network fka Health InfoNet", "plan_name": "Medicare Advantage", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "TriWest Healthcare Alliance Corporation", "plan_name": "TRICARE Prime", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "TriWest Healthcare Alliance Corporation", "plan_name": "TRICARE Select", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Blue Cross Blue Shield of Montana", "plan_name": "HealthLink Network", "standard_charge_percentage": 75, "methodology": "percent of total billed charges", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Blue Cross Blue Shield of Montana", "plan_name": "Traditional Network", "standard_charge_percentage": 75, "methodology": "percent of total billed charges", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Blue Cross Blue Shield of Montana", "plan_name": "POS Network", "standard_charge_percentage": 75, "methodology": "percent of total billed charges", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Blue Cross Blue Shield of Montana", "plan_name": "Closed Plan Network", "standard_charge_percentage": 75, "methodology": "percent of total billed charges", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Blue Cross Blue Shield of Montana", "plan_name": "Retail HMO POS Network", "standard_charge_percentage": 75, "methodology": "percent of total billed charges", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Blue Cross Blue Shield of Montana", "plan_name": "Blue Options Network", "standard_charge_percentage": 75, "methodology": "percent of total billed charges", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "PacificSource Health Plans", "plan_name": "Medicare Advantage", "standard_charge_percentage": 103, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" } ] } ] }, { "description": "Simultaneous Pancreas and Kidney Transplant with Hemodialysis", "code_information": [ { "code": "19", "type": "LOCAL" } ], "standard_charges": [ { "setting": "inpatient", "payers_information": [ { "payer_name": "Blue Cross Blue Shield of Montana", "plan_name": "Medicare Advantage", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "United Healthcare (UHC)", "plan_name": "Medicare Advantage", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "First Choice of the Midwest", "plan_name": "PPO", "standard_charge_percentage": 90, "methodology": "percent of total billed charges", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "United Healthcare (UHC)", "plan_name": "DSNP", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Employee Benefit Management Services (EBMS)", "plan_name": "EBMS SelectCare Network", "standard_charge_percentage": 80, "methodology": "percent of total billed charges", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Allegiance Provider Direct", "plan_name": "Medicare", "standard_charge_percentage": 229.99999999999997, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Claritev fka MultiPlan", "plan_name": "PPO", "standard_charge_percentage": 75, "methodology": "percent of total billed charges", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Medica Insurance Company", "plan_name": "Medicare Cost", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Medicare (CMS)", "plan_name": "Medicare", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Indian Health Services (IHS)", "plan_name": "Commercial", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "First Choice Health Network fka Health InfoNet", "plan_name": "Commercial", "standard_charge_percentage": 85, "methodology": "percent of total billed charges", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Humana Insurance Company", "plan_name": "Humana Medicare Advantage HMO", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Humana Insurance Company", "plan_name": "Humana Medicare Advantage PPO", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Humana Insurance Company", "plan_name": "Humana Medicare Advantage PFFS", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "First Choice Health Network fka Health InfoNet", "plan_name": "Workers Compensation", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Allegiance Provider Direct", "plan_name": "State of Montana Employee Benefit Plan (Self-Funded)", "standard_charge_percentage": 229.99999999999997, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Allegiance Provider Direct", "plan_name": "Montana Municipal Interlocal Authority (MMIA)", "standard_charge_percentage": 229.99999999999997, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Allegiance Provider Direct", "plan_name": "Montana Association of Counties (MACo)", "standard_charge_percentage": 229.99999999999997, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "First Choice Health Network fka Health InfoNet", "plan_name": "Medicare Advantage", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "TriWest Healthcare Alliance Corporation", "plan_name": "TRICARE Prime", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "TriWest Healthcare Alliance Corporation", "plan_name": "TRICARE Select", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Blue Cross Blue Shield of Montana", "plan_name": "HealthLink Network", "standard_charge_percentage": 75, "methodology": "percent of total billed charges", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Blue Cross Blue Shield of Montana", "plan_name": "Traditional Network", "standard_charge_percentage": 75, "methodology": "percent of total billed charges", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Blue Cross Blue Shield of Montana", "plan_name": "POS Network", "standard_charge_percentage": 75, "methodology": "percent of total billed charges", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Blue Cross Blue Shield of Montana", "plan_name": "Closed Plan Network", "standard_charge_percentage": 75, "methodology": "percent of total billed charges", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Blue Cross Blue Shield of Montana", "plan_name": "Retail HMO POS Network", "standard_charge_percentage": 75, "methodology": "percent of total billed charges", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Blue Cross Blue Shield of Montana", "plan_name": "Blue Options Network", "standard_charge_percentage": 75, "methodology": "percent of total billed charges", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "PacificSource Health Plans", "plan_name": "Medicare Advantage", "standard_charge_percentage": 103, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" } ] } ] }, { "description": "Intracranial Vascular Procedures with Principal Diagnosis Hemorrhage with MCC", "code_information": [ { "code": "20", "type": "LOCAL" } ], "standard_charges": [ { "setting": "inpatient", "payers_information": [ { "payer_name": "Blue Cross Blue Shield of Montana", "plan_name": "Medicare Advantage", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "United Healthcare (UHC)", "plan_name": "Medicare Advantage", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "First Choice of the Midwest", "plan_name": "PPO", "standard_charge_percentage": 90, "methodology": "percent of total billed charges", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "United Healthcare (UHC)", "plan_name": "DSNP", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Employee Benefit Management Services (EBMS)", "plan_name": "EBMS SelectCare Network", "standard_charge_percentage": 80, "methodology": "percent of total billed charges", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Allegiance Provider Direct", "plan_name": "Medicare", "standard_charge_percentage": 229.99999999999997, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Claritev fka MultiPlan", "plan_name": "PPO", "standard_charge_percentage": 75, "methodology": "percent of total billed charges", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Medica Insurance Company", "plan_name": "Medicare Cost", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Medicare (CMS)", "plan_name": "Medicare", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Indian Health Services (IHS)", "plan_name": "Commercial", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "First Choice Health Network fka Health InfoNet", "plan_name": "Commercial", "standard_charge_percentage": 85, "methodology": "percent of total billed charges", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Humana Insurance Company", "plan_name": "Humana Medicare Advantage HMO", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Humana Insurance Company", "plan_name": "Humana Medicare Advantage PPO", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Humana Insurance Company", "plan_name": "Humana Medicare Advantage PFFS", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "First Choice Health Network fka Health InfoNet", "plan_name": "Workers Compensation", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Allegiance Provider Direct", "plan_name": "State of Montana Employee Benefit Plan (Self-Funded)", "standard_charge_percentage": 229.99999999999997, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Allegiance Provider Direct", "plan_name": "Montana Municipal Interlocal Authority (MMIA)", "standard_charge_percentage": 229.99999999999997, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Allegiance Provider Direct", "plan_name": "Montana Association of Counties (MACo)", "standard_charge_percentage": 229.99999999999997, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "First Choice Health Network fka Health InfoNet", "plan_name": "Medicare Advantage", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "TriWest Healthcare Alliance Corporation", "plan_name": "TRICARE Prime", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "TriWest Healthcare Alliance Corporation", "plan_name": "TRICARE Select", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Blue Cross Blue Shield of Montana", "plan_name": "HealthLink Network", "standard_charge_percentage": 75, "methodology": "percent of total billed charges", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Blue Cross Blue Shield of Montana", "plan_name": "Traditional Network", "standard_charge_percentage": 75, "methodology": "percent of total billed charges", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Blue Cross Blue Shield of Montana", "plan_name": "POS Network", "standard_charge_percentage": 75, "methodology": "percent of total billed charges", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Blue Cross Blue Shield of Montana", "plan_name": "Closed Plan Network", "standard_charge_percentage": 75, "methodology": "percent of total billed charges", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Blue Cross Blue Shield of Montana", "plan_name": "Retail HMO POS Network", "standard_charge_percentage": 75, "methodology": "percent of total billed charges", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Blue Cross Blue Shield of Montana", "plan_name": "Blue Options Network", "standard_charge_percentage": 75, "methodology": "percent of total billed charges", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "PacificSource Health Plans", "plan_name": "Medicare Advantage", "standard_charge_percentage": 103, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" } ] } ] }, { "description": "Intracranial Vascular Procedures with Principal Diagnosis Hemorrhage with CC", "code_information": [ { "code": "21", "type": "LOCAL" } ], "standard_charges": [ { "setting": "inpatient", "payers_information": [ { "payer_name": "Blue Cross Blue Shield of Montana", "plan_name": "Medicare Advantage", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "United Healthcare (UHC)", "plan_name": "Medicare Advantage", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "First Choice of the Midwest", "plan_name": "PPO", "standard_charge_percentage": 90, "methodology": "percent of total billed charges", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "United Healthcare (UHC)", "plan_name": "DSNP", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Employee Benefit Management Services (EBMS)", "plan_name": "EBMS SelectCare Network", "standard_charge_percentage": 80, "methodology": "percent of total billed charges", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Allegiance Provider Direct", "plan_name": "Medicare", "standard_charge_percentage": 229.99999999999997, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Claritev fka MultiPlan", "plan_name": "PPO", "standard_charge_percentage": 75, "methodology": "percent of total billed charges", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Medica Insurance Company", "plan_name": "Medicare Cost", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Medicare (CMS)", "plan_name": "Medicare", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Indian Health Services (IHS)", "plan_name": "Commercial", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "First Choice Health Network fka Health InfoNet", "plan_name": "Commercial", "standard_charge_percentage": 85, "methodology": "percent of total billed charges", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Humana Insurance Company", "plan_name": "Humana Medicare Advantage HMO", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Humana Insurance Company", "plan_name": "Humana Medicare Advantage PPO", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Humana Insurance Company", "plan_name": "Humana Medicare Advantage PFFS", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "First Choice Health Network fka Health InfoNet", "plan_name": "Workers Compensation", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Allegiance Provider Direct", "plan_name": "State of Montana Employee Benefit Plan (Self-Funded)", "standard_charge_percentage": 229.99999999999997, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Allegiance Provider Direct", "plan_name": "Montana Municipal Interlocal Authority (MMIA)", "standard_charge_percentage": 229.99999999999997, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Allegiance Provider Direct", "plan_name": "Montana Association of Counties (MACo)", "standard_charge_percentage": 229.99999999999997, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "First Choice Health Network fka Health InfoNet", "plan_name": "Medicare Advantage", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "TriWest Healthcare Alliance Corporation", "plan_name": "TRICARE Prime", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "TriWest Healthcare Alliance Corporation", "plan_name": "TRICARE Select", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Blue Cross Blue Shield of Montana", "plan_name": "HealthLink Network", "standard_charge_percentage": 75, "methodology": "percent of total billed charges", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Blue Cross Blue Shield of Montana", "plan_name": "Traditional Network", "standard_charge_percentage": 75, "methodology": "percent of total billed charges", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Blue Cross Blue Shield of Montana", "plan_name": "POS Network", "standard_charge_percentage": 75, "methodology": "percent of total billed charges", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Blue Cross Blue Shield of Montana", "plan_name": "Closed Plan Network", "standard_charge_percentage": 75, "methodology": "percent of total billed charges", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Blue Cross Blue Shield of Montana", "plan_name": "Retail HMO POS Network", "standard_charge_percentage": 75, "methodology": "percent of total billed charges", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Blue Cross Blue Shield of Montana", "plan_name": "Blue Options Network", "standard_charge_percentage": 75, "methodology": "percent of total billed charges", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "PacificSource Health Plans", "plan_name": "Medicare Advantage", "standard_charge_percentage": 103, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" } ] } ] }, { "description": "Intracranial Vascular Procedures with Principal Diagnosis Hemorrhage without CC/MCC", "code_information": [ { "code": "22", "type": "LOCAL" } ], "standard_charges": [ { "setting": "inpatient", "payers_information": [ { "payer_name": "Blue Cross Blue Shield of Montana", "plan_name": "Medicare Advantage", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "United Healthcare (UHC)", "plan_name": "Medicare Advantage", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "First Choice of the Midwest", "plan_name": "PPO", "standard_charge_percentage": 90, "methodology": "percent of total billed charges", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "United Healthcare (UHC)", "plan_name": "DSNP", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Employee Benefit Management Services (EBMS)", "plan_name": "EBMS SelectCare Network", "standard_charge_percentage": 80, "methodology": "percent of total billed charges", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Allegiance Provider Direct", "plan_name": "Medicare", "standard_charge_percentage": 229.99999999999997, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Claritev fka MultiPlan", "plan_name": "PPO", "standard_charge_percentage": 75, "methodology": "percent of total billed charges", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Medica Insurance Company", "plan_name": "Medicare Cost", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Medicare (CMS)", "plan_name": "Medicare", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Indian Health Services (IHS)", "plan_name": "Commercial", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "First Choice Health Network fka Health InfoNet", "plan_name": "Commercial", "standard_charge_percentage": 85, "methodology": "percent of total billed charges", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Humana Insurance Company", "plan_name": "Humana Medicare Advantage HMO", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Humana Insurance Company", "plan_name": "Humana Medicare Advantage PPO", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Humana Insurance Company", "plan_name": "Humana Medicare Advantage PFFS", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "First Choice Health Network fka Health InfoNet", "plan_name": "Workers Compensation", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Allegiance Provider Direct", "plan_name": "State of Montana Employee Benefit Plan (Self-Funded)", "standard_charge_percentage": 229.99999999999997, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Allegiance Provider Direct", "plan_name": "Montana Municipal Interlocal Authority (MMIA)", "standard_charge_percentage": 229.99999999999997, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Allegiance Provider Direct", "plan_name": "Montana Association of Counties (MACo)", "standard_charge_percentage": 229.99999999999997, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "First Choice Health Network fka Health InfoNet", "plan_name": "Medicare Advantage", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "TriWest Healthcare Alliance Corporation", "plan_name": "TRICARE Prime", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "TriWest Healthcare Alliance Corporation", "plan_name": "TRICARE Select", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Blue Cross Blue Shield of Montana", "plan_name": "HealthLink Network", "standard_charge_percentage": 75, "methodology": "percent of total billed charges", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Blue Cross Blue Shield of Montana", "plan_name": "Traditional Network", "standard_charge_percentage": 75, "methodology": "percent of total billed charges", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Blue Cross Blue Shield of Montana", "plan_name": "POS Network", "standard_charge_percentage": 75, "methodology": "percent of total billed charges", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Blue Cross Blue Shield of Montana", "plan_name": "Closed Plan Network", "standard_charge_percentage": 75, "methodology": "percent of total billed charges", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Blue Cross Blue Shield of Montana", "plan_name": "Retail HMO POS Network", "standard_charge_percentage": 75, "methodology": "percent of total billed charges", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Blue Cross Blue Shield of Montana", "plan_name": "Blue Options Network", "standard_charge_percentage": 75, "methodology": "percent of total billed charges", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "PacificSource Health Plans", "plan_name": "Medicare Advantage", "standard_charge_percentage": 103, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" } ] } ] }, { "description": "Craniotomy with Major Device Implant or Acute Complex CNS Principal Diagnosis with MCC or Antineoplastic Implant or Epilepsy with Neurostimulator", "code_information": [ { "code": "23", "type": "LOCAL" } ], "standard_charges": [ { "setting": "inpatient", "payers_information": [ { "payer_name": "Blue Cross Blue Shield of Montana", "plan_name": "Medicare Advantage", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "United Healthcare (UHC)", "plan_name": "Medicare Advantage", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "First Choice of the Midwest", "plan_name": "PPO", "standard_charge_percentage": 90, "methodology": "percent of total billed charges", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "United Healthcare (UHC)", "plan_name": "DSNP", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Employee Benefit Management Services (EBMS)", "plan_name": "EBMS SelectCare Network", "standard_charge_percentage": 80, "methodology": "percent of total billed charges", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Allegiance Provider Direct", "plan_name": "Medicare", "standard_charge_percentage": 229.99999999999997, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Claritev fka MultiPlan", "plan_name": "PPO", "standard_charge_percentage": 75, "methodology": "percent of total billed charges", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Medica Insurance Company", "plan_name": "Medicare Cost", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Medicare (CMS)", "plan_name": "Medicare", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Indian Health Services (IHS)", "plan_name": "Commercial", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "First Choice Health Network fka Health InfoNet", "plan_name": "Commercial", "standard_charge_percentage": 85, "methodology": "percent of total billed charges", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Humana Insurance Company", "plan_name": "Humana Medicare Advantage HMO", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Humana Insurance Company", "plan_name": "Humana Medicare Advantage PPO", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Humana Insurance Company", "plan_name": "Humana Medicare Advantage PFFS", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "First Choice Health Network fka Health InfoNet", "plan_name": "Workers Compensation", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Allegiance Provider Direct", "plan_name": "State of Montana Employee Benefit Plan (Self-Funded)", "standard_charge_percentage": 229.99999999999997, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Allegiance Provider Direct", "plan_name": "Montana Municipal Interlocal Authority (MMIA)", "standard_charge_percentage": 229.99999999999997, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Allegiance Provider Direct", "plan_name": "Montana Association of Counties (MACo)", "standard_charge_percentage": 229.99999999999997, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "First Choice Health Network fka Health InfoNet", "plan_name": "Medicare Advantage", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "TriWest Healthcare Alliance Corporation", "plan_name": "TRICARE Prime", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "TriWest Healthcare Alliance Corporation", "plan_name": "TRICARE Select", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Blue Cross Blue Shield of Montana", "plan_name": "HealthLink Network", "standard_charge_percentage": 75, "methodology": "percent of total billed charges", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Blue Cross Blue Shield of Montana", "plan_name": "Traditional Network", "standard_charge_percentage": 75, "methodology": "percent of total billed charges", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Blue Cross Blue Shield of Montana", "plan_name": "POS Network", "standard_charge_percentage": 75, "methodology": "percent of total billed charges", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Blue Cross Blue Shield of Montana", "plan_name": "Closed Plan Network", "standard_charge_percentage": 75, "methodology": "percent of total billed charges", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Blue Cross Blue Shield of Montana", "plan_name": "Retail HMO POS Network", "standard_charge_percentage": 75, "methodology": "percent of total billed charges", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Blue Cross Blue Shield of Montana", "plan_name": "Blue Options Network", "standard_charge_percentage": 75, "methodology": "percent of total billed charges", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "PacificSource Health Plans", "plan_name": "Medicare Advantage", "standard_charge_percentage": 103, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" } ] } ] }, { "description": "Craniotomy with Major Device Implant or Acute Complex CNS Principal Diagnosis without MCC", "code_information": [ { "code": "24", "type": "LOCAL" } ], "standard_charges": [ { "setting": "inpatient", "payers_information": [ { "payer_name": "Blue Cross Blue Shield of Montana", "plan_name": "Medicare Advantage", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "United Healthcare (UHC)", "plan_name": "Medicare Advantage", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "First Choice of the Midwest", "plan_name": "PPO", "standard_charge_percentage": 90, "methodology": "percent of total billed charges", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "United Healthcare (UHC)", "plan_name": "DSNP", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Employee Benefit Management Services (EBMS)", "plan_name": "EBMS SelectCare Network", "standard_charge_percentage": 80, "methodology": "percent of total billed charges", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Allegiance Provider Direct", "plan_name": "Medicare", "standard_charge_percentage": 229.99999999999997, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Claritev fka MultiPlan", "plan_name": "PPO", "standard_charge_percentage": 75, "methodology": "percent of total billed charges", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Medica Insurance Company", "plan_name": "Medicare Cost", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Medicare (CMS)", "plan_name": "Medicare", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Indian Health Services (IHS)", "plan_name": "Commercial", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "First Choice Health Network fka Health InfoNet", "plan_name": "Commercial", "standard_charge_percentage": 85, "methodology": "percent of total billed charges", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Humana Insurance Company", "plan_name": "Humana Medicare Advantage HMO", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Humana Insurance Company", "plan_name": "Humana Medicare Advantage PPO", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Humana Insurance Company", "plan_name": "Humana Medicare Advantage PFFS", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "First Choice Health Network fka Health InfoNet", "plan_name": "Workers Compensation", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Allegiance Provider Direct", "plan_name": "State of Montana Employee Benefit Plan (Self-Funded)", "standard_charge_percentage": 229.99999999999997, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Allegiance Provider Direct", "plan_name": "Montana Municipal Interlocal Authority (MMIA)", "standard_charge_percentage": 229.99999999999997, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Allegiance Provider Direct", "plan_name": "Montana Association of Counties (MACo)", "standard_charge_percentage": 229.99999999999997, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "First Choice Health Network fka Health InfoNet", "plan_name": "Medicare Advantage", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "TriWest Healthcare Alliance Corporation", "plan_name": "TRICARE Prime", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "TriWest Healthcare Alliance Corporation", "plan_name": "TRICARE Select", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Blue Cross Blue Shield of Montana", "plan_name": "HealthLink Network", "standard_charge_percentage": 75, "methodology": "percent of total billed charges", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Blue Cross Blue Shield of Montana", "plan_name": "Traditional Network", "standard_charge_percentage": 75, "methodology": "percent of total billed charges", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Blue Cross Blue Shield of Montana", "plan_name": "POS Network", "standard_charge_percentage": 75, "methodology": "percent of total billed charges", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Blue Cross Blue Shield of Montana", "plan_name": "Closed Plan Network", "standard_charge_percentage": 75, "methodology": "percent of total billed charges", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Blue Cross Blue Shield of Montana", "plan_name": "Retail HMO POS Network", "standard_charge_percentage": 75, "methodology": "percent of total billed charges", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Blue Cross Blue Shield of Montana", "plan_name": "Blue Options Network", "standard_charge_percentage": 75, "methodology": "percent of total billed charges", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "PacificSource Health Plans", "plan_name": "Medicare Advantage", "standard_charge_percentage": 103, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" } ] } ] }, { "description": "Craniotomy and Endovascular Intracranial Procedures with MCC", "code_information": [ { "code": "25", "type": "LOCAL" } ], "standard_charges": [ { "setting": "inpatient", "payers_information": [ { "payer_name": "Blue Cross Blue Shield of Montana", "plan_name": "Medicare Advantage", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "United Healthcare (UHC)", "plan_name": "Medicare Advantage", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "First Choice of the Midwest", "plan_name": "PPO", "standard_charge_percentage": 90, "methodology": "percent of total billed charges", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "United Healthcare (UHC)", "plan_name": "DSNP", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Employee Benefit Management Services (EBMS)", "plan_name": "EBMS SelectCare Network", "standard_charge_percentage": 80, "methodology": "percent of total billed charges", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Allegiance Provider Direct", "plan_name": "Medicare", "standard_charge_percentage": 229.99999999999997, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Claritev fka MultiPlan", "plan_name": "PPO", "standard_charge_percentage": 75, "methodology": "percent of total billed charges", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Medica Insurance Company", "plan_name": "Medicare Cost", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Medicare (CMS)", "plan_name": "Medicare", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Indian Health Services (IHS)", "plan_name": "Commercial", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "First Choice Health Network fka Health InfoNet", "plan_name": "Commercial", "standard_charge_percentage": 85, "methodology": "percent of total billed charges", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Humana Insurance Company", "plan_name": "Humana Medicare Advantage HMO", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Humana Insurance Company", "plan_name": "Humana Medicare Advantage PPO", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Humana Insurance Company", "plan_name": "Humana Medicare Advantage PFFS", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "First Choice Health Network fka Health InfoNet", "plan_name": "Workers Compensation", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Allegiance Provider Direct", "plan_name": "State of Montana Employee Benefit Plan (Self-Funded)", "standard_charge_percentage": 229.99999999999997, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Allegiance Provider Direct", "plan_name": "Montana Municipal Interlocal Authority (MMIA)", "standard_charge_percentage": 229.99999999999997, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Allegiance Provider Direct", "plan_name": "Montana Association of Counties (MACo)", "standard_charge_percentage": 229.99999999999997, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "First Choice Health Network fka Health InfoNet", "plan_name": "Medicare Advantage", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "TriWest Healthcare Alliance Corporation", "plan_name": "TRICARE Prime", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "TriWest Healthcare Alliance Corporation", "plan_name": "TRICARE Select", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Blue Cross Blue Shield of Montana", "plan_name": "HealthLink Network", "standard_charge_percentage": 75, "methodology": "percent of total billed charges", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Blue Cross Blue Shield of Montana", "plan_name": "Traditional Network", "standard_charge_percentage": 75, "methodology": "percent of total billed charges", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Blue Cross Blue Shield of Montana", "plan_name": "POS Network", "standard_charge_percentage": 75, "methodology": "percent of total billed charges", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Blue Cross Blue Shield of Montana", "plan_name": "Closed Plan Network", "standard_charge_percentage": 75, "methodology": "percent of total billed charges", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Blue Cross Blue Shield of Montana", "plan_name": "Retail HMO POS Network", "standard_charge_percentage": 75, "methodology": "percent of total billed charges", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Blue Cross Blue Shield of Montana", "plan_name": "Blue Options Network", "standard_charge_percentage": 75, "methodology": "percent of total billed charges", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "PacificSource Health Plans", "plan_name": "Medicare Advantage", "standard_charge_percentage": 103, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" } ] } ] }, { "description": "Craniotomy and Endovascular Intracranial Procedures with CC", "code_information": [ { "code": "26", "type": "LOCAL" } ], "standard_charges": [ { "setting": "inpatient", "payers_information": [ { "payer_name": "Blue Cross Blue Shield of Montana", "plan_name": "Medicare Advantage", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "United Healthcare (UHC)", "plan_name": "Medicare Advantage", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "First Choice of the Midwest", "plan_name": "PPO", "standard_charge_percentage": 90, "methodology": "percent of total billed charges", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "United Healthcare (UHC)", "plan_name": "DSNP", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Employee Benefit Management Services (EBMS)", "plan_name": "EBMS SelectCare Network", "standard_charge_percentage": 80, "methodology": "percent of total billed charges", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Allegiance Provider Direct", "plan_name": "Medicare", "standard_charge_percentage": 229.99999999999997, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Claritev fka MultiPlan", "plan_name": "PPO", "standard_charge_percentage": 75, "methodology": "percent of total billed charges", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Medica Insurance Company", "plan_name": "Medicare Cost", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Medicare (CMS)", "plan_name": "Medicare", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Indian Health Services (IHS)", "plan_name": "Commercial", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "First Choice Health Network fka Health InfoNet", "plan_name": "Commercial", "standard_charge_percentage": 85, "methodology": "percent of total billed charges", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Humana Insurance Company", "plan_name": "Humana Medicare Advantage HMO", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Humana Insurance Company", "plan_name": "Humana Medicare Advantage PPO", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Humana Insurance Company", "plan_name": "Humana Medicare Advantage PFFS", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "First Choice Health Network fka Health InfoNet", "plan_name": "Workers Compensation", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Allegiance Provider Direct", "plan_name": "State of Montana Employee Benefit Plan (Self-Funded)", "standard_charge_percentage": 229.99999999999997, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Allegiance Provider Direct", "plan_name": "Montana Municipal Interlocal Authority (MMIA)", "standard_charge_percentage": 229.99999999999997, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Allegiance Provider Direct", "plan_name": "Montana Association of Counties (MACo)", "standard_charge_percentage": 229.99999999999997, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "First Choice Health Network fka Health InfoNet", "plan_name": "Medicare Advantage", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "TriWest Healthcare Alliance Corporation", "plan_name": "TRICARE Prime", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "TriWest Healthcare Alliance Corporation", "plan_name": "TRICARE Select", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Blue Cross Blue Shield of Montana", "plan_name": "HealthLink Network", "standard_charge_percentage": 75, "methodology": "percent of total billed charges", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Blue Cross Blue Shield of Montana", "plan_name": "Traditional Network", "standard_charge_percentage": 75, "methodology": "percent of total billed charges", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Blue Cross Blue Shield of Montana", "plan_name": "POS Network", "standard_charge_percentage": 75, "methodology": "percent of total billed charges", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Blue Cross Blue Shield of Montana", "plan_name": "Closed Plan Network", "standard_charge_percentage": 75, "methodology": "percent of total billed charges", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Blue Cross Blue Shield of Montana", "plan_name": "Retail HMO POS Network", "standard_charge_percentage": 75, "methodology": "percent of total billed charges", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Blue Cross Blue Shield of Montana", "plan_name": "Blue Options Network", "standard_charge_percentage": 75, "methodology": "percent of total billed charges", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "PacificSource Health Plans", "plan_name": "Medicare Advantage", "standard_charge_percentage": 103, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" } ] } ] }, { "description": "Craniotomy and Endovascular Intracranial Procedures without CC/MCC", "code_information": [ { "code": "27", "type": "LOCAL" } ], "standard_charges": [ { "setting": "inpatient", "payers_information": [ { "payer_name": "Blue Cross Blue Shield of Montana", "plan_name": "Medicare Advantage", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "United Healthcare (UHC)", "plan_name": "Medicare Advantage", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "First Choice of the Midwest", "plan_name": "PPO", "standard_charge_percentage": 90, "methodology": "percent of total billed charges", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "United Healthcare (UHC)", "plan_name": "DSNP", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Employee Benefit Management Services (EBMS)", "plan_name": "EBMS SelectCare Network", "standard_charge_percentage": 80, "methodology": "percent of total billed charges", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Allegiance Provider Direct", "plan_name": "Medicare", "standard_charge_percentage": 229.99999999999997, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Claritev fka MultiPlan", "plan_name": "PPO", "standard_charge_percentage": 75, "methodology": "percent of total billed charges", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Medica Insurance Company", "plan_name": "Medicare Cost", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Medicare (CMS)", "plan_name": "Medicare", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Indian Health Services (IHS)", "plan_name": "Commercial", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "First Choice Health Network fka Health InfoNet", "plan_name": "Commercial", "standard_charge_percentage": 85, "methodology": "percent of total billed charges", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Humana Insurance Company", "plan_name": "Humana Medicare Advantage HMO", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Humana Insurance Company", "plan_name": "Humana Medicare Advantage PPO", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Humana Insurance Company", "plan_name": "Humana Medicare Advantage PFFS", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "First Choice Health Network fka Health InfoNet", "plan_name": "Workers Compensation", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Allegiance Provider Direct", "plan_name": "State of Montana Employee Benefit Plan (Self-Funded)", "standard_charge_percentage": 229.99999999999997, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Allegiance Provider Direct", "plan_name": "Montana Municipal Interlocal Authority (MMIA)", "standard_charge_percentage": 229.99999999999997, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Allegiance Provider Direct", "plan_name": "Montana Association of Counties (MACo)", "standard_charge_percentage": 229.99999999999997, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "First Choice Health Network fka Health InfoNet", "plan_name": "Medicare Advantage", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "TriWest Healthcare Alliance Corporation", "plan_name": "TRICARE Prime", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "TriWest Healthcare Alliance Corporation", "plan_name": "TRICARE Select", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Blue Cross Blue Shield of Montana", "plan_name": "HealthLink Network", "standard_charge_percentage": 75, "methodology": "percent of total billed charges", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Blue Cross Blue Shield of Montana", "plan_name": "Traditional Network", "standard_charge_percentage": 75, "methodology": "percent of total billed charges", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Blue Cross Blue Shield of Montana", "plan_name": "POS Network", "standard_charge_percentage": 75, "methodology": "percent of total billed charges", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Blue Cross Blue Shield of Montana", "plan_name": "Closed Plan Network", "standard_charge_percentage": 75, "methodology": "percent of total billed charges", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Blue Cross Blue Shield of Montana", "plan_name": "Retail HMO POS Network", "standard_charge_percentage": 75, "methodology": "percent of total billed charges", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Blue Cross Blue Shield of Montana", "plan_name": "Blue Options Network", "standard_charge_percentage": 75, "methodology": "percent of total billed charges", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "PacificSource Health Plans", "plan_name": "Medicare Advantage", "standard_charge_percentage": 103, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" } ] } ] }, { "description": "Spinal Procedures with MCC", "code_information": [ { "code": "28", "type": "LOCAL" } ], "standard_charges": [ { "setting": "inpatient", "payers_information": [ { "payer_name": "Blue Cross Blue Shield of Montana", "plan_name": "Medicare Advantage", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "United Healthcare (UHC)", "plan_name": "Medicare Advantage", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "First Choice of the Midwest", "plan_name": "PPO", "standard_charge_percentage": 90, "methodology": "percent of total billed charges", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "United Healthcare (UHC)", "plan_name": "DSNP", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Employee Benefit Management Services (EBMS)", "plan_name": "EBMS SelectCare Network", "standard_charge_percentage": 80, "methodology": "percent of total billed charges", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Allegiance Provider Direct", "plan_name": "Medicare", "standard_charge_percentage": 229.99999999999997, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Claritev fka MultiPlan", "plan_name": "PPO", "standard_charge_percentage": 75, "methodology": "percent of total billed charges", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Medica Insurance Company", "plan_name": "Medicare Cost", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Medicare (CMS)", "plan_name": "Medicare", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Indian Health Services (IHS)", "plan_name": "Commercial", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "First Choice Health Network fka Health InfoNet", "plan_name": "Commercial", "standard_charge_percentage": 85, "methodology": "percent of total billed charges", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Humana Insurance Company", "plan_name": "Humana Medicare Advantage HMO", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Humana Insurance Company", "plan_name": "Humana Medicare Advantage PPO", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Humana Insurance Company", "plan_name": "Humana Medicare Advantage PFFS", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "First Choice Health Network fka Health InfoNet", "plan_name": "Workers Compensation", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Allegiance Provider Direct", "plan_name": "State of Montana Employee Benefit Plan (Self-Funded)", "standard_charge_percentage": 229.99999999999997, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Allegiance Provider Direct", "plan_name": "Montana Municipal Interlocal Authority (MMIA)", "standard_charge_percentage": 229.99999999999997, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Allegiance Provider Direct", "plan_name": "Montana Association of Counties (MACo)", "standard_charge_percentage": 229.99999999999997, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "First Choice Health Network fka Health InfoNet", "plan_name": "Medicare Advantage", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "TriWest Healthcare Alliance Corporation", "plan_name": "TRICARE Prime", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "TriWest Healthcare Alliance Corporation", "plan_name": "TRICARE Select", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Blue Cross Blue Shield of Montana", "plan_name": "HealthLink Network", "standard_charge_percentage": 75, "methodology": "percent of total billed charges", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Blue Cross Blue Shield of Montana", "plan_name": "Traditional Network", "standard_charge_percentage": 75, "methodology": "percent of total billed charges", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Blue Cross Blue Shield of Montana", "plan_name": "POS Network", "standard_charge_percentage": 75, "methodology": "percent of total billed charges", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Blue Cross Blue Shield of Montana", "plan_name": "Closed Plan Network", "standard_charge_percentage": 75, "methodology": "percent of total billed charges", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Blue Cross Blue Shield of Montana", "plan_name": "Retail HMO POS Network", "standard_charge_percentage": 75, "methodology": "percent of total billed charges", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Blue Cross Blue Shield of Montana", "plan_name": "Blue Options Network", "standard_charge_percentage": 75, "methodology": "percent of total billed charges", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "PacificSource Health Plans", "plan_name": "Medicare Advantage", "standard_charge_percentage": 103, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" } ] } ] }, { "description": "Spinal Procedures with CC or Spinal Neurostimulators", "code_information": [ { "code": "29", "type": "LOCAL" } ], "standard_charges": [ { "setting": "inpatient", "payers_information": [ { "payer_name": "Blue Cross Blue Shield of Montana", "plan_name": "Medicare Advantage", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "United Healthcare (UHC)", "plan_name": "Medicare Advantage", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "First Choice of the Midwest", "plan_name": "PPO", "standard_charge_percentage": 90, "methodology": "percent of total billed charges", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "United Healthcare (UHC)", "plan_name": "DSNP", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Employee Benefit Management Services (EBMS)", "plan_name": "EBMS SelectCare Network", "standard_charge_percentage": 80, "methodology": "percent of total billed charges", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Allegiance Provider Direct", "plan_name": "Medicare", "standard_charge_percentage": 229.99999999999997, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Claritev fka MultiPlan", "plan_name": "PPO", "standard_charge_percentage": 75, "methodology": "percent of total billed charges", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Medica Insurance Company", "plan_name": "Medicare Cost", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Medicare (CMS)", "plan_name": "Medicare", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Indian Health Services (IHS)", "plan_name": "Commercial", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "First Choice Health Network fka Health InfoNet", "plan_name": "Commercial", "standard_charge_percentage": 85, "methodology": "percent of total billed charges", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Humana Insurance Company", "plan_name": "Humana Medicare Advantage HMO", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Humana Insurance Company", "plan_name": "Humana Medicare Advantage PPO", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Humana Insurance Company", "plan_name": "Humana Medicare Advantage PFFS", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "First Choice Health Network fka Health InfoNet", "plan_name": "Workers Compensation", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Allegiance Provider Direct", "plan_name": "State of Montana Employee Benefit Plan (Self-Funded)", "standard_charge_percentage": 229.99999999999997, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Allegiance Provider Direct", "plan_name": "Montana Municipal Interlocal Authority (MMIA)", "standard_charge_percentage": 229.99999999999997, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Allegiance Provider Direct", "plan_name": "Montana Association of Counties (MACo)", "standard_charge_percentage": 229.99999999999997, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "First Choice Health Network fka Health InfoNet", "plan_name": "Medicare Advantage", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "TriWest Healthcare Alliance Corporation", "plan_name": "TRICARE Prime", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "TriWest Healthcare Alliance Corporation", "plan_name": "TRICARE Select", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Blue Cross Blue Shield of Montana", "plan_name": "HealthLink Network", "standard_charge_percentage": 75, "methodology": "percent of total billed charges", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Blue Cross Blue Shield of Montana", "plan_name": "Traditional Network", "standard_charge_percentage": 75, "methodology": "percent of total billed charges", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Blue Cross Blue Shield of Montana", "plan_name": "POS Network", "standard_charge_percentage": 75, "methodology": "percent of total billed charges", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Blue Cross Blue Shield of Montana", "plan_name": "Closed Plan Network", "standard_charge_percentage": 75, "methodology": "percent of total billed charges", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Blue Cross Blue Shield of Montana", "plan_name": "Retail HMO POS Network", "standard_charge_percentage": 75, "methodology": "percent of total billed charges", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Blue Cross Blue Shield of Montana", "plan_name": "Blue Options Network", "standard_charge_percentage": 75, "methodology": "percent of total billed charges", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "PacificSource Health Plans", "plan_name": "Medicare Advantage", "standard_charge_percentage": 103, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" } ] } ] }, { "description": "Spinal Procedures without CC/MCC", "code_information": [ { "code": "30", "type": "LOCAL" } ], "standard_charges": [ { "setting": "inpatient", "payers_information": [ { "payer_name": "Blue Cross Blue Shield of Montana", "plan_name": "Medicare Advantage", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "United Healthcare (UHC)", "plan_name": "Medicare Advantage", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "First Choice of the Midwest", "plan_name": "PPO", "standard_charge_percentage": 90, "methodology": "percent of total billed charges", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "United Healthcare (UHC)", "plan_name": "DSNP", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Employee Benefit Management Services (EBMS)", "plan_name": "EBMS SelectCare Network", "standard_charge_percentage": 80, "methodology": "percent of total billed charges", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Allegiance Provider Direct", "plan_name": "Medicare", "standard_charge_percentage": 229.99999999999997, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Claritev fka MultiPlan", "plan_name": "PPO", "standard_charge_percentage": 75, "methodology": "percent of total billed charges", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Medica Insurance Company", "plan_name": "Medicare Cost", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Medicare (CMS)", "plan_name": "Medicare", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Indian Health Services (IHS)", "plan_name": "Commercial", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "First Choice Health Network fka Health InfoNet", "plan_name": "Commercial", "standard_charge_percentage": 85, "methodology": "percent of total billed charges", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Humana Insurance Company", "plan_name": "Humana Medicare Advantage HMO", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Humana Insurance Company", "plan_name": "Humana Medicare Advantage PPO", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Humana Insurance Company", "plan_name": "Humana Medicare Advantage PFFS", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "First Choice Health Network fka Health InfoNet", "plan_name": "Workers Compensation", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Allegiance Provider Direct", "plan_name": "State of Montana Employee Benefit Plan (Self-Funded)", "standard_charge_percentage": 229.99999999999997, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Allegiance Provider Direct", "plan_name": "Montana Municipal Interlocal Authority (MMIA)", "standard_charge_percentage": 229.99999999999997, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Allegiance Provider Direct", "plan_name": "Montana Association of Counties (MACo)", "standard_charge_percentage": 229.99999999999997, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "First Choice Health Network fka Health InfoNet", "plan_name": "Medicare Advantage", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "TriWest Healthcare Alliance Corporation", "plan_name": "TRICARE Prime", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "TriWest Healthcare Alliance Corporation", "plan_name": "TRICARE Select", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Blue Cross Blue Shield of Montana", "plan_name": "HealthLink Network", "standard_charge_percentage": 75, "methodology": "percent of total billed charges", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Blue Cross Blue Shield of Montana", "plan_name": "Traditional Network", "standard_charge_percentage": 75, "methodology": "percent of total billed charges", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Blue Cross Blue Shield of Montana", "plan_name": "POS Network", "standard_charge_percentage": 75, "methodology": "percent of total billed charges", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Blue Cross Blue Shield of Montana", "plan_name": "Closed Plan Network", "standard_charge_percentage": 75, "methodology": "percent of total billed charges", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Blue Cross Blue Shield of Montana", "plan_name": "Retail HMO POS Network", "standard_charge_percentage": 75, "methodology": "percent of total billed charges", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Blue Cross Blue Shield of Montana", "plan_name": "Blue Options Network", "standard_charge_percentage": 75, "methodology": "percent of total billed charges", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "PacificSource Health Plans", "plan_name": "Medicare Advantage", "standard_charge_percentage": 103, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" } ] } ] }, { "description": "Ventricular Shunt Procedures with MCC", "code_information": [ { "code": "31", "type": "LOCAL" } ], "standard_charges": [ { "setting": "inpatient", "payers_information": [ { "payer_name": "Blue Cross Blue Shield of Montana", "plan_name": "Medicare Advantage", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "United Healthcare (UHC)", "plan_name": "Medicare Advantage", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "First Choice of the Midwest", "plan_name": "PPO", "standard_charge_percentage": 90, "methodology": "percent of total billed charges", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "United Healthcare (UHC)", "plan_name": "DSNP", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Employee Benefit Management Services (EBMS)", "plan_name": "EBMS SelectCare Network", "standard_charge_percentage": 80, "methodology": "percent of total billed charges", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Allegiance Provider Direct", "plan_name": "Medicare", "standard_charge_percentage": 229.99999999999997, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Claritev fka MultiPlan", "plan_name": "PPO", "standard_charge_percentage": 75, "methodology": "percent of total billed charges", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Medica Insurance Company", "plan_name": "Medicare Cost", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Medicare (CMS)", "plan_name": "Medicare", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Indian Health Services (IHS)", "plan_name": "Commercial", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "First Choice Health Network fka Health InfoNet", "plan_name": "Commercial", "standard_charge_percentage": 85, "methodology": "percent of total billed charges", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Humana Insurance Company", "plan_name": "Humana Medicare Advantage HMO", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Humana Insurance Company", "plan_name": "Humana Medicare Advantage PPO", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Humana Insurance Company", "plan_name": "Humana Medicare Advantage PFFS", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "First Choice Health Network fka Health InfoNet", "plan_name": "Workers Compensation", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Allegiance Provider Direct", "plan_name": "State of Montana Employee Benefit Plan (Self-Funded)", "standard_charge_percentage": 229.99999999999997, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Allegiance Provider Direct", "plan_name": "Montana Municipal Interlocal Authority (MMIA)", "standard_charge_percentage": 229.99999999999997, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Allegiance Provider Direct", "plan_name": "Montana Association of Counties (MACo)", "standard_charge_percentage": 229.99999999999997, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "First Choice Health Network fka Health InfoNet", "plan_name": "Medicare Advantage", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "TriWest Healthcare Alliance Corporation", "plan_name": "TRICARE Prime", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "TriWest Healthcare Alliance Corporation", "plan_name": "TRICARE Select", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Blue Cross Blue Shield of Montana", "plan_name": "HealthLink Network", "standard_charge_percentage": 75, "methodology": "percent of total billed charges", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Blue Cross Blue Shield of Montana", "plan_name": "Traditional Network", "standard_charge_percentage": 75, "methodology": "percent of total billed charges", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Blue Cross Blue Shield of Montana", "plan_name": "POS Network", "standard_charge_percentage": 75, "methodology": "percent of total billed charges", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Blue Cross Blue Shield of Montana", "plan_name": "Closed Plan Network", "standard_charge_percentage": 75, "methodology": "percent of total billed charges", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Blue Cross Blue Shield of Montana", "plan_name": "Retail HMO POS Network", "standard_charge_percentage": 75, "methodology": "percent of total billed charges", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Blue Cross Blue Shield of Montana", "plan_name": "Blue Options Network", "standard_charge_percentage": 75, "methodology": "percent of total billed charges", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "PacificSource Health Plans", "plan_name": "Medicare Advantage", "standard_charge_percentage": 103, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" } ] } ] }, { "description": "Ventricular Shunt Procedures with CC", "code_information": [ { "code": "32", "type": "LOCAL" } ], "standard_charges": [ { "setting": "inpatient", "payers_information": [ { "payer_name": "Blue Cross Blue Shield of Montana", "plan_name": "Medicare Advantage", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "United Healthcare (UHC)", "plan_name": "Medicare Advantage", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "First Choice of the Midwest", "plan_name": "PPO", "standard_charge_percentage": 90, "methodology": "percent of total billed charges", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "United Healthcare (UHC)", "plan_name": "DSNP", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Employee Benefit Management Services (EBMS)", "plan_name": "EBMS SelectCare Network", "standard_charge_percentage": 80, "methodology": "percent of total billed charges", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Allegiance Provider Direct", "plan_name": "Medicare", "standard_charge_percentage": 229.99999999999997, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Claritev fka MultiPlan", "plan_name": "PPO", "standard_charge_percentage": 75, "methodology": "percent of total billed charges", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Medica Insurance Company", "plan_name": "Medicare Cost", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Medicare (CMS)", "plan_name": "Medicare", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Indian Health Services (IHS)", "plan_name": "Commercial", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "First Choice Health Network fka Health InfoNet", "plan_name": "Commercial", "standard_charge_percentage": 85, "methodology": "percent of total billed charges", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Humana Insurance Company", "plan_name": "Humana Medicare Advantage HMO", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Humana Insurance Company", "plan_name": "Humana Medicare Advantage PPO", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Humana Insurance Company", "plan_name": "Humana Medicare Advantage PFFS", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "First Choice Health Network fka Health InfoNet", "plan_name": "Workers Compensation", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Allegiance Provider Direct", "plan_name": "State of Montana Employee Benefit Plan (Self-Funded)", "standard_charge_percentage": 229.99999999999997, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Allegiance Provider Direct", "plan_name": "Montana Municipal Interlocal Authority (MMIA)", "standard_charge_percentage": 229.99999999999997, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Allegiance Provider Direct", "plan_name": "Montana Association of Counties (MACo)", "standard_charge_percentage": 229.99999999999997, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "First Choice Health Network fka Health InfoNet", "plan_name": "Medicare Advantage", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "TriWest Healthcare Alliance Corporation", "plan_name": "TRICARE Prime", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "TriWest Healthcare Alliance Corporation", "plan_name": "TRICARE Select", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Blue Cross Blue Shield of Montana", "plan_name": "HealthLink Network", "standard_charge_percentage": 75, "methodology": "percent of total billed charges", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Blue Cross Blue Shield of Montana", "plan_name": "Traditional Network", "standard_charge_percentage": 75, "methodology": "percent of total billed charges", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Blue Cross Blue Shield of Montana", "plan_name": "POS Network", "standard_charge_percentage": 75, "methodology": "percent of total billed charges", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Blue Cross Blue Shield of Montana", "plan_name": "Closed Plan Network", "standard_charge_percentage": 75, "methodology": "percent of total billed charges", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Blue Cross Blue Shield of Montana", "plan_name": "Retail HMO POS Network", "standard_charge_percentage": 75, "methodology": "percent of total billed charges", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Blue Cross Blue Shield of Montana", "plan_name": "Blue Options Network", "standard_charge_percentage": 75, "methodology": "percent of total billed charges", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "PacificSource Health Plans", "plan_name": "Medicare Advantage", "standard_charge_percentage": 103, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" } ] } ] }, { "description": "Ventricular Shunt Procedures without CC/MCC", "code_information": [ { "code": "33", "type": "LOCAL" } ], "standard_charges": [ { "setting": "inpatient", "payers_information": [ { "payer_name": "Blue Cross Blue Shield of Montana", "plan_name": "Medicare Advantage", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "United Healthcare (UHC)", "plan_name": "Medicare Advantage", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "First Choice of the Midwest", "plan_name": "PPO", "standard_charge_percentage": 90, "methodology": "percent of total billed charges", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "United Healthcare (UHC)", "plan_name": "DSNP", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Employee Benefit Management Services (EBMS)", "plan_name": "EBMS SelectCare Network", "standard_charge_percentage": 80, "methodology": "percent of total billed charges", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Allegiance Provider Direct", "plan_name": "Medicare", "standard_charge_percentage": 229.99999999999997, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Claritev fka MultiPlan", "plan_name": "PPO", "standard_charge_percentage": 75, "methodology": "percent of total billed charges", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Medica Insurance Company", "plan_name": "Medicare Cost", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Medicare (CMS)", "plan_name": "Medicare", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Indian Health Services (IHS)", "plan_name": "Commercial", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "First Choice Health Network fka Health InfoNet", "plan_name": "Commercial", "standard_charge_percentage": 85, "methodology": "percent of total billed charges", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Humana Insurance Company", "plan_name": "Humana Medicare Advantage HMO", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Humana Insurance Company", "plan_name": "Humana Medicare Advantage PPO", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Humana Insurance Company", "plan_name": "Humana Medicare Advantage PFFS", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "First Choice Health Network fka Health InfoNet", "plan_name": "Workers Compensation", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Allegiance Provider Direct", "plan_name": "State of Montana Employee Benefit Plan (Self-Funded)", "standard_charge_percentage": 229.99999999999997, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Allegiance Provider Direct", "plan_name": "Montana Municipal Interlocal Authority (MMIA)", "standard_charge_percentage": 229.99999999999997, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Allegiance Provider Direct", "plan_name": "Montana Association of Counties (MACo)", "standard_charge_percentage": 229.99999999999997, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "First Choice Health Network fka Health InfoNet", "plan_name": "Medicare Advantage", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "TriWest Healthcare Alliance Corporation", "plan_name": "TRICARE Prime", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "TriWest Healthcare Alliance Corporation", "plan_name": "TRICARE Select", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Blue Cross Blue Shield of Montana", "plan_name": "HealthLink Network", "standard_charge_percentage": 75, "methodology": "percent of total billed charges", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Blue Cross Blue Shield of Montana", "plan_name": "Traditional Network", "standard_charge_percentage": 75, "methodology": "percent of total billed charges", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Blue Cross Blue Shield of Montana", "plan_name": "POS Network", "standard_charge_percentage": 75, "methodology": "percent of total billed charges", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Blue Cross Blue Shield of Montana", "plan_name": "Closed Plan Network", "standard_charge_percentage": 75, "methodology": "percent of total billed charges", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Blue Cross Blue Shield of Montana", "plan_name": "Retail HMO POS Network", "standard_charge_percentage": 75, "methodology": "percent of total billed charges", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Blue Cross Blue Shield of Montana", "plan_name": "Blue Options Network", "standard_charge_percentage": 75, "methodology": "percent of total billed charges", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "PacificSource Health Plans", "plan_name": "Medicare Advantage", "standard_charge_percentage": 103, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" } ] } ] }, { "description": "Carotid Artery Stent Procedures with MCC", "code_information": [ { "code": "34", "type": "LOCAL" } ], "standard_charges": [ { "setting": "inpatient", "payers_information": [ { "payer_name": "Blue Cross Blue Shield of Montana", "plan_name": "Medicare Advantage", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "United Healthcare (UHC)", "plan_name": "Medicare Advantage", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "First Choice of the Midwest", "plan_name": "PPO", "standard_charge_percentage": 90, "methodology": "percent of total billed charges", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "United Healthcare (UHC)", "plan_name": "DSNP", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Employee Benefit Management Services (EBMS)", "plan_name": "EBMS SelectCare Network", "standard_charge_percentage": 80, "methodology": "percent of total billed charges", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Allegiance Provider Direct", "plan_name": "Medicare", "standard_charge_percentage": 229.99999999999997, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Claritev fka MultiPlan", "plan_name": "PPO", "standard_charge_percentage": 75, "methodology": "percent of total billed charges", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Medica Insurance Company", "plan_name": "Medicare Cost", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Medicare (CMS)", "plan_name": "Medicare", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Indian Health Services (IHS)", "plan_name": "Commercial", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "First Choice Health Network fka Health InfoNet", "plan_name": "Commercial", "standard_charge_percentage": 85, "methodology": "percent of total billed charges", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Humana Insurance Company", "plan_name": "Humana Medicare Advantage HMO", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Humana Insurance Company", "plan_name": "Humana Medicare Advantage PPO", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Humana Insurance Company", "plan_name": "Humana Medicare Advantage PFFS", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "First Choice Health Network fka Health InfoNet", "plan_name": "Workers Compensation", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Allegiance Provider Direct", "plan_name": "State of Montana Employee Benefit Plan (Self-Funded)", "standard_charge_percentage": 229.99999999999997, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Allegiance Provider Direct", "plan_name": "Montana Municipal Interlocal Authority (MMIA)", "standard_charge_percentage": 229.99999999999997, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Allegiance Provider Direct", "plan_name": "Montana Association of Counties (MACo)", "standard_charge_percentage": 229.99999999999997, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "First Choice Health Network fka Health InfoNet", "plan_name": "Medicare Advantage", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "TriWest Healthcare Alliance Corporation", "plan_name": "TRICARE Prime", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "TriWest Healthcare Alliance Corporation", "plan_name": "TRICARE Select", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Blue Cross Blue Shield of Montana", "plan_name": "HealthLink Network", "standard_charge_percentage": 75, "methodology": "percent of total billed charges", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Blue Cross Blue Shield of Montana", "plan_name": "Traditional Network", "standard_charge_percentage": 75, "methodology": "percent of total billed charges", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Blue Cross Blue Shield of Montana", "plan_name": "POS Network", "standard_charge_percentage": 75, "methodology": "percent of total billed charges", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Blue Cross Blue Shield of Montana", "plan_name": "Closed Plan Network", "standard_charge_percentage": 75, "methodology": "percent of total billed charges", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Blue Cross Blue Shield of Montana", "plan_name": "Retail HMO POS Network", "standard_charge_percentage": 75, "methodology": "percent of total billed charges", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Blue Cross Blue Shield of Montana", "plan_name": "Blue Options Network", "standard_charge_percentage": 75, "methodology": "percent of total billed charges", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "PacificSource Health Plans", "plan_name": "Medicare Advantage", "standard_charge_percentage": 103, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" } ] } ] }, { "description": "Carotid Artery Stent Procedures with CC", "code_information": [ { "code": "35", "type": "LOCAL" } ], "standard_charges": [ { "setting": "inpatient", "payers_information": [ { "payer_name": "Blue Cross Blue Shield of Montana", "plan_name": "Medicare Advantage", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "United Healthcare (UHC)", "plan_name": "Medicare Advantage", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "First Choice of the Midwest", "plan_name": "PPO", "standard_charge_percentage": 90, "methodology": "percent of total billed charges", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "United Healthcare (UHC)", "plan_name": "DSNP", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Employee Benefit Management Services (EBMS)", "plan_name": "EBMS SelectCare Network", "standard_charge_percentage": 80, "methodology": "percent of total billed charges", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Allegiance Provider Direct", "plan_name": "Medicare", "standard_charge_percentage": 229.99999999999997, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Claritev fka MultiPlan", "plan_name": "PPO", "standard_charge_percentage": 75, "methodology": "percent of total billed charges", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Medica Insurance Company", "plan_name": "Medicare Cost", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Medicare (CMS)", "plan_name": "Medicare", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Indian Health Services (IHS)", "plan_name": "Commercial", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "First Choice Health Network fka Health InfoNet", "plan_name": "Commercial", "standard_charge_percentage": 85, "methodology": "percent of total billed charges", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Humana Insurance Company", "plan_name": "Humana Medicare Advantage HMO", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Humana Insurance Company", "plan_name": "Humana Medicare Advantage PPO", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Humana Insurance Company", "plan_name": "Humana Medicare Advantage PFFS", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "First Choice Health Network fka Health InfoNet", "plan_name": "Workers Compensation", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Allegiance Provider Direct", "plan_name": "State of Montana Employee Benefit Plan (Self-Funded)", "standard_charge_percentage": 229.99999999999997, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Allegiance Provider Direct", "plan_name": "Montana Municipal Interlocal Authority (MMIA)", "standard_charge_percentage": 229.99999999999997, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Allegiance Provider Direct", "plan_name": "Montana Association of Counties (MACo)", "standard_charge_percentage": 229.99999999999997, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "First Choice Health Network fka Health InfoNet", "plan_name": "Medicare Advantage", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "TriWest Healthcare Alliance Corporation", "plan_name": "TRICARE Prime", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "TriWest Healthcare Alliance Corporation", "plan_name": "TRICARE Select", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Blue Cross Blue Shield of Montana", "plan_name": "HealthLink Network", "standard_charge_percentage": 75, "methodology": "percent of total billed charges", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Blue Cross Blue Shield of Montana", "plan_name": "Traditional Network", "standard_charge_percentage": 75, "methodology": "percent of total billed charges", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Blue Cross Blue Shield of Montana", "plan_name": "POS Network", "standard_charge_percentage": 75, "methodology": "percent of total billed charges", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Blue Cross Blue Shield of Montana", "plan_name": "Closed Plan Network", "standard_charge_percentage": 75, "methodology": "percent of total billed charges", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Blue Cross Blue Shield of Montana", "plan_name": "Retail HMO POS Network", "standard_charge_percentage": 75, "methodology": "percent of total billed charges", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Blue Cross Blue Shield of Montana", "plan_name": "Blue Options Network", "standard_charge_percentage": 75, "methodology": "percent of total billed charges", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "PacificSource Health Plans", "plan_name": "Medicare Advantage", "standard_charge_percentage": 103, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" } ] } ] }, { "description": "Carotid Artery Stent Procedures without CC/MCC", "code_information": [ { "code": "36", "type": "LOCAL" } ], "standard_charges": [ { "setting": "inpatient", "payers_information": [ { "payer_name": "Blue Cross Blue Shield of Montana", "plan_name": "Medicare Advantage", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "United Healthcare (UHC)", "plan_name": "Medicare Advantage", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "First Choice of the Midwest", "plan_name": "PPO", "standard_charge_percentage": 90, "methodology": "percent of total billed charges", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "United Healthcare (UHC)", "plan_name": "DSNP", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Employee Benefit Management Services (EBMS)", "plan_name": "EBMS SelectCare Network", "standard_charge_percentage": 80, "methodology": "percent of total billed charges", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Allegiance Provider Direct", "plan_name": "Medicare", "standard_charge_percentage": 229.99999999999997, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Claritev fka MultiPlan", "plan_name": "PPO", "standard_charge_percentage": 75, "methodology": "percent of total billed charges", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Medica Insurance Company", "plan_name": "Medicare Cost", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Medicare (CMS)", "plan_name": "Medicare", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Indian Health Services (IHS)", "plan_name": "Commercial", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "First Choice Health Network fka Health InfoNet", "plan_name": "Commercial", "standard_charge_percentage": 85, "methodology": "percent of total billed charges", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Humana Insurance Company", "plan_name": "Humana Medicare Advantage HMO", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Humana Insurance Company", "plan_name": "Humana Medicare Advantage PPO", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Humana Insurance Company", "plan_name": "Humana Medicare Advantage PFFS", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "First Choice Health Network fka Health InfoNet", "plan_name": "Workers Compensation", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Allegiance Provider Direct", "plan_name": "State of Montana Employee Benefit Plan (Self-Funded)", "standard_charge_percentage": 229.99999999999997, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Allegiance Provider Direct", "plan_name": "Montana Municipal Interlocal Authority (MMIA)", "standard_charge_percentage": 229.99999999999997, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Allegiance Provider Direct", "plan_name": "Montana Association of Counties (MACo)", "standard_charge_percentage": 229.99999999999997, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "First Choice Health Network fka Health InfoNet", "plan_name": "Medicare Advantage", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "TriWest Healthcare Alliance Corporation", "plan_name": "TRICARE Prime", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "TriWest Healthcare Alliance Corporation", "plan_name": "TRICARE Select", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Blue Cross Blue Shield of Montana", "plan_name": "HealthLink Network", "standard_charge_percentage": 75, "methodology": "percent of total billed charges", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Blue Cross Blue Shield of Montana", "plan_name": "Traditional Network", "standard_charge_percentage": 75, "methodology": "percent of total billed charges", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Blue Cross Blue Shield of Montana", "plan_name": "POS Network", "standard_charge_percentage": 75, "methodology": "percent of total billed charges", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Blue Cross Blue Shield of Montana", "plan_name": "Closed Plan Network", "standard_charge_percentage": 75, "methodology": "percent of total billed charges", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Blue Cross Blue Shield of Montana", "plan_name": "Retail HMO POS Network", "standard_charge_percentage": 75, "methodology": "percent of total billed charges", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Blue Cross Blue Shield of Montana", "plan_name": "Blue Options Network", "standard_charge_percentage": 75, "methodology": "percent of total billed charges", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "PacificSource Health Plans", "plan_name": "Medicare Advantage", "standard_charge_percentage": 103, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" } ] } ] }, { "description": "Extracranial Procedures with MCC", "code_information": [ { "code": "37", "type": "LOCAL" } ], "standard_charges": [ { "setting": "inpatient", "payers_information": [ { "payer_name": "Blue Cross Blue Shield of Montana", "plan_name": "Medicare Advantage", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "United Healthcare (UHC)", "plan_name": "Medicare Advantage", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "First Choice of the Midwest", "plan_name": "PPO", "standard_charge_percentage": 90, "methodology": "percent of total billed charges", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "United Healthcare (UHC)", "plan_name": "DSNP", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Employee Benefit Management Services (EBMS)", "plan_name": "EBMS SelectCare Network", "standard_charge_percentage": 80, "methodology": "percent of total billed charges", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Allegiance Provider Direct", "plan_name": "Medicare", "standard_charge_percentage": 229.99999999999997, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Claritev fka MultiPlan", "plan_name": "PPO", "standard_charge_percentage": 75, "methodology": "percent of total billed charges", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Medica Insurance Company", "plan_name": "Medicare Cost", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Medicare (CMS)", "plan_name": "Medicare", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Indian Health Services (IHS)", "plan_name": "Commercial", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "First Choice Health Network fka Health InfoNet", "plan_name": "Commercial", "standard_charge_percentage": 85, "methodology": "percent of total billed charges", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Humana Insurance Company", "plan_name": "Humana Medicare Advantage HMO", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Humana Insurance Company", "plan_name": "Humana Medicare Advantage PPO", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Humana Insurance Company", "plan_name": "Humana Medicare Advantage PFFS", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "First Choice Health Network fka Health InfoNet", "plan_name": "Workers Compensation", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Allegiance Provider Direct", "plan_name": "State of Montana Employee Benefit Plan (Self-Funded)", "standard_charge_percentage": 229.99999999999997, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Allegiance Provider Direct", "plan_name": "Montana Municipal Interlocal Authority (MMIA)", "standard_charge_percentage": 229.99999999999997, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Allegiance Provider Direct", "plan_name": "Montana Association of Counties (MACo)", "standard_charge_percentage": 229.99999999999997, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "First Choice Health Network fka Health InfoNet", "plan_name": "Medicare Advantage", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "TriWest Healthcare Alliance Corporation", "plan_name": "TRICARE Prime", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "TriWest Healthcare Alliance Corporation", "plan_name": "TRICARE Select", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Blue Cross Blue Shield of Montana", "plan_name": "HealthLink Network", "standard_charge_percentage": 75, "methodology": "percent of total billed charges", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Blue Cross Blue Shield of Montana", "plan_name": "Traditional Network", "standard_charge_percentage": 75, "methodology": "percent of total billed charges", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Blue Cross Blue Shield of Montana", "plan_name": "POS Network", "standard_charge_percentage": 75, "methodology": "percent of total billed charges", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Blue Cross Blue Shield of Montana", "plan_name": "Closed Plan Network", "standard_charge_percentage": 75, "methodology": "percent of total billed charges", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Blue Cross Blue Shield of Montana", "plan_name": "Retail HMO POS Network", "standard_charge_percentage": 75, "methodology": "percent of total billed charges", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Blue Cross Blue Shield of Montana", "plan_name": "Blue Options Network", "standard_charge_percentage": 75, "methodology": "percent of total billed charges", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "PacificSource Health Plans", "plan_name": "Medicare Advantage", "standard_charge_percentage": 103, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" } ] } ] }, { "description": "Extracranial Procedures with CC", "code_information": [ { "code": "38", "type": "LOCAL" } ], "standard_charges": [ { "setting": "inpatient", "payers_information": [ { "payer_name": "Blue Cross Blue Shield of Montana", "plan_name": "Medicare Advantage", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "United Healthcare (UHC)", "plan_name": "Medicare Advantage", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "First Choice of the Midwest", "plan_name": "PPO", "standard_charge_percentage": 90, "methodology": "percent of total billed charges", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "United Healthcare (UHC)", "plan_name": "DSNP", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Employee Benefit Management Services (EBMS)", "plan_name": "EBMS SelectCare Network", "standard_charge_percentage": 80, "methodology": "percent of total billed charges", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Allegiance Provider Direct", "plan_name": "Medicare", "standard_charge_percentage": 229.99999999999997, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Claritev fka MultiPlan", "plan_name": "PPO", "standard_charge_percentage": 75, "methodology": "percent of total billed charges", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Medica Insurance Company", "plan_name": "Medicare Cost", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Medicare (CMS)", "plan_name": "Medicare", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Indian Health Services (IHS)", "plan_name": "Commercial", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "First Choice Health Network fka Health InfoNet", "plan_name": "Commercial", "standard_charge_percentage": 85, "methodology": "percent of total billed charges", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Humana Insurance Company", "plan_name": "Humana Medicare Advantage HMO", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Humana Insurance Company", "plan_name": "Humana Medicare Advantage PPO", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Humana Insurance Company", "plan_name": "Humana Medicare Advantage PFFS", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "First Choice Health Network fka Health InfoNet", "plan_name": "Workers Compensation", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Allegiance Provider Direct", "plan_name": "State of Montana Employee Benefit Plan (Self-Funded)", "standard_charge_percentage": 229.99999999999997, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Allegiance Provider Direct", "plan_name": "Montana Municipal Interlocal Authority (MMIA)", "standard_charge_percentage": 229.99999999999997, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Allegiance Provider Direct", "plan_name": "Montana Association of Counties (MACo)", "standard_charge_percentage": 229.99999999999997, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "First Choice Health Network fka Health InfoNet", "plan_name": "Medicare Advantage", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "TriWest Healthcare Alliance Corporation", "plan_name": "TRICARE Prime", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "TriWest Healthcare Alliance Corporation", "plan_name": "TRICARE Select", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Blue Cross Blue Shield of Montana", "plan_name": "HealthLink Network", "standard_charge_percentage": 75, "methodology": "percent of total billed charges", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Blue Cross Blue Shield of Montana", "plan_name": "Traditional Network", "standard_charge_percentage": 75, "methodology": "percent of total billed charges", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Blue Cross Blue Shield of Montana", "plan_name": "POS Network", "standard_charge_percentage": 75, "methodology": "percent of total billed charges", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Blue Cross Blue Shield of Montana", "plan_name": "Closed Plan Network", "standard_charge_percentage": 75, "methodology": "percent of total billed charges", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Blue Cross Blue Shield of Montana", "plan_name": "Retail HMO POS Network", "standard_charge_percentage": 75, "methodology": "percent of total billed charges", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Blue Cross Blue Shield of Montana", "plan_name": "Blue Options Network", "standard_charge_percentage": 75, "methodology": "percent of total billed charges", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "PacificSource Health Plans", "plan_name": "Medicare Advantage", "standard_charge_percentage": 103, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" } ] } ] }, { "description": "Extracranial Procedures without CC/MCC", "code_information": [ { "code": "39", "type": "LOCAL" } ], "standard_charges": [ { "setting": "inpatient", "payers_information": [ { "payer_name": "Blue Cross Blue Shield of Montana", "plan_name": "Medicare Advantage", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "United Healthcare (UHC)", "plan_name": "Medicare Advantage", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "First Choice of the Midwest", "plan_name": "PPO", "standard_charge_percentage": 90, "methodology": "percent of total billed charges", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "United Healthcare (UHC)", "plan_name": "DSNP", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Employee Benefit Management Services (EBMS)", "plan_name": "EBMS SelectCare Network", "standard_charge_percentage": 80, "methodology": "percent of total billed charges", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Allegiance Provider Direct", "plan_name": "Medicare", "standard_charge_percentage": 229.99999999999997, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Claritev fka MultiPlan", "plan_name": "PPO", "standard_charge_percentage": 75, "methodology": "percent of total billed charges", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Medica Insurance Company", "plan_name": "Medicare Cost", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Medicare (CMS)", "plan_name": "Medicare", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Indian Health Services (IHS)", "plan_name": "Commercial", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "First Choice Health Network fka Health InfoNet", "plan_name": "Commercial", "standard_charge_percentage": 85, "methodology": "percent of total billed charges", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Humana Insurance Company", "plan_name": "Humana Medicare Advantage HMO", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Humana Insurance Company", "plan_name": "Humana Medicare Advantage PPO", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Humana Insurance Company", "plan_name": "Humana Medicare Advantage PFFS", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "First Choice Health Network fka Health InfoNet", "plan_name": "Workers Compensation", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Allegiance Provider Direct", "plan_name": "State of Montana Employee Benefit Plan (Self-Funded)", "standard_charge_percentage": 229.99999999999997, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Allegiance Provider Direct", "plan_name": "Montana Municipal Interlocal Authority (MMIA)", "standard_charge_percentage": 229.99999999999997, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Allegiance Provider Direct", "plan_name": "Montana Association of Counties (MACo)", "standard_charge_percentage": 229.99999999999997, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "First Choice Health Network fka Health InfoNet", "plan_name": "Medicare Advantage", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "TriWest Healthcare Alliance Corporation", "plan_name": "TRICARE Prime", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "TriWest Healthcare Alliance Corporation", "plan_name": "TRICARE Select", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Blue Cross Blue Shield of Montana", "plan_name": "HealthLink Network", "standard_charge_percentage": 75, "methodology": "percent of total billed charges", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Blue Cross Blue Shield of Montana", "plan_name": "Traditional Network", "standard_charge_percentage": 75, "methodology": "percent of total billed charges", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Blue Cross Blue Shield of Montana", "plan_name": "POS Network", "standard_charge_percentage": 75, "methodology": "percent of total billed charges", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Blue Cross Blue Shield of Montana", "plan_name": "Closed Plan Network", "standard_charge_percentage": 75, "methodology": "percent of total billed charges", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Blue Cross Blue Shield of Montana", "plan_name": "Retail HMO POS Network", "standard_charge_percentage": 75, "methodology": "percent of total billed charges", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Blue Cross Blue Shield of Montana", "plan_name": "Blue Options Network", "standard_charge_percentage": 75, "methodology": "percent of total billed charges", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "PacificSource Health Plans", "plan_name": "Medicare Advantage", "standard_charge_percentage": 103, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" } ] } ] }, { "description": "Peripheral, Cranial Nerve and Other Nervous System Procedures with MCC", "code_information": [ { "code": "40", "type": "LOCAL" } ], "standard_charges": [ { "setting": "inpatient", "payers_information": [ { "payer_name": "Blue Cross Blue Shield of Montana", "plan_name": "Medicare Advantage", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "United Healthcare (UHC)", "plan_name": "Medicare Advantage", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "First Choice of the Midwest", "plan_name": "PPO", "standard_charge_percentage": 90, "methodology": "percent of total billed charges", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "United Healthcare (UHC)", "plan_name": "DSNP", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Employee Benefit Management Services (EBMS)", "plan_name": "EBMS SelectCare Network", "standard_charge_percentage": 80, "methodology": "percent of total billed charges", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Allegiance Provider Direct", "plan_name": "Medicare", "standard_charge_percentage": 229.99999999999997, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Claritev fka MultiPlan", "plan_name": "PPO", "standard_charge_percentage": 75, "methodology": "percent of total billed charges", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Medica Insurance Company", "plan_name": "Medicare Cost", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Medicare (CMS)", "plan_name": "Medicare", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Indian Health Services (IHS)", "plan_name": "Commercial", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "First Choice Health Network fka Health InfoNet", "plan_name": "Commercial", "standard_charge_percentage": 85, "methodology": "percent of total billed charges", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "First Choice Health Network fka Health InfoNet", "plan_name": "Workers Compensation", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Humana Insurance Company", "plan_name": "Humana Medicare Advantage HMO", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Humana Insurance Company", "plan_name": "Humana Medicare Advantage PPO", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Humana Insurance Company", "plan_name": "Humana Medicare Advantage PFFS", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Allegiance Provider Direct", "plan_name": "State of Montana Employee Benefit Plan (Self-Funded)", "standard_charge_percentage": 229.99999999999997, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Allegiance Provider Direct", "plan_name": "Montana Municipal Interlocal Authority (MMIA)", "standard_charge_percentage": 229.99999999999997, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Allegiance Provider Direct", "plan_name": "Montana Association of Counties (MACo)", "standard_charge_percentage": 229.99999999999997, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "First Choice Health Network fka Health InfoNet", "plan_name": "Medicare Advantage", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "TriWest Healthcare Alliance Corporation", "plan_name": "TRICARE Prime", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "TriWest Healthcare Alliance Corporation", "plan_name": "TRICARE Select", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Blue Cross Blue Shield of Montana", "plan_name": "HealthLink Network", "standard_charge_percentage": 75, "methodology": "percent of total billed charges", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Blue Cross Blue Shield of Montana", "plan_name": "Traditional Network", "standard_charge_percentage": 75, "methodology": "percent of total billed charges", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Blue Cross Blue Shield of Montana", "plan_name": "POS Network", "standard_charge_percentage": 75, "methodology": "percent of total billed charges", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Blue Cross Blue Shield of Montana", "plan_name": "Closed Plan Network", "standard_charge_percentage": 75, "methodology": "percent of total billed charges", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Blue Cross Blue Shield of Montana", "plan_name": "Retail HMO POS Network", "standard_charge_percentage": 75, "methodology": "percent of total billed charges", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Blue Cross Blue Shield of Montana", "plan_name": "Blue Options Network", "standard_charge_percentage": 75, "methodology": "percent of total billed charges", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "PacificSource Health Plans", "plan_name": "Medicare Advantage", "standard_charge_percentage": 103, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" } ] } ] }, { "description": "Peripheral, Cranial Nerve and Other Nervous System Procedures with CC or Peripheral Neurostimulator", "code_information": [ { "code": "41", "type": "LOCAL" } ], "standard_charges": [ { "setting": "inpatient", "payers_information": [ { "payer_name": "Blue Cross Blue Shield of Montana", "plan_name": "Medicare Advantage", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "United Healthcare (UHC)", "plan_name": "Medicare Advantage", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "First Choice of the Midwest", "plan_name": "PPO", "standard_charge_percentage": 90, "methodology": "percent of total billed charges", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "United Healthcare (UHC)", "plan_name": "DSNP", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Employee Benefit Management Services (EBMS)", "plan_name": "EBMS SelectCare Network", "standard_charge_percentage": 80, "methodology": "percent of total billed charges", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Allegiance Provider Direct", "plan_name": "Medicare", "standard_charge_percentage": 229.99999999999997, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Claritev fka MultiPlan", "plan_name": "PPO", "standard_charge_percentage": 75, "methodology": "percent of total billed charges", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Medica Insurance Company", "plan_name": "Medicare Cost", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Medicare (CMS)", "plan_name": "Medicare", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Indian Health Services (IHS)", "plan_name": "Commercial", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "First Choice Health Network fka Health InfoNet", "plan_name": "Commercial", "standard_charge_percentage": 85, "methodology": "percent of total billed charges", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "First Choice Health Network fka Health InfoNet", "plan_name": "Workers Compensation", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Humana Insurance Company", "plan_name": "Humana Medicare Advantage HMO", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Humana Insurance Company", "plan_name": "Humana Medicare Advantage PPO", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Humana Insurance Company", "plan_name": "Humana Medicare Advantage PFFS", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Allegiance Provider Direct", "plan_name": "State of Montana Employee Benefit Plan (Self-Funded)", "standard_charge_percentage": 229.99999999999997, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Allegiance Provider Direct", "plan_name": "Montana Municipal Interlocal Authority (MMIA)", "standard_charge_percentage": 229.99999999999997, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Allegiance Provider Direct", "plan_name": "Montana Association of Counties (MACo)", "standard_charge_percentage": 229.99999999999997, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "First Choice Health Network fka Health InfoNet", "plan_name": "Medicare Advantage", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "TriWest Healthcare Alliance Corporation", "plan_name": "TRICARE Prime", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "TriWest Healthcare Alliance Corporation", "plan_name": "TRICARE Select", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Blue Cross Blue Shield of Montana", "plan_name": "HealthLink Network", "standard_charge_percentage": 75, "methodology": "percent of total billed charges", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Blue Cross Blue Shield of Montana", "plan_name": "Traditional Network", "standard_charge_percentage": 75, "methodology": "percent of total billed charges", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Blue Cross Blue Shield of Montana", "plan_name": "POS Network", "standard_charge_percentage": 75, "methodology": "percent of total billed charges", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Blue Cross Blue Shield of Montana", "plan_name": "Closed Plan Network", "standard_charge_percentage": 75, "methodology": "percent of total billed charges", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Blue Cross Blue Shield of Montana", "plan_name": "Retail HMO POS Network", "standard_charge_percentage": 75, "methodology": "percent of total billed charges", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Blue Cross Blue Shield of Montana", "plan_name": "Blue Options Network", "standard_charge_percentage": 75, "methodology": "percent of total billed charges", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "PacificSource Health Plans", "plan_name": "Medicare Advantage", "standard_charge_percentage": 103, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" } ] } ] }, { "description": "Peripheral, Cranial Nerve and Other Nervous System Procedures without CC/MCC", "code_information": [ { "code": "42", "type": "LOCAL" } ], "standard_charges": [ { "setting": "inpatient", "payers_information": [ { "payer_name": "Blue Cross Blue Shield of Montana", "plan_name": "Medicare Advantage", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "United Healthcare (UHC)", "plan_name": "Medicare Advantage", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "First Choice of the Midwest", "plan_name": "PPO", "standard_charge_percentage": 90, "methodology": "percent of total billed charges", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "United Healthcare (UHC)", "plan_name": "DSNP", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Employee Benefit Management Services (EBMS)", "plan_name": "EBMS SelectCare Network", "standard_charge_percentage": 80, "methodology": "percent of total billed charges", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Allegiance Provider Direct", "plan_name": "Medicare", "standard_charge_percentage": 229.99999999999997, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Claritev fka MultiPlan", "plan_name": "PPO", "standard_charge_percentage": 75, "methodology": "percent of total billed charges", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Medica Insurance Company", "plan_name": "Medicare Cost", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Medicare (CMS)", "plan_name": "Medicare", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Indian Health Services (IHS)", "plan_name": "Commercial", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "First Choice Health Network fka Health InfoNet", "plan_name": "Commercial", "standard_charge_percentage": 85, "methodology": "percent of total billed charges", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "First Choice Health Network fka Health InfoNet", "plan_name": "Workers Compensation", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Humana Insurance Company", "plan_name": "Humana Medicare Advantage HMO", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Humana Insurance Company", "plan_name": "Humana Medicare Advantage PPO", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Humana Insurance Company", "plan_name": "Humana Medicare Advantage PFFS", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Allegiance Provider Direct", "plan_name": "State of Montana Employee Benefit Plan (Self-Funded)", "standard_charge_percentage": 229.99999999999997, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Allegiance Provider Direct", "plan_name": "Montana Municipal Interlocal Authority (MMIA)", "standard_charge_percentage": 229.99999999999997, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Allegiance Provider Direct", "plan_name": "Montana Association of Counties (MACo)", "standard_charge_percentage": 229.99999999999997, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "First Choice Health Network fka Health InfoNet", "plan_name": "Medicare Advantage", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "TriWest Healthcare Alliance Corporation", "plan_name": "TRICARE Prime", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "TriWest Healthcare Alliance Corporation", "plan_name": "TRICARE Select", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Blue Cross Blue Shield of Montana", "plan_name": "HealthLink Network", "standard_charge_percentage": 75, "methodology": "percent of total billed charges", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Blue Cross Blue Shield of Montana", "plan_name": "Traditional Network", "standard_charge_percentage": 75, "methodology": "percent of total billed charges", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Blue Cross Blue Shield of Montana", "plan_name": "POS Network", "standard_charge_percentage": 75, "methodology": "percent of total billed charges", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Blue Cross Blue Shield of Montana", "plan_name": "Closed Plan Network", "standard_charge_percentage": 75, "methodology": "percent of total billed charges", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Blue Cross Blue Shield of Montana", "plan_name": "Retail HMO POS Network", "standard_charge_percentage": 75, "methodology": "percent of total billed charges", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Blue Cross Blue Shield of Montana", "plan_name": "Blue Options Network", "standard_charge_percentage": 75, "methodology": "percent of total billed charges", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "PacificSource Health Plans", "plan_name": "Medicare Advantage", "standard_charge_percentage": 103, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" } ] } ] }, { "description": "Spinal Disorders and Injuries with CC/MCC", "code_information": [ { "code": "52", "type": "LOCAL" } ], "standard_charges": [ { "setting": "inpatient", "payers_information": [ { "payer_name": "Blue Cross Blue Shield of Montana", "plan_name": "Medicare Advantage", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "United Healthcare (UHC)", "plan_name": "Medicare Advantage", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "First Choice of the Midwest", "plan_name": "PPO", "standard_charge_percentage": 90, "methodology": "percent of total billed charges", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "United Healthcare (UHC)", "plan_name": "DSNP", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Employee Benefit Management Services (EBMS)", "plan_name": "EBMS SelectCare Network", "standard_charge_percentage": 80, "methodology": "percent of total billed charges", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Allegiance Provider Direct", "plan_name": "Medicare", "standard_charge_percentage": 229.99999999999997, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Claritev fka MultiPlan", "plan_name": "PPO", "standard_charge_percentage": 75, "methodology": "percent of total billed charges", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Medica Insurance Company", "plan_name": "Medicare Cost", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Medicare (CMS)", "plan_name": "Medicare", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Indian Health Services (IHS)", "plan_name": "Commercial", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "First Choice Health Network fka Health InfoNet", "plan_name": "Commercial", "standard_charge_percentage": 85, "methodology": "percent of total billed charges", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "First Choice Health Network fka Health InfoNet", "plan_name": "Workers Compensation", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Humana Insurance Company", "plan_name": "Humana Medicare Advantage HMO", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Humana Insurance Company", "plan_name": "Humana Medicare Advantage PPO", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Humana Insurance Company", "plan_name": "Humana Medicare Advantage PFFS", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Allegiance Provider Direct", "plan_name": "State of Montana Employee Benefit Plan (Self-Funded)", "standard_charge_percentage": 229.99999999999997, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Allegiance Provider Direct", "plan_name": "Montana Municipal Interlocal Authority (MMIA)", "standard_charge_percentage": 229.99999999999997, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Allegiance Provider Direct", "plan_name": "Montana Association of Counties (MACo)", "standard_charge_percentage": 229.99999999999997, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "First Choice Health Network fka Health InfoNet", "plan_name": "Medicare Advantage", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "TriWest Healthcare Alliance Corporation", "plan_name": "TRICARE Prime", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "TriWest Healthcare Alliance Corporation", "plan_name": "TRICARE Select", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Blue Cross Blue Shield of Montana", "plan_name": "HealthLink Network", "standard_charge_percentage": 75, "methodology": "percent of total billed charges", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Blue Cross Blue Shield of Montana", "plan_name": "Traditional Network", "standard_charge_percentage": 75, "methodology": "percent of total billed charges", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Blue Cross Blue Shield of Montana", "plan_name": "POS Network", "standard_charge_percentage": 75, "methodology": "percent of total billed charges", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Blue Cross Blue Shield of Montana", "plan_name": "Closed Plan Network", "standard_charge_percentage": 75, "methodology": "percent of total billed charges", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Blue Cross Blue Shield of Montana", "plan_name": "Retail HMO POS Network", "standard_charge_percentage": 75, "methodology": "percent of total billed charges", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Blue Cross Blue Shield of Montana", "plan_name": "Blue Options Network", "standard_charge_percentage": 75, "methodology": "percent of total billed charges", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "PacificSource Health Plans", "plan_name": "Medicare Advantage", "standard_charge_percentage": 103, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" } ] } ] }, { "description": "Spinal Disorders and Injuries without CC/MCC", "code_information": [ { "code": "53", "type": "LOCAL" } ], "standard_charges": [ { "setting": "inpatient", "payers_information": [ { "payer_name": "Blue Cross Blue Shield of Montana", "plan_name": "Medicare Advantage", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "United Healthcare (UHC)", "plan_name": "Medicare Advantage", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "First Choice of the Midwest", "plan_name": "PPO", "standard_charge_percentage": 90, "methodology": "percent of total billed charges", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "United Healthcare (UHC)", "plan_name": "DSNP", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Employee Benefit Management Services (EBMS)", "plan_name": "EBMS SelectCare Network", "standard_charge_percentage": 80, "methodology": "percent of total billed charges", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Allegiance Provider Direct", "plan_name": "Medicare", "standard_charge_percentage": 229.99999999999997, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Claritev fka MultiPlan", "plan_name": "PPO", "standard_charge_percentage": 75, "methodology": "percent of total billed charges", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Medica Insurance Company", "plan_name": "Medicare Cost", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Medicare (CMS)", "plan_name": "Medicare", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Indian Health Services (IHS)", "plan_name": "Commercial", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "First Choice Health Network fka Health InfoNet", "plan_name": "Commercial", "standard_charge_percentage": 85, "methodology": "percent of total billed charges", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "First Choice Health Network fka Health InfoNet", "plan_name": "Workers Compensation", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Humana Insurance Company", "plan_name": "Humana Medicare Advantage HMO", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Humana Insurance Company", "plan_name": "Humana Medicare Advantage PPO", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Humana Insurance Company", "plan_name": "Humana Medicare Advantage PFFS", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Allegiance Provider Direct", "plan_name": "State of Montana Employee Benefit Plan (Self-Funded)", "standard_charge_percentage": 229.99999999999997, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Allegiance Provider Direct", "plan_name": "Montana Municipal Interlocal Authority (MMIA)", "standard_charge_percentage": 229.99999999999997, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Allegiance Provider Direct", "plan_name": "Montana Association of Counties (MACo)", "standard_charge_percentage": 229.99999999999997, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "First Choice Health Network fka Health InfoNet", "plan_name": "Medicare Advantage", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "TriWest Healthcare Alliance Corporation", "plan_name": "TRICARE Prime", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "TriWest Healthcare Alliance Corporation", "plan_name": "TRICARE Select", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Blue Cross Blue Shield of Montana", "plan_name": "HealthLink Network", "standard_charge_percentage": 75, "methodology": "percent of total billed charges", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Blue Cross Blue Shield of Montana", "plan_name": "Traditional Network", "standard_charge_percentage": 75, "methodology": "percent of total billed charges", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Blue Cross Blue Shield of Montana", "plan_name": "POS Network", "standard_charge_percentage": 75, "methodology": "percent of total billed charges", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Blue Cross Blue Shield of Montana", "plan_name": "Closed Plan Network", "standard_charge_percentage": 75, "methodology": "percent of total billed charges", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Blue Cross Blue Shield of Montana", "plan_name": "Retail HMO POS Network", "standard_charge_percentage": 75, "methodology": "percent of total billed charges", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Blue Cross Blue Shield of Montana", "plan_name": "Blue Options Network", "standard_charge_percentage": 75, "methodology": "percent of total billed charges", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "PacificSource Health Plans", "plan_name": "Medicare Advantage", "standard_charge_percentage": 103, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" } ] } ] }, { "description": "Nervous System Neoplasms with MCC*", "code_information": [ { "code": "54", "type": "LOCAL" } ], "standard_charges": [ { "setting": "inpatient", "payers_information": [ { "payer_name": "Blue Cross Blue Shield of Montana", "plan_name": "Medicare Advantage", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "First Choice of the Midwest", "plan_name": "PPO", "standard_charge_percentage": 90, "methodology": "percent of total billed charges", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "United Healthcare (UHC)", "plan_name": "Medicare Advantage", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "United Healthcare (UHC)", "plan_name": "DSNP", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Employee Benefit Management Services (EBMS)", "plan_name": "EBMS SelectCare Network", "standard_charge_percentage": 80, "methodology": "percent of total billed charges", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Claritev fka MultiPlan", "plan_name": "PPO", "standard_charge_percentage": 75, "methodology": "percent of total billed charges", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Allegiance Provider Direct", "plan_name": "Medicare", "standard_charge_percentage": 229.99999999999997, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Medica Insurance Company", "plan_name": "Medicare Cost", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "First Choice Health Network fka Health InfoNet", "plan_name": "Commercial", "standard_charge_percentage": 85, "methodology": "percent of total billed charges", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Medicare (CMS)", "plan_name": "Medicare", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Indian Health Services (IHS)", "plan_name": "Commercial", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "First Choice Health Network fka Health InfoNet", "plan_name": "Workers Compensation", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Humana Insurance Company", "plan_name": "Humana Medicare Advantage HMO", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Humana Insurance Company", "plan_name": "Humana Medicare Advantage PPO", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Humana Insurance Company", "plan_name": "Humana Medicare Advantage PFFS", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Allegiance Provider Direct", "plan_name": "State of Montana Employee Benefit Plan (Self-Funded)", "standard_charge_percentage": 229.99999999999997, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Allegiance Provider Direct", "plan_name": "Montana Municipal Interlocal Authority (MMIA)", "standard_charge_percentage": 229.99999999999997, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Allegiance Provider Direct", "plan_name": "Montana Association of Counties (MACo)", "standard_charge_percentage": 229.99999999999997, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "First Choice Health Network fka Health InfoNet", "plan_name": "Medicare Advantage", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "TriWest Healthcare Alliance Corporation", "plan_name": "TRICARE Prime", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "TriWest Healthcare Alliance Corporation", "plan_name": "TRICARE Select", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Blue Cross Blue Shield of Montana", "plan_name": "HealthLink Network", "standard_charge_percentage": 75, "methodology": "percent of total billed charges", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Blue Cross Blue Shield of Montana", "plan_name": "Traditional Network", "standard_charge_percentage": 75, "methodology": "percent of total billed charges", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Blue Cross Blue Shield of Montana", "plan_name": "POS Network", "standard_charge_percentage": 75, "methodology": "percent of total billed charges", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Blue Cross Blue Shield of Montana", "plan_name": "Closed Plan Network", "standard_charge_percentage": 75, "methodology": "percent of total billed charges", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Blue Cross Blue Shield of Montana", "plan_name": "Retail HMO POS Network", "standard_charge_percentage": 75, "methodology": "percent of total billed charges", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Blue Cross Blue Shield of Montana", "plan_name": "Blue Options Network", "standard_charge_percentage": 75, "methodology": "percent of total billed charges", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "PacificSource Health Plans", "plan_name": "Medicare Advantage", "standard_charge_percentage": 103, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" } ] } ] }, { "description": "Nervous System Neoplasms without MCC*", "code_information": [ { "code": "55", "type": "LOCAL" } ], "standard_charges": [ { "setting": "inpatient", "payers_information": [ { "payer_name": "Blue Cross Blue Shield of Montana", "plan_name": "Medicare Advantage", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "United Healthcare (UHC)", "plan_name": "Medicare Advantage", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "First Choice of the Midwest", "plan_name": "PPO", "standard_charge_percentage": 90, "methodology": "percent of total billed charges", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "United Healthcare (UHC)", "plan_name": "DSNP", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Employee Benefit Management Services (EBMS)", "plan_name": "EBMS SelectCare Network", "standard_charge_percentage": 80, "methodology": "percent of total billed charges", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Allegiance Provider Direct", "plan_name": "Medicare", "standard_charge_percentage": 229.99999999999997, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Claritev fka MultiPlan", "plan_name": "PPO", "standard_charge_percentage": 75, "methodology": "percent of total billed charges", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Medica Insurance Company", "plan_name": "Medicare Cost", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Medicare (CMS)", "plan_name": "Medicare", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Indian Health Services (IHS)", "plan_name": "Commercial", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "First Choice Health Network fka Health InfoNet", "plan_name": "Commercial", "standard_charge_percentage": 85, "methodology": "percent of total billed charges", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "First Choice Health Network fka Health InfoNet", "plan_name": "Workers Compensation", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Humana Insurance Company", "plan_name": "Humana Medicare Advantage HMO", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Humana Insurance Company", "plan_name": "Humana Medicare Advantage PPO", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Humana Insurance Company", "plan_name": "Humana Medicare Advantage PFFS", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Allegiance Provider Direct", "plan_name": "State of Montana Employee Benefit Plan (Self-Funded)", "standard_charge_percentage": 229.99999999999997, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Allegiance Provider Direct", "plan_name": "Montana Municipal Interlocal Authority (MMIA)", "standard_charge_percentage": 229.99999999999997, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Allegiance Provider Direct", "plan_name": "Montana Association of Counties (MACo)", "standard_charge_percentage": 229.99999999999997, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "First Choice Health Network fka Health InfoNet", "plan_name": "Medicare Advantage", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "TriWest Healthcare Alliance Corporation", "plan_name": "TRICARE Prime", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "TriWest Healthcare Alliance Corporation", "plan_name": "TRICARE Select", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Blue Cross Blue Shield of Montana", "plan_name": "HealthLink Network", "standard_charge_percentage": 75, "methodology": "percent of total billed charges", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Blue Cross Blue Shield of Montana", "plan_name": "Traditional Network", "standard_charge_percentage": 75, "methodology": "percent of total billed charges", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Blue Cross Blue Shield of Montana", "plan_name": "POS Network", "standard_charge_percentage": 75, "methodology": "percent of total billed charges", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Blue Cross Blue Shield of Montana", "plan_name": "Closed Plan Network", "standard_charge_percentage": 75, "methodology": "percent of total billed charges", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Blue Cross Blue Shield of Montana", "plan_name": "Retail HMO POS Network", "standard_charge_percentage": 75, "methodology": "percent of total billed charges", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Blue Cross Blue Shield of Montana", "plan_name": "Blue Options Network", "standard_charge_percentage": 75, "methodology": "percent of total billed charges", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "PacificSource Health Plans", "plan_name": "Medicare Advantage", "standard_charge_percentage": 103, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" } ] } ] }, { "description": "Degenerative Nervous System Disorders with MCC", "code_information": [ { "code": "56", "type": "LOCAL" } ], "standard_charges": [ { "setting": "inpatient", "payers_information": [ { "payer_name": "Blue Cross Blue Shield of Montana", "plan_name": "Medicare Advantage", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "United Healthcare (UHC)", "plan_name": "Medicare Advantage", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "First Choice of the Midwest", "plan_name": "PPO", "standard_charge_percentage": 90, "methodology": "percent of total billed charges", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "United Healthcare (UHC)", "plan_name": "DSNP", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Employee Benefit Management Services (EBMS)", "plan_name": "EBMS SelectCare Network", "standard_charge_percentage": 80, "methodology": "percent of total billed charges", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Allegiance Provider Direct", "plan_name": "Medicare", "standard_charge_percentage": 229.99999999999997, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Claritev fka MultiPlan", "plan_name": "PPO", "standard_charge_percentage": 75, "methodology": "percent of total billed charges", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Medica Insurance Company", "plan_name": "Medicare Cost", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Medicare (CMS)", "plan_name": "Medicare", "standard_charge_percentage": 100, "methodology": "fee schedule", "median_amount": 37522.87, "10th_percentile": 28142.15, "90th_percentile": 37522.87, "count": "1 through 10" }, { "payer_name": "Indian Health Services (IHS)", "plan_name": "Commercial", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "First Choice Health Network fka Health InfoNet", "plan_name": "Commercial", "standard_charge_percentage": 85, "methodology": "percent of total billed charges", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "First Choice Health Network fka Health InfoNet", "plan_name": "Workers Compensation", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Humana Insurance Company", "plan_name": "Humana Medicare Advantage HMO", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Humana Insurance Company", "plan_name": "Humana Medicare Advantage PPO", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Humana Insurance Company", "plan_name": "Humana Medicare Advantage PFFS", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Allegiance Provider Direct", "plan_name": "State of Montana Employee Benefit Plan (Self-Funded)", "standard_charge_percentage": 229.99999999999997, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Allegiance Provider Direct", "plan_name": "Montana Municipal Interlocal Authority (MMIA)", "standard_charge_percentage": 229.99999999999997, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Allegiance Provider Direct", "plan_name": "Montana Association of Counties (MACo)", "standard_charge_percentage": 229.99999999999997, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "First Choice Health Network fka Health InfoNet", "plan_name": "Medicare Advantage", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "TriWest Healthcare Alliance Corporation", "plan_name": "TRICARE Prime", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "TriWest Healthcare Alliance Corporation", "plan_name": "TRICARE Select", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Blue Cross Blue Shield of Montana", "plan_name": "HealthLink Network", "standard_charge_percentage": 75, "methodology": "percent of total billed charges", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Blue Cross Blue Shield of Montana", "plan_name": "Traditional Network", "standard_charge_percentage": 75, "methodology": "percent of total billed charges", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Blue Cross Blue Shield of Montana", "plan_name": "POS Network", "standard_charge_percentage": 75, "methodology": "percent of total billed charges", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Blue Cross Blue Shield of Montana", "plan_name": "Closed Plan Network", "standard_charge_percentage": 75, "methodology": "percent of total billed charges", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Blue Cross Blue Shield of Montana", "plan_name": "Retail HMO POS Network", "standard_charge_percentage": 75, "methodology": "percent of total billed charges", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Blue Cross Blue Shield of Montana", "plan_name": "Blue Options Network", "standard_charge_percentage": 75, "methodology": "percent of total billed charges", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "PacificSource Health Plans", "plan_name": "Medicare Advantage", "standard_charge_percentage": 103, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" } ], "minimum": 37522.87, "maximum": 37522.87 } ] }, { "description": "Degenerative Nervous System Disorders without MCC", "code_information": [ { "code": "57", "type": "LOCAL" } ], "standard_charges": [ { "setting": "inpatient", "payers_information": [ { "payer_name": "Blue Cross Blue Shield of Montana", "plan_name": "Medicare Advantage", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "United Healthcare (UHC)", "plan_name": "Medicare Advantage", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "First Choice of the Midwest", "plan_name": "PPO", "standard_charge_percentage": 90, "methodology": "percent of total billed charges", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "United Healthcare (UHC)", "plan_name": "DSNP", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Employee Benefit Management Services (EBMS)", "plan_name": "EBMS SelectCare Network", "standard_charge_percentage": 80, "methodology": "percent of total billed charges", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Allegiance Provider Direct", "plan_name": "Medicare", "standard_charge_percentage": 229.99999999999997, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Claritev fka MultiPlan", "plan_name": "PPO", "standard_charge_percentage": 75, "methodology": "percent of total billed charges", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Medica Insurance Company", "plan_name": "Medicare Cost", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Medicare (CMS)", "plan_name": "Medicare", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Indian Health Services (IHS)", "plan_name": "Commercial", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "First Choice Health Network fka Health InfoNet", "plan_name": "Commercial", "standard_charge_percentage": 85, "methodology": "percent of total billed charges", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "First Choice Health Network fka Health InfoNet", "plan_name": "Workers Compensation", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Humana Insurance Company", "plan_name": "Humana Medicare Advantage HMO", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Humana Insurance Company", "plan_name": "Humana Medicare Advantage PPO", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Humana Insurance Company", "plan_name": "Humana Medicare Advantage PFFS", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Allegiance Provider Direct", "plan_name": "State of Montana Employee Benefit Plan (Self-Funded)", "standard_charge_percentage": 229.99999999999997, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Allegiance Provider Direct", "plan_name": "Montana Municipal Interlocal Authority (MMIA)", "standard_charge_percentage": 229.99999999999997, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Allegiance Provider Direct", "plan_name": "Montana Association of Counties (MACo)", "standard_charge_percentage": 229.99999999999997, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "First Choice Health Network fka Health InfoNet", "plan_name": "Medicare Advantage", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "TriWest Healthcare Alliance Corporation", "plan_name": "TRICARE Prime", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "TriWest Healthcare Alliance Corporation", "plan_name": "TRICARE Select", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Blue Cross Blue Shield of Montana", "plan_name": "HealthLink Network", "standard_charge_percentage": 75, "methodology": "percent of total billed charges", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Blue Cross Blue Shield of Montana", "plan_name": "Traditional Network", "standard_charge_percentage": 75, "methodology": "percent of total billed charges", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Blue Cross Blue Shield of Montana", "plan_name": "POS Network", "standard_charge_percentage": 75, "methodology": "percent of total billed charges", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Blue Cross Blue Shield of Montana", "plan_name": "Closed Plan Network", "standard_charge_percentage": 75, "methodology": "percent of total billed charges", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Blue Cross Blue Shield of Montana", "plan_name": "Retail HMO POS Network", "standard_charge_percentage": 75, "methodology": "percent of total billed charges", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Blue Cross Blue Shield of Montana", "plan_name": "Blue Options Network", "standard_charge_percentage": 75, "methodology": "percent of total billed charges", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "PacificSource Health Plans", "plan_name": "Medicare Advantage", "standard_charge_percentage": 103, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" } ] } ] }, { "description": "Multiple Sclerosis and Cerebellar Ataxia with MCC", "code_information": [ { "code": "58", "type": "LOCAL" } ], "standard_charges": [ { "setting": "inpatient", "payers_information": [ { "payer_name": "Blue Cross Blue Shield of Montana", "plan_name": "Medicare Advantage", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "United Healthcare (UHC)", "plan_name": "Medicare Advantage", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "First Choice of the Midwest", "plan_name": "PPO", "standard_charge_percentage": 90, "methodology": "percent of total billed charges", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "United Healthcare (UHC)", "plan_name": "DSNP", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Employee Benefit Management Services (EBMS)", "plan_name": "EBMS SelectCare Network", "standard_charge_percentage": 80, "methodology": "percent of total billed charges", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Allegiance Provider Direct", "plan_name": "Medicare", "standard_charge_percentage": 229.99999999999997, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Claritev fka MultiPlan", "plan_name": "PPO", "standard_charge_percentage": 75, "methodology": "percent of total billed charges", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Medica Insurance Company", "plan_name": "Medicare Cost", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Medicare (CMS)", "plan_name": "Medicare", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Indian Health Services (IHS)", "plan_name": "Commercial", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "First Choice Health Network fka Health InfoNet", "plan_name": "Commercial", "standard_charge_percentage": 85, "methodology": "percent of total billed charges", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "First Choice Health Network fka Health InfoNet", "plan_name": "Workers Compensation", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Humana Insurance Company", "plan_name": "Humana Medicare Advantage HMO", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Humana Insurance Company", "plan_name": "Humana Medicare Advantage PPO", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Humana Insurance Company", "plan_name": "Humana Medicare Advantage PFFS", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Allegiance Provider Direct", "plan_name": "State of Montana Employee Benefit Plan (Self-Funded)", "standard_charge_percentage": 229.99999999999997, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Allegiance Provider Direct", "plan_name": "Montana Municipal Interlocal Authority (MMIA)", "standard_charge_percentage": 229.99999999999997, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Allegiance Provider Direct", "plan_name": "Montana Association of Counties (MACo)", "standard_charge_percentage": 229.99999999999997, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "First Choice Health Network fka Health InfoNet", "plan_name": "Medicare Advantage", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "TriWest Healthcare Alliance Corporation", "plan_name": "TRICARE Prime", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "TriWest Healthcare Alliance Corporation", "plan_name": "TRICARE Select", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Blue Cross Blue Shield of Montana", "plan_name": "HealthLink Network", "standard_charge_percentage": 75, "methodology": "percent of total billed charges", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Blue Cross Blue Shield of Montana", "plan_name": "Traditional Network", "standard_charge_percentage": 75, "methodology": "percent of total billed charges", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Blue Cross Blue Shield of Montana", "plan_name": "POS Network", "standard_charge_percentage": 75, "methodology": "percent of total billed charges", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Blue Cross Blue Shield of Montana", "plan_name": "Closed Plan Network", "standard_charge_percentage": 75, "methodology": "percent of total billed charges", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Blue Cross Blue Shield of Montana", "plan_name": "Retail HMO POS Network", "standard_charge_percentage": 75, "methodology": "percent of total billed charges", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Blue Cross Blue Shield of Montana", "plan_name": "Blue Options Network", "standard_charge_percentage": 75, "methodology": "percent of total billed charges", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "PacificSource Health Plans", "plan_name": "Medicare Advantage", "standard_charge_percentage": 103, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" } ] } ] }, { "description": "Multiple Sclerosis and Cerebellar Ataxia with CC", "code_information": [ { "code": "59", "type": "LOCAL" } ], "standard_charges": [ { "setting": "inpatient", "payers_information": [ { "payer_name": "Blue Cross Blue Shield of Montana", "plan_name": "Medicare Advantage", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "United Healthcare (UHC)", "plan_name": "Medicare Advantage", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "First Choice of the Midwest", "plan_name": "PPO", "standard_charge_percentage": 90, "methodology": "percent of total billed charges", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "United Healthcare (UHC)", "plan_name": "DSNP", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Employee Benefit Management Services (EBMS)", "plan_name": "EBMS SelectCare Network", "standard_charge_percentage": 80, "methodology": "percent of total billed charges", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Allegiance Provider Direct", "plan_name": "Medicare", "standard_charge_percentage": 229.99999999999997, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Claritev fka MultiPlan", "plan_name": "PPO", "standard_charge_percentage": 75, "methodology": "percent of total billed charges", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Medica Insurance Company", "plan_name": "Medicare Cost", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Medicare (CMS)", "plan_name": "Medicare", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Indian Health Services (IHS)", "plan_name": "Commercial", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "First Choice Health Network fka Health InfoNet", "plan_name": "Commercial", "standard_charge_percentage": 85, "methodology": "percent of total billed charges", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "First Choice Health Network fka Health InfoNet", "plan_name": "Workers Compensation", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Humana Insurance Company", "plan_name": "Humana Medicare Advantage HMO", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Humana Insurance Company", "plan_name": "Humana Medicare Advantage PPO", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Humana Insurance Company", "plan_name": "Humana Medicare Advantage PFFS", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Allegiance Provider Direct", "plan_name": "State of Montana Employee Benefit Plan (Self-Funded)", "standard_charge_percentage": 229.99999999999997, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Allegiance Provider Direct", "plan_name": "Montana Municipal Interlocal Authority (MMIA)", "standard_charge_percentage": 229.99999999999997, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Allegiance Provider Direct", "plan_name": "Montana Association of Counties (MACo)", "standard_charge_percentage": 229.99999999999997, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "First Choice Health Network fka Health InfoNet", "plan_name": "Medicare Advantage", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "TriWest Healthcare Alliance Corporation", "plan_name": "TRICARE Prime", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "TriWest Healthcare Alliance Corporation", "plan_name": "TRICARE Select", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Blue Cross Blue Shield of Montana", "plan_name": "HealthLink Network", "standard_charge_percentage": 75, "methodology": "percent of total billed charges", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Blue Cross Blue Shield of Montana", "plan_name": "Traditional Network", "standard_charge_percentage": 75, "methodology": "percent of total billed charges", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Blue Cross Blue Shield of Montana", "plan_name": "POS Network", "standard_charge_percentage": 75, "methodology": "percent of total billed charges", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Blue Cross Blue Shield of Montana", "plan_name": "Closed Plan Network", "standard_charge_percentage": 75, "methodology": "percent of total billed charges", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Blue Cross Blue Shield of Montana", "plan_name": "Retail HMO POS Network", "standard_charge_percentage": 75, "methodology": "percent of total billed charges", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Blue Cross Blue Shield of Montana", "plan_name": "Blue Options Network", "standard_charge_percentage": 75, "methodology": "percent of total billed charges", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "PacificSource Health Plans", "plan_name": "Medicare Advantage", "standard_charge_percentage": 103, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" } ] } ] }, { "description": "Multiple Sclerosis and Cerebellar Ataxia without CC/MCC", "code_information": [ { "code": "60", "type": "LOCAL" } ], "standard_charges": [ { "setting": "inpatient", "payers_information": [ { "payer_name": "Blue Cross Blue Shield of Montana", "plan_name": "Medicare Advantage", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "United Healthcare (UHC)", "plan_name": "Medicare Advantage", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "First Choice of the Midwest", "plan_name": "PPO", "standard_charge_percentage": 90, "methodology": "percent of total billed charges", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "United Healthcare (UHC)", "plan_name": "DSNP", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Employee Benefit Management Services (EBMS)", "plan_name": "EBMS SelectCare Network", "standard_charge_percentage": 80, "methodology": "percent of total billed charges", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Allegiance Provider Direct", "plan_name": "Medicare", "standard_charge_percentage": 229.99999999999997, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Claritev fka MultiPlan", "plan_name": "PPO", "standard_charge_percentage": 75, "methodology": "percent of total billed charges", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Medica Insurance Company", "plan_name": "Medicare Cost", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Medicare (CMS)", "plan_name": "Medicare", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Indian Health Services (IHS)", "plan_name": "Commercial", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "First Choice Health Network fka Health InfoNet", "plan_name": "Commercial", "standard_charge_percentage": 85, "methodology": "percent of total billed charges", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "First Choice Health Network fka Health InfoNet", "plan_name": "Workers Compensation", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Humana Insurance Company", "plan_name": "Humana Medicare Advantage HMO", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Humana Insurance Company", "plan_name": "Humana Medicare Advantage PPO", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Humana Insurance Company", "plan_name": "Humana Medicare Advantage PFFS", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Allegiance Provider Direct", "plan_name": "State of Montana Employee Benefit Plan (Self-Funded)", "standard_charge_percentage": 229.99999999999997, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Allegiance Provider Direct", "plan_name": "Montana Municipal Interlocal Authority (MMIA)", "standard_charge_percentage": 229.99999999999997, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Allegiance Provider Direct", "plan_name": "Montana Association of Counties (MACo)", "standard_charge_percentage": 229.99999999999997, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "First Choice Health Network fka Health InfoNet", "plan_name": "Medicare Advantage", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "TriWest Healthcare Alliance Corporation", "plan_name": "TRICARE Prime", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "TriWest Healthcare Alliance Corporation", "plan_name": "TRICARE Select", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Blue Cross Blue Shield of Montana", "plan_name": "HealthLink Network", "standard_charge_percentage": 75, "methodology": "percent of total billed charges", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Blue Cross Blue Shield of Montana", "plan_name": "Traditional Network", "standard_charge_percentage": 75, "methodology": "percent of total billed charges", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Blue Cross Blue Shield of Montana", "plan_name": "POS Network", "standard_charge_percentage": 75, "methodology": "percent of total billed charges", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Blue Cross Blue Shield of Montana", "plan_name": "Closed Plan Network", "standard_charge_percentage": 75, "methodology": "percent of total billed charges", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Blue Cross Blue Shield of Montana", "plan_name": "Retail HMO POS Network", "standard_charge_percentage": 75, "methodology": "percent of total billed charges", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Blue Cross Blue Shield of Montana", "plan_name": "Blue Options Network", "standard_charge_percentage": 75, "methodology": "percent of total billed charges", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "PacificSource Health Plans", "plan_name": "Medicare Advantage", "standard_charge_percentage": 103, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" } ] } ] }, { "description": "Ischemic Stroke, Precerebral Occlusion or Transient Ischemia with Thrombolytic Agent with MCC", "code_information": [ { "code": "61", "type": "LOCAL" } ], "standard_charges": [ { "setting": "inpatient", "payers_information": [ { "payer_name": "Blue Cross Blue Shield of Montana", "plan_name": "Medicare Advantage", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "United Healthcare (UHC)", "plan_name": "Medicare Advantage", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "First Choice of the Midwest", "plan_name": "PPO", "standard_charge_percentage": 90, "methodology": "percent of total billed charges", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "United Healthcare (UHC)", "plan_name": "DSNP", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Employee Benefit Management Services (EBMS)", "plan_name": "EBMS SelectCare Network", "standard_charge_percentage": 80, "methodology": "percent of total billed charges", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Allegiance Provider Direct", "plan_name": "Medicare", "standard_charge_percentage": 229.99999999999997, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Claritev fka MultiPlan", "plan_name": "PPO", "standard_charge_percentage": 75, "methodology": "percent of total billed charges", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Medicare (CMS)", "plan_name": "Medicare", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Medica Insurance Company", "plan_name": "Medicare Cost", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Indian Health Services (IHS)", "plan_name": "Commercial", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "First Choice Health Network fka Health InfoNet", "plan_name": "Commercial", "standard_charge_percentage": 85, "methodology": "percent of total billed charges", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "First Choice Health Network fka Health InfoNet", "plan_name": "Workers Compensation", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Humana Insurance Company", "plan_name": "Humana Medicare Advantage HMO", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Humana Insurance Company", "plan_name": "Humana Medicare Advantage PPO", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Humana Insurance Company", "plan_name": "Humana Medicare Advantage PFFS", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Allegiance Provider Direct", "plan_name": "State of Montana Employee Benefit Plan (Self-Funded)", "standard_charge_percentage": 229.99999999999997, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Allegiance Provider Direct", "plan_name": "Montana Municipal Interlocal Authority (MMIA)", "standard_charge_percentage": 229.99999999999997, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Allegiance Provider Direct", "plan_name": "Montana Association of Counties (MACo)", "standard_charge_percentage": 229.99999999999997, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "First Choice Health Network fka Health InfoNet", "plan_name": "Medicare Advantage", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "TriWest Healthcare Alliance Corporation", "plan_name": "TRICARE Prime", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "TriWest Healthcare Alliance Corporation", "plan_name": "TRICARE Select", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Blue Cross Blue Shield of Montana", "plan_name": "HealthLink Network", "standard_charge_percentage": 75, "methodology": "percent of total billed charges", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Blue Cross Blue Shield of Montana", "plan_name": "Traditional Network", "standard_charge_percentage": 75, "methodology": "percent of total billed charges", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Blue Cross Blue Shield of Montana", "plan_name": "POS Network", "standard_charge_percentage": 75, "methodology": "percent of total billed charges", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Blue Cross Blue Shield of Montana", "plan_name": "Closed Plan Network", "standard_charge_percentage": 75, "methodology": "percent of total billed charges", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Blue Cross Blue Shield of Montana", "plan_name": "Retail HMO POS Network", "standard_charge_percentage": 75, "methodology": "percent of total billed charges", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Blue Cross Blue Shield of Montana", "plan_name": "Blue Options Network", "standard_charge_percentage": 75, "methodology": "percent of total billed charges", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "PacificSource Health Plans", "plan_name": "Medicare Advantage", "standard_charge_percentage": 103, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" } ] } ] }, { "description": "Ischemic Stroke, Precerebral Occlusion or Transient Ischemia with Thrombolytic Agent with CC", "code_information": [ { "code": "62", "type": "LOCAL" } ], "standard_charges": [ { "setting": "inpatient", "payers_information": [ { "payer_name": "Blue Cross Blue Shield of Montana", "plan_name": "Medicare Advantage", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "United Healthcare (UHC)", "plan_name": "Medicare Advantage", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "First Choice of the Midwest", "plan_name": "PPO", "standard_charge_percentage": 90, "methodology": "percent of total billed charges", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "United Healthcare (UHC)", "plan_name": "DSNP", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Employee Benefit Management Services (EBMS)", "plan_name": "EBMS SelectCare Network", "standard_charge_percentage": 80, "methodology": "percent of total billed charges", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Allegiance Provider Direct", "plan_name": "Medicare", "standard_charge_percentage": 229.99999999999997, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Claritev fka MultiPlan", "plan_name": "PPO", "standard_charge_percentage": 75, "methodology": "percent of total billed charges", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Medicare (CMS)", "plan_name": "Medicare", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Medica Insurance Company", "plan_name": "Medicare Cost", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Indian Health Services (IHS)", "plan_name": "Commercial", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "First Choice Health Network fka Health InfoNet", "plan_name": "Commercial", "standard_charge_percentage": 85, "methodology": "percent of total billed charges", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "First Choice Health Network fka Health InfoNet", "plan_name": "Workers Compensation", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Humana Insurance Company", "plan_name": "Humana Medicare Advantage HMO", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Humana Insurance Company", "plan_name": "Humana Medicare Advantage PPO", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Humana Insurance Company", "plan_name": "Humana Medicare Advantage PFFS", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Allegiance Provider Direct", "plan_name": "State of Montana Employee Benefit Plan (Self-Funded)", "standard_charge_percentage": 229.99999999999997, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Allegiance Provider Direct", "plan_name": "Montana Municipal Interlocal Authority (MMIA)", "standard_charge_percentage": 229.99999999999997, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Allegiance Provider Direct", "plan_name": "Montana Association of Counties (MACo)", "standard_charge_percentage": 229.99999999999997, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "First Choice Health Network fka Health InfoNet", "plan_name": "Medicare Advantage", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "TriWest Healthcare Alliance Corporation", "plan_name": "TRICARE Prime", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "TriWest Healthcare Alliance Corporation", "plan_name": "TRICARE Select", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Blue Cross Blue Shield of Montana", "plan_name": "HealthLink Network", "standard_charge_percentage": 75, "methodology": "percent of total billed charges", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Blue Cross Blue Shield of Montana", "plan_name": "Traditional Network", "standard_charge_percentage": 75, "methodology": "percent of total billed charges", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Blue Cross Blue Shield of Montana", "plan_name": "POS Network", "standard_charge_percentage": 75, "methodology": "percent of total billed charges", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Blue Cross Blue Shield of Montana", "plan_name": "Closed Plan Network", "standard_charge_percentage": 75, "methodology": "percent of total billed charges", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Blue Cross Blue Shield of Montana", "plan_name": "Retail HMO POS Network", "standard_charge_percentage": 75, "methodology": "percent of total billed charges", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Blue Cross Blue Shield of Montana", "plan_name": "Blue Options Network", "standard_charge_percentage": 75, "methodology": "percent of total billed charges", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "PacificSource Health Plans", "plan_name": "Medicare Advantage", "standard_charge_percentage": 103, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" } ] } ] }, { "description": "Ischemic Stroke, Precerebral Occlusion or Transient Ischemia with Thrombolytic Agent without CC/MCC", "code_information": [ { "code": "63", "type": "LOCAL" } ], "standard_charges": [ { "setting": "inpatient", "payers_information": [ { "payer_name": "Blue Cross Blue Shield of Montana", "plan_name": "Medicare Advantage", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "United Healthcare (UHC)", "plan_name": "Medicare Advantage", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "First Choice of the Midwest", "plan_name": "PPO", "standard_charge_percentage": 90, "methodology": "percent of total billed charges", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "United Healthcare (UHC)", "plan_name": "DSNP", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Employee Benefit Management Services (EBMS)", "plan_name": "EBMS SelectCare Network", "standard_charge_percentage": 80, "methodology": "percent of total billed charges", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Allegiance Provider Direct", "plan_name": "Medicare", "standard_charge_percentage": 229.99999999999997, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Claritev fka MultiPlan", "plan_name": "PPO", "standard_charge_percentage": 75, "methodology": "percent of total billed charges", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Medicare (CMS)", "plan_name": "Medicare", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Medica Insurance Company", "plan_name": "Medicare Cost", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Indian Health Services (IHS)", "plan_name": "Commercial", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "First Choice Health Network fka Health InfoNet", "plan_name": "Commercial", "standard_charge_percentage": 85, "methodology": "percent of total billed charges", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "First Choice Health Network fka Health InfoNet", "plan_name": "Workers Compensation", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Humana Insurance Company", "plan_name": "Humana Medicare Advantage HMO", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Humana Insurance Company", "plan_name": "Humana Medicare Advantage PPO", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Humana Insurance Company", "plan_name": "Humana Medicare Advantage PFFS", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Allegiance Provider Direct", "plan_name": "State of Montana Employee Benefit Plan (Self-Funded)", "standard_charge_percentage": 229.99999999999997, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Allegiance Provider Direct", "plan_name": "Montana Municipal Interlocal Authority (MMIA)", "standard_charge_percentage": 229.99999999999997, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Allegiance Provider Direct", "plan_name": "Montana Association of Counties (MACo)", "standard_charge_percentage": 229.99999999999997, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "First Choice Health Network fka Health InfoNet", "plan_name": "Medicare Advantage", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "TriWest Healthcare Alliance Corporation", "plan_name": "TRICARE Prime", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "TriWest Healthcare Alliance Corporation", "plan_name": "TRICARE Select", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Blue Cross Blue Shield of Montana", "plan_name": "HealthLink Network", "standard_charge_percentage": 75, "methodology": "percent of total billed charges", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Blue Cross Blue Shield of Montana", "plan_name": "Traditional Network", "standard_charge_percentage": 75, "methodology": "percent of total billed charges", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Blue Cross Blue Shield of Montana", "plan_name": "POS Network", "standard_charge_percentage": 75, "methodology": "percent of total billed charges", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Blue Cross Blue Shield of Montana", "plan_name": "Closed Plan Network", "standard_charge_percentage": 75, "methodology": "percent of total billed charges", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Blue Cross Blue Shield of Montana", "plan_name": "Retail HMO POS Network", "standard_charge_percentage": 75, "methodology": "percent of total billed charges", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Blue Cross Blue Shield of Montana", "plan_name": "Blue Options Network", "standard_charge_percentage": 75, "methodology": "percent of total billed charges", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "PacificSource Health Plans", "plan_name": "Medicare Advantage", "standard_charge_percentage": 103, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" } ] } ] }, { "description": "Intracranial Hemorrhage or Cerebral Infarction with MCC", "code_information": [ { "code": "64", "type": "LOCAL" } ], "standard_charges": [ { "setting": "inpatient", "payers_information": [ { "payer_name": "Blue Cross Blue Shield of Montana", "plan_name": "Medicare Advantage", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "United Healthcare (UHC)", "plan_name": "Medicare Advantage", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "First Choice of the Midwest", "plan_name": "PPO", "standard_charge_percentage": 90, "methodology": "percent of total billed charges", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "United Healthcare (UHC)", "plan_name": "DSNP", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Employee Benefit Management Services (EBMS)", "plan_name": "EBMS SelectCare Network", "standard_charge_percentage": 80, "methodology": "percent of total billed charges", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Allegiance Provider Direct", "plan_name": "Medicare", "standard_charge_percentage": 229.99999999999997, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Claritev fka MultiPlan", "plan_name": "PPO", "standard_charge_percentage": 75, "methodology": "percent of total billed charges", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Medicare (CMS)", "plan_name": "Medicare", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Medica Insurance Company", "plan_name": "Medicare Cost", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Indian Health Services (IHS)", "plan_name": "Commercial", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "First Choice Health Network fka Health InfoNet", "plan_name": "Commercial", "standard_charge_percentage": 85, "methodology": "percent of total billed charges", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "First Choice Health Network fka Health InfoNet", "plan_name": "Workers Compensation", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Humana Insurance Company", "plan_name": "Humana Medicare Advantage HMO", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Humana Insurance Company", "plan_name": "Humana Medicare Advantage PPO", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Humana Insurance Company", "plan_name": "Humana Medicare Advantage PFFS", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Allegiance Provider Direct", "plan_name": "State of Montana Employee Benefit Plan (Self-Funded)", "standard_charge_percentage": 229.99999999999997, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Allegiance Provider Direct", "plan_name": "Montana Municipal Interlocal Authority (MMIA)", "standard_charge_percentage": 229.99999999999997, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Allegiance Provider Direct", "plan_name": "Montana Association of Counties (MACo)", "standard_charge_percentage": 229.99999999999997, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "First Choice Health Network fka Health InfoNet", "plan_name": "Medicare Advantage", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "TriWest Healthcare Alliance Corporation", "plan_name": "TRICARE Prime", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "TriWest Healthcare Alliance Corporation", "plan_name": "TRICARE Select", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Blue Cross Blue Shield of Montana", "plan_name": "HealthLink Network", "standard_charge_percentage": 75, "methodology": "percent of total billed charges", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Blue Cross Blue Shield of Montana", "plan_name": "Traditional Network", "standard_charge_percentage": 75, "methodology": "percent of total billed charges", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Blue Cross Blue Shield of Montana", "plan_name": "POS Network", "standard_charge_percentage": 75, "methodology": "percent of total billed charges", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Blue Cross Blue Shield of Montana", "plan_name": "Closed Plan Network", "standard_charge_percentage": 75, "methodology": "percent of total billed charges", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Blue Cross Blue Shield of Montana", "plan_name": "Retail HMO POS Network", "standard_charge_percentage": 75, "methodology": "percent of total billed charges", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Blue Cross Blue Shield of Montana", "plan_name": "Blue Options Network", "standard_charge_percentage": 75, "methodology": "percent of total billed charges", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "PacificSource Health Plans", "plan_name": "Medicare Advantage", "standard_charge_percentage": 103, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" } ] } ] }, { "description": "Intracranial Hemorrhage or Cerebral Infarction with CC or tPA in 24 Hours", "code_information": [ { "code": "65", "type": "LOCAL" } ], "standard_charges": [ { "setting": "inpatient", "payers_information": [ { "payer_name": "Blue Cross Blue Shield of Montana", "plan_name": "Medicare Advantage", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "United Healthcare (UHC)", "plan_name": "Medicare Advantage", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "First Choice of the Midwest", "plan_name": "PPO", "standard_charge_percentage": 90, "methodology": "percent of total billed charges", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "United Healthcare (UHC)", "plan_name": "DSNP", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Employee Benefit Management Services (EBMS)", "plan_name": "EBMS SelectCare Network", "standard_charge_percentage": 80, "methodology": "percent of total billed charges", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Allegiance Provider Direct", "plan_name": "Medicare", "standard_charge_percentage": 229.99999999999997, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Claritev fka MultiPlan", "plan_name": "PPO", "standard_charge_percentage": 75, "methodology": "percent of total billed charges", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Medicare (CMS)", "plan_name": "Medicare", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Medica Insurance Company", "plan_name": "Medicare Cost", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Indian Health Services (IHS)", "plan_name": "Commercial", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "First Choice Health Network fka Health InfoNet", "plan_name": "Commercial", "standard_charge_percentage": 85, "methodology": "percent of total billed charges", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "First Choice Health Network fka Health InfoNet", "plan_name": "Workers Compensation", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Humana Insurance Company", "plan_name": "Humana Medicare Advantage HMO", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Humana Insurance Company", "plan_name": "Humana Medicare Advantage PPO", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Humana Insurance Company", "plan_name": "Humana Medicare Advantage PFFS", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Allegiance Provider Direct", "plan_name": "State of Montana Employee Benefit Plan (Self-Funded)", "standard_charge_percentage": 229.99999999999997, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Allegiance Provider Direct", "plan_name": "Montana Municipal Interlocal Authority (MMIA)", "standard_charge_percentage": 229.99999999999997, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Allegiance Provider Direct", "plan_name": "Montana Association of Counties (MACo)", "standard_charge_percentage": 229.99999999999997, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "First Choice Health Network fka Health InfoNet", "plan_name": "Medicare Advantage", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "TriWest Healthcare Alliance Corporation", "plan_name": "TRICARE Prime", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "TriWest Healthcare Alliance Corporation", "plan_name": "TRICARE Select", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Blue Cross Blue Shield of Montana", "plan_name": "HealthLink Network", "standard_charge_percentage": 75, "methodology": "percent of total billed charges", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Blue Cross Blue Shield of Montana", "plan_name": "Traditional Network", "standard_charge_percentage": 75, "methodology": "percent of total billed charges", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Blue Cross Blue Shield of Montana", "plan_name": "POS Network", "standard_charge_percentage": 75, "methodology": "percent of total billed charges", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Blue Cross Blue Shield of Montana", "plan_name": "Closed Plan Network", "standard_charge_percentage": 75, "methodology": "percent of total billed charges", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Blue Cross Blue Shield of Montana", "plan_name": "Retail HMO POS Network", "standard_charge_percentage": 75, "methodology": "percent of total billed charges", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Blue Cross Blue Shield of Montana", "plan_name": "Blue Options Network", "standard_charge_percentage": 75, "methodology": "percent of total billed charges", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "PacificSource Health Plans", "plan_name": "Medicare Advantage", "standard_charge_percentage": 103, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" } ] } ] }, { "description": "Intracranial Hemorrhage or Cerebral Infarction without CC/MCC", "code_information": [ { "code": "66", "type": "LOCAL" } ], "standard_charges": [ { "setting": "inpatient", "payers_information": [ { "payer_name": "Blue Cross Blue Shield of Montana", "plan_name": "Medicare Advantage", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "United Healthcare (UHC)", "plan_name": "Medicare Advantage", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "First Choice of the Midwest", "plan_name": "PPO", "standard_charge_percentage": 90, "methodology": "percent of total billed charges", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "United Healthcare (UHC)", "plan_name": "DSNP", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Employee Benefit Management Services (EBMS)", "plan_name": "EBMS SelectCare Network", "standard_charge_percentage": 80, "methodology": "percent of total billed charges", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Allegiance Provider Direct", "plan_name": "Medicare", "standard_charge_percentage": 229.99999999999997, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Claritev fka MultiPlan", "plan_name": "PPO", "standard_charge_percentage": 75, "methodology": "percent of total billed charges", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Medicare (CMS)", "plan_name": "Medicare", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Medica Insurance Company", "plan_name": "Medicare Cost", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "First Choice Health Network fka Health InfoNet", "plan_name": "Commercial", "standard_charge_percentage": 85, "methodology": "percent of total billed charges", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Indian Health Services (IHS)", "plan_name": "Commercial", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "First Choice Health Network fka Health InfoNet", "plan_name": "Workers Compensation", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Humana Insurance Company", "plan_name": "Humana Medicare Advantage HMO", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Humana Insurance Company", "plan_name": "Humana Medicare Advantage PPO", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Humana Insurance Company", "plan_name": "Humana Medicare Advantage PFFS", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Allegiance Provider Direct", "plan_name": "State of Montana Employee Benefit Plan (Self-Funded)", "standard_charge_percentage": 229.99999999999997, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Allegiance Provider Direct", "plan_name": "Montana Municipal Interlocal Authority (MMIA)", "standard_charge_percentage": 229.99999999999997, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Allegiance Provider Direct", "plan_name": "Montana Association of Counties (MACo)", "standard_charge_percentage": 229.99999999999997, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "First Choice Health Network fka Health InfoNet", "plan_name": "Medicare Advantage", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "TriWest Healthcare Alliance Corporation", "plan_name": "TRICARE Prime", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "TriWest Healthcare Alliance Corporation", "plan_name": "TRICARE Select", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Blue Cross Blue Shield of Montana", "plan_name": "HealthLink Network", "standard_charge_percentage": 75, "methodology": "percent of total billed charges", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Blue Cross Blue Shield of Montana", "plan_name": "Traditional Network", "standard_charge_percentage": 75, "methodology": "percent of total billed charges", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Blue Cross Blue Shield of Montana", "plan_name": "POS Network", "standard_charge_percentage": 75, "methodology": "percent of total billed charges", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Blue Cross Blue Shield of Montana", "plan_name": "Closed Plan Network", "standard_charge_percentage": 75, "methodology": "percent of total billed charges", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Blue Cross Blue Shield of Montana", "plan_name": "Retail HMO POS Network", "standard_charge_percentage": 75, "methodology": "percent of total billed charges", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Blue Cross Blue Shield of Montana", "plan_name": "Blue Options Network", "standard_charge_percentage": 75, "methodology": "percent of total billed charges", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "PacificSource Health Plans", "plan_name": "Medicare Advantage", "standard_charge_percentage": 103, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" } ] } ] }, { "description": "Precerebral Occlusion without Infarction with MCC", "code_information": [ { "code": "67", "type": "LOCAL" } ], "standard_charges": [ { "setting": "inpatient", "payers_information": [ { "payer_name": "Blue Cross Blue Shield of Montana", "plan_name": "Medicare Advantage", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "United Healthcare (UHC)", "plan_name": "Medicare Advantage", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "First Choice of the Midwest", "plan_name": "PPO", "standard_charge_percentage": 90, "methodology": "percent of total billed charges", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "United Healthcare (UHC)", "plan_name": "DSNP", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Employee Benefit Management Services (EBMS)", "plan_name": "EBMS SelectCare Network", "standard_charge_percentage": 80, "methodology": "percent of total billed charges", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Allegiance Provider Direct", "plan_name": "Medicare", "standard_charge_percentage": 229.99999999999997, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Claritev fka MultiPlan", "plan_name": "PPO", "standard_charge_percentage": 75, "methodology": "percent of total billed charges", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Medicare (CMS)", "plan_name": "Medicare", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Medica Insurance Company", "plan_name": "Medicare Cost", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "First Choice Health Network fka Health InfoNet", "plan_name": "Commercial", "standard_charge_percentage": 85, "methodology": "percent of total billed charges", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Indian Health Services (IHS)", "plan_name": "Commercial", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "First Choice Health Network fka Health InfoNet", "plan_name": "Workers Compensation", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Humana Insurance Company", "plan_name": "Humana Medicare Advantage HMO", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Humana Insurance Company", "plan_name": "Humana Medicare Advantage PPO", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Humana Insurance Company", "plan_name": "Humana Medicare Advantage PFFS", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Allegiance Provider Direct", "plan_name": "State of Montana Employee Benefit Plan (Self-Funded)", "standard_charge_percentage": 229.99999999999997, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Allegiance Provider Direct", "plan_name": "Montana Municipal Interlocal Authority (MMIA)", "standard_charge_percentage": 229.99999999999997, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Allegiance Provider Direct", "plan_name": "Montana Association of Counties (MACo)", "standard_charge_percentage": 229.99999999999997, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "First Choice Health Network fka Health InfoNet", "plan_name": "Medicare Advantage", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "TriWest Healthcare Alliance Corporation", "plan_name": "TRICARE Prime", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "TriWest Healthcare Alliance Corporation", "plan_name": "TRICARE Select", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Blue Cross Blue Shield of Montana", "plan_name": "HealthLink Network", "standard_charge_percentage": 75, "methodology": "percent of total billed charges", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Blue Cross Blue Shield of Montana", "plan_name": "Traditional Network", "standard_charge_percentage": 75, "methodology": "percent of total billed charges", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Blue Cross Blue Shield of Montana", "plan_name": "POS Network", "standard_charge_percentage": 75, "methodology": "percent of total billed charges", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Blue Cross Blue Shield of Montana", "plan_name": "Closed Plan Network", "standard_charge_percentage": 75, "methodology": "percent of total billed charges", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Blue Cross Blue Shield of Montana", "plan_name": "Retail HMO POS Network", "standard_charge_percentage": 75, "methodology": "percent of total billed charges", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Blue Cross Blue Shield of Montana", "plan_name": "Blue Options Network", "standard_charge_percentage": 75, "methodology": "percent of total billed charges", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "PacificSource Health Plans", "plan_name": "Medicare Advantage", "standard_charge_percentage": 103, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" } ] } ] }, { "description": "Precerebral Occlusion without Infarction without MCC", "code_information": [ { "code": "68", "type": "LOCAL" } ], "standard_charges": [ { "setting": "inpatient", "payers_information": [ { "payer_name": "Blue Cross Blue Shield of Montana", "plan_name": "Medicare Advantage", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "United Healthcare (UHC)", "plan_name": "Medicare Advantage", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "First Choice of the Midwest", "plan_name": "PPO", "standard_charge_percentage": 90, "methodology": "percent of total billed charges", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "United Healthcare (UHC)", "plan_name": "DSNP", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Employee Benefit Management Services (EBMS)", "plan_name": "EBMS SelectCare Network", "standard_charge_percentage": 80, "methodology": "percent of total billed charges", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Allegiance Provider Direct", "plan_name": "Medicare", "standard_charge_percentage": 229.99999999999997, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Claritev fka MultiPlan", "plan_name": "PPO", "standard_charge_percentage": 75, "methodology": "percent of total billed charges", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Medicare (CMS)", "plan_name": "Medicare", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Medica Insurance Company", "plan_name": "Medicare Cost", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "First Choice Health Network fka Health InfoNet", "plan_name": "Commercial", "standard_charge_percentage": 85, "methodology": "percent of total billed charges", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Indian Health Services (IHS)", "plan_name": "Commercial", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "First Choice Health Network fka Health InfoNet", "plan_name": "Workers Compensation", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Humana Insurance Company", "plan_name": "Humana Medicare Advantage HMO", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Humana Insurance Company", "plan_name": "Humana Medicare Advantage PPO", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Humana Insurance Company", "plan_name": "Humana Medicare Advantage PFFS", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Allegiance Provider Direct", "plan_name": "State of Montana Employee Benefit Plan (Self-Funded)", "standard_charge_percentage": 229.99999999999997, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Allegiance Provider Direct", "plan_name": "Montana Municipal Interlocal Authority (MMIA)", "standard_charge_percentage": 229.99999999999997, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Allegiance Provider Direct", "plan_name": "Montana Association of Counties (MACo)", "standard_charge_percentage": 229.99999999999997, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "First Choice Health Network fka Health InfoNet", "plan_name": "Medicare Advantage", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "TriWest Healthcare Alliance Corporation", "plan_name": "TRICARE Prime", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "TriWest Healthcare Alliance Corporation", "plan_name": "TRICARE Select", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Blue Cross Blue Shield of Montana", "plan_name": "HealthLink Network", "standard_charge_percentage": 75, "methodology": "percent of total billed charges", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Blue Cross Blue Shield of Montana", "plan_name": "Traditional Network", "standard_charge_percentage": 75, "methodology": "percent of total billed charges", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Blue Cross Blue Shield of Montana", "plan_name": "POS Network", "standard_charge_percentage": 75, "methodology": "percent of total billed charges", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Blue Cross Blue Shield of Montana", "plan_name": "Closed Plan Network", "standard_charge_percentage": 75, "methodology": "percent of total billed charges", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Blue Cross Blue Shield of Montana", "plan_name": "Retail HMO POS Network", "standard_charge_percentage": 75, "methodology": "percent of total billed charges", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Blue Cross Blue Shield of Montana", "plan_name": "Blue Options Network", "standard_charge_percentage": 75, "methodology": "percent of total billed charges", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "PacificSource Health Plans", "plan_name": "Medicare Advantage", "standard_charge_percentage": 103, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" } ] } ] }, { "description": "Transient Ischemia without Thrombolytic", "code_information": [ { "code": "69", "type": "LOCAL" } ], "standard_charges": [ { "setting": "inpatient", "payers_information": [ { "payer_name": "Blue Cross Blue Shield of Montana", "plan_name": "Medicare Advantage", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "United Healthcare (UHC)", "plan_name": "Medicare Advantage", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "First Choice of the Midwest", "plan_name": "PPO", "standard_charge_percentage": 90, "methodology": "percent of total billed charges", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "United Healthcare (UHC)", "plan_name": "DSNP", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Employee Benefit Management Services (EBMS)", "plan_name": "EBMS SelectCare Network", "standard_charge_percentage": 80, "methodology": "percent of total billed charges", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Allegiance Provider Direct", "plan_name": "Medicare", "standard_charge_percentage": 229.99999999999997, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Claritev fka MultiPlan", "plan_name": "PPO", "standard_charge_percentage": 75, "methodology": "percent of total billed charges", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Medicare (CMS)", "plan_name": "Medicare", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Medica Insurance Company", "plan_name": "Medicare Cost", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "First Choice Health Network fka Health InfoNet", "plan_name": "Commercial", "standard_charge_percentage": 85, "methodology": "percent of total billed charges", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Indian Health Services (IHS)", "plan_name": "Commercial", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "First Choice Health Network fka Health InfoNet", "plan_name": "Workers Compensation", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Humana Insurance Company", "plan_name": "Humana Medicare Advantage HMO", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Humana Insurance Company", "plan_name": "Humana Medicare Advantage PPO", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Humana Insurance Company", "plan_name": "Humana Medicare Advantage PFFS", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Allegiance Provider Direct", "plan_name": "State of Montana Employee Benefit Plan (Self-Funded)", "standard_charge_percentage": 229.99999999999997, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Allegiance Provider Direct", "plan_name": "Montana Municipal Interlocal Authority (MMIA)", "standard_charge_percentage": 229.99999999999997, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Allegiance Provider Direct", "plan_name": "Montana Association of Counties (MACo)", "standard_charge_percentage": 229.99999999999997, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "First Choice Health Network fka Health InfoNet", "plan_name": "Medicare Advantage", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "TriWest Healthcare Alliance Corporation", "plan_name": "TRICARE Prime", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "TriWest Healthcare Alliance Corporation", "plan_name": "TRICARE Select", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Blue Cross Blue Shield of Montana", "plan_name": "HealthLink Network", "standard_charge_percentage": 75, "methodology": "percent of total billed charges", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Blue Cross Blue Shield of Montana", "plan_name": "Traditional Network", "standard_charge_percentage": 75, "methodology": "percent of total billed charges", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Blue Cross Blue Shield of Montana", "plan_name": "POS Network", "standard_charge_percentage": 75, "methodology": "percent of total billed charges", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Blue Cross Blue Shield of Montana", "plan_name": "Closed Plan Network", "standard_charge_percentage": 75, "methodology": "percent of total billed charges", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Blue Cross Blue Shield of Montana", "plan_name": "Retail HMO POS Network", "standard_charge_percentage": 75, "methodology": "percent of total billed charges", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Blue Cross Blue Shield of Montana", "plan_name": "Blue Options Network", "standard_charge_percentage": 75, "methodology": "percent of total billed charges", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "PacificSource Health Plans", "plan_name": "Medicare Advantage", "standard_charge_percentage": 103, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" } ] } ] }, { "description": "Other Cerebrovascular Disorders with MCC*", "code_information": [ { "code": "70", "type": "LOCAL" } ], "standard_charges": [ { "setting": "inpatient", "payers_information": [ { "payer_name": "Blue Cross Blue Shield of Montana", "plan_name": "Medicare Advantage", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "United Healthcare (UHC)", "plan_name": "Medicare Advantage", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "First Choice of the Midwest", "plan_name": "PPO", "standard_charge_percentage": 90, "methodology": "percent of total billed charges", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "United Healthcare (UHC)", "plan_name": "DSNP", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Employee Benefit Management Services (EBMS)", "plan_name": "EBMS SelectCare Network", "standard_charge_percentage": 80, "methodology": "percent of total billed charges", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Allegiance Provider Direct", "plan_name": "Medicare", "standard_charge_percentage": 229.99999999999997, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Claritev fka MultiPlan", "plan_name": "PPO", "standard_charge_percentage": 75, "methodology": "percent of total billed charges", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Medicare (CMS)", "plan_name": "Medicare", "standard_charge_percentage": 100, "methodology": "fee schedule", "median_amount": 39466.46, "10th_percentile": 39466.46, "90th_percentile": 39466.46, "count": "1 through 10" }, { "payer_name": "Medica Insurance Company", "plan_name": "Medicare Cost", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "First Choice Health Network fka Health InfoNet", "plan_name": "Commercial", "standard_charge_percentage": 85, "methodology": "percent of total billed charges", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Indian Health Services (IHS)", "plan_name": "Commercial", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "First Choice Health Network fka Health InfoNet", "plan_name": "Workers Compensation", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Humana Insurance Company", "plan_name": "Humana Medicare Advantage HMO", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Humana Insurance Company", "plan_name": "Humana Medicare Advantage PPO", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Humana Insurance Company", "plan_name": "Humana Medicare Advantage PFFS", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Allegiance Provider Direct", "plan_name": "State of Montana Employee Benefit Plan (Self-Funded)", "standard_charge_percentage": 229.99999999999997, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Allegiance Provider Direct", "plan_name": "Montana Municipal Interlocal Authority (MMIA)", "standard_charge_percentage": 229.99999999999997, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Allegiance Provider Direct", "plan_name": "Montana Association of Counties (MACo)", "standard_charge_percentage": 229.99999999999997, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "First Choice Health Network fka Health InfoNet", "plan_name": "Medicare Advantage", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "TriWest Healthcare Alliance Corporation", "plan_name": "TRICARE Prime", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "TriWest Healthcare Alliance Corporation", "plan_name": "TRICARE Select", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Blue Cross Blue Shield of Montana", "plan_name": "HealthLink Network", "standard_charge_percentage": 75, "methodology": "percent of total billed charges", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Blue Cross Blue Shield of Montana", "plan_name": "Traditional Network", "standard_charge_percentage": 75, "methodology": "percent of total billed charges", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Blue Cross Blue Shield of Montana", "plan_name": "POS Network", "standard_charge_percentage": 75, "methodology": "percent of total billed charges", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Blue Cross Blue Shield of Montana", "plan_name": "Closed Plan Network", "standard_charge_percentage": 75, "methodology": "percent of total billed charges", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Blue Cross Blue Shield of Montana", "plan_name": "Retail HMO POS Network", "standard_charge_percentage": 75, "methodology": "percent of total billed charges", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Blue Cross Blue Shield of Montana", "plan_name": "Blue Options Network", "standard_charge_percentage": 75, "methodology": "percent of total billed charges", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "PacificSource Health Plans", "plan_name": "Medicare Advantage", "standard_charge_percentage": 103, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" } ], "minimum": 39466.46, "maximum": 39466.46 } ] }, { "description": "Other Cerebrovascular Disorders with CC*", "code_information": [ { "code": "71", "type": "LOCAL" } ], "standard_charges": [ { "setting": "inpatient", "payers_information": [ { "payer_name": "Blue Cross Blue Shield of Montana", "plan_name": "Medicare Advantage", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "United Healthcare (UHC)", "plan_name": "Medicare Advantage", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "First Choice of the Midwest", "plan_name": "PPO", "standard_charge_percentage": 90, "methodology": "percent of total billed charges", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "United Healthcare (UHC)", "plan_name": "DSNP", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Employee Benefit Management Services (EBMS)", "plan_name": "EBMS SelectCare Network", "standard_charge_percentage": 80, "methodology": "percent of total billed charges", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Allegiance Provider Direct", "plan_name": "Medicare", "standard_charge_percentage": 229.99999999999997, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Claritev fka MultiPlan", "plan_name": "PPO", "standard_charge_percentage": 75, "methodology": "percent of total billed charges", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Medicare (CMS)", "plan_name": "Medicare", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Medica Insurance Company", "plan_name": "Medicare Cost", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "First Choice Health Network fka Health InfoNet", "plan_name": "Commercial", "standard_charge_percentage": 85, "methodology": "percent of total billed charges", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Indian Health Services (IHS)", "plan_name": "Commercial", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "First Choice Health Network fka Health InfoNet", "plan_name": "Workers Compensation", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Humana Insurance Company", "plan_name": "Humana Medicare Advantage HMO", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Humana Insurance Company", "plan_name": "Humana Medicare Advantage PPO", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Humana Insurance Company", "plan_name": "Humana Medicare Advantage PFFS", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Allegiance Provider Direct", "plan_name": "State of Montana Employee Benefit Plan (Self-Funded)", "standard_charge_percentage": 229.99999999999997, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Allegiance Provider Direct", "plan_name": "Montana Municipal Interlocal Authority (MMIA)", "standard_charge_percentage": 229.99999999999997, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Allegiance Provider Direct", "plan_name": "Montana Association of Counties (MACo)", "standard_charge_percentage": 229.99999999999997, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "First Choice Health Network fka Health InfoNet", "plan_name": "Medicare Advantage", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "TriWest Healthcare Alliance Corporation", "plan_name": "TRICARE Prime", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "TriWest Healthcare Alliance Corporation", "plan_name": "TRICARE Select", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Blue Cross Blue Shield of Montana", "plan_name": "HealthLink Network", "standard_charge_percentage": 75, "methodology": "percent of total billed charges", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Blue Cross Blue Shield of Montana", "plan_name": "Traditional Network", "standard_charge_percentage": 75, "methodology": "percent of total billed charges", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Blue Cross Blue Shield of Montana", "plan_name": "POS Network", "standard_charge_percentage": 75, "methodology": "percent of total billed charges", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Blue Cross Blue Shield of Montana", "plan_name": "Closed Plan Network", "standard_charge_percentage": 75, "methodology": "percent of total billed charges", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Blue Cross Blue Shield of Montana", "plan_name": "Retail HMO POS Network", "standard_charge_percentage": 75, "methodology": "percent of total billed charges", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Blue Cross Blue Shield of Montana", "plan_name": "Blue Options Network", "standard_charge_percentage": 75, "methodology": "percent of total billed charges", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "PacificSource Health Plans", "plan_name": "Medicare Advantage", "standard_charge_percentage": 103, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" } ] } ] }, { "description": "Other Cerebrovascular Disorders without CC/MCC*", "code_information": [ { "code": "72", "type": "LOCAL" } ], "standard_charges": [ { "setting": "inpatient", "payers_information": [ { "payer_name": "Blue Cross Blue Shield of Montana", "plan_name": "Medicare Advantage", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "United Healthcare (UHC)", "plan_name": "Medicare Advantage", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "First Choice of the Midwest", "plan_name": "PPO", "standard_charge_percentage": 90, "methodology": "percent of total billed charges", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "United Healthcare (UHC)", "plan_name": "DSNP", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Employee Benefit Management Services (EBMS)", "plan_name": "EBMS SelectCare Network", "standard_charge_percentage": 80, "methodology": "percent of total billed charges", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Allegiance Provider Direct", "plan_name": "Medicare", "standard_charge_percentage": 229.99999999999997, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Claritev fka MultiPlan", "plan_name": "PPO", "standard_charge_percentage": 75, "methodology": "percent of total billed charges", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Medicare (CMS)", "plan_name": "Medicare", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Medica Insurance Company", "plan_name": "Medicare Cost", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "First Choice Health Network fka Health InfoNet", "plan_name": "Commercial", "standard_charge_percentage": 85, "methodology": "percent of total billed charges", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Indian Health Services (IHS)", "plan_name": "Commercial", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "First Choice Health Network fka Health InfoNet", "plan_name": "Workers Compensation", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Humana Insurance Company", "plan_name": "Humana Medicare Advantage HMO", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Humana Insurance Company", "plan_name": "Humana Medicare Advantage PPO", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Humana Insurance Company", "plan_name": "Humana Medicare Advantage PFFS", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Allegiance Provider Direct", "plan_name": "State of Montana Employee Benefit Plan (Self-Funded)", "standard_charge_percentage": 229.99999999999997, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Allegiance Provider Direct", "plan_name": "Montana Municipal Interlocal Authority (MMIA)", "standard_charge_percentage": 229.99999999999997, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Allegiance Provider Direct", "plan_name": "Montana Association of Counties (MACo)", "standard_charge_percentage": 229.99999999999997, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "First Choice Health Network fka Health InfoNet", "plan_name": "Medicare Advantage", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "TriWest Healthcare Alliance Corporation", "plan_name": "TRICARE Prime", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "TriWest Healthcare Alliance Corporation", "plan_name": "TRICARE Select", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Blue Cross Blue Shield of Montana", "plan_name": "HealthLink Network", "standard_charge_percentage": 75, "methodology": "percent of total billed charges", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Blue Cross Blue Shield of Montana", "plan_name": "Traditional Network", "standard_charge_percentage": 75, "methodology": "percent of total billed charges", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Blue Cross Blue Shield of Montana", "plan_name": "POS Network", "standard_charge_percentage": 75, "methodology": "percent of total billed charges", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Blue Cross Blue Shield of Montana", "plan_name": "Closed Plan Network", "standard_charge_percentage": 75, "methodology": "percent of total billed charges", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Blue Cross Blue Shield of Montana", "plan_name": "Retail HMO POS Network", "standard_charge_percentage": 75, "methodology": "percent of total billed charges", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Blue Cross Blue Shield of Montana", "plan_name": "Blue Options Network", "standard_charge_percentage": 75, "methodology": "percent of total billed charges", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "PacificSource Health Plans", "plan_name": "Medicare Advantage", "standard_charge_percentage": 103, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" } ] } ] }, { "description": "Cranial and Peripheral Nerve Disorders with MCC", "code_information": [ { "code": "73", "type": "LOCAL" } ], "standard_charges": [ { "setting": "inpatient", "payers_information": [ { "payer_name": "Blue Cross Blue Shield of Montana", "plan_name": "Medicare Advantage", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "United Healthcare (UHC)", "plan_name": "Medicare Advantage", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "First Choice of the Midwest", "plan_name": "PPO", "standard_charge_percentage": 90, "methodology": "percent of total billed charges", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "United Healthcare (UHC)", "plan_name": "DSNP", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Employee Benefit Management Services (EBMS)", "plan_name": "EBMS SelectCare Network", "standard_charge_percentage": 80, "methodology": "percent of total billed charges", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Allegiance Provider Direct", "plan_name": "Medicare", "standard_charge_percentage": 229.99999999999997, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Claritev fka MultiPlan", "plan_name": "PPO", "standard_charge_percentage": 75, "methodology": "percent of total billed charges", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Medicare (CMS)", "plan_name": "Medicare", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Medica Insurance Company", "plan_name": "Medicare Cost", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "First Choice Health Network fka Health InfoNet", "plan_name": "Commercial", "standard_charge_percentage": 85, "methodology": "percent of total billed charges", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Indian Health Services (IHS)", "plan_name": "Commercial", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "First Choice Health Network fka Health InfoNet", "plan_name": "Workers Compensation", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Humana Insurance Company", "plan_name": "Humana Medicare Advantage HMO", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Humana Insurance Company", "plan_name": "Humana Medicare Advantage PPO", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Humana Insurance Company", "plan_name": "Humana Medicare Advantage PFFS", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Allegiance Provider Direct", "plan_name": "State of Montana Employee Benefit Plan (Self-Funded)", "standard_charge_percentage": 229.99999999999997, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Allegiance Provider Direct", "plan_name": "Montana Municipal Interlocal Authority (MMIA)", "standard_charge_percentage": 229.99999999999997, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Allegiance Provider Direct", "plan_name": "Montana Association of Counties (MACo)", "standard_charge_percentage": 229.99999999999997, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "First Choice Health Network fka Health InfoNet", "plan_name": "Medicare Advantage", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "TriWest Healthcare Alliance Corporation", "plan_name": "TRICARE Prime", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "TriWest Healthcare Alliance Corporation", "plan_name": "TRICARE Select", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Blue Cross Blue Shield of Montana", "plan_name": "HealthLink Network", "standard_charge_percentage": 75, "methodology": "percent of total billed charges", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Blue Cross Blue Shield of Montana", "plan_name": "Traditional Network", "standard_charge_percentage": 75, "methodology": "percent of total billed charges", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Blue Cross Blue Shield of Montana", "plan_name": "POS Network", "standard_charge_percentage": 75, "methodology": "percent of total billed charges", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Blue Cross Blue Shield of Montana", "plan_name": "Closed Plan Network", "standard_charge_percentage": 75, "methodology": "percent of total billed charges", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Blue Cross Blue Shield of Montana", "plan_name": "Retail HMO POS Network", "standard_charge_percentage": 75, "methodology": "percent of total billed charges", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Blue Cross Blue Shield of Montana", "plan_name": "Blue Options Network", "standard_charge_percentage": 75, "methodology": "percent of total billed charges", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "PacificSource Health Plans", "plan_name": "Medicare Advantage", "standard_charge_percentage": 103, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" } ] } ] }, { "description": "Cranial and Peripheral Nerve Disorders without MCC", "code_information": [ { "code": "74", "type": "LOCAL" } ], "standard_charges": [ { "setting": "inpatient", "payers_information": [ { "payer_name": "Blue Cross Blue Shield of Montana", "plan_name": "Medicare Advantage", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "United Healthcare (UHC)", "plan_name": "Medicare Advantage", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "First Choice of the Midwest", "plan_name": "PPO", "standard_charge_percentage": 90, "methodology": "percent of total billed charges", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "United Healthcare (UHC)", "plan_name": "DSNP", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Employee Benefit Management Services (EBMS)", "plan_name": "EBMS SelectCare Network", "standard_charge_percentage": 80, "methodology": "percent of total billed charges", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Allegiance Provider Direct", "plan_name": "Medicare", "standard_charge_percentage": 229.99999999999997, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Claritev fka MultiPlan", "plan_name": "PPO", "standard_charge_percentage": 75, "methodology": "percent of total billed charges", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Medicare (CMS)", "plan_name": "Medicare", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Medica Insurance Company", "plan_name": "Medicare Cost", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "First Choice Health Network fka Health InfoNet", "plan_name": "Commercial", "standard_charge_percentage": 85, "methodology": "percent of total billed charges", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Indian Health Services (IHS)", "plan_name": "Commercial", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "First Choice Health Network fka Health InfoNet", "plan_name": "Workers Compensation", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Humana Insurance Company", "plan_name": "Humana Medicare Advantage HMO", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Humana Insurance Company", "plan_name": "Humana Medicare Advantage PPO", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Humana Insurance Company", "plan_name": "Humana Medicare Advantage PFFS", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Allegiance Provider Direct", "plan_name": "State of Montana Employee Benefit Plan (Self-Funded)", "standard_charge_percentage": 229.99999999999997, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Allegiance Provider Direct", "plan_name": "Montana Municipal Interlocal Authority (MMIA)", "standard_charge_percentage": 229.99999999999997, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Allegiance Provider Direct", "plan_name": "Montana Association of Counties (MACo)", "standard_charge_percentage": 229.99999999999997, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "First Choice Health Network fka Health InfoNet", "plan_name": "Medicare Advantage", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "TriWest Healthcare Alliance Corporation", "plan_name": "TRICARE Prime", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "TriWest Healthcare Alliance Corporation", "plan_name": "TRICARE Select", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Blue Cross Blue Shield of Montana", "plan_name": "HealthLink Network", "standard_charge_percentage": 75, "methodology": "percent of total billed charges", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Blue Cross Blue Shield of Montana", "plan_name": "Traditional Network", "standard_charge_percentage": 75, "methodology": "percent of total billed charges", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Blue Cross Blue Shield of Montana", "plan_name": "POS Network", "standard_charge_percentage": 75, "methodology": "percent of total billed charges", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Blue Cross Blue Shield of Montana", "plan_name": "Closed Plan Network", "standard_charge_percentage": 75, "methodology": "percent of total billed charges", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Blue Cross Blue Shield of Montana", "plan_name": "Retail HMO POS Network", "standard_charge_percentage": 75, "methodology": "percent of total billed charges", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Blue Cross Blue Shield of Montana", "plan_name": "Blue Options Network", "standard_charge_percentage": 75, "methodology": "percent of total billed charges", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "PacificSource Health Plans", "plan_name": "Medicare Advantage", "standard_charge_percentage": 103, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" } ] } ] }, { "description": "Viral Meningitis with CC/MCC", "code_information": [ { "code": "75", "type": "LOCAL" } ], "standard_charges": [ { "setting": "inpatient", "payers_information": [ { "payer_name": "Blue Cross Blue Shield of Montana", "plan_name": "Medicare Advantage", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "United Healthcare (UHC)", "plan_name": "Medicare Advantage", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "First Choice of the Midwest", "plan_name": "PPO", "standard_charge_percentage": 90, "methodology": "percent of total billed charges", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "United Healthcare (UHC)", "plan_name": "DSNP", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Employee Benefit Management Services (EBMS)", "plan_name": "EBMS SelectCare Network", "standard_charge_percentage": 80, "methodology": "percent of total billed charges", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Allegiance Provider Direct", "plan_name": "Medicare", "standard_charge_percentage": 229.99999999999997, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Claritev fka MultiPlan", "plan_name": "PPO", "standard_charge_percentage": 75, "methodology": "percent of total billed charges", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Medicare (CMS)", "plan_name": "Medicare", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Medica Insurance Company", "plan_name": "Medicare Cost", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "First Choice Health Network fka Health InfoNet", "plan_name": "Commercial", "standard_charge_percentage": 85, "methodology": "percent of total billed charges", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Indian Health Services (IHS)", "plan_name": "Commercial", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "First Choice Health Network fka Health InfoNet", "plan_name": "Workers Compensation", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Humana Insurance Company", "plan_name": "Humana Medicare Advantage HMO", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Humana Insurance Company", "plan_name": "Humana Medicare Advantage PPO", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Humana Insurance Company", "plan_name": "Humana Medicare Advantage PFFS", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Allegiance Provider Direct", "plan_name": "State of Montana Employee Benefit Plan (Self-Funded)", "standard_charge_percentage": 229.99999999999997, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Allegiance Provider Direct", "plan_name": "Montana Municipal Interlocal Authority (MMIA)", "standard_charge_percentage": 229.99999999999997, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Allegiance Provider Direct", "plan_name": "Montana Association of Counties (MACo)", "standard_charge_percentage": 229.99999999999997, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "First Choice Health Network fka Health InfoNet", "plan_name": "Medicare Advantage", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "TriWest Healthcare Alliance Corporation", "plan_name": "TRICARE Prime", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "TriWest Healthcare Alliance Corporation", "plan_name": "TRICARE Select", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Blue Cross Blue Shield of Montana", "plan_name": "HealthLink Network", "standard_charge_percentage": 75, "methodology": "percent of total billed charges", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Blue Cross Blue Shield of Montana", "plan_name": "Traditional Network", "standard_charge_percentage": 75, "methodology": "percent of total billed charges", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Blue Cross Blue Shield of Montana", "plan_name": "POS Network", "standard_charge_percentage": 75, "methodology": "percent of total billed charges", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Blue Cross Blue Shield of Montana", "plan_name": "Closed Plan Network", "standard_charge_percentage": 75, "methodology": "percent of total billed charges", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Blue Cross Blue Shield of Montana", "plan_name": "Retail HMO POS Network", "standard_charge_percentage": 75, "methodology": "percent of total billed charges", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Blue Cross Blue Shield of Montana", "plan_name": "Blue Options Network", "standard_charge_percentage": 75, "methodology": "percent of total billed charges", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "PacificSource Health Plans", "plan_name": "Medicare Advantage", "standard_charge_percentage": 103, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" } ] } ] }, { "description": "Viral Meningitis without CC/MCC", "code_information": [ { "code": "76", "type": "LOCAL" } ], "standard_charges": [ { "setting": "inpatient", "payers_information": [ { "payer_name": "Blue Cross Blue Shield of Montana", "plan_name": "Medicare Advantage", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "United Healthcare (UHC)", "plan_name": "Medicare Advantage", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "First Choice of the Midwest", "plan_name": "PPO", "standard_charge_percentage": 90, "methodology": "percent of total billed charges", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "United Healthcare (UHC)", "plan_name": "DSNP", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Employee Benefit Management Services (EBMS)", "plan_name": "EBMS SelectCare Network", "standard_charge_percentage": 80, "methodology": "percent of total billed charges", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Allegiance Provider Direct", "plan_name": "Medicare", "standard_charge_percentage": 229.99999999999997, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Claritev fka MultiPlan", "plan_name": "PPO", "standard_charge_percentage": 75, "methodology": "percent of total billed charges", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Medicare (CMS)", "plan_name": "Medicare", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Medica Insurance Company", "plan_name": "Medicare Cost", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "First Choice Health Network fka Health InfoNet", "plan_name": "Commercial", "standard_charge_percentage": 85, "methodology": "percent of total billed charges", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Indian Health Services (IHS)", "plan_name": "Commercial", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "First Choice Health Network fka Health InfoNet", "plan_name": "Workers Compensation", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Humana Insurance Company", "plan_name": "Humana Medicare Advantage HMO", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Humana Insurance Company", "plan_name": "Humana Medicare Advantage PPO", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Humana Insurance Company", "plan_name": "Humana Medicare Advantage PFFS", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Allegiance Provider Direct", "plan_name": "State of Montana Employee Benefit Plan (Self-Funded)", "standard_charge_percentage": 229.99999999999997, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Allegiance Provider Direct", "plan_name": "Montana Municipal Interlocal Authority (MMIA)", "standard_charge_percentage": 229.99999999999997, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Allegiance Provider Direct", "plan_name": "Montana Association of Counties (MACo)", "standard_charge_percentage": 229.99999999999997, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "First Choice Health Network fka Health InfoNet", "plan_name": "Medicare Advantage", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "TriWest Healthcare Alliance Corporation", "plan_name": "TRICARE Prime", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "TriWest Healthcare Alliance Corporation", "plan_name": "TRICARE Select", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Blue Cross Blue Shield of Montana", "plan_name": "HealthLink Network", "standard_charge_percentage": 75, "methodology": "percent of total billed charges", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Blue Cross Blue Shield of Montana", "plan_name": "Traditional Network", "standard_charge_percentage": 75, "methodology": "percent of total billed charges", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Blue Cross Blue Shield of Montana", "plan_name": "POS Network", "standard_charge_percentage": 75, "methodology": "percent of total billed charges", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Blue Cross Blue Shield of Montana", "plan_name": "Closed Plan Network", "standard_charge_percentage": 75, "methodology": "percent of total billed charges", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Blue Cross Blue Shield of Montana", "plan_name": "Retail HMO POS Network", "standard_charge_percentage": 75, "methodology": "percent of total billed charges", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Blue Cross Blue Shield of Montana", "plan_name": "Blue Options Network", "standard_charge_percentage": 75, "methodology": "percent of total billed charges", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "PacificSource Health Plans", "plan_name": "Medicare Advantage", "standard_charge_percentage": 103, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" } ] } ] }, { "description": "Nontraumatic Stupor and Coma with MCC", "code_information": [ { "code": "80", "type": "LOCAL" } ], "standard_charges": [ { "setting": "inpatient", "payers_information": [ { "payer_name": "Blue Cross Blue Shield of Montana", "plan_name": "Medicare Advantage", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "United Healthcare (UHC)", "plan_name": "Medicare Advantage", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "First Choice of the Midwest", "plan_name": "PPO", "standard_charge_percentage": 90, "methodology": "percent of total billed charges", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "United Healthcare (UHC)", "plan_name": "DSNP", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Employee Benefit Management Services (EBMS)", "plan_name": "EBMS SelectCare Network", "standard_charge_percentage": 80, "methodology": "percent of total billed charges", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Allegiance Provider Direct", "plan_name": "Medicare", "standard_charge_percentage": 229.99999999999997, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Claritev fka MultiPlan", "plan_name": "PPO", "standard_charge_percentage": 75, "methodology": "percent of total billed charges", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Medicare (CMS)", "plan_name": "Medicare", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Medica Insurance Company", "plan_name": "Medicare Cost", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "First Choice Health Network fka Health InfoNet", "plan_name": "Commercial", "standard_charge_percentage": 85, "methodology": "percent of total billed charges", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Indian Health Services (IHS)", "plan_name": "Commercial", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "First Choice Health Network fka Health InfoNet", "plan_name": "Workers Compensation", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Humana Insurance Company", "plan_name": "Humana Medicare Advantage HMO", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Humana Insurance Company", "plan_name": "Humana Medicare Advantage PPO", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Humana Insurance Company", "plan_name": "Humana Medicare Advantage PFFS", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Allegiance Provider Direct", "plan_name": "State of Montana Employee Benefit Plan (Self-Funded)", "standard_charge_percentage": 229.99999999999997, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Allegiance Provider Direct", "plan_name": "Montana Municipal Interlocal Authority (MMIA)", "standard_charge_percentage": 229.99999999999997, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Allegiance Provider Direct", "plan_name": "Montana Association of Counties (MACo)", "standard_charge_percentage": 229.99999999999997, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "First Choice Health Network fka Health InfoNet", "plan_name": "Medicare Advantage", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "TriWest Healthcare Alliance Corporation", "plan_name": "TRICARE Prime", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "TriWest Healthcare Alliance Corporation", "plan_name": "TRICARE Select", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Blue Cross Blue Shield of Montana", "plan_name": "HealthLink Network", "standard_charge_percentage": 75, "methodology": "percent of total billed charges", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Blue Cross Blue Shield of Montana", "plan_name": "Traditional Network", "standard_charge_percentage": 75, "methodology": "percent of total billed charges", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Blue Cross Blue Shield of Montana", "plan_name": "POS Network", "standard_charge_percentage": 75, "methodology": "percent of total billed charges", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Blue Cross Blue Shield of Montana", "plan_name": "Closed Plan Network", "standard_charge_percentage": 75, "methodology": "percent of total billed charges", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Blue Cross Blue Shield of Montana", "plan_name": "Retail HMO POS Network", "standard_charge_percentage": 75, "methodology": "percent of total billed charges", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Blue Cross Blue Shield of Montana", "plan_name": "Blue Options Network", "standard_charge_percentage": 75, "methodology": "percent of total billed charges", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "PacificSource Health Plans", "plan_name": "Medicare Advantage", "standard_charge_percentage": 103, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" } ] } ] }, { "description": "Nontraumatic Stupor and Coma without MCC", "code_information": [ { "code": "81", "type": "LOCAL" } ], "standard_charges": [ { "setting": "inpatient", "payers_information": [ { "payer_name": "Blue Cross Blue Shield of Montana", "plan_name": "Medicare Advantage", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "United Healthcare (UHC)", "plan_name": "Medicare Advantage", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "First Choice of the Midwest", "plan_name": "PPO", "standard_charge_percentage": 90, "methodology": "percent of total billed charges", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "United Healthcare (UHC)", "plan_name": "DSNP", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Employee Benefit Management Services (EBMS)", "plan_name": "EBMS SelectCare Network", "standard_charge_percentage": 80, "methodology": "percent of total billed charges", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Allegiance Provider Direct", "plan_name": "Medicare", "standard_charge_percentage": 229.99999999999997, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Claritev fka MultiPlan", "plan_name": "PPO", "standard_charge_percentage": 75, "methodology": "percent of total billed charges", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Medicare (CMS)", "plan_name": "Medicare", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Medica Insurance Company", "plan_name": "Medicare Cost", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "First Choice Health Network fka Health InfoNet", "plan_name": "Commercial", "standard_charge_percentage": 85, "methodology": "percent of total billed charges", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Indian Health Services (IHS)", "plan_name": "Commercial", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "First Choice Health Network fka Health InfoNet", "plan_name": "Workers Compensation", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Humana Insurance Company", "plan_name": "Humana Medicare Advantage HMO", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Humana Insurance Company", "plan_name": "Humana Medicare Advantage PPO", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Humana Insurance Company", "plan_name": "Humana Medicare Advantage PFFS", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Allegiance Provider Direct", "plan_name": "State of Montana Employee Benefit Plan (Self-Funded)", "standard_charge_percentage": 229.99999999999997, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Allegiance Provider Direct", "plan_name": "Montana Municipal Interlocal Authority (MMIA)", "standard_charge_percentage": 229.99999999999997, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Allegiance Provider Direct", "plan_name": "Montana Association of Counties (MACo)", "standard_charge_percentage": 229.99999999999997, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "First Choice Health Network fka Health InfoNet", "plan_name": "Medicare Advantage", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "TriWest Healthcare Alliance Corporation", "plan_name": "TRICARE Prime", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "TriWest Healthcare Alliance Corporation", "plan_name": "TRICARE Select", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Blue Cross Blue Shield of Montana", "plan_name": "HealthLink Network", "standard_charge_percentage": 75, "methodology": "percent of total billed charges", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Blue Cross Blue Shield of Montana", "plan_name": "Traditional Network", "standard_charge_percentage": 75, "methodology": "percent of total billed charges", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Blue Cross Blue Shield of Montana", "plan_name": "POS Network", "standard_charge_percentage": 75, "methodology": "percent of total billed charges", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Blue Cross Blue Shield of Montana", "plan_name": "Closed Plan Network", "standard_charge_percentage": 75, "methodology": "percent of total billed charges", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Blue Cross Blue Shield of Montana", "plan_name": "Retail HMO POS Network", "standard_charge_percentage": 75, "methodology": "percent of total billed charges", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Blue Cross Blue Shield of Montana", "plan_name": "Blue Options Network", "standard_charge_percentage": 75, "methodology": "percent of total billed charges", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "PacificSource Health Plans", "plan_name": "Medicare Advantage", "standard_charge_percentage": 103, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" } ] } ] }, { "description": "Traumatic Stupor and Coma >1 Hour with MCC", "code_information": [ { "code": "82", "type": "LOCAL" } ], "standard_charges": [ { "setting": "inpatient", "payers_information": [ { "payer_name": "Blue Cross Blue Shield of Montana", "plan_name": "Medicare Advantage", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "United Healthcare (UHC)", "plan_name": "Medicare Advantage", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "First Choice of the Midwest", "plan_name": "PPO", "standard_charge_percentage": 90, "methodology": "percent of total billed charges", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "United Healthcare (UHC)", "plan_name": "DSNP", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Employee Benefit Management Services (EBMS)", "plan_name": "EBMS SelectCare Network", "standard_charge_percentage": 80, "methodology": "percent of total billed charges", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Allegiance Provider Direct", "plan_name": "Medicare", "standard_charge_percentage": 229.99999999999997, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Claritev fka MultiPlan", "plan_name": "PPO", "standard_charge_percentage": 75, "methodology": "percent of total billed charges", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Medicare (CMS)", "plan_name": "Medicare", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Medica Insurance Company", "plan_name": "Medicare Cost", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "First Choice Health Network fka Health InfoNet", "plan_name": "Commercial", "standard_charge_percentage": 85, "methodology": "percent of total billed charges", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Indian Health Services (IHS)", "plan_name": "Commercial", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "First Choice Health Network fka Health InfoNet", "plan_name": "Workers Compensation", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Humana Insurance Company", "plan_name": "Humana Medicare Advantage HMO", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Humana Insurance Company", "plan_name": "Humana Medicare Advantage PPO", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Humana Insurance Company", "plan_name": "Humana Medicare Advantage PFFS", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Allegiance Provider Direct", "plan_name": "State of Montana Employee Benefit Plan (Self-Funded)", "standard_charge_percentage": 229.99999999999997, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Allegiance Provider Direct", "plan_name": "Montana Municipal Interlocal Authority (MMIA)", "standard_charge_percentage": 229.99999999999997, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Allegiance Provider Direct", "plan_name": "Montana Association of Counties (MACo)", "standard_charge_percentage": 229.99999999999997, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "First Choice Health Network fka Health InfoNet", "plan_name": "Medicare Advantage", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "TriWest Healthcare Alliance Corporation", "plan_name": "TRICARE Prime", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "TriWest Healthcare Alliance Corporation", "plan_name": "TRICARE Select", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Blue Cross Blue Shield of Montana", "plan_name": "HealthLink Network", "standard_charge_percentage": 75, "methodology": "percent of total billed charges", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Blue Cross Blue Shield of Montana", "plan_name": "Traditional Network", "standard_charge_percentage": 75, "methodology": "percent of total billed charges", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Blue Cross Blue Shield of Montana", "plan_name": "POS Network", "standard_charge_percentage": 75, "methodology": "percent of total billed charges", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Blue Cross Blue Shield of Montana", "plan_name": "Closed Plan Network", "standard_charge_percentage": 75, "methodology": "percent of total billed charges", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Blue Cross Blue Shield of Montana", "plan_name": "Retail HMO POS Network", "standard_charge_percentage": 75, "methodology": "percent of total billed charges", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Blue Cross Blue Shield of Montana", "plan_name": "Blue Options Network", "standard_charge_percentage": 75, "methodology": "percent of total billed charges", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "PacificSource Health Plans", "plan_name": "Medicare Advantage", "standard_charge_percentage": 103, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" } ] } ] }, { "description": "Traumatic Stupor and Coma >1 Hour with CC", "code_information": [ { "code": "83", "type": "LOCAL" } ], "standard_charges": [ { "setting": "inpatient", "payers_information": [ { "payer_name": "Blue Cross Blue Shield of Montana", "plan_name": "Medicare Advantage", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "United Healthcare (UHC)", "plan_name": "Medicare Advantage", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "First Choice of the Midwest", "plan_name": "PPO", "standard_charge_percentage": 90, "methodology": "percent of total billed charges", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "United Healthcare (UHC)", "plan_name": "DSNP", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Employee Benefit Management Services (EBMS)", "plan_name": "EBMS SelectCare Network", "standard_charge_percentage": 80, "methodology": "percent of total billed charges", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Claritev fka MultiPlan", "plan_name": "PPO", "standard_charge_percentage": 75, "methodology": "percent of total billed charges", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Allegiance Provider Direct", "plan_name": "Medicare", "standard_charge_percentage": 229.99999999999997, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Medicare (CMS)", "plan_name": "Medicare", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Medica Insurance Company", "plan_name": "Medicare Cost", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "First Choice Health Network fka Health InfoNet", "plan_name": "Commercial", "standard_charge_percentage": 85, "methodology": "percent of total billed charges", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Indian Health Services (IHS)", "plan_name": "Commercial", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "First Choice Health Network fka Health InfoNet", "plan_name": "Workers Compensation", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Humana Insurance Company", "plan_name": "Humana Medicare Advantage HMO", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Humana Insurance Company", "plan_name": "Humana Medicare Advantage PPO", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Humana Insurance Company", "plan_name": "Humana Medicare Advantage PFFS", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Allegiance Provider Direct", "plan_name": "State of Montana Employee Benefit Plan (Self-Funded)", "standard_charge_percentage": 229.99999999999997, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Allegiance Provider Direct", "plan_name": "Montana Municipal Interlocal Authority (MMIA)", "standard_charge_percentage": 229.99999999999997, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Allegiance Provider Direct", "plan_name": "Montana Association of Counties (MACo)", "standard_charge_percentage": 229.99999999999997, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "First Choice Health Network fka Health InfoNet", "plan_name": "Medicare Advantage", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "TriWest Healthcare Alliance Corporation", "plan_name": "TRICARE Prime", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "TriWest Healthcare Alliance Corporation", "plan_name": "TRICARE Select", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Blue Cross Blue Shield of Montana", "plan_name": "HealthLink Network", "standard_charge_percentage": 75, "methodology": "percent of total billed charges", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Blue Cross Blue Shield of Montana", "plan_name": "Traditional Network", "standard_charge_percentage": 75, "methodology": "percent of total billed charges", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Blue Cross Blue Shield of Montana", "plan_name": "POS Network", "standard_charge_percentage": 75, "methodology": "percent of total billed charges", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Blue Cross Blue Shield of Montana", "plan_name": "Closed Plan Network", "standard_charge_percentage": 75, "methodology": "percent of total billed charges", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Blue Cross Blue Shield of Montana", "plan_name": "Retail HMO POS Network", "standard_charge_percentage": 75, "methodology": "percent of total billed charges", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Blue Cross Blue Shield of Montana", "plan_name": "Blue Options Network", "standard_charge_percentage": 75, "methodology": "percent of total billed charges", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "PacificSource Health Plans", "plan_name": "Medicare Advantage", "standard_charge_percentage": 103, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" } ] } ] }, { "description": "Traumatic Stupor and Coma >1 Hour without CC/MCC", "code_information": [ { "code": "84", "type": "LOCAL" } ], "standard_charges": [ { "setting": "inpatient", "payers_information": [ { "payer_name": "Blue Cross Blue Shield of Montana", "plan_name": "Medicare Advantage", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "United Healthcare (UHC)", "plan_name": "Medicare Advantage", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "First Choice of the Midwest", "plan_name": "PPO", "standard_charge_percentage": 90, "methodology": "percent of total billed charges", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "United Healthcare (UHC)", "plan_name": "DSNP", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Employee Benefit Management Services (EBMS)", "plan_name": "EBMS SelectCare Network", "standard_charge_percentage": 80, "methodology": "percent of total billed charges", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Claritev fka MultiPlan", "plan_name": "PPO", "standard_charge_percentage": 75, "methodology": "percent of total billed charges", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Allegiance Provider Direct", "plan_name": "Medicare", "standard_charge_percentage": 229.99999999999997, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Medicare (CMS)", "plan_name": "Medicare", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Medica Insurance Company", "plan_name": "Medicare Cost", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "First Choice Health Network fka Health InfoNet", "plan_name": "Commercial", "standard_charge_percentage": 85, "methodology": "percent of total billed charges", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Indian Health Services (IHS)", "plan_name": "Commercial", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "First Choice Health Network fka Health InfoNet", "plan_name": "Workers Compensation", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Humana Insurance Company", "plan_name": "Humana Medicare Advantage HMO", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Humana Insurance Company", "plan_name": "Humana Medicare Advantage PPO", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Humana Insurance Company", "plan_name": "Humana Medicare Advantage PFFS", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Allegiance Provider Direct", "plan_name": "State of Montana Employee Benefit Plan (Self-Funded)", "standard_charge_percentage": 229.99999999999997, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Allegiance Provider Direct", "plan_name": "Montana Municipal Interlocal Authority (MMIA)", "standard_charge_percentage": 229.99999999999997, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Allegiance Provider Direct", "plan_name": "Montana Association of Counties (MACo)", "standard_charge_percentage": 229.99999999999997, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "First Choice Health Network fka Health InfoNet", "plan_name": "Medicare Advantage", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "TriWest Healthcare Alliance Corporation", "plan_name": "TRICARE Prime", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "TriWest Healthcare Alliance Corporation", "plan_name": "TRICARE Select", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Blue Cross Blue Shield of Montana", "plan_name": "HealthLink Network", "standard_charge_percentage": 75, "methodology": "percent of total billed charges", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Blue Cross Blue Shield of Montana", "plan_name": "Traditional Network", "standard_charge_percentage": 75, "methodology": "percent of total billed charges", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Blue Cross Blue Shield of Montana", "plan_name": "POS Network", "standard_charge_percentage": 75, "methodology": "percent of total billed charges", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Blue Cross Blue Shield of Montana", "plan_name": "Closed Plan Network", "standard_charge_percentage": 75, "methodology": "percent of total billed charges", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Blue Cross Blue Shield of Montana", "plan_name": "Retail HMO POS Network", "standard_charge_percentage": 75, "methodology": "percent of total billed charges", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Blue Cross Blue Shield of Montana", "plan_name": "Blue Options Network", "standard_charge_percentage": 75, "methodology": "percent of total billed charges", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "PacificSource Health Plans", "plan_name": "Medicare Advantage", "standard_charge_percentage": 103, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" } ] } ] }, { "description": "Traumatic Stupor and Coma <1 Hour with MCC", "code_information": [ { "code": "85", "type": "LOCAL" } ], "standard_charges": [ { "setting": "inpatient", "payers_information": [ { "payer_name": "Blue Cross Blue Shield of Montana", "plan_name": "Medicare Advantage", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "United Healthcare (UHC)", "plan_name": "Medicare Advantage", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "First Choice of the Midwest", "plan_name": "PPO", "standard_charge_percentage": 90, "methodology": "percent of total billed charges", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "United Healthcare (UHC)", "plan_name": "DSNP", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Employee Benefit Management Services (EBMS)", "plan_name": "EBMS SelectCare Network", "standard_charge_percentage": 80, "methodology": "percent of total billed charges", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Claritev fka MultiPlan", "plan_name": "PPO", "standard_charge_percentage": 75, "methodology": "percent of total billed charges", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Allegiance Provider Direct", "plan_name": "Medicare", "standard_charge_percentage": 229.99999999999997, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Medicare (CMS)", "plan_name": "Medicare", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Medica Insurance Company", "plan_name": "Medicare Cost", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "First Choice Health Network fka Health InfoNet", "plan_name": "Commercial", "standard_charge_percentage": 85, "methodology": "percent of total billed charges", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Indian Health Services (IHS)", "plan_name": "Commercial", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "First Choice Health Network fka Health InfoNet", "plan_name": "Workers Compensation", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Humana Insurance Company", "plan_name": "Humana Medicare Advantage HMO", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Humana Insurance Company", "plan_name": "Humana Medicare Advantage PPO", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Humana Insurance Company", "plan_name": "Humana Medicare Advantage PFFS", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Allegiance Provider Direct", "plan_name": "State of Montana Employee Benefit Plan (Self-Funded)", "standard_charge_percentage": 229.99999999999997, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Allegiance Provider Direct", "plan_name": "Montana Municipal Interlocal Authority (MMIA)", "standard_charge_percentage": 229.99999999999997, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Allegiance Provider Direct", "plan_name": "Montana Association of Counties (MACo)", "standard_charge_percentage": 229.99999999999997, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "First Choice Health Network fka Health InfoNet", "plan_name": "Medicare Advantage", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "TriWest Healthcare Alliance Corporation", "plan_name": "TRICARE Prime", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "TriWest Healthcare Alliance Corporation", "plan_name": "TRICARE Select", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Blue Cross Blue Shield of Montana", "plan_name": "HealthLink Network", "standard_charge_percentage": 75, "methodology": "percent of total billed charges", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Blue Cross Blue Shield of Montana", "plan_name": "Traditional Network", "standard_charge_percentage": 75, "methodology": "percent of total billed charges", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Blue Cross Blue Shield of Montana", "plan_name": "POS Network", "standard_charge_percentage": 75, "methodology": "percent of total billed charges", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Blue Cross Blue Shield of Montana", "plan_name": "Closed Plan Network", "standard_charge_percentage": 75, "methodology": "percent of total billed charges", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Blue Cross Blue Shield of Montana", "plan_name": "Retail HMO POS Network", "standard_charge_percentage": 75, "methodology": "percent of total billed charges", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Blue Cross Blue Shield of Montana", "plan_name": "Blue Options Network", "standard_charge_percentage": 75, "methodology": "percent of total billed charges", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "PacificSource Health Plans", "plan_name": "Medicare Advantage", "standard_charge_percentage": 103, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" } ] } ] }, { "description": "Traumatic Stupor and Coma <1 Hour with CC", "code_information": [ { "code": "86", "type": "LOCAL" } ], "standard_charges": [ { "setting": "inpatient", "payers_information": [ { "payer_name": "Blue Cross Blue Shield of Montana", "plan_name": "Medicare Advantage", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "United Healthcare (UHC)", "plan_name": "Medicare Advantage", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "First Choice of the Midwest", "plan_name": "PPO", "standard_charge_percentage": 90, "methodology": "percent of total billed charges", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "United Healthcare (UHC)", "plan_name": "DSNP", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Employee Benefit Management Services (EBMS)", "plan_name": "EBMS SelectCare Network", "standard_charge_percentage": 80, "methodology": "percent of total billed charges", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Claritev fka MultiPlan", "plan_name": "PPO", "standard_charge_percentage": 75, "methodology": "percent of total billed charges", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Allegiance Provider Direct", "plan_name": "Medicare", "standard_charge_percentage": 229.99999999999997, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Medicare (CMS)", "plan_name": "Medicare", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Medica Insurance Company", "plan_name": "Medicare Cost", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "First Choice Health Network fka Health InfoNet", "plan_name": "Commercial", "standard_charge_percentage": 85, "methodology": "percent of total billed charges", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Indian Health Services (IHS)", "plan_name": "Commercial", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "First Choice Health Network fka Health InfoNet", "plan_name": "Workers Compensation", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Humana Insurance Company", "plan_name": "Humana Medicare Advantage HMO", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Humana Insurance Company", "plan_name": "Humana Medicare Advantage PPO", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Humana Insurance Company", "plan_name": "Humana Medicare Advantage PFFS", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Allegiance Provider Direct", "plan_name": "State of Montana Employee Benefit Plan (Self-Funded)", "standard_charge_percentage": 229.99999999999997, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Allegiance Provider Direct", "plan_name": "Montana Municipal Interlocal Authority (MMIA)", "standard_charge_percentage": 229.99999999999997, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Allegiance Provider Direct", "plan_name": "Montana Association of Counties (MACo)", "standard_charge_percentage": 229.99999999999997, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "First Choice Health Network fka Health InfoNet", "plan_name": "Medicare Advantage", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "TriWest Healthcare Alliance Corporation", "plan_name": "TRICARE Prime", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "TriWest Healthcare Alliance Corporation", "plan_name": "TRICARE Select", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Blue Cross Blue Shield of Montana", "plan_name": "HealthLink Network", "standard_charge_percentage": 75, "methodology": "percent of total billed charges", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Blue Cross Blue Shield of Montana", "plan_name": "Traditional Network", "standard_charge_percentage": 75, "methodology": "percent of total billed charges", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Blue Cross Blue Shield of Montana", "plan_name": "POS Network", "standard_charge_percentage": 75, "methodology": "percent of total billed charges", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Blue Cross Blue Shield of Montana", "plan_name": "Closed Plan Network", "standard_charge_percentage": 75, "methodology": "percent of total billed charges", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Blue Cross Blue Shield of Montana", "plan_name": "Retail HMO POS Network", "standard_charge_percentage": 75, "methodology": "percent of total billed charges", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Blue Cross Blue Shield of Montana", "plan_name": "Blue Options Network", "standard_charge_percentage": 75, "methodology": "percent of total billed charges", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "PacificSource Health Plans", "plan_name": "Medicare Advantage", "standard_charge_percentage": 103, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" } ] } ] }, { "description": "Traumatic Stupor and Coma <1 Hour without CC/MCC", "code_information": [ { "code": "87", "type": "LOCAL" } ], "standard_charges": [ { "setting": "inpatient", "payers_information": [ { "payer_name": "Blue Cross Blue Shield of Montana", "plan_name": "Medicare Advantage", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "United Healthcare (UHC)", "plan_name": "Medicare Advantage", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "First Choice of the Midwest", "plan_name": "PPO", "standard_charge_percentage": 90, "methodology": "percent of total billed charges", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "United Healthcare (UHC)", "plan_name": "DSNP", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Employee Benefit Management Services (EBMS)", "plan_name": "EBMS SelectCare Network", "standard_charge_percentage": 80, "methodology": "percent of total billed charges", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Claritev fka MultiPlan", "plan_name": "PPO", "standard_charge_percentage": 75, "methodology": "percent of total billed charges", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Allegiance Provider Direct", "plan_name": "Medicare", "standard_charge_percentage": 229.99999999999997, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Medicare (CMS)", "plan_name": "Medicare", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Medica Insurance Company", "plan_name": "Medicare Cost", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "First Choice Health Network fka Health InfoNet", "plan_name": "Commercial", "standard_charge_percentage": 85, "methodology": "percent of total billed charges", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "First Choice Health Network fka Health InfoNet", "plan_name": "Workers Compensation", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Indian Health Services (IHS)", "plan_name": "Commercial", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Humana Insurance Company", "plan_name": "Humana Medicare Advantage HMO", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Humana Insurance Company", "plan_name": "Humana Medicare Advantage PPO", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Humana Insurance Company", "plan_name": "Humana Medicare Advantage PFFS", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Allegiance Provider Direct", "plan_name": "State of Montana Employee Benefit Plan (Self-Funded)", "standard_charge_percentage": 229.99999999999997, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Allegiance Provider Direct", "plan_name": "Montana Municipal Interlocal Authority (MMIA)", "standard_charge_percentage": 229.99999999999997, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Allegiance Provider Direct", "plan_name": "Montana Association of Counties (MACo)", "standard_charge_percentage": 229.99999999999997, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "First Choice Health Network fka Health InfoNet", "plan_name": "Medicare Advantage", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "TriWest Healthcare Alliance Corporation", "plan_name": "TRICARE Prime", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "TriWest Healthcare Alliance Corporation", "plan_name": "TRICARE Select", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Blue Cross Blue Shield of Montana", "plan_name": "HealthLink Network", "standard_charge_percentage": 75, "methodology": "percent of total billed charges", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Blue Cross Blue Shield of Montana", "plan_name": "Traditional Network", "standard_charge_percentage": 75, "methodology": "percent of total billed charges", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Blue Cross Blue Shield of Montana", "plan_name": "POS Network", "standard_charge_percentage": 75, "methodology": "percent of total billed charges", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Blue Cross Blue Shield of Montana", "plan_name": "Closed Plan Network", "standard_charge_percentage": 75, "methodology": "percent of total billed charges", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Blue Cross Blue Shield of Montana", "plan_name": "Retail HMO POS Network", "standard_charge_percentage": 75, "methodology": "percent of total billed charges", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Blue Cross Blue Shield of Montana", "plan_name": "Blue Options Network", "standard_charge_percentage": 75, "methodology": "percent of total billed charges", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "PacificSource Health Plans", "plan_name": "Medicare Advantage", "standard_charge_percentage": 103, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" } ] } ] }, { "description": "Concussion with MCC", "code_information": [ { "code": "88", "type": "LOCAL" } ], "standard_charges": [ { "setting": "inpatient", "payers_information": [ { "payer_name": "Blue Cross Blue Shield of Montana", "plan_name": "Medicare Advantage", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "United Healthcare (UHC)", "plan_name": "Medicare Advantage", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "First Choice of the Midwest", "plan_name": "PPO", "standard_charge_percentage": 90, "methodology": "percent of total billed charges", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "United Healthcare (UHC)", "plan_name": "DSNP", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Employee Benefit Management Services (EBMS)", "plan_name": "EBMS SelectCare Network", "standard_charge_percentage": 80, "methodology": "percent of total billed charges", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Claritev fka MultiPlan", "plan_name": "PPO", "standard_charge_percentage": 75, "methodology": "percent of total billed charges", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Allegiance Provider Direct", "plan_name": "Medicare", "standard_charge_percentage": 229.99999999999997, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Medicare (CMS)", "plan_name": "Medicare", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Medica Insurance Company", "plan_name": "Medicare Cost", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "First Choice Health Network fka Health InfoNet", "plan_name": "Commercial", "standard_charge_percentage": 85, "methodology": "percent of total billed charges", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "First Choice Health Network fka Health InfoNet", "plan_name": "Workers Compensation", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Indian Health Services (IHS)", "plan_name": "Commercial", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Humana Insurance Company", "plan_name": "Humana Medicare Advantage HMO", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Humana Insurance Company", "plan_name": "Humana Medicare Advantage PPO", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Humana Insurance Company", "plan_name": "Humana Medicare Advantage PFFS", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Allegiance Provider Direct", "plan_name": "State of Montana Employee Benefit Plan (Self-Funded)", "standard_charge_percentage": 229.99999999999997, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Allegiance Provider Direct", "plan_name": "Montana Municipal Interlocal Authority (MMIA)", "standard_charge_percentage": 229.99999999999997, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Allegiance Provider Direct", "plan_name": "Montana Association of Counties (MACo)", "standard_charge_percentage": 229.99999999999997, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "First Choice Health Network fka Health InfoNet", "plan_name": "Medicare Advantage", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "TriWest Healthcare Alliance Corporation", "plan_name": "TRICARE Prime", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "TriWest Healthcare Alliance Corporation", "plan_name": "TRICARE Select", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Blue Cross Blue Shield of Montana", "plan_name": "HealthLink Network", "standard_charge_percentage": 75, "methodology": "percent of total billed charges", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Blue Cross Blue Shield of Montana", "plan_name": "Traditional Network", "standard_charge_percentage": 75, "methodology": "percent of total billed charges", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Blue Cross Blue Shield of Montana", "plan_name": "POS Network", "standard_charge_percentage": 75, "methodology": "percent of total billed charges", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Blue Cross Blue Shield of Montana", "plan_name": "Closed Plan Network", "standard_charge_percentage": 75, "methodology": "percent of total billed charges", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Blue Cross Blue Shield of Montana", "plan_name": "Retail HMO POS Network", "standard_charge_percentage": 75, "methodology": "percent of total billed charges", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Blue Cross Blue Shield of Montana", "plan_name": "Blue Options Network", "standard_charge_percentage": 75, "methodology": "percent of total billed charges", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "PacificSource Health Plans", "plan_name": "Medicare Advantage", "standard_charge_percentage": 103, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" } ] } ] }, { "description": "Concussion with CC", "code_information": [ { "code": "89", "type": "LOCAL" } ], "standard_charges": [ { "setting": "inpatient", "payers_information": [ { "payer_name": "Blue Cross Blue Shield of Montana", "plan_name": "Medicare Advantage", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "United Healthcare (UHC)", "plan_name": "Medicare Advantage", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "First Choice of the Midwest", "plan_name": "PPO", "standard_charge_percentage": 90, "methodology": "percent of total billed charges", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "United Healthcare (UHC)", "plan_name": "DSNP", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Employee Benefit Management Services (EBMS)", "plan_name": "EBMS SelectCare Network", "standard_charge_percentage": 80, "methodology": "percent of total billed charges", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Claritev fka MultiPlan", "plan_name": "PPO", "standard_charge_percentage": 75, "methodology": "percent of total billed charges", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Allegiance Provider Direct", "plan_name": "Medicare", "standard_charge_percentage": 229.99999999999997, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Medicare (CMS)", "plan_name": "Medicare", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Medica Insurance Company", "plan_name": "Medicare Cost", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "First Choice Health Network fka Health InfoNet", "plan_name": "Commercial", "standard_charge_percentage": 85, "methodology": "percent of total billed charges", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "First Choice Health Network fka Health InfoNet", "plan_name": "Workers Compensation", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Indian Health Services (IHS)", "plan_name": "Commercial", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Humana Insurance Company", "plan_name": "Humana Medicare Advantage HMO", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Humana Insurance Company", "plan_name": "Humana Medicare Advantage PPO", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Humana Insurance Company", "plan_name": "Humana Medicare Advantage PFFS", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Allegiance Provider Direct", "plan_name": "State of Montana Employee Benefit Plan (Self-Funded)", "standard_charge_percentage": 229.99999999999997, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Allegiance Provider Direct", "plan_name": "Montana Municipal Interlocal Authority (MMIA)", "standard_charge_percentage": 229.99999999999997, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Allegiance Provider Direct", "plan_name": "Montana Association of Counties (MACo)", "standard_charge_percentage": 229.99999999999997, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "First Choice Health Network fka Health InfoNet", "plan_name": "Medicare Advantage", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "TriWest Healthcare Alliance Corporation", "plan_name": "TRICARE Prime", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "TriWest Healthcare Alliance Corporation", "plan_name": "TRICARE Select", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Blue Cross Blue Shield of Montana", "plan_name": "HealthLink Network", "standard_charge_percentage": 75, "methodology": "percent of total billed charges", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Blue Cross Blue Shield of Montana", "plan_name": "Traditional Network", "standard_charge_percentage": 75, "methodology": "percent of total billed charges", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Blue Cross Blue Shield of Montana", "plan_name": "POS Network", "standard_charge_percentage": 75, "methodology": "percent of total billed charges", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Blue Cross Blue Shield of Montana", "plan_name": "Closed Plan Network", "standard_charge_percentage": 75, "methodology": "percent of total billed charges", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Blue Cross Blue Shield of Montana", "plan_name": "Retail HMO POS Network", "standard_charge_percentage": 75, "methodology": "percent of total billed charges", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Blue Cross Blue Shield of Montana", "plan_name": "Blue Options Network", "standard_charge_percentage": 75, "methodology": "percent of total billed charges", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "PacificSource Health Plans", "plan_name": "Medicare Advantage", "standard_charge_percentage": 103, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" } ] } ] }, { "description": "Concussion without CC/MCC", "code_information": [ { "code": "90", "type": "LOCAL" } ], "standard_charges": [ { "setting": "inpatient", "payers_information": [ { "payer_name": "Blue Cross Blue Shield of Montana", "plan_name": "Medicare Advantage", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "United Healthcare (UHC)", "plan_name": "Medicare Advantage", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "First Choice of the Midwest", "plan_name": "PPO", "standard_charge_percentage": 90, "methodology": "percent of total billed charges", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "United Healthcare (UHC)", "plan_name": "DSNP", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Employee Benefit Management Services (EBMS)", "plan_name": "EBMS SelectCare Network", "standard_charge_percentage": 80, "methodology": "percent of total billed charges", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Claritev fka MultiPlan", "plan_name": "PPO", "standard_charge_percentage": 75, "methodology": "percent of total billed charges", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Allegiance Provider Direct", "plan_name": "Medicare", "standard_charge_percentage": 229.99999999999997, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Medicare (CMS)", "plan_name": "Medicare", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Medica Insurance Company", "plan_name": "Medicare Cost", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "First Choice Health Network fka Health InfoNet", "plan_name": "Commercial", "standard_charge_percentage": 85, "methodology": "percent of total billed charges", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "First Choice Health Network fka Health InfoNet", "plan_name": "Workers Compensation", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Indian Health Services (IHS)", "plan_name": "Commercial", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Humana Insurance Company", "plan_name": "Humana Medicare Advantage HMO", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Humana Insurance Company", "plan_name": "Humana Medicare Advantage PPO", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Humana Insurance Company", "plan_name": "Humana Medicare Advantage PFFS", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Allegiance Provider Direct", "plan_name": "State of Montana Employee Benefit Plan (Self-Funded)", "standard_charge_percentage": 229.99999999999997, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Allegiance Provider Direct", "plan_name": "Montana Municipal Interlocal Authority (MMIA)", "standard_charge_percentage": 229.99999999999997, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Allegiance Provider Direct", "plan_name": "Montana Association of Counties (MACo)", "standard_charge_percentage": 229.99999999999997, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "First Choice Health Network fka Health InfoNet", "plan_name": "Medicare Advantage", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "TriWest Healthcare Alliance Corporation", "plan_name": "TRICARE Prime", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "TriWest Healthcare Alliance Corporation", "plan_name": "TRICARE Select", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Blue Cross Blue Shield of Montana", "plan_name": "HealthLink Network", "standard_charge_percentage": 75, "methodology": "percent of total billed charges", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Blue Cross Blue Shield of Montana", "plan_name": "Traditional Network", "standard_charge_percentage": 75, "methodology": "percent of total billed charges", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Blue Cross Blue Shield of Montana", "plan_name": "POS Network", "standard_charge_percentage": 75, "methodology": "percent of total billed charges", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Blue Cross Blue Shield of Montana", "plan_name": "Closed Plan Network", "standard_charge_percentage": 75, "methodology": "percent of total billed charges", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Blue Cross Blue Shield of Montana", "plan_name": "Retail HMO POS Network", "standard_charge_percentage": 75, "methodology": "percent of total billed charges", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Blue Cross Blue Shield of Montana", "plan_name": "Blue Options Network", "standard_charge_percentage": 75, "methodology": "percent of total billed charges", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "PacificSource Health Plans", "plan_name": "Medicare Advantage", "standard_charge_percentage": 103, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" } ] } ] }, { "description": "Other Disorders of Nervous System with MCC*", "code_information": [ { "code": "91", "type": "LOCAL" } ], "standard_charges": [ { "setting": "inpatient", "payers_information": [ { "payer_name": "Blue Cross Blue Shield of Montana", "plan_name": "Medicare Advantage", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "United Healthcare (UHC)", "plan_name": "Medicare Advantage", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "First Choice of the Midwest", "plan_name": "PPO", "standard_charge_percentage": 90, "methodology": "percent of total billed charges", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "United Healthcare (UHC)", "plan_name": "DSNP", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Employee Benefit Management Services (EBMS)", "plan_name": "EBMS SelectCare Network", "standard_charge_percentage": 80, "methodology": "percent of total billed charges", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Claritev fka MultiPlan", "plan_name": "PPO", "standard_charge_percentage": 75, "methodology": "percent of total billed charges", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Allegiance Provider Direct", "plan_name": "Medicare", "standard_charge_percentage": 229.99999999999997, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Medicare (CMS)", "plan_name": "Medicare", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Medica Insurance Company", "plan_name": "Medicare Cost", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "First Choice Health Network fka Health InfoNet", "plan_name": "Commercial", "standard_charge_percentage": 85, "methodology": "percent of total billed charges", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "First Choice Health Network fka Health InfoNet", "plan_name": "Workers Compensation", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Indian Health Services (IHS)", "plan_name": "Commercial", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Humana Insurance Company", "plan_name": "Humana Medicare Advantage HMO", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Humana Insurance Company", "plan_name": "Humana Medicare Advantage PPO", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Humana Insurance Company", "plan_name": "Humana Medicare Advantage PFFS", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Allegiance Provider Direct", "plan_name": "State of Montana Employee Benefit Plan (Self-Funded)", "standard_charge_percentage": 229.99999999999997, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Allegiance Provider Direct", "plan_name": "Montana Municipal Interlocal Authority (MMIA)", "standard_charge_percentage": 229.99999999999997, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Allegiance Provider Direct", "plan_name": "Montana Association of Counties (MACo)", "standard_charge_percentage": 229.99999999999997, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "First Choice Health Network fka Health InfoNet", "plan_name": "Medicare Advantage", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "TriWest Healthcare Alliance Corporation", "plan_name": "TRICARE Prime", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "TriWest Healthcare Alliance Corporation", "plan_name": "TRICARE Select", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Blue Cross Blue Shield of Montana", "plan_name": "HealthLink Network", "standard_charge_percentage": 75, "methodology": "percent of total billed charges", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Blue Cross Blue Shield of Montana", "plan_name": "Traditional Network", "standard_charge_percentage": 75, "methodology": "percent of total billed charges", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Blue Cross Blue Shield of Montana", "plan_name": "POS Network", "standard_charge_percentage": 75, "methodology": "percent of total billed charges", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Blue Cross Blue Shield of Montana", "plan_name": "Closed Plan Network", "standard_charge_percentage": 75, "methodology": "percent of total billed charges", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Blue Cross Blue Shield of Montana", "plan_name": "Retail HMO POS Network", "standard_charge_percentage": 75, "methodology": "percent of total billed charges", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Blue Cross Blue Shield of Montana", "plan_name": "Blue Options Network", "standard_charge_percentage": 75, "methodology": "percent of total billed charges", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "PacificSource Health Plans", "plan_name": "Medicare Advantage", "standard_charge_percentage": 103, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" } ] } ] }, { "description": "Other Disorders of Nervous System with CC*", "code_information": [ { "code": "92", "type": "LOCAL" } ], "standard_charges": [ { "setting": "inpatient", "payers_information": [ { "payer_name": "Blue Cross Blue Shield of Montana", "plan_name": "Medicare Advantage", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "United Healthcare (UHC)", "plan_name": "Medicare Advantage", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "First Choice of the Midwest", "plan_name": "PPO", "standard_charge_percentage": 90, "methodology": "percent of total billed charges", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "United Healthcare (UHC)", "plan_name": "DSNP", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Employee Benefit Management Services (EBMS)", "plan_name": "EBMS SelectCare Network", "standard_charge_percentage": 80, "methodology": "percent of total billed charges", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Claritev fka MultiPlan", "plan_name": "PPO", "standard_charge_percentage": 75, "methodology": "percent of total billed charges", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Allegiance Provider Direct", "plan_name": "Medicare", "standard_charge_percentage": 229.99999999999997, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Medicare (CMS)", "plan_name": "Medicare", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Medica Insurance Company", "plan_name": "Medicare Cost", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "First Choice Health Network fka Health InfoNet", "plan_name": "Commercial", "standard_charge_percentage": 85, "methodology": "percent of total billed charges", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "First Choice Health Network fka Health InfoNet", "plan_name": "Workers Compensation", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Indian Health Services (IHS)", "plan_name": "Commercial", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Humana Insurance Company", "plan_name": "Humana Medicare Advantage HMO", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Humana Insurance Company", "plan_name": "Humana Medicare Advantage PPO", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Humana Insurance Company", "plan_name": "Humana Medicare Advantage PFFS", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Allegiance Provider Direct", "plan_name": "State of Montana Employee Benefit Plan (Self-Funded)", "standard_charge_percentage": 229.99999999999997, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Allegiance Provider Direct", "plan_name": "Montana Municipal Interlocal Authority (MMIA)", "standard_charge_percentage": 229.99999999999997, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Allegiance Provider Direct", "plan_name": "Montana Association of Counties (MACo)", "standard_charge_percentage": 229.99999999999997, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "First Choice Health Network fka Health InfoNet", "plan_name": "Medicare Advantage", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "TriWest Healthcare Alliance Corporation", "plan_name": "TRICARE Prime", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "TriWest Healthcare Alliance Corporation", "plan_name": "TRICARE Select", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Blue Cross Blue Shield of Montana", "plan_name": "HealthLink Network", "standard_charge_percentage": 75, "methodology": "percent of total billed charges", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Blue Cross Blue Shield of Montana", "plan_name": "Traditional Network", "standard_charge_percentage": 75, "methodology": "percent of total billed charges", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Blue Cross Blue Shield of Montana", "plan_name": "POS Network", "standard_charge_percentage": 75, "methodology": "percent of total billed charges", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Blue Cross Blue Shield of Montana", "plan_name": "Closed Plan Network", "standard_charge_percentage": 75, "methodology": "percent of total billed charges", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Blue Cross Blue Shield of Montana", "plan_name": "Retail HMO POS Network", "standard_charge_percentage": 75, "methodology": "percent of total billed charges", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Blue Cross Blue Shield of Montana", "plan_name": "Blue Options Network", "standard_charge_percentage": 75, "methodology": "percent of total billed charges", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "PacificSource Health Plans", "plan_name": "Medicare Advantage", "standard_charge_percentage": 103, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" } ] } ] }, { "description": "Other Disorders of Nervous System without CC/MCC*", "code_information": [ { "code": "93", "type": "LOCAL" } ], "standard_charges": [ { "setting": "inpatient", "payers_information": [ { "payer_name": "Blue Cross Blue Shield of Montana", "plan_name": "Medicare Advantage", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "United Healthcare (UHC)", "plan_name": "Medicare Advantage", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "First Choice of the Midwest", "plan_name": "PPO", "standard_charge_percentage": 90, "methodology": "percent of total billed charges", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "United Healthcare (UHC)", "plan_name": "DSNP", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Employee Benefit Management Services (EBMS)", "plan_name": "EBMS SelectCare Network", "standard_charge_percentage": 80, "methodology": "percent of total billed charges", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Claritev fka MultiPlan", "plan_name": "PPO", "standard_charge_percentage": 75, "methodology": "percent of total billed charges", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Allegiance Provider Direct", "plan_name": "Medicare", "standard_charge_percentage": 229.99999999999997, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Medicare (CMS)", "plan_name": "Medicare", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Medica Insurance Company", "plan_name": "Medicare Cost", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "First Choice Health Network fka Health InfoNet", "plan_name": "Commercial", "standard_charge_percentage": 85, "methodology": "percent of total billed charges", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "First Choice Health Network fka Health InfoNet", "plan_name": "Workers Compensation", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Indian Health Services (IHS)", "plan_name": "Commercial", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Humana Insurance Company", "plan_name": "Humana Medicare Advantage HMO", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Humana Insurance Company", "plan_name": "Humana Medicare Advantage PPO", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Humana Insurance Company", "plan_name": "Humana Medicare Advantage PFFS", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Allegiance Provider Direct", "plan_name": "State of Montana Employee Benefit Plan (Self-Funded)", "standard_charge_percentage": 229.99999999999997, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Allegiance Provider Direct", "plan_name": "Montana Municipal Interlocal Authority (MMIA)", "standard_charge_percentage": 229.99999999999997, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Allegiance Provider Direct", "plan_name": "Montana Association of Counties (MACo)", "standard_charge_percentage": 229.99999999999997, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "First Choice Health Network fka Health InfoNet", "plan_name": "Medicare Advantage", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "TriWest Healthcare Alliance Corporation", "plan_name": "TRICARE Prime", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "TriWest Healthcare Alliance Corporation", "plan_name": "TRICARE Select", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Blue Cross Blue Shield of Montana", "plan_name": "HealthLink Network", "standard_charge_percentage": 75, "methodology": "percent of total billed charges", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Blue Cross Blue Shield of Montana", "plan_name": "Traditional Network", "standard_charge_percentage": 75, "methodology": "percent of total billed charges", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Blue Cross Blue Shield of Montana", "plan_name": "POS Network", "standard_charge_percentage": 75, "methodology": "percent of total billed charges", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Blue Cross Blue Shield of Montana", "plan_name": "Closed Plan Network", "standard_charge_percentage": 75, "methodology": "percent of total billed charges", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Blue Cross Blue Shield of Montana", "plan_name": "Retail HMO POS Network", "standard_charge_percentage": 75, "methodology": "percent of total billed charges", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Blue Cross Blue Shield of Montana", "plan_name": "Blue Options Network", "standard_charge_percentage": 75, "methodology": "percent of total billed charges", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "PacificSource Health Plans", "plan_name": "Medicare Advantage", "standard_charge_percentage": 103, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" } ] } ] }, { "description": "Bacterial and Tuberculous Infections of Nervous System with MCC", "code_information": [ { "code": "94", "type": "LOCAL" } ], "standard_charges": [ { "setting": "inpatient", "payers_information": [ { "payer_name": "Blue Cross Blue Shield of Montana", "plan_name": "Medicare Advantage", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "United Healthcare (UHC)", "plan_name": "Medicare Advantage", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "First Choice of the Midwest", "plan_name": "PPO", "standard_charge_percentage": 90, "methodology": "percent of total billed charges", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "United Healthcare (UHC)", "plan_name": "DSNP", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Employee Benefit Management Services (EBMS)", "plan_name": "EBMS SelectCare Network", "standard_charge_percentage": 80, "methodology": "percent of total billed charges", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Claritev fka MultiPlan", "plan_name": "PPO", "standard_charge_percentage": 75, "methodology": "percent of total billed charges", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Allegiance Provider Direct", "plan_name": "Medicare", "standard_charge_percentage": 229.99999999999997, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Medicare (CMS)", "plan_name": "Medicare", "standard_charge_percentage": 100, "methodology": "fee schedule", "median_amount": 55947.7, "10th_percentile": 55947.7, "90th_percentile": 55947.7, "count": "1 through 10" }, { "payer_name": "Medica Insurance Company", "plan_name": "Medicare Cost", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "First Choice Health Network fka Health InfoNet", "plan_name": "Commercial", "standard_charge_percentage": 85, "methodology": "percent of total billed charges", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "First Choice Health Network fka Health InfoNet", "plan_name": "Workers Compensation", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Indian Health Services (IHS)", "plan_name": "Commercial", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Humana Insurance Company", "plan_name": "Humana Medicare Advantage HMO", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Humana Insurance Company", "plan_name": "Humana Medicare Advantage PPO", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Humana Insurance Company", "plan_name": "Humana Medicare Advantage PFFS", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Allegiance Provider Direct", "plan_name": "State of Montana Employee Benefit Plan (Self-Funded)", "standard_charge_percentage": 229.99999999999997, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Allegiance Provider Direct", "plan_name": "Montana Municipal Interlocal Authority (MMIA)", "standard_charge_percentage": 229.99999999999997, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Allegiance Provider Direct", "plan_name": "Montana Association of Counties (MACo)", "standard_charge_percentage": 229.99999999999997, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "First Choice Health Network fka Health InfoNet", "plan_name": "Medicare Advantage", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "TriWest Healthcare Alliance Corporation", "plan_name": "TRICARE Prime", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "TriWest Healthcare Alliance Corporation", "plan_name": "TRICARE Select", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Blue Cross Blue Shield of Montana", "plan_name": "HealthLink Network", "standard_charge_percentage": 75, "methodology": "percent of total billed charges", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Blue Cross Blue Shield of Montana", "plan_name": "Traditional Network", "standard_charge_percentage": 75, "methodology": "percent of total billed charges", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Blue Cross Blue Shield of Montana", "plan_name": "POS Network", "standard_charge_percentage": 75, "methodology": "percent of total billed charges", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Blue Cross Blue Shield of Montana", "plan_name": "Closed Plan Network", "standard_charge_percentage": 75, "methodology": "percent of total billed charges", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Blue Cross Blue Shield of Montana", "plan_name": "Retail HMO POS Network", "standard_charge_percentage": 75, "methodology": "percent of total billed charges", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Blue Cross Blue Shield of Montana", "plan_name": "Blue Options Network", "standard_charge_percentage": 75, "methodology": "percent of total billed charges", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "PacificSource Health Plans", "plan_name": "Medicare Advantage", "standard_charge_percentage": 103, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" } ], "minimum": 55947.7, "maximum": 55947.7 } ] }, { "description": "Bacterial and Tuberculous Infections of Nervous System with CC", "code_information": [ { "code": "95", "type": "LOCAL" } ], "standard_charges": [ { "setting": "inpatient", "payers_information": [ { "payer_name": "Blue Cross Blue Shield of Montana", "plan_name": "Medicare Advantage", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "United Healthcare (UHC)", "plan_name": "Medicare Advantage", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "First Choice of the Midwest", "plan_name": "PPO", "standard_charge_percentage": 90, "methodology": "percent of total billed charges", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "United Healthcare (UHC)", "plan_name": "DSNP", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Employee Benefit Management Services (EBMS)", "plan_name": "EBMS SelectCare Network", "standard_charge_percentage": 80, "methodology": "percent of total billed charges", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Claritev fka MultiPlan", "plan_name": "PPO", "standard_charge_percentage": 75, "methodology": "percent of total billed charges", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Allegiance Provider Direct", "plan_name": "Medicare", "standard_charge_percentage": 229.99999999999997, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Medicare (CMS)", "plan_name": "Medicare", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Medica Insurance Company", "plan_name": "Medicare Cost", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "First Choice Health Network fka Health InfoNet", "plan_name": "Commercial", "standard_charge_percentage": 85, "methodology": "percent of total billed charges", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "First Choice Health Network fka Health InfoNet", "plan_name": "Workers Compensation", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Indian Health Services (IHS)", "plan_name": "Commercial", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Humana Insurance Company", "plan_name": "Humana Medicare Advantage HMO", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Humana Insurance Company", "plan_name": "Humana Medicare Advantage PPO", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Humana Insurance Company", "plan_name": "Humana Medicare Advantage PFFS", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Allegiance Provider Direct", "plan_name": "State of Montana Employee Benefit Plan (Self-Funded)", "standard_charge_percentage": 229.99999999999997, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Allegiance Provider Direct", "plan_name": "Montana Municipal Interlocal Authority (MMIA)", "standard_charge_percentage": 229.99999999999997, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Allegiance Provider Direct", "plan_name": "Montana Association of Counties (MACo)", "standard_charge_percentage": 229.99999999999997, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "First Choice Health Network fka Health InfoNet", "plan_name": "Medicare Advantage", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "TriWest Healthcare Alliance Corporation", "plan_name": "TRICARE Prime", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "TriWest Healthcare Alliance Corporation", "plan_name": "TRICARE Select", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Blue Cross Blue Shield of Montana", "plan_name": "HealthLink Network", "standard_charge_percentage": 75, "methodology": "percent of total billed charges", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Blue Cross Blue Shield of Montana", "plan_name": "Traditional Network", "standard_charge_percentage": 75, "methodology": "percent of total billed charges", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Blue Cross Blue Shield of Montana", "plan_name": "POS Network", "standard_charge_percentage": 75, "methodology": "percent of total billed charges", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Blue Cross Blue Shield of Montana", "plan_name": "Closed Plan Network", "standard_charge_percentage": 75, "methodology": "percent of total billed charges", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Blue Cross Blue Shield of Montana", "plan_name": "Retail HMO POS Network", "standard_charge_percentage": 75, "methodology": "percent of total billed charges", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Blue Cross Blue Shield of Montana", "plan_name": "Blue Options Network", "standard_charge_percentage": 75, "methodology": "percent of total billed charges", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "PacificSource Health Plans", "plan_name": "Medicare Advantage", "standard_charge_percentage": 103, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" } ] } ] }, { "description": "Bacterial and Tuberculous Infections of Nervous System without CC/MCC", "code_information": [ { "code": "96", "type": "LOCAL" } ], "standard_charges": [ { "setting": "inpatient", "payers_information": [ { "payer_name": "Blue Cross Blue Shield of Montana", "plan_name": "Medicare Advantage", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "United Healthcare (UHC)", "plan_name": "Medicare Advantage", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "First Choice of the Midwest", "plan_name": "PPO", "standard_charge_percentage": 90, "methodology": "percent of total billed charges", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "United Healthcare (UHC)", "plan_name": "DSNP", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Employee Benefit Management Services (EBMS)", "plan_name": "EBMS SelectCare Network", "standard_charge_percentage": 80, "methodology": "percent of total billed charges", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Claritev fka MultiPlan", "plan_name": "PPO", "standard_charge_percentage": 75, "methodology": "percent of total billed charges", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Allegiance Provider Direct", "plan_name": "Medicare", "standard_charge_percentage": 229.99999999999997, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Medicare (CMS)", "plan_name": "Medicare", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Medica Insurance Company", "plan_name": "Medicare Cost", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "First Choice Health Network fka Health InfoNet", "plan_name": "Commercial", "standard_charge_percentage": 85, "methodology": "percent of total billed charges", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "First Choice Health Network fka Health InfoNet", "plan_name": "Workers Compensation", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Indian Health Services (IHS)", "plan_name": "Commercial", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Humana Insurance Company", "plan_name": "Humana Medicare Advantage HMO", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Humana Insurance Company", "plan_name": "Humana Medicare Advantage PPO", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Humana Insurance Company", "plan_name": "Humana Medicare Advantage PFFS", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Allegiance Provider Direct", "plan_name": "State of Montana Employee Benefit Plan (Self-Funded)", "standard_charge_percentage": 229.99999999999997, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Allegiance Provider Direct", "plan_name": "Montana Municipal Interlocal Authority (MMIA)", "standard_charge_percentage": 229.99999999999997, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Allegiance Provider Direct", "plan_name": "Montana Association of Counties (MACo)", "standard_charge_percentage": 229.99999999999997, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "First Choice Health Network fka Health InfoNet", "plan_name": "Medicare Advantage", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "TriWest Healthcare Alliance Corporation", "plan_name": "TRICARE Prime", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "TriWest Healthcare Alliance Corporation", "plan_name": "TRICARE Select", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Blue Cross Blue Shield of Montana", "plan_name": "HealthLink Network", "standard_charge_percentage": 75, "methodology": "percent of total billed charges", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Blue Cross Blue Shield of Montana", "plan_name": "Traditional Network", "standard_charge_percentage": 75, "methodology": "percent of total billed charges", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Blue Cross Blue Shield of Montana", "plan_name": "POS Network", "standard_charge_percentage": 75, "methodology": "percent of total billed charges", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Blue Cross Blue Shield of Montana", "plan_name": "Closed Plan Network", "standard_charge_percentage": 75, "methodology": "percent of total billed charges", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Blue Cross Blue Shield of Montana", "plan_name": "Retail HMO POS Network", "standard_charge_percentage": 75, "methodology": "percent of total billed charges", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Blue Cross Blue Shield of Montana", "plan_name": "Blue Options Network", "standard_charge_percentage": 75, "methodology": "percent of total billed charges", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "PacificSource Health Plans", "plan_name": "Medicare Advantage", "standard_charge_percentage": 103, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" } ] } ] }, { "description": "Non-Bacterial Infection of Nervous System Except Viral Meningitis with MCC", "code_information": [ { "code": "97", "type": "LOCAL" } ], "standard_charges": [ { "setting": "inpatient", "payers_information": [ { "payer_name": "Blue Cross Blue Shield of Montana", "plan_name": "Medicare Advantage", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "United Healthcare (UHC)", "plan_name": "Medicare Advantage", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "First Choice of the Midwest", "plan_name": "PPO", "standard_charge_percentage": 90, "methodology": "percent of total billed charges", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "United Healthcare (UHC)", "plan_name": "DSNP", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Employee Benefit Management Services (EBMS)", "plan_name": "EBMS SelectCare Network", "standard_charge_percentage": 80, "methodology": "percent of total billed charges", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Claritev fka MultiPlan", "plan_name": "PPO", "standard_charge_percentage": 75, "methodology": "percent of total billed charges", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Allegiance Provider Direct", "plan_name": "Medicare", "standard_charge_percentage": 229.99999999999997, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Medicare (CMS)", "plan_name": "Medicare", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Medica Insurance Company", "plan_name": "Medicare Cost", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "First Choice Health Network fka Health InfoNet", "plan_name": "Commercial", "standard_charge_percentage": 85, "methodology": "percent of total billed charges", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "First Choice Health Network fka Health InfoNet", "plan_name": "Workers Compensation", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Indian Health Services (IHS)", "plan_name": "Commercial", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Humana Insurance Company", "plan_name": "Humana Medicare Advantage HMO", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Humana Insurance Company", "plan_name": "Humana Medicare Advantage PPO", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Humana Insurance Company", "plan_name": "Humana Medicare Advantage PFFS", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Allegiance Provider Direct", "plan_name": "State of Montana Employee Benefit Plan (Self-Funded)", "standard_charge_percentage": 229.99999999999997, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Allegiance Provider Direct", "plan_name": "Montana Municipal Interlocal Authority (MMIA)", "standard_charge_percentage": 229.99999999999997, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Allegiance Provider Direct", "plan_name": "Montana Association of Counties (MACo)", "standard_charge_percentage": 229.99999999999997, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "First Choice Health Network fka Health InfoNet", "plan_name": "Medicare Advantage", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "TriWest Healthcare Alliance Corporation", "plan_name": "TRICARE Prime", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "TriWest Healthcare Alliance Corporation", "plan_name": "TRICARE Select", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Blue Cross Blue Shield of Montana", "plan_name": "HealthLink Network", "standard_charge_percentage": 75, "methodology": "percent of total billed charges", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Blue Cross Blue Shield of Montana", "plan_name": "Traditional Network", "standard_charge_percentage": 75, "methodology": "percent of total billed charges", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Blue Cross Blue Shield of Montana", "plan_name": "POS Network", "standard_charge_percentage": 75, "methodology": "percent of total billed charges", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Blue Cross Blue Shield of Montana", "plan_name": "Closed Plan Network", "standard_charge_percentage": 75, "methodology": "percent of total billed charges", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Blue Cross Blue Shield of Montana", "plan_name": "Retail HMO POS Network", "standard_charge_percentage": 75, "methodology": "percent of total billed charges", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Blue Cross Blue Shield of Montana", "plan_name": "Blue Options Network", "standard_charge_percentage": 75, "methodology": "percent of total billed charges", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "PacificSource Health Plans", "plan_name": "Medicare Advantage", "standard_charge_percentage": 103, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" } ] } ] }, { "description": "Non-Bacterial Infection of Nervous System Except Viral Meningitis with CC", "code_information": [ { "code": "98", "type": "LOCAL" } ], "standard_charges": [ { "setting": "inpatient", "payers_information": [ { "payer_name": "Blue Cross Blue Shield of Montana", "plan_name": "Medicare Advantage", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "United Healthcare (UHC)", "plan_name": "Medicare Advantage", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "First Choice of the Midwest", "plan_name": "PPO", "standard_charge_percentage": 90, "methodology": "percent of total billed charges", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "United Healthcare (UHC)", "plan_name": "DSNP", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Employee Benefit Management Services (EBMS)", "plan_name": "EBMS SelectCare Network", "standard_charge_percentage": 80, "methodology": "percent of total billed charges", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Claritev fka MultiPlan", "plan_name": "PPO", "standard_charge_percentage": 75, "methodology": "percent of total billed charges", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Allegiance Provider Direct", "plan_name": "Medicare", "standard_charge_percentage": 229.99999999999997, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Medicare (CMS)", "plan_name": "Medicare", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Medica Insurance Company", "plan_name": "Medicare Cost", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "First Choice Health Network fka Health InfoNet", "plan_name": "Commercial", "standard_charge_percentage": 85, "methodology": "percent of total billed charges", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "First Choice Health Network fka Health InfoNet", "plan_name": "Workers Compensation", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Indian Health Services (IHS)", "plan_name": "Commercial", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Humana Insurance Company", "plan_name": "Humana Medicare Advantage HMO", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Humana Insurance Company", "plan_name": "Humana Medicare Advantage PPO", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Humana Insurance Company", "plan_name": "Humana Medicare Advantage PFFS", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Allegiance Provider Direct", "plan_name": "State of Montana Employee Benefit Plan (Self-Funded)", "standard_charge_percentage": 229.99999999999997, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Allegiance Provider Direct", "plan_name": "Montana Municipal Interlocal Authority (MMIA)", "standard_charge_percentage": 229.99999999999997, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Allegiance Provider Direct", "plan_name": "Montana Association of Counties (MACo)", "standard_charge_percentage": 229.99999999999997, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "First Choice Health Network fka Health InfoNet", "plan_name": "Medicare Advantage", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "TriWest Healthcare Alliance Corporation", "plan_name": "TRICARE Prime", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "TriWest Healthcare Alliance Corporation", "plan_name": "TRICARE Select", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Blue Cross Blue Shield of Montana", "plan_name": "HealthLink Network", "standard_charge_percentage": 75, "methodology": "percent of total billed charges", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Blue Cross Blue Shield of Montana", "plan_name": "Traditional Network", "standard_charge_percentage": 75, "methodology": "percent of total billed charges", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Blue Cross Blue Shield of Montana", "plan_name": "POS Network", "standard_charge_percentage": 75, "methodology": "percent of total billed charges", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Blue Cross Blue Shield of Montana", "plan_name": "Closed Plan Network", "standard_charge_percentage": 75, "methodology": "percent of total billed charges", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Blue Cross Blue Shield of Montana", "plan_name": "Retail HMO POS Network", "standard_charge_percentage": 75, "methodology": "percent of total billed charges", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Blue Cross Blue Shield of Montana", "plan_name": "Blue Options Network", "standard_charge_percentage": 75, "methodology": "percent of total billed charges", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "PacificSource Health Plans", "plan_name": "Medicare Advantage", "standard_charge_percentage": 103, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" } ] } ] }, { "description": "Non-Bacterial Infection of Nervous System Except Viral Meningitis without CC/MCC", "code_information": [ { "code": "99", "type": "LOCAL" } ], "standard_charges": [ { "setting": "inpatient", "payers_information": [ { "payer_name": "Blue Cross Blue Shield of Montana", "plan_name": "Medicare Advantage", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "United Healthcare (UHC)", "plan_name": "Medicare Advantage", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "First Choice of the Midwest", "plan_name": "PPO", "standard_charge_percentage": 90, "methodology": "percent of total billed charges", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "United Healthcare (UHC)", "plan_name": "DSNP", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Employee Benefit Management Services (EBMS)", "plan_name": "EBMS SelectCare Network", "standard_charge_percentage": 80, "methodology": "percent of total billed charges", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Claritev fka MultiPlan", "plan_name": "PPO", "standard_charge_percentage": 75, "methodology": "percent of total billed charges", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Allegiance Provider Direct", "plan_name": "Medicare", "standard_charge_percentage": 229.99999999999997, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Medicare (CMS)", "plan_name": "Medicare", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Medica Insurance Company", "plan_name": "Medicare Cost", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "First Choice Health Network fka Health InfoNet", "plan_name": "Commercial", "standard_charge_percentage": 85, "methodology": "percent of total billed charges", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "First Choice Health Network fka Health InfoNet", "plan_name": "Workers Compensation", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Indian Health Services (IHS)", "plan_name": "Commercial", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Humana Insurance Company", "plan_name": "Humana Medicare Advantage HMO", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Humana Insurance Company", "plan_name": "Humana Medicare Advantage PPO", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Humana Insurance Company", "plan_name": "Humana Medicare Advantage PFFS", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Allegiance Provider Direct", "plan_name": "State of Montana Employee Benefit Plan (Self-Funded)", "standard_charge_percentage": 229.99999999999997, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Allegiance Provider Direct", "plan_name": "Montana Municipal Interlocal Authority (MMIA)", "standard_charge_percentage": 229.99999999999997, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Allegiance Provider Direct", "plan_name": "Montana Association of Counties (MACo)", "standard_charge_percentage": 229.99999999999997, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "First Choice Health Network fka Health InfoNet", "plan_name": "Medicare Advantage", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "TriWest Healthcare Alliance Corporation", "plan_name": "TRICARE Prime", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "TriWest Healthcare Alliance Corporation", "plan_name": "TRICARE Select", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Blue Cross Blue Shield of Montana", "plan_name": "HealthLink Network", "standard_charge_percentage": 75, "methodology": "percent of total billed charges", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Blue Cross Blue Shield of Montana", "plan_name": "Traditional Network", "standard_charge_percentage": 75, "methodology": "percent of total billed charges", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Blue Cross Blue Shield of Montana", "plan_name": "POS Network", "standard_charge_percentage": 75, "methodology": "percent of total billed charges", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Blue Cross Blue Shield of Montana", "plan_name": "Closed Plan Network", "standard_charge_percentage": 75, "methodology": "percent of total billed charges", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Blue Cross Blue Shield of Montana", "plan_name": "Retail HMO POS Network", "standard_charge_percentage": 75, "methodology": "percent of total billed charges", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Blue Cross Blue Shield of Montana", "plan_name": "Blue Options Network", "standard_charge_percentage": 75, "methodology": "percent of total billed charges", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "PacificSource Health Plans", "plan_name": "Medicare Advantage", "standard_charge_percentage": 103, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" } ] } ] }, { "description": "Orbital Procedures with CC/MCC", "code_information": [ { "code": "113", "type": "LOCAL" } ], "standard_charges": [ { "setting": "inpatient", "payers_information": [ { "payer_name": "Blue Cross Blue Shield of Montana", "plan_name": "Medicare Advantage", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "United Healthcare (UHC)", "plan_name": "Medicare Advantage", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "First Choice of the Midwest", "plan_name": "PPO", "standard_charge_percentage": 90, "methodology": "percent of total billed charges", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "United Healthcare (UHC)", "plan_name": "DSNP", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Employee Benefit Management Services (EBMS)", "plan_name": "EBMS SelectCare Network", "standard_charge_percentage": 80, "methodology": "percent of total billed charges", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Claritev fka MultiPlan", "plan_name": "PPO", "standard_charge_percentage": 75, "methodology": "percent of total billed charges", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Allegiance Provider Direct", "plan_name": "Medicare", "standard_charge_percentage": 229.99999999999997, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Medicare (CMS)", "plan_name": "Medicare", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Medica Insurance Company", "plan_name": "Medicare Cost", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "First Choice Health Network fka Health InfoNet", "plan_name": "Commercial", "standard_charge_percentage": 85, "methodology": "percent of total billed charges", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "First Choice Health Network fka Health InfoNet", "plan_name": "Workers Compensation", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Indian Health Services (IHS)", "plan_name": "Commercial", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Humana Insurance Company", "plan_name": "Humana Medicare Advantage HMO", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Humana Insurance Company", "plan_name": "Humana Medicare Advantage PPO", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Humana Insurance Company", "plan_name": "Humana Medicare Advantage PFFS", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Allegiance Provider Direct", "plan_name": "State of Montana Employee Benefit Plan (Self-Funded)", "standard_charge_percentage": 229.99999999999997, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Allegiance Provider Direct", "plan_name": "Montana Municipal Interlocal Authority (MMIA)", "standard_charge_percentage": 229.99999999999997, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Allegiance Provider Direct", "plan_name": "Montana Association of Counties (MACo)", "standard_charge_percentage": 229.99999999999997, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "First Choice Health Network fka Health InfoNet", "plan_name": "Medicare Advantage", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "TriWest Healthcare Alliance Corporation", "plan_name": "TRICARE Prime", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "TriWest Healthcare Alliance Corporation", "plan_name": "TRICARE Select", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Blue Cross Blue Shield of Montana", "plan_name": "HealthLink Network", "standard_charge_percentage": 75, "methodology": "percent of total billed charges", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Blue Cross Blue Shield of Montana", "plan_name": "Traditional Network", "standard_charge_percentage": 75, "methodology": "percent of total billed charges", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Blue Cross Blue Shield of Montana", "plan_name": "POS Network", "standard_charge_percentage": 75, "methodology": "percent of total billed charges", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Blue Cross Blue Shield of Montana", "plan_name": "Closed Plan Network", "standard_charge_percentage": 75, "methodology": "percent of total billed charges", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Blue Cross Blue Shield of Montana", "plan_name": "Retail HMO POS Network", "standard_charge_percentage": 75, "methodology": "percent of total billed charges", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Blue Cross Blue Shield of Montana", "plan_name": "Blue Options Network", "standard_charge_percentage": 75, "methodology": "percent of total billed charges", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "PacificSource Health Plans", "plan_name": "Medicare Advantage", "standard_charge_percentage": 103, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" } ] } ] }, { "description": "Orbital Procedures without CC/MCC", "code_information": [ { "code": "114", "type": "LOCAL" } ], "standard_charges": [ { "setting": "inpatient", "payers_information": [ { "payer_name": "Blue Cross Blue Shield of Montana", "plan_name": "Medicare Advantage", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "United Healthcare (UHC)", "plan_name": "Medicare Advantage", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "First Choice of the Midwest", "plan_name": "PPO", "standard_charge_percentage": 90, "methodology": "percent of total billed charges", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "United Healthcare (UHC)", "plan_name": "DSNP", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Employee Benefit Management Services (EBMS)", "plan_name": "EBMS SelectCare Network", "standard_charge_percentage": 80, "methodology": "percent of total billed charges", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Claritev fka MultiPlan", "plan_name": "PPO", "standard_charge_percentage": 75, "methodology": "percent of total billed charges", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Allegiance Provider Direct", "plan_name": "Medicare", "standard_charge_percentage": 229.99999999999997, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Medicare (CMS)", "plan_name": "Medicare", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Medica Insurance Company", "plan_name": "Medicare Cost", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "First Choice Health Network fka Health InfoNet", "plan_name": "Commercial", "standard_charge_percentage": 85, "methodology": "percent of total billed charges", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "First Choice Health Network fka Health InfoNet", "plan_name": "Workers Compensation", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Indian Health Services (IHS)", "plan_name": "Commercial", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Humana Insurance Company", "plan_name": "Humana Medicare Advantage HMO", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Humana Insurance Company", "plan_name": "Humana Medicare Advantage PPO", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Humana Insurance Company", "plan_name": "Humana Medicare Advantage PFFS", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Allegiance Provider Direct", "plan_name": "State of Montana Employee Benefit Plan (Self-Funded)", "standard_charge_percentage": 229.99999999999997, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Allegiance Provider Direct", "plan_name": "Montana Municipal Interlocal Authority (MMIA)", "standard_charge_percentage": 229.99999999999997, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Allegiance Provider Direct", "plan_name": "Montana Association of Counties (MACo)", "standard_charge_percentage": 229.99999999999997, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "First Choice Health Network fka Health InfoNet", "plan_name": "Medicare Advantage", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "TriWest Healthcare Alliance Corporation", "plan_name": "TRICARE Prime", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "TriWest Healthcare Alliance Corporation", "plan_name": "TRICARE Select", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Blue Cross Blue Shield of Montana", "plan_name": "HealthLink Network", "standard_charge_percentage": 75, "methodology": "percent of total billed charges", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Blue Cross Blue Shield of Montana", "plan_name": "Traditional Network", "standard_charge_percentage": 75, "methodology": "percent of total billed charges", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Blue Cross Blue Shield of Montana", "plan_name": "POS Network", "standard_charge_percentage": 75, "methodology": "percent of total billed charges", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Blue Cross Blue Shield of Montana", "plan_name": "Closed Plan Network", "standard_charge_percentage": 75, "methodology": "percent of total billed charges", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Blue Cross Blue Shield of Montana", "plan_name": "Retail HMO POS Network", "standard_charge_percentage": 75, "methodology": "percent of total billed charges", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Blue Cross Blue Shield of Montana", "plan_name": "Blue Options Network", "standard_charge_percentage": 75, "methodology": "percent of total billed charges", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "PacificSource Health Plans", "plan_name": "Medicare Advantage", "standard_charge_percentage": 103, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" } ] } ] }, { "description": "Extraocular Procedures Except Orbit", "code_information": [ { "code": "115", "type": "LOCAL" } ], "standard_charges": [ { "setting": "inpatient", "payers_information": [ { "payer_name": "Blue Cross Blue Shield of Montana", "plan_name": "Medicare Advantage", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "United Healthcare (UHC)", "plan_name": "Medicare Advantage", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "First Choice of the Midwest", "plan_name": "PPO", "standard_charge_percentage": 90, "methodology": "percent of total billed charges", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "United Healthcare (UHC)", "plan_name": "DSNP", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Employee Benefit Management Services (EBMS)", "plan_name": "EBMS SelectCare Network", "standard_charge_percentage": 80, "methodology": "percent of total billed charges", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Claritev fka MultiPlan", "plan_name": "PPO", "standard_charge_percentage": 75, "methodology": "percent of total billed charges", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Allegiance Provider Direct", "plan_name": "Medicare", "standard_charge_percentage": 229.99999999999997, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Medicare (CMS)", "plan_name": "Medicare", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Medica Insurance Company", "plan_name": "Medicare Cost", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "First Choice Health Network fka Health InfoNet", "plan_name": "Commercial", "standard_charge_percentage": 85, "methodology": "percent of total billed charges", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "First Choice Health Network fka Health InfoNet", "plan_name": "Workers Compensation", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Indian Health Services (IHS)", "plan_name": "Commercial", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Humana Insurance Company", "plan_name": "Humana Medicare Advantage HMO", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Humana Insurance Company", "plan_name": "Humana Medicare Advantage PPO", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Humana Insurance Company", "plan_name": "Humana Medicare Advantage PFFS", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Allegiance Provider Direct", "plan_name": "State of Montana Employee Benefit Plan (Self-Funded)", "standard_charge_percentage": 229.99999999999997, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Allegiance Provider Direct", "plan_name": "Montana Municipal Interlocal Authority (MMIA)", "standard_charge_percentage": 229.99999999999997, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Allegiance Provider Direct", "plan_name": "Montana Association of Counties (MACo)", "standard_charge_percentage": 229.99999999999997, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "First Choice Health Network fka Health InfoNet", "plan_name": "Medicare Advantage", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "TriWest Healthcare Alliance Corporation", "plan_name": "TRICARE Prime", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "TriWest Healthcare Alliance Corporation", "plan_name": "TRICARE Select", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Blue Cross Blue Shield of Montana", "plan_name": "HealthLink Network", "standard_charge_percentage": 75, "methodology": "percent of total billed charges", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Blue Cross Blue Shield of Montana", "plan_name": "Traditional Network", "standard_charge_percentage": 75, "methodology": "percent of total billed charges", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Blue Cross Blue Shield of Montana", "plan_name": "POS Network", "standard_charge_percentage": 75, "methodology": "percent of total billed charges", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Blue Cross Blue Shield of Montana", "plan_name": "Closed Plan Network", "standard_charge_percentage": 75, "methodology": "percent of total billed charges", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Blue Cross Blue Shield of Montana", "plan_name": "Retail HMO POS Network", "standard_charge_percentage": 75, "methodology": "percent of total billed charges", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Blue Cross Blue Shield of Montana", "plan_name": "Blue Options Network", "standard_charge_percentage": 75, "methodology": "percent of total billed charges", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "PacificSource Health Plans", "plan_name": "Medicare Advantage", "standard_charge_percentage": 103, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" } ] } ] }, { "description": "Intraocular Procedures with CC/MCC", "code_information": [ { "code": "116", "type": "LOCAL" } ], "standard_charges": [ { "setting": "inpatient", "payers_information": [ { "payer_name": "Blue Cross Blue Shield of Montana", "plan_name": "Medicare Advantage", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "United Healthcare (UHC)", "plan_name": "Medicare Advantage", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "First Choice of the Midwest", "plan_name": "PPO", "standard_charge_percentage": 90, "methodology": "percent of total billed charges", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "United Healthcare (UHC)", "plan_name": "DSNP", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Employee Benefit Management Services (EBMS)", "plan_name": "EBMS SelectCare Network", "standard_charge_percentage": 80, "methodology": "percent of total billed charges", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Claritev fka MultiPlan", "plan_name": "PPO", "standard_charge_percentage": 75, "methodology": "percent of total billed charges", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Allegiance Provider Direct", "plan_name": "Medicare", "standard_charge_percentage": 229.99999999999997, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Medicare (CMS)", "plan_name": "Medicare", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Medica Insurance Company", "plan_name": "Medicare Cost", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "First Choice Health Network fka Health InfoNet", "plan_name": "Commercial", "standard_charge_percentage": 85, "methodology": "percent of total billed charges", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "First Choice Health Network fka Health InfoNet", "plan_name": "Workers Compensation", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Indian Health Services (IHS)", "plan_name": "Commercial", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Humana Insurance Company", "plan_name": "Humana Medicare Advantage HMO", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Humana Insurance Company", "plan_name": "Humana Medicare Advantage PPO", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Humana Insurance Company", "plan_name": "Humana Medicare Advantage PFFS", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Allegiance Provider Direct", "plan_name": "State of Montana Employee Benefit Plan (Self-Funded)", "standard_charge_percentage": 229.99999999999997, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Allegiance Provider Direct", "plan_name": "Montana Municipal Interlocal Authority (MMIA)", "standard_charge_percentage": 229.99999999999997, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Allegiance Provider Direct", "plan_name": "Montana Association of Counties (MACo)", "standard_charge_percentage": 229.99999999999997, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "First Choice Health Network fka Health InfoNet", "plan_name": "Medicare Advantage", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "TriWest Healthcare Alliance Corporation", "plan_name": "TRICARE Prime", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "TriWest Healthcare Alliance Corporation", "plan_name": "TRICARE Select", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Blue Cross Blue Shield of Montana", "plan_name": "HealthLink Network", "standard_charge_percentage": 75, "methodology": "percent of total billed charges", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Blue Cross Blue Shield of Montana", "plan_name": "Traditional Network", "standard_charge_percentage": 75, "methodology": "percent of total billed charges", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Blue Cross Blue Shield of Montana", "plan_name": "POS Network", "standard_charge_percentage": 75, "methodology": "percent of total billed charges", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Blue Cross Blue Shield of Montana", "plan_name": "Closed Plan Network", "standard_charge_percentage": 75, "methodology": "percent of total billed charges", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Blue Cross Blue Shield of Montana", "plan_name": "Retail HMO POS Network", "standard_charge_percentage": 75, "methodology": "percent of total billed charges", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Blue Cross Blue Shield of Montana", "plan_name": "Blue Options Network", "standard_charge_percentage": 75, "methodology": "percent of total billed charges", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "PacificSource Health Plans", "plan_name": "Medicare Advantage", "standard_charge_percentage": 103, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" } ] } ] }, { "description": "Intraocular Procedures without CC/MCC", "code_information": [ { "code": "117", "type": "LOCAL" } ], "standard_charges": [ { "setting": "inpatient", "payers_information": [ { "payer_name": "Blue Cross Blue Shield of Montana", "plan_name": "Medicare Advantage", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "United Healthcare (UHC)", "plan_name": "Medicare Advantage", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "First Choice of the Midwest", "plan_name": "PPO", "standard_charge_percentage": 90, "methodology": "percent of total billed charges", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "United Healthcare (UHC)", "plan_name": "DSNP", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Employee Benefit Management Services (EBMS)", "plan_name": "EBMS SelectCare Network", "standard_charge_percentage": 80, "methodology": "percent of total billed charges", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Claritev fka MultiPlan", "plan_name": "PPO", "standard_charge_percentage": 75, "methodology": "percent of total billed charges", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Allegiance Provider Direct", "plan_name": "Medicare", "standard_charge_percentage": 229.99999999999997, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Medicare (CMS)", "plan_name": "Medicare", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Medica Insurance Company", "plan_name": "Medicare Cost", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "First Choice Health Network fka Health InfoNet", "plan_name": "Commercial", "standard_charge_percentage": 85, "methodology": "percent of total billed charges", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "First Choice Health Network fka Health InfoNet", "plan_name": "Workers Compensation", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Indian Health Services (IHS)", "plan_name": "Commercial", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Humana Insurance Company", "plan_name": "Humana Medicare Advantage HMO", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Humana Insurance Company", "plan_name": "Humana Medicare Advantage PPO", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Humana Insurance Company", "plan_name": "Humana Medicare Advantage PFFS", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Allegiance Provider Direct", "plan_name": "State of Montana Employee Benefit Plan (Self-Funded)", "standard_charge_percentage": 229.99999999999997, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Allegiance Provider Direct", "plan_name": "Montana Municipal Interlocal Authority (MMIA)", "standard_charge_percentage": 229.99999999999997, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Allegiance Provider Direct", "plan_name": "Montana Association of Counties (MACo)", "standard_charge_percentage": 229.99999999999997, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "First Choice Health Network fka Health InfoNet", "plan_name": "Medicare Advantage", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "TriWest Healthcare Alliance Corporation", "plan_name": "TRICARE Prime", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "TriWest Healthcare Alliance Corporation", "plan_name": "TRICARE Select", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Blue Cross Blue Shield of Montana", "plan_name": "HealthLink Network", "standard_charge_percentage": 75, "methodology": "percent of total billed charges", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Blue Cross Blue Shield of Montana", "plan_name": "Traditional Network", "standard_charge_percentage": 75, "methodology": "percent of total billed charges", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Blue Cross Blue Shield of Montana", "plan_name": "POS Network", "standard_charge_percentage": 75, "methodology": "percent of total billed charges", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Blue Cross Blue Shield of Montana", "plan_name": "Closed Plan Network", "standard_charge_percentage": 75, "methodology": "percent of total billed charges", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Blue Cross Blue Shield of Montana", "plan_name": "Retail HMO POS Network", "standard_charge_percentage": 75, "methodology": "percent of total billed charges", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Blue Cross Blue Shield of Montana", "plan_name": "Blue Options Network", "standard_charge_percentage": 75, "methodology": "percent of total billed charges", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "PacificSource Health Plans", "plan_name": "Medicare Advantage", "standard_charge_percentage": 103, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" } ] } ] }, { "description": "Acute Major Eye Infections with CC/MCC", "code_information": [ { "code": "121", "type": "LOCAL" } ], "standard_charges": [ { "setting": "inpatient", "payers_information": [ { "payer_name": "Blue Cross Blue Shield of Montana", "plan_name": "Medicare Advantage", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "United Healthcare (UHC)", "plan_name": "Medicare Advantage", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "First Choice of the Midwest", "plan_name": "PPO", "standard_charge_percentage": 90, "methodology": "percent of total billed charges", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "United Healthcare (UHC)", "plan_name": "DSNP", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Employee Benefit Management Services (EBMS)", "plan_name": "EBMS SelectCare Network", "standard_charge_percentage": 80, "methodology": "percent of total billed charges", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Claritev fka MultiPlan", "plan_name": "PPO", "standard_charge_percentage": 75, "methodology": "percent of total billed charges", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Allegiance Provider Direct", "plan_name": "Medicare", "standard_charge_percentage": 229.99999999999997, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Medicare (CMS)", "plan_name": "Medicare", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Medica Insurance Company", "plan_name": "Medicare Cost", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "First Choice Health Network fka Health InfoNet", "plan_name": "Commercial", "standard_charge_percentage": 85, "methodology": "percent of total billed charges", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "First Choice Health Network fka Health InfoNet", "plan_name": "Workers Compensation", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Indian Health Services (IHS)", "plan_name": "Commercial", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Humana Insurance Company", "plan_name": "Humana Medicare Advantage HMO", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Humana Insurance Company", "plan_name": "Humana Medicare Advantage PPO", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Humana Insurance Company", "plan_name": "Humana Medicare Advantage PFFS", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Allegiance Provider Direct", "plan_name": "State of Montana Employee Benefit Plan (Self-Funded)", "standard_charge_percentage": 229.99999999999997, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Allegiance Provider Direct", "plan_name": "Montana Municipal Interlocal Authority (MMIA)", "standard_charge_percentage": 229.99999999999997, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Allegiance Provider Direct", "plan_name": "Montana Association of Counties (MACo)", "standard_charge_percentage": 229.99999999999997, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "First Choice Health Network fka Health InfoNet", "plan_name": "Medicare Advantage", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "TriWest Healthcare Alliance Corporation", "plan_name": "TRICARE Prime", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "TriWest Healthcare Alliance Corporation", "plan_name": "TRICARE Select", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Blue Cross Blue Shield of Montana", "plan_name": "HealthLink Network", "standard_charge_percentage": 75, "methodology": "percent of total billed charges", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Blue Cross Blue Shield of Montana", "plan_name": "Traditional Network", "standard_charge_percentage": 75, "methodology": "percent of total billed charges", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Blue Cross Blue Shield of Montana", "plan_name": "POS Network", "standard_charge_percentage": 75, "methodology": "percent of total billed charges", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Blue Cross Blue Shield of Montana", "plan_name": "Closed Plan Network", "standard_charge_percentage": 75, "methodology": "percent of total billed charges", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Blue Cross Blue Shield of Montana", "plan_name": "Retail HMO POS Network", "standard_charge_percentage": 75, "methodology": "percent of total billed charges", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Blue Cross Blue Shield of Montana", "plan_name": "Blue Options Network", "standard_charge_percentage": 75, "methodology": "percent of total billed charges", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "PacificSource Health Plans", "plan_name": "Medicare Advantage", "standard_charge_percentage": 103, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" } ] } ] }, { "description": "Acute Major Eye Infections without CC/MCC", "code_information": [ { "code": "122", "type": "LOCAL" } ], "standard_charges": [ { "setting": "inpatient", "payers_information": [ { "payer_name": "Blue Cross Blue Shield of Montana", "plan_name": "Medicare Advantage", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "United Healthcare (UHC)", "plan_name": "Medicare Advantage", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "First Choice of the Midwest", "plan_name": "PPO", "standard_charge_percentage": 90, "methodology": "percent of total billed charges", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "United Healthcare (UHC)", "plan_name": "DSNP", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Employee Benefit Management Services (EBMS)", "plan_name": "EBMS SelectCare Network", "standard_charge_percentage": 80, "methodology": "percent of total billed charges", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Claritev fka MultiPlan", "plan_name": "PPO", "standard_charge_percentage": 75, "methodology": "percent of total billed charges", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Allegiance Provider Direct", "plan_name": "Medicare", "standard_charge_percentage": 229.99999999999997, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Medicare (CMS)", "plan_name": "Medicare", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Medica Insurance Company", "plan_name": "Medicare Cost", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "First Choice Health Network fka Health InfoNet", "plan_name": "Commercial", "standard_charge_percentage": 85, "methodology": "percent of total billed charges", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "First Choice Health Network fka Health InfoNet", "plan_name": "Workers Compensation", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Indian Health Services (IHS)", "plan_name": "Commercial", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Humana Insurance Company", "plan_name": "Humana Medicare Advantage HMO", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Humana Insurance Company", "plan_name": "Humana Medicare Advantage PPO", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Humana Insurance Company", "plan_name": "Humana Medicare Advantage PFFS", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Allegiance Provider Direct", "plan_name": "State of Montana Employee Benefit Plan (Self-Funded)", "standard_charge_percentage": 229.99999999999997, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Allegiance Provider Direct", "plan_name": "Montana Municipal Interlocal Authority (MMIA)", "standard_charge_percentage": 229.99999999999997, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Allegiance Provider Direct", "plan_name": "Montana Association of Counties (MACo)", "standard_charge_percentage": 229.99999999999997, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "First Choice Health Network fka Health InfoNet", "plan_name": "Medicare Advantage", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "TriWest Healthcare Alliance Corporation", "plan_name": "TRICARE Prime", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "TriWest Healthcare Alliance Corporation", "plan_name": "TRICARE Select", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Blue Cross Blue Shield of Montana", "plan_name": "HealthLink Network", "standard_charge_percentage": 75, "methodology": "percent of total billed charges", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Blue Cross Blue Shield of Montana", "plan_name": "Traditional Network", "standard_charge_percentage": 75, "methodology": "percent of total billed charges", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Blue Cross Blue Shield of Montana", "plan_name": "POS Network", "standard_charge_percentage": 75, "methodology": "percent of total billed charges", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Blue Cross Blue Shield of Montana", "plan_name": "Closed Plan Network", "standard_charge_percentage": 75, "methodology": "percent of total billed charges", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Blue Cross Blue Shield of Montana", "plan_name": "Retail HMO POS Network", "standard_charge_percentage": 75, "methodology": "percent of total billed charges", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Blue Cross Blue Shield of Montana", "plan_name": "Blue Options Network", "standard_charge_percentage": 75, "methodology": "percent of total billed charges", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "PacificSource Health Plans", "plan_name": "Medicare Advantage", "standard_charge_percentage": 103, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" } ] } ] }, { "description": "Neurological Eye Disorders", "code_information": [ { "code": "123", "type": "LOCAL" } ], "standard_charges": [ { "setting": "inpatient", "payers_information": [ { "payer_name": "Blue Cross Blue Shield of Montana", "plan_name": "Medicare Advantage", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "United Healthcare (UHC)", "plan_name": "Medicare Advantage", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "First Choice of the Midwest", "plan_name": "PPO", "standard_charge_percentage": 90, "methodology": "percent of total billed charges", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "United Healthcare (UHC)", "plan_name": "DSNP", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Employee Benefit Management Services (EBMS)", "plan_name": "EBMS SelectCare Network", "standard_charge_percentage": 80, "methodology": "percent of total billed charges", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Claritev fka MultiPlan", "plan_name": "PPO", "standard_charge_percentage": 75, "methodology": "percent of total billed charges", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Allegiance Provider Direct", "plan_name": "Medicare", "standard_charge_percentage": 229.99999999999997, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Medicare (CMS)", "plan_name": "Medicare", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Medica Insurance Company", "plan_name": "Medicare Cost", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "First Choice Health Network fka Health InfoNet", "plan_name": "Commercial", "standard_charge_percentage": 85, "methodology": "percent of total billed charges", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "First Choice Health Network fka Health InfoNet", "plan_name": "Workers Compensation", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Indian Health Services (IHS)", "plan_name": "Commercial", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Humana Insurance Company", "plan_name": "Humana Medicare Advantage HMO", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Humana Insurance Company", "plan_name": "Humana Medicare Advantage PPO", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Humana Insurance Company", "plan_name": "Humana Medicare Advantage PFFS", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Allegiance Provider Direct", "plan_name": "State of Montana Employee Benefit Plan (Self-Funded)", "standard_charge_percentage": 229.99999999999997, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Allegiance Provider Direct", "plan_name": "Montana Municipal Interlocal Authority (MMIA)", "standard_charge_percentage": 229.99999999999997, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Allegiance Provider Direct", "plan_name": "Montana Association of Counties (MACo)", "standard_charge_percentage": 229.99999999999997, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "First Choice Health Network fka Health InfoNet", "plan_name": "Medicare Advantage", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "TriWest Healthcare Alliance Corporation", "plan_name": "TRICARE Prime", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "TriWest Healthcare Alliance Corporation", "plan_name": "TRICARE Select", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Blue Cross Blue Shield of Montana", "plan_name": "HealthLink Network", "standard_charge_percentage": 75, "methodology": "percent of total billed charges", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Blue Cross Blue Shield of Montana", "plan_name": "Traditional Network", "standard_charge_percentage": 75, "methodology": "percent of total billed charges", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Blue Cross Blue Shield of Montana", "plan_name": "POS Network", "standard_charge_percentage": 75, "methodology": "percent of total billed charges", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Blue Cross Blue Shield of Montana", "plan_name": "Closed Plan Network", "standard_charge_percentage": 75, "methodology": "percent of total billed charges", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Blue Cross Blue Shield of Montana", "plan_name": "Retail HMO POS Network", "standard_charge_percentage": 75, "methodology": "percent of total billed charges", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Blue Cross Blue Shield of Montana", "plan_name": "Blue Options Network", "standard_charge_percentage": 75, "methodology": "percent of total billed charges", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "PacificSource Health Plans", "plan_name": "Medicare Advantage", "standard_charge_percentage": 103, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" } ] } ] }, { "description": "Other Disorders of the Eye with MCC or Thrombolytic Agent", "code_information": [ { "code": "124", "type": "LOCAL" } ], "standard_charges": [ { "setting": "inpatient", "payers_information": [ { "payer_name": "Blue Cross Blue Shield of Montana", "plan_name": "Medicare Advantage", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "United Healthcare (UHC)", "plan_name": "Medicare Advantage", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "First Choice of the Midwest", "plan_name": "PPO", "standard_charge_percentage": 90, "methodology": "percent of total billed charges", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "United Healthcare (UHC)", "plan_name": "DSNP", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Employee Benefit Management Services (EBMS)", "plan_name": "EBMS SelectCare Network", "standard_charge_percentage": 80, "methodology": "percent of total billed charges", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Claritev fka MultiPlan", "plan_name": "PPO", "standard_charge_percentage": 75, "methodology": "percent of total billed charges", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Allegiance Provider Direct", "plan_name": "Medicare", "standard_charge_percentage": 229.99999999999997, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Medicare (CMS)", "plan_name": "Medicare", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Medica Insurance Company", "plan_name": "Medicare Cost", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "First Choice Health Network fka Health InfoNet", "plan_name": "Commercial", "standard_charge_percentage": 85, "methodology": "percent of total billed charges", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "First Choice Health Network fka Health InfoNet", "plan_name": "Workers Compensation", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Indian Health Services (IHS)", "plan_name": "Commercial", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Humana Insurance Company", "plan_name": "Humana Medicare Advantage HMO", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Humana Insurance Company", "plan_name": "Humana Medicare Advantage PPO", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Humana Insurance Company", "plan_name": "Humana Medicare Advantage PFFS", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Allegiance Provider Direct", "plan_name": "State of Montana Employee Benefit Plan (Self-Funded)", "standard_charge_percentage": 229.99999999999997, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Allegiance Provider Direct", "plan_name": "Montana Municipal Interlocal Authority (MMIA)", "standard_charge_percentage": 229.99999999999997, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Allegiance Provider Direct", "plan_name": "Montana Association of Counties (MACo)", "standard_charge_percentage": 229.99999999999997, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "First Choice Health Network fka Health InfoNet", "plan_name": "Medicare Advantage", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "TriWest Healthcare Alliance Corporation", "plan_name": "TRICARE Prime", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "TriWest Healthcare Alliance Corporation", "plan_name": "TRICARE Select", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Blue Cross Blue Shield of Montana", "plan_name": "HealthLink Network", "standard_charge_percentage": 75, "methodology": "percent of total billed charges", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Blue Cross Blue Shield of Montana", "plan_name": "Traditional Network", "standard_charge_percentage": 75, "methodology": "percent of total billed charges", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Blue Cross Blue Shield of Montana", "plan_name": "POS Network", "standard_charge_percentage": 75, "methodology": "percent of total billed charges", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Blue Cross Blue Shield of Montana", "plan_name": "Closed Plan Network", "standard_charge_percentage": 75, "methodology": "percent of total billed charges", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Blue Cross Blue Shield of Montana", "plan_name": "Retail HMO POS Network", "standard_charge_percentage": 75, "methodology": "percent of total billed charges", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Blue Cross Blue Shield of Montana", "plan_name": "Blue Options Network", "standard_charge_percentage": 75, "methodology": "percent of total billed charges", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "PacificSource Health Plans", "plan_name": "Medicare Advantage", "standard_charge_percentage": 103, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" } ] } ] }, { "description": "Other Disorders of the Eye without MCC", "code_information": [ { "code": "125", "type": "LOCAL" } ], "standard_charges": [ { "setting": "inpatient", "payers_information": [ { "payer_name": "Blue Cross Blue Shield of Montana", "plan_name": "Medicare Advantage", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "United Healthcare (UHC)", "plan_name": "Medicare Advantage", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "First Choice of the Midwest", "plan_name": "PPO", "standard_charge_percentage": 90, "methodology": "percent of total billed charges", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "United Healthcare (UHC)", "plan_name": "DSNP", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Employee Benefit Management Services (EBMS)", "plan_name": "EBMS SelectCare Network", "standard_charge_percentage": 80, "methodology": "percent of total billed charges", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Claritev fka MultiPlan", "plan_name": "PPO", "standard_charge_percentage": 75, "methodology": "percent of total billed charges", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Allegiance Provider Direct", "plan_name": "Medicare", "standard_charge_percentage": 229.99999999999997, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Medicare (CMS)", "plan_name": "Medicare", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Medica Insurance Company", "plan_name": "Medicare Cost", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "First Choice Health Network fka Health InfoNet", "plan_name": "Commercial", "standard_charge_percentage": 85, "methodology": "percent of total billed charges", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "First Choice Health Network fka Health InfoNet", "plan_name": "Workers Compensation", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Indian Health Services (IHS)", "plan_name": "Commercial", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Humana Insurance Company", "plan_name": "Humana Medicare Advantage HMO", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Humana Insurance Company", "plan_name": "Humana Medicare Advantage PPO", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Humana Insurance Company", "plan_name": "Humana Medicare Advantage PFFS", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Allegiance Provider Direct", "plan_name": "State of Montana Employee Benefit Plan (Self-Funded)", "standard_charge_percentage": 229.99999999999997, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Allegiance Provider Direct", "plan_name": "Montana Municipal Interlocal Authority (MMIA)", "standard_charge_percentage": 229.99999999999997, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Allegiance Provider Direct", "plan_name": "Montana Association of Counties (MACo)", "standard_charge_percentage": 229.99999999999997, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "First Choice Health Network fka Health InfoNet", "plan_name": "Medicare Advantage", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "TriWest Healthcare Alliance Corporation", "plan_name": "TRICARE Prime", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "TriWest Healthcare Alliance Corporation", "plan_name": "TRICARE Select", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Blue Cross Blue Shield of Montana", "plan_name": "HealthLink Network", "standard_charge_percentage": 75, "methodology": "percent of total billed charges", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Blue Cross Blue Shield of Montana", "plan_name": "Traditional Network", "standard_charge_percentage": 75, "methodology": "percent of total billed charges", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Blue Cross Blue Shield of Montana", "plan_name": "POS Network", "standard_charge_percentage": 75, "methodology": "percent of total billed charges", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Blue Cross Blue Shield of Montana", "plan_name": "Closed Plan Network", "standard_charge_percentage": 75, "methodology": "percent of total billed charges", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Blue Cross Blue Shield of Montana", "plan_name": "Retail HMO POS Network", "standard_charge_percentage": 75, "methodology": "percent of total billed charges", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Blue Cross Blue Shield of Montana", "plan_name": "Blue Options Network", "standard_charge_percentage": 75, "methodology": "percent of total billed charges", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "PacificSource Health Plans", "plan_name": "Medicare Advantage", "standard_charge_percentage": 103, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" } ] } ] }, { "description": "Sinus and Mastoid Procedures with CC/MCC", "code_information": [ { "code": "135", "type": "LOCAL" } ], "standard_charges": [ { "setting": "inpatient", "payers_information": [ { "payer_name": "Blue Cross Blue Shield of Montana", "plan_name": "Medicare Advantage", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "United Healthcare (UHC)", "plan_name": "Medicare Advantage", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "First Choice of the Midwest", "plan_name": "PPO", "standard_charge_percentage": 90, "methodology": "percent of total billed charges", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "United Healthcare (UHC)", "plan_name": "DSNP", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Employee Benefit Management Services (EBMS)", "plan_name": "EBMS SelectCare Network", "standard_charge_percentage": 80, "methodology": "percent of total billed charges", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Claritev fka MultiPlan", "plan_name": "PPO", "standard_charge_percentage": 75, "methodology": "percent of total billed charges", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Allegiance Provider Direct", "plan_name": "Medicare", "standard_charge_percentage": 229.99999999999997, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Medicare (CMS)", "plan_name": "Medicare", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Medica Insurance Company", "plan_name": "Medicare Cost", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "First Choice Health Network fka Health InfoNet", "plan_name": "Commercial", "standard_charge_percentage": 85, "methodology": "percent of total billed charges", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "First Choice Health Network fka Health InfoNet", "plan_name": "Workers Compensation", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Indian Health Services (IHS)", "plan_name": "Commercial", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Humana Insurance Company", "plan_name": "Humana Medicare Advantage HMO", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Humana Insurance Company", "plan_name": "Humana Medicare Advantage PPO", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Humana Insurance Company", "plan_name": "Humana Medicare Advantage PFFS", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Allegiance Provider Direct", "plan_name": "State of Montana Employee Benefit Plan (Self-Funded)", "standard_charge_percentage": 229.99999999999997, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Allegiance Provider Direct", "plan_name": "Montana Municipal Interlocal Authority (MMIA)", "standard_charge_percentage": 229.99999999999997, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Allegiance Provider Direct", "plan_name": "Montana Association of Counties (MACo)", "standard_charge_percentage": 229.99999999999997, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "First Choice Health Network fka Health InfoNet", "plan_name": "Medicare Advantage", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "TriWest Healthcare Alliance Corporation", "plan_name": "TRICARE Prime", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "TriWest Healthcare Alliance Corporation", "plan_name": "TRICARE Select", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Blue Cross Blue Shield of Montana", "plan_name": "HealthLink Network", "standard_charge_percentage": 75, "methodology": "percent of total billed charges", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Blue Cross Blue Shield of Montana", "plan_name": "Traditional Network", "standard_charge_percentage": 75, "methodology": "percent of total billed charges", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Blue Cross Blue Shield of Montana", "plan_name": "POS Network", "standard_charge_percentage": 75, "methodology": "percent of total billed charges", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Blue Cross Blue Shield of Montana", "plan_name": "Closed Plan Network", "standard_charge_percentage": 75, "methodology": "percent of total billed charges", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Blue Cross Blue Shield of Montana", "plan_name": "Retail HMO POS Network", "standard_charge_percentage": 75, "methodology": "percent of total billed charges", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Blue Cross Blue Shield of Montana", "plan_name": "Blue Options Network", "standard_charge_percentage": 75, "methodology": "percent of total billed charges", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "PacificSource Health Plans", "plan_name": "Medicare Advantage", "standard_charge_percentage": 103, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" } ] } ] }, { "description": "Sinus and Mastoid Procedures without CC/MCC", "code_information": [ { "code": "136", "type": "LOCAL" } ], "standard_charges": [ { "setting": "inpatient", "payers_information": [ { "payer_name": "Blue Cross Blue Shield of Montana", "plan_name": "Medicare Advantage", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "United Healthcare (UHC)", "plan_name": "Medicare Advantage", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "First Choice of the Midwest", "plan_name": "PPO", "standard_charge_percentage": 90, "methodology": "percent of total billed charges", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "United Healthcare (UHC)", "plan_name": "DSNP", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Employee Benefit Management Services (EBMS)", "plan_name": "EBMS SelectCare Network", "standard_charge_percentage": 80, "methodology": "percent of total billed charges", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Claritev fka MultiPlan", "plan_name": "PPO", "standard_charge_percentage": 75, "methodology": "percent of total billed charges", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Allegiance Provider Direct", "plan_name": "Medicare", "standard_charge_percentage": 229.99999999999997, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Medicare (CMS)", "plan_name": "Medicare", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Medica Insurance Company", "plan_name": "Medicare Cost", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "First Choice Health Network fka Health InfoNet", "plan_name": "Commercial", "standard_charge_percentage": 85, "methodology": "percent of total billed charges", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "First Choice Health Network fka Health InfoNet", "plan_name": "Workers Compensation", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Indian Health Services (IHS)", "plan_name": "Commercial", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Humana Insurance Company", "plan_name": "Humana Medicare Advantage HMO", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Humana Insurance Company", "plan_name": "Humana Medicare Advantage PPO", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Humana Insurance Company", "plan_name": "Humana Medicare Advantage PFFS", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Allegiance Provider Direct", "plan_name": "State of Montana Employee Benefit Plan (Self-Funded)", "standard_charge_percentage": 229.99999999999997, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Allegiance Provider Direct", "plan_name": "Montana Municipal Interlocal Authority (MMIA)", "standard_charge_percentage": 229.99999999999997, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Allegiance Provider Direct", "plan_name": "Montana Association of Counties (MACo)", "standard_charge_percentage": 229.99999999999997, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "First Choice Health Network fka Health InfoNet", "plan_name": "Medicare Advantage", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "TriWest Healthcare Alliance Corporation", "plan_name": "TRICARE Prime", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "TriWest Healthcare Alliance Corporation", "plan_name": "TRICARE Select", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Blue Cross Blue Shield of Montana", "plan_name": "HealthLink Network", "standard_charge_percentage": 75, "methodology": "percent of total billed charges", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Blue Cross Blue Shield of Montana", "plan_name": "Traditional Network", "standard_charge_percentage": 75, "methodology": "percent of total billed charges", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Blue Cross Blue Shield of Montana", "plan_name": "POS Network", "standard_charge_percentage": 75, "methodology": "percent of total billed charges", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Blue Cross Blue Shield of Montana", "plan_name": "Closed Plan Network", "standard_charge_percentage": 75, "methodology": "percent of total billed charges", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Blue Cross Blue Shield of Montana", "plan_name": "Retail HMO POS Network", "standard_charge_percentage": 75, "methodology": "percent of total billed charges", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Blue Cross Blue Shield of Montana", "plan_name": "Blue Options Network", "standard_charge_percentage": 75, "methodology": "percent of total billed charges", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "PacificSource Health Plans", "plan_name": "Medicare Advantage", "standard_charge_percentage": 103, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" } ] } ] }, { "description": "Amputation for Circulatory System Disorders Except Upper Limb and Toe with MCC", "code_information": [ { "code": "239", "type": "LOCAL" } ], "standard_charges": [ { "setting": "inpatient", "payers_information": [ { "payer_name": "Blue Cross Blue Shield of Montana", "plan_name": "Medicare Advantage", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "United Healthcare (UHC)", "plan_name": "Medicare Advantage", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "First Choice of the Midwest", "plan_name": "PPO", "standard_charge_percentage": 90, "methodology": "percent of total billed charges", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "United Healthcare (UHC)", "plan_name": "DSNP", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Employee Benefit Management Services (EBMS)", "plan_name": "EBMS SelectCare Network", "standard_charge_percentage": 80, "methodology": "percent of total billed charges", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Claritev fka MultiPlan", "plan_name": "PPO", "standard_charge_percentage": 75, "methodology": "percent of total billed charges", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Allegiance Provider Direct", "plan_name": "Medicare", "standard_charge_percentage": 229.99999999999997, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Medicare (CMS)", "plan_name": "Medicare", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Medica Insurance Company", "plan_name": "Medicare Cost", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "First Choice Health Network fka Health InfoNet", "plan_name": "Commercial", "standard_charge_percentage": 85, "methodology": "percent of total billed charges", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Indian Health Services (IHS)", "plan_name": "Commercial", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "First Choice Health Network fka Health InfoNet", "plan_name": "Workers Compensation", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Humana Insurance Company", "plan_name": "Humana Medicare Advantage HMO", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Humana Insurance Company", "plan_name": "Humana Medicare Advantage PPO", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Humana Insurance Company", "plan_name": "Humana Medicare Advantage PFFS", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Allegiance Provider Direct", "plan_name": "State of Montana Employee Benefit Plan (Self-Funded)", "standard_charge_percentage": 229.99999999999997, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Allegiance Provider Direct", "plan_name": "Montana Municipal Interlocal Authority (MMIA)", "standard_charge_percentage": 229.99999999999997, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Allegiance Provider Direct", "plan_name": "Montana Association of Counties (MACo)", "standard_charge_percentage": 229.99999999999997, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "First Choice Health Network fka Health InfoNet", "plan_name": "Medicare Advantage", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "TriWest Healthcare Alliance Corporation", "plan_name": "TRICARE Prime", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "TriWest Healthcare Alliance Corporation", "plan_name": "TRICARE Select", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Blue Cross Blue Shield of Montana", "plan_name": "HealthLink Network", "standard_charge_percentage": 75, "methodology": "percent of total billed charges", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Blue Cross Blue Shield of Montana", "plan_name": "Traditional Network", "standard_charge_percentage": 75, "methodology": "percent of total billed charges", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Blue Cross Blue Shield of Montana", "plan_name": "POS Network", "standard_charge_percentage": 75, "methodology": "percent of total billed charges", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Blue Cross Blue Shield of Montana", "plan_name": "Closed Plan Network", "standard_charge_percentage": 75, "methodology": "percent of total billed charges", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Blue Cross Blue Shield of Montana", "plan_name": "Retail HMO POS Network", "standard_charge_percentage": 75, "methodology": "percent of total billed charges", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Blue Cross Blue Shield of Montana", "plan_name": "Blue Options Network", "standard_charge_percentage": 75, "methodology": "percent of total billed charges", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "PacificSource Health Plans", "plan_name": "Medicare Advantage", "standard_charge_percentage": 103, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" } ] } ] }, { "description": "Amputation for Circulatory System Disorders Except Upper Limb and Toe with CC", "code_information": [ { "code": "240", "type": "LOCAL" } ], "standard_charges": [ { "setting": "inpatient", "payers_information": [ { "payer_name": "Blue Cross Blue Shield of Montana", "plan_name": "Medicare Advantage", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "United Healthcare (UHC)", "plan_name": "Medicare Advantage", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "First Choice of the Midwest", "plan_name": "PPO", "standard_charge_percentage": 90, "methodology": "percent of total billed charges", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "United Healthcare (UHC)", "plan_name": "DSNP", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Employee Benefit Management Services (EBMS)", "plan_name": "EBMS SelectCare Network", "standard_charge_percentage": 80, "methodology": "percent of total billed charges", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Claritev fka MultiPlan", "plan_name": "PPO", "standard_charge_percentage": 75, "methodology": "percent of total billed charges", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Allegiance Provider Direct", "plan_name": "Medicare", "standard_charge_percentage": 229.99999999999997, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Medicare (CMS)", "plan_name": "Medicare", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Medica Insurance Company", "plan_name": "Medicare Cost", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "First Choice Health Network fka Health InfoNet", "plan_name": "Commercial", "standard_charge_percentage": 85, "methodology": "percent of total billed charges", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Indian Health Services (IHS)", "plan_name": "Commercial", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "First Choice Health Network fka Health InfoNet", "plan_name": "Workers Compensation", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Humana Insurance Company", "plan_name": "Humana Medicare Advantage HMO", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Humana Insurance Company", "plan_name": "Humana Medicare Advantage PPO", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Humana Insurance Company", "plan_name": "Humana Medicare Advantage PFFS", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Allegiance Provider Direct", "plan_name": "State of Montana Employee Benefit Plan (Self-Funded)", "standard_charge_percentage": 229.99999999999997, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Allegiance Provider Direct", "plan_name": "Montana Municipal Interlocal Authority (MMIA)", "standard_charge_percentage": 229.99999999999997, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Allegiance Provider Direct", "plan_name": "Montana Association of Counties (MACo)", "standard_charge_percentage": 229.99999999999997, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "First Choice Health Network fka Health InfoNet", "plan_name": "Medicare Advantage", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "TriWest Healthcare Alliance Corporation", "plan_name": "TRICARE Prime", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "TriWest Healthcare Alliance Corporation", "plan_name": "TRICARE Select", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Blue Cross Blue Shield of Montana", "plan_name": "HealthLink Network", "standard_charge_percentage": 75, "methodology": "percent of total billed charges", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Blue Cross Blue Shield of Montana", "plan_name": "Traditional Network", "standard_charge_percentage": 75, "methodology": "percent of total billed charges", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Blue Cross Blue Shield of Montana", "plan_name": "POS Network", "standard_charge_percentage": 75, "methodology": "percent of total billed charges", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Blue Cross Blue Shield of Montana", "plan_name": "Closed Plan Network", "standard_charge_percentage": 75, "methodology": "percent of total billed charges", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Blue Cross Blue Shield of Montana", "plan_name": "Retail HMO POS Network", "standard_charge_percentage": 75, "methodology": "percent of total billed charges", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Blue Cross Blue Shield of Montana", "plan_name": "Blue Options Network", "standard_charge_percentage": 75, "methodology": "percent of total billed charges", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "PacificSource Health Plans", "plan_name": "Medicare Advantage", "standard_charge_percentage": 103, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" } ] } ] }, { "description": "Amputation for Circulatory System Disorders Except Upper Limb and Toe without CC/MCC", "code_information": [ { "code": "241", "type": "LOCAL" } ], "standard_charges": [ { "setting": "inpatient", "payers_information": [ { "payer_name": "Blue Cross Blue Shield of Montana", "plan_name": "Medicare Advantage", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "United Healthcare (UHC)", "plan_name": "Medicare Advantage", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "First Choice of the Midwest", "plan_name": "PPO", "standard_charge_percentage": 90, "methodology": "percent of total billed charges", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "United Healthcare (UHC)", "plan_name": "DSNP", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Employee Benefit Management Services (EBMS)", "plan_name": "EBMS SelectCare Network", "standard_charge_percentage": 80, "methodology": "percent of total billed charges", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Claritev fka MultiPlan", "plan_name": "PPO", "standard_charge_percentage": 75, "methodology": "percent of total billed charges", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Allegiance Provider Direct", "plan_name": "Medicare", "standard_charge_percentage": 229.99999999999997, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Medicare (CMS)", "plan_name": "Medicare", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Medica Insurance Company", "plan_name": "Medicare Cost", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "First Choice Health Network fka Health InfoNet", "plan_name": "Commercial", "standard_charge_percentage": 85, "methodology": "percent of total billed charges", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Indian Health Services (IHS)", "plan_name": "Commercial", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "First Choice Health Network fka Health InfoNet", "plan_name": "Workers Compensation", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Humana Insurance Company", "plan_name": "Humana Medicare Advantage HMO", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Humana Insurance Company", "plan_name": "Humana Medicare Advantage PPO", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Humana Insurance Company", "plan_name": "Humana Medicare Advantage PFFS", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Allegiance Provider Direct", "plan_name": "State of Montana Employee Benefit Plan (Self-Funded)", "standard_charge_percentage": 229.99999999999997, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Allegiance Provider Direct", "plan_name": "Montana Municipal Interlocal Authority (MMIA)", "standard_charge_percentage": 229.99999999999997, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Allegiance Provider Direct", "plan_name": "Montana Association of Counties (MACo)", "standard_charge_percentage": 229.99999999999997, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "First Choice Health Network fka Health InfoNet", "plan_name": "Medicare Advantage", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "TriWest Healthcare Alliance Corporation", "plan_name": "TRICARE Prime", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "TriWest Healthcare Alliance Corporation", "plan_name": "TRICARE Select", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Blue Cross Blue Shield of Montana", "plan_name": "HealthLink Network", "standard_charge_percentage": 75, "methodology": "percent of total billed charges", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Blue Cross Blue Shield of Montana", "plan_name": "Traditional Network", "standard_charge_percentage": 75, "methodology": "percent of total billed charges", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Blue Cross Blue Shield of Montana", "plan_name": "POS Network", "standard_charge_percentage": 75, "methodology": "percent of total billed charges", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Blue Cross Blue Shield of Montana", "plan_name": "Closed Plan Network", "standard_charge_percentage": 75, "methodology": "percent of total billed charges", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Blue Cross Blue Shield of Montana", "plan_name": "Retail HMO POS Network", "standard_charge_percentage": 75, "methodology": "percent of total billed charges", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Blue Cross Blue Shield of Montana", "plan_name": "Blue Options Network", "standard_charge_percentage": 75, "methodology": "percent of total billed charges", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "PacificSource Health Plans", "plan_name": "Medicare Advantage", "standard_charge_percentage": 103, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" } ] } ] }, { "description": "Permanent Cardiac Pacemaker Implant with MCC", "code_information": [ { "code": "242", "type": "LOCAL" } ], "standard_charges": [ { "setting": "inpatient", "payers_information": [ { "payer_name": "Blue Cross Blue Shield of Montana", "plan_name": "Medicare Advantage", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "United Healthcare (UHC)", "plan_name": "Medicare Advantage", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "First Choice of the Midwest", "plan_name": "PPO", "standard_charge_percentage": 90, "methodology": "percent of total billed charges", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "United Healthcare (UHC)", "plan_name": "DSNP", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Employee Benefit Management Services (EBMS)", "plan_name": "EBMS SelectCare Network", "standard_charge_percentage": 80, "methodology": "percent of total billed charges", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Claritev fka MultiPlan", "plan_name": "PPO", "standard_charge_percentage": 75, "methodology": "percent of total billed charges", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Allegiance Provider Direct", "plan_name": "Medicare", "standard_charge_percentage": 229.99999999999997, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Medicare (CMS)", "plan_name": "Medicare", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Medica Insurance Company", "plan_name": "Medicare Cost", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "First Choice Health Network fka Health InfoNet", "plan_name": "Commercial", "standard_charge_percentage": 85, "methodology": "percent of total billed charges", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Indian Health Services (IHS)", "plan_name": "Commercial", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "First Choice Health Network fka Health InfoNet", "plan_name": "Workers Compensation", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Humana Insurance Company", "plan_name": "Humana Medicare Advantage HMO", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Humana Insurance Company", "plan_name": "Humana Medicare Advantage PPO", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Humana Insurance Company", "plan_name": "Humana Medicare Advantage PFFS", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Allegiance Provider Direct", "plan_name": "State of Montana Employee Benefit Plan (Self-Funded)", "standard_charge_percentage": 229.99999999999997, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Allegiance Provider Direct", "plan_name": "Montana Municipal Interlocal Authority (MMIA)", "standard_charge_percentage": 229.99999999999997, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Allegiance Provider Direct", "plan_name": "Montana Association of Counties (MACo)", "standard_charge_percentage": 229.99999999999997, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "First Choice Health Network fka Health InfoNet", "plan_name": "Medicare Advantage", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "TriWest Healthcare Alliance Corporation", "plan_name": "TRICARE Prime", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "TriWest Healthcare Alliance Corporation", "plan_name": "TRICARE Select", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Blue Cross Blue Shield of Montana", "plan_name": "HealthLink Network", "standard_charge_percentage": 75, "methodology": "percent of total billed charges", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Blue Cross Blue Shield of Montana", "plan_name": "Traditional Network", "standard_charge_percentage": 75, "methodology": "percent of total billed charges", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Blue Cross Blue Shield of Montana", "plan_name": "POS Network", "standard_charge_percentage": 75, "methodology": "percent of total billed charges", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Blue Cross Blue Shield of Montana", "plan_name": "Closed Plan Network", "standard_charge_percentage": 75, "methodology": "percent of total billed charges", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Blue Cross Blue Shield of Montana", "plan_name": "Retail HMO POS Network", "standard_charge_percentage": 75, "methodology": "percent of total billed charges", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Blue Cross Blue Shield of Montana", "plan_name": "Blue Options Network", "standard_charge_percentage": 75, "methodology": "percent of total billed charges", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "PacificSource Health Plans", "plan_name": "Medicare Advantage", "standard_charge_percentage": 103, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" } ] } ] }, { "description": "Permanent Cardiac Pacemaker Implant with CC", "code_information": [ { "code": "243", "type": "LOCAL" } ], "standard_charges": [ { "setting": "inpatient", "payers_information": [ { "payer_name": "Blue Cross Blue Shield of Montana", "plan_name": "Medicare Advantage", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "United Healthcare (UHC)", "plan_name": "Medicare Advantage", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "First Choice of the Midwest", "plan_name": "PPO", "standard_charge_percentage": 90, "methodology": "percent of total billed charges", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "United Healthcare (UHC)", "plan_name": "DSNP", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Employee Benefit Management Services (EBMS)", "plan_name": "EBMS SelectCare Network", "standard_charge_percentage": 80, "methodology": "percent of total billed charges", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Claritev fka MultiPlan", "plan_name": "PPO", "standard_charge_percentage": 75, "methodology": "percent of total billed charges", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Allegiance Provider Direct", "plan_name": "Medicare", "standard_charge_percentage": 229.99999999999997, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Medicare (CMS)", "plan_name": "Medicare", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Medica Insurance Company", "plan_name": "Medicare Cost", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "First Choice Health Network fka Health InfoNet", "plan_name": "Commercial", "standard_charge_percentage": 85, "methodology": "percent of total billed charges", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Indian Health Services (IHS)", "plan_name": "Commercial", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "First Choice Health Network fka Health InfoNet", "plan_name": "Workers Compensation", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Humana Insurance Company", "plan_name": "Humana Medicare Advantage HMO", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Humana Insurance Company", "plan_name": "Humana Medicare Advantage PPO", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Humana Insurance Company", "plan_name": "Humana Medicare Advantage PFFS", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Allegiance Provider Direct", "plan_name": "State of Montana Employee Benefit Plan (Self-Funded)", "standard_charge_percentage": 229.99999999999997, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Allegiance Provider Direct", "plan_name": "Montana Municipal Interlocal Authority (MMIA)", "standard_charge_percentage": 229.99999999999997, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Allegiance Provider Direct", "plan_name": "Montana Association of Counties (MACo)", "standard_charge_percentage": 229.99999999999997, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "First Choice Health Network fka Health InfoNet", "plan_name": "Medicare Advantage", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "TriWest Healthcare Alliance Corporation", "plan_name": "TRICARE Prime", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "TriWest Healthcare Alliance Corporation", "plan_name": "TRICARE Select", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Blue Cross Blue Shield of Montana", "plan_name": "HealthLink Network", "standard_charge_percentage": 75, "methodology": "percent of total billed charges", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Blue Cross Blue Shield of Montana", "plan_name": "Traditional Network", "standard_charge_percentage": 75, "methodology": "percent of total billed charges", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Blue Cross Blue Shield of Montana", "plan_name": "POS Network", "standard_charge_percentage": 75, "methodology": "percent of total billed charges", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Blue Cross Blue Shield of Montana", "plan_name": "Closed Plan Network", "standard_charge_percentage": 75, "methodology": "percent of total billed charges", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Blue Cross Blue Shield of Montana", "plan_name": "Retail HMO POS Network", "standard_charge_percentage": 75, "methodology": "percent of total billed charges", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Blue Cross Blue Shield of Montana", "plan_name": "Blue Options Network", "standard_charge_percentage": 75, "methodology": "percent of total billed charges", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "PacificSource Health Plans", "plan_name": "Medicare Advantage", "standard_charge_percentage": 103, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" } ] } ] }, { "description": "Permanent Cardiac Pacemaker Implant without CC/MCC", "code_information": [ { "code": "244", "type": "LOCAL" } ], "standard_charges": [ { "setting": "inpatient", "payers_information": [ { "payer_name": "Blue Cross Blue Shield of Montana", "plan_name": "Medicare Advantage", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "United Healthcare (UHC)", "plan_name": "Medicare Advantage", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "First Choice of the Midwest", "plan_name": "PPO", "standard_charge_percentage": 90, "methodology": "percent of total billed charges", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "United Healthcare (UHC)", "plan_name": "DSNP", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Employee Benefit Management Services (EBMS)", "plan_name": "EBMS SelectCare Network", "standard_charge_percentage": 80, "methodology": "percent of total billed charges", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Claritev fka MultiPlan", "plan_name": "PPO", "standard_charge_percentage": 75, "methodology": "percent of total billed charges", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Allegiance Provider Direct", "plan_name": "Medicare", "standard_charge_percentage": 229.99999999999997, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Medicare (CMS)", "plan_name": "Medicare", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Medica Insurance Company", "plan_name": "Medicare Cost", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "First Choice Health Network fka Health InfoNet", "plan_name": "Commercial", "standard_charge_percentage": 85, "methodology": "percent of total billed charges", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Indian Health Services (IHS)", "plan_name": "Commercial", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "First Choice Health Network fka Health InfoNet", "plan_name": "Workers Compensation", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Humana Insurance Company", "plan_name": "Humana Medicare Advantage HMO", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Humana Insurance Company", "plan_name": "Humana Medicare Advantage PPO", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Humana Insurance Company", "plan_name": "Humana Medicare Advantage PFFS", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Allegiance Provider Direct", "plan_name": "State of Montana Employee Benefit Plan (Self-Funded)", "standard_charge_percentage": 229.99999999999997, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Allegiance Provider Direct", "plan_name": "Montana Municipal Interlocal Authority (MMIA)", "standard_charge_percentage": 229.99999999999997, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Allegiance Provider Direct", "plan_name": "Montana Association of Counties (MACo)", "standard_charge_percentage": 229.99999999999997, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "First Choice Health Network fka Health InfoNet", "plan_name": "Medicare Advantage", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "TriWest Healthcare Alliance Corporation", "plan_name": "TRICARE Prime", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "TriWest Healthcare Alliance Corporation", "plan_name": "TRICARE Select", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Blue Cross Blue Shield of Montana", "plan_name": "HealthLink Network", "standard_charge_percentage": 75, "methodology": "percent of total billed charges", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Blue Cross Blue Shield of Montana", "plan_name": "Traditional Network", "standard_charge_percentage": 75, "methodology": "percent of total billed charges", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Blue Cross Blue Shield of Montana", "plan_name": "POS Network", "standard_charge_percentage": 75, "methodology": "percent of total billed charges", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Blue Cross Blue Shield of Montana", "plan_name": "Closed Plan Network", "standard_charge_percentage": 75, "methodology": "percent of total billed charges", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Blue Cross Blue Shield of Montana", "plan_name": "Retail HMO POS Network", "standard_charge_percentage": 75, "methodology": "percent of total billed charges", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Blue Cross Blue Shield of Montana", "plan_name": "Blue Options Network", "standard_charge_percentage": 75, "methodology": "percent of total billed charges", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "PacificSource Health Plans", "plan_name": "Medicare Advantage", "standard_charge_percentage": 103, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" } ] } ] }, { "description": "AICD Generator Procedures", "code_information": [ { "code": "245", "type": "LOCAL" } ], "standard_charges": [ { "setting": "inpatient", "payers_information": [ { "payer_name": "Blue Cross Blue Shield of Montana", "plan_name": "Medicare Advantage", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "United Healthcare (UHC)", "plan_name": "Medicare Advantage", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "First Choice of the Midwest", "plan_name": "PPO", "standard_charge_percentage": 90, "methodology": "percent of total billed charges", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "United Healthcare (UHC)", "plan_name": "DSNP", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Employee Benefit Management Services (EBMS)", "plan_name": "EBMS SelectCare Network", "standard_charge_percentage": 80, "methodology": "percent of total billed charges", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Claritev fka MultiPlan", "plan_name": "PPO", "standard_charge_percentage": 75, "methodology": "percent of total billed charges", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Allegiance Provider Direct", "plan_name": "Medicare", "standard_charge_percentage": 229.99999999999997, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Medicare (CMS)", "plan_name": "Medicare", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Medica Insurance Company", "plan_name": "Medicare Cost", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "First Choice Health Network fka Health InfoNet", "plan_name": "Commercial", "standard_charge_percentage": 85, "methodology": "percent of total billed charges", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Indian Health Services (IHS)", "plan_name": "Commercial", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "First Choice Health Network fka Health InfoNet", "plan_name": "Workers Compensation", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Humana Insurance Company", "plan_name": "Humana Medicare Advantage HMO", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Humana Insurance Company", "plan_name": "Humana Medicare Advantage PPO", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Humana Insurance Company", "plan_name": "Humana Medicare Advantage PFFS", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Allegiance Provider Direct", "plan_name": "State of Montana Employee Benefit Plan (Self-Funded)", "standard_charge_percentage": 229.99999999999997, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Allegiance Provider Direct", "plan_name": "Montana Municipal Interlocal Authority (MMIA)", "standard_charge_percentage": 229.99999999999997, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Allegiance Provider Direct", "plan_name": "Montana Association of Counties (MACo)", "standard_charge_percentage": 229.99999999999997, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "First Choice Health Network fka Health InfoNet", "plan_name": "Medicare Advantage", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "TriWest Healthcare Alliance Corporation", "plan_name": "TRICARE Prime", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "TriWest Healthcare Alliance Corporation", "plan_name": "TRICARE Select", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Blue Cross Blue Shield of Montana", "plan_name": "HealthLink Network", "standard_charge_percentage": 75, "methodology": "percent of total billed charges", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Blue Cross Blue Shield of Montana", "plan_name": "Traditional Network", "standard_charge_percentage": 75, "methodology": "percent of total billed charges", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Blue Cross Blue Shield of Montana", "plan_name": "POS Network", "standard_charge_percentage": 75, "methodology": "percent of total billed charges", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Blue Cross Blue Shield of Montana", "plan_name": "Closed Plan Network", "standard_charge_percentage": 75, "methodology": "percent of total billed charges", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Blue Cross Blue Shield of Montana", "plan_name": "Retail HMO POS Network", "standard_charge_percentage": 75, "methodology": "percent of total billed charges", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Blue Cross Blue Shield of Montana", "plan_name": "Blue Options Network", "standard_charge_percentage": 75, "methodology": "percent of total billed charges", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "PacificSource Health Plans", "plan_name": "Medicare Advantage", "standard_charge_percentage": 103, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" } ] } ] }, { "description": "Percutaneous Cardiovascular Procedures without Intraluminal Device with MCC", "code_information": [ { "code": "250", "type": "LOCAL" } ], "standard_charges": [ { "setting": "inpatient", "payers_information": [ { "payer_name": "Blue Cross Blue Shield of Montana", "plan_name": "Medicare Advantage", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "United Healthcare (UHC)", "plan_name": "Medicare Advantage", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "First Choice of the Midwest", "plan_name": "PPO", "standard_charge_percentage": 90, "methodology": "percent of total billed charges", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "United Healthcare (UHC)", "plan_name": "DSNP", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Employee Benefit Management Services (EBMS)", "plan_name": "EBMS SelectCare Network", "standard_charge_percentage": 80, "methodology": "percent of total billed charges", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Claritev fka MultiPlan", "plan_name": "PPO", "standard_charge_percentage": 75, "methodology": "percent of total billed charges", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Allegiance Provider Direct", "plan_name": "Medicare", "standard_charge_percentage": 229.99999999999997, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Medicare (CMS)", "plan_name": "Medicare", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Medica Insurance Company", "plan_name": "Medicare Cost", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "First Choice Health Network fka Health InfoNet", "plan_name": "Commercial", "standard_charge_percentage": 85, "methodology": "percent of total billed charges", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Indian Health Services (IHS)", "plan_name": "Commercial", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "First Choice Health Network fka Health InfoNet", "plan_name": "Workers Compensation", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Humana Insurance Company", "plan_name": "Humana Medicare Advantage HMO", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Humana Insurance Company", "plan_name": "Humana Medicare Advantage PPO", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Humana Insurance Company", "plan_name": "Humana Medicare Advantage PFFS", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Allegiance Provider Direct", "plan_name": "State of Montana Employee Benefit Plan (Self-Funded)", "standard_charge_percentage": 229.99999999999997, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Allegiance Provider Direct", "plan_name": "Montana Municipal Interlocal Authority (MMIA)", "standard_charge_percentage": 229.99999999999997, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Allegiance Provider Direct", "plan_name": "Montana Association of Counties (MACo)", "standard_charge_percentage": 229.99999999999997, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "First Choice Health Network fka Health InfoNet", "plan_name": "Medicare Advantage", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "TriWest Healthcare Alliance Corporation", "plan_name": "TRICARE Prime", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "TriWest Healthcare Alliance Corporation", "plan_name": "TRICARE Select", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Blue Cross Blue Shield of Montana", "plan_name": "HealthLink Network", "standard_charge_percentage": 75, "methodology": "percent of total billed charges", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Blue Cross Blue Shield of Montana", "plan_name": "Traditional Network", "standard_charge_percentage": 75, "methodology": "percent of total billed charges", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Blue Cross Blue Shield of Montana", "plan_name": "POS Network", "standard_charge_percentage": 75, "methodology": "percent of total billed charges", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Blue Cross Blue Shield of Montana", "plan_name": "Closed Plan Network", "standard_charge_percentage": 75, "methodology": "percent of total billed charges", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Blue Cross Blue Shield of Montana", "plan_name": "Retail HMO POS Network", "standard_charge_percentage": 75, "methodology": "percent of total billed charges", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Blue Cross Blue Shield of Montana", "plan_name": "Blue Options Network", "standard_charge_percentage": 75, "methodology": "percent of total billed charges", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "PacificSource Health Plans", "plan_name": "Medicare Advantage", "standard_charge_percentage": 103, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" } ] } ] }, { "description": "Percutaneous Cardiovascular Procedures without Intraluminal Device without MCC", "code_information": [ { "code": "251", "type": "LOCAL" } ], "standard_charges": [ { "setting": "inpatient", "payers_information": [ { "payer_name": "Blue Cross Blue Shield of Montana", "plan_name": "Medicare Advantage", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "United Healthcare (UHC)", "plan_name": "Medicare Advantage", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "First Choice of the Midwest", "plan_name": "PPO", "standard_charge_percentage": 90, "methodology": "percent of total billed charges", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "United Healthcare (UHC)", "plan_name": "DSNP", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Employee Benefit Management Services (EBMS)", "plan_name": "EBMS SelectCare Network", "standard_charge_percentage": 80, "methodology": "percent of total billed charges", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Claritev fka MultiPlan", "plan_name": "PPO", "standard_charge_percentage": 75, "methodology": "percent of total billed charges", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Allegiance Provider Direct", "plan_name": "Medicare", "standard_charge_percentage": 229.99999999999997, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Medicare (CMS)", "plan_name": "Medicare", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Medica Insurance Company", "plan_name": "Medicare Cost", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "First Choice Health Network fka Health InfoNet", "plan_name": "Commercial", "standard_charge_percentage": 85, "methodology": "percent of total billed charges", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Indian Health Services (IHS)", "plan_name": "Commercial", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "First Choice Health Network fka Health InfoNet", "plan_name": "Workers Compensation", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Humana Insurance Company", "plan_name": "Humana Medicare Advantage HMO", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Humana Insurance Company", "plan_name": "Humana Medicare Advantage PPO", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Humana Insurance Company", "plan_name": "Humana Medicare Advantage PFFS", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Allegiance Provider Direct", "plan_name": "State of Montana Employee Benefit Plan (Self-Funded)", "standard_charge_percentage": 229.99999999999997, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Allegiance Provider Direct", "plan_name": "Montana Municipal Interlocal Authority (MMIA)", "standard_charge_percentage": 229.99999999999997, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Allegiance Provider Direct", "plan_name": "Montana Association of Counties (MACo)", "standard_charge_percentage": 229.99999999999997, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "First Choice Health Network fka Health InfoNet", "plan_name": "Medicare Advantage", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "TriWest Healthcare Alliance Corporation", "plan_name": "TRICARE Prime", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "TriWest Healthcare Alliance Corporation", "plan_name": "TRICARE Select", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Blue Cross Blue Shield of Montana", "plan_name": "HealthLink Network", "standard_charge_percentage": 75, "methodology": "percent of total billed charges", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Blue Cross Blue Shield of Montana", "plan_name": "Traditional Network", "standard_charge_percentage": 75, "methodology": "percent of total billed charges", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Blue Cross Blue Shield of Montana", "plan_name": "POS Network", "standard_charge_percentage": 75, "methodology": "percent of total billed charges", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Blue Cross Blue Shield of Montana", "plan_name": "Closed Plan Network", "standard_charge_percentage": 75, "methodology": "percent of total billed charges", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Blue Cross Blue Shield of Montana", "plan_name": "Retail HMO POS Network", "standard_charge_percentage": 75, "methodology": "percent of total billed charges", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Blue Cross Blue Shield of Montana", "plan_name": "Blue Options Network", "standard_charge_percentage": 75, "methodology": "percent of total billed charges", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "PacificSource Health Plans", "plan_name": "Medicare Advantage", "standard_charge_percentage": 103, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" } ] } ] }, { "description": "Other Vascular Procedures with MCC", "code_information": [ { "code": "252", "type": "LOCAL" } ], "standard_charges": [ { "setting": "inpatient", "payers_information": [ { "payer_name": "Blue Cross Blue Shield of Montana", "plan_name": "Medicare Advantage", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "United Healthcare (UHC)", "plan_name": "Medicare Advantage", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "First Choice of the Midwest", "plan_name": "PPO", "standard_charge_percentage": 90, "methodology": "percent of total billed charges", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "United Healthcare (UHC)", "plan_name": "DSNP", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Employee Benefit Management Services (EBMS)", "plan_name": "EBMS SelectCare Network", "standard_charge_percentage": 80, "methodology": "percent of total billed charges", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Claritev fka MultiPlan", "plan_name": "PPO", "standard_charge_percentage": 75, "methodology": "percent of total billed charges", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Allegiance Provider Direct", "plan_name": "Medicare", "standard_charge_percentage": 229.99999999999997, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Medicare (CMS)", "plan_name": "Medicare", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Medica Insurance Company", "plan_name": "Medicare Cost", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "First Choice Health Network fka Health InfoNet", "plan_name": "Commercial", "standard_charge_percentage": 85, "methodology": "percent of total billed charges", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Indian Health Services (IHS)", "plan_name": "Commercial", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "First Choice Health Network fka Health InfoNet", "plan_name": "Workers Compensation", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Humana Insurance Company", "plan_name": "Humana Medicare Advantage HMO", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Humana Insurance Company", "plan_name": "Humana Medicare Advantage PPO", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Humana Insurance Company", "plan_name": "Humana Medicare Advantage PFFS", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Allegiance Provider Direct", "plan_name": "State of Montana Employee Benefit Plan (Self-Funded)", "standard_charge_percentage": 229.99999999999997, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Allegiance Provider Direct", "plan_name": "Montana Municipal Interlocal Authority (MMIA)", "standard_charge_percentage": 229.99999999999997, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Allegiance Provider Direct", "plan_name": "Montana Association of Counties (MACo)", "standard_charge_percentage": 229.99999999999997, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "First Choice Health Network fka Health InfoNet", "plan_name": "Medicare Advantage", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "TriWest Healthcare Alliance Corporation", "plan_name": "TRICARE Prime", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "TriWest Healthcare Alliance Corporation", "plan_name": "TRICARE Select", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Blue Cross Blue Shield of Montana", "plan_name": "HealthLink Network", "standard_charge_percentage": 75, "methodology": "percent of total billed charges", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Blue Cross Blue Shield of Montana", "plan_name": "Traditional Network", "standard_charge_percentage": 75, "methodology": "percent of total billed charges", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Blue Cross Blue Shield of Montana", "plan_name": "POS Network", "standard_charge_percentage": 75, "methodology": "percent of total billed charges", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Blue Cross Blue Shield of Montana", "plan_name": "Closed Plan Network", "standard_charge_percentage": 75, "methodology": "percent of total billed charges", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Blue Cross Blue Shield of Montana", "plan_name": "Retail HMO POS Network", "standard_charge_percentage": 75, "methodology": "percent of total billed charges", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Blue Cross Blue Shield of Montana", "plan_name": "Blue Options Network", "standard_charge_percentage": 75, "methodology": "percent of total billed charges", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "PacificSource Health Plans", "plan_name": "Medicare Advantage", "standard_charge_percentage": 103, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" } ] } ] }, { "description": "Other Vascular Procedures with CC", "code_information": [ { "code": "253", "type": "LOCAL" } ], "standard_charges": [ { "setting": "inpatient", "payers_information": [ { "payer_name": "Blue Cross Blue Shield of Montana", "plan_name": "Medicare Advantage", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "United Healthcare (UHC)", "plan_name": "Medicare Advantage", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "First Choice of the Midwest", "plan_name": "PPO", "standard_charge_percentage": 90, "methodology": "percent of total billed charges", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "United Healthcare (UHC)", "plan_name": "DSNP", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Employee Benefit Management Services (EBMS)", "plan_name": "EBMS SelectCare Network", "standard_charge_percentage": 80, "methodology": "percent of total billed charges", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Claritev fka MultiPlan", "plan_name": "PPO", "standard_charge_percentage": 75, "methodology": "percent of total billed charges", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Allegiance Provider Direct", "plan_name": "Medicare", "standard_charge_percentage": 229.99999999999997, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Medicare (CMS)", "plan_name": "Medicare", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Medica Insurance Company", "plan_name": "Medicare Cost", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "First Choice Health Network fka Health InfoNet", "plan_name": "Commercial", "standard_charge_percentage": 85, "methodology": "percent of total billed charges", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Indian Health Services (IHS)", "plan_name": "Commercial", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "First Choice Health Network fka Health InfoNet", "plan_name": "Workers Compensation", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Humana Insurance Company", "plan_name": "Humana Medicare Advantage HMO", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Humana Insurance Company", "plan_name": "Humana Medicare Advantage PPO", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Humana Insurance Company", "plan_name": "Humana Medicare Advantage PFFS", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Allegiance Provider Direct", "plan_name": "State of Montana Employee Benefit Plan (Self-Funded)", "standard_charge_percentage": 229.99999999999997, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Allegiance Provider Direct", "plan_name": "Montana Municipal Interlocal Authority (MMIA)", "standard_charge_percentage": 229.99999999999997, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Allegiance Provider Direct", "plan_name": "Montana Association of Counties (MACo)", "standard_charge_percentage": 229.99999999999997, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "First Choice Health Network fka Health InfoNet", "plan_name": "Medicare Advantage", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "TriWest Healthcare Alliance Corporation", "plan_name": "TRICARE Prime", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "TriWest Healthcare Alliance Corporation", "plan_name": "TRICARE Select", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Blue Cross Blue Shield of Montana", "plan_name": "HealthLink Network", "standard_charge_percentage": 75, "methodology": "percent of total billed charges", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Blue Cross Blue Shield of Montana", "plan_name": "Traditional Network", "standard_charge_percentage": 75, "methodology": "percent of total billed charges", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Blue Cross Blue Shield of Montana", "plan_name": "POS Network", "standard_charge_percentage": 75, "methodology": "percent of total billed charges", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Blue Cross Blue Shield of Montana", "plan_name": "Closed Plan Network", "standard_charge_percentage": 75, "methodology": "percent of total billed charges", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Blue Cross Blue Shield of Montana", "plan_name": "Retail HMO POS Network", "standard_charge_percentage": 75, "methodology": "percent of total billed charges", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Blue Cross Blue Shield of Montana", "plan_name": "Blue Options Network", "standard_charge_percentage": 75, "methodology": "percent of total billed charges", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "PacificSource Health Plans", "plan_name": "Medicare Advantage", "standard_charge_percentage": 103, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" } ] } ] }, { "description": "Other Vascular Procedures without CC/MCC", "code_information": [ { "code": "254", "type": "LOCAL" } ], "standard_charges": [ { "setting": "inpatient", "payers_information": [ { "payer_name": "Blue Cross Blue Shield of Montana", "plan_name": "Medicare Advantage", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "United Healthcare (UHC)", "plan_name": "Medicare Advantage", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "First Choice of the Midwest", "plan_name": "PPO", "standard_charge_percentage": 90, "methodology": "percent of total billed charges", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "United Healthcare (UHC)", "plan_name": "DSNP", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Employee Benefit Management Services (EBMS)", "plan_name": "EBMS SelectCare Network", "standard_charge_percentage": 80, "methodology": "percent of total billed charges", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Claritev fka MultiPlan", "plan_name": "PPO", "standard_charge_percentage": 75, "methodology": "percent of total billed charges", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Allegiance Provider Direct", "plan_name": "Medicare", "standard_charge_percentage": 229.99999999999997, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Medicare (CMS)", "plan_name": "Medicare", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Medica Insurance Company", "plan_name": "Medicare Cost", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "First Choice Health Network fka Health InfoNet", "plan_name": "Commercial", "standard_charge_percentage": 85, "methodology": "percent of total billed charges", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Indian Health Services (IHS)", "plan_name": "Commercial", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "First Choice Health Network fka Health InfoNet", "plan_name": "Workers Compensation", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Humana Insurance Company", "plan_name": "Humana Medicare Advantage HMO", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Humana Insurance Company", "plan_name": "Humana Medicare Advantage PPO", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Humana Insurance Company", "plan_name": "Humana Medicare Advantage PFFS", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Allegiance Provider Direct", "plan_name": "State of Montana Employee Benefit Plan (Self-Funded)", "standard_charge_percentage": 229.99999999999997, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Allegiance Provider Direct", "plan_name": "Montana Municipal Interlocal Authority (MMIA)", "standard_charge_percentage": 229.99999999999997, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Allegiance Provider Direct", "plan_name": "Montana Association of Counties (MACo)", "standard_charge_percentage": 229.99999999999997, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "First Choice Health Network fka Health InfoNet", "plan_name": "Medicare Advantage", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "TriWest Healthcare Alliance Corporation", "plan_name": "TRICARE Prime", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "TriWest Healthcare Alliance Corporation", "plan_name": "TRICARE Select", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Blue Cross Blue Shield of Montana", "plan_name": "HealthLink Network", "standard_charge_percentage": 75, "methodology": "percent of total billed charges", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Blue Cross Blue Shield of Montana", "plan_name": "Traditional Network", "standard_charge_percentage": 75, "methodology": "percent of total billed charges", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Blue Cross Blue Shield of Montana", "plan_name": "POS Network", "standard_charge_percentage": 75, "methodology": "percent of total billed charges", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Blue Cross Blue Shield of Montana", "plan_name": "Closed Plan Network", "standard_charge_percentage": 75, "methodology": "percent of total billed charges", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Blue Cross Blue Shield of Montana", "plan_name": "Retail HMO POS Network", "standard_charge_percentage": 75, "methodology": "percent of total billed charges", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Blue Cross Blue Shield of Montana", "plan_name": "Blue Options Network", "standard_charge_percentage": 75, "methodology": "percent of total billed charges", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "PacificSource Health Plans", "plan_name": "Medicare Advantage", "standard_charge_percentage": 103, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" } ] } ] }, { "description": "Upper Limb and Toe Amputation for Circulatory System Disorders with MCC", "code_information": [ { "code": "255", "type": "LOCAL" } ], "standard_charges": [ { "setting": "inpatient", "payers_information": [ { "payer_name": "Blue Cross Blue Shield of Montana", "plan_name": "Medicare Advantage", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "United Healthcare (UHC)", "plan_name": "Medicare Advantage", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "First Choice of the Midwest", "plan_name": "PPO", "standard_charge_percentage": 90, "methodology": "percent of total billed charges", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "United Healthcare (UHC)", "plan_name": "DSNP", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Employee Benefit Management Services (EBMS)", "plan_name": "EBMS SelectCare Network", "standard_charge_percentage": 80, "methodology": "percent of total billed charges", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Claritev fka MultiPlan", "plan_name": "PPO", "standard_charge_percentage": 75, "methodology": "percent of total billed charges", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Allegiance Provider Direct", "plan_name": "Medicare", "standard_charge_percentage": 229.99999999999997, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Medicare (CMS)", "plan_name": "Medicare", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Medica Insurance Company", "plan_name": "Medicare Cost", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "First Choice Health Network fka Health InfoNet", "plan_name": "Commercial", "standard_charge_percentage": 85, "methodology": "percent of total billed charges", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Indian Health Services (IHS)", "plan_name": "Commercial", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "First Choice Health Network fka Health InfoNet", "plan_name": "Workers Compensation", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Humana Insurance Company", "plan_name": "Humana Medicare Advantage HMO", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Humana Insurance Company", "plan_name": "Humana Medicare Advantage PPO", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Humana Insurance Company", "plan_name": "Humana Medicare Advantage PFFS", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Allegiance Provider Direct", "plan_name": "State of Montana Employee Benefit Plan (Self-Funded)", "standard_charge_percentage": 229.99999999999997, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Allegiance Provider Direct", "plan_name": "Montana Municipal Interlocal Authority (MMIA)", "standard_charge_percentage": 229.99999999999997, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Allegiance Provider Direct", "plan_name": "Montana Association of Counties (MACo)", "standard_charge_percentage": 229.99999999999997, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "First Choice Health Network fka Health InfoNet", "plan_name": "Medicare Advantage", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "TriWest Healthcare Alliance Corporation", "plan_name": "TRICARE Prime", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "TriWest Healthcare Alliance Corporation", "plan_name": "TRICARE Select", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Blue Cross Blue Shield of Montana", "plan_name": "HealthLink Network", "standard_charge_percentage": 75, "methodology": "percent of total billed charges", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Blue Cross Blue Shield of Montana", "plan_name": "Traditional Network", "standard_charge_percentage": 75, "methodology": "percent of total billed charges", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Blue Cross Blue Shield of Montana", "plan_name": "POS Network", "standard_charge_percentage": 75, "methodology": "percent of total billed charges", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Blue Cross Blue Shield of Montana", "plan_name": "Closed Plan Network", "standard_charge_percentage": 75, "methodology": "percent of total billed charges", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Blue Cross Blue Shield of Montana", "plan_name": "Retail HMO POS Network", "standard_charge_percentage": 75, "methodology": "percent of total billed charges", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Blue Cross Blue Shield of Montana", "plan_name": "Blue Options Network", "standard_charge_percentage": 75, "methodology": "percent of total billed charges", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "PacificSource Health Plans", "plan_name": "Medicare Advantage", "standard_charge_percentage": 103, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" } ] } ] }, { "description": "Upper Limb and Toe Amputation for Circulatory System Disorders with CC", "code_information": [ { "code": "256", "type": "LOCAL" } ], "standard_charges": [ { "setting": "inpatient", "payers_information": [ { "payer_name": "Blue Cross Blue Shield of Montana", "plan_name": "Medicare Advantage", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "United Healthcare (UHC)", "plan_name": "Medicare Advantage", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "First Choice of the Midwest", "plan_name": "PPO", "standard_charge_percentage": 90, "methodology": "percent of total billed charges", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "United Healthcare (UHC)", "plan_name": "DSNP", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Employee Benefit Management Services (EBMS)", "plan_name": "EBMS SelectCare Network", "standard_charge_percentage": 80, "methodology": "percent of total billed charges", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Claritev fka MultiPlan", "plan_name": "PPO", "standard_charge_percentage": 75, "methodology": "percent of total billed charges", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Allegiance Provider Direct", "plan_name": "Medicare", "standard_charge_percentage": 229.99999999999997, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Medicare (CMS)", "plan_name": "Medicare", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Medica Insurance Company", "plan_name": "Medicare Cost", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "First Choice Health Network fka Health InfoNet", "plan_name": "Commercial", "standard_charge_percentage": 85, "methodology": "percent of total billed charges", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Indian Health Services (IHS)", "plan_name": "Commercial", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "First Choice Health Network fka Health InfoNet", "plan_name": "Workers Compensation", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Humana Insurance Company", "plan_name": "Humana Medicare Advantage HMO", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Humana Insurance Company", "plan_name": "Humana Medicare Advantage PPO", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Humana Insurance Company", "plan_name": "Humana Medicare Advantage PFFS", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Allegiance Provider Direct", "plan_name": "State of Montana Employee Benefit Plan (Self-Funded)", "standard_charge_percentage": 229.99999999999997, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Allegiance Provider Direct", "plan_name": "Montana Municipal Interlocal Authority (MMIA)", "standard_charge_percentage": 229.99999999999997, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Allegiance Provider Direct", "plan_name": "Montana Association of Counties (MACo)", "standard_charge_percentage": 229.99999999999997, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "First Choice Health Network fka Health InfoNet", "plan_name": "Medicare Advantage", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "TriWest Healthcare Alliance Corporation", "plan_name": "TRICARE Prime", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "TriWest Healthcare Alliance Corporation", "plan_name": "TRICARE Select", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Blue Cross Blue Shield of Montana", "plan_name": "HealthLink Network", "standard_charge_percentage": 75, "methodology": "percent of total billed charges", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Blue Cross Blue Shield of Montana", "plan_name": "Traditional Network", "standard_charge_percentage": 75, "methodology": "percent of total billed charges", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Blue Cross Blue Shield of Montana", "plan_name": "POS Network", "standard_charge_percentage": 75, "methodology": "percent of total billed charges", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Blue Cross Blue Shield of Montana", "plan_name": "Closed Plan Network", "standard_charge_percentage": 75, "methodology": "percent of total billed charges", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Blue Cross Blue Shield of Montana", "plan_name": "Retail HMO POS Network", "standard_charge_percentage": 75, "methodology": "percent of total billed charges", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Blue Cross Blue Shield of Montana", "plan_name": "Blue Options Network", "standard_charge_percentage": 75, "methodology": "percent of total billed charges", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "PacificSource Health Plans", "plan_name": "Medicare Advantage", "standard_charge_percentage": 103, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" } ] } ] }, { "description": "Upper Limb and Toe Amputation for Circulatory System Disorders without CC/MCC", "code_information": [ { "code": "257", "type": "LOCAL" } ], "standard_charges": [ { "setting": "inpatient", "payers_information": [ { "payer_name": "Blue Cross Blue Shield of Montana", "plan_name": "Medicare Advantage", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "United Healthcare (UHC)", "plan_name": "Medicare Advantage", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "First Choice of the Midwest", "plan_name": "PPO", "standard_charge_percentage": 90, "methodology": "percent of total billed charges", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "United Healthcare (UHC)", "plan_name": "DSNP", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Employee Benefit Management Services (EBMS)", "plan_name": "EBMS SelectCare Network", "standard_charge_percentage": 80, "methodology": "percent of total billed charges", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Claritev fka MultiPlan", "plan_name": "PPO", "standard_charge_percentage": 75, "methodology": "percent of total billed charges", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Allegiance Provider Direct", "plan_name": "Medicare", "standard_charge_percentage": 229.99999999999997, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Medicare (CMS)", "plan_name": "Medicare", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Medica Insurance Company", "plan_name": "Medicare Cost", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "First Choice Health Network fka Health InfoNet", "plan_name": "Commercial", "standard_charge_percentage": 85, "methodology": "percent of total billed charges", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Indian Health Services (IHS)", "plan_name": "Commercial", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "First Choice Health Network fka Health InfoNet", "plan_name": "Workers Compensation", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Humana Insurance Company", "plan_name": "Humana Medicare Advantage HMO", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Humana Insurance Company", "plan_name": "Humana Medicare Advantage PPO", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Humana Insurance Company", "plan_name": "Humana Medicare Advantage PFFS", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Allegiance Provider Direct", "plan_name": "State of Montana Employee Benefit Plan (Self-Funded)", "standard_charge_percentage": 229.99999999999997, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Allegiance Provider Direct", "plan_name": "Montana Municipal Interlocal Authority (MMIA)", "standard_charge_percentage": 229.99999999999997, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Allegiance Provider Direct", "plan_name": "Montana Association of Counties (MACo)", "standard_charge_percentage": 229.99999999999997, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "First Choice Health Network fka Health InfoNet", "plan_name": "Medicare Advantage", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "TriWest Healthcare Alliance Corporation", "plan_name": "TRICARE Prime", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "TriWest Healthcare Alliance Corporation", "plan_name": "TRICARE Select", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Blue Cross Blue Shield of Montana", "plan_name": "HealthLink Network", "standard_charge_percentage": 75, "methodology": "percent of total billed charges", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Blue Cross Blue Shield of Montana", "plan_name": "Traditional Network", "standard_charge_percentage": 75, "methodology": "percent of total billed charges", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Blue Cross Blue Shield of Montana", "plan_name": "POS Network", "standard_charge_percentage": 75, "methodology": "percent of total billed charges", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Blue Cross Blue Shield of Montana", "plan_name": "Closed Plan Network", "standard_charge_percentage": 75, "methodology": "percent of total billed charges", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Blue Cross Blue Shield of Montana", "plan_name": "Retail HMO POS Network", "standard_charge_percentage": 75, "methodology": "percent of total billed charges", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Blue Cross Blue Shield of Montana", "plan_name": "Blue Options Network", "standard_charge_percentage": 75, "methodology": "percent of total billed charges", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "PacificSource Health Plans", "plan_name": "Medicare Advantage", "standard_charge_percentage": 103, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" } ] } ] }, { "description": "Cardiac Pacemaker Device Replacement with MCC", "code_information": [ { "code": "258", "type": "LOCAL" } ], "standard_charges": [ { "setting": "inpatient", "payers_information": [ { "payer_name": "Blue Cross Blue Shield of Montana", "plan_name": "Medicare Advantage", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "United Healthcare (UHC)", "plan_name": "Medicare Advantage", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "First Choice of the Midwest", "plan_name": "PPO", "standard_charge_percentage": 90, "methodology": "percent of total billed charges", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "United Healthcare (UHC)", "plan_name": "DSNP", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Employee Benefit Management Services (EBMS)", "plan_name": "EBMS SelectCare Network", "standard_charge_percentage": 80, "methodology": "percent of total billed charges", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Claritev fka MultiPlan", "plan_name": "PPO", "standard_charge_percentage": 75, "methodology": "percent of total billed charges", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Allegiance Provider Direct", "plan_name": "Medicare", "standard_charge_percentage": 229.99999999999997, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Medica Insurance Company", "plan_name": "Medicare Cost", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Medicare (CMS)", "plan_name": "Medicare", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "First Choice Health Network fka Health InfoNet", "plan_name": "Commercial", "standard_charge_percentage": 85, "methodology": "percent of total billed charges", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Indian Health Services (IHS)", "plan_name": "Commercial", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "First Choice Health Network fka Health InfoNet", "plan_name": "Workers Compensation", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Humana Insurance Company", "plan_name": "Humana Medicare Advantage HMO", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Humana Insurance Company", "plan_name": "Humana Medicare Advantage PPO", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Humana Insurance Company", "plan_name": "Humana Medicare Advantage PFFS", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Allegiance Provider Direct", "plan_name": "State of Montana Employee Benefit Plan (Self-Funded)", "standard_charge_percentage": 229.99999999999997, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Allegiance Provider Direct", "plan_name": "Montana Municipal Interlocal Authority (MMIA)", "standard_charge_percentage": 229.99999999999997, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Allegiance Provider Direct", "plan_name": "Montana Association of Counties (MACo)", "standard_charge_percentage": 229.99999999999997, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "First Choice Health Network fka Health InfoNet", "plan_name": "Medicare Advantage", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "TriWest Healthcare Alliance Corporation", "plan_name": "TRICARE Prime", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "TriWest Healthcare Alliance Corporation", "plan_name": "TRICARE Select", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Blue Cross Blue Shield of Montana", "plan_name": "HealthLink Network", "standard_charge_percentage": 75, "methodology": "percent of total billed charges", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Blue Cross Blue Shield of Montana", "plan_name": "Traditional Network", "standard_charge_percentage": 75, "methodology": "percent of total billed charges", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Blue Cross Blue Shield of Montana", "plan_name": "POS Network", "standard_charge_percentage": 75, "methodology": "percent of total billed charges", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Blue Cross Blue Shield of Montana", "plan_name": "Closed Plan Network", "standard_charge_percentage": 75, "methodology": "percent of total billed charges", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Blue Cross Blue Shield of Montana", "plan_name": "Retail HMO POS Network", "standard_charge_percentage": 75, "methodology": "percent of total billed charges", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Blue Cross Blue Shield of Montana", "plan_name": "Blue Options Network", "standard_charge_percentage": 75, "methodology": "percent of total billed charges", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "PacificSource Health Plans", "plan_name": "Medicare Advantage", "standard_charge_percentage": 103, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" } ] } ] }, { "description": "Cardiac Pacemaker Device Replacement without MCC", "code_information": [ { "code": "259", "type": "LOCAL" } ], "standard_charges": [ { "setting": "inpatient", "payers_information": [ { "payer_name": "Blue Cross Blue Shield of Montana", "plan_name": "Medicare Advantage", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "United Healthcare (UHC)", "plan_name": "Medicare Advantage", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "First Choice of the Midwest", "plan_name": "PPO", "standard_charge_percentage": 90, "methodology": "percent of total billed charges", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "United Healthcare (UHC)", "plan_name": "DSNP", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Employee Benefit Management Services (EBMS)", "plan_name": "EBMS SelectCare Network", "standard_charge_percentage": 80, "methodology": "percent of total billed charges", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Claritev fka MultiPlan", "plan_name": "PPO", "standard_charge_percentage": 75, "methodology": "percent of total billed charges", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Allegiance Provider Direct", "plan_name": "Medicare", "standard_charge_percentage": 229.99999999999997, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Medica Insurance Company", "plan_name": "Medicare Cost", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Medicare (CMS)", "plan_name": "Medicare", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "First Choice Health Network fka Health InfoNet", "plan_name": "Commercial", "standard_charge_percentage": 85, "methodology": "percent of total billed charges", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Indian Health Services (IHS)", "plan_name": "Commercial", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "First Choice Health Network fka Health InfoNet", "plan_name": "Workers Compensation", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Humana Insurance Company", "plan_name": "Humana Medicare Advantage HMO", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Humana Insurance Company", "plan_name": "Humana Medicare Advantage PPO", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Humana Insurance Company", "plan_name": "Humana Medicare Advantage PFFS", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Allegiance Provider Direct", "plan_name": "State of Montana Employee Benefit Plan (Self-Funded)", "standard_charge_percentage": 229.99999999999997, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Allegiance Provider Direct", "plan_name": "Montana Municipal Interlocal Authority (MMIA)", "standard_charge_percentage": 229.99999999999997, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Allegiance Provider Direct", "plan_name": "Montana Association of Counties (MACo)", "standard_charge_percentage": 229.99999999999997, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "First Choice Health Network fka Health InfoNet", "plan_name": "Medicare Advantage", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "TriWest Healthcare Alliance Corporation", "plan_name": "TRICARE Prime", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "TriWest Healthcare Alliance Corporation", "plan_name": "TRICARE Select", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Blue Cross Blue Shield of Montana", "plan_name": "HealthLink Network", "standard_charge_percentage": 75, "methodology": "percent of total billed charges", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Blue Cross Blue Shield of Montana", "plan_name": "Traditional Network", "standard_charge_percentage": 75, "methodology": "percent of total billed charges", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Blue Cross Blue Shield of Montana", "plan_name": "POS Network", "standard_charge_percentage": 75, "methodology": "percent of total billed charges", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Blue Cross Blue Shield of Montana", "plan_name": "Closed Plan Network", "standard_charge_percentage": 75, "methodology": "percent of total billed charges", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Blue Cross Blue Shield of Montana", "plan_name": "Retail HMO POS Network", "standard_charge_percentage": 75, "methodology": "percent of total billed charges", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Blue Cross Blue Shield of Montana", "plan_name": "Blue Options Network", "standard_charge_percentage": 75, "methodology": "percent of total billed charges", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "PacificSource Health Plans", "plan_name": "Medicare Advantage", "standard_charge_percentage": 103, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" } ] } ] }, { "description": "Cardiac Pacemaker Revision Except Device Replacement with MCC", "code_information": [ { "code": "260", "type": "LOCAL" } ], "standard_charges": [ { "setting": "inpatient", "payers_information": [ { "payer_name": "Blue Cross Blue Shield of Montana", "plan_name": "Medicare Advantage", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "United Healthcare (UHC)", "plan_name": "Medicare Advantage", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "First Choice of the Midwest", "plan_name": "PPO", "standard_charge_percentage": 90, "methodology": "percent of total billed charges", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "United Healthcare (UHC)", "plan_name": "DSNP", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Employee Benefit Management Services (EBMS)", "plan_name": "EBMS SelectCare Network", "standard_charge_percentage": 80, "methodology": "percent of total billed charges", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Claritev fka MultiPlan", "plan_name": "PPO", "standard_charge_percentage": 75, "methodology": "percent of total billed charges", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Allegiance Provider Direct", "plan_name": "Medicare", "standard_charge_percentage": 229.99999999999997, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Medica Insurance Company", "plan_name": "Medicare Cost", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Medicare (CMS)", "plan_name": "Medicare", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "First Choice Health Network fka Health InfoNet", "plan_name": "Commercial", "standard_charge_percentage": 85, "methodology": "percent of total billed charges", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Indian Health Services (IHS)", "plan_name": "Commercial", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "First Choice Health Network fka Health InfoNet", "plan_name": "Workers Compensation", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Humana Insurance Company", "plan_name": "Humana Medicare Advantage HMO", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Humana Insurance Company", "plan_name": "Humana Medicare Advantage PPO", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Humana Insurance Company", "plan_name": "Humana Medicare Advantage PFFS", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Allegiance Provider Direct", "plan_name": "State of Montana Employee Benefit Plan (Self-Funded)", "standard_charge_percentage": 229.99999999999997, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Allegiance Provider Direct", "plan_name": "Montana Municipal Interlocal Authority (MMIA)", "standard_charge_percentage": 229.99999999999997, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Allegiance Provider Direct", "plan_name": "Montana Association of Counties (MACo)", "standard_charge_percentage": 229.99999999999997, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "First Choice Health Network fka Health InfoNet", "plan_name": "Medicare Advantage", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "TriWest Healthcare Alliance Corporation", "plan_name": "TRICARE Prime", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "TriWest Healthcare Alliance Corporation", "plan_name": "TRICARE Select", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Blue Cross Blue Shield of Montana", "plan_name": "HealthLink Network", "standard_charge_percentage": 75, "methodology": "percent of total billed charges", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Blue Cross Blue Shield of Montana", "plan_name": "Traditional Network", "standard_charge_percentage": 75, "methodology": "percent of total billed charges", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Blue Cross Blue Shield of Montana", "plan_name": "POS Network", "standard_charge_percentage": 75, "methodology": "percent of total billed charges", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Blue Cross Blue Shield of Montana", "plan_name": "Closed Plan Network", "standard_charge_percentage": 75, "methodology": "percent of total billed charges", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Blue Cross Blue Shield of Montana", "plan_name": "Retail HMO POS Network", "standard_charge_percentage": 75, "methodology": "percent of total billed charges", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Blue Cross Blue Shield of Montana", "plan_name": "Blue Options Network", "standard_charge_percentage": 75, "methodology": "percent of total billed charges", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "PacificSource Health Plans", "plan_name": "Medicare Advantage", "standard_charge_percentage": 103, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" } ] } ] }, { "description": "Cardiac Pacemaker Revision Except Device Replacement with CC", "code_information": [ { "code": "261", "type": "LOCAL" } ], "standard_charges": [ { "setting": "inpatient", "payers_information": [ { "payer_name": "Blue Cross Blue Shield of Montana", "plan_name": "Medicare Advantage", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "United Healthcare (UHC)", "plan_name": "Medicare Advantage", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "First Choice of the Midwest", "plan_name": "PPO", "standard_charge_percentage": 90, "methodology": "percent of total billed charges", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "United Healthcare (UHC)", "plan_name": "DSNP", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Employee Benefit Management Services (EBMS)", "plan_name": "EBMS SelectCare Network", "standard_charge_percentage": 80, "methodology": "percent of total billed charges", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Claritev fka MultiPlan", "plan_name": "PPO", "standard_charge_percentage": 75, "methodology": "percent of total billed charges", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Allegiance Provider Direct", "plan_name": "Medicare", "standard_charge_percentage": 229.99999999999997, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Medica Insurance Company", "plan_name": "Medicare Cost", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Medicare (CMS)", "plan_name": "Medicare", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "First Choice Health Network fka Health InfoNet", "plan_name": "Commercial", "standard_charge_percentage": 85, "methodology": "percent of total billed charges", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Indian Health Services (IHS)", "plan_name": "Commercial", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "First Choice Health Network fka Health InfoNet", "plan_name": "Workers Compensation", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Humana Insurance Company", "plan_name": "Humana Medicare Advantage HMO", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Humana Insurance Company", "plan_name": "Humana Medicare Advantage PPO", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Humana Insurance Company", "plan_name": "Humana Medicare Advantage PFFS", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Allegiance Provider Direct", "plan_name": "State of Montana Employee Benefit Plan (Self-Funded)", "standard_charge_percentage": 229.99999999999997, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Allegiance Provider Direct", "plan_name": "Montana Municipal Interlocal Authority (MMIA)", "standard_charge_percentage": 229.99999999999997, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Allegiance Provider Direct", "plan_name": "Montana Association of Counties (MACo)", "standard_charge_percentage": 229.99999999999997, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "First Choice Health Network fka Health InfoNet", "plan_name": "Medicare Advantage", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "TriWest Healthcare Alliance Corporation", "plan_name": "TRICARE Prime", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "TriWest Healthcare Alliance Corporation", "plan_name": "TRICARE Select", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Blue Cross Blue Shield of Montana", "plan_name": "HealthLink Network", "standard_charge_percentage": 75, "methodology": "percent of total billed charges", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Blue Cross Blue Shield of Montana", "plan_name": "Traditional Network", "standard_charge_percentage": 75, "methodology": "percent of total billed charges", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Blue Cross Blue Shield of Montana", "plan_name": "POS Network", "standard_charge_percentage": 75, "methodology": "percent of total billed charges", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Blue Cross Blue Shield of Montana", "plan_name": "Closed Plan Network", "standard_charge_percentage": 75, "methodology": "percent of total billed charges", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Blue Cross Blue Shield of Montana", "plan_name": "Retail HMO POS Network", "standard_charge_percentage": 75, "methodology": "percent of total billed charges", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Blue Cross Blue Shield of Montana", "plan_name": "Blue Options Network", "standard_charge_percentage": 75, "methodology": "percent of total billed charges", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "PacificSource Health Plans", "plan_name": "Medicare Advantage", "standard_charge_percentage": 103, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" } ] } ] }, { "description": "Cardiac Pacemaker Revision Except Device Replacement without CC/MCC", "code_information": [ { "code": "262", "type": "LOCAL" } ], "standard_charges": [ { "setting": "inpatient", "payers_information": [ { "payer_name": "Blue Cross Blue Shield of Montana", "plan_name": "Medicare Advantage", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "United Healthcare (UHC)", "plan_name": "Medicare Advantage", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "First Choice of the Midwest", "plan_name": "PPO", "standard_charge_percentage": 90, "methodology": "percent of total billed charges", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "United Healthcare (UHC)", "plan_name": "DSNP", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Employee Benefit Management Services (EBMS)", "plan_name": "EBMS SelectCare Network", "standard_charge_percentage": 80, "methodology": "percent of total billed charges", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Claritev fka MultiPlan", "plan_name": "PPO", "standard_charge_percentage": 75, "methodology": "percent of total billed charges", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Allegiance Provider Direct", "plan_name": "Medicare", "standard_charge_percentage": 229.99999999999997, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Medica Insurance Company", "plan_name": "Medicare Cost", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Medicare (CMS)", "plan_name": "Medicare", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "First Choice Health Network fka Health InfoNet", "plan_name": "Commercial", "standard_charge_percentage": 85, "methodology": "percent of total billed charges", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Indian Health Services (IHS)", "plan_name": "Commercial", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "First Choice Health Network fka Health InfoNet", "plan_name": "Workers Compensation", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Humana Insurance Company", "plan_name": "Humana Medicare Advantage HMO", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Humana Insurance Company", "plan_name": "Humana Medicare Advantage PPO", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Humana Insurance Company", "plan_name": "Humana Medicare Advantage PFFS", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Allegiance Provider Direct", "plan_name": "State of Montana Employee Benefit Plan (Self-Funded)", "standard_charge_percentage": 229.99999999999997, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Allegiance Provider Direct", "plan_name": "Montana Municipal Interlocal Authority (MMIA)", "standard_charge_percentage": 229.99999999999997, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Allegiance Provider Direct", "plan_name": "Montana Association of Counties (MACo)", "standard_charge_percentage": 229.99999999999997, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "First Choice Health Network fka Health InfoNet", "plan_name": "Medicare Advantage", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "TriWest Healthcare Alliance Corporation", "plan_name": "TRICARE Prime", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "TriWest Healthcare Alliance Corporation", "plan_name": "TRICARE Select", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Blue Cross Blue Shield of Montana", "plan_name": "HealthLink Network", "standard_charge_percentage": 75, "methodology": "percent of total billed charges", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Blue Cross Blue Shield of Montana", "plan_name": "Traditional Network", "standard_charge_percentage": 75, "methodology": "percent of total billed charges", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Blue Cross Blue Shield of Montana", "plan_name": "POS Network", "standard_charge_percentage": 75, "methodology": "percent of total billed charges", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Blue Cross Blue Shield of Montana", "plan_name": "Closed Plan Network", "standard_charge_percentage": 75, "methodology": "percent of total billed charges", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Blue Cross Blue Shield of Montana", "plan_name": "Retail HMO POS Network", "standard_charge_percentage": 75, "methodology": "percent of total billed charges", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Blue Cross Blue Shield of Montana", "plan_name": "Blue Options Network", "standard_charge_percentage": 75, "methodology": "percent of total billed charges", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "PacificSource Health Plans", "plan_name": "Medicare Advantage", "standard_charge_percentage": 103, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" } ] } ] }, { "description": "Vein Ligation and Stripping", "code_information": [ { "code": "263", "type": "LOCAL" } ], "standard_charges": [ { "setting": "inpatient", "payers_information": [ { "payer_name": "Blue Cross Blue Shield of Montana", "plan_name": "Medicare Advantage", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "United Healthcare (UHC)", "plan_name": "Medicare Advantage", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "First Choice of the Midwest", "plan_name": "PPO", "standard_charge_percentage": 90, "methodology": "percent of total billed charges", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "United Healthcare (UHC)", "plan_name": "DSNP", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Employee Benefit Management Services (EBMS)", "plan_name": "EBMS SelectCare Network", "standard_charge_percentage": 80, "methodology": "percent of total billed charges", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Claritev fka MultiPlan", "plan_name": "PPO", "standard_charge_percentage": 75, "methodology": "percent of total billed charges", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Allegiance Provider Direct", "plan_name": "Medicare", "standard_charge_percentage": 229.99999999999997, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Medica Insurance Company", "plan_name": "Medicare Cost", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Medicare (CMS)", "plan_name": "Medicare", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "First Choice Health Network fka Health InfoNet", "plan_name": "Commercial", "standard_charge_percentage": 85, "methodology": "percent of total billed charges", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Indian Health Services (IHS)", "plan_name": "Commercial", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "First Choice Health Network fka Health InfoNet", "plan_name": "Workers Compensation", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Humana Insurance Company", "plan_name": "Humana Medicare Advantage HMO", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Humana Insurance Company", "plan_name": "Humana Medicare Advantage PPO", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Humana Insurance Company", "plan_name": "Humana Medicare Advantage PFFS", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Allegiance Provider Direct", "plan_name": "State of Montana Employee Benefit Plan (Self-Funded)", "standard_charge_percentage": 229.99999999999997, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Allegiance Provider Direct", "plan_name": "Montana Municipal Interlocal Authority (MMIA)", "standard_charge_percentage": 229.99999999999997, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Allegiance Provider Direct", "plan_name": "Montana Association of Counties (MACo)", "standard_charge_percentage": 229.99999999999997, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "First Choice Health Network fka Health InfoNet", "plan_name": "Medicare Advantage", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "TriWest Healthcare Alliance Corporation", "plan_name": "TRICARE Prime", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "TriWest Healthcare Alliance Corporation", "plan_name": "TRICARE Select", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Blue Cross Blue Shield of Montana", "plan_name": "HealthLink Network", "standard_charge_percentage": 75, "methodology": "percent of total billed charges", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Blue Cross Blue Shield of Montana", "plan_name": "Traditional Network", "standard_charge_percentage": 75, "methodology": "percent of total billed charges", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Blue Cross Blue Shield of Montana", "plan_name": "POS Network", "standard_charge_percentage": 75, "methodology": "percent of total billed charges", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Blue Cross Blue Shield of Montana", "plan_name": "Closed Plan Network", "standard_charge_percentage": 75, "methodology": "percent of total billed charges", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Blue Cross Blue Shield of Montana", "plan_name": "Retail HMO POS Network", "standard_charge_percentage": 75, "methodology": "percent of total billed charges", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Blue Cross Blue Shield of Montana", "plan_name": "Blue Options Network", "standard_charge_percentage": 75, "methodology": "percent of total billed charges", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "PacificSource Health Plans", "plan_name": "Medicare Advantage", "standard_charge_percentage": 103, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" } ] } ] }, { "description": "Other Circulatory System O.R. Procedures", "code_information": [ { "code": "264", "type": "LOCAL" } ], "standard_charges": [ { "setting": "inpatient", "payers_information": [ { "payer_name": "Blue Cross Blue Shield of Montana", "plan_name": "Medicare Advantage", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "United Healthcare (UHC)", "plan_name": "Medicare Advantage", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "First Choice of the Midwest", "plan_name": "PPO", "standard_charge_percentage": 90, "methodology": "percent of total billed charges", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "United Healthcare (UHC)", "plan_name": "DSNP", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Employee Benefit Management Services (EBMS)", "plan_name": "EBMS SelectCare Network", "standard_charge_percentage": 80, "methodology": "percent of total billed charges", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Claritev fka MultiPlan", "plan_name": "PPO", "standard_charge_percentage": 75, "methodology": "percent of total billed charges", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Allegiance Provider Direct", "plan_name": "Medicare", "standard_charge_percentage": 229.99999999999997, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Medica Insurance Company", "plan_name": "Medicare Cost", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Medicare (CMS)", "plan_name": "Medicare", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "First Choice Health Network fka Health InfoNet", "plan_name": "Commercial", "standard_charge_percentage": 85, "methodology": "percent of total billed charges", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Indian Health Services (IHS)", "plan_name": "Commercial", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "First Choice Health Network fka Health InfoNet", "plan_name": "Workers Compensation", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Humana Insurance Company", "plan_name": "Humana Medicare Advantage HMO", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Humana Insurance Company", "plan_name": "Humana Medicare Advantage PPO", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Humana Insurance Company", "plan_name": "Humana Medicare Advantage PFFS", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Allegiance Provider Direct", "plan_name": "State of Montana Employee Benefit Plan (Self-Funded)", "standard_charge_percentage": 229.99999999999997, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Allegiance Provider Direct", "plan_name": "Montana Municipal Interlocal Authority (MMIA)", "standard_charge_percentage": 229.99999999999997, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Allegiance Provider Direct", "plan_name": "Montana Association of Counties (MACo)", "standard_charge_percentage": 229.99999999999997, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "First Choice Health Network fka Health InfoNet", "plan_name": "Medicare Advantage", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "TriWest Healthcare Alliance Corporation", "plan_name": "TRICARE Prime", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "TriWest Healthcare Alliance Corporation", "plan_name": "TRICARE Select", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Blue Cross Blue Shield of Montana", "plan_name": "HealthLink Network", "standard_charge_percentage": 75, "methodology": "percent of total billed charges", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Blue Cross Blue Shield of Montana", "plan_name": "Traditional Network", "standard_charge_percentage": 75, "methodology": "percent of total billed charges", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Blue Cross Blue Shield of Montana", "plan_name": "POS Network", "standard_charge_percentage": 75, "methodology": "percent of total billed charges", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Blue Cross Blue Shield of Montana", "plan_name": "Closed Plan Network", "standard_charge_percentage": 75, "methodology": "percent of total billed charges", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Blue Cross Blue Shield of Montana", "plan_name": "Retail HMO POS Network", "standard_charge_percentage": 75, "methodology": "percent of total billed charges", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Blue Cross Blue Shield of Montana", "plan_name": "Blue Options Network", "standard_charge_percentage": 75, "methodology": "percent of total billed charges", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "PacificSource Health Plans", "plan_name": "Medicare Advantage", "standard_charge_percentage": 103, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" } ] } ] }, { "description": "AICD Lead Procedures", "code_information": [ { "code": "265", "type": "LOCAL" } ], "standard_charges": [ { "setting": "inpatient", "payers_information": [ { "payer_name": "Blue Cross Blue Shield of Montana", "plan_name": "Medicare Advantage", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "United Healthcare (UHC)", "plan_name": "Medicare Advantage", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "First Choice of the Midwest", "plan_name": "PPO", "standard_charge_percentage": 90, "methodology": "percent of total billed charges", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "United Healthcare (UHC)", "plan_name": "DSNP", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Employee Benefit Management Services (EBMS)", "plan_name": "EBMS SelectCare Network", "standard_charge_percentage": 80, "methodology": "percent of total billed charges", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Claritev fka MultiPlan", "plan_name": "PPO", "standard_charge_percentage": 75, "methodology": "percent of total billed charges", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Allegiance Provider Direct", "plan_name": "Medicare", "standard_charge_percentage": 229.99999999999997, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Medica Insurance Company", "plan_name": "Medicare Cost", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Medicare (CMS)", "plan_name": "Medicare", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "First Choice Health Network fka Health InfoNet", "plan_name": "Commercial", "standard_charge_percentage": 85, "methodology": "percent of total billed charges", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Indian Health Services (IHS)", "plan_name": "Commercial", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "First Choice Health Network fka Health InfoNet", "plan_name": "Workers Compensation", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Humana Insurance Company", "plan_name": "Humana Medicare Advantage HMO", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Humana Insurance Company", "plan_name": "Humana Medicare Advantage PPO", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Humana Insurance Company", "plan_name": "Humana Medicare Advantage PFFS", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Allegiance Provider Direct", "plan_name": "State of Montana Employee Benefit Plan (Self-Funded)", "standard_charge_percentage": 229.99999999999997, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Allegiance Provider Direct", "plan_name": "Montana Municipal Interlocal Authority (MMIA)", "standard_charge_percentage": 229.99999999999997, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Allegiance Provider Direct", "plan_name": "Montana Association of Counties (MACo)", "standard_charge_percentage": 229.99999999999997, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "First Choice Health Network fka Health InfoNet", "plan_name": "Medicare Advantage", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "TriWest Healthcare Alliance Corporation", "plan_name": "TRICARE Prime", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "TriWest Healthcare Alliance Corporation", "plan_name": "TRICARE Select", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Blue Cross Blue Shield of Montana", "plan_name": "HealthLink Network", "standard_charge_percentage": 75, "methodology": "percent of total billed charges", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Blue Cross Blue Shield of Montana", "plan_name": "Traditional Network", "standard_charge_percentage": 75, "methodology": "percent of total billed charges", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Blue Cross Blue Shield of Montana", "plan_name": "POS Network", "standard_charge_percentage": 75, "methodology": "percent of total billed charges", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Blue Cross Blue Shield of Montana", "plan_name": "Closed Plan Network", "standard_charge_percentage": 75, "methodology": "percent of total billed charges", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Blue Cross Blue Shield of Montana", "plan_name": "Retail HMO POS Network", "standard_charge_percentage": 75, "methodology": "percent of total billed charges", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Blue Cross Blue Shield of Montana", "plan_name": "Blue Options Network", "standard_charge_percentage": 75, "methodology": "percent of total billed charges", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "PacificSource Health Plans", "plan_name": "Medicare Advantage", "standard_charge_percentage": 103, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" } ] } ] }, { "description": "Endovascular Cardiac Valve Replacement and Supplement Procedures with MCC", "code_information": [ { "code": "266", "type": "LOCAL" } ], "standard_charges": [ { "setting": "inpatient", "payers_information": [ { "payer_name": "Blue Cross Blue Shield of Montana", "plan_name": "Medicare Advantage", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "United Healthcare (UHC)", "plan_name": "Medicare Advantage", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "First Choice of the Midwest", "plan_name": "PPO", "standard_charge_percentage": 90, "methodology": "percent of total billed charges", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "United Healthcare (UHC)", "plan_name": "DSNP", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Employee Benefit Management Services (EBMS)", "plan_name": "EBMS SelectCare Network", "standard_charge_percentage": 80, "methodology": "percent of total billed charges", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Claritev fka MultiPlan", "plan_name": "PPO", "standard_charge_percentage": 75, "methodology": "percent of total billed charges", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Allegiance Provider Direct", "plan_name": "Medicare", "standard_charge_percentage": 229.99999999999997, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Medica Insurance Company", "plan_name": "Medicare Cost", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Medicare (CMS)", "plan_name": "Medicare", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "First Choice Health Network fka Health InfoNet", "plan_name": "Commercial", "standard_charge_percentage": 85, "methodology": "percent of total billed charges", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Indian Health Services (IHS)", "plan_name": "Commercial", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "First Choice Health Network fka Health InfoNet", "plan_name": "Workers Compensation", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Humana Insurance Company", "plan_name": "Humana Medicare Advantage HMO", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Humana Insurance Company", "plan_name": "Humana Medicare Advantage PPO", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Humana Insurance Company", "plan_name": "Humana Medicare Advantage PFFS", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Allegiance Provider Direct", "plan_name": "State of Montana Employee Benefit Plan (Self-Funded)", "standard_charge_percentage": 229.99999999999997, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Allegiance Provider Direct", "plan_name": "Montana Municipal Interlocal Authority (MMIA)", "standard_charge_percentage": 229.99999999999997, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Allegiance Provider Direct", "plan_name": "Montana Association of Counties (MACo)", "standard_charge_percentage": 229.99999999999997, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "First Choice Health Network fka Health InfoNet", "plan_name": "Medicare Advantage", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "TriWest Healthcare Alliance Corporation", "plan_name": "TRICARE Prime", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "TriWest Healthcare Alliance Corporation", "plan_name": "TRICARE Select", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Blue Cross Blue Shield of Montana", "plan_name": "HealthLink Network", "standard_charge_percentage": 75, "methodology": "percent of total billed charges", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Blue Cross Blue Shield of Montana", "plan_name": "Traditional Network", "standard_charge_percentage": 75, "methodology": "percent of total billed charges", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Blue Cross Blue Shield of Montana", "plan_name": "POS Network", "standard_charge_percentage": 75, "methodology": "percent of total billed charges", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Blue Cross Blue Shield of Montana", "plan_name": "Closed Plan Network", "standard_charge_percentage": 75, "methodology": "percent of total billed charges", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Blue Cross Blue Shield of Montana", "plan_name": "Retail HMO POS Network", "standard_charge_percentage": 75, "methodology": "percent of total billed charges", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Blue Cross Blue Shield of Montana", "plan_name": "Blue Options Network", "standard_charge_percentage": 75, "methodology": "percent of total billed charges", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "PacificSource Health Plans", "plan_name": "Medicare Advantage", "standard_charge_percentage": 103, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" } ] } ] }, { "description": "Endovascular Cardiac Valve Replacement and Supplement Procedures without MCC", "code_information": [ { "code": "267", "type": "LOCAL" } ], "standard_charges": [ { "setting": "inpatient", "payers_information": [ { "payer_name": "Blue Cross Blue Shield of Montana", "plan_name": "Medicare Advantage", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "United Healthcare (UHC)", "plan_name": "Medicare Advantage", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "First Choice of the Midwest", "plan_name": "PPO", "standard_charge_percentage": 90, "methodology": "percent of total billed charges", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "United Healthcare (UHC)", "plan_name": "DSNP", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Employee Benefit Management Services (EBMS)", "plan_name": "EBMS SelectCare Network", "standard_charge_percentage": 80, "methodology": "percent of total billed charges", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Claritev fka MultiPlan", "plan_name": "PPO", "standard_charge_percentage": 75, "methodology": "percent of total billed charges", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Allegiance Provider Direct", "plan_name": "Medicare", "standard_charge_percentage": 229.99999999999997, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Medicare (CMS)", "plan_name": "Medicare", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Medica Insurance Company", "plan_name": "Medicare Cost", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "First Choice Health Network fka Health InfoNet", "plan_name": "Commercial", "standard_charge_percentage": 85, "methodology": "percent of total billed charges", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Indian Health Services (IHS)", "plan_name": "Commercial", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "First Choice Health Network fka Health InfoNet", "plan_name": "Workers Compensation", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Humana Insurance Company", "plan_name": "Humana Medicare Advantage HMO", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Humana Insurance Company", "plan_name": "Humana Medicare Advantage PPO", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Humana Insurance Company", "plan_name": "Humana Medicare Advantage PFFS", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Allegiance Provider Direct", "plan_name": "State of Montana Employee Benefit Plan (Self-Funded)", "standard_charge_percentage": 229.99999999999997, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Allegiance Provider Direct", "plan_name": "Montana Municipal Interlocal Authority (MMIA)", "standard_charge_percentage": 229.99999999999997, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Allegiance Provider Direct", "plan_name": "Montana Association of Counties (MACo)", "standard_charge_percentage": 229.99999999999997, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "First Choice Health Network fka Health InfoNet", "plan_name": "Medicare Advantage", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "TriWest Healthcare Alliance Corporation", "plan_name": "TRICARE Prime", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "TriWest Healthcare Alliance Corporation", "plan_name": "TRICARE Select", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Blue Cross Blue Shield of Montana", "plan_name": "HealthLink Network", "standard_charge_percentage": 75, "methodology": "percent of total billed charges", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Blue Cross Blue Shield of Montana", "plan_name": "Traditional Network", "standard_charge_percentage": 75, "methodology": "percent of total billed charges", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Blue Cross Blue Shield of Montana", "plan_name": "POS Network", "standard_charge_percentage": 75, "methodology": "percent of total billed charges", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Blue Cross Blue Shield of Montana", "plan_name": "Closed Plan Network", "standard_charge_percentage": 75, "methodology": "percent of total billed charges", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Blue Cross Blue Shield of Montana", "plan_name": "Retail HMO POS Network", "standard_charge_percentage": 75, "methodology": "percent of total billed charges", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Blue Cross Blue Shield of Montana", "plan_name": "Blue Options Network", "standard_charge_percentage": 75, "methodology": "percent of total billed charges", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "PacificSource Health Plans", "plan_name": "Medicare Advantage", "standard_charge_percentage": 103, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" } ] } ] }, { "description": "Aortic and Heart Assist Procedures Except Pulsation Balloon with MCC", "code_information": [ { "code": "268", "type": "LOCAL" } ], "standard_charges": [ { "setting": "inpatient", "payers_information": [ { "payer_name": "Blue Cross Blue Shield of Montana", "plan_name": "Medicare Advantage", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "United Healthcare (UHC)", "plan_name": "Medicare Advantage", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "First Choice of the Midwest", "plan_name": "PPO", "standard_charge_percentage": 90, "methodology": "percent of total billed charges", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "United Healthcare (UHC)", "plan_name": "DSNP", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Employee Benefit Management Services (EBMS)", "plan_name": "EBMS SelectCare Network", "standard_charge_percentage": 80, "methodology": "percent of total billed charges", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Claritev fka MultiPlan", "plan_name": "PPO", "standard_charge_percentage": 75, "methodology": "percent of total billed charges", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Allegiance Provider Direct", "plan_name": "Medicare", "standard_charge_percentage": 229.99999999999997, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Medicare (CMS)", "plan_name": "Medicare", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Medica Insurance Company", "plan_name": "Medicare Cost", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "First Choice Health Network fka Health InfoNet", "plan_name": "Commercial", "standard_charge_percentage": 85, "methodology": "percent of total billed charges", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Indian Health Services (IHS)", "plan_name": "Commercial", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "First Choice Health Network fka Health InfoNet", "plan_name": "Workers Compensation", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Humana Insurance Company", "plan_name": "Humana Medicare Advantage HMO", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Humana Insurance Company", "plan_name": "Humana Medicare Advantage PPO", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Humana Insurance Company", "plan_name": "Humana Medicare Advantage PFFS", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Allegiance Provider Direct", "plan_name": "State of Montana Employee Benefit Plan (Self-Funded)", "standard_charge_percentage": 229.99999999999997, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Allegiance Provider Direct", "plan_name": "Montana Municipal Interlocal Authority (MMIA)", "standard_charge_percentage": 229.99999999999997, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Allegiance Provider Direct", "plan_name": "Montana Association of Counties (MACo)", "standard_charge_percentage": 229.99999999999997, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "First Choice Health Network fka Health InfoNet", "plan_name": "Medicare Advantage", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "TriWest Healthcare Alliance Corporation", "plan_name": "TRICARE Prime", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "TriWest Healthcare Alliance Corporation", "plan_name": "TRICARE Select", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Blue Cross Blue Shield of Montana", "plan_name": "HealthLink Network", "standard_charge_percentage": 75, "methodology": "percent of total billed charges", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Blue Cross Blue Shield of Montana", "plan_name": "Traditional Network", "standard_charge_percentage": 75, "methodology": "percent of total billed charges", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Blue Cross Blue Shield of Montana", "plan_name": "POS Network", "standard_charge_percentage": 75, "methodology": "percent of total billed charges", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Blue Cross Blue Shield of Montana", "plan_name": "Closed Plan Network", "standard_charge_percentage": 75, "methodology": "percent of total billed charges", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Blue Cross Blue Shield of Montana", "plan_name": "Retail HMO POS Network", "standard_charge_percentage": 75, "methodology": "percent of total billed charges", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Blue Cross Blue Shield of Montana", "plan_name": "Blue Options Network", "standard_charge_percentage": 75, "methodology": "percent of total billed charges", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "PacificSource Health Plans", "plan_name": "Medicare Advantage", "standard_charge_percentage": 103, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" } ] } ] }, { "description": "Aortic and Heart Assist Procedures Except Pulsation Balloon without MCC", "code_information": [ { "code": "269", "type": "LOCAL" } ], "standard_charges": [ { "setting": "inpatient", "payers_information": [ { "payer_name": "Blue Cross Blue Shield of Montana", "plan_name": "Medicare Advantage", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "United Healthcare (UHC)", "plan_name": "Medicare Advantage", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "First Choice of the Midwest", "plan_name": "PPO", "standard_charge_percentage": 90, "methodology": "percent of total billed charges", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "United Healthcare (UHC)", "plan_name": "DSNP", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Employee Benefit Management Services (EBMS)", "plan_name": "EBMS SelectCare Network", "standard_charge_percentage": 80, "methodology": "percent of total billed charges", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Claritev fka MultiPlan", "plan_name": "PPO", "standard_charge_percentage": 75, "methodology": "percent of total billed charges", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Allegiance Provider Direct", "plan_name": "Medicare", "standard_charge_percentage": 229.99999999999997, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Medicare (CMS)", "plan_name": "Medicare", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Medica Insurance Company", "plan_name": "Medicare Cost", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "First Choice Health Network fka Health InfoNet", "plan_name": "Commercial", "standard_charge_percentage": 85, "methodology": "percent of total billed charges", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Indian Health Services (IHS)", "plan_name": "Commercial", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "First Choice Health Network fka Health InfoNet", "plan_name": "Workers Compensation", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Humana Insurance Company", "plan_name": "Humana Medicare Advantage HMO", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Humana Insurance Company", "plan_name": "Humana Medicare Advantage PPO", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Humana Insurance Company", "plan_name": "Humana Medicare Advantage PFFS", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Allegiance Provider Direct", "plan_name": "State of Montana Employee Benefit Plan (Self-Funded)", "standard_charge_percentage": 229.99999999999997, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Allegiance Provider Direct", "plan_name": "Montana Municipal Interlocal Authority (MMIA)", "standard_charge_percentage": 229.99999999999997, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Allegiance Provider Direct", "plan_name": "Montana Association of Counties (MACo)", "standard_charge_percentage": 229.99999999999997, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "First Choice Health Network fka Health InfoNet", "plan_name": "Medicare Advantage", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "TriWest Healthcare Alliance Corporation", "plan_name": "TRICARE Prime", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "TriWest Healthcare Alliance Corporation", "plan_name": "TRICARE Select", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Blue Cross Blue Shield of Montana", "plan_name": "HealthLink Network", "standard_charge_percentage": 75, "methodology": "percent of total billed charges", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Blue Cross Blue Shield of Montana", "plan_name": "Traditional Network", "standard_charge_percentage": 75, "methodology": "percent of total billed charges", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Blue Cross Blue Shield of Montana", "plan_name": "POS Network", "standard_charge_percentage": 75, "methodology": "percent of total billed charges", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Blue Cross Blue Shield of Montana", "plan_name": "Closed Plan Network", "standard_charge_percentage": 75, "methodology": "percent of total billed charges", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Blue Cross Blue Shield of Montana", "plan_name": "Retail HMO POS Network", "standard_charge_percentage": 75, "methodology": "percent of total billed charges", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Blue Cross Blue Shield of Montana", "plan_name": "Blue Options Network", "standard_charge_percentage": 75, "methodology": "percent of total billed charges", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "PacificSource Health Plans", "plan_name": "Medicare Advantage", "standard_charge_percentage": 103, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" } ] } ] }, { "description": "Other Major Cardiovascular Procedures with MCC", "code_information": [ { "code": "270", "type": "LOCAL" } ], "standard_charges": [ { "setting": "inpatient", "payers_information": [ { "payer_name": "Blue Cross Blue Shield of Montana", "plan_name": "Medicare Advantage", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "United Healthcare (UHC)", "plan_name": "Medicare Advantage", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "First Choice of the Midwest", "plan_name": "PPO", "standard_charge_percentage": 90, "methodology": "percent of total billed charges", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "United Healthcare (UHC)", "plan_name": "DSNP", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Employee Benefit Management Services (EBMS)", "plan_name": "EBMS SelectCare Network", "standard_charge_percentage": 80, "methodology": "percent of total billed charges", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Claritev fka MultiPlan", "plan_name": "PPO", "standard_charge_percentage": 75, "methodology": "percent of total billed charges", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Allegiance Provider Direct", "plan_name": "Medicare", "standard_charge_percentage": 229.99999999999997, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Medicare (CMS)", "plan_name": "Medicare", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Medica Insurance Company", "plan_name": "Medicare Cost", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "First Choice Health Network fka Health InfoNet", "plan_name": "Commercial", "standard_charge_percentage": 85, "methodology": "percent of total billed charges", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Indian Health Services (IHS)", "plan_name": "Commercial", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "First Choice Health Network fka Health InfoNet", "plan_name": "Workers Compensation", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Humana Insurance Company", "plan_name": "Humana Medicare Advantage HMO", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Humana Insurance Company", "plan_name": "Humana Medicare Advantage PPO", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Humana Insurance Company", "plan_name": "Humana Medicare Advantage PFFS", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Allegiance Provider Direct", "plan_name": "State of Montana Employee Benefit Plan (Self-Funded)", "standard_charge_percentage": 229.99999999999997, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Allegiance Provider Direct", "plan_name": "Montana Municipal Interlocal Authority (MMIA)", "standard_charge_percentage": 229.99999999999997, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Allegiance Provider Direct", "plan_name": "Montana Association of Counties (MACo)", "standard_charge_percentage": 229.99999999999997, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "First Choice Health Network fka Health InfoNet", "plan_name": "Medicare Advantage", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "TriWest Healthcare Alliance Corporation", "plan_name": "TRICARE Prime", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "TriWest Healthcare Alliance Corporation", "plan_name": "TRICARE Select", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Blue Cross Blue Shield of Montana", "plan_name": "HealthLink Network", "standard_charge_percentage": 75, "methodology": "percent of total billed charges", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Blue Cross Blue Shield of Montana", "plan_name": "Traditional Network", "standard_charge_percentage": 75, "methodology": "percent of total billed charges", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Blue Cross Blue Shield of Montana", "plan_name": "POS Network", "standard_charge_percentage": 75, "methodology": "percent of total billed charges", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Blue Cross Blue Shield of Montana", "plan_name": "Closed Plan Network", "standard_charge_percentage": 75, "methodology": "percent of total billed charges", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Blue Cross Blue Shield of Montana", "plan_name": "Retail HMO POS Network", "standard_charge_percentage": 75, "methodology": "percent of total billed charges", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Blue Cross Blue Shield of Montana", "plan_name": "Blue Options Network", "standard_charge_percentage": 75, "methodology": "percent of total billed charges", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "PacificSource Health Plans", "plan_name": "Medicare Advantage", "standard_charge_percentage": 103, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" } ] } ] }, { "description": "Other Major Cardiovascular Procedures with CC", "code_information": [ { "code": "271", "type": "LOCAL" } ], "standard_charges": [ { "setting": "inpatient", "payers_information": [ { "payer_name": "Blue Cross Blue Shield of Montana", "plan_name": "Medicare Advantage", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "United Healthcare (UHC)", "plan_name": "Medicare Advantage", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "First Choice of the Midwest", "plan_name": "PPO", "standard_charge_percentage": 90, "methodology": "percent of total billed charges", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "United Healthcare (UHC)", "plan_name": "DSNP", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Employee Benefit Management Services (EBMS)", "plan_name": "EBMS SelectCare Network", "standard_charge_percentage": 80, "methodology": "percent of total billed charges", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Claritev fka MultiPlan", "plan_name": "PPO", "standard_charge_percentage": 75, "methodology": "percent of total billed charges", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Allegiance Provider Direct", "plan_name": "Medicare", "standard_charge_percentage": 229.99999999999997, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Medicare (CMS)", "plan_name": "Medicare", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Medica Insurance Company", "plan_name": "Medicare Cost", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "First Choice Health Network fka Health InfoNet", "plan_name": "Commercial", "standard_charge_percentage": 85, "methodology": "percent of total billed charges", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Indian Health Services (IHS)", "plan_name": "Commercial", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "First Choice Health Network fka Health InfoNet", "plan_name": "Workers Compensation", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Humana Insurance Company", "plan_name": "Humana Medicare Advantage HMO", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Humana Insurance Company", "plan_name": "Humana Medicare Advantage PPO", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Humana Insurance Company", "plan_name": "Humana Medicare Advantage PFFS", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Allegiance Provider Direct", "plan_name": "State of Montana Employee Benefit Plan (Self-Funded)", "standard_charge_percentage": 229.99999999999997, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Allegiance Provider Direct", "plan_name": "Montana Municipal Interlocal Authority (MMIA)", "standard_charge_percentage": 229.99999999999997, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Allegiance Provider Direct", "plan_name": "Montana Association of Counties (MACo)", "standard_charge_percentage": 229.99999999999997, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "First Choice Health Network fka Health InfoNet", "plan_name": "Medicare Advantage", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "TriWest Healthcare Alliance Corporation", "plan_name": "TRICARE Prime", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "TriWest Healthcare Alliance Corporation", "plan_name": "TRICARE Select", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Blue Cross Blue Shield of Montana", "plan_name": "HealthLink Network", "standard_charge_percentage": 75, "methodology": "percent of total billed charges", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Blue Cross Blue Shield of Montana", "plan_name": "Traditional Network", "standard_charge_percentage": 75, "methodology": "percent of total billed charges", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Blue Cross Blue Shield of Montana", "plan_name": "POS Network", "standard_charge_percentage": 75, "methodology": "percent of total billed charges", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Blue Cross Blue Shield of Montana", "plan_name": "Closed Plan Network", "standard_charge_percentage": 75, "methodology": "percent of total billed charges", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Blue Cross Blue Shield of Montana", "plan_name": "Retail HMO POS Network", "standard_charge_percentage": 75, "methodology": "percent of total billed charges", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Blue Cross Blue Shield of Montana", "plan_name": "Blue Options Network", "standard_charge_percentage": 75, "methodology": "percent of total billed charges", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "PacificSource Health Plans", "plan_name": "Medicare Advantage", "standard_charge_percentage": 103, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" } ] } ] }, { "description": "Other Major Cardiovascular Procedures without CC/MCC", "code_information": [ { "code": "272", "type": "LOCAL" } ], "standard_charges": [ { "setting": "inpatient", "payers_information": [ { "payer_name": "Blue Cross Blue Shield of Montana", "plan_name": "Medicare Advantage", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "United Healthcare (UHC)", "plan_name": "Medicare Advantage", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "First Choice of the Midwest", "plan_name": "PPO", "standard_charge_percentage": 90, "methodology": "percent of total billed charges", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "United Healthcare (UHC)", "plan_name": "DSNP", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Employee Benefit Management Services (EBMS)", "plan_name": "EBMS SelectCare Network", "standard_charge_percentage": 80, "methodology": "percent of total billed charges", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Claritev fka MultiPlan", "plan_name": "PPO", "standard_charge_percentage": 75, "methodology": "percent of total billed charges", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Allegiance Provider Direct", "plan_name": "Medicare", "standard_charge_percentage": 229.99999999999997, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Medicare (CMS)", "plan_name": "Medicare", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Medica Insurance Company", "plan_name": "Medicare Cost", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "First Choice Health Network fka Health InfoNet", "plan_name": "Commercial", "standard_charge_percentage": 85, "methodology": "percent of total billed charges", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Indian Health Services (IHS)", "plan_name": "Commercial", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "First Choice Health Network fka Health InfoNet", "plan_name": "Workers Compensation", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Humana Insurance Company", "plan_name": "Humana Medicare Advantage HMO", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Humana Insurance Company", "plan_name": "Humana Medicare Advantage PPO", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Humana Insurance Company", "plan_name": "Humana Medicare Advantage PFFS", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Allegiance Provider Direct", "plan_name": "State of Montana Employee Benefit Plan (Self-Funded)", "standard_charge_percentage": 229.99999999999997, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Allegiance Provider Direct", "plan_name": "Montana Municipal Interlocal Authority (MMIA)", "standard_charge_percentage": 229.99999999999997, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Allegiance Provider Direct", "plan_name": "Montana Association of Counties (MACo)", "standard_charge_percentage": 229.99999999999997, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "First Choice Health Network fka Health InfoNet", "plan_name": "Medicare Advantage", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "TriWest Healthcare Alliance Corporation", "plan_name": "TRICARE Prime", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "TriWest Healthcare Alliance Corporation", "plan_name": "TRICARE Select", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Blue Cross Blue Shield of Montana", "plan_name": "HealthLink Network", "standard_charge_percentage": 75, "methodology": "percent of total billed charges", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Blue Cross Blue Shield of Montana", "plan_name": "Traditional Network", "standard_charge_percentage": 75, "methodology": "percent of total billed charges", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Blue Cross Blue Shield of Montana", "plan_name": "POS Network", "standard_charge_percentage": 75, "methodology": "percent of total billed charges", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Blue Cross Blue Shield of Montana", "plan_name": "Closed Plan Network", "standard_charge_percentage": 75, "methodology": "percent of total billed charges", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Blue Cross Blue Shield of Montana", "plan_name": "Retail HMO POS Network", "standard_charge_percentage": 75, "methodology": "percent of total billed charges", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Blue Cross Blue Shield of Montana", "plan_name": "Blue Options Network", "standard_charge_percentage": 75, "methodology": "percent of total billed charges", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "PacificSource Health Plans", "plan_name": "Medicare Advantage", "standard_charge_percentage": 103, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" } ] } ] }, { "description": "Percutaneous and Other Intracardiac Procedures with MCC", "code_information": [ { "code": "273", "type": "LOCAL" } ], "standard_charges": [ { "setting": "inpatient", "payers_information": [ { "payer_name": "Blue Cross Blue Shield of Montana", "plan_name": "Medicare Advantage", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "United Healthcare (UHC)", "plan_name": "Medicare Advantage", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "First Choice of the Midwest", "plan_name": "PPO", "standard_charge_percentage": 90, "methodology": "percent of total billed charges", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "United Healthcare (UHC)", "plan_name": "DSNP", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Employee Benefit Management Services (EBMS)", "plan_name": "EBMS SelectCare Network", "standard_charge_percentage": 80, "methodology": "percent of total billed charges", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Claritev fka MultiPlan", "plan_name": "PPO", "standard_charge_percentage": 75, "methodology": "percent of total billed charges", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Allegiance Provider Direct", "plan_name": "Medicare", "standard_charge_percentage": 229.99999999999997, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Medicare (CMS)", "plan_name": "Medicare", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Medica Insurance Company", "plan_name": "Medicare Cost", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "First Choice Health Network fka Health InfoNet", "plan_name": "Commercial", "standard_charge_percentage": 85, "methodology": "percent of total billed charges", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Indian Health Services (IHS)", "plan_name": "Commercial", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "First Choice Health Network fka Health InfoNet", "plan_name": "Workers Compensation", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Humana Insurance Company", "plan_name": "Humana Medicare Advantage HMO", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Humana Insurance Company", "plan_name": "Humana Medicare Advantage PPO", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Humana Insurance Company", "plan_name": "Humana Medicare Advantage PFFS", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Allegiance Provider Direct", "plan_name": "State of Montana Employee Benefit Plan (Self-Funded)", "standard_charge_percentage": 229.99999999999997, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Allegiance Provider Direct", "plan_name": "Montana Municipal Interlocal Authority (MMIA)", "standard_charge_percentage": 229.99999999999997, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Allegiance Provider Direct", "plan_name": "Montana Association of Counties (MACo)", "standard_charge_percentage": 229.99999999999997, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "First Choice Health Network fka Health InfoNet", "plan_name": "Medicare Advantage", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "TriWest Healthcare Alliance Corporation", "plan_name": "TRICARE Prime", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "TriWest Healthcare Alliance Corporation", "plan_name": "TRICARE Select", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Blue Cross Blue Shield of Montana", "plan_name": "HealthLink Network", "standard_charge_percentage": 75, "methodology": "percent of total billed charges", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Blue Cross Blue Shield of Montana", "plan_name": "Traditional Network", "standard_charge_percentage": 75, "methodology": "percent of total billed charges", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Blue Cross Blue Shield of Montana", "plan_name": "POS Network", "standard_charge_percentage": 75, "methodology": "percent of total billed charges", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Blue Cross Blue Shield of Montana", "plan_name": "Closed Plan Network", "standard_charge_percentage": 75, "methodology": "percent of total billed charges", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Blue Cross Blue Shield of Montana", "plan_name": "Retail HMO POS Network", "standard_charge_percentage": 75, "methodology": "percent of total billed charges", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Blue Cross Blue Shield of Montana", "plan_name": "Blue Options Network", "standard_charge_percentage": 75, "methodology": "percent of total billed charges", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "PacificSource Health Plans", "plan_name": "Medicare Advantage", "standard_charge_percentage": 103, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" } ] } ] }, { "description": "Percutaneous and Other Intracardiac Procedures without MCC", "code_information": [ { "code": "274", "type": "LOCAL" } ], "standard_charges": [ { "setting": "inpatient", "payers_information": [ { "payer_name": "Blue Cross Blue Shield of Montana", "plan_name": "Medicare Advantage", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "United Healthcare (UHC)", "plan_name": "Medicare Advantage", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "First Choice of the Midwest", "plan_name": "PPO", "standard_charge_percentage": 90, "methodology": "percent of total billed charges", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "United Healthcare (UHC)", "plan_name": "DSNP", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Employee Benefit Management Services (EBMS)", "plan_name": "EBMS SelectCare Network", "standard_charge_percentage": 80, "methodology": "percent of total billed charges", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Claritev fka MultiPlan", "plan_name": "PPO", "standard_charge_percentage": 75, "methodology": "percent of total billed charges", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Allegiance Provider Direct", "plan_name": "Medicare", "standard_charge_percentage": 229.99999999999997, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Medicare (CMS)", "plan_name": "Medicare", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Medica Insurance Company", "plan_name": "Medicare Cost", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "First Choice Health Network fka Health InfoNet", "plan_name": "Commercial", "standard_charge_percentage": 85, "methodology": "percent of total billed charges", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Indian Health Services (IHS)", "plan_name": "Commercial", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "First Choice Health Network fka Health InfoNet", "plan_name": "Workers Compensation", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Humana Insurance Company", "plan_name": "Humana Medicare Advantage HMO", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Humana Insurance Company", "plan_name": "Humana Medicare Advantage PPO", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Humana Insurance Company", "plan_name": "Humana Medicare Advantage PFFS", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Allegiance Provider Direct", "plan_name": "State of Montana Employee Benefit Plan (Self-Funded)", "standard_charge_percentage": 229.99999999999997, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Allegiance Provider Direct", "plan_name": "Montana Municipal Interlocal Authority (MMIA)", "standard_charge_percentage": 229.99999999999997, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Allegiance Provider Direct", "plan_name": "Montana Association of Counties (MACo)", "standard_charge_percentage": 229.99999999999997, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "First Choice Health Network fka Health InfoNet", "plan_name": "Medicare Advantage", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "TriWest Healthcare Alliance Corporation", "plan_name": "TRICARE Prime", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "TriWest Healthcare Alliance Corporation", "plan_name": "TRICARE Select", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Blue Cross Blue Shield of Montana", "plan_name": "HealthLink Network", "standard_charge_percentage": 75, "methodology": "percent of total billed charges", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Blue Cross Blue Shield of Montana", "plan_name": "Traditional Network", "standard_charge_percentage": 75, "methodology": "percent of total billed charges", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Blue Cross Blue Shield of Montana", "plan_name": "POS Network", "standard_charge_percentage": 75, "methodology": "percent of total billed charges", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Blue Cross Blue Shield of Montana", "plan_name": "Closed Plan Network", "standard_charge_percentage": 75, "methodology": "percent of total billed charges", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Blue Cross Blue Shield of Montana", "plan_name": "Retail HMO POS Network", "standard_charge_percentage": 75, "methodology": "percent of total billed charges", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Blue Cross Blue Shield of Montana", "plan_name": "Blue Options Network", "standard_charge_percentage": 75, "methodology": "percent of total billed charges", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "PacificSource Health Plans", "plan_name": "Medicare Advantage", "standard_charge_percentage": 103, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" } ] } ] }, { "description": "Cardiac Defibrillator Implant with Cardiac Catheterization and MCC", "code_information": [ { "code": "275", "type": "LOCAL" } ], "standard_charges": [ { "setting": "inpatient", "payers_information": [ { "payer_name": "Blue Cross Blue Shield of Montana", "plan_name": "Medicare Advantage", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "United Healthcare (UHC)", "plan_name": "Medicare Advantage", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "First Choice of the Midwest", "plan_name": "PPO", "standard_charge_percentage": 90, "methodology": "percent of total billed charges", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "United Healthcare (UHC)", "plan_name": "DSNP", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Employee Benefit Management Services (EBMS)", "plan_name": "EBMS SelectCare Network", "standard_charge_percentage": 80, "methodology": "percent of total billed charges", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Claritev fka MultiPlan", "plan_name": "PPO", "standard_charge_percentage": 75, "methodology": "percent of total billed charges", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Allegiance Provider Direct", "plan_name": "Medicare", "standard_charge_percentage": 229.99999999999997, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Medicare (CMS)", "plan_name": "Medicare", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Medica Insurance Company", "plan_name": "Medicare Cost", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "First Choice Health Network fka Health InfoNet", "plan_name": "Commercial", "standard_charge_percentage": 85, "methodology": "percent of total billed charges", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Indian Health Services (IHS)", "plan_name": "Commercial", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "First Choice Health Network fka Health InfoNet", "plan_name": "Workers Compensation", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Humana Insurance Company", "plan_name": "Humana Medicare Advantage HMO", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Humana Insurance Company", "plan_name": "Humana Medicare Advantage PPO", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Humana Insurance Company", "plan_name": "Humana Medicare Advantage PFFS", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Allegiance Provider Direct", "plan_name": "State of Montana Employee Benefit Plan (Self-Funded)", "standard_charge_percentage": 229.99999999999997, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Allegiance Provider Direct", "plan_name": "Montana Municipal Interlocal Authority (MMIA)", "standard_charge_percentage": 229.99999999999997, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Allegiance Provider Direct", "plan_name": "Montana Association of Counties (MACo)", "standard_charge_percentage": 229.99999999999997, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "First Choice Health Network fka Health InfoNet", "plan_name": "Medicare Advantage", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "TriWest Healthcare Alliance Corporation", "plan_name": "TRICARE Prime", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "TriWest Healthcare Alliance Corporation", "plan_name": "TRICARE Select", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Blue Cross Blue Shield of Montana", "plan_name": "HealthLink Network", "standard_charge_percentage": 75, "methodology": "percent of total billed charges", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Blue Cross Blue Shield of Montana", "plan_name": "Traditional Network", "standard_charge_percentage": 75, "methodology": "percent of total billed charges", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Blue Cross Blue Shield of Montana", "plan_name": "POS Network", "standard_charge_percentage": 75, "methodology": "percent of total billed charges", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Blue Cross Blue Shield of Montana", "plan_name": "Closed Plan Network", "standard_charge_percentage": 75, "methodology": "percent of total billed charges", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Blue Cross Blue Shield of Montana", "plan_name": "Retail HMO POS Network", "standard_charge_percentage": 75, "methodology": "percent of total billed charges", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Blue Cross Blue Shield of Montana", "plan_name": "Blue Options Network", "standard_charge_percentage": 75, "methodology": "percent of total billed charges", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "PacificSource Health Plans", "plan_name": "Medicare Advantage", "standard_charge_percentage": 103, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" } ] } ] }, { "description": "Cardiac Defibrillator Implant with MCC or Carotid Sinus Neurostimulator", "code_information": [ { "code": "276", "type": "LOCAL" } ], "standard_charges": [ { "setting": "inpatient", "payers_information": [ { "payer_name": "Blue Cross Blue Shield of Montana", "plan_name": "Medicare Advantage", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "United Healthcare (UHC)", "plan_name": "Medicare Advantage", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "First Choice of the Midwest", "plan_name": "PPO", "standard_charge_percentage": 90, "methodology": "percent of total billed charges", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "United Healthcare (UHC)", "plan_name": "DSNP", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Employee Benefit Management Services (EBMS)", "plan_name": "EBMS SelectCare Network", "standard_charge_percentage": 80, "methodology": "percent of total billed charges", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Claritev fka MultiPlan", "plan_name": "PPO", "standard_charge_percentage": 75, "methodology": "percent of total billed charges", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Allegiance Provider Direct", "plan_name": "Medicare", "standard_charge_percentage": 229.99999999999997, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Medicare (CMS)", "plan_name": "Medicare", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Medica Insurance Company", "plan_name": "Medicare Cost", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "First Choice Health Network fka Health InfoNet", "plan_name": "Commercial", "standard_charge_percentage": 85, "methodology": "percent of total billed charges", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Indian Health Services (IHS)", "plan_name": "Commercial", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "First Choice Health Network fka Health InfoNet", "plan_name": "Workers Compensation", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Humana Insurance Company", "plan_name": "Humana Medicare Advantage HMO", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Humana Insurance Company", "plan_name": "Humana Medicare Advantage PPO", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Humana Insurance Company", "plan_name": "Humana Medicare Advantage PFFS", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Allegiance Provider Direct", "plan_name": "State of Montana Employee Benefit Plan (Self-Funded)", "standard_charge_percentage": 229.99999999999997, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Allegiance Provider Direct", "plan_name": "Montana Municipal Interlocal Authority (MMIA)", "standard_charge_percentage": 229.99999999999997, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Allegiance Provider Direct", "plan_name": "Montana Association of Counties (MACo)", "standard_charge_percentage": 229.99999999999997, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "First Choice Health Network fka Health InfoNet", "plan_name": "Medicare Advantage", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "TriWest Healthcare Alliance Corporation", "plan_name": "TRICARE Prime", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "TriWest Healthcare Alliance Corporation", "plan_name": "TRICARE Select", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Blue Cross Blue Shield of Montana", "plan_name": "HealthLink Network", "standard_charge_percentage": 75, "methodology": "percent of total billed charges", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Blue Cross Blue Shield of Montana", "plan_name": "Traditional Network", "standard_charge_percentage": 75, "methodology": "percent of total billed charges", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Blue Cross Blue Shield of Montana", "plan_name": "POS Network", "standard_charge_percentage": 75, "methodology": "percent of total billed charges", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Blue Cross Blue Shield of Montana", "plan_name": "Closed Plan Network", "standard_charge_percentage": 75, "methodology": "percent of total billed charges", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Blue Cross Blue Shield of Montana", "plan_name": "Retail HMO POS Network", "standard_charge_percentage": 75, "methodology": "percent of total billed charges", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Blue Cross Blue Shield of Montana", "plan_name": "Blue Options Network", "standard_charge_percentage": 75, "methodology": "percent of total billed charges", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "PacificSource Health Plans", "plan_name": "Medicare Advantage", "standard_charge_percentage": 103, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" } ] } ] }, { "description": "Chronic Obstructive Pulmonary Disease with CC*", "code_information": [ { "code": "191", "type": "LOCAL" } ], "standard_charges": [ { "setting": "inpatient", "payers_information": [ { "payer_name": "Blue Cross Blue Shield of Montana", "plan_name": "Medicare Advantage", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "United Healthcare (UHC)", "plan_name": "Medicare Advantage", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "First Choice of the Midwest", "plan_name": "PPO", "standard_charge_percentage": 90, "methodology": "percent of total billed charges", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "United Healthcare (UHC)", "plan_name": "DSNP", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Employee Benefit Management Services (EBMS)", "plan_name": "EBMS SelectCare Network", "standard_charge_percentage": 80, "methodology": "percent of total billed charges", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Claritev fka MultiPlan", "plan_name": "PPO", "standard_charge_percentage": 75, "methodology": "percent of total billed charges", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Allegiance Provider Direct", "plan_name": "Medicare", "standard_charge_percentage": 229.99999999999997, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Medicare (CMS)", "plan_name": "Medicare", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Medica Insurance Company", "plan_name": "Medicare Cost", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Indian Health Services (IHS)", "plan_name": "Commercial", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Humana Insurance Company", "plan_name": "Humana Medicare Advantage HMO", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Humana Insurance Company", "plan_name": "Humana Medicare Advantage PPO", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Humana Insurance Company", "plan_name": "Humana Medicare Advantage PFFS", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "First Choice Health Network fka Health InfoNet", "plan_name": "Commercial", "standard_charge_percentage": 85, "methodology": "percent of total billed charges", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "First Choice Health Network fka Health InfoNet", "plan_name": "Workers Compensation", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Allegiance Provider Direct", "plan_name": "State of Montana Employee Benefit Plan (Self-Funded)", "standard_charge_percentage": 229.99999999999997, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Allegiance Provider Direct", "plan_name": "Montana Municipal Interlocal Authority (MMIA)", "standard_charge_percentage": 229.99999999999997, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Allegiance Provider Direct", "plan_name": "Montana Association of Counties (MACo)", "standard_charge_percentage": 229.99999999999997, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "First Choice Health Network fka Health InfoNet", "plan_name": "Medicare Advantage", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "TriWest Healthcare Alliance Corporation", "plan_name": "TRICARE Prime", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "TriWest Healthcare Alliance Corporation", "plan_name": "TRICARE Select", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Blue Cross Blue Shield of Montana", "plan_name": "HealthLink Network", "standard_charge_percentage": 75, "methodology": "percent of total billed charges", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Blue Cross Blue Shield of Montana", "plan_name": "Traditional Network", "standard_charge_percentage": 75, "methodology": "percent of total billed charges", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Blue Cross Blue Shield of Montana", "plan_name": "POS Network", "standard_charge_percentage": 75, "methodology": "percent of total billed charges", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Blue Cross Blue Shield of Montana", "plan_name": "Closed Plan Network", "standard_charge_percentage": 75, "methodology": "percent of total billed charges", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Blue Cross Blue Shield of Montana", "plan_name": "Retail HMO POS Network", "standard_charge_percentage": 75, "methodology": "percent of total billed charges", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Blue Cross Blue Shield of Montana", "plan_name": "Blue Options Network", "standard_charge_percentage": 75, "methodology": "percent of total billed charges", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "PacificSource Health Plans", "plan_name": "Medicare Advantage", "standard_charge_percentage": 103, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" } ] } ] }, { "description": "Chronic Obstructive Pulmonary Disease without CC/MCC*", "code_information": [ { "code": "192", "type": "LOCAL" } ], "standard_charges": [ { "setting": "inpatient", "payers_information": [ { "payer_name": "Blue Cross Blue Shield of Montana", "plan_name": "Medicare Advantage", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "United Healthcare (UHC)", "plan_name": "Medicare Advantage", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "First Choice of the Midwest", "plan_name": "PPO", "standard_charge_percentage": 90, "methodology": "percent of total billed charges", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "United Healthcare (UHC)", "plan_name": "DSNP", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Employee Benefit Management Services (EBMS)", "plan_name": "EBMS SelectCare Network", "standard_charge_percentage": 80, "methodology": "percent of total billed charges", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Claritev fka MultiPlan", "plan_name": "PPO", "standard_charge_percentage": 75, "methodology": "percent of total billed charges", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Allegiance Provider Direct", "plan_name": "Medicare", "standard_charge_percentage": 229.99999999999997, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Medicare (CMS)", "plan_name": "Medicare", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Medica Insurance Company", "plan_name": "Medicare Cost", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Indian Health Services (IHS)", "plan_name": "Commercial", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Humana Insurance Company", "plan_name": "Humana Medicare Advantage HMO", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Humana Insurance Company", "plan_name": "Humana Medicare Advantage PPO", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Humana Insurance Company", "plan_name": "Humana Medicare Advantage PFFS", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "First Choice Health Network fka Health InfoNet", "plan_name": "Commercial", "standard_charge_percentage": 85, "methodology": "percent of total billed charges", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "First Choice Health Network fka Health InfoNet", "plan_name": "Workers Compensation", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Allegiance Provider Direct", "plan_name": "State of Montana Employee Benefit Plan (Self-Funded)", "standard_charge_percentage": 229.99999999999997, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Allegiance Provider Direct", "plan_name": "Montana Municipal Interlocal Authority (MMIA)", "standard_charge_percentage": 229.99999999999997, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Allegiance Provider Direct", "plan_name": "Montana Association of Counties (MACo)", "standard_charge_percentage": 229.99999999999997, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "First Choice Health Network fka Health InfoNet", "plan_name": "Medicare Advantage", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "TriWest Healthcare Alliance Corporation", "plan_name": "TRICARE Prime", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "TriWest Healthcare Alliance Corporation", "plan_name": "TRICARE Select", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Blue Cross Blue Shield of Montana", "plan_name": "HealthLink Network", "standard_charge_percentage": 75, "methodology": "percent of total billed charges", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Blue Cross Blue Shield of Montana", "plan_name": "Traditional Network", "standard_charge_percentage": 75, "methodology": "percent of total billed charges", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Blue Cross Blue Shield of Montana", "plan_name": "POS Network", "standard_charge_percentage": 75, "methodology": "percent of total billed charges", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Blue Cross Blue Shield of Montana", "plan_name": "Closed Plan Network", "standard_charge_percentage": 75, "methodology": "percent of total billed charges", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Blue Cross Blue Shield of Montana", "plan_name": "Retail HMO POS Network", "standard_charge_percentage": 75, "methodology": "percent of total billed charges", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Blue Cross Blue Shield of Montana", "plan_name": "Blue Options Network", "standard_charge_percentage": 75, "methodology": "percent of total billed charges", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "PacificSource Health Plans", "plan_name": "Medicare Advantage", "standard_charge_percentage": 103, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" } ] } ] }, { "description": "Simple Pneumonia and Pleurisy with MCC*", "code_information": [ { "code": "193", "type": "LOCAL" } ], "standard_charges": [ { "setting": "inpatient", "payers_information": [ { "payer_name": "Blue Cross Blue Shield of Montana", "plan_name": "Medicare Advantage", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "United Healthcare (UHC)", "plan_name": "Medicare Advantage", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "First Choice of the Midwest", "plan_name": "PPO", "standard_charge_percentage": 90, "methodology": "percent of total billed charges", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "United Healthcare (UHC)", "plan_name": "DSNP", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Employee Benefit Management Services (EBMS)", "plan_name": "EBMS SelectCare Network", "standard_charge_percentage": 80, "methodology": "percent of total billed charges", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Claritev fka MultiPlan", "plan_name": "PPO", "standard_charge_percentage": 75, "methodology": "percent of total billed charges", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Allegiance Provider Direct", "plan_name": "Medicare", "standard_charge_percentage": 229.99999999999997, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Medicare (CMS)", "plan_name": "Medicare", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Medica Insurance Company", "plan_name": "Medicare Cost", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Indian Health Services (IHS)", "plan_name": "Commercial", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Humana Insurance Company", "plan_name": "Humana Medicare Advantage HMO", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Humana Insurance Company", "plan_name": "Humana Medicare Advantage PPO", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Humana Insurance Company", "plan_name": "Humana Medicare Advantage PFFS", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "First Choice Health Network fka Health InfoNet", "plan_name": "Commercial", "standard_charge_percentage": 85, "methodology": "percent of total billed charges", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "First Choice Health Network fka Health InfoNet", "plan_name": "Workers Compensation", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Allegiance Provider Direct", "plan_name": "State of Montana Employee Benefit Plan (Self-Funded)", "standard_charge_percentage": 229.99999999999997, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Allegiance Provider Direct", "plan_name": "Montana Municipal Interlocal Authority (MMIA)", "standard_charge_percentage": 229.99999999999997, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Allegiance Provider Direct", "plan_name": "Montana Association of Counties (MACo)", "standard_charge_percentage": 229.99999999999997, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "First Choice Health Network fka Health InfoNet", "plan_name": "Medicare Advantage", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "TriWest Healthcare Alliance Corporation", "plan_name": "TRICARE Prime", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "TriWest Healthcare Alliance Corporation", "plan_name": "TRICARE Select", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Blue Cross Blue Shield of Montana", "plan_name": "HealthLink Network", "standard_charge_percentage": 75, "methodology": "percent of total billed charges", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Blue Cross Blue Shield of Montana", "plan_name": "Traditional Network", "standard_charge_percentage": 75, "methodology": "percent of total billed charges", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Blue Cross Blue Shield of Montana", "plan_name": "POS Network", "standard_charge_percentage": 75, "methodology": "percent of total billed charges", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Blue Cross Blue Shield of Montana", "plan_name": "Closed Plan Network", "standard_charge_percentage": 75, "methodology": "percent of total billed charges", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Blue Cross Blue Shield of Montana", "plan_name": "Retail HMO POS Network", "standard_charge_percentage": 75, "methodology": "percent of total billed charges", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Blue Cross Blue Shield of Montana", "plan_name": "Blue Options Network", "standard_charge_percentage": 75, "methodology": "percent of total billed charges", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "PacificSource Health Plans", "plan_name": "Medicare Advantage", "standard_charge_percentage": 103, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" } ] } ] }, { "description": "Simple Pneumonia and Pleurisy with CC*", "code_information": [ { "code": "194", "type": "LOCAL" } ], "standard_charges": [ { "setting": "inpatient", "payers_information": [ { "payer_name": "Blue Cross Blue Shield of Montana", "plan_name": "Medicare Advantage", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "United Healthcare (UHC)", "plan_name": "Medicare Advantage", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "First Choice of the Midwest", "plan_name": "PPO", "standard_charge_percentage": 90, "methodology": "percent of total billed charges", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "United Healthcare (UHC)", "plan_name": "DSNP", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Employee Benefit Management Services (EBMS)", "plan_name": "EBMS SelectCare Network", "standard_charge_percentage": 80, "methodology": "percent of total billed charges", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Claritev fka MultiPlan", "plan_name": "PPO", "standard_charge_percentage": 75, "methodology": "percent of total billed charges", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Allegiance Provider Direct", "plan_name": "Medicare", "standard_charge_percentage": 229.99999999999997, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Medicare (CMS)", "plan_name": "Medicare", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Medica Insurance Company", "plan_name": "Medicare Cost", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Indian Health Services (IHS)", "plan_name": "Commercial", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Humana Insurance Company", "plan_name": "Humana Medicare Advantage HMO", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Humana Insurance Company", "plan_name": "Humana Medicare Advantage PPO", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Humana Insurance Company", "plan_name": "Humana Medicare Advantage PFFS", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "First Choice Health Network fka Health InfoNet", "plan_name": "Commercial", "standard_charge_percentage": 85, "methodology": "percent of total billed charges", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "First Choice Health Network fka Health InfoNet", "plan_name": "Workers Compensation", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Allegiance Provider Direct", "plan_name": "State of Montana Employee Benefit Plan (Self-Funded)", "standard_charge_percentage": 229.99999999999997, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Allegiance Provider Direct", "plan_name": "Montana Municipal Interlocal Authority (MMIA)", "standard_charge_percentage": 229.99999999999997, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Allegiance Provider Direct", "plan_name": "Montana Association of Counties (MACo)", "standard_charge_percentage": 229.99999999999997, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "First Choice Health Network fka Health InfoNet", "plan_name": "Medicare Advantage", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "TriWest Healthcare Alliance Corporation", "plan_name": "TRICARE Prime", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "TriWest Healthcare Alliance Corporation", "plan_name": "TRICARE Select", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Blue Cross Blue Shield of Montana", "plan_name": "HealthLink Network", "standard_charge_percentage": 75, "methodology": "percent of total billed charges", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Blue Cross Blue Shield of Montana", "plan_name": "Traditional Network", "standard_charge_percentage": 75, "methodology": "percent of total billed charges", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Blue Cross Blue Shield of Montana", "plan_name": "POS Network", "standard_charge_percentage": 75, "methodology": "percent of total billed charges", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Blue Cross Blue Shield of Montana", "plan_name": "Closed Plan Network", "standard_charge_percentage": 75, "methodology": "percent of total billed charges", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Blue Cross Blue Shield of Montana", "plan_name": "Retail HMO POS Network", "standard_charge_percentage": 75, "methodology": "percent of total billed charges", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Blue Cross Blue Shield of Montana", "plan_name": "Blue Options Network", "standard_charge_percentage": 75, "methodology": "percent of total billed charges", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "PacificSource Health Plans", "plan_name": "Medicare Advantage", "standard_charge_percentage": 103, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" } ] } ] }, { "description": "Simple Pneumonia and Pleurisy without CC/MCC*", "code_information": [ { "code": "195", "type": "LOCAL" } ], "standard_charges": [ { "setting": "inpatient", "payers_information": [ { "payer_name": "Blue Cross Blue Shield of Montana", "plan_name": "Medicare Advantage", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "United Healthcare (UHC)", "plan_name": "Medicare Advantage", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "First Choice of the Midwest", "plan_name": "PPO", "standard_charge_percentage": 90, "methodology": "percent of total billed charges", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "United Healthcare (UHC)", "plan_name": "DSNP", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Employee Benefit Management Services (EBMS)", "plan_name": "EBMS SelectCare Network", "standard_charge_percentage": 80, "methodology": "percent of total billed charges", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Claritev fka MultiPlan", "plan_name": "PPO", "standard_charge_percentage": 75, "methodology": "percent of total billed charges", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Allegiance Provider Direct", "plan_name": "Medicare", "standard_charge_percentage": 229.99999999999997, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Medicare (CMS)", "plan_name": "Medicare", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Medica Insurance Company", "plan_name": "Medicare Cost", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Indian Health Services (IHS)", "plan_name": "Commercial", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Humana Insurance Company", "plan_name": "Humana Medicare Advantage HMO", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Humana Insurance Company", "plan_name": "Humana Medicare Advantage PPO", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Humana Insurance Company", "plan_name": "Humana Medicare Advantage PFFS", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "First Choice Health Network fka Health InfoNet", "plan_name": "Commercial", "standard_charge_percentage": 85, "methodology": "percent of total billed charges", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "First Choice Health Network fka Health InfoNet", "plan_name": "Workers Compensation", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Allegiance Provider Direct", "plan_name": "State of Montana Employee Benefit Plan (Self-Funded)", "standard_charge_percentage": 229.99999999999997, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Allegiance Provider Direct", "plan_name": "Montana Municipal Interlocal Authority (MMIA)", "standard_charge_percentage": 229.99999999999997, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Allegiance Provider Direct", "plan_name": "Montana Association of Counties (MACo)", "standard_charge_percentage": 229.99999999999997, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "First Choice Health Network fka Health InfoNet", "plan_name": "Medicare Advantage", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "TriWest Healthcare Alliance Corporation", "plan_name": "TRICARE Prime", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "TriWest Healthcare Alliance Corporation", "plan_name": "TRICARE Select", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Blue Cross Blue Shield of Montana", "plan_name": "HealthLink Network", "standard_charge_percentage": 75, "methodology": "percent of total billed charges", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Blue Cross Blue Shield of Montana", "plan_name": "Traditional Network", "standard_charge_percentage": 75, "methodology": "percent of total billed charges", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Blue Cross Blue Shield of Montana", "plan_name": "POS Network", "standard_charge_percentage": 75, "methodology": "percent of total billed charges", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Blue Cross Blue Shield of Montana", "plan_name": "Closed Plan Network", "standard_charge_percentage": 75, "methodology": "percent of total billed charges", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Blue Cross Blue Shield of Montana", "plan_name": "Retail HMO POS Network", "standard_charge_percentage": 75, "methodology": "percent of total billed charges", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Blue Cross Blue Shield of Montana", "plan_name": "Blue Options Network", "standard_charge_percentage": 75, "methodology": "percent of total billed charges", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "PacificSource Health Plans", "plan_name": "Medicare Advantage", "standard_charge_percentage": 103, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" } ] } ] }, { "description": "Interstitial Lung Disease with MCC", "code_information": [ { "code": "196", "type": "LOCAL" } ], "standard_charges": [ { "setting": "inpatient", "payers_information": [ { "payer_name": "Blue Cross Blue Shield of Montana", "plan_name": "Medicare Advantage", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "United Healthcare (UHC)", "plan_name": "Medicare Advantage", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "First Choice of the Midwest", "plan_name": "PPO", "standard_charge_percentage": 90, "methodology": "percent of total billed charges", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "United Healthcare (UHC)", "plan_name": "DSNP", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Employee Benefit Management Services (EBMS)", "plan_name": "EBMS SelectCare Network", "standard_charge_percentage": 80, "methodology": "percent of total billed charges", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Claritev fka MultiPlan", "plan_name": "PPO", "standard_charge_percentage": 75, "methodology": "percent of total billed charges", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Allegiance Provider Direct", "plan_name": "Medicare", "standard_charge_percentage": 229.99999999999997, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Medicare (CMS)", "plan_name": "Medicare", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Medica Insurance Company", "plan_name": "Medicare Cost", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Indian Health Services (IHS)", "plan_name": "Commercial", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Humana Insurance Company", "plan_name": "Humana Medicare Advantage HMO", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Humana Insurance Company", "plan_name": "Humana Medicare Advantage PPO", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Humana Insurance Company", "plan_name": "Humana Medicare Advantage PFFS", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "First Choice Health Network fka Health InfoNet", "plan_name": "Commercial", "standard_charge_percentage": 85, "methodology": "percent of total billed charges", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "First Choice Health Network fka Health InfoNet", "plan_name": "Workers Compensation", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Allegiance Provider Direct", "plan_name": "State of Montana Employee Benefit Plan (Self-Funded)", "standard_charge_percentage": 229.99999999999997, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Allegiance Provider Direct", "plan_name": "Montana Municipal Interlocal Authority (MMIA)", "standard_charge_percentage": 229.99999999999997, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Allegiance Provider Direct", "plan_name": "Montana Association of Counties (MACo)", "standard_charge_percentage": 229.99999999999997, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "First Choice Health Network fka Health InfoNet", "plan_name": "Medicare Advantage", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "TriWest Healthcare Alliance Corporation", "plan_name": "TRICARE Prime", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "TriWest Healthcare Alliance Corporation", "plan_name": "TRICARE Select", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Blue Cross Blue Shield of Montana", "plan_name": "HealthLink Network", "standard_charge_percentage": 75, "methodology": "percent of total billed charges", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Blue Cross Blue Shield of Montana", "plan_name": "Traditional Network", "standard_charge_percentage": 75, "methodology": "percent of total billed charges", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Blue Cross Blue Shield of Montana", "plan_name": "POS Network", "standard_charge_percentage": 75, "methodology": "percent of total billed charges", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Blue Cross Blue Shield of Montana", "plan_name": "Closed Plan Network", "standard_charge_percentage": 75, "methodology": "percent of total billed charges", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Blue Cross Blue Shield of Montana", "plan_name": "Retail HMO POS Network", "standard_charge_percentage": 75, "methodology": "percent of total billed charges", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Blue Cross Blue Shield of Montana", "plan_name": "Blue Options Network", "standard_charge_percentage": 75, "methodology": "percent of total billed charges", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "PacificSource Health Plans", "plan_name": "Medicare Advantage", "standard_charge_percentage": 103, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" } ] } ] }, { "description": "Interstitial Lung Disease with CC", "code_information": [ { "code": "197", "type": "LOCAL" } ], "standard_charges": [ { "setting": "inpatient", "payers_information": [ { "payer_name": "Blue Cross Blue Shield of Montana", "plan_name": "Medicare Advantage", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "United Healthcare (UHC)", "plan_name": "Medicare Advantage", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "First Choice of the Midwest", "plan_name": "PPO", "standard_charge_percentage": 90, "methodology": "percent of total billed charges", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "United Healthcare (UHC)", "plan_name": "DSNP", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Employee Benefit Management Services (EBMS)", "plan_name": "EBMS SelectCare Network", "standard_charge_percentage": 80, "methodology": "percent of total billed charges", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Claritev fka MultiPlan", "plan_name": "PPO", "standard_charge_percentage": 75, "methodology": "percent of total billed charges", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Allegiance Provider Direct", "plan_name": "Medicare", "standard_charge_percentage": 229.99999999999997, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Medicare (CMS)", "plan_name": "Medicare", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Medica Insurance Company", "plan_name": "Medicare Cost", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Indian Health Services (IHS)", "plan_name": "Commercial", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Humana Insurance Company", "plan_name": "Humana Medicare Advantage HMO", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Humana Insurance Company", "plan_name": "Humana Medicare Advantage PPO", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Humana Insurance Company", "plan_name": "Humana Medicare Advantage PFFS", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "First Choice Health Network fka Health InfoNet", "plan_name": "Commercial", "standard_charge_percentage": 85, "methodology": "percent of total billed charges", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "First Choice Health Network fka Health InfoNet", "plan_name": "Workers Compensation", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Allegiance Provider Direct", "plan_name": "State of Montana Employee Benefit Plan (Self-Funded)", "standard_charge_percentage": 229.99999999999997, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Allegiance Provider Direct", "plan_name": "Montana Municipal Interlocal Authority (MMIA)", "standard_charge_percentage": 229.99999999999997, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Allegiance Provider Direct", "plan_name": "Montana Association of Counties (MACo)", "standard_charge_percentage": 229.99999999999997, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "First Choice Health Network fka Health InfoNet", "plan_name": "Medicare Advantage", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "TriWest Healthcare Alliance Corporation", "plan_name": "TRICARE Prime", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "TriWest Healthcare Alliance Corporation", "plan_name": "TRICARE Select", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Blue Cross Blue Shield of Montana", "plan_name": "HealthLink Network", "standard_charge_percentage": 75, "methodology": "percent of total billed charges", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Blue Cross Blue Shield of Montana", "plan_name": "Traditional Network", "standard_charge_percentage": 75, "methodology": "percent of total billed charges", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Blue Cross Blue Shield of Montana", "plan_name": "POS Network", "standard_charge_percentage": 75, "methodology": "percent of total billed charges", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Blue Cross Blue Shield of Montana", "plan_name": "Closed Plan Network", "standard_charge_percentage": 75, "methodology": "percent of total billed charges", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Blue Cross Blue Shield of Montana", "plan_name": "Retail HMO POS Network", "standard_charge_percentage": 75, "methodology": "percent of total billed charges", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Blue Cross Blue Shield of Montana", "plan_name": "Blue Options Network", "standard_charge_percentage": 75, "methodology": "percent of total billed charges", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "PacificSource Health Plans", "plan_name": "Medicare Advantage", "standard_charge_percentage": 103, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" } ] } ] }, { "description": "Interstitial Lung Disease without CC/MCC", "code_information": [ { "code": "198", "type": "LOCAL" } ], "standard_charges": [ { "setting": "inpatient", "payers_information": [ { "payer_name": "Blue Cross Blue Shield of Montana", "plan_name": "Medicare Advantage", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "United Healthcare (UHC)", "plan_name": "Medicare Advantage", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "First Choice of the Midwest", "plan_name": "PPO", "standard_charge_percentage": 90, "methodology": "percent of total billed charges", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "United Healthcare (UHC)", "plan_name": "DSNP", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Employee Benefit Management Services (EBMS)", "plan_name": "EBMS SelectCare Network", "standard_charge_percentage": 80, "methodology": "percent of total billed charges", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Claritev fka MultiPlan", "plan_name": "PPO", "standard_charge_percentage": 75, "methodology": "percent of total billed charges", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Allegiance Provider Direct", "plan_name": "Medicare", "standard_charge_percentage": 229.99999999999997, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Medicare (CMS)", "plan_name": "Medicare", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Medica Insurance Company", "plan_name": "Medicare Cost", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Indian Health Services (IHS)", "plan_name": "Commercial", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Humana Insurance Company", "plan_name": "Humana Medicare Advantage HMO", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Humana Insurance Company", "plan_name": "Humana Medicare Advantage PPO", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Humana Insurance Company", "plan_name": "Humana Medicare Advantage PFFS", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "First Choice Health Network fka Health InfoNet", "plan_name": "Commercial", "standard_charge_percentage": 85, "methodology": "percent of total billed charges", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "First Choice Health Network fka Health InfoNet", "plan_name": "Workers Compensation", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Allegiance Provider Direct", "plan_name": "State of Montana Employee Benefit Plan (Self-Funded)", "standard_charge_percentage": 229.99999999999997, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Allegiance Provider Direct", "plan_name": "Montana Municipal Interlocal Authority (MMIA)", "standard_charge_percentage": 229.99999999999997, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Allegiance Provider Direct", "plan_name": "Montana Association of Counties (MACo)", "standard_charge_percentage": 229.99999999999997, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "First Choice Health Network fka Health InfoNet", "plan_name": "Medicare Advantage", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "TriWest Healthcare Alliance Corporation", "plan_name": "TRICARE Prime", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "TriWest Healthcare Alliance Corporation", "plan_name": "TRICARE Select", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Blue Cross Blue Shield of Montana", "plan_name": "HealthLink Network", "standard_charge_percentage": 75, "methodology": "percent of total billed charges", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Blue Cross Blue Shield of Montana", "plan_name": "Traditional Network", "standard_charge_percentage": 75, "methodology": "percent of total billed charges", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Blue Cross Blue Shield of Montana", "plan_name": "POS Network", "standard_charge_percentage": 75, "methodology": "percent of total billed charges", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Blue Cross Blue Shield of Montana", "plan_name": "Closed Plan Network", "standard_charge_percentage": 75, "methodology": "percent of total billed charges", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Blue Cross Blue Shield of Montana", "plan_name": "Retail HMO POS Network", "standard_charge_percentage": 75, "methodology": "percent of total billed charges", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Blue Cross Blue Shield of Montana", "plan_name": "Blue Options Network", "standard_charge_percentage": 75, "methodology": "percent of total billed charges", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "PacificSource Health Plans", "plan_name": "Medicare Advantage", "standard_charge_percentage": 103, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" } ] } ] }, { "description": "Pneumothorax with MCC", "code_information": [ { "code": "199", "type": "LOCAL" } ], "standard_charges": [ { "setting": "inpatient", "payers_information": [ { "payer_name": "Blue Cross Blue Shield of Montana", "plan_name": "Medicare Advantage", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "United Healthcare (UHC)", "plan_name": "Medicare Advantage", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "First Choice of the Midwest", "plan_name": "PPO", "standard_charge_percentage": 90, "methodology": "percent of total billed charges", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "United Healthcare (UHC)", "plan_name": "DSNP", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Employee Benefit Management Services (EBMS)", "plan_name": "EBMS SelectCare Network", "standard_charge_percentage": 80, "methodology": "percent of total billed charges", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Claritev fka MultiPlan", "plan_name": "PPO", "standard_charge_percentage": 75, "methodology": "percent of total billed charges", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Allegiance Provider Direct", "plan_name": "Medicare", "standard_charge_percentage": 229.99999999999997, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Medicare (CMS)", "plan_name": "Medicare", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Medica Insurance Company", "plan_name": "Medicare Cost", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Indian Health Services (IHS)", "plan_name": "Commercial", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Humana Insurance Company", "plan_name": "Humana Medicare Advantage HMO", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Humana Insurance Company", "plan_name": "Humana Medicare Advantage PPO", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Humana Insurance Company", "plan_name": "Humana Medicare Advantage PFFS", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "First Choice Health Network fka Health InfoNet", "plan_name": "Commercial", "standard_charge_percentage": 85, "methodology": "percent of total billed charges", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "First Choice Health Network fka Health InfoNet", "plan_name": "Workers Compensation", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Allegiance Provider Direct", "plan_name": "State of Montana Employee Benefit Plan (Self-Funded)", "standard_charge_percentage": 229.99999999999997, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Allegiance Provider Direct", "plan_name": "Montana Municipal Interlocal Authority (MMIA)", "standard_charge_percentage": 229.99999999999997, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Allegiance Provider Direct", "plan_name": "Montana Association of Counties (MACo)", "standard_charge_percentage": 229.99999999999997, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "First Choice Health Network fka Health InfoNet", "plan_name": "Medicare Advantage", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "TriWest Healthcare Alliance Corporation", "plan_name": "TRICARE Prime", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "TriWest Healthcare Alliance Corporation", "plan_name": "TRICARE Select", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Blue Cross Blue Shield of Montana", "plan_name": "HealthLink Network", "standard_charge_percentage": 75, "methodology": "percent of total billed charges", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Blue Cross Blue Shield of Montana", "plan_name": "Traditional Network", "standard_charge_percentage": 75, "methodology": "percent of total billed charges", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Blue Cross Blue Shield of Montana", "plan_name": "POS Network", "standard_charge_percentage": 75, "methodology": "percent of total billed charges", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Blue Cross Blue Shield of Montana", "plan_name": "Closed Plan Network", "standard_charge_percentage": 75, "methodology": "percent of total billed charges", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Blue Cross Blue Shield of Montana", "plan_name": "Retail HMO POS Network", "standard_charge_percentage": 75, "methodology": "percent of total billed charges", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Blue Cross Blue Shield of Montana", "plan_name": "Blue Options Network", "standard_charge_percentage": 75, "methodology": "percent of total billed charges", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "PacificSource Health Plans", "plan_name": "Medicare Advantage", "standard_charge_percentage": 103, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" } ] } ] }, { "description": "Pneumothorax with CC", "code_information": [ { "code": "200", "type": "LOCAL" } ], "standard_charges": [ { "setting": "inpatient", "payers_information": [ { "payer_name": "Blue Cross Blue Shield of Montana", "plan_name": "Medicare Advantage", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "United Healthcare (UHC)", "plan_name": "Medicare Advantage", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "First Choice of the Midwest", "plan_name": "PPO", "standard_charge_percentage": 90, "methodology": "percent of total billed charges", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "United Healthcare (UHC)", "plan_name": "DSNP", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Employee Benefit Management Services (EBMS)", "plan_name": "EBMS SelectCare Network", "standard_charge_percentage": 80, "methodology": "percent of total billed charges", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Claritev fka MultiPlan", "plan_name": "PPO", "standard_charge_percentage": 75, "methodology": "percent of total billed charges", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Allegiance Provider Direct", "plan_name": "Medicare", "standard_charge_percentage": 229.99999999999997, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Medicare (CMS)", "plan_name": "Medicare", "standard_charge_percentage": 100, "methodology": "fee schedule", "median_amount": 15139.39, "10th_percentile": 15139.39, "90th_percentile": 15139.39, "count": "1 through 10" }, { "payer_name": "Medica Insurance Company", "plan_name": "Medicare Cost", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Indian Health Services (IHS)", "plan_name": "Commercial", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Humana Insurance Company", "plan_name": "Humana Medicare Advantage HMO", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Humana Insurance Company", "plan_name": "Humana Medicare Advantage PPO", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Humana Insurance Company", "plan_name": "Humana Medicare Advantage PFFS", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "First Choice Health Network fka Health InfoNet", "plan_name": "Commercial", "standard_charge_percentage": 85, "methodology": "percent of total billed charges", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "First Choice Health Network fka Health InfoNet", "plan_name": "Workers Compensation", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Allegiance Provider Direct", "plan_name": "State of Montana Employee Benefit Plan (Self-Funded)", "standard_charge_percentage": 229.99999999999997, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Allegiance Provider Direct", "plan_name": "Montana Municipal Interlocal Authority (MMIA)", "standard_charge_percentage": 229.99999999999997, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Allegiance Provider Direct", "plan_name": "Montana Association of Counties (MACo)", "standard_charge_percentage": 229.99999999999997, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "First Choice Health Network fka Health InfoNet", "plan_name": "Medicare Advantage", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "TriWest Healthcare Alliance Corporation", "plan_name": "TRICARE Prime", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "TriWest Healthcare Alliance Corporation", "plan_name": "TRICARE Select", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Blue Cross Blue Shield of Montana", "plan_name": "HealthLink Network", "standard_charge_percentage": 75, "methodology": "percent of total billed charges", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Blue Cross Blue Shield of Montana", "plan_name": "Traditional Network", "standard_charge_percentage": 75, "methodology": "percent of total billed charges", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Blue Cross Blue Shield of Montana", "plan_name": "POS Network", "standard_charge_percentage": 75, "methodology": "percent of total billed charges", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Blue Cross Blue Shield of Montana", "plan_name": "Closed Plan Network", "standard_charge_percentage": 75, "methodology": "percent of total billed charges", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Blue Cross Blue Shield of Montana", "plan_name": "Retail HMO POS Network", "standard_charge_percentage": 75, "methodology": "percent of total billed charges", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Blue Cross Blue Shield of Montana", "plan_name": "Blue Options Network", "standard_charge_percentage": 75, "methodology": "percent of total billed charges", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "PacificSource Health Plans", "plan_name": "Medicare Advantage", "standard_charge_percentage": 103, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" } ], "minimum": 15139.39, "maximum": 15139.39 } ] }, { "description": "Pneumothorax without CC/MCC", "code_information": [ { "code": "201", "type": "LOCAL" } ], "standard_charges": [ { "setting": "inpatient", "payers_information": [ { "payer_name": "Blue Cross Blue Shield of Montana", "plan_name": "Medicare Advantage", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "United Healthcare (UHC)", "plan_name": "Medicare Advantage", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "First Choice of the Midwest", "plan_name": "PPO", "standard_charge_percentage": 90, "methodology": "percent of total billed charges", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "United Healthcare (UHC)", "plan_name": "DSNP", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Employee Benefit Management Services (EBMS)", "plan_name": "EBMS SelectCare Network", "standard_charge_percentage": 80, "methodology": "percent of total billed charges", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Claritev fka MultiPlan", "plan_name": "PPO", "standard_charge_percentage": 75, "methodology": "percent of total billed charges", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Allegiance Provider Direct", "plan_name": "Medicare", "standard_charge_percentage": 229.99999999999997, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Medicare (CMS)", "plan_name": "Medicare", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Medica Insurance Company", "plan_name": "Medicare Cost", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Indian Health Services (IHS)", "plan_name": "Commercial", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Humana Insurance Company", "plan_name": "Humana Medicare Advantage HMO", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Humana Insurance Company", "plan_name": "Humana Medicare Advantage PPO", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Humana Insurance Company", "plan_name": "Humana Medicare Advantage PFFS", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "First Choice Health Network fka Health InfoNet", "plan_name": "Commercial", "standard_charge_percentage": 85, "methodology": "percent of total billed charges", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "First Choice Health Network fka Health InfoNet", "plan_name": "Workers Compensation", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Allegiance Provider Direct", "plan_name": "State of Montana Employee Benefit Plan (Self-Funded)", "standard_charge_percentage": 229.99999999999997, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Allegiance Provider Direct", "plan_name": "Montana Municipal Interlocal Authority (MMIA)", "standard_charge_percentage": 229.99999999999997, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Allegiance Provider Direct", "plan_name": "Montana Association of Counties (MACo)", "standard_charge_percentage": 229.99999999999997, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "First Choice Health Network fka Health InfoNet", "plan_name": "Medicare Advantage", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "TriWest Healthcare Alliance Corporation", "plan_name": "TRICARE Prime", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "TriWest Healthcare Alliance Corporation", "plan_name": "TRICARE Select", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Blue Cross Blue Shield of Montana", "plan_name": "HealthLink Network", "standard_charge_percentage": 75, "methodology": "percent of total billed charges", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Blue Cross Blue Shield of Montana", "plan_name": "Traditional Network", "standard_charge_percentage": 75, "methodology": "percent of total billed charges", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Blue Cross Blue Shield of Montana", "plan_name": "POS Network", "standard_charge_percentage": 75, "methodology": "percent of total billed charges", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Blue Cross Blue Shield of Montana", "plan_name": "Closed Plan Network", "standard_charge_percentage": 75, "methodology": "percent of total billed charges", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Blue Cross Blue Shield of Montana", "plan_name": "Retail HMO POS Network", "standard_charge_percentage": 75, "methodology": "percent of total billed charges", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Blue Cross Blue Shield of Montana", "plan_name": "Blue Options Network", "standard_charge_percentage": 75, "methodology": "percent of total billed charges", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "PacificSource Health Plans", "plan_name": "Medicare Advantage", "standard_charge_percentage": 103, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" } ] } ] }, { "description": "Bronchitis and Asthma with CC/MCC", "code_information": [ { "code": "202", "type": "LOCAL" } ], "standard_charges": [ { "setting": "inpatient", "payers_information": [ { "payer_name": "Blue Cross Blue Shield of Montana", "plan_name": "Medicare Advantage", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "United Healthcare (UHC)", "plan_name": "Medicare Advantage", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "First Choice of the Midwest", "plan_name": "PPO", "standard_charge_percentage": 90, "methodology": "percent of total billed charges", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "United Healthcare (UHC)", "plan_name": "DSNP", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Employee Benefit Management Services (EBMS)", "plan_name": "EBMS SelectCare Network", "standard_charge_percentage": 80, "methodology": "percent of total billed charges", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Claritev fka MultiPlan", "plan_name": "PPO", "standard_charge_percentage": 75, "methodology": "percent of total billed charges", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Allegiance Provider Direct", "plan_name": "Medicare", "standard_charge_percentage": 229.99999999999997, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Medicare (CMS)", "plan_name": "Medicare", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Medica Insurance Company", "plan_name": "Medicare Cost", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Indian Health Services (IHS)", "plan_name": "Commercial", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Humana Insurance Company", "plan_name": "Humana Medicare Advantage HMO", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Humana Insurance Company", "plan_name": "Humana Medicare Advantage PPO", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Humana Insurance Company", "plan_name": "Humana Medicare Advantage PFFS", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "First Choice Health Network fka Health InfoNet", "plan_name": "Commercial", "standard_charge_percentage": 85, "methodology": "percent of total billed charges", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "First Choice Health Network fka Health InfoNet", "plan_name": "Workers Compensation", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Allegiance Provider Direct", "plan_name": "State of Montana Employee Benefit Plan (Self-Funded)", "standard_charge_percentage": 229.99999999999997, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Allegiance Provider Direct", "plan_name": "Montana Municipal Interlocal Authority (MMIA)", "standard_charge_percentage": 229.99999999999997, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Allegiance Provider Direct", "plan_name": "Montana Association of Counties (MACo)", "standard_charge_percentage": 229.99999999999997, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "First Choice Health Network fka Health InfoNet", "plan_name": "Medicare Advantage", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "TriWest Healthcare Alliance Corporation", "plan_name": "TRICARE Prime", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "TriWest Healthcare Alliance Corporation", "plan_name": "TRICARE Select", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Blue Cross Blue Shield of Montana", "plan_name": "HealthLink Network", "standard_charge_percentage": 75, "methodology": "percent of total billed charges", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Blue Cross Blue Shield of Montana", "plan_name": "Traditional Network", "standard_charge_percentage": 75, "methodology": "percent of total billed charges", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Blue Cross Blue Shield of Montana", "plan_name": "POS Network", "standard_charge_percentage": 75, "methodology": "percent of total billed charges", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Blue Cross Blue Shield of Montana", "plan_name": "Closed Plan Network", "standard_charge_percentage": 75, "methodology": "percent of total billed charges", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Blue Cross Blue Shield of Montana", "plan_name": "Retail HMO POS Network", "standard_charge_percentage": 75, "methodology": "percent of total billed charges", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Blue Cross Blue Shield of Montana", "plan_name": "Blue Options Network", "standard_charge_percentage": 75, "methodology": "percent of total billed charges", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "PacificSource Health Plans", "plan_name": "Medicare Advantage", "standard_charge_percentage": 103, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" } ] } ] }, { "description": "Bronchitis and Asthma without CC/MCC", "code_information": [ { "code": "203", "type": "LOCAL" } ], "standard_charges": [ { "setting": "inpatient", "payers_information": [ { "payer_name": "Blue Cross Blue Shield of Montana", "plan_name": "Medicare Advantage", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "United Healthcare (UHC)", "plan_name": "Medicare Advantage", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "First Choice of the Midwest", "plan_name": "PPO", "standard_charge_percentage": 90, "methodology": "percent of total billed charges", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "United Healthcare (UHC)", "plan_name": "DSNP", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Employee Benefit Management Services (EBMS)", "plan_name": "EBMS SelectCare Network", "standard_charge_percentage": 80, "methodology": "percent of total billed charges", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Claritev fka MultiPlan", "plan_name": "PPO", "standard_charge_percentage": 75, "methodology": "percent of total billed charges", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Allegiance Provider Direct", "plan_name": "Medicare", "standard_charge_percentage": 229.99999999999997, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Medicare (CMS)", "plan_name": "Medicare", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Medica Insurance Company", "plan_name": "Medicare Cost", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Indian Health Services (IHS)", "plan_name": "Commercial", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Humana Insurance Company", "plan_name": "Humana Medicare Advantage HMO", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Humana Insurance Company", "plan_name": "Humana Medicare Advantage PPO", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Humana Insurance Company", "plan_name": "Humana Medicare Advantage PFFS", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "First Choice Health Network fka Health InfoNet", "plan_name": "Commercial", "standard_charge_percentage": 85, "methodology": "percent of total billed charges", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "First Choice Health Network fka Health InfoNet", "plan_name": "Workers Compensation", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Allegiance Provider Direct", "plan_name": "State of Montana Employee Benefit Plan (Self-Funded)", "standard_charge_percentage": 229.99999999999997, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Allegiance Provider Direct", "plan_name": "Montana Municipal Interlocal Authority (MMIA)", "standard_charge_percentage": 229.99999999999997, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Allegiance Provider Direct", "plan_name": "Montana Association of Counties (MACo)", "standard_charge_percentage": 229.99999999999997, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "First Choice Health Network fka Health InfoNet", "plan_name": "Medicare Advantage", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "TriWest Healthcare Alliance Corporation", "plan_name": "TRICARE Prime", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "TriWest Healthcare Alliance Corporation", "plan_name": "TRICARE Select", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Blue Cross Blue Shield of Montana", "plan_name": "HealthLink Network", "standard_charge_percentage": 75, "methodology": "percent of total billed charges", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Blue Cross Blue Shield of Montana", "plan_name": "Traditional Network", "standard_charge_percentage": 75, "methodology": "percent of total billed charges", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Blue Cross Blue Shield of Montana", "plan_name": "POS Network", "standard_charge_percentage": 75, "methodology": "percent of total billed charges", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Blue Cross Blue Shield of Montana", "plan_name": "Closed Plan Network", "standard_charge_percentage": 75, "methodology": "percent of total billed charges", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Blue Cross Blue Shield of Montana", "plan_name": "Retail HMO POS Network", "standard_charge_percentage": 75, "methodology": "percent of total billed charges", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Blue Cross Blue Shield of Montana", "plan_name": "Blue Options Network", "standard_charge_percentage": 75, "methodology": "percent of total billed charges", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "PacificSource Health Plans", "plan_name": "Medicare Advantage", "standard_charge_percentage": 103, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" } ] } ] }, { "description": "Respiratory Signs and Symptoms", "code_information": [ { "code": "204", "type": "LOCAL" } ], "standard_charges": [ { "setting": "inpatient", "payers_information": [ { "payer_name": "Blue Cross Blue Shield of Montana", "plan_name": "Medicare Advantage", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "United Healthcare (UHC)", "plan_name": "Medicare Advantage", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "First Choice of the Midwest", "plan_name": "PPO", "standard_charge_percentage": 90, "methodology": "percent of total billed charges", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "United Healthcare (UHC)", "plan_name": "DSNP", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Employee Benefit Management Services (EBMS)", "plan_name": "EBMS SelectCare Network", "standard_charge_percentage": 80, "methodology": "percent of total billed charges", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Claritev fka MultiPlan", "plan_name": "PPO", "standard_charge_percentage": 75, "methodology": "percent of total billed charges", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Allegiance Provider Direct", "plan_name": "Medicare", "standard_charge_percentage": 229.99999999999997, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Medicare (CMS)", "plan_name": "Medicare", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Medica Insurance Company", "plan_name": "Medicare Cost", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Indian Health Services (IHS)", "plan_name": "Commercial", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Humana Insurance Company", "plan_name": "Humana Medicare Advantage HMO", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Humana Insurance Company", "plan_name": "Humana Medicare Advantage PPO", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Humana Insurance Company", "plan_name": "Humana Medicare Advantage PFFS", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "First Choice Health Network fka Health InfoNet", "plan_name": "Commercial", "standard_charge_percentage": 85, "methodology": "percent of total billed charges", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "First Choice Health Network fka Health InfoNet", "plan_name": "Workers Compensation", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Allegiance Provider Direct", "plan_name": "State of Montana Employee Benefit Plan (Self-Funded)", "standard_charge_percentage": 229.99999999999997, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Allegiance Provider Direct", "plan_name": "Montana Municipal Interlocal Authority (MMIA)", "standard_charge_percentage": 229.99999999999997, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Allegiance Provider Direct", "plan_name": "Montana Association of Counties (MACo)", "standard_charge_percentage": 229.99999999999997, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "First Choice Health Network fka Health InfoNet", "plan_name": "Medicare Advantage", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "TriWest Healthcare Alliance Corporation", "plan_name": "TRICARE Prime", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "TriWest Healthcare Alliance Corporation", "plan_name": "TRICARE Select", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Blue Cross Blue Shield of Montana", "plan_name": "HealthLink Network", "standard_charge_percentage": 75, "methodology": "percent of total billed charges", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Blue Cross Blue Shield of Montana", "plan_name": "Traditional Network", "standard_charge_percentage": 75, "methodology": "percent of total billed charges", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Blue Cross Blue Shield of Montana", "plan_name": "POS Network", "standard_charge_percentage": 75, "methodology": "percent of total billed charges", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Blue Cross Blue Shield of Montana", "plan_name": "Closed Plan Network", "standard_charge_percentage": 75, "methodology": "percent of total billed charges", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Blue Cross Blue Shield of Montana", "plan_name": "Retail HMO POS Network", "standard_charge_percentage": 75, "methodology": "percent of total billed charges", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Blue Cross Blue Shield of Montana", "plan_name": "Blue Options Network", "standard_charge_percentage": 75, "methodology": "percent of total billed charges", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "PacificSource Health Plans", "plan_name": "Medicare Advantage", "standard_charge_percentage": 103, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" } ] } ] }, { "description": "Other Respiratory System Diagnoses with MCC", "code_information": [ { "code": "205", "type": "LOCAL" } ], "standard_charges": [ { "setting": "inpatient", "payers_information": [ { "payer_name": "Blue Cross Blue Shield of Montana", "plan_name": "Medicare Advantage", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "United Healthcare (UHC)", "plan_name": "Medicare Advantage", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "First Choice of the Midwest", "plan_name": "PPO", "standard_charge_percentage": 90, "methodology": "percent of total billed charges", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "United Healthcare (UHC)", "plan_name": "DSNP", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Employee Benefit Management Services (EBMS)", "plan_name": "EBMS SelectCare Network", "standard_charge_percentage": 80, "methodology": "percent of total billed charges", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Claritev fka MultiPlan", "plan_name": "PPO", "standard_charge_percentage": 75, "methodology": "percent of total billed charges", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Allegiance Provider Direct", "plan_name": "Medicare", "standard_charge_percentage": 229.99999999999997, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Medicare (CMS)", "plan_name": "Medicare", "standard_charge_percentage": 100, "methodology": "fee schedule", "median_amount": 68495.84, "10th_percentile": 68495.84, "90th_percentile": 68495.84, "count": "1 through 10" }, { "payer_name": "Medica Insurance Company", "plan_name": "Medicare Cost", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Indian Health Services (IHS)", "plan_name": "Commercial", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Humana Insurance Company", "plan_name": "Humana Medicare Advantage HMO", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Humana Insurance Company", "plan_name": "Humana Medicare Advantage PPO", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Humana Insurance Company", "plan_name": "Humana Medicare Advantage PFFS", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "First Choice Health Network fka Health InfoNet", "plan_name": "Commercial", "standard_charge_percentage": 85, "methodology": "percent of total billed charges", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "First Choice Health Network fka Health InfoNet", "plan_name": "Workers Compensation", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Allegiance Provider Direct", "plan_name": "State of Montana Employee Benefit Plan (Self-Funded)", "standard_charge_percentage": 229.99999999999997, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Allegiance Provider Direct", "plan_name": "Montana Municipal Interlocal Authority (MMIA)", "standard_charge_percentage": 229.99999999999997, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Allegiance Provider Direct", "plan_name": "Montana Association of Counties (MACo)", "standard_charge_percentage": 229.99999999999997, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "First Choice Health Network fka Health InfoNet", "plan_name": "Medicare Advantage", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "TriWest Healthcare Alliance Corporation", "plan_name": "TRICARE Prime", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "TriWest Healthcare Alliance Corporation", "plan_name": "TRICARE Select", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Blue Cross Blue Shield of Montana", "plan_name": "HealthLink Network", "standard_charge_percentage": 75, "methodology": "percent of total billed charges", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Blue Cross Blue Shield of Montana", "plan_name": "Traditional Network", "standard_charge_percentage": 75, "methodology": "percent of total billed charges", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Blue Cross Blue Shield of Montana", "plan_name": "POS Network", "standard_charge_percentage": 75, "methodology": "percent of total billed charges", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Blue Cross Blue Shield of Montana", "plan_name": "Closed Plan Network", "standard_charge_percentage": 75, "methodology": "percent of total billed charges", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Blue Cross Blue Shield of Montana", "plan_name": "Retail HMO POS Network", "standard_charge_percentage": 75, "methodology": "percent of total billed charges", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Blue Cross Blue Shield of Montana", "plan_name": "Blue Options Network", "standard_charge_percentage": 75, "methodology": "percent of total billed charges", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "PacificSource Health Plans", "plan_name": "Medicare Advantage", "standard_charge_percentage": 103, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" } ], "minimum": 68495.84, "maximum": 68495.84 } ] }, { "description": "Other Respiratory System Diagnoses without MCC", "code_information": [ { "code": "206", "type": "LOCAL" } ], "standard_charges": [ { "setting": "inpatient", "payers_information": [ { "payer_name": "Blue Cross Blue Shield of Montana", "plan_name": "Medicare Advantage", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "United Healthcare (UHC)", "plan_name": "Medicare Advantage", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "First Choice of the Midwest", "plan_name": "PPO", "standard_charge_percentage": 90, "methodology": "percent of total billed charges", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "United Healthcare (UHC)", "plan_name": "DSNP", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Employee Benefit Management Services (EBMS)", "plan_name": "EBMS SelectCare Network", "standard_charge_percentage": 80, "methodology": "percent of total billed charges", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Claritev fka MultiPlan", "plan_name": "PPO", "standard_charge_percentage": 75, "methodology": "percent of total billed charges", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Allegiance Provider Direct", "plan_name": "Medicare", "standard_charge_percentage": 229.99999999999997, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Medicare (CMS)", "plan_name": "Medicare", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Medica Insurance Company", "plan_name": "Medicare Cost", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Indian Health Services (IHS)", "plan_name": "Commercial", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Humana Insurance Company", "plan_name": "Humana Medicare Advantage HMO", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Humana Insurance Company", "plan_name": "Humana Medicare Advantage PPO", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Humana Insurance Company", "plan_name": "Humana Medicare Advantage PFFS", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "First Choice Health Network fka Health InfoNet", "plan_name": "Commercial", "standard_charge_percentage": 85, "methodology": "percent of total billed charges", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "First Choice Health Network fka Health InfoNet", "plan_name": "Workers Compensation", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Allegiance Provider Direct", "plan_name": "State of Montana Employee Benefit Plan (Self-Funded)", "standard_charge_percentage": 229.99999999999997, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Allegiance Provider Direct", "plan_name": "Montana Municipal Interlocal Authority (MMIA)", "standard_charge_percentage": 229.99999999999997, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Allegiance Provider Direct", "plan_name": "Montana Association of Counties (MACo)", "standard_charge_percentage": 229.99999999999997, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "First Choice Health Network fka Health InfoNet", "plan_name": "Medicare Advantage", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "TriWest Healthcare Alliance Corporation", "plan_name": "TRICARE Prime", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "TriWest Healthcare Alliance Corporation", "plan_name": "TRICARE Select", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Blue Cross Blue Shield of Montana", "plan_name": "HealthLink Network", "standard_charge_percentage": 75, "methodology": "percent of total billed charges", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Blue Cross Blue Shield of Montana", "plan_name": "Traditional Network", "standard_charge_percentage": 75, "methodology": "percent of total billed charges", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Blue Cross Blue Shield of Montana", "plan_name": "POS Network", "standard_charge_percentage": 75, "methodology": "percent of total billed charges", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Blue Cross Blue Shield of Montana", "plan_name": "Closed Plan Network", "standard_charge_percentage": 75, "methodology": "percent of total billed charges", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Blue Cross Blue Shield of Montana", "plan_name": "Retail HMO POS Network", "standard_charge_percentage": 75, "methodology": "percent of total billed charges", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Blue Cross Blue Shield of Montana", "plan_name": "Blue Options Network", "standard_charge_percentage": 75, "methodology": "percent of total billed charges", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "PacificSource Health Plans", "plan_name": "Medicare Advantage", "standard_charge_percentage": 103, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" } ] } ] }, { "description": "Respiratory System Diagnosis with Ventilator Support >96 Hours", "code_information": [ { "code": "207", "type": "LOCAL" } ], "standard_charges": [ { "setting": "inpatient", "payers_information": [ { "payer_name": "Blue Cross Blue Shield of Montana", "plan_name": "Medicare Advantage", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "First Choice of the Midwest", "plan_name": "PPO", "standard_charge_percentage": 90, "methodology": "percent of total billed charges", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "United Healthcare (UHC)", "plan_name": "Medicare Advantage", "standard_charge_percentage": 100, "methodology": "fee schedule", "median_amount": 90258.74, "10th_percentile": 90258.74, "90th_percentile": 90258.74, "count": "1 through 10" }, { "payer_name": "United Healthcare (UHC)", "plan_name": "DSNP", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Employee Benefit Management Services (EBMS)", "plan_name": "EBMS SelectCare Network", "standard_charge_percentage": 80, "methodology": "percent of total billed charges", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Claritev fka MultiPlan", "plan_name": "PPO", "standard_charge_percentage": 75, "methodology": "percent of total billed charges", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Allegiance Provider Direct", "plan_name": "Medicare", "standard_charge_percentage": 229.99999999999997, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Medicare (CMS)", "plan_name": "Medicare", "standard_charge_percentage": 100, "methodology": "fee schedule", "median_amount": 90258.74, "10th_percentile": 27943.88, "90th_percentile": 96354.97, "count": "1 through 10" }, { "payer_name": "Medica Insurance Company", "plan_name": "Medicare Cost", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Indian Health Services (IHS)", "plan_name": "Commercial", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Humana Insurance Company", "plan_name": "Humana Medicare Advantage HMO", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Humana Insurance Company", "plan_name": "Humana Medicare Advantage PPO", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Humana Insurance Company", "plan_name": "Humana Medicare Advantage PFFS", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "First Choice Health Network fka Health InfoNet", "plan_name": "Commercial", "standard_charge_percentage": 85, "methodology": "percent of total billed charges", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "First Choice Health Network fka Health InfoNet", "plan_name": "Workers Compensation", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Allegiance Provider Direct", "plan_name": "State of Montana Employee Benefit Plan (Self-Funded)", "standard_charge_percentage": 229.99999999999997, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Allegiance Provider Direct", "plan_name": "Montana Municipal Interlocal Authority (MMIA)", "standard_charge_percentage": 229.99999999999997, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Allegiance Provider Direct", "plan_name": "Montana Association of Counties (MACo)", "standard_charge_percentage": 229.99999999999997, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "First Choice Health Network fka Health InfoNet", "plan_name": "Medicare Advantage", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "TriWest Healthcare Alliance Corporation", "plan_name": "TRICARE Prime", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "TriWest Healthcare Alliance Corporation", "plan_name": "TRICARE Select", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Blue Cross Blue Shield of Montana", "plan_name": "HealthLink Network", "standard_charge_percentage": 75, "methodology": "percent of total billed charges", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Blue Cross Blue Shield of Montana", "plan_name": "Traditional Network", "standard_charge_percentage": 75, "methodology": "percent of total billed charges", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Blue Cross Blue Shield of Montana", "plan_name": "POS Network", "standard_charge_percentage": 75, "methodology": "percent of total billed charges", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Blue Cross Blue Shield of Montana", "plan_name": "Closed Plan Network", "standard_charge_percentage": 75, "methodology": "percent of total billed charges", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Blue Cross Blue Shield of Montana", "plan_name": "Retail HMO POS Network", "standard_charge_percentage": 75, "methodology": "percent of total billed charges", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Blue Cross Blue Shield of Montana", "plan_name": "Blue Options Network", "standard_charge_percentage": 75, "methodology": "percent of total billed charges", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "PacificSource Health Plans", "plan_name": "Medicare Advantage", "standard_charge_percentage": 103, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" } ], "minimum": 90258.74, "maximum": 90258.74 } ] }, { "description": "Respiratory System Diagnosis with Ventilator Support <=96 Hours", "code_information": [ { "code": "208", "type": "LOCAL" } ], "standard_charges": [ { "setting": "inpatient", "payers_information": [ { "payer_name": "Blue Cross Blue Shield of Montana", "plan_name": "Medicare Advantage", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "First Choice of the Midwest", "plan_name": "PPO", "standard_charge_percentage": 90, "methodology": "percent of total billed charges", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "United Healthcare (UHC)", "plan_name": "Medicare Advantage", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "United Healthcare (UHC)", "plan_name": "DSNP", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Employee Benefit Management Services (EBMS)", "plan_name": "EBMS SelectCare Network", "standard_charge_percentage": 80, "methodology": "percent of total billed charges", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Claritev fka MultiPlan", "plan_name": "PPO", "standard_charge_percentage": 75, "methodology": "percent of total billed charges", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Allegiance Provider Direct", "plan_name": "Medicare", "standard_charge_percentage": 229.99999999999997, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Medicare (CMS)", "plan_name": "Medicare", "standard_charge_percentage": 100, "methodology": "fee schedule", "median_amount": 49785.83, "10th_percentile": 49785.83, "90th_percentile": 55247.4, "count": "1 through 10" }, { "payer_name": "Medica Insurance Company", "plan_name": "Medicare Cost", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Indian Health Services (IHS)", "plan_name": "Commercial", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Humana Insurance Company", "plan_name": "Humana Medicare Advantage HMO", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Humana Insurance Company", "plan_name": "Humana Medicare Advantage PPO", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Humana Insurance Company", "plan_name": "Humana Medicare Advantage PFFS", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "First Choice Health Network fka Health InfoNet", "plan_name": "Commercial", "standard_charge_percentage": 85, "methodology": "percent of total billed charges", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "First Choice Health Network fka Health InfoNet", "plan_name": "Workers Compensation", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Allegiance Provider Direct", "plan_name": "State of Montana Employee Benefit Plan (Self-Funded)", "standard_charge_percentage": 229.99999999999997, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Allegiance Provider Direct", "plan_name": "Montana Municipal Interlocal Authority (MMIA)", "standard_charge_percentage": 229.99999999999997, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Allegiance Provider Direct", "plan_name": "Montana Association of Counties (MACo)", "standard_charge_percentage": 229.99999999999997, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "First Choice Health Network fka Health InfoNet", "plan_name": "Medicare Advantage", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "TriWest Healthcare Alliance Corporation", "plan_name": "TRICARE Prime", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "TriWest Healthcare Alliance Corporation", "plan_name": "TRICARE Select", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Blue Cross Blue Shield of Montana", "plan_name": "HealthLink Network", "standard_charge_percentage": 75, "methodology": "percent of total billed charges", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Blue Cross Blue Shield of Montana", "plan_name": "Traditional Network", "standard_charge_percentage": 75, "methodology": "percent of total billed charges", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Blue Cross Blue Shield of Montana", "plan_name": "POS Network", "standard_charge_percentage": 75, "methodology": "percent of total billed charges", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Blue Cross Blue Shield of Montana", "plan_name": "Closed Plan Network", "standard_charge_percentage": 75, "methodology": "percent of total billed charges", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Blue Cross Blue Shield of Montana", "plan_name": "Retail HMO POS Network", "standard_charge_percentage": 75, "methodology": "percent of total billed charges", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Blue Cross Blue Shield of Montana", "plan_name": "Blue Options Network", "standard_charge_percentage": 75, "methodology": "percent of total billed charges", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "PacificSource Health Plans", "plan_name": "Medicare Advantage", "standard_charge_percentage": 103, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" } ], "minimum": 49785.83, "maximum": 49785.83 } ] }, { "description": "Complex Aortic Arch Procedures", "code_information": [ { "code": "209", "type": "LOCAL" } ], "standard_charges": [ { "setting": "inpatient", "payers_information": [ { "payer_name": "Blue Cross Blue Shield of Montana", "plan_name": "Medicare Advantage", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "First Choice of the Midwest", "plan_name": "PPO", "standard_charge_percentage": 90, "methodology": "percent of total billed charges", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "United Healthcare (UHC)", "plan_name": "Medicare Advantage", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "United Healthcare (UHC)", "plan_name": "DSNP", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Employee Benefit Management Services (EBMS)", "plan_name": "EBMS SelectCare Network", "standard_charge_percentage": 80, "methodology": "percent of total billed charges", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Claritev fka MultiPlan", "plan_name": "PPO", "standard_charge_percentage": 75, "methodology": "percent of total billed charges", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Allegiance Provider Direct", "plan_name": "Medicare", "standard_charge_percentage": 229.99999999999997, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Medicare (CMS)", "plan_name": "Medicare", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Medica Insurance Company", "plan_name": "Medicare Cost", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Indian Health Services (IHS)", "plan_name": "Commercial", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Humana Insurance Company", "plan_name": "Humana Medicare Advantage HMO", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Humana Insurance Company", "plan_name": "Humana Medicare Advantage PPO", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Humana Insurance Company", "plan_name": "Humana Medicare Advantage PFFS", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "First Choice Health Network fka Health InfoNet", "plan_name": "Commercial", "standard_charge_percentage": 85, "methodology": "percent of total billed charges", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "First Choice Health Network fka Health InfoNet", "plan_name": "Workers Compensation", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Allegiance Provider Direct", "plan_name": "State of Montana Employee Benefit Plan (Self-Funded)", "standard_charge_percentage": 229.99999999999997, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Allegiance Provider Direct", "plan_name": "Montana Municipal Interlocal Authority (MMIA)", "standard_charge_percentage": 229.99999999999997, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Allegiance Provider Direct", "plan_name": "Montana Association of Counties (MACo)", "standard_charge_percentage": 229.99999999999997, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "First Choice Health Network fka Health InfoNet", "plan_name": "Medicare Advantage", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "TriWest Healthcare Alliance Corporation", "plan_name": "TRICARE Prime", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "TriWest Healthcare Alliance Corporation", "plan_name": "TRICARE Select", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Blue Cross Blue Shield of Montana", "plan_name": "HealthLink Network", "standard_charge_percentage": 75, "methodology": "percent of total billed charges", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Blue Cross Blue Shield of Montana", "plan_name": "Traditional Network", "standard_charge_percentage": 75, "methodology": "percent of total billed charges", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Blue Cross Blue Shield of Montana", "plan_name": "POS Network", "standard_charge_percentage": 75, "methodology": "percent of total billed charges", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Blue Cross Blue Shield of Montana", "plan_name": "Closed Plan Network", "standard_charge_percentage": 75, "methodology": "percent of total billed charges", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Blue Cross Blue Shield of Montana", "plan_name": "Retail HMO POS Network", "standard_charge_percentage": 75, "methodology": "percent of total billed charges", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Blue Cross Blue Shield of Montana", "plan_name": "Blue Options Network", "standard_charge_percentage": 75, "methodology": "percent of total billed charges", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "PacificSource Health Plans", "plan_name": "Medicare Advantage", "standard_charge_percentage": 103, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" } ] } ] }, { "description": "Concomitant Aortic and Mitral Valve Procedures", "code_information": [ { "code": "212", "type": "LOCAL" } ], "standard_charges": [ { "setting": "inpatient", "payers_information": [ { "payer_name": "Blue Cross Blue Shield of Montana", "plan_name": "Medicare Advantage", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "First Choice of the Midwest", "plan_name": "PPO", "standard_charge_percentage": 90, "methodology": "percent of total billed charges", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "United Healthcare (UHC)", "plan_name": "Medicare Advantage", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "United Healthcare (UHC)", "plan_name": "DSNP", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Employee Benefit Management Services (EBMS)", "plan_name": "EBMS SelectCare Network", "standard_charge_percentage": 80, "methodology": "percent of total billed charges", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Claritev fka MultiPlan", "plan_name": "PPO", "standard_charge_percentage": 75, "methodology": "percent of total billed charges", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Allegiance Provider Direct", "plan_name": "Medicare", "standard_charge_percentage": 229.99999999999997, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Medicare (CMS)", "plan_name": "Medicare", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Medica Insurance Company", "plan_name": "Medicare Cost", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Indian Health Services (IHS)", "plan_name": "Commercial", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Humana Insurance Company", "plan_name": "Humana Medicare Advantage HMO", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Humana Insurance Company", "plan_name": "Humana Medicare Advantage PPO", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Humana Insurance Company", "plan_name": "Humana Medicare Advantage PFFS", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "First Choice Health Network fka Health InfoNet", "plan_name": "Commercial", "standard_charge_percentage": 85, "methodology": "percent of total billed charges", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "First Choice Health Network fka Health InfoNet", "plan_name": "Workers Compensation", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Allegiance Provider Direct", "plan_name": "State of Montana Employee Benefit Plan (Self-Funded)", "standard_charge_percentage": 229.99999999999997, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Allegiance Provider Direct", "plan_name": "Montana Municipal Interlocal Authority (MMIA)", "standard_charge_percentage": 229.99999999999997, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Allegiance Provider Direct", "plan_name": "Montana Association of Counties (MACo)", "standard_charge_percentage": 229.99999999999997, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "First Choice Health Network fka Health InfoNet", "plan_name": "Medicare Advantage", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "TriWest Healthcare Alliance Corporation", "plan_name": "TRICARE Prime", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "TriWest Healthcare Alliance Corporation", "plan_name": "TRICARE Select", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Blue Cross Blue Shield of Montana", "plan_name": "HealthLink Network", "standard_charge_percentage": 75, "methodology": "percent of total billed charges", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Blue Cross Blue Shield of Montana", "plan_name": "Traditional Network", "standard_charge_percentage": 75, "methodology": "percent of total billed charges", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Blue Cross Blue Shield of Montana", "plan_name": "POS Network", "standard_charge_percentage": 75, "methodology": "percent of total billed charges", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Blue Cross Blue Shield of Montana", "plan_name": "Closed Plan Network", "standard_charge_percentage": 75, "methodology": "percent of total billed charges", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Blue Cross Blue Shield of Montana", "plan_name": "Retail HMO POS Network", "standard_charge_percentage": 75, "methodology": "percent of total billed charges", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Blue Cross Blue Shield of Montana", "plan_name": "Blue Options Network", "standard_charge_percentage": 75, "methodology": "percent of total billed charges", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "PacificSource Health Plans", "plan_name": "Medicare Advantage", "standard_charge_percentage": 103, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" } ] } ] }, { "description": "Endovascular Abdominal Aorta with Iliac Branch Procedures", "code_information": [ { "code": "213", "type": "LOCAL" } ], "standard_charges": [ { "setting": "inpatient", "payers_information": [ { "payer_name": "Blue Cross Blue Shield of Montana", "plan_name": "Medicare Advantage", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "First Choice of the Midwest", "plan_name": "PPO", "standard_charge_percentage": 90, "methodology": "percent of total billed charges", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "United Healthcare (UHC)", "plan_name": "Medicare Advantage", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "United Healthcare (UHC)", "plan_name": "DSNP", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Employee Benefit Management Services (EBMS)", "plan_name": "EBMS SelectCare Network", "standard_charge_percentage": 80, "methodology": "percent of total billed charges", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Claritev fka MultiPlan", "plan_name": "PPO", "standard_charge_percentage": 75, "methodology": "percent of total billed charges", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Allegiance Provider Direct", "plan_name": "Medicare", "standard_charge_percentage": 229.99999999999997, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Medicare (CMS)", "plan_name": "Medicare", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Medica Insurance Company", "plan_name": "Medicare Cost", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Indian Health Services (IHS)", "plan_name": "Commercial", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Humana Insurance Company", "plan_name": "Humana Medicare Advantage HMO", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Humana Insurance Company", "plan_name": "Humana Medicare Advantage PPO", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Humana Insurance Company", "plan_name": "Humana Medicare Advantage PFFS", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "First Choice Health Network fka Health InfoNet", "plan_name": "Commercial", "standard_charge_percentage": 85, "methodology": "percent of total billed charges", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "First Choice Health Network fka Health InfoNet", "plan_name": "Workers Compensation", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Allegiance Provider Direct", "plan_name": "State of Montana Employee Benefit Plan (Self-Funded)", "standard_charge_percentage": 229.99999999999997, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Allegiance Provider Direct", "plan_name": "Montana Municipal Interlocal Authority (MMIA)", "standard_charge_percentage": 229.99999999999997, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Allegiance Provider Direct", "plan_name": "Montana Association of Counties (MACo)", "standard_charge_percentage": 229.99999999999997, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "First Choice Health Network fka Health InfoNet", "plan_name": "Medicare Advantage", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "TriWest Healthcare Alliance Corporation", "plan_name": "TRICARE Prime", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "TriWest Healthcare Alliance Corporation", "plan_name": "TRICARE Select", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Blue Cross Blue Shield of Montana", "plan_name": "HealthLink Network", "standard_charge_percentage": 75, "methodology": "percent of total billed charges", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Blue Cross Blue Shield of Montana", "plan_name": "Traditional Network", "standard_charge_percentage": 75, "methodology": "percent of total billed charges", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Blue Cross Blue Shield of Montana", "plan_name": "POS Network", "standard_charge_percentage": 75, "methodology": "percent of total billed charges", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Blue Cross Blue Shield of Montana", "plan_name": "Closed Plan Network", "standard_charge_percentage": 75, "methodology": "percent of total billed charges", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Blue Cross Blue Shield of Montana", "plan_name": "Retail HMO POS Network", "standard_charge_percentage": 75, "methodology": "percent of total billed charges", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Blue Cross Blue Shield of Montana", "plan_name": "Blue Options Network", "standard_charge_percentage": 75, "methodology": "percent of total billed charges", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "PacificSource Health Plans", "plan_name": "Medicare Advantage", "standard_charge_percentage": 103, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" } ] } ] }, { "description": "Other Heart Assist System Implant", "code_information": [ { "code": "215", "type": "LOCAL" } ], "standard_charges": [ { "setting": "inpatient", "payers_information": [ { "payer_name": "Blue Cross Blue Shield of Montana", "plan_name": "Medicare Advantage", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "First Choice of the Midwest", "plan_name": "PPO", "standard_charge_percentage": 90, "methodology": "percent of total billed charges", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "United Healthcare (UHC)", "plan_name": "Medicare Advantage", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "United Healthcare (UHC)", "plan_name": "DSNP", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Employee Benefit Management Services (EBMS)", "plan_name": "EBMS SelectCare Network", "standard_charge_percentage": 80, "methodology": "percent of total billed charges", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Claritev fka MultiPlan", "plan_name": "PPO", "standard_charge_percentage": 75, "methodology": "percent of total billed charges", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Allegiance Provider Direct", "plan_name": "Medicare", "standard_charge_percentage": 229.99999999999997, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Medicare (CMS)", "plan_name": "Medicare", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Medica Insurance Company", "plan_name": "Medicare Cost", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Indian Health Services (IHS)", "plan_name": "Commercial", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Humana Insurance Company", "plan_name": "Humana Medicare Advantage HMO", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Humana Insurance Company", "plan_name": "Humana Medicare Advantage PPO", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Humana Insurance Company", "plan_name": "Humana Medicare Advantage PFFS", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "First Choice Health Network fka Health InfoNet", "plan_name": "Commercial", "standard_charge_percentage": 85, "methodology": "percent of total billed charges", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "First Choice Health Network fka Health InfoNet", "plan_name": "Workers Compensation", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Allegiance Provider Direct", "plan_name": "State of Montana Employee Benefit Plan (Self-Funded)", "standard_charge_percentage": 229.99999999999997, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Allegiance Provider Direct", "plan_name": "Montana Municipal Interlocal Authority (MMIA)", "standard_charge_percentage": 229.99999999999997, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Allegiance Provider Direct", "plan_name": "Montana Association of Counties (MACo)", "standard_charge_percentage": 229.99999999999997, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "First Choice Health Network fka Health InfoNet", "plan_name": "Medicare Advantage", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "TriWest Healthcare Alliance Corporation", "plan_name": "TRICARE Prime", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "TriWest Healthcare Alliance Corporation", "plan_name": "TRICARE Select", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Blue Cross Blue Shield of Montana", "plan_name": "HealthLink Network", "standard_charge_percentage": 75, "methodology": "percent of total billed charges", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Blue Cross Blue Shield of Montana", "plan_name": "Traditional Network", "standard_charge_percentage": 75, "methodology": "percent of total billed charges", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Blue Cross Blue Shield of Montana", "plan_name": "POS Network", "standard_charge_percentage": 75, "methodology": "percent of total billed charges", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Blue Cross Blue Shield of Montana", "plan_name": "Closed Plan Network", "standard_charge_percentage": 75, "methodology": "percent of total billed charges", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Blue Cross Blue Shield of Montana", "plan_name": "Retail HMO POS Network", "standard_charge_percentage": 75, "methodology": "percent of total billed charges", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Blue Cross Blue Shield of Montana", "plan_name": "Blue Options Network", "standard_charge_percentage": 75, "methodology": "percent of total billed charges", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "PacificSource Health Plans", "plan_name": "Medicare Advantage", "standard_charge_percentage": 103, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" } ] } ] }, { "description": "Cardiac Valve and Other Major Cardiothoracic Procedures with Cardiac Catheterization with MCC", "code_information": [ { "code": "216", "type": "LOCAL" } ], "standard_charges": [ { "setting": "inpatient", "payers_information": [ { "payer_name": "Blue Cross Blue Shield of Montana", "plan_name": "Medicare Advantage", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "First Choice of the Midwest", "plan_name": "PPO", "standard_charge_percentage": 90, "methodology": "percent of total billed charges", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "United Healthcare (UHC)", "plan_name": "Medicare Advantage", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "United Healthcare (UHC)", "plan_name": "DSNP", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Employee Benefit Management Services (EBMS)", "plan_name": "EBMS SelectCare Network", "standard_charge_percentage": 80, "methodology": "percent of total billed charges", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Claritev fka MultiPlan", "plan_name": "PPO", "standard_charge_percentage": 75, "methodology": "percent of total billed charges", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Allegiance Provider Direct", "plan_name": "Medicare", "standard_charge_percentage": 229.99999999999997, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Medicare (CMS)", "plan_name": "Medicare", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Medica Insurance Company", "plan_name": "Medicare Cost", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Indian Health Services (IHS)", "plan_name": "Commercial", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Humana Insurance Company", "plan_name": "Humana Medicare Advantage HMO", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Humana Insurance Company", "plan_name": "Humana Medicare Advantage PPO", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Humana Insurance Company", "plan_name": "Humana Medicare Advantage PFFS", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "First Choice Health Network fka Health InfoNet", "plan_name": "Commercial", "standard_charge_percentage": 85, "methodology": "percent of total billed charges", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "First Choice Health Network fka Health InfoNet", "plan_name": "Workers Compensation", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Allegiance Provider Direct", "plan_name": "State of Montana Employee Benefit Plan (Self-Funded)", "standard_charge_percentage": 229.99999999999997, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Allegiance Provider Direct", "plan_name": "Montana Municipal Interlocal Authority (MMIA)", "standard_charge_percentage": 229.99999999999997, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Allegiance Provider Direct", "plan_name": "Montana Association of Counties (MACo)", "standard_charge_percentage": 229.99999999999997, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "First Choice Health Network fka Health InfoNet", "plan_name": "Medicare Advantage", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "TriWest Healthcare Alliance Corporation", "plan_name": "TRICARE Prime", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "TriWest Healthcare Alliance Corporation", "plan_name": "TRICARE Select", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Blue Cross Blue Shield of Montana", "plan_name": "HealthLink Network", "standard_charge_percentage": 75, "methodology": "percent of total billed charges", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Blue Cross Blue Shield of Montana", "plan_name": "Traditional Network", "standard_charge_percentage": 75, "methodology": "percent of total billed charges", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Blue Cross Blue Shield of Montana", "plan_name": "POS Network", "standard_charge_percentage": 75, "methodology": "percent of total billed charges", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Blue Cross Blue Shield of Montana", "plan_name": "Closed Plan Network", "standard_charge_percentage": 75, "methodology": "percent of total billed charges", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Blue Cross Blue Shield of Montana", "plan_name": "Retail HMO POS Network", "standard_charge_percentage": 75, "methodology": "percent of total billed charges", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Blue Cross Blue Shield of Montana", "plan_name": "Blue Options Network", "standard_charge_percentage": 75, "methodology": "percent of total billed charges", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "PacificSource Health Plans", "plan_name": "Medicare Advantage", "standard_charge_percentage": 103, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" } ] } ] }, { "description": "Cardiac Valve and Other Major Cardiothoracic Procedures with Cardiac Catheterization with CC", "code_information": [ { "code": "217", "type": "LOCAL" } ], "standard_charges": [ { "setting": "inpatient", "payers_information": [ { "payer_name": "Blue Cross Blue Shield of Montana", "plan_name": "Medicare Advantage", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "First Choice of the Midwest", "plan_name": "PPO", "standard_charge_percentage": 90, "methodology": "percent of total billed charges", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "United Healthcare (UHC)", "plan_name": "Medicare Advantage", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "United Healthcare (UHC)", "plan_name": "DSNP", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Employee Benefit Management Services (EBMS)", "plan_name": "EBMS SelectCare Network", "standard_charge_percentage": 80, "methodology": "percent of total billed charges", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Claritev fka MultiPlan", "plan_name": "PPO", "standard_charge_percentage": 75, "methodology": "percent of total billed charges", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Allegiance Provider Direct", "plan_name": "Medicare", "standard_charge_percentage": 229.99999999999997, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Medicare (CMS)", "plan_name": "Medicare", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Medica Insurance Company", "plan_name": "Medicare Cost", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Indian Health Services (IHS)", "plan_name": "Commercial", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Humana Insurance Company", "plan_name": "Humana Medicare Advantage HMO", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Humana Insurance Company", "plan_name": "Humana Medicare Advantage PPO", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Humana Insurance Company", "plan_name": "Humana Medicare Advantage PFFS", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "First Choice Health Network fka Health InfoNet", "plan_name": "Commercial", "standard_charge_percentage": 85, "methodology": "percent of total billed charges", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "First Choice Health Network fka Health InfoNet", "plan_name": "Workers Compensation", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Allegiance Provider Direct", "plan_name": "State of Montana Employee Benefit Plan (Self-Funded)", "standard_charge_percentage": 229.99999999999997, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Allegiance Provider Direct", "plan_name": "Montana Municipal Interlocal Authority (MMIA)", "standard_charge_percentage": 229.99999999999997, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Allegiance Provider Direct", "plan_name": "Montana Association of Counties (MACo)", "standard_charge_percentage": 229.99999999999997, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "First Choice Health Network fka Health InfoNet", "plan_name": "Medicare Advantage", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "TriWest Healthcare Alliance Corporation", "plan_name": "TRICARE Prime", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "TriWest Healthcare Alliance Corporation", "plan_name": "TRICARE Select", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Blue Cross Blue Shield of Montana", "plan_name": "HealthLink Network", "standard_charge_percentage": 75, "methodology": "percent of total billed charges", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Blue Cross Blue Shield of Montana", "plan_name": "Traditional Network", "standard_charge_percentage": 75, "methodology": "percent of total billed charges", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Blue Cross Blue Shield of Montana", "plan_name": "POS Network", "standard_charge_percentage": 75, "methodology": "percent of total billed charges", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Blue Cross Blue Shield of Montana", "plan_name": "Closed Plan Network", "standard_charge_percentage": 75, "methodology": "percent of total billed charges", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Blue Cross Blue Shield of Montana", "plan_name": "Retail HMO POS Network", "standard_charge_percentage": 75, "methodology": "percent of total billed charges", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Blue Cross Blue Shield of Montana", "plan_name": "Blue Options Network", "standard_charge_percentage": 75, "methodology": "percent of total billed charges", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "PacificSource Health Plans", "plan_name": "Medicare Advantage", "standard_charge_percentage": 103, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" } ] } ] }, { "description": "Cardiac Valve and Other Major Cardiothoracic Procedures with Cardiac Catheterization without CC/MCC", "code_information": [ { "code": "218", "type": "LOCAL" } ], "standard_charges": [ { "setting": "inpatient", "payers_information": [ { "payer_name": "Blue Cross Blue Shield of Montana", "plan_name": "Medicare Advantage", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "United Healthcare (UHC)", "plan_name": "Medicare Advantage", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "First Choice of the Midwest", "plan_name": "PPO", "standard_charge_percentage": 90, "methodology": "percent of total billed charges", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "United Healthcare (UHC)", "plan_name": "DSNP", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Employee Benefit Management Services (EBMS)", "plan_name": "EBMS SelectCare Network", "standard_charge_percentage": 80, "methodology": "percent of total billed charges", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Claritev fka MultiPlan", "plan_name": "PPO", "standard_charge_percentage": 75, "methodology": "percent of total billed charges", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Allegiance Provider Direct", "plan_name": "Medicare", "standard_charge_percentage": 229.99999999999997, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Medicare (CMS)", "plan_name": "Medicare", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Medica Insurance Company", "plan_name": "Medicare Cost", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Indian Health Services (IHS)", "plan_name": "Commercial", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Humana Insurance Company", "plan_name": "Humana Medicare Advantage HMO", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Humana Insurance Company", "plan_name": "Humana Medicare Advantage PPO", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Humana Insurance Company", "plan_name": "Humana Medicare Advantage PFFS", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "First Choice Health Network fka Health InfoNet", "plan_name": "Commercial", "standard_charge_percentage": 85, "methodology": "percent of total billed charges", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "First Choice Health Network fka Health InfoNet", "plan_name": "Workers Compensation", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Allegiance Provider Direct", "plan_name": "State of Montana Employee Benefit Plan (Self-Funded)", "standard_charge_percentage": 229.99999999999997, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Allegiance Provider Direct", "plan_name": "Montana Municipal Interlocal Authority (MMIA)", "standard_charge_percentage": 229.99999999999997, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Allegiance Provider Direct", "plan_name": "Montana Association of Counties (MACo)", "standard_charge_percentage": 229.99999999999997, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "First Choice Health Network fka Health InfoNet", "plan_name": "Medicare Advantage", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "TriWest Healthcare Alliance Corporation", "plan_name": "TRICARE Prime", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "TriWest Healthcare Alliance Corporation", "plan_name": "TRICARE Select", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Blue Cross Blue Shield of Montana", "plan_name": "HealthLink Network", "standard_charge_percentage": 75, "methodology": "percent of total billed charges", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Blue Cross Blue Shield of Montana", "plan_name": "Traditional Network", "standard_charge_percentage": 75, "methodology": "percent of total billed charges", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Blue Cross Blue Shield of Montana", "plan_name": "POS Network", "standard_charge_percentage": 75, "methodology": "percent of total billed charges", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Blue Cross Blue Shield of Montana", "plan_name": "Closed Plan Network", "standard_charge_percentage": 75, "methodology": "percent of total billed charges", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Blue Cross Blue Shield of Montana", "plan_name": "Retail HMO POS Network", "standard_charge_percentage": 75, "methodology": "percent of total billed charges", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Blue Cross Blue Shield of Montana", "plan_name": "Blue Options Network", "standard_charge_percentage": 75, "methodology": "percent of total billed charges", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "PacificSource Health Plans", "plan_name": "Medicare Advantage", "standard_charge_percentage": 103, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" } ] } ] }, { "description": "Cardiac Valve and Other Major Cardiothoracic Procedures without Cardiac Catheterization with MCC", "code_information": [ { "code": "219", "type": "LOCAL" } ], "standard_charges": [ { "setting": "inpatient", "payers_information": [ { "payer_name": "Blue Cross Blue Shield of Montana", "plan_name": "Medicare Advantage", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "United Healthcare (UHC)", "plan_name": "Medicare Advantage", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "First Choice of the Midwest", "plan_name": "PPO", "standard_charge_percentage": 90, "methodology": "percent of total billed charges", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "United Healthcare (UHC)", "plan_name": "DSNP", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Employee Benefit Management Services (EBMS)", "plan_name": "EBMS SelectCare Network", "standard_charge_percentage": 80, "methodology": "percent of total billed charges", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Claritev fka MultiPlan", "plan_name": "PPO", "standard_charge_percentage": 75, "methodology": "percent of total billed charges", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Allegiance Provider Direct", "plan_name": "Medicare", "standard_charge_percentage": 229.99999999999997, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Medicare (CMS)", "plan_name": "Medicare", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Medica Insurance Company", "plan_name": "Medicare Cost", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "First Choice Health Network fka Health InfoNet", "plan_name": "Commercial", "standard_charge_percentage": 85, "methodology": "percent of total billed charges", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Indian Health Services (IHS)", "plan_name": "Commercial", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "First Choice Health Network fka Health InfoNet", "plan_name": "Workers Compensation", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Humana Insurance Company", "plan_name": "Humana Medicare Advantage HMO", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Humana Insurance Company", "plan_name": "Humana Medicare Advantage PPO", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Humana Insurance Company", "plan_name": "Humana Medicare Advantage PFFS", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Allegiance Provider Direct", "plan_name": "State of Montana Employee Benefit Plan (Self-Funded)", "standard_charge_percentage": 229.99999999999997, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Allegiance Provider Direct", "plan_name": "Montana Municipal Interlocal Authority (MMIA)", "standard_charge_percentage": 229.99999999999997, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Allegiance Provider Direct", "plan_name": "Montana Association of Counties (MACo)", "standard_charge_percentage": 229.99999999999997, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "First Choice Health Network fka Health InfoNet", "plan_name": "Medicare Advantage", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "TriWest Healthcare Alliance Corporation", "plan_name": "TRICARE Prime", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "TriWest Healthcare Alliance Corporation", "plan_name": "TRICARE Select", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Blue Cross Blue Shield of Montana", "plan_name": "HealthLink Network", "standard_charge_percentage": 75, "methodology": "percent of total billed charges", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Blue Cross Blue Shield of Montana", "plan_name": "Traditional Network", "standard_charge_percentage": 75, "methodology": "percent of total billed charges", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Blue Cross Blue Shield of Montana", "plan_name": "POS Network", "standard_charge_percentage": 75, "methodology": "percent of total billed charges", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Blue Cross Blue Shield of Montana", "plan_name": "Closed Plan Network", "standard_charge_percentage": 75, "methodology": "percent of total billed charges", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Blue Cross Blue Shield of Montana", "plan_name": "Retail HMO POS Network", "standard_charge_percentage": 75, "methodology": "percent of total billed charges", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Blue Cross Blue Shield of Montana", "plan_name": "Blue Options Network", "standard_charge_percentage": 75, "methodology": "percent of total billed charges", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "PacificSource Health Plans", "plan_name": "Medicare Advantage", "standard_charge_percentage": 103, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" } ] } ] }, { "description": "Cardiac Valve and Other Major Cardiothoracic Procedures without Cardiac Catheterization with CC", "code_information": [ { "code": "220", "type": "LOCAL" } ], "standard_charges": [ { "setting": "inpatient", "payers_information": [ { "payer_name": "Blue Cross Blue Shield of Montana", "plan_name": "Medicare Advantage", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "United Healthcare (UHC)", "plan_name": "Medicare Advantage", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "First Choice of the Midwest", "plan_name": "PPO", "standard_charge_percentage": 90, "methodology": "percent of total billed charges", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "United Healthcare (UHC)", "plan_name": "DSNP", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Employee Benefit Management Services (EBMS)", "plan_name": "EBMS SelectCare Network", "standard_charge_percentage": 80, "methodology": "percent of total billed charges", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Claritev fka MultiPlan", "plan_name": "PPO", "standard_charge_percentage": 75, "methodology": "percent of total billed charges", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Allegiance Provider Direct", "plan_name": "Medicare", "standard_charge_percentage": 229.99999999999997, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Medicare (CMS)", "plan_name": "Medicare", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Medica Insurance Company", "plan_name": "Medicare Cost", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "First Choice Health Network fka Health InfoNet", "plan_name": "Commercial", "standard_charge_percentage": 85, "methodology": "percent of total billed charges", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Indian Health Services (IHS)", "plan_name": "Commercial", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "First Choice Health Network fka Health InfoNet", "plan_name": "Workers Compensation", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Humana Insurance Company", "plan_name": "Humana Medicare Advantage HMO", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Humana Insurance Company", "plan_name": "Humana Medicare Advantage PPO", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Humana Insurance Company", "plan_name": "Humana Medicare Advantage PFFS", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Allegiance Provider Direct", "plan_name": "State of Montana Employee Benefit Plan (Self-Funded)", "standard_charge_percentage": 229.99999999999997, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Allegiance Provider Direct", "plan_name": "Montana Municipal Interlocal Authority (MMIA)", "standard_charge_percentage": 229.99999999999997, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Allegiance Provider Direct", "plan_name": "Montana Association of Counties (MACo)", "standard_charge_percentage": 229.99999999999997, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "First Choice Health Network fka Health InfoNet", "plan_name": "Medicare Advantage", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "TriWest Healthcare Alliance Corporation", "plan_name": "TRICARE Prime", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "TriWest Healthcare Alliance Corporation", "plan_name": "TRICARE Select", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Blue Cross Blue Shield of Montana", "plan_name": "HealthLink Network", "standard_charge_percentage": 75, "methodology": "percent of total billed charges", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Blue Cross Blue Shield of Montana", "plan_name": "Traditional Network", "standard_charge_percentage": 75, "methodology": "percent of total billed charges", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Blue Cross Blue Shield of Montana", "plan_name": "POS Network", "standard_charge_percentage": 75, "methodology": "percent of total billed charges", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Blue Cross Blue Shield of Montana", "plan_name": "Closed Plan Network", "standard_charge_percentage": 75, "methodology": "percent of total billed charges", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Blue Cross Blue Shield of Montana", "plan_name": "Retail HMO POS Network", "standard_charge_percentage": 75, "methodology": "percent of total billed charges", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Blue Cross Blue Shield of Montana", "plan_name": "Blue Options Network", "standard_charge_percentage": 75, "methodology": "percent of total billed charges", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "PacificSource Health Plans", "plan_name": "Medicare Advantage", "standard_charge_percentage": 103, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" } ] } ] }, { "description": "Cardiac Valve and Other Major Cardiothoracic Procedures without Cardiac Catheterization without CC/MCC", "code_information": [ { "code": "221", "type": "LOCAL" } ], "standard_charges": [ { "setting": "inpatient", "payers_information": [ { "payer_name": "Blue Cross Blue Shield of Montana", "plan_name": "Medicare Advantage", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "United Healthcare (UHC)", "plan_name": "Medicare Advantage", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "First Choice of the Midwest", "plan_name": "PPO", "standard_charge_percentage": 90, "methodology": "percent of total billed charges", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "United Healthcare (UHC)", "plan_name": "DSNP", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Employee Benefit Management Services (EBMS)", "plan_name": "EBMS SelectCare Network", "standard_charge_percentage": 80, "methodology": "percent of total billed charges", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Claritev fka MultiPlan", "plan_name": "PPO", "standard_charge_percentage": 75, "methodology": "percent of total billed charges", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Allegiance Provider Direct", "plan_name": "Medicare", "standard_charge_percentage": 229.99999999999997, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Medicare (CMS)", "plan_name": "Medicare", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Medica Insurance Company", "plan_name": "Medicare Cost", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "First Choice Health Network fka Health InfoNet", "plan_name": "Commercial", "standard_charge_percentage": 85, "methodology": "percent of total billed charges", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Indian Health Services (IHS)", "plan_name": "Commercial", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "First Choice Health Network fka Health InfoNet", "plan_name": "Workers Compensation", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Humana Insurance Company", "plan_name": "Humana Medicare Advantage HMO", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Humana Insurance Company", "plan_name": "Humana Medicare Advantage PPO", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Humana Insurance Company", "plan_name": "Humana Medicare Advantage PFFS", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Allegiance Provider Direct", "plan_name": "State of Montana Employee Benefit Plan (Self-Funded)", "standard_charge_percentage": 229.99999999999997, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Allegiance Provider Direct", "plan_name": "Montana Municipal Interlocal Authority (MMIA)", "standard_charge_percentage": 229.99999999999997, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Allegiance Provider Direct", "plan_name": "Montana Association of Counties (MACo)", "standard_charge_percentage": 229.99999999999997, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "First Choice Health Network fka Health InfoNet", "plan_name": "Medicare Advantage", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "TriWest Healthcare Alliance Corporation", "plan_name": "TRICARE Prime", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "TriWest Healthcare Alliance Corporation", "plan_name": "TRICARE Select", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Blue Cross Blue Shield of Montana", "plan_name": "HealthLink Network", "standard_charge_percentage": 75, "methodology": "percent of total billed charges", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Blue Cross Blue Shield of Montana", "plan_name": "Traditional Network", "standard_charge_percentage": 75, "methodology": "percent of total billed charges", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Blue Cross Blue Shield of Montana", "plan_name": "POS Network", "standard_charge_percentage": 75, "methodology": "percent of total billed charges", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Blue Cross Blue Shield of Montana", "plan_name": "Closed Plan Network", "standard_charge_percentage": 75, "methodology": "percent of total billed charges", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Blue Cross Blue Shield of Montana", "plan_name": "Retail HMO POS Network", "standard_charge_percentage": 75, "methodology": "percent of total billed charges", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Blue Cross Blue Shield of Montana", "plan_name": "Blue Options Network", "standard_charge_percentage": 75, "methodology": "percent of total billed charges", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "PacificSource Health Plans", "plan_name": "Medicare Advantage", "standard_charge_percentage": 103, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" } ] } ] }, { "description": "Other Cardiothoracic Procedures with MCC", "code_information": [ { "code": "228", "type": "LOCAL" } ], "standard_charges": [ { "setting": "inpatient", "payers_information": [ { "payer_name": "Blue Cross Blue Shield of Montana", "plan_name": "Medicare Advantage", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "United Healthcare (UHC)", "plan_name": "Medicare Advantage", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "First Choice of the Midwest", "plan_name": "PPO", "standard_charge_percentage": 90, "methodology": "percent of total billed charges", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "United Healthcare (UHC)", "plan_name": "DSNP", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Employee Benefit Management Services (EBMS)", "plan_name": "EBMS SelectCare Network", "standard_charge_percentage": 80, "methodology": "percent of total billed charges", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Claritev fka MultiPlan", "plan_name": "PPO", "standard_charge_percentage": 75, "methodology": "percent of total billed charges", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Allegiance Provider Direct", "plan_name": "Medicare", "standard_charge_percentage": 229.99999999999997, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Medicare (CMS)", "plan_name": "Medicare", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Medica Insurance Company", "plan_name": "Medicare Cost", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "First Choice Health Network fka Health InfoNet", "plan_name": "Commercial", "standard_charge_percentage": 85, "methodology": "percent of total billed charges", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Indian Health Services (IHS)", "plan_name": "Commercial", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "First Choice Health Network fka Health InfoNet", "plan_name": "Workers Compensation", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Humana Insurance Company", "plan_name": "Humana Medicare Advantage HMO", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Humana Insurance Company", "plan_name": "Humana Medicare Advantage PPO", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Humana Insurance Company", "plan_name": "Humana Medicare Advantage PFFS", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Allegiance Provider Direct", "plan_name": "State of Montana Employee Benefit Plan (Self-Funded)", "standard_charge_percentage": 229.99999999999997, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Allegiance Provider Direct", "plan_name": "Montana Municipal Interlocal Authority (MMIA)", "standard_charge_percentage": 229.99999999999997, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Allegiance Provider Direct", "plan_name": "Montana Association of Counties (MACo)", "standard_charge_percentage": 229.99999999999997, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "First Choice Health Network fka Health InfoNet", "plan_name": "Medicare Advantage", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "TriWest Healthcare Alliance Corporation", "plan_name": "TRICARE Prime", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "TriWest Healthcare Alliance Corporation", "plan_name": "TRICARE Select", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Blue Cross Blue Shield of Montana", "plan_name": "HealthLink Network", "standard_charge_percentage": 75, "methodology": "percent of total billed charges", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Blue Cross Blue Shield of Montana", "plan_name": "Traditional Network", "standard_charge_percentage": 75, "methodology": "percent of total billed charges", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Blue Cross Blue Shield of Montana", "plan_name": "POS Network", "standard_charge_percentage": 75, "methodology": "percent of total billed charges", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Blue Cross Blue Shield of Montana", "plan_name": "Closed Plan Network", "standard_charge_percentage": 75, "methodology": "percent of total billed charges", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Blue Cross Blue Shield of Montana", "plan_name": "Retail HMO POS Network", "standard_charge_percentage": 75, "methodology": "percent of total billed charges", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Blue Cross Blue Shield of Montana", "plan_name": "Blue Options Network", "standard_charge_percentage": 75, "methodology": "percent of total billed charges", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "PacificSource Health Plans", "plan_name": "Medicare Advantage", "standard_charge_percentage": 103, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" } ] } ] }, { "description": "Other Cardiothoracic Procedures without MCC", "code_information": [ { "code": "229", "type": "LOCAL" } ], "standard_charges": [ { "setting": "inpatient", "payers_information": [ { "payer_name": "Blue Cross Blue Shield of Montana", "plan_name": "Medicare Advantage", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "United Healthcare (UHC)", "plan_name": "Medicare Advantage", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "First Choice of the Midwest", "plan_name": "PPO", "standard_charge_percentage": 90, "methodology": "percent of total billed charges", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "United Healthcare (UHC)", "plan_name": "DSNP", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Employee Benefit Management Services (EBMS)", "plan_name": "EBMS SelectCare Network", "standard_charge_percentage": 80, "methodology": "percent of total billed charges", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Claritev fka MultiPlan", "plan_name": "PPO", "standard_charge_percentage": 75, "methodology": "percent of total billed charges", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Allegiance Provider Direct", "plan_name": "Medicare", "standard_charge_percentage": 229.99999999999997, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Medicare (CMS)", "plan_name": "Medicare", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Medica Insurance Company", "plan_name": "Medicare Cost", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "First Choice Health Network fka Health InfoNet", "plan_name": "Commercial", "standard_charge_percentage": 85, "methodology": "percent of total billed charges", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Indian Health Services (IHS)", "plan_name": "Commercial", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "First Choice Health Network fka Health InfoNet", "plan_name": "Workers Compensation", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Humana Insurance Company", "plan_name": "Humana Medicare Advantage HMO", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Humana Insurance Company", "plan_name": "Humana Medicare Advantage PPO", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Humana Insurance Company", "plan_name": "Humana Medicare Advantage PFFS", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Allegiance Provider Direct", "plan_name": "State of Montana Employee Benefit Plan (Self-Funded)", "standard_charge_percentage": 229.99999999999997, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Allegiance Provider Direct", "plan_name": "Montana Municipal Interlocal Authority (MMIA)", "standard_charge_percentage": 229.99999999999997, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Allegiance Provider Direct", "plan_name": "Montana Association of Counties (MACo)", "standard_charge_percentage": 229.99999999999997, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "First Choice Health Network fka Health InfoNet", "plan_name": "Medicare Advantage", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "TriWest Healthcare Alliance Corporation", "plan_name": "TRICARE Prime", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "TriWest Healthcare Alliance Corporation", "plan_name": "TRICARE Select", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Blue Cross Blue Shield of Montana", "plan_name": "HealthLink Network", "standard_charge_percentage": 75, "methodology": "percent of total billed charges", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Blue Cross Blue Shield of Montana", "plan_name": "Traditional Network", "standard_charge_percentage": 75, "methodology": "percent of total billed charges", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Blue Cross Blue Shield of Montana", "plan_name": "POS Network", "standard_charge_percentage": 75, "methodology": "percent of total billed charges", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Blue Cross Blue Shield of Montana", "plan_name": "Closed Plan Network", "standard_charge_percentage": 75, "methodology": "percent of total billed charges", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Blue Cross Blue Shield of Montana", "plan_name": "Retail HMO POS Network", "standard_charge_percentage": 75, "methodology": "percent of total billed charges", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Blue Cross Blue Shield of Montana", "plan_name": "Blue Options Network", "standard_charge_percentage": 75, "methodology": "percent of total billed charges", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "PacificSource Health Plans", "plan_name": "Medicare Advantage", "standard_charge_percentage": 103, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" } ] } ] }, { "description": "Coronary Bypass with PTCA with MCC", "code_information": [ { "code": "231", "type": "LOCAL" } ], "standard_charges": [ { "setting": "inpatient", "payers_information": [ { "payer_name": "Blue Cross Blue Shield of Montana", "plan_name": "Medicare Advantage", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "United Healthcare (UHC)", "plan_name": "Medicare Advantage", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "First Choice of the Midwest", "plan_name": "PPO", "standard_charge_percentage": 90, "methodology": "percent of total billed charges", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "United Healthcare (UHC)", "plan_name": "DSNP", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Employee Benefit Management Services (EBMS)", "plan_name": "EBMS SelectCare Network", "standard_charge_percentage": 80, "methodology": "percent of total billed charges", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Claritev fka MultiPlan", "plan_name": "PPO", "standard_charge_percentage": 75, "methodology": "percent of total billed charges", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Allegiance Provider Direct", "plan_name": "Medicare", "standard_charge_percentage": 229.99999999999997, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Medicare (CMS)", "plan_name": "Medicare", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Medica Insurance Company", "plan_name": "Medicare Cost", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "First Choice Health Network fka Health InfoNet", "plan_name": "Commercial", "standard_charge_percentage": 85, "methodology": "percent of total billed charges", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Indian Health Services (IHS)", "plan_name": "Commercial", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "First Choice Health Network fka Health InfoNet", "plan_name": "Workers Compensation", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Humana Insurance Company", "plan_name": "Humana Medicare Advantage HMO", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Humana Insurance Company", "plan_name": "Humana Medicare Advantage PPO", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Humana Insurance Company", "plan_name": "Humana Medicare Advantage PFFS", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Allegiance Provider Direct", "plan_name": "State of Montana Employee Benefit Plan (Self-Funded)", "standard_charge_percentage": 229.99999999999997, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Allegiance Provider Direct", "plan_name": "Montana Municipal Interlocal Authority (MMIA)", "standard_charge_percentage": 229.99999999999997, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Allegiance Provider Direct", "plan_name": "Montana Association of Counties (MACo)", "standard_charge_percentage": 229.99999999999997, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "First Choice Health Network fka Health InfoNet", "plan_name": "Medicare Advantage", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "TriWest Healthcare Alliance Corporation", "plan_name": "TRICARE Prime", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "TriWest Healthcare Alliance Corporation", "plan_name": "TRICARE Select", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Blue Cross Blue Shield of Montana", "plan_name": "HealthLink Network", "standard_charge_percentage": 75, "methodology": "percent of total billed charges", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Blue Cross Blue Shield of Montana", "plan_name": "Traditional Network", "standard_charge_percentage": 75, "methodology": "percent of total billed charges", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Blue Cross Blue Shield of Montana", "plan_name": "POS Network", "standard_charge_percentage": 75, "methodology": "percent of total billed charges", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Blue Cross Blue Shield of Montana", "plan_name": "Closed Plan Network", "standard_charge_percentage": 75, "methodology": "percent of total billed charges", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Blue Cross Blue Shield of Montana", "plan_name": "Retail HMO POS Network", "standard_charge_percentage": 75, "methodology": "percent of total billed charges", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Blue Cross Blue Shield of Montana", "plan_name": "Blue Options Network", "standard_charge_percentage": 75, "methodology": "percent of total billed charges", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "PacificSource Health Plans", "plan_name": "Medicare Advantage", "standard_charge_percentage": 103, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" } ] } ] }, { "description": "Coronary Bypass with PTCA without MCC", "code_information": [ { "code": "232", "type": "LOCAL" } ], "standard_charges": [ { "setting": "inpatient", "payers_information": [ { "payer_name": "Blue Cross Blue Shield of Montana", "plan_name": "Medicare Advantage", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "United Healthcare (UHC)", "plan_name": "Medicare Advantage", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "First Choice of the Midwest", "plan_name": "PPO", "standard_charge_percentage": 90, "methodology": "percent of total billed charges", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "United Healthcare (UHC)", "plan_name": "DSNP", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Employee Benefit Management Services (EBMS)", "plan_name": "EBMS SelectCare Network", "standard_charge_percentage": 80, "methodology": "percent of total billed charges", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Claritev fka MultiPlan", "plan_name": "PPO", "standard_charge_percentage": 75, "methodology": "percent of total billed charges", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Allegiance Provider Direct", "plan_name": "Medicare", "standard_charge_percentage": 229.99999999999997, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Medicare (CMS)", "plan_name": "Medicare", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Medica Insurance Company", "plan_name": "Medicare Cost", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "First Choice Health Network fka Health InfoNet", "plan_name": "Commercial", "standard_charge_percentage": 85, "methodology": "percent of total billed charges", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Indian Health Services (IHS)", "plan_name": "Commercial", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "First Choice Health Network fka Health InfoNet", "plan_name": "Workers Compensation", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Humana Insurance Company", "plan_name": "Humana Medicare Advantage HMO", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Humana Insurance Company", "plan_name": "Humana Medicare Advantage PPO", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Humana Insurance Company", "plan_name": "Humana Medicare Advantage PFFS", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Allegiance Provider Direct", "plan_name": "State of Montana Employee Benefit Plan (Self-Funded)", "standard_charge_percentage": 229.99999999999997, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Allegiance Provider Direct", "plan_name": "Montana Municipal Interlocal Authority (MMIA)", "standard_charge_percentage": 229.99999999999997, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Allegiance Provider Direct", "plan_name": "Montana Association of Counties (MACo)", "standard_charge_percentage": 229.99999999999997, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "First Choice Health Network fka Health InfoNet", "plan_name": "Medicare Advantage", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "TriWest Healthcare Alliance Corporation", "plan_name": "TRICARE Prime", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "TriWest Healthcare Alliance Corporation", "plan_name": "TRICARE Select", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Blue Cross Blue Shield of Montana", "plan_name": "HealthLink Network", "standard_charge_percentage": 75, "methodology": "percent of total billed charges", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Blue Cross Blue Shield of Montana", "plan_name": "Traditional Network", "standard_charge_percentage": 75, "methodology": "percent of total billed charges", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Blue Cross Blue Shield of Montana", "plan_name": "POS Network", "standard_charge_percentage": 75, "methodology": "percent of total billed charges", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Blue Cross Blue Shield of Montana", "plan_name": "Closed Plan Network", "standard_charge_percentage": 75, "methodology": "percent of total billed charges", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Blue Cross Blue Shield of Montana", "plan_name": "Retail HMO POS Network", "standard_charge_percentage": 75, "methodology": "percent of total billed charges", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Blue Cross Blue Shield of Montana", "plan_name": "Blue Options Network", "standard_charge_percentage": 75, "methodology": "percent of total billed charges", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "PacificSource Health Plans", "plan_name": "Medicare Advantage", "standard_charge_percentage": 103, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" } ] } ] }, { "description": "Coronary Bypass with Cardiac Catheterization or Open Ablation with MCC", "code_information": [ { "code": "233", "type": "LOCAL" } ], "standard_charges": [ { "setting": "inpatient", "payers_information": [ { "payer_name": "Blue Cross Blue Shield of Montana", "plan_name": "Medicare Advantage", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "United Healthcare (UHC)", "plan_name": "Medicare Advantage", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "First Choice of the Midwest", "plan_name": "PPO", "standard_charge_percentage": 90, "methodology": "percent of total billed charges", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "United Healthcare (UHC)", "plan_name": "DSNP", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Employee Benefit Management Services (EBMS)", "plan_name": "EBMS SelectCare Network", "standard_charge_percentage": 80, "methodology": "percent of total billed charges", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Claritev fka MultiPlan", "plan_name": "PPO", "standard_charge_percentage": 75, "methodology": "percent of total billed charges", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Allegiance Provider Direct", "plan_name": "Medicare", "standard_charge_percentage": 229.99999999999997, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Medicare (CMS)", "plan_name": "Medicare", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Medica Insurance Company", "plan_name": "Medicare Cost", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "First Choice Health Network fka Health InfoNet", "plan_name": "Commercial", "standard_charge_percentage": 85, "methodology": "percent of total billed charges", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Indian Health Services (IHS)", "plan_name": "Commercial", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "First Choice Health Network fka Health InfoNet", "plan_name": "Workers Compensation", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Humana Insurance Company", "plan_name": "Humana Medicare Advantage HMO", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Humana Insurance Company", "plan_name": "Humana Medicare Advantage PPO", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Humana Insurance Company", "plan_name": "Humana Medicare Advantage PFFS", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Allegiance Provider Direct", "plan_name": "State of Montana Employee Benefit Plan (Self-Funded)", "standard_charge_percentage": 229.99999999999997, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Allegiance Provider Direct", "plan_name": "Montana Municipal Interlocal Authority (MMIA)", "standard_charge_percentage": 229.99999999999997, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Allegiance Provider Direct", "plan_name": "Montana Association of Counties (MACo)", "standard_charge_percentage": 229.99999999999997, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "First Choice Health Network fka Health InfoNet", "plan_name": "Medicare Advantage", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "TriWest Healthcare Alliance Corporation", "plan_name": "TRICARE Prime", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "TriWest Healthcare Alliance Corporation", "plan_name": "TRICARE Select", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Blue Cross Blue Shield of Montana", "plan_name": "HealthLink Network", "standard_charge_percentage": 75, "methodology": "percent of total billed charges", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Blue Cross Blue Shield of Montana", "plan_name": "Traditional Network", "standard_charge_percentage": 75, "methodology": "percent of total billed charges", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Blue Cross Blue Shield of Montana", "plan_name": "POS Network", "standard_charge_percentage": 75, "methodology": "percent of total billed charges", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Blue Cross Blue Shield of Montana", "plan_name": "Closed Plan Network", "standard_charge_percentage": 75, "methodology": "percent of total billed charges", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Blue Cross Blue Shield of Montana", "plan_name": "Retail HMO POS Network", "standard_charge_percentage": 75, "methodology": "percent of total billed charges", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Blue Cross Blue Shield of Montana", "plan_name": "Blue Options Network", "standard_charge_percentage": 75, "methodology": "percent of total billed charges", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "PacificSource Health Plans", "plan_name": "Medicare Advantage", "standard_charge_percentage": 103, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" } ] } ] }, { "description": "Coronary Bypass with Cardiac Catheterization or Open Ablation without MCC", "code_information": [ { "code": "234", "type": "LOCAL" } ], "standard_charges": [ { "setting": "inpatient", "payers_information": [ { "payer_name": "Blue Cross Blue Shield of Montana", "plan_name": "Medicare Advantage", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "United Healthcare (UHC)", "plan_name": "Medicare Advantage", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "First Choice of the Midwest", "plan_name": "PPO", "standard_charge_percentage": 90, "methodology": "percent of total billed charges", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "United Healthcare (UHC)", "plan_name": "DSNP", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Employee Benefit Management Services (EBMS)", "plan_name": "EBMS SelectCare Network", "standard_charge_percentage": 80, "methodology": "percent of total billed charges", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Claritev fka MultiPlan", "plan_name": "PPO", "standard_charge_percentage": 75, "methodology": "percent of total billed charges", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Allegiance Provider Direct", "plan_name": "Medicare", "standard_charge_percentage": 229.99999999999997, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Medicare (CMS)", "plan_name": "Medicare", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Medica Insurance Company", "plan_name": "Medicare Cost", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "First Choice Health Network fka Health InfoNet", "plan_name": "Commercial", "standard_charge_percentage": 85, "methodology": "percent of total billed charges", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Indian Health Services (IHS)", "plan_name": "Commercial", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "First Choice Health Network fka Health InfoNet", "plan_name": "Workers Compensation", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Humana Insurance Company", "plan_name": "Humana Medicare Advantage HMO", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Humana Insurance Company", "plan_name": "Humana Medicare Advantage PPO", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Humana Insurance Company", "plan_name": "Humana Medicare Advantage PFFS", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Allegiance Provider Direct", "plan_name": "State of Montana Employee Benefit Plan (Self-Funded)", "standard_charge_percentage": 229.99999999999997, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Allegiance Provider Direct", "plan_name": "Montana Municipal Interlocal Authority (MMIA)", "standard_charge_percentage": 229.99999999999997, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Allegiance Provider Direct", "plan_name": "Montana Association of Counties (MACo)", "standard_charge_percentage": 229.99999999999997, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "First Choice Health Network fka Health InfoNet", "plan_name": "Medicare Advantage", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "TriWest Healthcare Alliance Corporation", "plan_name": "TRICARE Prime", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "TriWest Healthcare Alliance Corporation", "plan_name": "TRICARE Select", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Blue Cross Blue Shield of Montana", "plan_name": "HealthLink Network", "standard_charge_percentage": 75, "methodology": "percent of total billed charges", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Blue Cross Blue Shield of Montana", "plan_name": "Traditional Network", "standard_charge_percentage": 75, "methodology": "percent of total billed charges", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Blue Cross Blue Shield of Montana", "plan_name": "POS Network", "standard_charge_percentage": 75, "methodology": "percent of total billed charges", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Blue Cross Blue Shield of Montana", "plan_name": "Closed Plan Network", "standard_charge_percentage": 75, "methodology": "percent of total billed charges", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Blue Cross Blue Shield of Montana", "plan_name": "Retail HMO POS Network", "standard_charge_percentage": 75, "methodology": "percent of total billed charges", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Blue Cross Blue Shield of Montana", "plan_name": "Blue Options Network", "standard_charge_percentage": 75, "methodology": "percent of total billed charges", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "PacificSource Health Plans", "plan_name": "Medicare Advantage", "standard_charge_percentage": 103, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" } ] } ] }, { "description": "Coronary Bypass without Cardiac Catheterization with MCC", "code_information": [ { "code": "235", "type": "LOCAL" } ], "standard_charges": [ { "setting": "inpatient", "payers_information": [ { "payer_name": "Blue Cross Blue Shield of Montana", "plan_name": "Medicare Advantage", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "United Healthcare (UHC)", "plan_name": "Medicare Advantage", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "First Choice of the Midwest", "plan_name": "PPO", "standard_charge_percentage": 90, "methodology": "percent of total billed charges", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "United Healthcare (UHC)", "plan_name": "DSNP", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Employee Benefit Management Services (EBMS)", "plan_name": "EBMS SelectCare Network", "standard_charge_percentage": 80, "methodology": "percent of total billed charges", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Claritev fka MultiPlan", "plan_name": "PPO", "standard_charge_percentage": 75, "methodology": "percent of total billed charges", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Allegiance Provider Direct", "plan_name": "Medicare", "standard_charge_percentage": 229.99999999999997, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Medicare (CMS)", "plan_name": "Medicare", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Medica Insurance Company", "plan_name": "Medicare Cost", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "First Choice Health Network fka Health InfoNet", "plan_name": "Commercial", "standard_charge_percentage": 85, "methodology": "percent of total billed charges", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Indian Health Services (IHS)", "plan_name": "Commercial", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "First Choice Health Network fka Health InfoNet", "plan_name": "Workers Compensation", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Humana Insurance Company", "plan_name": "Humana Medicare Advantage HMO", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Humana Insurance Company", "plan_name": "Humana Medicare Advantage PPO", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Humana Insurance Company", "plan_name": "Humana Medicare Advantage PFFS", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Allegiance Provider Direct", "plan_name": "State of Montana Employee Benefit Plan (Self-Funded)", "standard_charge_percentage": 229.99999999999997, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Allegiance Provider Direct", "plan_name": "Montana Municipal Interlocal Authority (MMIA)", "standard_charge_percentage": 229.99999999999997, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Allegiance Provider Direct", "plan_name": "Montana Association of Counties (MACo)", "standard_charge_percentage": 229.99999999999997, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "First Choice Health Network fka Health InfoNet", "plan_name": "Medicare Advantage", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "TriWest Healthcare Alliance Corporation", "plan_name": "TRICARE Prime", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "TriWest Healthcare Alliance Corporation", "plan_name": "TRICARE Select", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Blue Cross Blue Shield of Montana", "plan_name": "HealthLink Network", "standard_charge_percentage": 75, "methodology": "percent of total billed charges", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Blue Cross Blue Shield of Montana", "plan_name": "Traditional Network", "standard_charge_percentage": 75, "methodology": "percent of total billed charges", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Blue Cross Blue Shield of Montana", "plan_name": "POS Network", "standard_charge_percentage": 75, "methodology": "percent of total billed charges", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Blue Cross Blue Shield of Montana", "plan_name": "Closed Plan Network", "standard_charge_percentage": 75, "methodology": "percent of total billed charges", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Blue Cross Blue Shield of Montana", "plan_name": "Retail HMO POS Network", "standard_charge_percentage": 75, "methodology": "percent of total billed charges", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Blue Cross Blue Shield of Montana", "plan_name": "Blue Options Network", "standard_charge_percentage": 75, "methodology": "percent of total billed charges", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "PacificSource Health Plans", "plan_name": "Medicare Advantage", "standard_charge_percentage": 103, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" } ] } ] }, { "description": "Coronary Bypass without Cardiac Catheterization without MCC", "code_information": [ { "code": "236", "type": "LOCAL" } ], "standard_charges": [ { "setting": "inpatient", "payers_information": [ { "payer_name": "Blue Cross Blue Shield of Montana", "plan_name": "Medicare Advantage", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "United Healthcare (UHC)", "plan_name": "Medicare Advantage", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "First Choice of the Midwest", "plan_name": "PPO", "standard_charge_percentage": 90, "methodology": "percent of total billed charges", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "United Healthcare (UHC)", "plan_name": "DSNP", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Employee Benefit Management Services (EBMS)", "plan_name": "EBMS SelectCare Network", "standard_charge_percentage": 80, "methodology": "percent of total billed charges", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Claritev fka MultiPlan", "plan_name": "PPO", "standard_charge_percentage": 75, "methodology": "percent of total billed charges", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Allegiance Provider Direct", "plan_name": "Medicare", "standard_charge_percentage": 229.99999999999997, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Medicare (CMS)", "plan_name": "Medicare", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Medica Insurance Company", "plan_name": "Medicare Cost", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "First Choice Health Network fka Health InfoNet", "plan_name": "Commercial", "standard_charge_percentage": 85, "methodology": "percent of total billed charges", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Indian Health Services (IHS)", "plan_name": "Commercial", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "First Choice Health Network fka Health InfoNet", "plan_name": "Workers Compensation", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Humana Insurance Company", "plan_name": "Humana Medicare Advantage HMO", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Humana Insurance Company", "plan_name": "Humana Medicare Advantage PPO", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Humana Insurance Company", "plan_name": "Humana Medicare Advantage PFFS", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Allegiance Provider Direct", "plan_name": "State of Montana Employee Benefit Plan (Self-Funded)", "standard_charge_percentage": 229.99999999999997, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Allegiance Provider Direct", "plan_name": "Montana Municipal Interlocal Authority (MMIA)", "standard_charge_percentage": 229.99999999999997, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Allegiance Provider Direct", "plan_name": "Montana Association of Counties (MACo)", "standard_charge_percentage": 229.99999999999997, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "First Choice Health Network fka Health InfoNet", "plan_name": "Medicare Advantage", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "TriWest Healthcare Alliance Corporation", "plan_name": "TRICARE Prime", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "TriWest Healthcare Alliance Corporation", "plan_name": "TRICARE Select", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Blue Cross Blue Shield of Montana", "plan_name": "HealthLink Network", "standard_charge_percentage": 75, "methodology": "percent of total billed charges", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Blue Cross Blue Shield of Montana", "plan_name": "Traditional Network", "standard_charge_percentage": 75, "methodology": "percent of total billed charges", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Blue Cross Blue Shield of Montana", "plan_name": "POS Network", "standard_charge_percentage": 75, "methodology": "percent of total billed charges", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Blue Cross Blue Shield of Montana", "plan_name": "Closed Plan Network", "standard_charge_percentage": 75, "methodology": "percent of total billed charges", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Blue Cross Blue Shield of Montana", "plan_name": "Retail HMO POS Network", "standard_charge_percentage": 75, "methodology": "percent of total billed charges", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Blue Cross Blue Shield of Montana", "plan_name": "Blue Options Network", "standard_charge_percentage": 75, "methodology": "percent of total billed charges", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "PacificSource Health Plans", "plan_name": "Medicare Advantage", "standard_charge_percentage": 103, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" } ] } ] }, { "description": "Malignancy of Hepatobiliary System or Pancreas without CC/MCC*", "code_information": [ { "code": "437", "type": "LOCAL" } ], "standard_charges": [ { "setting": "inpatient", "payers_information": [ { "payer_name": "Blue Cross Blue Shield of Montana", "plan_name": "Medicare Advantage", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "United Healthcare (UHC)", "plan_name": "Medicare Advantage", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "First Choice of the Midwest", "plan_name": "PPO", "standard_charge_percentage": 90, "methodology": "percent of total billed charges", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "United Healthcare (UHC)", "plan_name": "DSNP", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Employee Benefit Management Services (EBMS)", "plan_name": "EBMS SelectCare Network", "standard_charge_percentage": 80, "methodology": "percent of total billed charges", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Claritev fka MultiPlan", "plan_name": "PPO", "standard_charge_percentage": 75, "methodology": "percent of total billed charges", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Allegiance Provider Direct", "plan_name": "Medicare", "standard_charge_percentage": 229.99999999999997, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Medica Insurance Company", "plan_name": "Medicare Cost", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Medicare (CMS)", "plan_name": "Medicare", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Indian Health Services (IHS)", "plan_name": "Commercial", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "First Choice Health Network fka Health InfoNet", "plan_name": "Commercial", "standard_charge_percentage": 85, "methodology": "percent of total billed charges", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "First Choice Health Network fka Health InfoNet", "plan_name": "Workers Compensation", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Humana Insurance Company", "plan_name": "Humana Medicare Advantage HMO", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Humana Insurance Company", "plan_name": "Humana Medicare Advantage PPO", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Humana Insurance Company", "plan_name": "Humana Medicare Advantage PFFS", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Allegiance Provider Direct", "plan_name": "State of Montana Employee Benefit Plan (Self-Funded)", "standard_charge_percentage": 229.99999999999997, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Allegiance Provider Direct", "plan_name": "Montana Municipal Interlocal Authority (MMIA)", "standard_charge_percentage": 229.99999999999997, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Allegiance Provider Direct", "plan_name": "Montana Association of Counties (MACo)", "standard_charge_percentage": 229.99999999999997, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "First Choice Health Network fka Health InfoNet", "plan_name": "Medicare Advantage", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "TriWest Healthcare Alliance Corporation", "plan_name": "TRICARE Prime", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "TriWest Healthcare Alliance Corporation", "plan_name": "TRICARE Select", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Blue Cross Blue Shield of Montana", "plan_name": "HealthLink Network", "standard_charge_percentage": 75, "methodology": "percent of total billed charges", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Blue Cross Blue Shield of Montana", "plan_name": "Traditional Network", "standard_charge_percentage": 75, "methodology": "percent of total billed charges", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Blue Cross Blue Shield of Montana", "plan_name": "POS Network", "standard_charge_percentage": 75, "methodology": "percent of total billed charges", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Blue Cross Blue Shield of Montana", "plan_name": "Closed Plan Network", "standard_charge_percentage": 75, "methodology": "percent of total billed charges", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Blue Cross Blue Shield of Montana", "plan_name": "Retail HMO POS Network", "standard_charge_percentage": 75, "methodology": "percent of total billed charges", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Blue Cross Blue Shield of Montana", "plan_name": "Blue Options Network", "standard_charge_percentage": 75, "methodology": "percent of total billed charges", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "PacificSource Health Plans", "plan_name": "Medicare Advantage", "standard_charge_percentage": 103, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" } ] } ] }, { "description": "Disorders of Pancreas Except Malignancy with MCC*", "code_information": [ { "code": "438", "type": "LOCAL" } ], "standard_charges": [ { "setting": "inpatient", "payers_information": [ { "payer_name": "Blue Cross Blue Shield of Montana", "plan_name": "Medicare Advantage", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "United Healthcare (UHC)", "plan_name": "Medicare Advantage", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "First Choice of the Midwest", "plan_name": "PPO", "standard_charge_percentage": 90, "methodology": "percent of total billed charges", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "United Healthcare (UHC)", "plan_name": "DSNP", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Employee Benefit Management Services (EBMS)", "plan_name": "EBMS SelectCare Network", "standard_charge_percentage": 80, "methodology": "percent of total billed charges", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Claritev fka MultiPlan", "plan_name": "PPO", "standard_charge_percentage": 75, "methodology": "percent of total billed charges", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Allegiance Provider Direct", "plan_name": "Medicare", "standard_charge_percentage": 229.99999999999997, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Medica Insurance Company", "plan_name": "Medicare Cost", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Medicare (CMS)", "plan_name": "Medicare", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Indian Health Services (IHS)", "plan_name": "Commercial", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "First Choice Health Network fka Health InfoNet", "plan_name": "Commercial", "standard_charge_percentage": 85, "methodology": "percent of total billed charges", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "First Choice Health Network fka Health InfoNet", "plan_name": "Workers Compensation", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Humana Insurance Company", "plan_name": "Humana Medicare Advantage HMO", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Humana Insurance Company", "plan_name": "Humana Medicare Advantage PPO", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Humana Insurance Company", "plan_name": "Humana Medicare Advantage PFFS", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Allegiance Provider Direct", "plan_name": "State of Montana Employee Benefit Plan (Self-Funded)", "standard_charge_percentage": 229.99999999999997, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Allegiance Provider Direct", "plan_name": "Montana Municipal Interlocal Authority (MMIA)", "standard_charge_percentage": 229.99999999999997, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Allegiance Provider Direct", "plan_name": "Montana Association of Counties (MACo)", "standard_charge_percentage": 229.99999999999997, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "First Choice Health Network fka Health InfoNet", "plan_name": "Medicare Advantage", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "TriWest Healthcare Alliance Corporation", "plan_name": "TRICARE Prime", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "TriWest Healthcare Alliance Corporation", "plan_name": "TRICARE Select", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Blue Cross Blue Shield of Montana", "plan_name": "HealthLink Network", "standard_charge_percentage": 75, "methodology": "percent of total billed charges", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Blue Cross Blue Shield of Montana", "plan_name": "Traditional Network", "standard_charge_percentage": 75, "methodology": "percent of total billed charges", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Blue Cross Blue Shield of Montana", "plan_name": "POS Network", "standard_charge_percentage": 75, "methodology": "percent of total billed charges", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Blue Cross Blue Shield of Montana", "plan_name": "Closed Plan Network", "standard_charge_percentage": 75, "methodology": "percent of total billed charges", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Blue Cross Blue Shield of Montana", "plan_name": "Retail HMO POS Network", "standard_charge_percentage": 75, "methodology": "percent of total billed charges", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Blue Cross Blue Shield of Montana", "plan_name": "Blue Options Network", "standard_charge_percentage": 75, "methodology": "percent of total billed charges", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "PacificSource Health Plans", "plan_name": "Medicare Advantage", "standard_charge_percentage": 103, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" } ] } ] }, { "description": "Disorders of Pancreas Except Malignancy with CC*", "code_information": [ { "code": "439", "type": "LOCAL" } ], "standard_charges": [ { "setting": "inpatient", "payers_information": [ { "payer_name": "Blue Cross Blue Shield of Montana", "plan_name": "Medicare Advantage", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "United Healthcare (UHC)", "plan_name": "Medicare Advantage", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "First Choice of the Midwest", "plan_name": "PPO", "standard_charge_percentage": 90, "methodology": "percent of total billed charges", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "United Healthcare (UHC)", "plan_name": "DSNP", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Employee Benefit Management Services (EBMS)", "plan_name": "EBMS SelectCare Network", "standard_charge_percentage": 80, "methodology": "percent of total billed charges", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Claritev fka MultiPlan", "plan_name": "PPO", "standard_charge_percentage": 75, "methodology": "percent of total billed charges", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Allegiance Provider Direct", "plan_name": "Medicare", "standard_charge_percentage": 229.99999999999997, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Medica Insurance Company", "plan_name": "Medicare Cost", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Medicare (CMS)", "plan_name": "Medicare", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Indian Health Services (IHS)", "plan_name": "Commercial", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "First Choice Health Network fka Health InfoNet", "plan_name": "Commercial", "standard_charge_percentage": 85, "methodology": "percent of total billed charges", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "First Choice Health Network fka Health InfoNet", "plan_name": "Workers Compensation", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Humana Insurance Company", "plan_name": "Humana Medicare Advantage HMO", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Humana Insurance Company", "plan_name": "Humana Medicare Advantage PPO", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Humana Insurance Company", "plan_name": "Humana Medicare Advantage PFFS", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Allegiance Provider Direct", "plan_name": "State of Montana Employee Benefit Plan (Self-Funded)", "standard_charge_percentage": 229.99999999999997, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Allegiance Provider Direct", "plan_name": "Montana Municipal Interlocal Authority (MMIA)", "standard_charge_percentage": 229.99999999999997, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Allegiance Provider Direct", "plan_name": "Montana Association of Counties (MACo)", "standard_charge_percentage": 229.99999999999997, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "First Choice Health Network fka Health InfoNet", "plan_name": "Medicare Advantage", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "TriWest Healthcare Alliance Corporation", "plan_name": "TRICARE Prime", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "TriWest Healthcare Alliance Corporation", "plan_name": "TRICARE Select", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Blue Cross Blue Shield of Montana", "plan_name": "HealthLink Network", "standard_charge_percentage": 75, "methodology": "percent of total billed charges", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Blue Cross Blue Shield of Montana", "plan_name": "Traditional Network", "standard_charge_percentage": 75, "methodology": "percent of total billed charges", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Blue Cross Blue Shield of Montana", "plan_name": "POS Network", "standard_charge_percentage": 75, "methodology": "percent of total billed charges", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Blue Cross Blue Shield of Montana", "plan_name": "Closed Plan Network", "standard_charge_percentage": 75, "methodology": "percent of total billed charges", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Blue Cross Blue Shield of Montana", "plan_name": "Retail HMO POS Network", "standard_charge_percentage": 75, "methodology": "percent of total billed charges", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Blue Cross Blue Shield of Montana", "plan_name": "Blue Options Network", "standard_charge_percentage": 75, "methodology": "percent of total billed charges", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "PacificSource Health Plans", "plan_name": "Medicare Advantage", "standard_charge_percentage": 103, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" } ] } ] }, { "description": "Disorders of Pancreas Except Malignancy without CC/MCC*", "code_information": [ { "code": "440", "type": "LOCAL" } ], "standard_charges": [ { "setting": "inpatient", "payers_information": [ { "payer_name": "Blue Cross Blue Shield of Montana", "plan_name": "Medicare Advantage", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "United Healthcare (UHC)", "plan_name": "Medicare Advantage", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "First Choice of the Midwest", "plan_name": "PPO", "standard_charge_percentage": 90, "methodology": "percent of total billed charges", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "United Healthcare (UHC)", "plan_name": "DSNP", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Employee Benefit Management Services (EBMS)", "plan_name": "EBMS SelectCare Network", "standard_charge_percentage": 80, "methodology": "percent of total billed charges", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Claritev fka MultiPlan", "plan_name": "PPO", "standard_charge_percentage": 75, "methodology": "percent of total billed charges", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Allegiance Provider Direct", "plan_name": "Medicare", "standard_charge_percentage": 229.99999999999997, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Medica Insurance Company", "plan_name": "Medicare Cost", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Medicare (CMS)", "plan_name": "Medicare", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Indian Health Services (IHS)", "plan_name": "Commercial", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "First Choice Health Network fka Health InfoNet", "plan_name": "Commercial", "standard_charge_percentage": 85, "methodology": "percent of total billed charges", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "First Choice Health Network fka Health InfoNet", "plan_name": "Workers Compensation", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Humana Insurance Company", "plan_name": "Humana Medicare Advantage HMO", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Humana Insurance Company", "plan_name": "Humana Medicare Advantage PPO", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Humana Insurance Company", "plan_name": "Humana Medicare Advantage PFFS", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Allegiance Provider Direct", "plan_name": "State of Montana Employee Benefit Plan (Self-Funded)", "standard_charge_percentage": 229.99999999999997, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Allegiance Provider Direct", "plan_name": "Montana Municipal Interlocal Authority (MMIA)", "standard_charge_percentage": 229.99999999999997, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Allegiance Provider Direct", "plan_name": "Montana Association of Counties (MACo)", "standard_charge_percentage": 229.99999999999997, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "First Choice Health Network fka Health InfoNet", "plan_name": "Medicare Advantage", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "TriWest Healthcare Alliance Corporation", "plan_name": "TRICARE Prime", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "TriWest Healthcare Alliance Corporation", "plan_name": "TRICARE Select", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Blue Cross Blue Shield of Montana", "plan_name": "HealthLink Network", "standard_charge_percentage": 75, "methodology": "percent of total billed charges", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Blue Cross Blue Shield of Montana", "plan_name": "Traditional Network", "standard_charge_percentage": 75, "methodology": "percent of total billed charges", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Blue Cross Blue Shield of Montana", "plan_name": "POS Network", "standard_charge_percentage": 75, "methodology": "percent of total billed charges", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Blue Cross Blue Shield of Montana", "plan_name": "Closed Plan Network", "standard_charge_percentage": 75, "methodology": "percent of total billed charges", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Blue Cross Blue Shield of Montana", "plan_name": "Retail HMO POS Network", "standard_charge_percentage": 75, "methodology": "percent of total billed charges", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Blue Cross Blue Shield of Montana", "plan_name": "Blue Options Network", "standard_charge_percentage": 75, "methodology": "percent of total billed charges", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "PacificSource Health Plans", "plan_name": "Medicare Advantage", "standard_charge_percentage": 103, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" } ] } ] }, { "description": "Disorders of Liver Except Malignancy, Cirrhosis or Alcoholic Hepatitis with MCC*", "code_information": [ { "code": "441", "type": "LOCAL" } ], "standard_charges": [ { "setting": "inpatient", "payers_information": [ { "payer_name": "Blue Cross Blue Shield of Montana", "plan_name": "Medicare Advantage", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "United Healthcare (UHC)", "plan_name": "Medicare Advantage", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "First Choice of the Midwest", "plan_name": "PPO", "standard_charge_percentage": 90, "methodology": "percent of total billed charges", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "United Healthcare (UHC)", "plan_name": "DSNP", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Employee Benefit Management Services (EBMS)", "plan_name": "EBMS SelectCare Network", "standard_charge_percentage": 80, "methodology": "percent of total billed charges", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Claritev fka MultiPlan", "plan_name": "PPO", "standard_charge_percentage": 75, "methodology": "percent of total billed charges", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Allegiance Provider Direct", "plan_name": "Medicare", "standard_charge_percentage": 229.99999999999997, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Medica Insurance Company", "plan_name": "Medicare Cost", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Medicare (CMS)", "plan_name": "Medicare", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Indian Health Services (IHS)", "plan_name": "Commercial", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "First Choice Health Network fka Health InfoNet", "plan_name": "Commercial", "standard_charge_percentage": 85, "methodology": "percent of total billed charges", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "First Choice Health Network fka Health InfoNet", "plan_name": "Workers Compensation", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Humana Insurance Company", "plan_name": "Humana Medicare Advantage HMO", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Humana Insurance Company", "plan_name": "Humana Medicare Advantage PPO", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Humana Insurance Company", "plan_name": "Humana Medicare Advantage PFFS", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Allegiance Provider Direct", "plan_name": "State of Montana Employee Benefit Plan (Self-Funded)", "standard_charge_percentage": 229.99999999999997, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Allegiance Provider Direct", "plan_name": "Montana Municipal Interlocal Authority (MMIA)", "standard_charge_percentage": 229.99999999999997, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Allegiance Provider Direct", "plan_name": "Montana Association of Counties (MACo)", "standard_charge_percentage": 229.99999999999997, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "First Choice Health Network fka Health InfoNet", "plan_name": "Medicare Advantage", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "TriWest Healthcare Alliance Corporation", "plan_name": "TRICARE Prime", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "TriWest Healthcare Alliance Corporation", "plan_name": "TRICARE Select", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Blue Cross Blue Shield of Montana", "plan_name": "HealthLink Network", "standard_charge_percentage": 75, "methodology": "percent of total billed charges", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Blue Cross Blue Shield of Montana", "plan_name": "Traditional Network", "standard_charge_percentage": 75, "methodology": "percent of total billed charges", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Blue Cross Blue Shield of Montana", "plan_name": "POS Network", "standard_charge_percentage": 75, "methodology": "percent of total billed charges", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Blue Cross Blue Shield of Montana", "plan_name": "Closed Plan Network", "standard_charge_percentage": 75, "methodology": "percent of total billed charges", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Blue Cross Blue Shield of Montana", "plan_name": "Retail HMO POS Network", "standard_charge_percentage": 75, "methodology": "percent of total billed charges", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Blue Cross Blue Shield of Montana", "plan_name": "Blue Options Network", "standard_charge_percentage": 75, "methodology": "percent of total billed charges", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "PacificSource Health Plans", "plan_name": "Medicare Advantage", "standard_charge_percentage": 103, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" } ] } ] }, { "description": "Disorders of Liver Except Malignancy, Cirrhosis or Alcoholic Hepatitis with CC*", "code_information": [ { "code": "442", "type": "LOCAL" } ], "standard_charges": [ { "setting": "inpatient", "payers_information": [ { "payer_name": "Blue Cross Blue Shield of Montana", "plan_name": "Medicare Advantage", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "United Healthcare (UHC)", "plan_name": "Medicare Advantage", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "First Choice of the Midwest", "plan_name": "PPO", "standard_charge_percentage": 90, "methodology": "percent of total billed charges", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "United Healthcare (UHC)", "plan_name": "DSNP", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Employee Benefit Management Services (EBMS)", "plan_name": "EBMS SelectCare Network", "standard_charge_percentage": 80, "methodology": "percent of total billed charges", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Claritev fka MultiPlan", "plan_name": "PPO", "standard_charge_percentage": 75, "methodology": "percent of total billed charges", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Allegiance Provider Direct", "plan_name": "Medicare", "standard_charge_percentage": 229.99999999999997, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Medica Insurance Company", "plan_name": "Medicare Cost", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Medicare (CMS)", "plan_name": "Medicare", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Indian Health Services (IHS)", "plan_name": "Commercial", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "First Choice Health Network fka Health InfoNet", "plan_name": "Commercial", "standard_charge_percentage": 85, "methodology": "percent of total billed charges", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "First Choice Health Network fka Health InfoNet", "plan_name": "Workers Compensation", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Humana Insurance Company", "plan_name": "Humana Medicare Advantage HMO", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Humana Insurance Company", "plan_name": "Humana Medicare Advantage PPO", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Humana Insurance Company", "plan_name": "Humana Medicare Advantage PFFS", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Allegiance Provider Direct", "plan_name": "State of Montana Employee Benefit Plan (Self-Funded)", "standard_charge_percentage": 229.99999999999997, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Allegiance Provider Direct", "plan_name": "Montana Municipal Interlocal Authority (MMIA)", "standard_charge_percentage": 229.99999999999997, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Allegiance Provider Direct", "plan_name": "Montana Association of Counties (MACo)", "standard_charge_percentage": 229.99999999999997, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "First Choice Health Network fka Health InfoNet", "plan_name": "Medicare Advantage", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "TriWest Healthcare Alliance Corporation", "plan_name": "TRICARE Prime", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "TriWest Healthcare Alliance Corporation", "plan_name": "TRICARE Select", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Blue Cross Blue Shield of Montana", "plan_name": "HealthLink Network", "standard_charge_percentage": 75, "methodology": "percent of total billed charges", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Blue Cross Blue Shield of Montana", "plan_name": "Traditional Network", "standard_charge_percentage": 75, "methodology": "percent of total billed charges", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Blue Cross Blue Shield of Montana", "plan_name": "POS Network", "standard_charge_percentage": 75, "methodology": "percent of total billed charges", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Blue Cross Blue Shield of Montana", "plan_name": "Closed Plan Network", "standard_charge_percentage": 75, "methodology": "percent of total billed charges", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Blue Cross Blue Shield of Montana", "plan_name": "Retail HMO POS Network", "standard_charge_percentage": 75, "methodology": "percent of total billed charges", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Blue Cross Blue Shield of Montana", "plan_name": "Blue Options Network", "standard_charge_percentage": 75, "methodology": "percent of total billed charges", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "PacificSource Health Plans", "plan_name": "Medicare Advantage", "standard_charge_percentage": 103, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" } ] } ] }, { "description": "Disorders of Liver Except Malignancy, Cirrhosis or Alcoholic Hepatitis without CC/MCC*", "code_information": [ { "code": "443", "type": "LOCAL" } ], "standard_charges": [ { "setting": "inpatient", "payers_information": [ { "payer_name": "Blue Cross Blue Shield of Montana", "plan_name": "Medicare Advantage", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "United Healthcare (UHC)", "plan_name": "Medicare Advantage", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "First Choice of the Midwest", "plan_name": "PPO", "standard_charge_percentage": 90, "methodology": "percent of total billed charges", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "United Healthcare (UHC)", "plan_name": "DSNP", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Employee Benefit Management Services (EBMS)", "plan_name": "EBMS SelectCare Network", "standard_charge_percentage": 80, "methodology": "percent of total billed charges", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Claritev fka MultiPlan", "plan_name": "PPO", "standard_charge_percentage": 75, "methodology": "percent of total billed charges", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Allegiance Provider Direct", "plan_name": "Medicare", "standard_charge_percentage": 229.99999999999997, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Medica Insurance Company", "plan_name": "Medicare Cost", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Medicare (CMS)", "plan_name": "Medicare", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Indian Health Services (IHS)", "plan_name": "Commercial", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "First Choice Health Network fka Health InfoNet", "plan_name": "Commercial", "standard_charge_percentage": 85, "methodology": "percent of total billed charges", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "First Choice Health Network fka Health InfoNet", "plan_name": "Workers Compensation", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Humana Insurance Company", "plan_name": "Humana Medicare Advantage HMO", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Humana Insurance Company", "plan_name": "Humana Medicare Advantage PPO", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Humana Insurance Company", "plan_name": "Humana Medicare Advantage PFFS", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Allegiance Provider Direct", "plan_name": "State of Montana Employee Benefit Plan (Self-Funded)", "standard_charge_percentage": 229.99999999999997, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Allegiance Provider Direct", "plan_name": "Montana Municipal Interlocal Authority (MMIA)", "standard_charge_percentage": 229.99999999999997, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Allegiance Provider Direct", "plan_name": "Montana Association of Counties (MACo)", "standard_charge_percentage": 229.99999999999997, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "First Choice Health Network fka Health InfoNet", "plan_name": "Medicare Advantage", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "TriWest Healthcare Alliance Corporation", "plan_name": "TRICARE Prime", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "TriWest Healthcare Alliance Corporation", "plan_name": "TRICARE Select", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Blue Cross Blue Shield of Montana", "plan_name": "HealthLink Network", "standard_charge_percentage": 75, "methodology": "percent of total billed charges", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Blue Cross Blue Shield of Montana", "plan_name": "Traditional Network", "standard_charge_percentage": 75, "methodology": "percent of total billed charges", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Blue Cross Blue Shield of Montana", "plan_name": "POS Network", "standard_charge_percentage": 75, "methodology": "percent of total billed charges", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Blue Cross Blue Shield of Montana", "plan_name": "Closed Plan Network", "standard_charge_percentage": 75, "methodology": "percent of total billed charges", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Blue Cross Blue Shield of Montana", "plan_name": "Retail HMO POS Network", "standard_charge_percentage": 75, "methodology": "percent of total billed charges", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Blue Cross Blue Shield of Montana", "plan_name": "Blue Options Network", "standard_charge_percentage": 75, "methodology": "percent of total billed charges", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "PacificSource Health Plans", "plan_name": "Medicare Advantage", "standard_charge_percentage": 103, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" } ] } ] }, { "description": "Disorders of the Biliary Tract with MCC", "code_information": [ { "code": "444", "type": "LOCAL" } ], "standard_charges": [ { "setting": "inpatient", "payers_information": [ { "payer_name": "Blue Cross Blue Shield of Montana", "plan_name": "Medicare Advantage", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "United Healthcare (UHC)", "plan_name": "Medicare Advantage", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "First Choice of the Midwest", "plan_name": "PPO", "standard_charge_percentage": 90, "methodology": "percent of total billed charges", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "United Healthcare (UHC)", "plan_name": "DSNP", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Employee Benefit Management Services (EBMS)", "plan_name": "EBMS SelectCare Network", "standard_charge_percentage": 80, "methodology": "percent of total billed charges", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Claritev fka MultiPlan", "plan_name": "PPO", "standard_charge_percentage": 75, "methodology": "percent of total billed charges", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Allegiance Provider Direct", "plan_name": "Medicare", "standard_charge_percentage": 229.99999999999997, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Medica Insurance Company", "plan_name": "Medicare Cost", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Medicare (CMS)", "plan_name": "Medicare", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Indian Health Services (IHS)", "plan_name": "Commercial", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "First Choice Health Network fka Health InfoNet", "plan_name": "Commercial", "standard_charge_percentage": 85, "methodology": "percent of total billed charges", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "First Choice Health Network fka Health InfoNet", "plan_name": "Workers Compensation", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Humana Insurance Company", "plan_name": "Humana Medicare Advantage HMO", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Humana Insurance Company", "plan_name": "Humana Medicare Advantage PPO", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Humana Insurance Company", "plan_name": "Humana Medicare Advantage PFFS", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Allegiance Provider Direct", "plan_name": "State of Montana Employee Benefit Plan (Self-Funded)", "standard_charge_percentage": 229.99999999999997, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Allegiance Provider Direct", "plan_name": "Montana Municipal Interlocal Authority (MMIA)", "standard_charge_percentage": 229.99999999999997, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Allegiance Provider Direct", "plan_name": "Montana Association of Counties (MACo)", "standard_charge_percentage": 229.99999999999997, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "First Choice Health Network fka Health InfoNet", "plan_name": "Medicare Advantage", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "TriWest Healthcare Alliance Corporation", "plan_name": "TRICARE Prime", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "TriWest Healthcare Alliance Corporation", "plan_name": "TRICARE Select", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Blue Cross Blue Shield of Montana", "plan_name": "HealthLink Network", "standard_charge_percentage": 75, "methodology": "percent of total billed charges", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Blue Cross Blue Shield of Montana", "plan_name": "Traditional Network", "standard_charge_percentage": 75, "methodology": "percent of total billed charges", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Blue Cross Blue Shield of Montana", "plan_name": "POS Network", "standard_charge_percentage": 75, "methodology": "percent of total billed charges", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Blue Cross Blue Shield of Montana", "plan_name": "Closed Plan Network", "standard_charge_percentage": 75, "methodology": "percent of total billed charges", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Blue Cross Blue Shield of Montana", "plan_name": "Retail HMO POS Network", "standard_charge_percentage": 75, "methodology": "percent of total billed charges", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Blue Cross Blue Shield of Montana", "plan_name": "Blue Options Network", "standard_charge_percentage": 75, "methodology": "percent of total billed charges", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "PacificSource Health Plans", "plan_name": "Medicare Advantage", "standard_charge_percentage": 103, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" } ] } ] }, { "description": "Disorders of the Biliary Tract with CC", "code_information": [ { "code": "445", "type": "LOCAL" } ], "standard_charges": [ { "setting": "inpatient", "payers_information": [ { "payer_name": "Blue Cross Blue Shield of Montana", "plan_name": "Medicare Advantage", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "United Healthcare (UHC)", "plan_name": "Medicare Advantage", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "First Choice of the Midwest", "plan_name": "PPO", "standard_charge_percentage": 90, "methodology": "percent of total billed charges", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "United Healthcare (UHC)", "plan_name": "DSNP", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Employee Benefit Management Services (EBMS)", "plan_name": "EBMS SelectCare Network", "standard_charge_percentage": 80, "methodology": "percent of total billed charges", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Claritev fka MultiPlan", "plan_name": "PPO", "standard_charge_percentage": 75, "methodology": "percent of total billed charges", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Allegiance Provider Direct", "plan_name": "Medicare", "standard_charge_percentage": 229.99999999999997, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Medica Insurance Company", "plan_name": "Medicare Cost", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Medicare (CMS)", "plan_name": "Medicare", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Indian Health Services (IHS)", "plan_name": "Commercial", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "First Choice Health Network fka Health InfoNet", "plan_name": "Commercial", "standard_charge_percentage": 85, "methodology": "percent of total billed charges", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "First Choice Health Network fka Health InfoNet", "plan_name": "Workers Compensation", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Humana Insurance Company", "plan_name": "Humana Medicare Advantage HMO", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Humana Insurance Company", "plan_name": "Humana Medicare Advantage PPO", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Humana Insurance Company", "plan_name": "Humana Medicare Advantage PFFS", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Allegiance Provider Direct", "plan_name": "State of Montana Employee Benefit Plan (Self-Funded)", "standard_charge_percentage": 229.99999999999997, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Allegiance Provider Direct", "plan_name": "Montana Municipal Interlocal Authority (MMIA)", "standard_charge_percentage": 229.99999999999997, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Allegiance Provider Direct", "plan_name": "Montana Association of Counties (MACo)", "standard_charge_percentage": 229.99999999999997, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "First Choice Health Network fka Health InfoNet", "plan_name": "Medicare Advantage", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "TriWest Healthcare Alliance Corporation", "plan_name": "TRICARE Prime", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "TriWest Healthcare Alliance Corporation", "plan_name": "TRICARE Select", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Blue Cross Blue Shield of Montana", "plan_name": "HealthLink Network", "standard_charge_percentage": 75, "methodology": "percent of total billed charges", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Blue Cross Blue Shield of Montana", "plan_name": "Traditional Network", "standard_charge_percentage": 75, "methodology": "percent of total billed charges", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Blue Cross Blue Shield of Montana", "plan_name": "POS Network", "standard_charge_percentage": 75, "methodology": "percent of total billed charges", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Blue Cross Blue Shield of Montana", "plan_name": "Closed Plan Network", "standard_charge_percentage": 75, "methodology": "percent of total billed charges", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Blue Cross Blue Shield of Montana", "plan_name": "Retail HMO POS Network", "standard_charge_percentage": 75, "methodology": "percent of total billed charges", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Blue Cross Blue Shield of Montana", "plan_name": "Blue Options Network", "standard_charge_percentage": 75, "methodology": "percent of total billed charges", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "PacificSource Health Plans", "plan_name": "Medicare Advantage", "standard_charge_percentage": 103, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" } ] } ] }, { "description": "Disorders of the Biliary Tract without CC/MCC", "code_information": [ { "code": "446", "type": "LOCAL" } ], "standard_charges": [ { "setting": "inpatient", "payers_information": [ { "payer_name": "Blue Cross Blue Shield of Montana", "plan_name": "Medicare Advantage", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "United Healthcare (UHC)", "plan_name": "Medicare Advantage", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "First Choice of the Midwest", "plan_name": "PPO", "standard_charge_percentage": 90, "methodology": "percent of total billed charges", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "United Healthcare (UHC)", "plan_name": "DSNP", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Employee Benefit Management Services (EBMS)", "plan_name": "EBMS SelectCare Network", "standard_charge_percentage": 80, "methodology": "percent of total billed charges", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Claritev fka MultiPlan", "plan_name": "PPO", "standard_charge_percentage": 75, "methodology": "percent of total billed charges", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Allegiance Provider Direct", "plan_name": "Medicare", "standard_charge_percentage": 229.99999999999997, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Medica Insurance Company", "plan_name": "Medicare Cost", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Medicare (CMS)", "plan_name": "Medicare", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Indian Health Services (IHS)", "plan_name": "Commercial", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "First Choice Health Network fka Health InfoNet", "plan_name": "Commercial", "standard_charge_percentage": 85, "methodology": "percent of total billed charges", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "First Choice Health Network fka Health InfoNet", "plan_name": "Workers Compensation", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Humana Insurance Company", "plan_name": "Humana Medicare Advantage HMO", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Humana Insurance Company", "plan_name": "Humana Medicare Advantage PPO", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Humana Insurance Company", "plan_name": "Humana Medicare Advantage PFFS", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Allegiance Provider Direct", "plan_name": "State of Montana Employee Benefit Plan (Self-Funded)", "standard_charge_percentage": 229.99999999999997, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Allegiance Provider Direct", "plan_name": "Montana Municipal Interlocal Authority (MMIA)", "standard_charge_percentage": 229.99999999999997, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Allegiance Provider Direct", "plan_name": "Montana Association of Counties (MACo)", "standard_charge_percentage": 229.99999999999997, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "First Choice Health Network fka Health InfoNet", "plan_name": "Medicare Advantage", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "TriWest Healthcare Alliance Corporation", "plan_name": "TRICARE Prime", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "TriWest Healthcare Alliance Corporation", "plan_name": "TRICARE Select", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Blue Cross Blue Shield of Montana", "plan_name": "HealthLink Network", "standard_charge_percentage": 75, "methodology": "percent of total billed charges", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Blue Cross Blue Shield of Montana", "plan_name": "Traditional Network", "standard_charge_percentage": 75, "methodology": "percent of total billed charges", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Blue Cross Blue Shield of Montana", "plan_name": "POS Network", "standard_charge_percentage": 75, "methodology": "percent of total billed charges", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Blue Cross Blue Shield of Montana", "plan_name": "Closed Plan Network", "standard_charge_percentage": 75, "methodology": "percent of total billed charges", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Blue Cross Blue Shield of Montana", "plan_name": "Retail HMO POS Network", "standard_charge_percentage": 75, "methodology": "percent of total billed charges", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Blue Cross Blue Shield of Montana", "plan_name": "Blue Options Network", "standard_charge_percentage": 75, "methodology": "percent of total billed charges", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "PacificSource Health Plans", "plan_name": "Medicare Advantage", "standard_charge_percentage": 103, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" } ] } ] }, { "description": "Multiple Level Spinal Fusion Except Cervical with MCC or Custom-Made Anatomically Designed Interbody Fusion Device", "code_information": [ { "code": "447", "type": "LOCAL" } ], "standard_charges": [ { "setting": "inpatient", "payers_information": [ { "payer_name": "Blue Cross Blue Shield of Montana", "plan_name": "Medicare Advantage", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "United Healthcare (UHC)", "plan_name": "Medicare Advantage", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "First Choice of the Midwest", "plan_name": "PPO", "standard_charge_percentage": 90, "methodology": "percent of total billed charges", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "United Healthcare (UHC)", "plan_name": "DSNP", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Employee Benefit Management Services (EBMS)", "plan_name": "EBMS SelectCare Network", "standard_charge_percentage": 80, "methodology": "percent of total billed charges", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Claritev fka MultiPlan", "plan_name": "PPO", "standard_charge_percentage": 75, "methodology": "percent of total billed charges", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Allegiance Provider Direct", "plan_name": "Medicare", "standard_charge_percentage": 229.99999999999997, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Medica Insurance Company", "plan_name": "Medicare Cost", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Medicare (CMS)", "plan_name": "Medicare", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Indian Health Services (IHS)", "plan_name": "Commercial", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "First Choice Health Network fka Health InfoNet", "plan_name": "Commercial", "standard_charge_percentage": 85, "methodology": "percent of total billed charges", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "First Choice Health Network fka Health InfoNet", "plan_name": "Workers Compensation", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Humana Insurance Company", "plan_name": "Humana Medicare Advantage HMO", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Humana Insurance Company", "plan_name": "Humana Medicare Advantage PPO", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Humana Insurance Company", "plan_name": "Humana Medicare Advantage PFFS", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Allegiance Provider Direct", "plan_name": "State of Montana Employee Benefit Plan (Self-Funded)", "standard_charge_percentage": 229.99999999999997, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Allegiance Provider Direct", "plan_name": "Montana Municipal Interlocal Authority (MMIA)", "standard_charge_percentage": 229.99999999999997, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Allegiance Provider Direct", "plan_name": "Montana Association of Counties (MACo)", "standard_charge_percentage": 229.99999999999997, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "First Choice Health Network fka Health InfoNet", "plan_name": "Medicare Advantage", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "TriWest Healthcare Alliance Corporation", "plan_name": "TRICARE Prime", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "TriWest Healthcare Alliance Corporation", "plan_name": "TRICARE Select", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Blue Cross Blue Shield of Montana", "plan_name": "HealthLink Network", "standard_charge_percentage": 75, "methodology": "percent of total billed charges", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Blue Cross Blue Shield of Montana", "plan_name": "Traditional Network", "standard_charge_percentage": 75, "methodology": "percent of total billed charges", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Blue Cross Blue Shield of Montana", "plan_name": "POS Network", "standard_charge_percentage": 75, "methodology": "percent of total billed charges", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Blue Cross Blue Shield of Montana", "plan_name": "Closed Plan Network", "standard_charge_percentage": 75, "methodology": "percent of total billed charges", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Blue Cross Blue Shield of Montana", "plan_name": "Retail HMO POS Network", "standard_charge_percentage": 75, "methodology": "percent of total billed charges", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Blue Cross Blue Shield of Montana", "plan_name": "Blue Options Network", "standard_charge_percentage": 75, "methodology": "percent of total billed charges", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "PacificSource Health Plans", "plan_name": "Medicare Advantage", "standard_charge_percentage": 103, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" } ] } ] }, { "description": "Multiple Level Spinal Fusion Except Cervical without MCC", "code_information": [ { "code": "448", "type": "LOCAL" } ], "standard_charges": [ { "setting": "inpatient", "payers_information": [ { "payer_name": "Blue Cross Blue Shield of Montana", "plan_name": "Medicare Advantage", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "United Healthcare (UHC)", "plan_name": "Medicare Advantage", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "First Choice of the Midwest", "plan_name": "PPO", "standard_charge_percentage": 90, "methodology": "percent of total billed charges", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "United Healthcare (UHC)", "plan_name": "DSNP", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Employee Benefit Management Services (EBMS)", "plan_name": "EBMS SelectCare Network", "standard_charge_percentage": 80, "methodology": "percent of total billed charges", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Claritev fka MultiPlan", "plan_name": "PPO", "standard_charge_percentage": 75, "methodology": "percent of total billed charges", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Allegiance Provider Direct", "plan_name": "Medicare", "standard_charge_percentage": 229.99999999999997, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Medica Insurance Company", "plan_name": "Medicare Cost", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Medicare (CMS)", "plan_name": "Medicare", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Indian Health Services (IHS)", "plan_name": "Commercial", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "First Choice Health Network fka Health InfoNet", "plan_name": "Commercial", "standard_charge_percentage": 85, "methodology": "percent of total billed charges", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "First Choice Health Network fka Health InfoNet", "plan_name": "Workers Compensation", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Humana Insurance Company", "plan_name": "Humana Medicare Advantage HMO", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Humana Insurance Company", "plan_name": "Humana Medicare Advantage PPO", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Humana Insurance Company", "plan_name": "Humana Medicare Advantage PFFS", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Allegiance Provider Direct", "plan_name": "State of Montana Employee Benefit Plan (Self-Funded)", "standard_charge_percentage": 229.99999999999997, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Allegiance Provider Direct", "plan_name": "Montana Municipal Interlocal Authority (MMIA)", "standard_charge_percentage": 229.99999999999997, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Allegiance Provider Direct", "plan_name": "Montana Association of Counties (MACo)", "standard_charge_percentage": 229.99999999999997, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "First Choice Health Network fka Health InfoNet", "plan_name": "Medicare Advantage", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "TriWest Healthcare Alliance Corporation", "plan_name": "TRICARE Prime", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "TriWest Healthcare Alliance Corporation", "plan_name": "TRICARE Select", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Blue Cross Blue Shield of Montana", "plan_name": "HealthLink Network", "standard_charge_percentage": 75, "methodology": "percent of total billed charges", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Blue Cross Blue Shield of Montana", "plan_name": "Traditional Network", "standard_charge_percentage": 75, "methodology": "percent of total billed charges", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Blue Cross Blue Shield of Montana", "plan_name": "POS Network", "standard_charge_percentage": 75, "methodology": "percent of total billed charges", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Blue Cross Blue Shield of Montana", "plan_name": "Closed Plan Network", "standard_charge_percentage": 75, "methodology": "percent of total billed charges", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Blue Cross Blue Shield of Montana", "plan_name": "Retail HMO POS Network", "standard_charge_percentage": 75, "methodology": "percent of total billed charges", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Blue Cross Blue Shield of Montana", "plan_name": "Blue Options Network", "standard_charge_percentage": 75, "methodology": "percent of total billed charges", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "PacificSource Health Plans", "plan_name": "Medicare Advantage", "standard_charge_percentage": 103, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" } ] } ] }, { "description": "Single Level Spinal Fusion Except Cervical with MCC or Custom-Made Anatomically Designed Interbody Fusion Device", "code_information": [ { "code": "450", "type": "LOCAL" } ], "standard_charges": [ { "setting": "inpatient", "payers_information": [ { "payer_name": "Blue Cross Blue Shield of Montana", "plan_name": "Medicare Advantage", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "United Healthcare (UHC)", "plan_name": "Medicare Advantage", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "First Choice of the Midwest", "plan_name": "PPO", "standard_charge_percentage": 90, "methodology": "percent of total billed charges", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "United Healthcare (UHC)", "plan_name": "DSNP", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Employee Benefit Management Services (EBMS)", "plan_name": "EBMS SelectCare Network", "standard_charge_percentage": 80, "methodology": "percent of total billed charges", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Claritev fka MultiPlan", "plan_name": "PPO", "standard_charge_percentage": 75, "methodology": "percent of total billed charges", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Allegiance Provider Direct", "plan_name": "Medicare", "standard_charge_percentage": 229.99999999999997, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Medica Insurance Company", "plan_name": "Medicare Cost", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Medicare (CMS)", "plan_name": "Medicare", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Indian Health Services (IHS)", "plan_name": "Commercial", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "First Choice Health Network fka Health InfoNet", "plan_name": "Commercial", "standard_charge_percentage": 85, "methodology": "percent of total billed charges", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "First Choice Health Network fka Health InfoNet", "plan_name": "Workers Compensation", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Humana Insurance Company", "plan_name": "Humana Medicare Advantage HMO", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Humana Insurance Company", "plan_name": "Humana Medicare Advantage PPO", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Humana Insurance Company", "plan_name": "Humana Medicare Advantage PFFS", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Allegiance Provider Direct", "plan_name": "State of Montana Employee Benefit Plan (Self-Funded)", "standard_charge_percentage": 229.99999999999997, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Allegiance Provider Direct", "plan_name": "Montana Municipal Interlocal Authority (MMIA)", "standard_charge_percentage": 229.99999999999997, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Allegiance Provider Direct", "plan_name": "Montana Association of Counties (MACo)", "standard_charge_percentage": 229.99999999999997, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "First Choice Health Network fka Health InfoNet", "plan_name": "Medicare Advantage", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "TriWest Healthcare Alliance Corporation", "plan_name": "TRICARE Prime", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "TriWest Healthcare Alliance Corporation", "plan_name": "TRICARE Select", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Blue Cross Blue Shield of Montana", "plan_name": "HealthLink Network", "standard_charge_percentage": 75, "methodology": "percent of total billed charges", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Blue Cross Blue Shield of Montana", "plan_name": "Traditional Network", "standard_charge_percentage": 75, "methodology": "percent of total billed charges", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Blue Cross Blue Shield of Montana", "plan_name": "POS Network", "standard_charge_percentage": 75, "methodology": "percent of total billed charges", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Blue Cross Blue Shield of Montana", "plan_name": "Closed Plan Network", "standard_charge_percentage": 75, "methodology": "percent of total billed charges", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Blue Cross Blue Shield of Montana", "plan_name": "Retail HMO POS Network", "standard_charge_percentage": 75, "methodology": "percent of total billed charges", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Blue Cross Blue Shield of Montana", "plan_name": "Blue Options Network", "standard_charge_percentage": 75, "methodology": "percent of total billed charges", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "PacificSource Health Plans", "plan_name": "Medicare Advantage", "standard_charge_percentage": 103, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" } ] } ] }, { "description": "Single Level Spinal Fusion Except Cervical without MCC", "code_information": [ { "code": "451", "type": "LOCAL" } ], "standard_charges": [ { "setting": "inpatient", "payers_information": [ { "payer_name": "Blue Cross Blue Shield of Montana", "plan_name": "Medicare Advantage", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "United Healthcare (UHC)", "plan_name": "Medicare Advantage", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "First Choice of the Midwest", "plan_name": "PPO", "standard_charge_percentage": 90, "methodology": "percent of total billed charges", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "United Healthcare (UHC)", "plan_name": "DSNP", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Employee Benefit Management Services (EBMS)", "plan_name": "EBMS SelectCare Network", "standard_charge_percentage": 80, "methodology": "percent of total billed charges", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Claritev fka MultiPlan", "plan_name": "PPO", "standard_charge_percentage": 75, "methodology": "percent of total billed charges", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Allegiance Provider Direct", "plan_name": "Medicare", "standard_charge_percentage": 229.99999999999997, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Medica Insurance Company", "plan_name": "Medicare Cost", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Medicare (CMS)", "plan_name": "Medicare", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Indian Health Services (IHS)", "plan_name": "Commercial", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "First Choice Health Network fka Health InfoNet", "plan_name": "Commercial", "standard_charge_percentage": 85, "methodology": "percent of total billed charges", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "First Choice Health Network fka Health InfoNet", "plan_name": "Workers Compensation", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Humana Insurance Company", "plan_name": "Humana Medicare Advantage HMO", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Humana Insurance Company", "plan_name": "Humana Medicare Advantage PPO", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Humana Insurance Company", "plan_name": "Humana Medicare Advantage PFFS", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Allegiance Provider Direct", "plan_name": "State of Montana Employee Benefit Plan (Self-Funded)", "standard_charge_percentage": 229.99999999999997, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Allegiance Provider Direct", "plan_name": "Montana Municipal Interlocal Authority (MMIA)", "standard_charge_percentage": 229.99999999999997, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Allegiance Provider Direct", "plan_name": "Montana Association of Counties (MACo)", "standard_charge_percentage": 229.99999999999997, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "First Choice Health Network fka Health InfoNet", "plan_name": "Medicare Advantage", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "TriWest Healthcare Alliance Corporation", "plan_name": "TRICARE Prime", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "TriWest Healthcare Alliance Corporation", "plan_name": "TRICARE Select", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Blue Cross Blue Shield of Montana", "plan_name": "HealthLink Network", "standard_charge_percentage": 75, "methodology": "percent of total billed charges", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Blue Cross Blue Shield of Montana", "plan_name": "Traditional Network", "standard_charge_percentage": 75, "methodology": "percent of total billed charges", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Blue Cross Blue Shield of Montana", "plan_name": "POS Network", "standard_charge_percentage": 75, "methodology": "percent of total billed charges", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Blue Cross Blue Shield of Montana", "plan_name": "Closed Plan Network", "standard_charge_percentage": 75, "methodology": "percent of total billed charges", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Blue Cross Blue Shield of Montana", "plan_name": "Retail HMO POS Network", "standard_charge_percentage": 75, "methodology": "percent of total billed charges", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Blue Cross Blue Shield of Montana", "plan_name": "Blue Options Network", "standard_charge_percentage": 75, "methodology": "percent of total billed charges", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "PacificSource Health Plans", "plan_name": "Medicare Advantage", "standard_charge_percentage": 103, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" } ] } ] }, { "description": "Spinal Fusion Except Cervical with Spinal Curvature, Malignancy, Infection or Extensive Fusions with MCC", "code_information": [ { "code": "456", "type": "LOCAL" } ], "standard_charges": [ { "setting": "inpatient", "payers_information": [ { "payer_name": "Blue Cross Blue Shield of Montana", "plan_name": "Medicare Advantage", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "United Healthcare (UHC)", "plan_name": "Medicare Advantage", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "First Choice of the Midwest", "plan_name": "PPO", "standard_charge_percentage": 90, "methodology": "percent of total billed charges", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "United Healthcare (UHC)", "plan_name": "DSNP", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Employee Benefit Management Services (EBMS)", "plan_name": "EBMS SelectCare Network", "standard_charge_percentage": 80, "methodology": "percent of total billed charges", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Claritev fka MultiPlan", "plan_name": "PPO", "standard_charge_percentage": 75, "methodology": "percent of total billed charges", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Allegiance Provider Direct", "plan_name": "Medicare", "standard_charge_percentage": 229.99999999999997, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Medica Insurance Company", "plan_name": "Medicare Cost", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Medicare (CMS)", "plan_name": "Medicare", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Indian Health Services (IHS)", "plan_name": "Commercial", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "First Choice Health Network fka Health InfoNet", "plan_name": "Commercial", "standard_charge_percentage": 85, "methodology": "percent of total billed charges", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "First Choice Health Network fka Health InfoNet", "plan_name": "Workers Compensation", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Humana Insurance Company", "plan_name": "Humana Medicare Advantage HMO", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Humana Insurance Company", "plan_name": "Humana Medicare Advantage PPO", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Humana Insurance Company", "plan_name": "Humana Medicare Advantage PFFS", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Allegiance Provider Direct", "plan_name": "State of Montana Employee Benefit Plan (Self-Funded)", "standard_charge_percentage": 229.99999999999997, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Allegiance Provider Direct", "plan_name": "Montana Municipal Interlocal Authority (MMIA)", "standard_charge_percentage": 229.99999999999997, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Allegiance Provider Direct", "plan_name": "Montana Association of Counties (MACo)", "standard_charge_percentage": 229.99999999999997, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "First Choice Health Network fka Health InfoNet", "plan_name": "Medicare Advantage", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "TriWest Healthcare Alliance Corporation", "plan_name": "TRICARE Prime", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "TriWest Healthcare Alliance Corporation", "plan_name": "TRICARE Select", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Blue Cross Blue Shield of Montana", "plan_name": "HealthLink Network", "standard_charge_percentage": 75, "methodology": "percent of total billed charges", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Blue Cross Blue Shield of Montana", "plan_name": "Traditional Network", "standard_charge_percentage": 75, "methodology": "percent of total billed charges", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Blue Cross Blue Shield of Montana", "plan_name": "POS Network", "standard_charge_percentage": 75, "methodology": "percent of total billed charges", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Blue Cross Blue Shield of Montana", "plan_name": "Closed Plan Network", "standard_charge_percentage": 75, "methodology": "percent of total billed charges", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Blue Cross Blue Shield of Montana", "plan_name": "Retail HMO POS Network", "standard_charge_percentage": 75, "methodology": "percent of total billed charges", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Blue Cross Blue Shield of Montana", "plan_name": "Blue Options Network", "standard_charge_percentage": 75, "methodology": "percent of total billed charges", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "PacificSource Health Plans", "plan_name": "Medicare Advantage", "standard_charge_percentage": 103, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" } ] } ] }, { "description": "Spinal Fusion Except Cervical with Spinal Curvature, Malignancy, Infection or Extensive Fusions with CC", "code_information": [ { "code": "457", "type": "LOCAL" } ], "standard_charges": [ { "setting": "inpatient", "payers_information": [ { "payer_name": "Blue Cross Blue Shield of Montana", "plan_name": "Medicare Advantage", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "United Healthcare (UHC)", "plan_name": "Medicare Advantage", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "First Choice of the Midwest", "plan_name": "PPO", "standard_charge_percentage": 90, "methodology": "percent of total billed charges", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "United Healthcare (UHC)", "plan_name": "DSNP", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Employee Benefit Management Services (EBMS)", "plan_name": "EBMS SelectCare Network", "standard_charge_percentage": 80, "methodology": "percent of total billed charges", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Claritev fka MultiPlan", "plan_name": "PPO", "standard_charge_percentage": 75, "methodology": "percent of total billed charges", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Allegiance Provider Direct", "plan_name": "Medicare", "standard_charge_percentage": 229.99999999999997, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Medica Insurance Company", "plan_name": "Medicare Cost", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Medicare (CMS)", "plan_name": "Medicare", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Indian Health Services (IHS)", "plan_name": "Commercial", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "First Choice Health Network fka Health InfoNet", "plan_name": "Commercial", "standard_charge_percentage": 85, "methodology": "percent of total billed charges", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "First Choice Health Network fka Health InfoNet", "plan_name": "Workers Compensation", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Humana Insurance Company", "plan_name": "Humana Medicare Advantage HMO", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Humana Insurance Company", "plan_name": "Humana Medicare Advantage PPO", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Humana Insurance Company", "plan_name": "Humana Medicare Advantage PFFS", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Allegiance Provider Direct", "plan_name": "State of Montana Employee Benefit Plan (Self-Funded)", "standard_charge_percentage": 229.99999999999997, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Allegiance Provider Direct", "plan_name": "Montana Municipal Interlocal Authority (MMIA)", "standard_charge_percentage": 229.99999999999997, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Allegiance Provider Direct", "plan_name": "Montana Association of Counties (MACo)", "standard_charge_percentage": 229.99999999999997, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "First Choice Health Network fka Health InfoNet", "plan_name": "Medicare Advantage", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "TriWest Healthcare Alliance Corporation", "plan_name": "TRICARE Prime", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "TriWest Healthcare Alliance Corporation", "plan_name": "TRICARE Select", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Blue Cross Blue Shield of Montana", "plan_name": "HealthLink Network", "standard_charge_percentage": 75, "methodology": "percent of total billed charges", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Blue Cross Blue Shield of Montana", "plan_name": "Traditional Network", "standard_charge_percentage": 75, "methodology": "percent of total billed charges", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Blue Cross Blue Shield of Montana", "plan_name": "POS Network", "standard_charge_percentage": 75, "methodology": "percent of total billed charges", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Blue Cross Blue Shield of Montana", "plan_name": "Closed Plan Network", "standard_charge_percentage": 75, "methodology": "percent of total billed charges", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Blue Cross Blue Shield of Montana", "plan_name": "Retail HMO POS Network", "standard_charge_percentage": 75, "methodology": "percent of total billed charges", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Blue Cross Blue Shield of Montana", "plan_name": "Blue Options Network", "standard_charge_percentage": 75, "methodology": "percent of total billed charges", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "PacificSource Health Plans", "plan_name": "Medicare Advantage", "standard_charge_percentage": 103, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" } ] } ] }, { "description": "Spinal Fusion Except Cervical with Spinal Curvature, Malignancy, Infection or Extensive Fusions without CC/MCC", "code_information": [ { "code": "458", "type": "LOCAL" } ], "standard_charges": [ { "setting": "inpatient", "payers_information": [ { "payer_name": "Blue Cross Blue Shield of Montana", "plan_name": "Medicare Advantage", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "United Healthcare (UHC)", "plan_name": "Medicare Advantage", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "First Choice of the Midwest", "plan_name": "PPO", "standard_charge_percentage": 90, "methodology": "percent of total billed charges", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "United Healthcare (UHC)", "plan_name": "DSNP", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Employee Benefit Management Services (EBMS)", "plan_name": "EBMS SelectCare Network", "standard_charge_percentage": 80, "methodology": "percent of total billed charges", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Claritev fka MultiPlan", "plan_name": "PPO", "standard_charge_percentage": 75, "methodology": "percent of total billed charges", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Allegiance Provider Direct", "plan_name": "Medicare", "standard_charge_percentage": 229.99999999999997, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Medica Insurance Company", "plan_name": "Medicare Cost", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Medicare (CMS)", "plan_name": "Medicare", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Indian Health Services (IHS)", "plan_name": "Commercial", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "First Choice Health Network fka Health InfoNet", "plan_name": "Commercial", "standard_charge_percentage": 85, "methodology": "percent of total billed charges", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "First Choice Health Network fka Health InfoNet", "plan_name": "Workers Compensation", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Humana Insurance Company", "plan_name": "Humana Medicare Advantage HMO", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Humana Insurance Company", "plan_name": "Humana Medicare Advantage PPO", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Humana Insurance Company", "plan_name": "Humana Medicare Advantage PFFS", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Allegiance Provider Direct", "plan_name": "State of Montana Employee Benefit Plan (Self-Funded)", "standard_charge_percentage": 229.99999999999997, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Allegiance Provider Direct", "plan_name": "Montana Municipal Interlocal Authority (MMIA)", "standard_charge_percentage": 229.99999999999997, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Allegiance Provider Direct", "plan_name": "Montana Association of Counties (MACo)", "standard_charge_percentage": 229.99999999999997, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "First Choice Health Network fka Health InfoNet", "plan_name": "Medicare Advantage", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "TriWest Healthcare Alliance Corporation", "plan_name": "TRICARE Prime", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "TriWest Healthcare Alliance Corporation", "plan_name": "TRICARE Select", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Blue Cross Blue Shield of Montana", "plan_name": "HealthLink Network", "standard_charge_percentage": 75, "methodology": "percent of total billed charges", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Blue Cross Blue Shield of Montana", "plan_name": "Traditional Network", "standard_charge_percentage": 75, "methodology": "percent of total billed charges", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Blue Cross Blue Shield of Montana", "plan_name": "POS Network", "standard_charge_percentage": 75, "methodology": "percent of total billed charges", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Blue Cross Blue Shield of Montana", "plan_name": "Closed Plan Network", "standard_charge_percentage": 75, "methodology": "percent of total billed charges", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Blue Cross Blue Shield of Montana", "plan_name": "Retail HMO POS Network", "standard_charge_percentage": 75, "methodology": "percent of total billed charges", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Blue Cross Blue Shield of Montana", "plan_name": "Blue Options Network", "standard_charge_percentage": 75, "methodology": "percent of total billed charges", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "PacificSource Health Plans", "plan_name": "Medicare Advantage", "standard_charge_percentage": 103, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" } ] } ] }, { "description": "Cardiac Defibrillator Implant without MCC", "code_information": [ { "code": "277", "type": "LOCAL" } ], "standard_charges": [ { "setting": "inpatient", "payers_information": [ { "payer_name": "Blue Cross Blue Shield of Montana", "plan_name": "Medicare Advantage", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "United Healthcare (UHC)", "plan_name": "Medicare Advantage", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "First Choice of the Midwest", "plan_name": "PPO", "standard_charge_percentage": 90, "methodology": "percent of total billed charges", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "United Healthcare (UHC)", "plan_name": "DSNP", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Employee Benefit Management Services (EBMS)", "plan_name": "EBMS SelectCare Network", "standard_charge_percentage": 80, "methodology": "percent of total billed charges", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Claritev fka MultiPlan", "plan_name": "PPO", "standard_charge_percentage": 75, "methodology": "percent of total billed charges", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Allegiance Provider Direct", "plan_name": "Medicare", "standard_charge_percentage": 229.99999999999997, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Medicare (CMS)", "plan_name": "Medicare", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Medica Insurance Company", "plan_name": "Medicare Cost", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "First Choice Health Network fka Health InfoNet", "plan_name": "Commercial", "standard_charge_percentage": 85, "methodology": "percent of total billed charges", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Indian Health Services (IHS)", "plan_name": "Commercial", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "First Choice Health Network fka Health InfoNet", "plan_name": "Workers Compensation", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Humana Insurance Company", "plan_name": "Humana Medicare Advantage HMO", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Humana Insurance Company", "plan_name": "Humana Medicare Advantage PPO", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Humana Insurance Company", "plan_name": "Humana Medicare Advantage PFFS", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Allegiance Provider Direct", "plan_name": "State of Montana Employee Benefit Plan (Self-Funded)", "standard_charge_percentage": 229.99999999999997, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Allegiance Provider Direct", "plan_name": "Montana Municipal Interlocal Authority (MMIA)", "standard_charge_percentage": 229.99999999999997, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Allegiance Provider Direct", "plan_name": "Montana Association of Counties (MACo)", "standard_charge_percentage": 229.99999999999997, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "First Choice Health Network fka Health InfoNet", "plan_name": "Medicare Advantage", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "TriWest Healthcare Alliance Corporation", "plan_name": "TRICARE Prime", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "TriWest Healthcare Alliance Corporation", "plan_name": "TRICARE Select", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Blue Cross Blue Shield of Montana", "plan_name": "HealthLink Network", "standard_charge_percentage": 75, "methodology": "percent of total billed charges", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Blue Cross Blue Shield of Montana", "plan_name": "Traditional Network", "standard_charge_percentage": 75, "methodology": "percent of total billed charges", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Blue Cross Blue Shield of Montana", "plan_name": "POS Network", "standard_charge_percentage": 75, "methodology": "percent of total billed charges", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Blue Cross Blue Shield of Montana", "plan_name": "Closed Plan Network", "standard_charge_percentage": 75, "methodology": "percent of total billed charges", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Blue Cross Blue Shield of Montana", "plan_name": "Retail HMO POS Network", "standard_charge_percentage": 75, "methodology": "percent of total billed charges", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Blue Cross Blue Shield of Montana", "plan_name": "Blue Options Network", "standard_charge_percentage": 75, "methodology": "percent of total billed charges", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "PacificSource Health Plans", "plan_name": "Medicare Advantage", "standard_charge_percentage": 103, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" } ] } ] }, { "description": "Ultrasound Accelerated and Other Thrombolysis of Peripheral Vascular Structures with MCC", "code_information": [ { "code": "278", "type": "LOCAL" } ], "standard_charges": [ { "setting": "inpatient", "payers_information": [ { "payer_name": "Blue Cross Blue Shield of Montana", "plan_name": "Medicare Advantage", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "United Healthcare (UHC)", "plan_name": "Medicare Advantage", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "First Choice of the Midwest", "plan_name": "PPO", "standard_charge_percentage": 90, "methodology": "percent of total billed charges", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "United Healthcare (UHC)", "plan_name": "DSNP", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Employee Benefit Management Services (EBMS)", "plan_name": "EBMS SelectCare Network", "standard_charge_percentage": 80, "methodology": "percent of total billed charges", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Claritev fka MultiPlan", "plan_name": "PPO", "standard_charge_percentage": 75, "methodology": "percent of total billed charges", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Allegiance Provider Direct", "plan_name": "Medicare", "standard_charge_percentage": 229.99999999999997, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Medicare (CMS)", "plan_name": "Medicare", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Medica Insurance Company", "plan_name": "Medicare Cost", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "First Choice Health Network fka Health InfoNet", "plan_name": "Commercial", "standard_charge_percentage": 85, "methodology": "percent of total billed charges", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Indian Health Services (IHS)", "plan_name": "Commercial", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "First Choice Health Network fka Health InfoNet", "plan_name": "Workers Compensation", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Humana Insurance Company", "plan_name": "Humana Medicare Advantage HMO", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Humana Insurance Company", "plan_name": "Humana Medicare Advantage PPO", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Humana Insurance Company", "plan_name": "Humana Medicare Advantage PFFS", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Allegiance Provider Direct", "plan_name": "State of Montana Employee Benefit Plan (Self-Funded)", "standard_charge_percentage": 229.99999999999997, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Allegiance Provider Direct", "plan_name": "Montana Municipal Interlocal Authority (MMIA)", "standard_charge_percentage": 229.99999999999997, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Allegiance Provider Direct", "plan_name": "Montana Association of Counties (MACo)", "standard_charge_percentage": 229.99999999999997, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "First Choice Health Network fka Health InfoNet", "plan_name": "Medicare Advantage", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "TriWest Healthcare Alliance Corporation", "plan_name": "TRICARE Prime", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "TriWest Healthcare Alliance Corporation", "plan_name": "TRICARE Select", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Blue Cross Blue Shield of Montana", "plan_name": "HealthLink Network", "standard_charge_percentage": 75, "methodology": "percent of total billed charges", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Blue Cross Blue Shield of Montana", "plan_name": "Traditional Network", "standard_charge_percentage": 75, "methodology": "percent of total billed charges", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Blue Cross Blue Shield of Montana", "plan_name": "POS Network", "standard_charge_percentage": 75, "methodology": "percent of total billed charges", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Blue Cross Blue Shield of Montana", "plan_name": "Closed Plan Network", "standard_charge_percentage": 75, "methodology": "percent of total billed charges", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Blue Cross Blue Shield of Montana", "plan_name": "Retail HMO POS Network", "standard_charge_percentage": 75, "methodology": "percent of total billed charges", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Blue Cross Blue Shield of Montana", "plan_name": "Blue Options Network", "standard_charge_percentage": 75, "methodology": "percent of total billed charges", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "PacificSource Health Plans", "plan_name": "Medicare Advantage", "standard_charge_percentage": 103, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" } ] } ] }, { "description": "Ultrasound Accelerated and Other Thrombolysis of Peripheral Vascular Structures without MCC", "code_information": [ { "code": "279", "type": "LOCAL" } ], "standard_charges": [ { "setting": "inpatient", "payers_information": [ { "payer_name": "Blue Cross Blue Shield of Montana", "plan_name": "Medicare Advantage", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "United Healthcare (UHC)", "plan_name": "Medicare Advantage", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "First Choice of the Midwest", "plan_name": "PPO", "standard_charge_percentage": 90, "methodology": "percent of total billed charges", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "United Healthcare (UHC)", "plan_name": "DSNP", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Employee Benefit Management Services (EBMS)", "plan_name": "EBMS SelectCare Network", "standard_charge_percentage": 80, "methodology": "percent of total billed charges", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Claritev fka MultiPlan", "plan_name": "PPO", "standard_charge_percentage": 75, "methodology": "percent of total billed charges", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Allegiance Provider Direct", "plan_name": "Medicare", "standard_charge_percentage": 229.99999999999997, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Medicare (CMS)", "plan_name": "Medicare", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Medica Insurance Company", "plan_name": "Medicare Cost", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "First Choice Health Network fka Health InfoNet", "plan_name": "Commercial", "standard_charge_percentage": 85, "methodology": "percent of total billed charges", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Indian Health Services (IHS)", "plan_name": "Commercial", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "First Choice Health Network fka Health InfoNet", "plan_name": "Workers Compensation", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Humana Insurance Company", "plan_name": "Humana Medicare Advantage HMO", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Humana Insurance Company", "plan_name": "Humana Medicare Advantage PPO", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count": "0" }, { "payer_name": "Humana Insurance Company", "plan_name": "Humana Medicare Advantage PFFS", "standard_charge_percentage": 100, "methodology": "fee schedule", "additional_payer_notes": "No claims data available for the lookback period", "count":